Board Meeting Date: Thursday 25Th January 2018 Time: Commencing at 1:30Pm Until 5:00Pm Venue: Braintree Town Hall, Fairfield Road, Braintree, CM7 3YG

Board Meeting Date: Thursday 25th January 2018 Time: Commencing at 1:30pm until 5:00pm Venue: Braintree Town Hall, Fairfield Road, Braintree, CM7 3YG

We want everyone in mid Essex to Live Well

Mid Essex Clinical Commissioning Group Board Meeting Thursday, 25 January 2018 - Commencing at 1.30 pm Braintree Town Hall, Fairfield Road, Braintree, CM7 3YG

PART I AGENDA

Item Time Title Lead Action Papers Page No 1. 1.30 – Welcome, apologies for Caroline Dollery To note Verbal - 1.35 pm absence and declarations of interest. 2. 1.35 – Questions from the Public Caroline Dollery To receive Verbal - 1.50 pm 3. 1.50 – Register of Interests Caroline Dollery To note Attached 1 - 6 1.55 pm 4. 1.55 – Minutes of Previous Meeting Caroline Dollery To approve Attached 7 - 27 2.00 pm 5. 2.00 – Action Log from Previous Caroline Dollery To approve Attached 28 - 29 2.05 pm Meeting 6. 2.05 – Matters Arising from last Caroline Dollery To note Verbal - 2.10 pm Meeting (not on agenda) Standing Items 7. 2.10 – Chair’s Update Caroline Dollery To note Verbal 30 - 31 2.15 pm 8. 2.15 – Accountable Officer Update Caroline Rassell To note Attached 32 - 36 2.20 pm 9. 2.20 – Patient Story Rachel Hearn To note Verbal - 2.35 pm 10. 2 .35 – Performance Overview 3.00 pm 10.1 Patient Safety & Quality Rachel Hearn To note Attached 37 - 46 Report

10.2 Performance Report James Wilson To note Attached 47 - 65

10.3 Financial Savings Plan Dee Davey To note Attached 66 - 68

10.4 Finance Report Dee Davey To note Attached 69 - 90

10.5 Primary Care Report Viv Barnes To note Attached 91 - 100

11. 3.00 – STP Joint Committee 3.05 pm 11.1 Chair’s Update Report 101 – 102

11.2 Minutes 103 - 123 12. 3.00 – Reporting from Committees Caroline Dollery 3.05 pm 12.1 Audit Committee To note Attached 124 - 125 Summary Report

Item Time Title Lead Action Papers Page No 12.2 Quality & Governance To note Attached 126 - 127 Committee Summary Report

12.3 Finance & Performance To note Attached 128 - 130 Committee Summary Report

12.4 Live Well Committee To note Attached 131 - 132 Summary Report

12.5 Primary Care To note Attached 133 - 134 Commissioning Committee

3.10 – Break 3.20 pm 13. 3.20 – Communications & Anne-Marie To note Attached 3.30 pm Engagement Report Garrigan 135 - 151

14. 3.30 – Policies Update Viv Barnes To approve Attached 152 - 153 3.35 pm 15. 3.3 5 – Assurance Framework and Viv Barnes To approve Attached 154 - 174 3.45 pm Risk Register 16. 3.45 – Any further questions from Caroline Dollery To receive Verbal - 3.55 pm the public Non-Standard Items

17. 3.5 5 – Home First – Update on Caroline Rassell To note Attached 175 - 211 4.10 pm Engagement Process 18. 4.10 – Primary Care Foundations Dan Doherty For decision Attached 212 - 221 4.30 pm Viv Barnes

19. 4. 30 – 2018/19 Financial Plan Dee Davey To note Attached 222 - 225 4.40 pm 20. 4.40 – Revised Committee Terms of Viv Barnes To approve Attached 226 - 228 4.45 pm Reference 21. 4.4 5 – Emergency Powers Decisions Viv Barnes To note Attached 229 - 230 4.50 pm 22. 4.50 – Any Other Business Caroline Dollery To note Verbal - 5.00 pm 23. Date and time of next Board Caroline Dollery To note Verbal - Meeting in Public:

1.30 pm – 5.00 pm on Thursday, 29 March 2018 at Maldon Town Hall, Market Hill, Maldon CM9 4RL

MID ESSEX CCG REGISTER OF BOARD MEMBERS' INTERESTS - JANUARY 2018 Historic interests will remain on the register for at least six months. Declared Interest Is the interest Type of Interest First Name Surname Current Position (Name of the organisation and direct or Nature of Interest Date of Interest Actions taken to mitigate risk Declared nature of business) indirect? From To Financial Non-Financial Non-Financial Non-Financial Personal Interest Interest Personal Professional Interest Interest Professional Keith Andrew Lay Member Chelmer Housing Partnership Ltd x Direct Trustee Mar-10 Oct 2019 I would always declare this interest. However I would Housing Association only be a 'method' of introducing the parties Keith Andrew Lay Member Myraid Capital Ltd - subsidiary of x Direct Director 2014 Ongoing This company is only used as a vehicle to form a bond Chelmer Housing Partnership (CHP) for CHP. A conflict is not likely to materialise raising finance for CHP. Keith Andrew Lay Member Keith Andrew Associates Business x Direct Owner Feb-98 Ongoing Not likely tp materialise into a conflict but would declare Consultants if that were the case

Mike Bailey MECCG Elected Board Trustee of BEARS (Basics Essex) x Direct Provides emergency 1985 Ongoing It is unlikely that a conflict of interest will arise as there Member and Clinical Lead Immediate Care Scheme paramedic/doctor is no financial or other connection between the CCG support to East of and this organisation. However, should a situation England Ambulance arise, I will declare the interest Service. No longer respond clinically

Mike Bailey MECCG Elected Board Former Partner at Writtle GP x Indirect Ceased clinical work in 1980 Ongoing I will declare my interest if at any time issues specific to Member and Clinical Lead Surgery March 2016. I remain this Surgery are discussed so that appropriate friends with the staff at arrangements can be implemented Writtle Surgery Mike Bailey MECCG Elected Board Various NHS Trusts in the East of x Indirect Close family member is Ongoing I will declare my interest if at any time issues specific to Member. MECCG Clinical England a Junior Doctor on this Hospital are discussed so that appropriate Lead for Immediate Care rotation at various arrangements can be implemented hospitals

Mike Bailey MECCG Elected Board Share Portfolio x I hold a very small Ongoing I will declare my interest if at any time issues arise that Member and Clinical Lead portfolio of shares in may be relevant to my shareholding various companies, some of which are pharmaceutical Mike Bailey MECCG Elected Board Various NHS Trusts in the East of x Indirect Close family member is Ongoing I will declare my interest if at any time issues specific to Member and Clinical Lead England a Junior Doctor on the relevant Hospital are discussed so that appropriate rotation at various arrangements can be implemented hospitals

Vivienne Barnes Director of Corporate Nil N/A Services 1 Declared Interest Is the interest Type of Interest First Name Surname Current Position (Name of the organisation and direct or Nature of Interest Date of Interest Actions taken to mitigate risk Declared nature of business) indirect? From To Financial Non-Financial Non-Financial Non-Financial Personal Interest Interest Personal Professional Interest Interest Professional Joanne Beavis Co-opted Essex County Braintree District Council x Direct District Councillor 2003 Ongoing I will declare my interest if at any time issues relevant Council representative on to Braintree District Council are discussed so that Mid Essex CCG Board appropriate arrangements can be implemented.

Joanne Beavis Co-opted Essex County Essex County Council x Direct County Councillor 2017 Ongoing I will declare my interest if at any time issues relevant Council representative on to Essex County Council are discussed so that Mid Essex CCG Board appropriate arrangements can be implemented.

Joanne Beavis Co-opted Essex County Local Government Association x Direct Councillor 2014 Ongoing I will declare my interest if at any time issues relevant Council representative on to Braintree District Council are discussed so that Mid Essex CCG Board appropriate arrangements can be implemented.

James Booth Clinical Lead GP for Partner at Melbourne House Surgery x x GP partner providing Aug-06 Ongoing I will declare my interest if at any time issues relevant Safeguarding Children & services under GMS to the Surgery are discussed so that appropriate Elected GP contact arrangements can be implemented

James Booth Clinical Lead GP for Shareholder in Chelmer Healthcare x I am the named Ongoing I will declare my interest if at any time issues relevant Safeguarding Children & Ltd shareholder to the Surgery are discussed so that appropriate Elected GP representing the arrangements can be implemented practice

James Booth Clinical Lead GP for Mid Essex CCG Board x Close family relative Apr-15 Ongoing Interest recorded on Board Register and declared at Safeguarding Children & also sits on MECCG Board meetings Elected GP board Dee Davey Chief Finance Officer St Helens & Knowsley Teaching x Indirect Close members of Aug-16 Ongoing Agreed with line manager that I would declare my Hospitals family employed interest and withdraw from any decision-making processes and/or financial authorisations involving the Trust

Dee Davey Chief Finance Officer Resilinet Limited, IT Consultancy x Direct Secretary of Resilinet 09/01/2006 Ongoing The company is now dormant but still registered at Limited Companies House. Interest declared for audit purposes

2 Declared Interest Is the interest Type of Interest First Name Surname Current Position (Name of the organisation and direct or Nature of Interest Date of Interest Actions taken to mitigate risk Declared nature of business) indirect? From To Financial Non-Financial Non-Financial Non-Financial Personal Interest Interest Personal Professional Interest Interest Professional Daniel Doherty Director of Clinical Mid and South Essex Success x Direct Interim Director of 01/09/17 I will declare interest at all relevant meetings so that a Commissioning Regime Clinical Commissioning decision can be taken on whether or not I should step- down from voting

Daniel Doherty Director of Clinical North East London Foundation Trust x Indirect Spouse is a Community 01/09/17 There is a potential that this organisation could bid for Commissioning Physiotherapist at work with the CCG, at which point I would declare my NELFT interest so that appropriate arrangements can be implemented

Daniel Doherty Director of Clinical Provide Community Interest x Direct Honorary Clinical 01/09/17 I am not currently working under this contract, but it Commissioning Company Contract remains in place to perform clinical work if required. I will declare the interest if necessary so that appropriate arrangements can be implemented

Daniel Doherty Director of Clinical All Saints (CoE) Primary School x Direct Parent Governor of All 01/09/17 Agreed with Line Manager that it is unlikely that this Commissioning Maldon Saints Primary School interest is relevant to my current position, but I will Maldon declare my interest where relevant so that appropriate action can be taken

Caroline Dollery Chair of MECCG & Elected Danbury Medical Centre x Direct Salaried GP 01/09/15 Ongoing I will declare my interest if at any time issues relevant GP to the organisation are discussed so that appropriate arrangements can be implemented

Caroline Dollery Chair of MECCG & Elected East of England Strategic Clinical x Direct Clinical Director 01/04/12 Ongoing I will declare my interest if at any time issues relevant GP Network for Mental Health, Learning to the organisation are discussed so that appropriate Disability and Neurology arrangements can be implemented Caroline Dollery Chair of MECCG & Elected Eastern Region Collaborations for x Direct Non-Executive Director 01/07/15 Ongoing I will declare my interest if at any time issues relevant GP Leadership in Applied Health to the organisation are discussed so that appropriate Research & Care arrangements can be implemented Caroline Dollery Chair of MECCG & Elected Health Education England x Direct Leadership Courses 07/12/16 Ongoing I will declare my interest if at any time issues relevant GP to the organisation are discussed so that appropriate arrangements can be implemented Caroline Dollery Chair of MECCG & Elected Local Workforce Action Board x Direct Chair of Local 14/12/17 Ongoing I will declare my interest if at any time issues relevant GP (LWAB) Workforce Action Board to the organisation are discussed so that appropriate (LWAB) arrangements can be implemented 3 Declared Interest Is the interest Type of Interest First Name Surname Current Position (Name of the organisation and direct or Nature of Interest Date of Interest Actions taken to mitigate risk Declared nature of business) indirect? From To Financial Non-Financial Non-Financial Non-Financial Personal Interest Interest Personal Professional Interest Interest Professional Caroline Dollery Chair of MECCG & Elected Essex Health & Wellbeing Board x Direct Vice Chair of Essex 07/11/17 Ongoing I will declare my interest if at any time issues relevant GP Health & Wellbeing to the organisation are discussed so that appropriate Board arrangements can be implemented Anne Marie Garrigan Lay Board Member (PPE) Latchingdon Primary School x Direct Chair of Governors / Sep-96 Ongoing School is not a provider of any health services Governor Anne Marie Garrigan Lay Board Member (PPE) Barnardo's x Direct Healthy Family Team 01/10/17 Ongoing This service is within Rayleigh (outside of MECCG Leader (formerly Area area), although I would disclose my interest in Manager for Children’s’ Barnardos and withdraw from any discussions or Centre). decision-making processes to this organisation. Anne Marie Garrigan Lay Board Member (PPE) White Brick Renovation Company x Direct Secretary of the 18/11/2013 Ongoing The company is currently not trading. In the unlikely Ltd Company event that a conflict of interest arises, I will declare my interest and withdraw from any discussions or decision- making processes relevant to the company

Anne Marie Garrigan Lay Board Member (PPE) Pre-School Learning Alliance x Direct Area Manager for Jul-12 24/04/17 The Children Centres that I managed were based in Childrens' Centre Rayleigh, Rochford and Wickford (outside of MECCG area)

Rachel Hearn Acting Director of Nursing Nil N/A and Quality Alan Hubbard Lay Member (Commercial) Office of the Police, Fire and Crime x Direct Independent Joint Audit 01/03/15 31/03/19 Agreed with the Chair that I would declare my interest Commissioner for Essex Committee Member for and withdraw from any decision-making processes the Essex Police, Fire & and/or financial authorisations involving Essex Police Crime Commissioner & Chief Constable

Alan Hubbard Lay Member (Commercial) Essex Police, Fire and Crime x Direct Independent Member of 01/10/17 Ongoing Agreed with the Chair that I would declare my interest Commissioner, Fire & rescue the Audit Committee and withdraw from any decision-making processes Authority and/or financial authorisations involving Essex Police

4 Declared Interest Is the interest Type of Interest First Name Surname Current Position (Name of the organisation and direct or Nature of Interest Date of Interest Actions taken to mitigate risk Declared nature of business) indirect? From To Financial Non-Financial Non-Financial Non-Financial Personal Interest Interest Personal Professional Interest Interest Professional Maggie Pacini Public Health Lead Essex County Council. x Direct Employee of local 03/09/15 Ongoing To be clear about distinction when presenting an Consultant - Essex County authority partner to the independent professional opinion and when the view of Council CCG. Role is to offer ECC. independent professional advice under mandated offer from public health in local government to the NHS. Maggie Pacini Public Health Lead West Essex CCG x Direct Board member of 03/09/15 Ongoing My role is to provide independent professional public Consultant - Essex County WECCG in my capacity health advice and therefore independent of any Council as Consultant in Public position of the organisations I work for/with. I will Health offering declare this interest where a decision of Mid Essex independent CCG may impact upon West Essex CCG and maintain professional advice confidentiality where appropriate. under mandated offer from public health in local government to the NHS.

Caroline Rassell Accountable Officer Mid Mid and South Essex Sustainability x Direct SRO - Mid and South 25/03/16 Ongoing Interest recorded on Register and declared at meetings Essex CCG & Transformation Partnership (STP) Essex STP (Locality so that appropriate action can be implemented if Health and Care) decisions regarding the STP are required

Caroline Rassell Accountable Officer Mid Mid and South Essex Sustainability x Direct Lead Accountable 01/09/17 Ongoing Interest recorded on Register and declared at meetings Essex CCG & Transformation Partnership (STP) Officer for Joint so that appropriate action can be implemented if Committee decisions regarding the STP are required

Caroline Rassell Accountable Officer Mid Care UK Limited x Indirect Spouse is an employee 07/07/17 Ongoing Interest recorded on Register and declared at meetings Essex CCG of Care UK Limited so that appropriate action can be implemented if decisions regarding Care UK are required

Elizabeth Towers Clinical Lead Whitley House GP Surgery, x Direct GP Partner. Ongoing I will declare my interest if at any time issues relevant Chelmsford. to the Surgery are discussed so that appropriate arrangements can be implemented Elizabeth Towers Clinical Lead Macmillan Direct Macmillan GP Ongoing Declared at appropriate meetings. Elizabeth Towers Clinical Lead Farleigh Hospice x x Direct Director 14/03/05 Ongoing Declared my interest in my role as Clinical Lead for End of Life and Cancer and in the various Committes and working groups I sit on for the CCG

5 Declared Interest Is the interest Type of Interest First Name Surname Current Position (Name of the organisation and direct or Nature of Interest Date of Interest Actions taken to mitigate risk Declared nature of business) indirect? From To Financial Non-Financial Non-Financial Non-Financial Personal Interest Interest Personal Professional Interest Interest Professional Elizabeth Towers Clinical Lead Mid Essex CCG Board x Indirect Close relative of another 01/04/15 Ongoing Included on the Board Register of Interests and elected GP Board declared at Board meetings member. Elizabeth Towers Clinical Lead Chelmer Healthcare Limited x Direct Shareholder Ongoing Declared at appropriate meetings Elizabeth Towers Clinical Lead Whitley Urgent Care Limited N/A No longer relevant - see N/A N/A This was a consultancy business but ceased trading in actions taken to mitigate 2014 but is still registed at Companies House, so risk declared for audit purposes James Wilson Acting Director of Price Waterhouse Coopers (PWC) x Indirect Relative is a Partner at Ongoing I will declare my interest if at any time issues relevant Commissioning PWC to the organisationare discussed so that appropriate arrangements can be implemented

6 PUBLIC BOARD MEETING 1.30 pm – 5.00 pm. Thursday, 28 September 2017 Chelmsford City Football Club, Salerno Road, Chelmsford, CM1 2EH

PART I MINUTES

PRESENT:

Dr Caroline Dollery (CD) – Chair Caroline Rassell (CR) – Accountable Officer Mid Essex CCG; Lead Accountable Officer for Joint Committee; Senior Responsible Officer – Mid and South Essex STP (Locality Health and Care) Carol Anderson (CA) – Managing Director Rachel Hearn (RHe) - Acting Director of Nursing & Quality Dan Doherty (DDo) – Interim Director of Clinical Commissioning, Essex Success Regime (Locality Health and Care) Melanie Crass (MC) - Director of Primary Care & Resilience Alan Hubbard (AH) – Lay Member (Commercial) Anne-Marie Garrigan (AMG) – Lay Member (Patient & Public Engagement) (items 19 – 24 only) Dr Mike Bailey (MB) – Elected GP Board Member James Wilson (JW) - Acting Director of Acute Clinical Commissioning Dr Donald McGeachy (DMc) – Medical Director Dee Davey (DD) – Chief Finance Officer Dr Liz Towers (LT) – Elected GP Board Member Maggie Pacini (MP) – Public Health Consultant, Essex County Council (ECC) Councillor Jo Beavis – Essex County Council (items 1 - 8 only)

APOLOGIES Keith Andrew (KA) – Deputy Chair, Mid Essex CCG Dr James Booth (JB) – Vice Chair (Clinical) Viv Barnes (VB) - Director of Corporate Services

IN ATTENDANCE Viv Barker (VRB) - Head of Nursing Alison Connolly (AC) Head of Planned Care Rachel Harkes (RHa) – Head of Communications and Engagement Sara O’Connor (SO) - Head of Corporate Governance (Minute Taker)

Item No Item 1. Welcome, Apologies for Absence and Declarations of Interest: Presented by Dr Caroline Dollery

CD welcomed all those present to the Board meeting. Apologies were recorded as noted above.

2. Questions from the Public: Presented by Dr Caroline Dollery

Cathy Trevaldwyn, Public Governor for Essex Partnership University Trust (EPUT), advised that she would be interested to hear about dementia and mental health care following the latest Care Quality Commission inspections and asked what the CCG was doing to assist the homeless and rough sleepers.

MP advised that she recently met with colleagues from ECC to update the Homelessness Health Needs Assessment, including identifying any 7

Item No Item changing/emerging needs given the recent changes to the welfare system.

CD advised that Health Watch had also published a piece of work undertaken in North Essex regarding how homeless people were accessing physical and mental health care.

RHe explained that the former North East Partnership Foundation Trust (NEPFT) and South Essex Partnership Trust (SEPT) had merged to form EPUT. Whereas NEPFT had received a CQC rating of ‘requires improvement’, SEPT had received a ‘good’ overall rating. One of the aims of the merger was to bring some of the good practice from SEPT to the areas formerly covered by NEPFT. Oversight of EPUT, including regular assurance checks, continued and the Trust was currently on-target for completing actions to achieve the required improvements.

CD explained that she was actively involved with the East of England Parity of Esteem Board which was developing a mental health dashboard. The dashboard would be used to ensure that there was sufficient data to measure outcomes and provide clarity on funding requirements. CD confirmed that the Board had been made fully aware of issues relating to the provision of mental health services.

Pauline Amos from Support the NHS, Halstead asked if it was correct that the hospital eye services would no longer be provided because it was out for tender?

CR advised that a review of Ophthalmology services had been undertaken across the Mid and South Essex Sustainability and Transformation Partnership (STP) in conjunction with the acute hospitals to ensure that whatever service was introduced would be Consultant-led. Ophthalmology Consultants had recommended that some patients could in future be treated by local Optometrists and were in the process of agreeing which types of patients could be safely and effectively treated locally. Consultants would retain the authority to decide where patients would be treated.

JW advised that patients requiring cataract operation follow-ups would be the first group to be treated by local Optometrists where this was clinically appropriate, with complex cases remaining with hospital Consultants. DDo explained that this initiative was possible due to technology that was previously only available at hospitals now being widely used in local opticians. It was envisaged that the new arrangements would help a larger number of patients to access services locally.

Mrs Amos then referred to an article written in 2016 by Colin Hutchinson, retired Ophthalmology Consultant, in which he expressed concern about the withdrawal of a number of ophthalmology services locally and the effect on the skilled workforce. Mrs Amos asked whether the decision of the CCG and hospital to change the way services were provided was evidence-based.

DMc explained that there was very good evidence that if healthcare experts and their teams were concentrated together it produced better outcomes for patients.

Mrs Janet Cloake asked members for an update on plans for St Peter’s Hospital and the Maldon area.

MC advised that there had been a lot of progress regarding plans for the Maldon health hub and the CCG had been working with Maldon District Council, practices and local patient representatives to identify solutions for the area. There were currently two proposals, the first being to continue with a traditional method of care provision, and the second a new model of care provision, which included the ‘Home First’ model which would be discussed later on the agenda.

MC advised that the last stages of the outline business case was being produced and 8

Item No Item would include a full description of the two options. However, it was not yet possible to say what the preferred option would be at this time as the CCG needed to test the model being proposed under Home First across the system. MC confirmed that the CCG had kept the District Council fully informed so that it was aware of the reasons why the business case had not been completed by the end of September as originally suggested.

Mrs Cloake expressed concern that District Councillors did not appear to be fully aware of progress. MC confirmed that there were a number of local Councillors on the Maldon Stakeholder Group who would be aware of plans, as well as other issues relating to primary care provision, and outlined the meetings that had been held. MC agreed to provide a list of Councillors who had been involved in discussions to Mrs Cloake.

[Action: MC to provide Mrs Janet Cloake with a list of Maldon District Councillors involved in discussions regarding future healthcare provision within the Maldon area].

3. Register of Interests: Presented by Dr Caroline Dollery

The Board noted the most recent version of the register of interests. CD reminded members to declare any relevant interests in relation to specific agenda items as they arose.

4. Minutes of the Previous Meeting: Presented by Dr Caroline Dollery

The minutes of the Part I Board meeting held on 29 June 2017 were approved, subject to the following amendments:

• Page 10, item 9.4, first sentence – ‘DD’ to be amended to ‘RB’.

Mrs Amos referred to page 9, item 9.2 and advised that at the last meeting AH had raised a query regarding how the hospital/CCG identified someone who turned up at A&E regularly instead of going to their own doctor. CA confirmed that over the last year there were over 3,000 occasions where patients had not been registered with a GP, which included those attending A&E and for surgery. CA confirmed further work was being done to identify the proportion of these relating to just one visit per person or multiple attendances per person.

5. Action Log: Presented by Dr Caroline Dollery

The Action Log was received and progress updates noted as follows:-

• 29/09/2016, item 18, End of Life Strategy Equality Impact Assessment – now completed, to be removed from Action Log. • 30/03/2017, item 5, Emotional Wellbeing and Mental Services – it was noted that an update report was included at item 18 on the Board agenda and this action would therefore be closed. • 30/03/2017, item 17, 2017/18 Budget – agreed that both outstanding actions could be closed due to ongoing discussions with NHS England regarding the CCG’s financial position and changes being made to the way the CCG communicates with practices.

[Action: SO to update Action Log].

6. Matters Arising from Last Meeting (Not on Agenda): Presented by Dr Caroline Dollery.

There were no matters arising. 9

Item No Item 7. Chair’s Update Report: Presented by Dr Caroline Dollery

CD provided members with a verbal update on the following issues:

• CD and DDo had attended a series of practice visits to discuss any difficulties and demographic pressures they were experiencing and what support the CCG could offer them. The CCG was currently reviewing workflows to identify whether better systems could be implemented to reduce the burden on GPs and their staff. Some pilots were currently in place within Braintree and Chelmsford. • Following the implementation of the STP Joint Committee, the CCG was reviewing its values, vision, objectives and its staffing structure to ensure it could continue to meet its obligations effectively. • CD had recently attended a meeting regarding an opportunity for significant investment in estates. • One to one meetings had been held with the new Chair of the Health and Wellbeing Board who was very interested in initiatives to support those suffering social isolation/loneliness. • CD continued to chair the Local Workforce Area Board. Workforce shortages remained a challenge for the CCG and providers. • The work of the Primary Care Forum was being reviewed to enable it to provide an increased problem solving environment for its members.

Resolved: The Board noted the content of the Chair’s update report.

8. Accountable Officer Update Report: Presented by Caroline Rassell

CR provided members with a verbal update on the issues outlined in her report as follows:

• CR reminded members of the challenges the CCG faced in delivering the required £9 million surplus in 2017/18. However, the CCG had benefitted from some external support to drive forward several schemes, a number of which were predominantly focused on improving outcomes for patients. The CCG was planning to significantly invest in care for vulnerable patients outside of a hospital setting. • Performance at Broomfield Hospital A&E Department continued to be challenging. The Hospital was currently focusing on achieving at least 90% against the 4-hour A&E target, although the national target was 95%. All Trusts in England had been graded 1-4 (with 4 being the lowest) against their ability to achieve the 4-hour 95% target. Broomfield Hospital had been graded 3. CR and MB had attended a national event, led by Jeremy Hunt, the previous week, at which NHS organisations had been strongly encouraged to work together as a system to deliver standards. • A number of executive positions had been appointed to the STP Joint Committee. CR advised that she had been appointed as the Accountable Officer for the STP Joint Committee and was delighted to confirm that Carol Anderson had been appointed as the Chief Nurse. CR thanked CA for her work with the CCG Board. • CR advised that following a question raised by Cathy Trevaldwyn at the previous Board meeting, Board members had considered the way in which the CCG complied with the Public Services (Social Value) Act 2012. • Discussions with MEHT at Executive level and with Provide, at Board level, had taken place regarding working together across the STP. • Dr Anna Davey, JW, CD and CA had all successfully completed development programmes. The programme completed by CD and CA included a project on loneliness. • The Communications and Engagement Team were the only CCG team in the country nominated as finalists in the Public Sector Communications Awards.

Item No Item Unfortunately the team did not win, with first place going to Guys and St Thomas’s for their approach during the London terror attacks.

Resolved: The Board noted the content of the Accountable Officer update report.

9. Performance Overview:

9.1 Patient Safety & Quality Report: Presented by Rachel Hearn

RHe provided a verbal update on a number of key issues outlined within her report.

RHe confirmed that following a serious incident at MEHT relating to a retained swab, the Medical Director at MEHT was ensuring that use of the safer surgery checklist was being reiterated. RHe advised that this incident was being dealt with as a Never Event and she would advise members of the outcome of the investigation in due course.

RHe confirmed that the three 12-hour trolley breaches for mental health patients admitted to A&E in June 2017 had been taken very seriously by the CCG. A workshop on this issue, which was attended by various stakeholders including the CCG, MEHT, EPUT and ECC, had resulted in a number of positive outcomes, including the formation of some new pathways and improved relationships between organisations. RHe indicated there had been a further breach in September that was currently being investigated and she would advise members of the outcome of the investigation once completed.

RHe detailed the present mortality position and highlighted that herself, Dr Anna Davey and DMc had attended a number of Mortality Review Group meetings across the STP to discuss mortality rates and ascertain what the Trusts were doing to improve their position.

RHe confirmed that harm reviews continued to take place for patients who had breached the cancer 104 day standard and 52 weeks Referral to Treatment (RTT). To date, a preliminary review had found there was no evidence of significant physical or psychological harm being caused to patients, however there remained a backlog of cases to review at present.

AH asked if there were any causal factors that had been identified in relation to the current mortality rates. DMc advised that when intermittent ‘flags’ occurred for certain conditions, formal audits of patient records occurred. This included asking clinicians whether a patient’s death had been unexpected. In the majority of cases the answer was ‘no’ as the patient was reaching end-of-life.

DMc explained there were also issues relating to hospital coding, including initial diagnoses not being amended when further investigations had been performed, which could affect the accuracy of mortality rates.

DMc advised that Medical Examiners had been appointed within the hospital to review each in-hospital death and if they identified any issues of concern, the relevant patient’s records were thoroughly audited. DMc also advised that reviewing the records of all patients who died within 30 days of discharge was the right direction of travel, although there were resource issues that affected the ability to routinely do this.

CA advised that since RHe’s report had been written, there had been an East of England Cancer Alliance Board meeting where concerns regarding the inter-hospital cancer referral process had been discussed. CA explained that from next year, 11

Item No Item breaches would be counted differently. In the interim, all hospitals in the east of England had agreed to sign up to a new inter-Trust referral policy which would mean all patients would be processed and referred on by day 38 at the latest, which would result in a significant reduction in the number of 62 and 104 day breaches.

MP asked if end-of-life care patients were included in mortality rates and queried whether the coding for these patients was being performed correctly. DMc advised that palliative care codes were excluded from the Summary Hospital-level Mortality Indicator (SHMI) mortality rate, but were included within the Hospital Standardised Mortality Ratio (HSMR) rate. DMc further explained that unless a patient near end-of- life had been formally referred to the Palliative Care Team within the hospital, they would not be given a palliative care code. CA advised that there was work being undertaken to review arrangements regarding palliative care referrals and a senior clinician from the Hospice would be seconded to the hospital to assist in this regard.

LT advised that two of the elderly wards at MEHT were now implementing the Gold Standard Framework which included training staff to identify patients in the last year of life. In addition, a new care of the elderly Consultant was sitting on the Mid Essex Locality Group for End-of-Life Care, which would support more joined-up work across the area.

In response to a query from CR regarding learning identified from the harm review process, RHe advised that the CCG had provided support to the hospital to set up the process. The hospital had considered which circumstances should trigger a harm review and, as well as breaches of cancer standards, harm reviews were now undertaken for patients who had breached the referral to treatment 52 week standard and those who experienced extended trolley waits within the A&E Department.

LT advised that whilst the culture of harm reviews was welcome, it should be noted that some patients would inevitably breach the 62 or 104 day cancer standards due to the nature of their condition and their consequent inability to commence treatment.

In response to a query from DDo, DMc provided clarification on how mortality rates were calculated and confirmed that training of junior staff to ensure that diagnoses were correctly coded and updated as necessary was key to avoiding inaccurate mortality rate calculations.

RHe explained that the rules regarding palliative codes being allocated following a formal referral to palliative care were being robustly enforced due to national concerns about use of the Liverpool Care Pathway as well as criticism of some Trusts regarding their coding and the way mortality rates had been calculated.

MC commented that it was surprising that MEHT had scored poorly against the HSMR and so well against the SHMI. DMc explained that the calculations were very complex, but clarified that HSMR related purely to in-hospital mortality, whereas the SHMI took a wider view and included deaths up to 30 days after discharge, plus the absence of palliative care coding. MP commented that another consideration was that there could be up to a twelve-month lag in the data used to calculate mortality rates.

MB reiterated his previously expressed view that if MEHT implemented the ‘SAFER’ bundle across all areas, this would result in much better outcomes and patient flow. CA advised that the Trust had been striving to do this but a high turnover of senior staff had impacted on the Trust’s ability to complete this work. However, there were currently at least three wards that had implemented the SAFER bundle well and CA had encouraged the Trust to revisit this to ensure effective implementation throughout the organisation. RHe confirmed that a new clinical lead for SAFER had been appointed to take this forward and the Clinical Quality Review Group for MEHT 12

Item No Item would discuss and monitor progress at future meetings.

Resolved: The Board noted the content of the Patient Safety and Quality report and Scorecard set out at Appendix A.

[Action: RHe to advise the Board of the outcome of the investigation into the Never Event relating to a retained swab once known].

9.2 Performance Report: Presented by James Wilson

JW outlined the challenges being faced by MEHT following the implementation of the new patient administration system, Lorenzo. This had resulted in some data inaccuracies in relation to performance against the 18 week referral to treatment target, which was reported as 82.7% during July. It was expected that data would be more accurate from October and that the Trust would be compliant with the 92% target by that time.

JW advised that there were a significant number of patients who were breaching the 52 week waiting target, mainly within plastics, and outlined the reasons for this. JW confirmed there was a plan in place, overseen by himself and colleagues from NHS England/NHS Improvement to recover the situation by April 2018. However, the capacity nationally to accommodate the volume of patients for deep inferior epigastric perforators (DIEP) flap breast reconstructions was challenged. Patients who had breached the target included some from other Trusts who had requested the procedure to be carried out at MEHT by a particular surgeon. Work was ongoing to try to repatriate these patients. Other options were also being considered, including outsourcing other work that the surgeon performed to free up his time to undertake DIEP flap procedures.

JW advised that there had been inaccuracies in the data for cancer, also due to Lorenzo implementation, which had now been addressed. There had been a focus on governance within cancer services and the Cancer Alliance was anticipating recovery by September 2017. JW highlighted the table on page 41 showing the number of patients treated on the 62 day pathway per month up to July 2017 and advised that approximately 160 treatments had been carried out in August 2017 which was a substantial increase from previous months. The Trust was aiming for 85% compliance by September and there was daily oversight of this by the Trust’s Managing Director, including escalation of any patients who were in danger of breaching. There would be a number of clinically led workshops held to identify issues within the cancer pathway with a view to addressing these to ensure sustainable future performance across the STP.

JW advised that there had been an improvement in Red 1 ambulance performance, although Red 2 performance had remained static. There had been an overall reduction in the number of ambulance conveyances which had contributed to overall improved performance. An external review on the longer term sustainability of the ambulance contract, undertaken by Deloittes, had been provided to commissioners. New national ambulance performance standards were due to be implemented, which would build in additional time for call-handling.

The ability to meet the Improved Access to Psychological Therapies (IAPT) target was still challenged, although recovery performance was meeting trajectory. The CCG Primary Care Team had been providing support in this regard.

The Dementia target had stagnated slightly in its performance, but the CCG aspired to meet the national target of 67% by March 2018.

In response to a query from AH regarding the longest 52+ week wait, JW advised that 13

Item No Item currently one patient had waited 140 weeks. Action was being taken to provide them with the treatment they required at the earliest opportunity.

DMc explained that 52+ week waits could be due to many reasons, including patients postponing for personal reasons, patient choice in relation to the surgeon/hospital they wished to use and national capacity to perform certain procedures.

RHe confirmed that patients who had waited 52+ weeks were included in the harm review process and the Trust had been very candid about the reasons for these waits. CA advised that a number of patients had chosen to wait rather than go elsewhere for their procedures.

In response to a query from AH, CA advised that she was of the view that the Trust should be given the opportunity to resolve data quality issues arising from implementation of Lorenzo so that an accurate picture of performance could be obtained, before deciding on any further action required. CA advised that theatre capacity and patient recovery times also impacted upon waiting times. JW assured AH and other members that there was an intense effort to improve the situation and agreed to discuss action being taken with AH following the Board meeting.

In response to a query from MC regarding learning identified following 104+ day cancer breaches, CA advised that late work-up and handover from other hospitals were the main reasons identified for breaching. However, the agreement to hand over patients by day 38 at the latest would make a significant difference to performance.

Resolved: The Board noted the actions and risks still presenting to the CCG around performance and achieving some key national standards.

[Action: JW to contact AH to discuss information on action being taken to reduce over 52 week waits].

9.3 Financial Savings Plan: Presented by Dee Davey

DDa reminded members that the CCG had a savings target of £23.5 million and advised there remained significant risks to the CCG achieving this. External reviews of the savings programme by Deloittes and Boston Consulting Group (BCG) had endorsed the schemes proposed by the CCG, but some schemes had been very difficult to progress at the pace originally planned.

DDa advised that although the CCG was reporting delivery of 80% of the savings target for month 5, the profile of expected savings escalated significantly as the year progressed and there were substantial delivery risks related to schemes that were planned to come to fruition later in the year.

The Board noted that there were a number of new schemes which were currently being worked on. The CCG was also in discussion with MEHT to reach financial agreement on the contract value for 2017/18 and this would provide more certainty regarding the CCG’s financial position. DDa explained that implementation of the new patient administration system at MEHT (Lorenzo) had also caused difficulties in establishing the financial position in relation to the impact of demand management schemes.

The Executive team were having discussions about reprioritising schemes as there were some which were more likely to be achieved this year and the CCG would need to focus on those which offered the biggest impact on savings.

Resolved: The Board noted the QIPP delivery position at the end of month five 14

Item No Item and forecast outturn.

9.4 Finance Report: Presented by Dee Davey

DDa highlighted the key issues contained within the Finance Report, which reflected the position as at the end of month five.

DDa reiterated that the Board had been very well sighted on the risks to delivering the required savings but other unforeseen cost pressures had materialised. Implementation of the Lorenzo system at MEHT had made it very difficult to understand the impact of demand management schemes due to changes in the way some activity was recorded and delays in information flows. Changes in definitions and responsibility for the payment of some specialist activity and the reporting of some NHSE activity within CCG national data had also impacted on the CCG’s ability to identify activity and cost trends this financial year. DDa advised that it was of concern that the CCG was about to commence next year’s financial planning process without a clear understanding of the underlying activity flows.

DDa advised members that problems relating to the supply of cheaper generic drugs were also being encountered. To date, there was a cost pressure of £0.5 million which was entirely outside of the CCG’s control as patients have had to be prescribed more expensive versions in lieu of normal supply. The supply issue had affected the expected savings from reductions in the price of Pregablin as cost savings had not materialised due to drug supply issues. The CCG was currently not aware how long the drug supply issues were likely to continue. The CCG was due to meet with NHS England the following day and DDa would update members in due course

In addition, NHS England had identified some benefits to CCGs from changes to generic drug prices which they saw as an unforeseen benefit and were therefore trying to claw that back from CCGs. The Board noted the inequity of NHSE clawing back unforeseen benefits, whilst leaving the CCG with unforeseen cost pressures. Discussions were ongoing in this regard.

There were also financial pressures relating to the move to market rents by NHS Property Services (NHSPS). The CCG had been advised that the cost pressure was largely covered in its resource limit allocation but this would be contested as the percentage of the pressure assumed to be in Mid Essex CCG’s baseline compared to some neighbouring CCGs seemed unusually high. The CCG was pursuing this with NHS Property Services.

DDa went on to explain that the national Out-of-Hours procurement had been paused and the CCG therefore needed to extend its current OOH arrangements, which resulted in an additional unplanned cost-pressure.

Fast track CHC packages for end-of-life care patients were now running at twice the number compared to last year which, whilst good for patient care, had caused financial pressures on the CCG. Responsibility for funding a number of very expensive learning disability care packages had also recently been passed from social care to the CCG.

CR referred to Appendix H and queried the reason for the large number of creditors outstanding over 90 days. DDa agreed to provide CR with a detailed breakdown of these figures.

DDa referred to Appendix C on page 69 and advised that the CCG had received some additional funding for invest to save schemes under the Improved Better Care Fund.

Item No Item Resolved: The Board:

• Considered and noted the 2017/18 financial position reported to date, the forecast outturn and the risks to delivering the CCG control total; • Noted the risks set out in Appendix F and not reflected in the forecast outturn; • Noted progress on clearing CHC retrospective cases set out in Appendix I.

[Action: DDa to provide CR with a detailed breakdown of creditors outstanding over 90 days].

9.5 Primary Care Sustainability & Development Report: Presented by Melanie Crass

MC highlighted key issues contained within the Primary Care Sustainability & Development Report:

MC advised that there were still four practices in Maldon and Braintree which had ongoing list closures. MC acknowledged the challenges faced by these practices. However, two surgeries had made appointments via the European Union GP Recruitment programme. The appointed Doctors were currently undergoing the final stages of the recruitment process and should be starting with the practices very shortly.

MC explained that partnership arrangements had been established for Dickens Place Surgery which meant that the surgery and service provision would not need to be re- procured. The CCG and NHSE had worked collaboratively with the practice to ensure continuity of provision and to date there had been no reports of patients’ complaints or concerns.

MC clarified that the Project Initiation Document for estates within the Southminster area was being developed by William Fisher Surgery, not the Dengie Medical Surgery.

With regards to estates development, the CCG was progressing with Estates & Technology Transformation Fund bids where it could and was working collaboratively with NHS England colleagues in relation to the bid process.

MC confirmed that there were a number of practices within the CCG who had been successful in accessing central NHSE resilience funds. She also reported that there had been a high volume of submissions, approximately £5m, with £600k of available funding. She advised that the CCG was working on an STP-wide basis including the Local Medical Committee (LMC), to develop a framework for supporting practices.

MC also highlighted that there were a number of national targets for primary care development and transformation, including the requirement to offer seven day working. CR referred to the target for 50% of patients to have extended access, including weekends, to primary care services by 31 March 2018, and asked whether OOH provision by the hospital, pharmacists and other providers was included within this definition. MC advised that services being delivered by pharmacists and nurses, not necessarily a GP, could possibly be included in the definition, potentially on a locality basis.

CR then referred to the re-procurement of OOH services and asked whether the impact of delivering extended access to primary care services out of normal working time had been taken into account when considering future OOH demand and provision. DMc advised that many of the requirements were still prospective and until services had been progressed further, or existed, the CCG would have to plan 16

Item No Item for OOH services based on current information. However, he was aware that in areas where extended opening hours were already in place and were robust enough, relevant CCGs had been able to decommission some OOH services.

MC advised that she had already discussed this issue with the Lead Commissioner to ensure that within the procurement process there would be a degree of flexibility to alter OOH provision by a simple contract variation should this be developed as part of the Mid Essex proposals.

LT suggested that additional service provision could include medicine reviews by Pharmacists. CD commented that the availability of pharmacists was currently a concern. DMc highlighted that GP resources were scarce and would affect the CCG’s ability to implement extended opening hours. MC explained that additional funding would be made available to implement extended services, but acknowledged GP and wider workforce resources would remain a challenge. CA commented that the CCG needed to consider new models of care to implement these requirements.

In response to a query from JW regarding piloting of new text messaging services by some practices, MC advised that although practices were using text messages for appointment reminders, this particular pilot was slightly different and was being implemented via the STP process.

Resolved: The Board noted the content of the Primary Care Sustainability & Development Report. U 10. Reporting from Committees: Presented by Dr Caroline Dollery

10.1 Audit Committee Summary Report:

The Board noted the summary of matters discussed at the Audit Committee meeting held on 4 September 2017 and noted the Internal Audit Charter dated September 2017.

10.2 Quality & Governance Committee Summary Report:

Board members noted the summary of matters discussed at the Quality & Governance Committee meeting held 6 September 2017.

10.3 Finance & Performance Committee Summary Report:

Board members noted the summary of matters discussed at the Finance & Performance Committee meeting held on 25 July 2017.

10.4 Live Well Committee Summary Report:

Board members noted the summaries of matters discussed at the Live Well Committee meetings held on 4 July, 1 August and 5 September 2017.

10.5 Primary Care Commissioning Committee:

Board members noted the summaries of matters discussed at the Primary Care Commissioning Committee meetings held on 19 July and 6 September 2017.

11. Communications & Engagement Report: Presented by Rachel Harkes

RHa drew members attention to the main headlines in the report, including:-

• The Communications and Engagement Team, along with a number of clinicians, 17

Item No Item members of the pharmacy team and 111 colleagues, had a good presence at many community events over the summer, including the Pride Festival and the Little Legs Festival. • The team, along with LT, attended an event to discuss how people could stay well during the winter months. • The team also met with some community groups regarding spotting the signs of cancer early. • CCG Pharmacists had been talking to patients regarding how they could utilise pharmacists within practices to make sure they are getting the best out of the medicines they have been prescribed. • The Communications and Engagement Team had also been working with the Primary Care Team to develop a comprehensive care home manual. The manual would be used by residential and care home staff homes across mid Essex to provide guidance on common illnesses and conditions that their residents might experience and provides contact details for the various services available and advice on when to call a GP or other medical professional. New posters would be provided to practices to display in their reception areas to prompt conversations regarding patients using readily available and cheap over- the-counter medicines, as well as trying to increase the number of people signposted to pharmacy to enable them to be supported to self-care. • There continued to be really good social media interaction, with one of the biggest Tweets this quarter (25,500 impressions) resulting from the CCG re-tweeting some of the signs that had been displayed at train stations by the Samaritans.

MP advised that the national resources for Suicide Prevention Day were issued quite late, but the team had responded very well to promote this. MB commended the team for their work, in particular in relation to their involvement with the Pride Event.

In response to a query from AH, RHa advised that the care home manual was produced in ring binder format to enable updates to be inserted easily. There would also be an interactive ‘pdf’ document which would be distributed to homes. Updates would be sent electronically so that homes could print and insert these into their copy of the manual. There would also be a revision schedule implemented to ensure that the document was reviewed on a regular basis.

JW asked if there were plans to implement a similar manual for domiciliary care providers. RHe advised that the CCG was in the process of implementing an Any Qualified Provider (AQP) Framework for domiciliary care providers who met the criteria for provision of Continuing Health Care services, all of which would be engaged on a standard NHS contract. Consequently, they would all be required to follow particular processes, so similar arrangements and guidance would need to be put in place.

CA asked RHa to consider how interactions by other members of CCG staff could be recorded and included in future reports. RHe asked RHa if additional information on social media could also be included.

CA advised that as part of the work of the STP, a first listening event for children and young adults with cancer would be held on Saturday 18 November 2017 at Essex County Cricket Club between 10.00 am and 2.00 pm. CA asked RHa to ensure this was communicated to relevant stakeholders.

MP advised that the Live Well branding, which Braintree District Council had led on, was now being rolled-out to the other district councils in Essex. The Public Health Fund had been used to develop Braintree’s Live Well website as the platform for the other councils. The website would include basic Live Well information as well as local activities taking place within each district. RHa confirmed that she was aware of this and was linking with Krishna Ramkhelawon, Public Health Consultant, in this regard. 18

Item No Item

Resolved: The Board noted the content of the Communications & Engagement report.

[Action: RHa to consider how interactions by other members of CCG staff and additional information on social media could be included within future Communications & Engagement reports to Board].

[Action: RHa to communicate the listening event for children and young adults with cancer, on Saturday, 18 November 2017 at Essex County Cricket Club between 10.00 am and 2.00 pm, to relevant stakeholders].

12. Policies Update: Presented by Dr Caroline Dollery

CD asked the Board to adopt the following policies which had been approved by the Audit Committee on 4 September 2017 or the Quality & Governance Committee on 6 September 2017:

• MECCG003 - Conflicts of Interest Policy • MECCG014 – Serious Incident Management Policy • MECCG040 – Information Governance Management Framework 2017/18 • MECCG041 - Gifts & Hospitality Policy • MECCG066 – Business Continuity Plan • MECCG073 – On-call Director Policy • MECCG077 - Emergency Planning, Resilience and Response and Business Continuity Strategy • MECCG105 - Absence Management Policy • MECCG112 - Standards of Business Conduct Policy • MECCG126 – Continuing Health Care Standard Operating Procedure

CD also asked the Board to confirm that, on the recommendation of Audit Committee, the Whistleblowing Policy and Procedures (MECCG012) could be rolled forward for another year as no amendments were required.

Resolved: The Board:

• agreed to adopt the policies as listed above and • agreed to the Whistleblowing Policy being rolled forward for another year.

[Action: SOU toU ensure the above policies are highlighted in the ‘Digest Live’ staff newsletter and posted on the CCG website.]

13. Assurance Framework and Risk Register: Presented by Sara O’Connor

SO advised that there was one new strategic risk (ID72) relating to the risk of cyber-attacks and advised that there was work being undertaken at national and local level to ensure a robust response to any future attacks. SO outlined changes to a number of risk ratings as outlined in the report and confirmed that there were no strategic risks that had been closed since the last Board meeting.

SO advised that currently there were no assurances available for one strategic risk (ID26) relating to NHS Property Services charging arrangements and highlighted a number of risks where there were no plans to implement further controls for the reasons outlined in the report.

CR advised that she had been asked on behalf of Mid and South Essex to provide a briefing for a meeting on Monday with the Chief Executive of NHS Property Services, 19

Item No Item at which she would be raising a number of issues relating to the move to market rents.

AH queried whether a risk relating the CCG’s capacity to meet its obligations following a number of senior staff changes due to the work of the STP was included on the risk register. SO and CR confirmed that there was an operational risk relating to this issue which was reviewed prior to each round of Committee and Board meetings. However, the risk rating and whether it should be escalated to strategic level would now need to be reviewed as further staff changes had just been announced.

Resolved: The Board noted the Strategic Risk Register set out at Appendix A.

14. Any Further Questions from the Public: Presented by Dr Caroline Dollery

Cathy Trevaldwyn recommended that Board members listen to a radio programme introducing the Suicide Awareness Week which was available at Mersea Care’s website. Ms Trevaldwyn advised that the current thinking was that suicide was an illness that could be cured and she had been impressed that every member of EPUT mental health teams had received suicide awareness training, including receptionists who were often the first point of contact for patients. Ms Trevaldwyn advised that whilst attending the MEHT Annual General Meeting she was asked where MEHT staff could access the training and asked the CCG to champion this approach with its providers.

MP advised that there had been a slight delay in launching the Suicide Prevention Strategy as it was still undergoing internal review and approval, but a number of recommendations were nonetheless being implemented, including provision of suicide prevention awareness training. MP was leading a group, including colleagues from EPUT, Safeguarding, Police and MIND, to do this. Nominations to attend ‘train the trainer’ training had been sought to enable those trained to cascade the training out to other staff. Unfortunately, a bid for additional funding from the Police and Crimes Commissioner to fund this training had been unsuccessful but alternative funding was being sought.

CD confirmed that she was in discussion with Natalie Hammonds and Stanley Morris at EPUT about linking with Mersea Care so that they could learn from the work that was being undertaken by that organisation.

Pauline Amos referred to points 9.3 and 9.4 of the minutes of the meeting held on 29 June 2017 and asked which QIPP schemes were very high risk. DDa agreed to contact Mrs Amos following the meeting to provide her with the relevant information.

Mrs Amos also asked whether the maternity unit at William Julien Courtauld Hospital, Braintree, was having to shut because of staffing problems. RHe advised that, due to the current midwife to patient ratio, the ward would be shut for safety reasons in the evening and out-of-hours, but would remain open from 9.00 am to 5.00 pm between Monday to Friday. Outside of these times, mothers would attend Broomfield Hospital. RHe confirmed that all affected expectant mothers had been made fully aware of the restrictions, which were in place until the end of September. To date, there had been no adverse effects reported.

Mrs Amos asked if the CCG had considered the evidence from other areas, e.g. Telford, where maternity hours had been reduced. RHe confirmed she would review this information.

Mr Tom Kelly had submitted a number of written questions relating to Home First and the GP Resilience Fund. CD confirmed that a written response would be submitted to Mr Kelly as soon as possible. 20

Item No Item

[Action: DDa to contact Mrs Pauline Amos to provide her with information on high risk QIPP schemes].

[Action: RHe to review information on the impact experienced following a reduction in maternity unit opening hours in the Telford area].

[Action: SO to arrange for Mr Tom Kelly to be provided with a written response to his questions].

15. Sustainability and Transformation Partnership (STP) Update: Presented by Caroline Rassell

CR advised that the paper being presented to the Mid Essex CCG Board would also be submitted to the other CCG Boards within the Mid and South Essex STP. CR advised that at every future CCG Board meeting a report highlighting the key issues discussed by the STP Joint Committee would be provided, including the minutes of the meetings held in public.

CR advised that the Mid and South Essex STP, along with the other STPs, was graded following a review of its plans by NHS England and NHS Improvement and had achieved a rating of “category 2 – advanced”.

The executive team for the STP was nearly complete, appointments having been made to the Chief Nurse, Chief Finance Officer and Director of Commissioning posts. The Medical lead for the STP would be appointed as soon as possible. Following this, the STP would work with the five CCGs to align staff who delivered acute functions so there would be capacity for STP Directors to utilise these staff.

Resolved: The Board noted the STP Update report and the minutes of the STP Joint Committee meeting held in public on 7 July 2017.

16. Home First: Presented by Caroline Rassell, Rachel Hearn, Alison Connolly and Viv Barker

RHe advised that just over a year ago, she and the Quality Team liaised with Essex County Council and the CCG’s community provider, Provide, to consider alternative models of patient care. This included visiting Yarmouth and Waveney CCG to see their discharge to assess process and talking to the local provider of the service. The CCG subsequently decided to investigate the possibility of implementing a similar system for mid Essex. BCG had assisted the CCG to put this proposal into a local context. RHe introduced Alison Connolly, Head of Planned Care, who had led on the project, and Viv Barker, Head of Nursing, who would present the case for change.

AC advised that there were three patient groups likely to benefit from Home First. The first of these groups were patients in community hospital beds. An audit had been performed to understand the characteristics and needs of this group, which strongly indicated that a high percentage of patients in community hospital beds could receive safe care in an alternative setting were the Home First model available, however it was recognised that there was a small percentage of patients, 7 – 12% that would still require care in a traditional community hospital bed.

The second group was those patients who required assessment under the continuing care health framework (CHC). It was often the case that this cohort of patients could spend a significant amount of time in the acute hospital after their acute intervention had been completed. Recent audits indicated that this could be as long as four weeks. The CHC framework identified that the individual should not be assessed until 21

Item No Item they had reached clinical and functional stability. Currently this period of time was spent in the acute Trust where it was recognised that patients could de-condition and were at further risk of developing hospital acquired infection.

Therefore, when the assessment finally took place in the acute setting, patients were being assessed on what could be described as an artificial picture of their ability, due to their de-conditioning. This had the potential for the CHC assessment identifying a greater level of dependence and consequently recommending a higher level of care which the patient might not have required had they not remained in a hospital setting. AC explained that although care packages for patients who experienced de-conditioning were potentially more expensive, more importantly, to continue with the existing arrangements for assessment was not in the best interests of the patient because it set a trend of dependence going forward.

The third group that would indirectly benefit from Home First were patients waiting for orthopaedic procedures. An audit of patients on the Braintree community hospital beds ward identified that only approximately 29% were actually registered with a Braintree GP. This highlighted that patients were not necessarily being admitted to hospital beds closest to their home, but rather on the grounds of clinical need. In addition, two technically advanced theatres in Braintree Hospital were currently being under-utilised as the procedures taking place there were relatively minor. However, complex orthopaedic procedures could be performed there, which would assist MEHT to reduce waiting times for orthopaedic patients.

AC explained that Home First could offer an opportunity to address these three groups. It worked on the principle that as soon as someone was medically fit for discharge, and they no longer needed to remain in an acute or community hospital setting for their recovery, plans could be made to discharge them to another setting. Under Home First this would ideally be to the patient’s home, where the necessary services would go in to look after them. This would be similar to the Stroke Early Supported Discharge (ESD) service where stroke patients return home and therapy services are provided in their home.

If discharge to home was not possible, the patient might be admitted to an enhanced nursing home bed, set in a nursing home, but with additional nursing, medical and therapy support in place to deliver care.

If the above two options were not possible, then delivering care in a community hospital setting would be considered.

AC explained that during this rehabilitation time, care would be funded by the NHS and if there were domiciliary care needs, this would be factored in. There would not be a ‘one size fits all’ approach, but care would be determined around individual patients’ needs.

AC summarised the rationale for Home First as avoiding physical de-conditioning, promoting independence, supporting patients’ wishes to go back home, where possible, and allowing patients to recover in a setting that was most suitable for them. The proposal would also benefit the wider health economy as it would make better use of the workforce and would assist with system flow resulting in increased bed capacity at Broomfield Hospital. AC confirmed that similar models were in use elsewhere in the country and the proposal also took account of NHS England guidance.

AC advised that the CCG envisaged delivering the service within existing contractual arrangements, with existing staff who were already part of the community wards being used to support care in a different setting. Initial discussions with providers and their staff were generally very supportive of Home First. The CCG would also ensure that 22

Item No Item the services currently using the theatres at Braintree were fully catered for, as well as ensuring that there were no adverse impacts on primary care.

AC advised that although the CCG genuinely believe that Home First was the right thing to do for patients, it was conscious that the public and health care professionals might have concerns. Consequently an engagement exercise would commence on 9 October 2017 to capture their views and factor in any concerns to ensure Home First worked as effectively as possible. AC drew members’ attention to the communication plan for the engagement exercise at Appendix 5 of the report.

CR thanked AC and VRB for the huge amount of work that had been undertaken in relation to Home First. CR reiterated the positive benefits for patients who would be cared for under the new model as well as orthopaedic patients whose procedures would in future be performed in a purpose built facility at Braintree Hospital. CR also acknowledged that the public would have anxieties and referred to a written question raised by Mr Tom Kelly asking if the model was evidence based as an example.

LT advised that she fully endorsed the proposal, and although there would always be a level of risk when implementing a new care model, this had to be weighed against the risk to patients who unnecessarily remained in an acute setting. MB also supported the initiative and highlighted the benefits that would arise as a result of acute hospital beds being freed up.

DDo compared Home First with the Stroke ESD model, which had shown that patients fared better when they were assessed in their home environment. DDo advised that the evidence-base was growing that this had positive effects for patients, although at the time of implementation concern amongst patients and professionals was quite high. DDo highlighted that evidence relating to the harm that de-conditioning causes patients also had to be considered.

In response to a query from CA regarding the new assessment process and documentation to support Home First, VRB advised that parallel assessment was being trialled to ensure that patients were assessed to a level that allowed health care professionals to make safe judgements regarding what the patient wants and where they could be cared for, but avoiding unnecessary time intensive assessments.

VRB explained that there was still a large of amount of work required in this regard to ensure that over prescription of care was avoided. However, as a comparison, VRB advised members that the current CHC caseload included very unwell patients who were cared for really well and safely at home, in a place they wanted to be, with mechanisms to support them if things went wrong. There was, therefore, no reason why patients within the categories outlined above could not be cared for under Home First.

RHe referred to a second written question by Mr Tom Kelly in which he suggested Home First would work well in an urban area, but not so well in rural areas due to workforce challenges. RHe confirmed that the CCG had considered this. VRB advised that there were CHC patients who lived in very rural areas of mid Essex who were adequately cared for. VRB explained that work was being undertaken to build a Domiciliary Care Framework which would require providers to assure the CCG that they would be able to meet the needs of patients in both urban and rural areas. VRB acknowledged that it could be more challenging to recruit carers in rural areas, but the CCG should strive to ensure that patients in both communities received the care they deserved, with patient safety being the primary focus.

Resolved: The Board:

• Noted the case for change 23

Item No Item • Agreed in principle the Home First model and opportunities for Braintree ward as the basis upon which to communicate and engage with the public • Agreed the proposed programme of communication and engagement.

17. Better Care Fund (BCF) Overview and 2017/18 Improved Better Care Fund (IBCF): Presented by James Wilson

JW advised that the report described the background of the Better Care Fund. JW advised he would be able to provide members with a more detailed breakdown of specific money that the CCG had access to, if required.

JW advised that the CCG had access to £2.2 million from the Better Care Fund to spend on schemes that would improve care for patients, which had been agreed with Essex County Council (ECC). These included Home First; the Dementia Crisis Support Team which provides support for up to six weeks to avoid unnecessary admissions; working with Provide and Farleigh Hospice to re-establish/improve End- of Life pathways; supporting care homes by collecting data on non-elective admissions, setting an improvement trajectory and considering how the CCG could use some of the money to support care homes not to admit patients; working with the CHC team to implement arrangements to ensure CHC assessments requiring mental health and social work input are completed quicker; and funding to support Health Navigators pilot support for people at risk of needing additional care.

In addition, a smaller amount of money was available for key projects arising as a result of winter pressure to enable the CCG to target specific schemes as necessary.

In response to a query from MP regarding Health Navigators, JW advised that they would use social prescribing as a potential solution to help individuals stay out of hospital by building a support network around them.

CR advised that use of the Better Care Fund was a good example of STP wide working between the five CCGs and ECC.

Resolved: The Board noted the progress on the IBCF and supported the commitment of funds to the nominated schemes.

18. Emotional Wellbeing and Mental Health Services (EWMHS): Presented by Melanie Crass

MC advised that she would take the update report on EWMHS as read and would be happy to answer any questions.

CA advised that since the new service had been implemented, there had been significant improvements for children in crisis admitted to A&E, as there was now more collaboration between services to ensure they were transferred as quickly as possible to the appropriate mental health service.

DDo advised that Michelle Parker, the CCG’s Clinical Lead for Maternity and Children’s Services, had given a presentation to the CCG’s executive team providing an overview on the legislation around the special educational needs and disabilities (SEND) agenda and mental health services for children and adolescents and had agreed to give the presentation to other CCG staff along with JB.

DMc confirmed that GPs had also identified benefits following implementation of the new EWMHS.

CA advised that the provider had developed a proposal for the future delivery of Tier 4 services, but this would not be progressed until the end of the current contract. 24

Item No Item

Resolved: The Board noted the Emotional Wellbeing and Mental Health Services report.

19. Emergency Planning, Resilience and Response (EPRR) Assurance Process: Presented by Sara O’Connor

SO advised that NHS England undertake an annual EPRR assurance process. Jackie King, Head of Emergency Planning and Maxine Hazle, Emergency Planning Officer, worked across the seven Essex CCGs to assist them to undertake a self- assessment of their EPRR arrangements. SO advised that a link to Appendix 1 had been included within the Board papers should members wish to view the CCG’s self- assessment in full.

There were 52 core standards, of which 12 were not applicable to CCGs. Mid Essex CCG’s self-assessment rated the CCG as ‘green – fully compliant’. In addition, there was also a deep dive carried out on EPRR governance, following which it was agreed that reporting on EPRR to the Audit Committee would increase from twice a year to quarterly to improve compliance against this standard.

This year there would be a focus on plans for mass casualties, evacuation and cyber security incidents, which were included on the Emergency Planning Team’s workplan at Appendix 2. A training needs analysis for CCG staff was also included at Appendix 3.

MB asked whether the CCG was confident that the training provided to Directors and on-call managers provided them with the confidence to respond appropriately in the event of a major incident. RHe advised that on-call Directors and managers were required to attend Gold Command training, which included having to pass a short exam, and this was being offered to all relevant staff.

DMc advised that although medical/nursing and other healthcare professionals might have a wealth of operational experience, they are still heavily dependent on having clear and accessible policies and protocols to guide them on action required in the event of a major incident occurring. SO advised that all on-call Directors/managers receive a ‘grab-bag’ which contains hard copies of all policies and procedures, all of which were also available on Resilience Direct.

AH asked SO to request JK to review the timescales set out in Appendix 2 and, where appropriate, insert specific dates for completion as opposed to stating ‘ongoing’.

Resolved: The Board:

• Noted the results of the EPRR self-assessment • Noted the level of compliance achieved against the core EPRR standards • Noted the level of deep dive compliance achieved for Governance • Noted the action plan for achieving compliance against the amber deep dive standard DD4.

[Action: SO to ask JK to insert specific dates in the timescales column of the EPRR workplan].

20. Service Restriction Policies: Presented by Dr Donald McGeachy

DMc advised that the CCG had previously committed to an annual review of its Service Restriction Policies (SRPs), which applied to a wide range of conditions and access to services and treatments for these conditions.

Item No Item The newly formed STP Joint Committee had certain functions delegated to it by CCG Boards, including review of SRPs. Therefore, an STP-wide review of SRPs was in the process of being undertaken which might require some form of public consultation before STP-wide policies could be finalised.

Therefore, the Board was being asked to agree that existing SRPs, including In Vitro Fertilisation (IVF) treatment, would remain in place until September 2018 or until there was an agreed set of SRPs covering the Mid and South Essex STP (anticipated date April 2018).

DMc also asked members to approve the inclusion of collagenase as an option for treatment of Dupuytren’s Contracture as per the relevant NICE Technology Appraisal Guidance (TAG).

Resolved: The Board

• Agreed the inclusion of collagenase as an option for treatment of Dupuytren’s Contracture, as per NICE TAG, for implementation by October 2017. • Agreed that the remainder of the CCG’s SRPs, including In Vitro Fertilisation (IVF) treatment, would remain in place until the next formal review in September 2018 or until there was an agreed common set of SRPs covering Mid and South Essex CCGs (anticipated date April 2018).

21. Annual Audit Letter 2016/17: Presented by Dee Davey

DDa advised that the Audit Committee had delegated authority to sign off the annual accounts for submission on behalf of the Board. DDa reminded members that it was frustrating that the CCG had received a qualified regulatory opinion because of the accumulated deficit and an exception report on the value for money opinion, as had been reported in previous Board reports. DDa asked members to note the content of the Annual Audit Letter 2016/17.

The Board noted the content of the External Audit Annual Audit Letter 2016/17.

22. Revised Committee Terms of Reference: Presented by Sara O’Connor

SO advised that the Terms of Reference for Audit, Live Well, Quality & Governance and Finance and Performance Committees, had been amended to include authority for them to approve minor amendments to policies.

DDa advised that the Finance and Performance Committee Terms of Reference had also been amended to recognise changes in the role of the Savings Programme Board and in the Committee membership.

SO explained that the Primary Care Commissioning Committee (PCCC) had been amended to take account of the fact that North East Essex CCG was no longer part of a joint commissioning arrangement with NHS England.

AMG also highlighted that the PCCC membership had been amended to include two lay members to ensure the meeting would be quorate if she, as Chair of PCCC, was unavailable.

Resolved: The Board approved the amended Terms of Reference of the Audit, Finance & Performance (including approval of additional objective regarding minor amendments to policies), Live Well, Quality & Governance Committee, and Primary Care Commissioning Committees.

26 Item No Item [Action: SO to ensure the revised Terms of Reference for the above Committees are posted on the CCG’s website].

23. Any Other Business: Presented by Dr Caroline Dollery

23.2 Thanks to Board Members from CA

CA thanked members for the support she had received from the CCG Board, especially during the period she was appointed Acting Accountable Officer. CD offered thanks on behalf of the Board to CA for the work that she had undertaken on behalf of the CCG.

23.3 Patient Story

In response to a query from LT regarding the absence of the patient story from the Board agenda, RHe advised that there had been unexpected quality issues whilst producing the latest patient story in-house. However, the Quality and Communications teams were considering how to resolve these issues before the next Board meeting.

24. Date and Time of Next Board Meeting in Public: Presented by Caroline Dollery CD advised that the next Board meeting would take place at 1.30 pm on Thursday, 25 January 2018 at Braintree Town Hall, Market Place, Braintree, Essex, CM7 3YG.

27 Mid Essex Clinical Commissioning Group Board - Part I Action Log

Meeting Agenda Action Lead Deadline for Outcome/Update Date Item Completion 29/06/2017 7 Chair’s Update Report Primary Care Commissioning Arrangements for Mr Paul Osman to provide Dr C Dollery and ASAP Manager (DB) has been asked to a presentation on Carers to GPs at M Crass agree arrangements with practices at locality/sub-locality level to be agreed. sub-locality level so this action can be closed by January Board meeting. 28/09/2017 2 Questions from the Public Completed (12/10/17) - Mrs Cloake Mrs Janet Cloake to be provided with a list M Crass 31 October 2017 was emailed a list of Maldon DC of Maldon District Councillors involved in representatives/councillors who discussions regarding future healthcare attended the Maldon Health Hub provision within the Maldon area. Stakeholders Project Board meeting in August 2017. 28/09/2017 5 Action Log Action log to be updated S O’Connor ASAP Completed 28/09/2017 9.1 Patient Safety and Quality Report The thorough investigation of this has Board members to be advised of the R Hearn 25 January 2018 identified probable root cause and outcome of the investigation into the Never additional learning relating to actions Event relating to a retained swab once taken by some staff once the incident known. was identified. Human factors and policy training underway with the team and learning shared with all surgical teams. Action to be closed. 28/09/2017 9.2 Performance Report Alan Hubbard to be contacted to discuss J Wilson 31 October 2017 Completed information on action being taken to reduce over 52 weeks waits 28/09/2017 9.4 Finance Report Caroline Rassell to be provided with a D Davey 15 November 2017 Completed detailed breakdown of creditors outstanding over 90 days. 28/09/2017 11 Communications & Engagement Report R Harkes to consider how interactions by R Harkes 25 January 2018 The format of the next other members of CCG staff and additional 28 Communications & Engagement Meeting Agenda Action Lead Deadline for Outcome/Update Date Item Completion information on social media could be Board report will be amended and will included within future Communications & include more information on social Engagement reports to Board. media

R Hearn to communicate the listening event R Harkes ASAP Completed for children and young adults with cancer, on Saturday, 8 November 2017 at Essex County Cricket Club between 10.00 am and 2.00 pm, to relevant stakeholders. 28/09/2017 12 Policies Update Policies approved by Board to be S O’Connor ASAP Completed highlighted in ‘Digest Live’ newsletter and posted on the CCG website. 28/09/2017 14 Further Questions from the Public Mrs Pauline Amos to be provided with D Davey 31 October 2017 Completed information on high risk QIPP schemes.

Information on the impact experienced R Hearn 31 October 2017 Completed - RH has received and following a reduction in maternity unit reviewed the information. opening hours in the Telford area to be reviewed.

Mr Tom Kelly to be provided with a written S O’Connor 31 October 2017 Completed response to his questions. 28/09/2017 19 EPRR Assurance Process Head of Emergency Planning to be asked to S O’Connor 31 October 2017 Completed use definite dates in the timescales column of the EPRR workplan. 28/09/2017 22 Revised Committee Terms of Reference S O’Connor 31 October 2017 Completed Revised Committee Terms of Reference to be posted on the CCG’s website.

29 Report to: Part 1 Board Meeting Date: 25 January 2018

Agenda No: 7 Report Title: Chair’s Update Report to Board Written by: Dr Caroline Dollery, Chair of Mid Essex CCG Purpose of Report: To provide the Board with an update on key actions taken by the Chair since the last Board meeting.

Patient & Public N/A Engagement: Significant Risks N/A identified: Recommendations and The Board is asked to note the content of the Chair’s update decision/actions report. required by the Committee/Board:

30 CHAIR’S UPDATE

Submitted by: Dr Caroline Dollery, Chair Status: For Noting ______

Since the last Board there have been a few key areas I have focused on.

The first was supporting the development and launch of our Primary Care Foundations programme which will invest in workforce and technology across the patch, and will provide cover for practices to come together to discuss their needs and how best to meet them. Caroline Rassell, Dan Doherty and myself met with Brian Balmer, Chief Executive of the Local Medical Committee, who is very supportive of our approach. We also have strong links with the new medical school to train and develop existing and new staff. The Royal College of General Practitioners attended one of our locality meetings and are keen to offer us national support as well.

Linked to this was my attendance with Caroline Rassell at the public Joint Committee to discuss the Pre-Consultation Business Case and to launch the formal public consultation, a crucial part of the success of the Sustainability and Transformation Partnership (STP). Our STP has successfully secured significant estates investment for the acute hospitals as part of this work, and we are now focusing on the Out of Hospital transformation, pulling together all the individual CCG plans and resources to deliver the needed investment and changes in service. The Out of Hospital work is vital if we are to recruit and retain high quality staff, develop access to a much broader set of services closer to home and reduce the significant pressures on the existing health and social care systems.

In response to the changes with the Joint Committee, I, with the Board, have been supporting Caroline Rassell in carrying out an internal CCG consultation on new roles and responsibilities, with a new focus on our Out of Hospital care, as there will be a shift to the Joint Committee over time for managing the acute contract.

I continue to co-chair the Mid and South Essex Local Workforce Action Board, and attended my first Midlands and East Local Education and Training Board (LETB) with a focus on medical training. There will be an increase by 25% in medical school places next year, but the challenge lies in managing in the interim as it takes seven years to train doctors. Much agreement was reached on the need to train the wider workforce in separate settings and gaining experience which allows people to practice in different organisations across STPs. The importance of undergraduate and postgraduate mental health expertise was emphasised. The cancer and mental health workforce are top national priorities and I will be part of the regional MH workforce group.

I attended my first Health & Wellbeing Board meeting as Vice Chair, and we have agreed that both social isolation / loneliness and autism should be key priority areas for the Council. In addition, I will be assisting in the refresh of the Essex strategy and Joint Strategic Needs Assessment.

I have attended various engagement events around Home First, and met with James Cleverly, MP, and Derrick Louis, Chair of Provide, to discuss Home First, the future of Braintree Hospital and wider systemic issues, which was very productive.

We have also secured support from Essex Police and Essex Partnership University Trust to participate in a national innovation project for high utilisers of services, offering a personalised care approach including the Police to help people recover from serious social and mental health problems. This will be an exciting project, with the potential to help people lose dependence on crisis services and develop better coping strategies, reduce the rate of self-harm and suicide and reduce the impact on the criminal justice system. The plan is for it to go live from April this year.

Recommendation

The Board are asked to note the content of this update report.

Dr Caroline Dollery Chair, NHS Mid Essex CCG 31 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 8 Report Title: Accountable Officer’s Update Written by: Caroline Rassell Purpose of Report: To update the Board on recent CCG developments Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe Strategic Objective 2 To meet the financial challenge through responsible use of resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees N/A that have reviewed this document).

Patient & Public N/A Engagement: Significant Risks identified: Recommendations and The Board is requested to note the report. The Board is decision/actions specifically asked to note the awarding of contracts as required by the outlined in section 4. Committee/Board:

ACCOUNTABLE OFFICER REPORT

Submitted by: Caroline Rassell, Accountable Officer

Status: For Noting ______

1. Introduction

This report will provide the Board with a brief update of key issues/events that have taken place since the last meeting, the awarding of contracts and an oversight of potential developments expected in the next few months.

2. Performance Issues

The Board will be aware of considerable pressures that MEHT have faced in terms of delivery of the 4 hour A&E performance standard. While performance improved in October and over 90% of patients were seen within the 4 hour standard, subsequent to this performance has deteriorated. The position considerably worsened immediately after Christmas. At the time of writing this report the whole of the health system in Mid Essex has been under pressure, including NHS 111 which has seen a significant increase in calls ( a 47% increase for the weekend before Christmas compared to a normal weekend).

The system has been working together to:

• Seek to reduce demand by increasing communications messages about flu vaccinations and signposting to other services, particularly pharmacy; • Work with EEAST to use referrals to Rapid Access services in the community; • Provide extended access physios in A&E to help with minors; • Move the GP in ED to triage patients to ensure a more efficient process in A&E; • Continue access to Out of Hours for minor referrals from A&E during periods of less demand at Broomfield for this service; • Use local GP support for discharge events (MADE) and review of patients in ED; • Provide on-site support from nursing teams to expedite CHC and fast track discharge; • Provide very senior leadership across the system to co-ordinate discharge.

There is a new Managing Director at MEHT, Dorothy Hosein who started on 2nd January. There is also increased support from the Hospital Group for the Integrated Discharge team, which is welcomed. In addition to this NHS England is sourcing national support to help with data flows and some of the process reviews that are required. A verbal update will be given at the meeting in terms of whether these actions have started to deliver an improvement.

There is continued pressure on the referral to treatment 18 week standard and cancer standards, in particular by MEHT. This will be impacted by the pressures faced at the front door of the hospital. This is coupled with the challenges that continue with the implementation of the Lorenzo IT system at MEHT. Concerns have been escalated to the Executive at MEHT with specific plans being revised to take into account the current pressures. The number of 52 weeks breaches has deteriorated since the last board meeting. As a consequence of this the CCGs executive are currently reviewing plans in 33 conjunction with MEHT to limit the number of out of area referrals coming into MEHT to enable capacity to be focused on treating the backlog of patients. Further detail is provided in the Performance report.

3. Financial Position and QIPP delivery

Regrettably, the Month 9 forecast outturn position reflects slippage from the CCG’s control total of the target surplus of £9m by £2.6m to a surplus of £6.4m. The Board will recall that that the CCG had considered the delivery of a £9m surplus as too challenging, given the CCG’s relatively low funding per head and the fact that the Resource Limit funding was already £5.8m below target funding.

Despite slippage against an extremely challenging QIPP target, the CCG was forecasting delivery of the control total to date. However, as flagged in previous Board reports, there have been a number of unplanned cost pressures. Given the scale of the savings already required to be delivered it has not been possible to contain the atypical cost pressures within the resources available. The most material of these is the impact on prescribing costs of the national “No Cheaper Stock Option” supply issues that have been referenced in earlier Board reports. The national supply problem has resulted in forecast costs £2.7m above what would typically have been payable for similar drugs. The Local Area NHS England team have been flagging the scale of the challenge on all CCGs with the national NHS England team but to date no national mitigation has been announced, however prescribing price benefits have been retained by NHS England. The CCG has therefore formally declared a variance from the target surplus. The variance has been discussed and agreed with the Local Area Team. See the Finance Report for more information.

4. Awarding Of Contracts

Due to the contracting timescales for a number of cross STP or joint procurements, the following decisions were made with the delegated authority of the Board:

Corporate and GP IT Services:

On behalf of the Board the AO and CFO approved the recommendation of the Procurement Programme Board (7 CCGs) to award the contract for the provision of Corporate and GP IT services to Arden & Gem CSU. The contract commences on 1 July 2018.

GP Wi-Fi:

The AO and CFO approved on behalf of the Board the recommendation of the GP Wi-Fi Procurement Group (5 STP CCGs) to award the contract for the provision of GP Wi-Fi services to BT. Installation is to be completed by 31 March 2018 , followed by a 2 year service contract.

Commissioning Support Services:

The Board has approved MECCG hosting the Lead Provider Framework contract for commissioning support services on behalf of the MECCG and the 4 South Essex CCGs. Tenders are to be submitted during January and the Board has delegated authority to the Chair of the F&P Committee, the AO and CFO to award the contract upon the recommendation of the CSS Steering Group (5 CCGs).

In addition to these contracts, the 111/Out Of Hours (integrated urgent care) contract has been awarded to IC24 who currently provide the 111 service in North Essex. The new 34 service will begin in July this year and will provide higher levels of clinical input than is currently available. The new service will cover the population of Mid and South Essex

The award of this contract has been approved by the STP CCG Joint Committee.

5. STP Joint Committee

Elsewhere on the agenda are the minutes of the STP CCG Joint Committee. The key issue to note in respect of recent Joint Committee decisions is the agreement that was given at the end of November to start consulting upon the reorganisation of acute services. Each CCG will host a number of these events where there will be the opportunity to talk with the public not only about the acute proposals but also some of the changes that are planned locally.

6. Primary Care Foundations

A significant amount of work has been undertaken by the CCG over the last few months to build on the Live Well strategy and start to have a clear and focused strategy for improving and enhancing capacity within primary care. Dan Doherty has been supporting the clinical discussions that have been occurring and this has culminated in the production of the Primary Care Foundations Programme (see paper later on agenda) This programme will be fundamental in ensuring that the CCG can move forward with a structured and robust out of hospital plan and ensure that it has the capacity and capability to deliver the ask of services from the public, the regulators and the acute reconfiguration. Some of these plans will be tested in the consultation mentioned above.

7. Reorganisation of CCG

As Board Members will be aware, the CCG has been consulting with staff about the changes required in the CCG to reflect both the implementation of the Joint Commissioning Team but also the refocusing of the CCG on out of hospital care. The outcome of the consultation with staff was relayed on 15 December and changes were made to the proposals in the light of the feedback received.

At the time of writing this report appointments have not been made to all posts but there will be 5 Board level Executive posts – excluding my own. These posts will be:

Director of Clinical Transformation & Deputy Accountable Officer* Dan Doherty Director of Quality and Nursing * Rachel Hearn Chief Financial Officer * Dee Davey Director of Governance and Performance In Recruitment Chief Transformation Officer In Recruitment

The asterisked posts are currently proposed to be voting members of the Board. When the recruitment process has been completed, a more detailed paper confirming the final Board membership, voting rights and clinical majority step down arrangements will be presented to the Board for approval of the required changes to the CCG’s constitution.

8. Engagement on Home First

Elsewhere on the agenda is a paper on the engagement process and Home First. There were a number of engagement events across Mid Essex during November. A number of our local GPs, nurses and managers took part in these events, along with Provide and MEHT staff. The process was extremely useful and has helped to shape the paper on the agenda. I would like to thank everyone involved in the events, both public and staff. 35 9. Loss of a Colleague

I have decided to take the unusual step of paying tribute to much a respect colleague who sadly died suddenly in November while working for the CCG. John White had been with the organization since the start of the year. He was brought in to support the delivery of our CHC QIPP programme. It soon became obvious that John could do so much more than this and he quickly became involved in the transformation of how we buy care from domiciliary providers. This piece of work greatly improved our external relationships with providers but the output has also meant that patients receive a more streamlined service and get the care they need quicker. John cared deeply about patients and the team with which he worked and it was with incredible sadness that a number of us attended his funeral to pay our respects and say goodbye to a wonderful colleague.

10. Awards

I am delighted to be able to inform the Board that since our last meeting in September the CCG has attended two awards ceremonies where we have been nominated as a finalist. The Active Essex awards in early December saw the CCG get a highly commended for Active Workplace of the Year as a result of our 100 day challenge.

Later in December the CCG attended the Health Business Awards in London. The CCG again was highly commended for the CCG of the Year award and I am extremely proud to announce that the CCG won the NHS Publicity Campaign Award for our internal communications for the 100 day challenge. This is particularly pleasing as it was genuinely the efforts of the staff in the CCG and the 52 million miles that were walked which earned this. My thanks go to everyone in the CCG.

11. Key Meetings

Since the last Board Meeting, James Booth and I have had our quarterly meetings with local MPs where a range of issues were discussed including GP recruitment and sustainability, our funding position and the emerging Home First proposal.

I met also with the Minister of Health, Philip Dunne, in my capacity as the SRO for Local Health and Care for the STP and I have also met on a number of occasions with the MPs in Mid and South Essex to discuss to work of the STP.

I attended twice the NHS National Investment Committee, chaired by Paul Baumann, to discuss the submission made by the STP for capital funding for the acute reconfiguration proposals. I am delighted to say that, as announced in the budget, we secured £118m of capital (subject to an approvals process) to assist with our proposals.

I was also invited to speak at the HFMA Eastern Annual Conference about integration in October. I took this as an opportunity to talk and show case Live Well.

In November I attended the One Chelmsford Strategic Partnership Board. This is a cross public sector meeting focusing on current issues within Chelmsford that all agencies can work on together.

I also attended the Essex Health Overview and Scrutiny Committee in November with Ali Connolly and Viv Barker to present on Home First.

12. Recommendation

The Board is asked to note the contents of this report. 36 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 10.1 Report Title: Patient Safety and Quality Report Written by: Chris Patridge, Acting Deputy Director of Nursing & Quality Rachel Hearn, Director of Nursing & Quality Purpose of Report: This report provides assurance and information to the Clinical Commissioning Group Board in relation to the wider patient safety and quality agenda. How does this issue link to the CCG’s Strategic Objectives? Please Tick Strategic Objective 1 To improve quality and outcomes for all and keep x patients safe Strategic Objective 2 To meet the financial challenge through responsible use of resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services x Strategic Objective 6 To ensure the CCG has the necessary governance, x capacity and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Quality and Governance Committee reviewed elements 12/12/2017 Groups/Committees of this report and linked Annual Reports that have reviewed this document). Reports Submitted to Board only: Date signed-off by Executive Team. (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed off Yes No N/A by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick )

Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: Nil Patient & Public Details within the report Engagement: Significant Risks Nil identified: Recommendations and The Board is asked to note the Patient Safety and Quality Report decision/actions required and Scorecard (Appendix A). by the Committee/Board:

PATIENT SAFETY AND QUALITY REPORT

Submitted by: Rachel Hearn, Director of Nursing & Quality Status: For noting

1. Introduction

This report provides assurance to the Clinical Commissioning Group Board in relation to patient safety and quality and links to key strategic objectives one, five and six.

The report includes the patient safety and quality dashboard which provides the Board with red, amber and green ratings against a number of quality indicators and is presented in the Care Quality Commission (CQC) domains. Quarter 2 data was presented to CCG Quality & Governance Committee. Where possible this has been updated to the end of November.

2. Infection Prevention and Control (IP&C)

As detailed on the dashboard in Appendix A, the CCG position regarding Clostridium difficile (C difficile) incidence year to date (April – November) was 67 cases against an annual ceiling of 71. It is therefore certain the CCG year-end position will result in a breach against this ceiling. The data does include those cases successfully appealed by acute trusts as occurring despite all policy being followed. Mid Essex Hospitals Trust (MEHT) reported 35 cases in this period against their year-end ceiling of 13. It is of note that 17 of these cases have so far been successfully appealed, as found not to be associated with breaches in key policy compliance. 8 cases have not been brought to appeal as breaches in policy were identified at investigation. A number of cases will be heard in the January Scrutiny Panel. The new MEHT infection prevention and control Matron has drawn up a C difficile Reduction Plan which is to be presented to the CCG in January.

MEHT continue to notify the CCG of incidence of infections caused by pan-resistant bacteria, now called CRO (Carbapenem Resistant Organisms). Of particular note are cases admitted from overseas to the Regional Burns Unit with 2 new cases transferred in December. Robust IP&C strategies on this unit have to date contained these organisms.

There have been 6 cases of MRSA bacteraemia reported in Mid Essex patients to December 2017. 3 of these were assigned to MEHT, 2 to the CCG and 1 was a third party assignment. The table below offers detail on learning from investigations. Actions arising from investigations are monitored through the provider contract review processes and through IP&C network processes.

Month Assignment Learning April 2017 MEHT Previous MRSA colonisation status not recognised or acted upon. April 2017 MEHT Patient in hospital for 2 months. Acquired MRSA colonisation during admission however not recognised as rescreen policy not followed. October 2017 Third Party Foot ulcer considered probable source of sepsis. Patient resident in a Nursing Home where all policies and procedures in place and followed. November 2017 CCG Patient had several admissions to the acute hospital and also under care of District Nursing teams when home. MRSA status not always recognised and managed in line with policy. Also policy compliance shortfalls re management of urinary catheter in community. November 2017 CCG Acquisition of MRSA colonisation during rehabilitation admission to community bed. Policy not always followed. Joint work needed with acute trust to further investigate acquisition and necessary actions. December 2017 MEHT Investigation presently underway 38

3. Complaints and PALS (Patient Advice and Liaison Service)

Complaints: The Mid Essex CCG PALS and Complaints Policy reflects the best practice principles for complaints handling advocated by the Parliamentary & Health Service Ombudsman (PHSO). In accordance with the Principles for Remedy, the CCG places a strong emphasis on putting things right and ensuring continuous improvement and learning from complaints.

The report below details the complaints, PALS, compliments and MP enquiries received in Quarter 2 and Quarter 3. This is followed by a more detailed breakdown of the Quarter 2 data. A full breakdown of Quarter 3 will be presented at the next Board.

Monthly Complaints Data

Complaints PALS Compliments MP

July 17 15 53 0 5

August 17 12 64 1 7

September 17 5 47 4 3

Total Q2 32 164 5 15

October 17 7 36 1 7

November 17 5 50 0 3

December 17 3 31 0 6

Total Q3 15 117 1 16

Grand Total 47 281 6 31

Table 2: PALS, Complaints and MP Enquiries data Quarter 2 and 3 2017-18

Of the complaints received in Quarter 2, 50% relate to the Continuing Healthcare (CHC) process. This is consistent with previous quarters but analysis of the data shows a reduction in CHC complaints relating to Arden and GEM CSU, who undertake the retrospective reviews on our behalf.

Access to CHC Commissioning Waiting Attitude Care CHC Communication Transport services retrospective decision Time Arden & GEM 0 0 0 0 7 1 0 0 0 MECCG 2 0 1 5 4 1 2 0 1 ERS Medical 0 0 0 0 0 0 0 1 0 MEHT 0 0 2 0 0 0 0 0 0 Primecare - Out of Hours GP 0 2 0 0 0 1 0 0 0 Provide 1 0 0 0 0 0 0 0 0 Ramsay Healthcare 0 0 1 0 0 0 0 0 0 Table 3: Complaints analysis Quarter 2 2017-18

Learning from complaints: There have been a number of service improvements actioned as a result of complaints made via the CCG. This includes the creation of a single point of contact at the Retrospective Review Service at Arden and GEM CSU, Primecare have introduced a staff standard in relation to welfare checks and processes changed within the CHC admin team following the sending of an incorrect letter to the family of a patient.

PALS: The largest percentage of PALS enquiries received relate directly to MECCG; of these over 50% relate to services the CCG commissions. In most cases, PALS advises the complainant, ensuring that they are signposted to the correct service provider. In some cases the PALS team will act on behalf of the complainant, particularly in cases where the complainant has communication difficulties. 39

Graph 1 PALS analysis Quarter 1 2017-18

The charts below provide a breakdown of enquires received in relation to the CCG and ERS Medical who provide non-emergency patient transport, as they are the 2 largest areas of enquiry.

Graph 2: ERS Complaints

Graph 3: MECCG Analysis Quarter 2 2017-18

Compliments: The CCG received 5 compliments in Quarter 2:

• 2 related to assistance given by the Central Referral Service • 1 related to the CHC team for their assistance • 1 related to a services delivered by Primecare • 1 related directly to the PALS service

All compliments received were gratefully received and fed back to the relevant team. 40

4. Serious Incidents and Never Events

Serious Incidents There were a total of 57 serious incidents reported in Mid Essex during Quarter 3, of which 3 were classified as never events. Pressure Ulcers which occur and are associated with breaches in key policy are now included in total SI data and not listed separately, therefore preventing comparison with previous quarters. The following table provides a further breakdown of reported SIs by origin.

Sector Provider Q3 2017/18 Q2 2017/18 Q1 2017/18 Q4 2016/17 Total Acute MEHT 43 24 30 21 118 Provide 10 3 8 9 30 Community BCH 1 1 0 2 4 Out of Hours Primecare 0 0 0 0 0

Mid Essex 0 0 0 0 0 CCG Continuing Healthcare (adult) 0 0 0 0 0 Children’s Continuing Care 0 0 0 0 0 Hospice Farleigh 0 0 0 0 0 Patient ERS Medical 0 0 1 0 1 Transport Private Ramsay - Springfield 2 0 1 0 3 Hospital Longmead Court Nursing Home 0 0 1 0 1 Lawns Nursing Home 0 0 0 1 1

Guide at Sandon (formerly Chelmsford Nursing Home) 0 0 0 1 1 St George’s Nursing Home 1 0 0 0 1 TOTALS 57 28 41 34 160 Table 4: SI origin Never Events There have been 2 never events reported by MEHT in Quarter 3. The first event involved retention of a surgical swab. The investigation into this is closed with learning around surgical safety processes in the operating theatre. Recommendations and the resulting action plan will be monitored through the acute Clinical Quality Review Group (CQRG) and reported further to Board. The second event concerned wrong site anesthetic block and the investigation is presently underway. A third never event in Mid Essex area was reported by Ramsey Springfield hospital. This also concerned a wrong site anesthetic block however it is noted these 2 incidents involved different surgical teams.

5. Mental Health

MEHT had four 12 hour trolley waits in the Emergency Department between April and September 2017. Analysis of breaches highlighted concerns around sourcing timely mental health assessments, specialist transport and mental health bed availability. Subsequently we held a risk summit with collaborative actions agreed by MEHT, CCG and Essex Partnership University Trust (EPUT). Areas that were actioned included delays in sourcing inpatient mental health beds, delays in accessing Mental Health Act assessments and delays in mental health transport. Action plans continue to have oversight through the Clinical Quality Review Group (CQRG) forums. There were a further two breaches reported in October, with new themes emerging around staffing of private facilities and out of 41

area placements. A further workshop has now been planned to look at potential solutions for mental health patients in acute crisis, outside of the emergency environment.

The outcome from the Essex Police investigations into unexpected deaths at The Linden Centre is still presently awaited. The Care Quality Commission (CQC) has undertaken visits to the Chelmsford based mental health wards and the formal report is anticipated in February 2018. The outcomes will be reported to the next Board.

6. Safeguarding Children and Adults

Areas of Concern/Nursing Care Home Suspensions A schedule for quality assurance visits to nursing homes continues, which has now extended to Domiciliary Care providers. There are currently no suspensions to admissions in the Mid Essex area. Voluntary suspensions to admissions have been lifted recently in relation to Guide at Broomfield (formerly Chelmer Valley Care Home) and Elmcroft in Tolleshunt Major.

Deprivation of Liberty Safeguards (DoLS) In October 2017 the Government made an interim statement in response to the detailed proposals for reform of the law on mental capacity and deprivation of liberty made by the Law Commission in March 2017. The statement recognised the criticisms made of the current system and welcomed the Law Commission’s work on proposals for reform. The Government states that a full response will be given in spring 2018. Therefore the pragmatic advice remains that DoLS issues will need to be continued to be tackled within the current legislation. Although, it is envisaged that there may be significant changes ahead, particularly in relation to responsibility for authorisation of DoLS which will potentially transfer to the funding organisation rather than predominantly with the Local Authority.

Prevent Prevent forms part of the Government’s Counter-Terrorism Strategy (CONTEST) and aims to reduce the threat to the UK from terrorism by stopping people becoming terrorists or supporting terrorism. The Prevent Duty requires all specified authorities to ensure that there are mechanisms in place for staff to understand the risk of radicalisation, and how to report concerns. Prevent Training and Competencies Framework (NHS England Oct 2017) has clearly outlined that all frontline professionals should have WRAP (Workshop Raising Awareness of Prevent) training. The staff within MECCG are currently compliant with the requirements, and there is a plan to deliver training to GP Practices in 2018. MECCG will need to ensure that the requirements are included within contracts and key performance indicators of Providers. The need for compliance has been stipulated by both the Home Office and NHS England, with a legal requirement for submission of data from Acute and Foundation Trusts.

NHS England Safeguarding Tool (SAT) In March 2017 NHS England launched the SAT across the Midlands and East region. It is an online system to record evidence of compliance with safeguarding assurance standards. CCGs self-assess compliance by recording evidence and action plans, followed by NHS England and CCG peer review. Evidence was submitted against the nine standards of leadership and organizational accountability, governance and commissioning, training, safer recruitment, interagency working, supervision, patient engagement, lessons learnt and policy implementation. Following peer review NHS England have recommended the overall assurance status is amber-green. The safeguarding team always works to continuously to ensure that safeguarding practice is up to date, informed by best practice and meets all statutory requirements. The safeguarding agenda is constantly evolving and for this reason it is likely that future overall assurance statuses are likely to be amber-green.

Working Together to Safeguard Children (2015) This is the statutory guidance in interagency working to safeguard and promote the welfare of children. It aims to help professionals understand what they need to do and what they can expect of one another to safeguard children. All health services have a duty under section 11 of the Children Act 2004 to ensure that they consider the need to safeguard and promote the welfare of children when carrying out their functions. Alan Wood’s review of the role and functions of local safeguarding children boards, The Wood Review of Local Safeguarding Children Boards, was published in March 2016. The review found widespread agreement that the current system of local multi-agency child safeguarding needed to change and proposed a new model to ensure collective accountability across local 42

authorities, the police service and the NHS. It also recommended a new system of local and national reviews to replace serious case reviews, and the transfer of responsibility for child death review policy from the Department of Education to the Department of Health.

A summary of key changes highlights the replacement of Local Safeguarding Children Boards (LSCBs) with local safeguarding partners; Learning from serious cases and new regulations on local and national reviews; Transfer of responsibility for child death reviews from LSCBs to new Child Death Review Partners. The Government consultation closed on 31st December 2017 and Board will be advised on developments once the Government responds to the consultation feedback.

7. Safer Staffing

The CCG continues to monitor provider nurse staffing levels in line with the national requirements.

Provide Data showing fill rates for community wards during Quarter 1 have been presented to the Clinical Quality Review Group (CQRG) and show fill rates above 95%. Staffing for Integrated Care teams has posed a challenge at times with mitigation provided by Community Matrons and other Senior Nurses. Provide have been requested to provide staffing assurance for Quarters 2 and 3 in a new format, that enables oversight of not only fill rates, but also on the use of temporary staffing against substantive staff within each establishment. These will be available for the next Board meeting.

Mid Essex Hospitals Trust (MEHT) Recruitment strategies continue in the UK, Europe and overseas. Job offers have been made to nurses some of whom still have to complete the International English Language Testing System (IELTS), which is a Nursing Midwifery Council (NMC) requirement for nurses trained outside the UK. Total nurse vacancy rate, (including qualified and unqualified) is slightly improved at 18%. The qualified ward nurse rate however is now 26%. Mitigation includes ward manager clinical shifts and use of agency staff, both off and on framework. Reported red flag incidents related to staffing concerns, totaling 17 in November, all resulted in no harm.

Essex Partnership University Trust (EPUT) The CCG continue to have oversight of the staffing levels in Mid Essex inpatient areas. A visit was undertaken by the Acting Deputy Director of Nursing and Dr James Booth to the Crystal centre to review the over-establishment of healthcare assistants in relation to qualified nursing staff. The model was seen to be effectively working, whilst recruitment continues.

8. Quality Assurance Visits/Deep Dives

Quarter 2 assurance visits have focused on a ‘back to basics’ ethos; falls, pressure ulcers, general reviews and assessments of patients, with announced visits to MEHT, Provide community wards, Ramsay Springfield and the Crystal Centre.

The visits have highlighted the considerable work that has been completed in all providers in relation to falls reduction and severity of falls. MEHT are looking at innovative ways of investigating what has happened when falls occur using SWARM methodology, which aims to immediately examine why. Areas highlighted for attention across all areas included unclear staff identification and inappropriate jewellery. All providers have been responsive in addressing these areas.

9. Mortality

The December meeting of Mortality Review Group was cancelled due to operational pressures. Mortality review work however is continuing.

The MEHT December 2017 mortality review report highlights HSMR for the rolling 12 month period (October 2016-September 2017) to be 120.68 ‘higher than expected’. MEHT has the third worst HSMR figure in the East of England group and the sixth worst nationally. There is additionally a significant difference between weekday and weekend HSMR; both are higher than expected, with the weekend significantly higher than expected: 43 • Weekday HSMR (Admissions) = 118 (118.46lm) • Weekend HSMR (Admissions) = 126.58 (127.97 lm)

The SHMI predicted 12 month period Aug 16 – July17 = 105.07 – ‘above expected’. The In-Hospital = 104.05 and the Out-of-Hospital = 107.52 Latest published HSCIC (Jan16-Dec16) 107.55 within expected The trust is one of ten in the East of England group with SHMI over 100. Only six have a SHMI below 100.

10. Cancer 104 day Harm Reviews

Through the harm review process for all over 104 day cancer breaches, key themes and actions have been discussed at the MEHT panel, including the requirement to increase capacity in diagnosis areas, improve waiting times for diagnostic tests, Improve communication with tertiary referral centers and for GPs to encourage patients to attend appointments within 2 weeks.

Where Harm Reviews, for both physical and psychological harm, have been completed there has been no evidence that significant harm has occurred. The Board will continue to receive an update on the cancer harm review process and themes that emerge from the learning moving forward.

11. Recommendation

The Board is asked to note the Patient Safety and Quality Scorecard (Appendix A)

12. Appendices

Appendix A – Patient Safety and Quality Scoreboard

44 Appendix A - Mid Essex Quality & Safety Dashboard 2017/18

3 month 3 month 3 month 3 month Exception Assurance criteria Detail Threshold(s) Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 YTD Trend Trend Trend Trend Reporting

Operational Standards   Eliminating Mixed Sex Clinically unjustified breaches (MEHT) Nil 3 5 2 10 2 0 0 2 0 12 Accommodation (EMSA) (National Clinically unjustified breaches (Provide) Nil 0 0 0 0  0 0 0 0  0 0 indicator) Clinically unjustified breaches (CHUFT) Nil 0 4 0 4  0 0 0 0  4

Risk Assessment Screening 95% 97.1% 88.5% 68.9% No data No data No data VTE Prophylaxis following positive screening? No data No data No data No data No data No data No data No data Yes Number of RCA's received for hospital acquired VTE? 0 0 0 0 1 0 0 1  0 National Quality Requirements MRSA Bacteraemia (MEHT) Annual = 0 2 0 0 2  0 0 0 0  0 0 0 2 MRSA Bacteraemia (CHUFT) Annual = 0 0 0 0 0  0 0 0 0  0 0 0 0 Report

MRSA Bacteraemia (CCG) Annual = 0 0 0 0 0  0 0 1 1  1 2 3 5 Healthcare Associated Infections Clostridium difficile infections declared post 72hrs (MEHT) 8 3 2 13  5 7 3 15  3 4 7 35 Annual = 13 (HCAI) No following appeal 4 0 0 4  0 1 2 3  1 0 1 8

Clostridium difficile infections declared post 72hrs (CHUFT) 0 3 3 6  1 1 2 4  0 1 1 11 Annual = 18 No following appeal 0 1 0 1  0 0 0 0  0 0 0 1 Mid Essex CCG Clostridium difficile infections Annual = 71 12 4 4 20  8 16 9 33  3 11 14 67

No Reported (MEHT) Nil 16 60 75 151  98 99 118 315  466 No of new patients breached in month (MEHT 16 49 31 96 35 26 36 97  193 52 Week Breaches Yes % harm reviews completed and reviewed at Panel (MEHT) 19% 6% 3% 11% 0% 0% Harm identified 0 0 0 0  0 0 0 0  0

No Reported (MEHT) Nil 6 8 12 26 9 No data No data 26 Yes 104 day cancer Breaches %harm reviews completed and reviewed at Panel (MEHT) 50% 75% 0% 0% No data No data Harm Identified 0 0 0 0  0 No data No data 0

12 Hour Trolley Breaches No of breaches reported (MEHT) 0 0 3 3  0 0 1 1  4

Each failure to notify the Relevant 0 breaches 0 0 2 2  1 0 1 2  4 Person of a suspected or actual Reportable Patient Incident (MEHT) Duty of Candour Each failure to notify the Relevant Person of a suspected or actual Reportable Patient Incident 0 breaches 0 0 0 0  0 0 0 0  0 (Provide) Local Quality Requirements Domain 2 - Enhancing the quality of life of people with long-term conditions % of patients aged 75 and over to whom case finding is applied 90% 74.8% 73.5% 62.7%  61.7% 70.4% No data  following an episode of emergency unplanned care (MEHT) % of patients identified as potentially having dementia or 90% 41.7% 50% 21.1%  23.5% 46.7% No data  delirium who are appropriately assessed (MEHT) % of patients aged 75 and over who have had a diagnostic 90% 41.7% 50% 21.1% 23.5% 46.7% No data  Dementia & Delirium assessment and referred for further diagnostic advice (MEHT) % of patients aged 75 and over to whom case finding is applied following an episode of emergency unplanned care to either hospital or community services (PROVIDE) 90% 100% 90% 94%  91% 90% 100%  % of patients identified as potentially having dementia or delirium who are appropriately assessed (PROVIDE) Domain 3 Helping people to recover from episodes of ill health or following injury SAFER Bundle Flow % of patients to have had a senior review (Registrar and 80% 100% No data No data No data No data No data No data Senior review before midday above) before midday Red - 80% % of patients reviewed by a Consultant within 14hrs of Patient Review Amber 85% No data No data No data No data No data No data No data emergency admission weekdays / weekends Green - 90% Elective - Red - 85% Amber - 90% 100% 100% 100% Green - 95% Emergency - Red - 40% Expected Discharge Date All patients to have an EDD within 48hrs of admission Amber - 50% No data No data No data 100%  100% Green - 60% Yes Care of Elderly - Red - 30% Amber - 40% 29% 100% 100% 100% Green - 50% Red - 20% AM Discharge Patients discharged from base inpatient wards before midday Amber - 25% 15.76% 16.50% 17.11% 16.00% 15.00% Green 33% Red - 80% An MDT systematic review of patients with extended lengths of Amber - 90% No data No data No data No data No data Review of extended Length of stay stay (> 7 days) Green - 100% Domain 4 - Ensuring that people have a positive experience of care MP Letters Numbers received by CCG No target 5 5 2 12  5 7 3 15  7 5 3 15  42 Report PALS Contacts Numbers received by CCG No target 33 39 50 122  53 64 47 164  36 50 31 117  403 Compliments Number received by CCG No target 1 2 3 6  0 1 4 5  1 0 0 1  12 Complaints Number received by CCG No target 8 11 6 25  15 12 5 32  7 3 6 16  73 FFT - Provide Monthly Score 97% 99% 98%  97% 97% 95%  FFT - MEHT (Inpatients) Monthly Score 97% 97% 95%  45 91% 86% 91%  Monthly Score 89% 89% 86%  87% 88% 89%  FFT - MEHT (A&E) Report Appendix A - Mid Essex Quality & Safety Dashboard 2017/18

3 month 3 month 3 month 3 month Exception Assurance criteria Detail Threshold(s) Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 YTD Trend Trend Trend Trend Reporting Report FFT - CHUFT (Inpatients) Monthly Score 98% 98% 98%  98% 97% 98%  FFT - CHUFT (A&E) Monthly Score 89% 87% 88%  85% 87% 84% 

FFT - MEHT Staff (Work) Quarterly % recommended 61% No data

FFT - MEHT Staff (Care) Quarterly % recommended 76% No data

FFT - CHUFT Staff (Work) Quarterly % recommended 53% 61% 

FFT - CHUFT Staff (Care) Quarterly % recommended 82% 73% 

Q3 - 50% Patients offered opportunity to discuss in timely manner Q4 - 75% 40% No data Q2 - Q4 - Trajectory TBA Q2 - 50% Gold Standard Framework (GSF) wards - % of patients identified as Q3 - 65% 53% 50% EoL with evidence of individual care plans Q4 - 75% End of Life DNAR Documentation - % of patients involved in DNAR decision (if 85% No data No data have capacity) DNAR Documentation - % of patients not involved in DNAR 27% No data No data decision (with documented evidence) DNAR Documentation - % of patient carers informed of decision (if 84% No data No data patient doesn't have capacity) Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm

Number reported (all Mid providers) Nil 0 0 0 0  0 1 0 1  2 2 3 Report Never Events Number reported (CHUFT) Nil 0 0 0 0  0 1 0 1  1

No. Open Serious Incidents 50 57 54  47 50 42  53 65 63 Report Serious Incidents (SI) No. Open Serious Incidents that are inactive 0 0 0 0 0 0 0 1 1 No. new SIs in month 10 17 19 46  8 12 8 28  25 17 15 57  131 SIs subsequently de-escalated 1 2 2 5 0 0 0 0 0 0 0 0 5

Grade 2 Pressure ulcers where breaches in compliance with policy 1 4 1 6  2 0 0 2  0 0 Report have been identified (MEHT) by Incident date Grade 3 Pressure ulcers where breaches in compliance with policy 1 3 2 6  4 1 1 6  0 0 have been identified (MEHT) by Incident date Grade 4 Pressure ulcers where breaches in compliance with policy 0 0 0 0  0 0 0 0  0 0 have been identified (MEHT) by Incident date Pressure Ulcers Grade 2 Pressure ulcers where breaches in compliance with policy 0 0 0 0  0 0 0 0  0 have been identified (PROVIDE) by reported date Grade 3 Pressure ulcers where breaches in compliance with policy 0 2 3 5  1 1 0 2  0 have been identified (PROVIDE) by reported date Grade 4 Pressure ulcers where breaches in compliance with policy 0 0 0 0  0 0 0 0  0 have been identified (PROVIDE) by reported date Maternity Performance - MEHT Births Total Number of Births max 4900 (410 per month) 358 351 387 1,096  404 437 431 1,272  392 392 2,760 C Section Total Rate Planned + Emergency 26% 24.58% 29.34% 27.91%  27.48% 28.60% 26.22%  28.57% Smoking (Quality Premium) Total At Time of Delivery <11% 6.41% 5.60% 3.10%  2.60% 4.57% 3.25%  3.57% Other areas of concern

Key Data not due Area of concern - considerably outside threshold/trajectory Area of concern - slightly outside of threshold/trajectory No concern - within threshold/trajectory

46 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 10.2 Report Title: Performance Report Written by: Head of Performance Executive Summary: This report provides the Board with the CCG position against national targets and highlights where areas of performance are a major concern. The CCG continues to work with partners across the system to improve performance, meet national standards and ensure patient care is provided with the best possible outcomes.

Have any financial implications been signed N/A off by the Chief Finance Officer?  Have the following Assessments been carried out? Yes N/A Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Patient & Public Stakeholders are actively involved in many of the CCG’s Engagement: planning processes Significant Risks There is continued significant risk to achieving key targets identified: within the NHS Constitution in relation to Cancer, A&E and RTT. The CCG is also not achieving the Dementia and IAPT national targets. Recommendations and The Board is asked to note the actions and risks still decision/actions presenting to the CCG around performance and achieving required by the Board: some key national standards.

47 CCG Board Performance Report January 2018

Mid Essex Clinical Commissioning Group

48 Headline Performance (please note the data in this report relates to the latest published data)

Referral to Treatment (18 Weeks) MEHT RTT performance continues to fall below compliance. October is 75.8% against the standard of 92%. This is mainly attributed to the quality of the data from Lorenzo following its implementation in May. The waiting list as a whole has grown considerably since Lorenzo implementation as data quality issues are identified and resolved. Validation teams continue to work to resolve the data issues in conjunction with intensive retraining of staff to use Lorenzo correctly (one of the main issues affecting validation now). A further upgrade to the Lorenzo system is scheduled for 31st January which should clear the majority of known multiple entries.

The Intensive Support Team (IST) has been in the Trust since 18th October 2017 investigating the Lorenzo issues. They have produced a report but they have not identified any further issues than those the Trust is currently addressing. However the IST is ow fully aware of the issues and will continue to support the Trust, recognising that there is not a ‘quick fix’ to this problem.

Routine operations – cancellations In November/December 116 T&O routine operations have been cancelled and MEHT has continued to cancel routine operations in January in accordance with national guidance. The Trust will continue to treat urgent, cancer and 52+ waiters.

52+ weeks The number of 52+ weeks waits was 124 in October, 111 were in plastics and related mainly to the move of breast reconstruction patients to the RTT list. The additional 13 patients reported in October were associated with data validation of Lorenzo showing RTT inaccuracies entered on the previous system. These patients now have treatment dates.

Diagnostics MEHT has been struggling to achieve the national standard for 6 weeks wait for diagnostics since June 2017 due to a loss of staff in March 2017 and needing to recruit more Sonographers and Radiologists. The breakdown of both MRI scans and more complex demand has also had an impact. The Trust is actively recruiting. The expectation is a new MRI scanner will be on site by March 2018.

A&E Year to Date 31st Dec 84.78% December 74.24% November 83.40%

49 Winter pressures have significantly impacted upon performance with more attendances and more acuity arriving at A&E, mainly around respiratory conditions

Cancer (62 day standard) MEHT has set up an Executive led daily ‘Command Room’ with a task group focusing on improving the cancer standards. The task group monitors daily the cancer patient waits to ensure capacity is available to enable the Trust to achieve 85% for the 62 day pathway. The Trust is currently achieving 73% with the volume on the skin/plastics pathway having the majority of breaches.

A workshop was held on 1st December 2017 to address the pathway issues associated with the skin/plastics pathway and actions were highlighted to improve processes. These have been escalated by the CCG and they are now included in the Trust recovery plan and the ADO for skin/plastics has started to address the issues with timely actions. Recovery is now expected by March 2018.

Number of patients treated on the 62day pathway:

62 day Target Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 All Patients 91.5 110.5 118 101.5 113 132 115.5 Seen in target 73.5 87 81 71.5 91.5 98.5 84 Seen outside target 18 23.5 37 30 21.5 33.5 31.5 % seen within target 80.3% 78.7% 68.6% 70.4% 81.0% 74.6% 72.7%

Cancer - 104+ days

In October the Trust had 14 patients treated over 104+days:

Non admitted: • 2 complex and needing multiple tests • 1 ill patient • 1patient did not attend test appointments

Admitted: • 3 complex patients, one patient was transferred from another tumor site and the other patient had investigations with both the colorectal and lung sites

50 • 2 late referrals from other Trusts, one patient on the skin pathway was received in MEHT on day 69 from Basildon and the other patient was on the upper gastro pathway and was late as needed many tests. • 2 very ill patients so unable to progress treatment timely • 1 patient needed a 6 week fitness programme • 2 patients were not available and DNA appointments

IAPT The IAPT service has not been achieving the access targets for some time. Contract breach notices are in place. Following the independent report covering the demand/capacity modelling of the IAPT service, the CCG has agreed to a new Joint/Collaborative recovery plan which contains multiple actions around recruitment, efficiencies, 1st/2nd appointments and increasing referrals from Primary Care.

Dementia Work continues with primary and secondary care to increase the number of patients diagnosed with dementia. The October data shows an improvement to 61.2% from the September position of 60.7%. The national target of 67% is expected to be achieved by March 2018.

Diabetes The CCG is seeking to improve GP practice participation in the national audit for 2016/17 and to do this is supporting all practices in providing access to the information they need to accurately report attainment of treatment targets and compliance with the local diabetes programme.

51 Section 1: CCG Improvement & Assessment Framework

By Exception Red Indicators:

Better Health

• Diabetes

Better Care

• 62 day Cancer • A&E • IAPT • Dementia • 18 weeks

Sustainability

• Working relationships in local system • CCG Leadership

Section 2: MEHT and STP Providers Performance against the Constitution Standards

MEHT

Month- Month- Month- Month- Month- Month- Month- Direction (vs MEHT - NHS Constitution Target Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 prev mth) 18 week RTT - incomplete % within 18 weeks 92% 90.6% 90.4% 87.3% 82.7% 80.0% 80.8% 75.7%  Number of 52 week Referral to Treatment Pathways 0 17 60 74 92 99 118 121  Cancer: Two Week Wait 93% 93.6% 95.6% 92.4% 91.2% 90.2% 92.98% 94.2%  Cancer: Breast Symptom Two Week Wait 93% 96.9% 95.6% 90.0% 92.4% 89.5% 87.3% 98.2%  Cancer: 31 Day First Treatment 96% 93.6% 92.8% 93.2% 93.6% 91.3% 88.1% 90.4%  Cancer: 31 Day Subsequent Treatment - Surgery 94% 90.5% 88.2% 88.8% 86.4% 83.9% 81.8% 81.4%  Cancer: 31 Day - Drug Treatments 98% 100.0% 98.5% 98.2% 98.5% 98.4% 100.0% 98.5%  Cancer: 31 Day - Radiotherapy 94% N/A N/A N/A N/A N/A N/A N/A Cancer Plan: 62 Day Standard 85% 80.2% 78.3% 68.4% 70.1% 81.0% 74.4% 72.1%  Cancer: 62 Day Screening Standard 90% 83.3% 71.4% 90.9% 83.3% 76.9% 72.7% 78.6%  % waiting 6 weeks or more for diagnostic tests <1% 0.7% NO DATA NO DATA NO DATA NO DATA 8.9% 9.5%  % of patients who spent 4 hours or less in A&E (MEHT) 95% 90.4% 85.6% 81.0% 84.3% 83.6% 90.5% 92.9%  Trolley waits in A&E: Patients who have waited over 12 hours in 0 0 0 3 0 0 1 2  A&E from decision to admit to admission (MEHT) STP

Basildon & Target Period MEHT Southend Essex STP Trusts - Performance Thurrock 18 week RTT - Incomplete Pathways % within 18 weeks 92% 75.7% 83.2% 84.2% Number of 52+ week Referral to Treatment Pathways 0 121 11 3 % of patients who spent 4 hours or less in A&E 95% Oct-17 92.86% 90.17% 89.38% A&E 12 hr Trolley waits 0 2 0 0 % waiting 6 weeks or more for Diagnostic Tests <1% 9.5% 0.4% 1.6% Cancer: Two Week Wait 93% 94.2% 94.0% 96.9% Cancer: Breast Symptom Two Week Wait 93% 98.2% 97.0% 100.0% Cancer: 31 Day First Treatment 96% 90.4% 97.7% 98.7% Cancer: 31 Day Subsequent Treatment - Surgery 94% 81.4% 100.0% 90.5% Cancer: 31 Day Subsequent Treatment - Drug 98% Oct-17 98.5% 100.0% 99.2% Cancer: 31 Day Subsequent Treatment - Radiotherapy 94% N/A N/A 97.7% Cancer: 62 Day Standard 85% 72.7% 72.8% 80.3% Cancer: 62 Day Screening Standard 90% 78.6% 37.5% 96.6% Cancer: 62 Day Upgrade No Target 100.0% 75.0% 80.0% Cancelled Ops - % not treated within 28 days Reduce Q2 2017/18 20.4% 11.6% 14.4%

53 Section 3: Exception report against Red and at risk indicators:

3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date Year on year attendances have 1) Attendances Year on Year 1a). There is an action plan against minors breaches which includes increased slightly but changes A&E attendances in 17/18 (up to 8th review of staffing and rotas and looking at how things can be done to the emergency village have December) are 1.8% higher than the differently given the staffing issues in ED. The majority of breaches made it difficult to compare the same period last year. Majors activity are due to staffing. ANP/ENP nurses have been trained to treat 2 years. between 1st April and 8th December illness (as well as injury). This work is ongoing. has increased by 8%. 1b) Streaming/rapid assessment roll out to ensure rapid streaming to the most appropriate place in the emergency village/PC streaming- 2) It continues to be the case that from October, work to continue to embed this throughout Nov and performance typically deteriorates in Dec. the evenings and overnight. 1c) Work is underway to increase the number of patients streamed to the ACU and increase opening hours. Roll out of 20 pathways. - 3) Lack of flow through the Trust starting from October. expect to start seeing an increase in activity in remains as issue Nov, ramping up through Nov. and Dec. - Discharges before 12.30 remain 2a).Review of high attendance days to review where peaks in significantly below the 35% trajectory attendances come from and work with the CCG to look at which at 24% for November, but this is an practices may need additional visits to discuss actions that could increase compared to October at help to reduce demand- awaiting data from MEHT to progress 22%. 2b) GP Streaming: GP in ED continues. Plans in development for enhanced GP streaming model based on national guidance and capital funding becoming available. Plan to run service from new clinical space below A&E. Working closely with OOH provider to ensure seamless and consistent value in and out of hours. Aim to see an average of 32 patients per day. Further information pending agreement on finances – expected start date of late Jan 2c) Frailty Pathways: Work is currently focusing on understanding the current Central Point of Access (CPA) and community rapid response services and developing these services to improve them as these two services are pivotal in the success of our frailty programme. A frailty oversight group continues to run monthly with attendance from across at executive level to monitor, the delivery of the plan and Latest data resolve any blockages which may hinder delivery of actions- ongoing YTD Urgent & Emergency Oct 92.86% Readmissions audit complete for ESDAAR rapid response. Further All Types 31st Dec 95% Mar-18 Care (A&E)- MEHT Nov 83.40%  work is required with the Trust to ensure that discharge plans are 84.97% Dec 74.24% made clear to all relevant organisations involved in the patients care to ensure that they are managed in the community. Work continues with the hospital to build on the frailty assessment unit to increase the level of admission avoidances at the front door of A&E. 2d) End of Life: Enhanced service due to go live in January- pending staffing. Hospice are currently recruiting and comms plan has been developed. 2e) Dementia intensive support service went live on 2nd October- aim to reduce attendances and admissions for patients with dementia 2f) The Care Homes manual has now been rolled out to all homes in Mid Essex with Chelmsford and Maldon launched in November. Initial signs are positive with the Central Point of Access (gatekeeper for rapid response service) seeing a 109 further calls in November compared to that in October. (46 calls in October compared to 155 in November from Care Homes.) 3) Emergency Physician on Call (EPIC) Nurse in Charge (NIC) and majors and minors nurse coordinators role definition completed in in place, escalation updates and 2 hourly ED board round in place overnight 4a) Hospital Flow: Continued push to increase pre 12.30pm discharges/pull to the discharge lounge by 10am underway to ensure bed capacity early on in the day to enable flow. Looking to increase discharge lounge capacity as part of bed reconfiguration work over winter. 4b) Red2 Green day process continues 5. Two winter planning workshops have taken place- focus on discharge and focus on admission avoidance.

54 3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date The number of DTOCs attributed 1.The number of health DTOC's 1a) Sourcing delays are being escalated to Essex County, and they to health contiunes to rise and attributed to health continues to rise are associated with residential and nursing placements. ECC have this is at 65% ccompared to and for November this is at 65% met with residential and nursing providers to look at options to 35% for social care . compared to 35% for Social Care. support more timely assessments and admissions and the option of Social care delays- due to the lack of trusted assessor to complete such assessments is being sourcing capacity for care/residential considered. ECC are in discussion with providers to trial this but homes' packages and location as progress is slow- Ongoing more need for care in rural areas. Additional funding has been identified through iBCF to support this. Health delays- due to lack of b) Home first: Social Care- Social care have 3 home to assess assessors within the IDT and staff schemes in place- reablement, Hilton and short term care service shortages within the CCG CHC team. (Essex Cares). 2. Reablement- Capacity is - Social care are utilising Hilton to bridge care packages and significantly underutilised and there reablement package delays in order to assist the flow in the trust. are ongoing issues with capacity - There is an action plan in development to look at improving being reported. The number of patients utilisation of reablement- Dec-Jan that Allied Health Care have reported c) A system wide workshop was held on 24th Nov to look at who have completed the 6 week reablement, short term care and Red Cross to look at what each reablement package but require a care service offers, referral pathways in, additional support they could offer package following this, has also and any issues to ensure capacity available in each service is added pressure to the system, maximised. This was a system wide workshop with a number of because it has affected the amount of agreed actions coming out of it to improve utilisation of services and capacity available for discharges in also improve admission avoidance using these schemes and other Meeting DTOC - MEHT Loss Bed Days Nov-1.7%  3.5% the trust. This has been caused by community services the lack of sourcing capacity for d) Home First: Health- Work continues towards Discharge to Assess. trajectory packages in the system. Live audits now complete. Engagement ends 15th December. planning of mobilisation with providers is ongoing - Ongoing between now and Feb 18 e) Vacancies with IDT- issue is ongoing and is reviewed weekly to ensure agency cover where possible. Roles are out to recruitment. f) Joint Farleigh/MEHT post has been agreed to support EOL assessments and education on wards 2.a) There is an action plan in development to look at improving utilisation of reablement, following the workshop that took place in September. Monthly meetings are in place to progress- Dec-Jan b) At the end of October, ECC were rolling out a process by which the majority of assessments (simple cases) for those who have finished their period of Reablement will be completed via another team who are in a position to turn these around quickly and improving flow through the service. Should see an impact from Nov.

55 3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date Ambulance clinical quality – Regionally the Mth 07 (Oct) 2018/19 Contract Funding 2018/19 Contract Funding Category A (Red 1) 8 min 69.36%  75% performance of the Ambulance The main issue for EEAST for EEAST Under mediation agreement moved to a block contract to provide response time Service for Red 1 continues the continues to be capacity and the stability with additional funding to original CCG plans totalling £218m. steady decent seen all year now funding required to support this as Allowing further use of supplementary premium priced PAS and Ambulance clinical quality - at 67.55% in Oct (Target 75%). outlined in the 2017/18 mediation agency staff and requiring an agreed performance trajectory to be Oct Category A 19 min transportation 91.95%  95% Red 2 also suffers the same outcome. met. time continued decline now at Ambulance Response Deloitte’s have been commissioned to independently review EEAST Ambulance clinical quality – 56.39% in Oct (Target 75%) Performance as part of the mediation outcome. A recent presentation to Category A (Red 2) 8 min 61.02%  75% whilst A19 (Target 95%) stayed NHS England’s new ambulance Commissioners noted 4 key areas; Ambulance response time static at 88.40% in Oct. Greens response standards giving call • Cost Base and Urgents have broadly seen handlers more time to assess 999 • Efficiency minor increases but from a very calls that are not immediately life- • Contracting Model poor position already. G4 is the threatening, enabling them to identify • Capacity exception that has declined to patients’ needs better and send the Draft of report with AOs in New Year 2018 for review. 79.82% in Oct but this still most appropriate response. Ambulance Response Performance surpasses the 75% target. Requires more double staffed EEAST commenced 18th Oct 2017 increasing operational efficiency ambulances therefore reducing RRVs but requires time to ‘bed-in’. • Mid Essex CCG Mth 07 (Oct) (rapid response vehicles) single 2018/19 contract includes new standards to monitor. Red 1 has deteriorated from staffed, adding to capacity issue. Rapid Response Vehicles reduction on a phased basis. surpassing the 75% target in Reporting Oct / Nov Turnaround both Aug and Sept to a Turnaround A&E improvement trajectory of 30% reduction to handover delays. substantial decline at 53.13% Broomfield turnaround delays, Oversight through (Arrival to Handover) Urgent Care Oversight Group Apr-18 Aug also decreasing the YTD to significant in recent winter pressures. and A&E Delivery Board 69.36%. Red 2 and A19 have ePCR seen minor increases of less The Electronic Patient Clinical Record than 1% improvement each with was unavailable to crews, make Red 2 remaining significantly finding records far easier and aid below 75% target at 58.43% in crews in accessing DoS (Directory of Oct and 91.56% against 95% Services) to avoid unnecessary A&E target for A19. Green 3 has conveyances. seen a significant increase in Oct to 72.22% but YTD only at 58.28% (Target 75%), Green 4 has also improved at 85.71% in Oct (Target 75%). Urgents have mixed movement but overall remain drastically short of 75% target.

56 3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date MEHT (all commissioners) 1. Performance continues to be 1 The Trust has installed Command Room daily status, 1.30PM October data shows still below affected from the implementation of daily, focusing on A&E & Cancer re covery and sight of RTT and standard 75.8% which is less Lorenzo. Targeted intense retraining to Lorenzo validation & upgrade /RTT training. than October 80.8% but still staff on the use of the system is being 1a) Lorenzo-The Trust has an Executive Lead for the overarching concerns about quality of data undertaken by a Lorenzo task group. Lorenzo action plan to ensure full sight of all issues associated with from Lorenzo. Waiting list as a 2. Neurology continues with high Lorenzo implementation and data quality for accountability and whole has grown considerably demand and consultant vacancy. governance. A steering group, Director led, continues to meet weekly since the implementation of 3. T&O - the Braintree orthopaedic overseeing the action plan -main issues and produces a dashboard Lorenzo. There are still about project continues in order to support which covers the main issues and tracts the backlogs. This the impact of winter pressures T&O with the backlog clearance plan dashboard is also produced daily for the Command Room to monitor and cancelled routine by providing ring-fenced beds. timely. operations. 4. Plastics - OP and IP capacity . 1b) MEHT has a team of internal validators working at pace to Complex breast surgery, theatre validate PTL. 1b) RTT validation - Combined with PTL validation is capacity , specialist staffing is the intense targeted retraining of hospital staff both in using the Lorenzo biggest challenge and contributing to system and applying the correct RTT rules. 1c) IST support has the long waiting patients over 40/52+ been in the Trust since 18th October, and has produced a report weeks, staff vacancies hindering which highlights and agrees with the issues MEHT is addressing.. number of procedures undertaken and 2. ADO for Plastics focusing on Plastics/DIEPs Recovery Action October Incomplete 92% also dependent on outsourcing . Plan and 52+ plan with trajectories. 2a) Trust has a rolling 6 week Mar-18 75.8%  5.Rhuematology - Consultant recruitment drive to attract more surgical nurses which has seen capacity as recruiting locum to cover more interest from Nurses and Student Nurses from the University. maternity leave. The Trust is also now offering enhanced bank rates and looking 7. Respiratory - loss of consultant has looking at flexible rota working. 2b) Saturday plastics breast led to pressure on the service and sessions to start in January. similar pressures in other Trusts in 3.T&O - ring fence beds. BCH business case being finalised to STP. reduce orthopaedic pressure. 4.Neurology still recruiting for a substantive Consultant post. 5. Rheumatology - Recruiting. 6.The Trust holds a bi-weekly Elective Board to which the CCG is RTT (18 Weeks) - now invited. MEHT 7.Regular weekly meetings, including oversight group to monitor 52+, are held to monitor closely and trigger escalation. 8. 8.Updated RTT recovery plan by speciality and predicted trajectories by speciality. 9.Monthly contract review meetings review and monitor. Contract performance letters issued for 18wk non compliance and 52+, plus DIEP recovery and risk mitigation actions for challenged DIEP 52+ recovery Contract performance notice in 1. Recruitment of skilled specialised 1. The CCG is considering options in dialogue with MEHT to manage place for patients excess of 52 workforce the demand and treat the patients waiting in access of 52weeks. weeks. 2 Outsourcing delayed 2.Agreement to outsource 2 DIEPs per month to a Private Provider 111 are plastics and mainly 3.Protected ward capacity 3. MEHT has a 6 week rolling recruitment drive. and has recently breast reconstruction and 13 4·Booking of pre-ops, scheduling agreed enhance bank rates and looking at flexible working rotas, others which have been validated theatre capacity and post op capacity which has led to more staff interested in extra time and interest from following the Lorenzo with sufficient skilled specialist nurses the University . Saturday sessions to start in January 2018. implementation and have 5. Increase in 'immediates' over and Continuing to increase clinical workforce to meet demand from the treatment dates. above predicted activity Bank, Agencies, Adverts and internal. 4. Pursuing NHS/IS Provider when a patient requests an earlier October 52 weeks 0 appointment and is willing to consider another Provider. Mar-18 124  5. Suspension of all new out of the Region referrals for delayed reconstruction. 8.Duty of Candour –Harm review process reported to CQRG which provides data in number of cases delayed, number investigated, number presented to panel and harm outcomes. 9. Recovery plan in place and agreed with NHSE/NHSI, monitored weekly.

3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date MEHT has not been reporting The main reasons for the reduction in 1. Additional weekend sessions, outsourcing and recruitment drive diagnostics since May due to performance are: are the key actions to recover. Recruitment at pace, including the implementation of Lorenzo. 1. Breakdown of both MRI scans with agency staff to support 7 day working, extra weekend sessions and Data is now being reported and no opportunity to rebook the patients outsourcing scans to catch up. whilst the Trust has always met in month ahead of the 6 week target 2. Business Case agreed for new MRI scan, to be in place March this target they are not date 2018. currently achieving it. Extra 3. Demand higher and recruitment of 3.Contract for Diagnostics reporting now procured across the three sessions provided in November staff continues. More sonographers Trusts to be in place by early 2018 with KPIs for improved reporting and December are aimed to and radiologists needed - hindered by turnaround. October get back to compliance. lack of suitable candidates. 3. Sharing where possible capacity across the STP, but all Trusts Diagnostics 6 weeks <1% 4.Capacity -DNA rates high in 18-35yr under pressure as well as outsourcing Mar-18 9.5%  group for ultrasound scans. To identify 4. Trust working with Ipswich for recruitment of student trainees as practices and identify issues. more likely to commit when trained. 4.MRI new scanner needed. 5. A recovery plan is in place and monitored. 5.Referrals for MRI scans more 6. DNA rates high in 18-35yr group for ultrasound scans. To identify complex so placing further pressure practices and identify issues. on capacity 7. Diagnostics evening session with MEHT clinicians and GPs being arranged for early 2018 to share concerns, and raise issues etc.

Cancer Access - The Trust has not met the The main reasons for the continued 1 The Trust has installed Command Room daily status with a Task 2-week wait (all) 94.2% 93% MEHT  target of 85% for the 62 day underperformance are: Group prioritising cancer recovery to 85% Looking at all patients standard. Contract Performance 1) Skin /Plastics continues to (20+) by tumor site and backlog particularly skin to be escalated and 2-week wait (breast) 98.2%  93% Notice in place. underperform with capacity and capacity prioritised in diagnostics and OP & IP theatre capacity to process issues. A workshop held on treat patients to reach 85%. 31-day wait (all) 90.2% 96% 1st December covered the process 2. OP booking now pooling 2ww within 7days to provide future  issues: a) Medical Secretary support leverage for sustainability. and Waiting list support particularly at 3. New 2ww appointment letter being sent patients with distinction 31-day wait (surgery) 81.4% 94% Oct  Colchester. from routine appt aimed to reduce choice breaches and ensure GPs b) MDT support at Colchester tell patients. GP summit on 8th November 2018 targeted cancer 31-day wait (subsequent) 98.5%  98% c) CNS supporting the clinics at services and 2ww referrals process and improving the interface 31-day wait (radiotherapy) N/A N/A 94% Colchester d) Waiting list and OP working between Primary and Secondary care. booking support to Plastcs (St 4. Diagnostics -early booking of diagnostics to leverage the pathway. Mar-18 62-day wait (screening) 78.6%  90% Andrews) e) reviewing rota for theatre MRI scan Business Case approved, to be on site by March 2018 . lists and capacity National monies have targeted to increase histology and sharing 2) Late referrals from Providers capacity across the STP. Continued recruitment drive for more 62-day wait (all) 72.1% 85%  3) Backlog - 45% skin. Sonographers and Radiologists 4) Diagnostics - increase in capacity 5. Late referrals - Trust set up weekly meetings/telecom with other Trusts to track patients more closely. 6. Embed learning from PAH visit. 7. Weekly and monthly monitor meetings. Contract CPN in place.

3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date A Contract Performance Notice The main reasons for the Following the independent report covering the demand /capacity (CPN) was raised in November underperformance are: modelling of the IAPT service the CCG has agreed to a new Joint 2015 and will remain in place 1. Continued low referrals from GPs / Collaborative recovery plan which contains multiple actions around until access above target is 2. Ongoing workforce capacity recruitment, efficiencies, 1st/2nd appts and to increase referrals from sustained for minimum one Primary Care. Quarter. In summary the CCG and Providers have agreed jointly in the October performance recovery plan to: underachieved , for the month * All workforce roles filled 1%/1.39% = - 154. YTD * Efficiency improvements To ensure 15% of prevalence from 7.87%/8.89% = - 402 * Unlimited referrals the national psychiatric morbidity YTD IAPT - Access to October 15%-Q1-3 Expectation from national 5YFP * Rebalance of 1st to 2nd appointments survey 2000 for the CCG to 7.78% (- Mar-18 Treatment 1%(-154)  Q416.8% to achieve 16.8% in Q4. Given compliance with these in Q3/4 we believe we can: access treatment and increase to 402) * Achieve 15% Access for 2017/18 16.8% by the end of 2017/18. * Potentially achieve 16.8% Access for 2017/18 * Sustain Recovery rates above target * Sustain achievement of 1st waits - possibly with some compromise on current over achievement * Improve relationships/confidence with Primary Care & Acute Care * Improve treatment numbers for Long Term Condition clients

Work continues to increase and Key issues to address:: 1. Primary care targeted visits to offer support and discuss the improve the number of patients 1. Dementia Diagnosis and coding in benefits of a diagnosis. diagnosed with dementia. Primary Care 2.Memory assessment - agreement now to outsource scans in the Performance has improved in 2. Memory Assessment Service has interim has been finalised with planned fast track diagnosis for those October to 61.2% from 60.7% delays in the pathways due to patients to increase throughput. in September. scanning capacity 3. Funding is available for a 'dementia care home nurse' for a period of 3. Care Home services have a number 7 months to work with care homes to support diagnosis, this follows of patients requiring dementia the roll out of the Virtual Dementia Tour and Care Home manual to assessment due to possible improve delivery of care. identification of dementia symptoms. 4. The Dementia Intensive Support Service has commenced phase 2 Increase the rate of dementia October 4. Increase in both primary care and roll out as of the 2nd November and is beginning to demonstrate Dementia diagnosis from estimated 67% Mar-18 61.2%  community awareness around the interventions taking place to increase the dementia diagnosis rate, prevalence of 65+ benefits to a timely diagnosis and the reduce avoidable admissions to A&E and offer support prior to crisis support functions available for both the situations arising. patient and their carer. 5. Work is being undertaken within the community in line with Dementia Action Alliances to increase awareness around dementia and demonstrate that clinical interventions with a timely diagnosis can reduce the decline of dementia and provide the ability to live well for longer and within the community.

59 3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date Anti –microbial resistance: To reduce the inappropriate antibiotic 1. The prescribing targets are included within MOLES (Medicines appropriate prescribing of prescribing for Urinary Tract Infection Optimisation Local Enhanced Scheme, which GP practices have antibiotics in Primary Care- (UTI) in primary care. The required signed up to. reducing the inappropriate use of performance in 2017/18 must be: 2. Also included in MOLES is a continued review of restricted antibiotics will delay the a) 10% reduction (or greater) in the antibiotic prescribing (co-amoxiclav, cephalosporins, quinolones development of antimicrobial Trimethoprim: Nitrofurantoin prescribing prescribing to be less than 10% of total antibacterial items), asking ratio based on CCG baseline data resistance that leads to patient practices to meet as a locality quarterly and as part of this meeting (June15-May16) for 2017/18 harm from infections that are their peer review antibiotic prescribing, and also practices not meeting The CCG is tasked with achieving a harder and most costly to treat. one or more of the national quality premium targets should complete target ratio of 1.658 for 2017/18. Ratio Reducing inappropriate antibiotic the RCGP TARGET webinars on antibiotic prescribing. Antimicrobial as at Oct 17 1.575 Baseline use will also protect patients 3. Trimethoprim has been replaced with cefalexin as the antibiotic of resistance: b) 10% reduction (or greater) in the 10,308 10% from healthcare acquired number of trimethoprim items choice in elderly patients for UTI within the mid Essex primary care appropriate Reduce the inappropriate use of Oct -10,869 reduction infections such as Clostridium prescribed to patients aged 70 years or antibiotic guidelines. Therefore, this should assist in reducing the Oct-18 prescribing of antibiotics in Primary Care  difficile infections. number of trimethoprim prescriptions issued to patients over 70 years target- greater on baseline data (June15- antibiotics in Primary May16) for 2017/18. of age where not suitable for nitrofurantoin. Care 9277 Baseline 10,308, therefore target is 4.The CCG is in the top decile of CCGs with the highest amount of 9,277. As at October 2017 10,869. Trimethoprim prescribing in this age group so a lot of work to do in There has been an increase in the changing prescribing habits. number of items prescribed since Nov 5.Practices are sent their data on a monthly basis. 2016.

42 out of the 45 practices are 1.Herts Partnership Foundation Trust 1.Bespoke LD training has been held in all Mid Essex localities. signed up to provide the delivered the bespoke LD Training to 2.The training was attended by both GPS and nurses. Information Learning Disabilities DES. all localities in Mid Essex. and easy read resources have also been shared through email The three practices who have 2. GP Practices have also been given bulletins, GP link and were handed out at the time of the training. not signed up to the DES will communication tools and guides to 3.Requirements for carrying out LD health checks at practice level look after their LD patients encourage patients to attend the and issues around it were discussed as part of the PM meetings exactly the same way as in appointment for the health check. The held over summer last year, and the findings and the key discussions other patients. training also included elements of were fed back to the trainers prior to the training being delivered. what reasonable adjustments the 4.The training subsequently addressed the issues and concerns practice needs to do to carry out this raised and provided a platform for doctors and nurses to further clarify health check – e.g. longer times, time issues and provided clarity on the key requirements for practices to Increase of the day, more space, easy read deliver the training in order to meet the needs of the patients with Annual communication, all were encapsulated learning disabilities. To ensure people with learning number of measure within this training. 5.The training sessions were interactive and also included information Learning Disabilities disabiltiies over the age of 14yrs NA health Oct-18 2015/16 3.The practices challenged the LD about STOMP-LD. are offered a health check. checks 38.5% health checks data from last year. 6. Practices have been offered support to ensure they are coding and offered recording data accurately .

3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date National ambition to eliminate The CCG has seen a considerable The establishment of the Mental Health assessment unit which has inappropriate Out of Area decline in out of area placements over been signed off by EPUT will ensure patients are turned around within Placements in mental health the last 3 months, which is a very 72 hours of being admitted. There is discussion around the services in acute patient care by positive downward trend and whilst it investment needed from North commissioners to be fully operational 2020/21. Associated with poor is not unusual for this time of the year, by 1st April 2018. patient experience, poor it is expected that the plans underway outcomes and high cost. to implement an 18 bedded Mental Health assessment unit model in the North of Essex should ensure that this The number of bed days for Q3 - Oct declining trend is sustained. inappropriate out of area Mental Health -Out of 204 days Eliminate placements in mental health NA Area Placements Nov 75 days  by 2020/21 services for adults in non- Dec 34 days specialist acute inpatient care

Improve participation in the The main issues are: The CCG has developed a comprehensive diabetes plan: National Diabetes Audit: 1. Thirteen practices have been • providing accurate current information to each GP Practice on their • Ensure all practices participate identified as not reporting and diabetes population including information on monitoring, attainment of in the national audit. targeted with support and advised that treatment targets, and compliance with any current Local Diabetes this is a contractual requirement from Programmes (e.g. education etc.) Annual All practices July 2017. • allowing rapid identification of those patients at highest risk to Diabetes Patients that have measure to report to enable prioritisation of these individuals and enhanced support. Diabetes achieved all the NICE NA Mar-18 2015/16 the National • enabling integrated care, remote reviews and efficient utilisation of recommended treatment targets 33.6% Audit the extended healthcare team through the creation of a dynamic centralised database.

61 3 mth Recovery Service Standard KPI YTD Month Target Comme nts Issues Actions Trend Date The CCG is tasked with The main issues are: 1. Progress is now being made with routine referrals all being booked improving the booking of e - 1. ensuring all referrals are made on ers. I ssues with MEHT processes have now been identified and referrals to get to 100% and electronically on what is called rectified. paperless.. ‘eReferrals’ 2. Focus is now on amending the ‘urgent’ process where patients are 2. that the hospitals have roceses in not considered emergencies or meet 2ww criteria to exclude cancer, place to accept all e-referrals and but need to be prioritised to be seen in outpatients within 4-6 weeks. clinic slots available to accept the This needs to be completed by end of March 2018. bookings. 3. ensure that 2wws are being booked To increase the number of through eRS-. This has now reached referrals on the electronic approximiately 50% of estimated 2ww E-Referrals NA 67.3% 100% Q2 -2018 eRefferal system with the aim to  referrals so on track to move to 100%. for 2ww referrals. become paperless. 4. to consider how to manage ‘urgent’ referrals which are currently going directly to the hospital but not through eRS

62 Section 5: CCG Improvement and Assessment Indicators – How we compare:

Castle Basildon & Current Mid Essex Point & Southend Thurrock Domain Area No Name Frequency Brentwood England Update CCG Rochford CCG CCG CCG CCG 2013/14 to Child obesity 1 Percentage of children aged 10-11 classified as overweight or obese Annual 30.7% 31.4% 31.1% 32.0% 37.6% 33.7% 2015/16 Diabetes patients that have achieved all the NICE recommended treatment 2 targets: three (HbA1c, cholesterol and blood pressure) for adults and one Annual 2015-16 33.6% 40.5% 41.5% 41.0% 41.8% 39.0% Diabetes (HbA1c) for children People with diabetes diagnosed less than a year who attend a structured 3 Annual 2014 8.0% 7.9% 22.7% 21.8% 8.6% 7.4% education course Falls 4 Injuries from falls in people aged 65 and over Quarter 16-17 Q4 1,712 1,583 1,996 2,190 1,788 1,939 Better HealthPersonalisation and choice 5 Personal health budgets Quarter 17-18 Q1 5.2 23.5 8.1 18.2 30.5 23.3 Inequality in unplanned hospitalisation for chronic ambulatory care Health inequalities 6 Quarter 16-17 Q4 1,728 1,312 1,624 2,462 1,717 2,061 sensitive and urgent care sensitive conditions Antimicrobial resistance: appropriate prescribing of antibiotics in primary 7 Month Jun-17 1.118 1.201 1.110 1.140 1.141 1.051 care Antimicrobial resistance Antimicrobial resistance: appropriate prescribing of broad spectrum 8 Month Jun-17 9.8% 9.8% 11.5% 11.5% 8.4% 8.9% antibiotics in primary care The proportion of carers with a long term condition who feel supported to Carers 9 New indicator - Annual Survey manage their condition

63 Castle Basildon & Current Mid Essex Point & Southend Thurrock Domain Area No Name Frequency Brentwood England Update CCG Rochford CCG CCG CCG CCG 10 Provision of high quality care: hospital - CQC score ratings Quarter 17-18 Q1 59.3 61.4 59.1 57.8 63.6 N/A Provision of high quality 11 Provision of high quality care: primary medical services - CQC score ratings Quarter 17-18 Q1 65.3 63.1 59 60.7 63.7 N/A care 12 Provision of high quality care: adult social care - CQC score ratings Quarter 17-18 Q1 60.9 63.3 63.3 62.2 62.9 N/A 13 Cancers diagnosed at early stage Annual 2015 55.7% 55.6% 49.6% 51.5% 55.4% 52.4% People with urgent GP referral having first definitive treatment for cancer 14 Quarter 17-18 Q2 75.8% 72.6% 79.3% 77.1% 61.3% 82.0% Cancer within 62 days of referral 15 One-year survival from all cancers Annual 2014 70.4% 69.8% 69.8% 70.3% 67.1% 70.4% 16 Cancer patient experience Annual 2016 8.7 8.8 8.8 8.8 8.8 N/A 3mth 17 Improving Access to Psychological Therapies – recovery Month rolling to 50.8% 49.7% 48.5% 46.5% 57.3% 50.6% Jun-17 18 Improving Access to Psychological Therapies – access Month Oct-17 YTD 7.87% 12mth Mental Health People with first episode of psychosis starting treatment with a NICE- 19 Quarter rolling to 82.1% 86.7% 83.3% 63.6% 83.9% 76.2% recommended package of care treated within 2 weeks of referral Oct-17 20 Children and young people’s mental health services transformation Quarter Q2 Above Plan 21 Mental health out of area placements Quarter Dec-17 34 days 22 Mental health crisis team provision Annual Survey Reliance on specialist inpatient care for people with a learning disability 23 Quarter 17-18 Q1 51 51 51 51 51 N/A and/or autism Learning disability Proportion of people with a learning disability on the GP register receiving 24 Annual 2015-16 38.5% 34.1% 36.1% 44.6% 25.3% 37.1% an annual health check Better Care 25 Completeness of the GP learning disability register Annual- new indicator QOF data 26 Maternal smoking at delivery Quarter 17-18 Q2 7.0% 12.1% 5.8% 12.5% 9.2% 11.0% 27 Neonatal mortality and stillbirths Annual 2015 4.7 3.2 5.0 5.4 5.1 N/A Maternity 28 Women’s experience of maternity services Biannual 2015 80.6 80.3 79.4 75.3 82.0 N/A 29 Choices in maternity services Biannual 2015 68.2 64.3 60.5 61.7 65.2 65.4 30 Estimated diagnosis rate for people with dementia Month Nov-17 61.2% 64.4% 61.7% 74.3% 66.9% 68.7% Dementia 31 Dementia care planning and post-diagnostic support Annual 2015-16 77.2% 76.5% 70.3% 76.1% 75.5% N/A 32 Emergency admissions for urgent care sensitive conditions Quarter 16-17 Q4 1,976 1,765 2,414 2,925 1,789 2,369 Percentage of patients admitted, transferred or discharged from A&E within Urgent and emergency 33 Month Sep-17 90.1% 91.4% 88.6% 87.5% 93.6% 89.7% 4 hours care 34 Delayed transfers of care attributable to the NHS per 100,000 population Month Aug-17 11.7 12.7 12.0 9.7 7.7 13.5 35 Population use of hospital beds following emergency admission Quarter 16-17 Q4 417.3 553.0 411.2 379.4 546.3 505.0 Percentage of deaths with three or more emergency admissions in last End of life care 36 New measure being defined three months of life 37 Patient experience of GP services Annual Jan-Mar-17 80.6% 80.0% 85.4% 83.0% 77.1% 84.8% Primary care access – percentage of registered population offered full Primary care 38 New measure- quarterly data not yet available extended access 39 Primary care workforce Biannual Mar-17 1.03 0.79 0.87 0.91 0.83 1.02 Elective access 40 Patients waiting 18 weeks or less from referral to hospital treatment Month Oct-17 78.4% 83.5% 85.4% 86.8% 81.8% 89.3% 7 day services 41 Achievement of clinical standards in the delivery of 7 day services Weighted against 4 clinical priorities- 6mthly report -not available yet NHS Continuing Percentage of NHS Continuing Healthcare full assessments taking place in 42 Quarter 17-18 Q1 62.7% 87.8% 14.3% 9.1% 1.0% 26.7% Healthcare an acute hospital setting Evidence that sepsis awareness raising amongst healthcare professionals Patient Safety 43 Measure being developed has been prioritised by the CCG

64 Castle Basildon & Current Mid Essex Point & Southend Thurrock Domain Area No Name Frequency Brentwood England Update CCG Rochford CCG CCG CCG CCG Financial sustainability 44 In-year financial performance Quarter 17-18 Q1 Amber Green Amber Red Green N/A Sustainability Paper-free at the point Utilisation of the NHS e-referral service to enable choice at first routine 45 Month Oct-17 67.3% 41.3% 62.5% 63.1% 44.1% 57.5% of care elective referral Probity and corporate Fully Fully Partially Partially Fully 46 Probity and corporate governance Quarter 17-18 Q1 N/A governance compliant compliant compliant compliant compliant 47 Staff engagement index Annual 2016 3.8 3.8 3.8 3.8 3.8 3.8 Workforce engagement 48 Progress against the Workforce Race Equality Standard Annual 2016 0.1 0.1 0.1 0.1 0.1 0.1 Leadership CCGs' local relationships 49 Effectiveness of working relationships in the local system Annual 16-17 61.7 57.2 75.2 68.3 77.2 N/A Patient and community Compliance with statutory guidance on patient and public participation in New indicator - Piloted 16/17 CCG rated needs improvement. Process being reviewd to align with 50 engagement commissioning health and care CCG assurance in 18/19 and onwards. Quality of leadership 51 Quality of CCG leadership Quarter 17-18 Q1 Red Red Amber Red Red N/A

65 Report to: Part 1 Board Meeting Date: 25 January 2018

Agenda No: 10.3 Report Title: 2017/18 Financial Savings Plan Written by: Dee Davey, CFO and Peter Wyatt, Head of PMO Purpose of Report: To update the Board on the position of the 2017/18 QIPP savings programme Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees The Finance & Performance Committee and the Board receive a that have reviewed this QIPP financial update and forecast outturn at each meeting. document). The Savings Programme Board reviews progress with savings plan delivery.

Patient & Public N/A Engagement: Significant Risks The 2017/18 QIPP savings target of £23.5m is extremely identified: challenging. A shortfall in delivery could result in the CCG being unable to deliver its financial control total. Recommendations and The Board is requested to note the QIPP delivery position at decision/actions the end of Month 9 and forecast outturn. required by the Committee/Board:

66 Summary £23.5m of savings is required in 2017/18 to offset expected cost pressures and to meet the NHS England requirement to repay £9m of the CCG’s accumulated deficit. The savings target represents 5.1% of funding allocation. The Board has been fully aware of the significant risks in the plans, driven to a considerable extent by the nationally mandated requirement to deliver a £9m (2%) in-year surplus. At Month 9, the forecast QIPP delivery is £20m with a stretch forecast of £20.5m which is £3m short of the target. The impact of the shortfall upon the overall forecast financial outturn is covered in the separate Finance report on the agenda.

Whilst the shortfall in delivery is disappointing, it should be seen in the context that delivery of the forecast would result in QIPP delivery as a percentage of total expenditure of 4.6% which exceeds the average for the Mid & South Essex STP, the local NHSE area team footprint, the Midlands & East Region and the national forecast.

Progress to Date £10.2m of savings is estimated to have been delivered to Month 9, 77% of the target for the year to date. It should be noted that the profiled impact of planned savings escalates as the financial year progresses.

2017/18 QIPP SUMMARY Actuals and full year forecast as at M9 - 31 December 2017

Forecast Forecast with Per Plan % Plan YTD Actual YTD Variance CCG Stretch £000 £000 £000 £000 £000 £000 Overall Project Risk Rating Table

R 4,214 18% 1,419 0 1,419 9 9 A 5,336 23% 3,135 2,383 752 3,965 4,473 G 10,902 46% 6,649 5,731 918 9,270 9,270 Bl 3,048 13% 2,090 2,089 1 6,748 6,748 Total 23,500 100% 13,293 10,202 3,091 19,992 20,500 Overall Finance Risk Rating Table

R 5,720 24% 2,240 0 2,240 99 141 A 2,900 12% 1,793 853 940 1,260 1,260 G 11,832 50% 7,171 7,261 -90 11,885 12,351 Bl 3,048 13% 2,090 2,089 1 6,748 6,748

Total 23,500 100% 13,293 10,202 3,091 19,992 20,500 Percentage of profiled QIPP delivered 77% Percentage of annual plan profiled and delivery to date 57% 43% Percentage of year to date 75%

A large number of projects have successfully gone live in recent months, including Consultant Connect, Health Navigators and the APOS therapy pilot. The new local Dementia Service was also fully rolled out in Quarter 3. The financial impact of these innovations have yet to be felt but they represent exciting developments which should be better for patients as well as better value for money.

These schemes will be of considerable aid in 2018/19 but the financial impact in the current year will be modest. The CCG’s emphasis is now on maximising delivery of existing projects

67 and on planning for next year, as any new schemes will not be deliverable in time to have an effect in 2017/18.

Forecast Outturn As shown in the tables above the forecast outturn is that £20m of QIPP can be achieved (£20.5m with stretch). The risk ratings for project delivery and financial savings shown above illustrate that there continues to be significant risk in some of these projections although the risk has reduced significantly. The CCG will continue to investigate opportunities for cost reductions, budget savings and efficiencies that can be delivered in year to close the gap.

Recommendation

The Board is requested to note the QIPP delivery position at the end of Month 9 and forecast outturn.

68 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 10.4 Report Title: 2017/18 Finance Report – Position at 31 December 2017 (Period 9) Written by: Ruth Blake, Deputy Chief Finance Officer and Dee Davey, Chief Finance Officer Purpose of Report: To provide an update on the 2017/18 financial position

NHSE set the CCG an extremely challenging financial control total of a £9m in-year surplus (2% of Resource Limit) in order to make a further repayment of the CCG’s accumulated deficit.

Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Board members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Patient & Public n/a Engagement: Significant Risks Controlling expenditure within approved resources is a key requirement identified: of the CCG. Ability to achieve the NHSE set financial control total will determine the nature of the performance monitoring and management intervention arrangements applied to the CCG.

Service performance is monitored against national and regional targets. The NHS constitution sets out rights and pledges for patients and the public which the CCG is required to fulfil. The report references the relevant risks included in the Risk Register. Recommendations and • To consider the 2017/18 financial position reported to date, the decision/actions forecast outturn and the risks to delivering the CCG control total; • required: To note the risks set out in Appendix F and not reflected in the forecast outturn; • To note progress on clearing CHC retrospective cases set out in Appendix I. • To note the non-recurrent winter funding that has been made available to the Mid Essex system.

Acronym Full Name BCF Better Care Fund CHC Continuing Healthcare CHUFT Colchester Hospital University NHS Foundation Trust CSU Commissioning Support Unit DToC Delayed Transfers of Care (discharges from hospital to a follow on care provider) ECC Essex County Council EPUT Essex Partnership University Trust (newly formed from the South and North Essex Partnership Trusts) ETTF Estates & Technology Transformation Fund F&P Finance & Performance Committee IBCF Improved Better Care Fund MEHT Mid Essex Hospital Services NHS Trust MH Mental Health NEL Non-elective activity NHS BSA NHS Business Services Authority (roles include providing GP prescribing forecasts) PbR Payment by Results – national tariffs for acute activity on a pay-as-you-use basis PCSDT Primary Care Sustainability, Development & Transformation Investment Fund PPA Prescription Pricing Authority QIPP Quality, Innovation, Productivity & Prevention (savings schemes) Run rate The level of monthly expenditure/income consistent with the expenditure or income provided for in the annual budget. SRG Systems Resilience Group STF Sustainability & Transformation Fund/Funding

1. Headline Messages

1.1 The CCG’s control total is to deliver an in-year surplus of £9m. The Board will be aware of the ongoing dialogue with NHSE regarding the feasibility of delivering an in- year surplus of 2% and the Local Area Team has been proactive in reflecting these concerns through the national reporting process. The challenge for MECCG is exacerbated by the CCG’s relatively low funding per head and the fact that the 2017/18 Resource Limit funding is already £5.8m below target funding.

1.2 Despite good progress with a very challenging QIPP delivery target, slippage against full delivery of the target and some significant unplanned costs pressures have resulted at M9 in the CCG reporting an adverse expenditure variance to date of £1.95m. The unplanned cost pressures mainly relate to acute overspends/QIPP slippage and overspends in Continuing Healthcare and GP Prescribing.

1.3 In the light of the position to date, the CCG has been permitted to reduce the forecast outturn surplus delivery by £2.6m to a surplus of £6.4m compared to the £9m control total.

1.4 There is a further net risk of £1m to delivering the £6.4m which mainly relates to the continued uncertainty around the scale of drugs remaining in the ‘No Cheaper Stock Obtainable’ category and the resulting cost pressures from pharmacists not being able to source generics at tariff prices.

1.5 The CCG and MEHT entered into a binding arbitration process in December in order to settle disputes on the charging of some non-elective admissions and SEPSIS cases. The decisions found in favour of the CCG and have protected the CCG from significant unplanned expenditure with the Trust. If the arbitration had found in favour of the Trust there would have been an even larger deterioration in our forecast outturn.

1.6 A financial dashboard of some key metrics is included in this report.

1.7 The CCG is required by NHSE to repay £9m of the accumulated deficit in 2017/18. When planning requirements were issued in December 2016, a further £9.3m was to be required to be repaid in 2018/19. It is pleasing to note that recent planning information has reduced the 2018/19 repayment requirement to £3m – presumably in recognition of the feasibility of the earlier target. The current repayment requirement is therefore as set out below:

Required Accumulated In-Year Surplus/ Deficit Deficit Repyment at 31 March £m £m

Accumulated deficit 31 March 2016 24.9 2016/17 surplus/repayment 3.0 Accumulated deficit 31 March 2017 21.9 Required 2017/18 in-year surplus 9.0 Accumulated deficit 31 March 2018 12.9 Required 2018/19 in-year surplus 3.0 Accumulated deficit 31 March 2019 9.9

2 Background

2.1 The CCG is funded at £1,163 per head of population – which is £5.8m (1.3%) below formula funding target and £18 per head less than the next lowest funded CCG in Essex. Appendix A summarises the funding position. The CCG’s accumulated deficit is significantly less than the accumulated under-funding.

2.2 The £23.5m cost savings target required to achieve the 2017/18 control total represents a savings target of 5.1% of current funding allocation on an already relatively low level of expenditure.

2.3 In 2017/18 the CCG is co-commissioning GP primary care services with NHSE but the cost of primary care contracts are not accounted for within the CCG’s accounts. The CCG does account for some enhanced services payments and for the Primary Care Sustainability, Development and Transformation Investment Fund (PCSDT).

3 2017/18 Expenditure and Variances to Budget

3.1 Appendix B summarises the expenditure position to date and forecast outturn. Programme expenditure is £1.95m over profiled budget to date. The most significant areas of forecast overspending are acute activity (£1.6m), GP prescribing (£2.0m), adult CHC (£1.8m) and community services (non-achievement of savings on the community equipment contract and pressures on the neuro-rehab budget).

3.2 Monitoring of activity trends is particularly complex this year due to the changes in definitions of activity paid for by CCGs and those services (specialised commissioning) paid by NHSE. The CHUFT and EPUT contracts are both on a block basis for 2017/18.

3.3 The MEHT contract was on a PbR (pay as you go) basis for 2017/18. Board members will be aware that the monitoring of activity at MEHT is even further complicated this year by the ongoing data issues from the new Patient Record system (Lorenzo) which generated counting and coding issues that have yet to be resolved.

3.4 The M8 MEHT activity has been received and indicates that non-elective activity is continuing to run significantly above plan (£4.9m). However, our analysis indicated that the variance is largely due to changes in patient pathways and recording as part of the redesign of unplanned care pathways. The discrepancies were taken to local arbitration in December and the CCG was successful. As part of that negotiation process, MEHT and MECCG have agreed a block payment arrangement for 2017/18. There is an outstanding issue over the charging for SEPSIS complications. However, we are now clear that the agreed position on MEHT will not exceed £166m (£2.9m above budget).

3.5 Month 7 data for GP prescribing has been received and has been reflected in the ledger as an adverse variance year to date (£1.7m) and a forecast adverse variance of £2.0m. Significant cost pressures in the form of substantially higher prices due to a shortage of a number of generic drugs persist and it is not clear how long this will continue although we have been told to plan for 2018/19 without these cost pressures. Representations by the Local Area Team to NHSE nationally are continuing. In addition, NHSE have started to claw back from CCGs savings made from generic drug price changes (those not affected by the issues above).

3.6 The M9 CHC forecast remains at a £1.8m overspend (M8 - £1.8m). This is a result of a significant increase in LD and fast track packages and costs. CHC continues to be an area of special focus for 2017/18.

3.7 The risks flagged in the risk register in respect of the above issues are described as follows:

Risk Risk Initial Current Target ID No Rating Rating Rating 4 IF the CCG experiences unplanned costs 15 20 5 THEN this will result in revenue expenditure not being contained within the R R Y approved Financial Plan RESULTING IN escalation to NHSE Regional Team and potential qualification of statutory accounts and loss of autonomy.

4 QIPP/Financial Recovery Plan

4.1 The 2017/18 cost savings target is for £23.5m net savings (5.1% of Resource Limit). An update on progress and risks on scheme delivery is included as a separate item on today’s agenda.

4.2 The following risk is flagged in the risk register.

Risk Risk Initial Current Target ID No Rating Rating Rating 3 If cost savings are not achieved, 25 25 5 THEN it may not be possible to contain revenue expenditure within the R R Y approved Financial Plan RESULTING IN escalation to NHSE Regional Team and potential qualification of statutory accounts and loss of autonomy.

5 Capital

5.1 The CCG is not expecting to require a capital allocation for 2017/18. GP IT capital expenditure is accounted for by NHS England.

5.2 The Mid and South Essex footprint has been awarded Estates & Technology Transformation Funding (ETTF) for 2017/18. This includes an allocation towards some GP premises project work and a share of transformation funding to progress primary care mobile working. ETTF expenditure is accounted for by NHSE.

Risk Initial Current Target Rating Rating Rating 6 IF capital expenditure is not contained within approved limit, 15 5 5 THEN there is a risk that the CCG will receive a qualified Audit opinion R Y Y RESULTING IN leading to reputational and regulatory risk.

6 Transformation Funds

6.1 In 2016/17 the CCG was permitted to keep the benefit from the mandated underspending of the 1% CCG transformation fund (£4.4m). In 2017/18 we are permitted to spend half of the 1% transformation fund (£2.3m) and have already committed part of this (£0.5m) to fund the first tranche of the £3 per head of registered patient that we are required by the GP Five Year Forward View plans to make available to Primary Care non-recurrently by the end of 2018/19. We are mandated to hold the other half of the 1% as a risk reserve towards balancing the national position. We are not permitted to take the benefit of underspending against this second half percent towards delivering our financial control total.

7 Better Care Fund

7.1 £22.8m of CCG funding is in a ring-fenced budget with Essex County Council. The budgets are committed to existing health and social care services. For healthcare services the expenditure has been included in the service lines in which the services are managed in the summary in Appendix B. The remaining £8.4m is separately identified and represents the Protection of Social Care funding plus a required contribution towards the cost pressure of the implementation of the Care Act, a shared Head of Dementia post and administration costs. Appendix C summarises the overall BCF position.

7.2 For 2017/18 ECC and the CCG continue to carry the financial risk of service contracts/costs met from the BCF on the same basis as prior to the creation of the BCF i.e. the organisation which commissions the service carries the financial risk.

7.3 In the Government’s March Budget it was announced that additional transitional funding was to be allocated to social care (Improved Better Care Fund). The funding is non-recurrent and reduces over a three year period. For Essex County Council, this amounted to around £24.7m in 2017/18, £16.8m in 2018/19 and £8.3m in 2019/20. The Grant Determination Letter states that the grant is to be used to: • Meet adult social care needs; • Reduce the pressures on NHS (especially delayed transfers of care (DToC)); • Stabilise the care market.

7.4 Essex County Council identified £8.6m of the 2017-18 IBCF to invest in schemes that support the NHS and help the care market – of which £2.2m has been allocated to the Mid Essex CCG population. £0.5m of this has been allocated to Mid’s share of ECC county wide schemes and £1.7m to CCG schemes. Details are included in Appendix C(ii).

8 Winter Pressures Funding

The CCG has recurrent systems resilience funding of £2.1m which is spent annually on schemes approved by the Systems Resilience Group. In addition NHSE has recently confirmed non-recurrent winter pressures funding of £2.46m for bids submitted by Mid Essex partners as follows:

Category Total MECCG, Detail of Schemes Funding paid to MEHT & EPUT MECCG Mental £220k Approved Mental £50k Health Health Practitioner, Transport & Beds Primary £173k Additional NHS 111 & £173k Care Out of Hours capacity, EEAST tent and SOS bus, enhanced GP access Winter £2,071k Writtle ward, £1,006k Capacity community beds and nursing home beds

Plans are in place for all schemes and progress on spend against the funding received by the CCG will be included in Appendix N as the funding is received from NHSE.

9 Statement of Financial Position

9.1 The CCG Statement of Financial Position is set out in Appendix G together with an analysis of aged creditors and debtors in Appendix H.

10 Retrospective Continuing Healthcare Claims

10.1 We continue to monitor the risk on the outstanding liabilities in respect of retrospective continuing healthcare claims. NHS England have confirmed that no further contribution to the risk pool will be required by CCGs in 2017/18 and that NHSE will pick up the cost of making redress payments to patients and their families

following any successful appeals against earlier decisions relating to this cohort of claims.

10.2 Arden & GEM CSU is continuing work to determine financial redress for the 61 eligible cases. Our share of the NHSE risk share provision still required is calculated at £1.2m (£0.4m for cases found eligible and partly eligible and £0.8m for appeals received).

10.3 As at 31 December 2017, 53 of the 61 (87%) cases found eligible or partly eligible had been settled. The appeals process can take up to two years so work on these cases will continue beyond 2017/18. The SLA with Arden GEM CSU ended on 31 March 2017. The CSU has agreed to complete all financial redress and manage all appeals on these cases through to conclusion for no extra cost. The CCG is now receiving regular progress reports on the 8 cases outstanding for financial settlement due to the length of time they are taking to complete. There are currently 43 appeals in progress with 12 further cases still within the 6 month window to make an appeal. Following progress through the local dispute resolution service run by Arden GEM, claimants are still able to make further appeals to NHSE or to the Ombudsman.

11 Fines and Penalties

11.1 The CCG is required to report on the application of fines and penalties against provider organisations. The 2017/18 arrangements are very complex because of the additional implications for provider access to System Transformation Funding (STF).

11.2 The CCG has normally taken the financial benefit of fines and penalties in order to assist in managing the year end position. CCGs are not allowed to levy fines and penalties on acute trusts for performance targets/measures that are also required to be delivered as part of trust eligibility for national Sustainability and Transformation Funding (STF).

12 Cashflow

12.1 Appendix D summarises the cash flow position. The CCG closely monitors and reports the cash position on a monthly basis. There are opportunities later in the year to request additional cash so we do not anticipate any issues at year end.

13 Monthly Expenditure and Underlying Position

13.1 Appendix E tracks the trends in monthly expenditure/accruals.

13.2 There are a number of non-recurrent benefits supporting the forecast outturn and the forecast underlying surplus is £0.5m.

14 Risks and Opportunities

14.1 The CCG closely monitors risks and opportunities that have not been included in the forecast outturn. At the start of a financial year the range of the unbudgeted risk is significant and is expected to reduce as the year progresses and more risks and benefits either crystallise to the extent that they need to be included in the forecast or are dissipated (Appendix F).

14.2 Although the forecast outturn is now £2.6m below the approved plan, there is a further £1m of unmitigated risk, largely relating to prescribing cost pressures arising from the “No Cheaper Stock Option” issues. NHSE Local Area team continue to

lobby on behalf of CCGs for relief for the very significant cost pressures experienced by all CCGs.

14.3 Due to the pressure on the CCG to deliver a significant surplus this year, the CCG should be particularly alert to how it assures itself that there is no material misstatement or manipulation of the reported financial position by management.

Risk Risk Initial Current Target ID No Rating Rating Rating 22 IF there are material mis-statements within Financial Statements due to fraud or 10 10 5 error A A Y THEN the accounts either cannot be signed-off by the Auditors or receive a qualified audit opinion RESULTING IN escalation to NHSE and also reputational and regulatory risk.

15 Running Costs

15.1 The QIPP programme includes £1m running cost savings. The current forecast is that just over £0.8m of this target will be achieved.

16 Impact Upon Deficit Repayment

16.1 It is regrettable that the CCG will not be able to deliver the full £9m deficit repayment in 2017/18.

16.2 As referred to in section 6.1, all CCGs have been required to hold 0.5% of budget towards the national acute sector risk reserve. The forecast outturn currently assumes that the reserve will be required to be paid over. However, if the accounting treatment adopted last year is replicated, then the CCGs will receive an instruction to report the resource as uncommitted in M12 which will increase the size of the in-year surplus but is not taken into account when assessing CCG delivery of the control total.

16.3 Whilst the underspend does not score for delivery of control total, if the arrangements work as last year then the increased surplus of £2.3m will largely offset the currently forecast £2.6m slippage against the in-year surplus. If there is no further deterioration in the in-year position, the CCG would therefore make a significant (£8.7m) repayment of the deficit in 2017/18.

Required Accumulated In-Year Surplus/ Deficit Deficit Repyment at 31 March £m £m

Accumulated deficit 31 March 2016 24.9 2016/17 surplus/repayment 3.0 Accumulated deficit 31 March 2017 21.9 Forecast 2017/18 in-year surplus 6.4 Impact of release of 0.5% risk reserve 2.3 Total 2017/18 in-year surplus 8.7 Accumulated deficit 31 March 2018 13.2 Required 2018/19 in-year surplus 3.0 Accumulated deficit 31 March 2019 10.2

76 17 2018/19 Budget

17.1 There is a separate report on the 2018/19 budget elsewhere on the Agenda. National guidance has been significantly delayed.

18 Recommendation

The Board is requested to:

• Consider the 2017/18 financial position reported to date and the forecast outturn; • Note the regrettable deterioration in the forecast outturn to a £6.4m in-year surplus; • Note the risks set out in Appendix F and not reflected in the forecast outturn; • Note the position on CHC retrospectives as set out in Appendix I; • Note the CCG’s recurrent underlying position of a £0.5m surplus. • Note the non-recurrent winter pressures funding that has been allocated to Mid Essex.

77 Mid Essex CCG - Financial Dashboard - as at 31 December 2017 (M9)

1) Year to Date - Programme & Running Cost Commentary Pressure on year to date budgets predominantly from QIPP slippage on acute and Plan Actual Variance Variance community schemes and GP Prescribing and CHC cost pressures £m £m £m % In-Year (Surplus) / Deficit (6.8) (4.8) 2.0 0.6% YTD

2) Full Year Forecast - Programme & Running Cost Commentary Plan Current Variance Variance

£m £m £m % In-Year (Surplus) / Deficit (9.0) (6.4) 2.6 -0.6% FCOT

3) Movement in Forecast Outturn Reasons for movement from previous month Last Month This Month Change Change Agreement from NHSE that we could move forecast position by £2.6m (previously £m £m £m % held as unmitigated risk) In-Year (Surplus) / Deficit (9.0) (6.4) 2.6 -0.6% Movement

4) Expected Value Commentary £m Risks not reflected in the position 4.60 RisksNet unmitigated not reflected risk inis remainingthe position risk on 'No Cheaper Stock Obtainable' drugs not Mitigations not reflected (3.60) Mitigationsincluded in the not forecast reflected outturn Net Risk / (Headroom) 1.00 Net Risk / (Headroom)

5) QIPP Delivery Year to Date Delivered Forecast Delivery £m % of Plan £m % of Plan Recurrent 2.46 81% 17.13 86.0% Recurrent Non-Recurrent 0.89 72% 3.37 94.4% Non-Recurrent Unidentified Total QIPP Target - £23.5m 3.35 78% 20.50 87.2% Total QIPP Target - £23.5m Shortfall against plan 3.00 12.8%

6) YTD Budget YTD Actual Variance Variance Commentary £m £m £m % Running Costs 5.68 5.68 0.00 0.0% Running Costs

7) Full Year Full Year Variance Variance Commentary Budget Forecast £m £m £m % Running Costs 7.50 7.50 0.00 0.0% Running Costs

8) Actual and Forecast Commentary

Residual Work ongoing to assess need for capital works in preparation for HSCN changes - FOT Variance Funding max £38k of £75k allocation Forecast to Capital Required in GP IT capital expenditure is accounted for by NHSE. YTD Actual Outturn Required 2017-18 National Estates Technology and Transformation Fund (ETTF) capital funding for £000s £000s £000s £000s primary care projects has been awarded - accounted for in NHSE books. Approved Capital Position 0.00 38.00 (37.00) 0.00 Approved Capital Position

9) MH Parity £ Commentary 16/17 Gross Allocations 440,637 RunningCCG is required Costs to increase Mental Health spend in line with % of growth received in total CCG Allocation. 17/18 Gross Allocation 451,727 Gross RL increase was 2.5% - does not reflect the CCG requirement to underspend Gross Growth 11,090 by £9m. Requirement to underspend Allocations in 16/17 and 17/18 (£3m in 16/17 (6,000) and £9m in 17/18) Net Growth 5,090 Net Growth in % (Required to spend on MH) 1.16% CCG view of comparable metric (including LD and Dementia) 17/18 16/17 Commentary Forecast MH Parity Spend details £'000s £'000s % Growth Increase is due to the CAMHs Transformation fund underspend Emotional Wellbeing and Mental Health Services 2,691 2,922 8.58% in 16/17. Adult Mental Health & Improved Access to Psychological 30,525 30,840 1.03% Therapies

CHC, MH & Prescribing 7,067 7,697 8.91% Prescribing exp for 1617 may need restated in line with Planning guidance.

Sub total excluding LD and separately reported dementia 40,283 41,459 2.92% Plan approved by NHSE provided for 1.7%

LD and separately reported dementia 7,786 9,851 26.52% Mainly due to increase in CHC LD forecast compared to 16/17.

Total 48,069 51,310 6.74% Plan approved by NHSE provided for 2.5% MH Growth in % 6.74%

78 Appendix A Mid Essex CCG 2017/18 Resource Limit Funding - as at 31 December 2017 (M9)

Resource Limit Allocation Non- Recurrent Recurrent Total £000 £000 £000 Programme Costs Confirmed Identification Rules ( 6,770) ( 6,770) HRG4+ Tariff 3,140 3,140 Rest of Baseline Allocation 451,727 451,727 Health & Justice Transfer ( 84) ( 84) Reception and clerical training - (Training Care Navigators and Medical Assistants) 66 66 Diabetes Treatment and Care Transformation Fund 107 107 Diabetes Treatment and Care Transformation Fund 24 24 GP WiFi 156 156 Property Services - estates market rents adjustment 68 68 Paramedic Rebanding Additional Funding 2017-18 165 165 NHS Network funding - change to payment arrangements (HSCN) 233 233 Infrastructure funding for STP 248 248 Cancer 62 day target - MEHT (pass through) 234 234 Transfer HSCN - CCG funding from programme to running costs ( 16) ( 16) ICDIAT TFR ( 10) ( 10) National Diabetes - Transformation Funding (Structured Education) ( 84) ( 84) Additional month 5 Identification Rule Changes ( 269) ( 269) Structured Education: Diabetes Treatment and Care Transformation 107 107 Treatment Targets: Diabetes Treatment and Care Transformation 24 24 Urgent & Emergency Care Centre - STP allocation 478 478 Perinatal Tranche 1 Funding 17/18 M7 117 117 National Diabetes - Transformation funding M7 ( 84) ( 84) Urgent & Emergency Care funding M8 ( 325) ( 325) STP Comms & Engagement M8 50 50 Charge Exempt Overseas Visitor (CEOV) Adjustment M8 ( 649) ( 649) Transformation Funding M9 400 400 BASPCAN Safeguarding M9 1 1 Quality Premium 16/17 stage one payment - All QP measures except for performance on cancers diagnosed at an early stage. M9 189 189 62 Day Wait Midlands and East Tranche 2 M9 100 100 Structured Education: Diabetes Transformation Fund - ID: DTCM09 M9 107 107 Treatment Targets: Diabetes Transformation Fund - ID: DTCM09 M9 23 23 GP WIFI - rounding correctn to M3 Allocation M9 ( 1) ( 1) Additional Winter Funding - Mental Health bids M9 50 50 Additional Winter Funding - (GP Winter Access Bid etc. ) M9 148 148

447,734 1,936 449,670

Running Costs - Confirmed 8,338 8,338 Market Rents - Admin adjustment 7 7 Transfer HSCN - CCG funding from programme to running costs 16 16 Rapid Support for Right Care Programme 65 65 - In-year Resource Limit 456,072 2,024 458,096

Deduction of accumulated programme cost deficit - confirmed ( 21,903) ( 21,903) Net Resource Limit 456,072 ( 19,879) 436,193

Closing distance Closing Baseline (under)/ over distance allocation target from Population per capita funding target £ £m % NHS Mid Essex CCG 388,407 1,163 (5.8) -1.3% NHS Thurrock CCG 174,118 1,181 (0.7) -0.3% NHS Basildon and Brentwood CCG 277,053 1,226 (1.1) -0.3% NHS Castle Point and Rochford CCG 184,667 1,258 3.0 1.3% NHS Southend CCG 188,063 1,296 (1.4) -0.6% Mid and South Essex Success Regime 1,212,308 1,215 (6.0)

NHS North East Essex CCG 344,642 1,323 (7.6) -1.6% NHS West Essex CCG 309,449 1,236 (2.3) -0.6%

Essex 1,866,399 1,239 (15.9)

Midlands and East 1,206 -1.3% England 1,239 0.0%

79 Appendix B Mid Essex CCG 2017/18 Financial Performance - as at 31 December 2017 (M9)

Year to Variance Forecast Forecast 2017/18 Actual to 15/01/2018 12:18 Date over/ Outturn at Variance over/ Budget Date Of Budget (under) M8 (under) eSpend Variance Programm £000 £000 £000 £000 % £000 % £000 PROGRAMME COSTS

Acute and Emergency Transport Services SLAs 236,420 176,786 178,205 1,419 1 238,062 54 1,642 Non Contracted Activity 3,281 2,461 2,625 164 7 3,500 1 219 MEHT non SLA 1,158 869 871 2 0 1,158 0 0 Mental Health 34,850 26,096 26,121 25 0 34,828 8 -22 Learning Disabilities 3,812 2,859 2,833 -26 (1) 3,858 1 46 Community Services 38,621 30,339 31,582 1,243 4 40,024 9 1,403 Urgent Care & Out of Hours 4,909 3,567 3,419 -148 (4) 4,782 1 -127 Continuing/Funded Nursing Care 28,118 21,105 22,838 1,733 8 29,891 7 1,773 Primary Care Services 3,147 1,936 1,845 -91 (5) 2,996 1 -151 Other Commissioning & Partnership Funding 1,306 979 895 -84 (9) 1,188 0 -118 GP Prescribing 54,897 41,172 42,928 1,756 4 56,872 13 1,975 Other Prescribing & Medicines Management 13,236 9,926 9,346 -580 (6) 12,492 3 -744

Safeguarding and Other Programme Management & GPIT 3,699 2,771 2,636 -135 (5) 3,603 1 -96

BCF - Protection of Social Care 8,398 6,298 6,300 2 0 8,398 2 0

TOTAL COMMISSIONING 435,852 327,164 332,444 5,280 2 441,652 99 5,800

Success Regime/STP 248 0 0 0 0 248 0 0

Quality Premium 0 0 0 0 0 0 0 0

Reserves 5,496 3,330 0 -3,330 (100) 2,296 1 -3,200

TOTAL CCG PROGRAMME COSTS 441,596 330,494 332,444 1,950 1 444,196 2,600

RESOURCE LIMIT FUNDING Programme Resource Limit - Confirmed -449,735 -337,351 -337,351 0 -449,735 0 Programme Resource Limit - Anticipated 0 0 0 0 0 0 TOTAL RESOURCE LIMIT FUNDING -449,735 -337,351 -337,351 0 0 -449,735 0

PROGRAMME COSTS NET IN YEAR -8,139 -6,857 -4,907 1,950 -5,539 2,600 (SURPLUS)/DEFICIT

CCG RUNNING COSTS Salaries & Allowances 6,493 4,823 4,375 -448 (9) 5,721 -772 CSU 466 350 326 -24 (7) 455 -11 Other Running Costs 541 508 980 472 93 1,324 783

TOTAL CCG RUNNING COSTS 7,500 5,681 5,681 0 0 7,500 0

Running Cost Resource Limit - Confirmed -8,361 -5,574 -5,574 0 0 -8,361 0

RUNNING COSTS NET (SURPLUS)/DEFICIT -861 107 107 0 -861 0

DEFICIT BROUGHT FORWARD 21,903 16,427 16,427 0 21,903 0

ACCUMULATED CCG (SURPLUS)/ DEFICIT 12,903 9,677 11,627 1,950 15,503 2,600

80 Appendix Ci Mid Essex Better Care Fund 2017/18

Annual Budget - As at 30th November 2017 (M8)

Scheme Budget to Actual to Variance to Forecast Forecast Forecast Health PoSC Total Date Date Date Outturn Variance 1718

BCF Schedule £000 £000 £000 £000 £000 £000 £000 £000 £000

Scheme 1 - ENHANCING COMMUNITY HEALTH & CARE SERVICES

Care Act Additional Costs 1D 839 - 839 559 559 - 839 - 839

Protection of Social Care

Older People Home Support Services (over 85s) 1C 5,972 5,972 3,981 3,981 - 5,972 - 5,972 Essex Cares Contract - Reablement 1A 1,458 1,458 972 972 - 1,458 - 1,458 ESD Social Workers (2. w.t.e.) 1G 91 91 61 61 - 91 - 91

- 7,521 7,521 5,014 5,014 - 7,521 - 7,521

Reablement - healthcare funding 1A 903 903 602 602 - 903 - 903

Community health services incl admission

Community Services - Provide 1E 12,344 12,344 8,230 8,230 - 12,344 - 12,344

CHC - Assessment Team 1F 699 699 466 466 - 699 699 Stroke Psychology 185 185 123 123 - 185 185

13,229 - 13,229 8,819 8,819 - 13,229 - 13,229

TOTAL SCHEME 1 14,971 7,521 22,492 14,995 14,995 - 22,492 - 22,492

Scheme 2 - MENTAL HEALTH MDT Support 104 104 69 69 - 104 - 104 Head of Dementia Post 7 7 15 10 10 - 15 - 15

TOTAL SCHEME 2 111 7 118 79 79 - 118 - 118

Scheme 3 - IMPROVING SUPPORT FOR CARERS

Carer Grants 3 154 154 102 102 - 154 - 154

PROGRAMME & ADMINISTRATION COSTS 10.0 12.7 23 15 15 - 23 - 23

Total Funding Accounted for in CCG Accounts 15,245 7,541 22,787 15,191 15,191 0 22,787 0 22,787

Scheme 4 - DISABILITIES FACILITIES GRANT 4 2,085

Total Value of the Mid Essex Ring Fenced Pool 24,871

Over/(under) Mid Essex CCG Non-elective Performance 2017/18 Target* Cumulative Actuals Cumulative cumulative Target Actuals target % M1 2,724 2,724 2,818 2,818 3.45% M2 2,810 5,534 3,132 5,950 7.52% M3 2,741 8,275 2,932 8,882 7.34% M4 2,815 11,090 2,980 11,862 6.96% M5 2,806 13,896 3,023 14,885 7.12% M6 2,873 16,769 3,133 18,018 7.45% M7 2,999 19,768 3,107 21,125 6.86% M8 2,950 22,718 21,125 -7.01% M9 3,080 25,798 21,125 -18.11% M10 3,083 28,881 21,125 -26.86% M11 2,777 31,658 21,125 -33.27% M12 3,055 34,713

34,713 21,125

*1718 Better Care Fund performance is being measured against target non-electives as set out in the operational plan using figures before QIPP is removed. Actual affordable non electives admissions targets (after QIPP deducted) are lower

81 Appendix Cii Mid Essex Better Care Fund 2017/18 iBCF Annual Budget - As at 30th November 2017 (M8)

Scheme Budget to Actual to Variance to Forecast Forecast ECC CCG Total Date Date Date Outturn Variance £000 £000 £000 £000 £000 £000 £000 £000

Home to Assess 500 500 333 0 333 500 -

Dementia Crisis Support 505 505 337 245 92 505 -

Building Nursing Home Capacity 92 92 61 67 - 6 92 -

Health Navigators 72 72 48 0 48 72 -

Discharge Co-ordinator - IDT 60 60 40 35 5 60 -

Dedicated CHC Social Work and MH worker 60 60 40 0 40 60 -

End of Life 200 200 133 31 102 200 -

Consultant Connect 51 51 34 6 28 51 -

Primary Care Streaming 91 91 61 10 51 91 -

ECC trusted assessors 211 211 141 35 106 211 -

Care Market Quality improvement initiatives e.g Prosper, End 322 322 215 54 161 322 - of Life Gold Standards, medicines training etc

Bridging service reablement 54 54 36 9 27 54 -

IDT Support Officer 13 13 9 2 7 13 - Falls 47 47 31 8 24 47 -

Total 634 1,644 2,278 1,519 502 1,017 2,278 -

82 Appendix D Mid Essex CCG Cashflow Statement - as at 31 December 2017 (M9)

- as at 31 December 2017 (M9)

£000 CCG Cash Limit as at 31 December 446,905 Anticipated Adjustments 2,600 Income and Opening Cash 8,898 Capital Cash 0 Forecast Maximum Cash Available 458,403 Forecast Cash Used 458,286 Forecast Cash Balance in Bank as at 31st March 2018 118 0

Apr to June July to Sept Oct to Dec Jan to Mar Actual Actual Actual Forecast TOTALS £000 £000 £000 £000 £000

BALANCE BROUGHT FORWARD 249 4,058 3,900 2,503 249

CASH IN Cash Limit - Main Funds 101,500 99,500 100,500 97,555 399,055 - Prescribing Income 12,288 13,002 13,160 12,000 50,450 VAT Refund 244 297 159 45 746 Other Income 6,448 815 429 212 7,904 Total Cash Income 120,480 113,614 114,249 109,812 458,155

CASH OUT Service Level Agreements/Contracts 87,041 85,191 87,738 83,695 343,666 PPA Topslice 12,288 13,002 13,160 12,000 50,450 Salaries, Tax, NI & Pensions 1,750 1,768 1,751 1,818 7,087 BACS 15,291 13,384 12,805 14,500 55,980 Capital Expenditure 0 0 0 0 0 Other 301 428 190 184 1,102

Total Cash Expenditure 116,670 113,773 115,645 112,197 458,286

BALANCE CARRIED FORWARD 4,058 3,900 2,503 118 118

83 Appendix E

Mid Essex CCG Expenditure/Accruals Profile and Underlying Surplus Position

Expenditure/Accruals Profile (Programme spend)

£25,000

£20,000

Acute SLAs & NCAs £15,000 Mental Health (incl. IAPT) Community Services CHC/Funded Nursing Care £10,000 GP Prescribing Other Commissioning

£5,000

£0 M1 M2 M3 M4 M5 M6 M7 M8 M9

Over/ (Under) Forecast Monthly M9 Budget to Date Actual to Date to Date Over/ (Under) Avg to M8 £000 £000 £000 £000 £000 £000

Acute Activity 179,247 180,830 1,583 1,861 20,152 19,617 Mental Health (incl. IAPT) 26,096 26,121 25 (22) 2,895 2,964 Community Services 30,339 31,582 1,243 1,403 3,489 3,673 Continuing/Funded Nursing Care 21,105 22,838 1,733 1,773 2,553 2,412 GP Prescribing 41,172 42,928 1,756 1,975 4,772 4,752 Other Clinical & Programme Services 29,205 28,145 (1,060) - 942 3,124 3,154 Reserves & Central Financing 3,330 - (3,330) (3,200)

330,494 332,444 1,950 2,848 36,984 36,572

84 Appendix F

Mid Essex CCG 2017/18 Risk & Mitigations Schedule - as at 31 December 2017 (M9)

RISKS MITIGATIONS Variance Net Risks/ included in (Mitigations) Risk Comments

forecast QIPP not included in Other Other e Issues e Funding Contract Potential Potential Prescribing Mitigations

outturn Performanc forecast £m £m £m £m £m £m £m £m £m

Acute Services 0.9 2.0 0.1 - - - - (1.9) 0.2 Mental Health Services 0.0 0.2 - - - - - (0.1) 0.1 Out of area patients Community Health Services 0.8 - 0.1 - - - - (0.1) - Continuing Care Services 1.8 - 0.4 0.1 - 0.0 - - 0.5 Prescribing 2.0 - 1.0 1.0 "No Cheaper Stock Obtainable" Other Primary Care Services (0.3) - 0.5 - - - (0.5) - Other Programme Services (2.7) - - - - 0.1 (0.2) (0.7) (0.8) Commissioning Services Total 2.6 2.2 1.1 0.1 1.0 0.1 (0.2) (3.3) 1.0 Running Costs - - - - - 0.1 - (0.1) - Unidentified QIPP ------

TOTAL CCG NET EXPENDITURE 2.6 2.2 1.1 0.1 1.0 0.2 (0.2) (3.4) 1.0

85 Appendix G

NHS Mid Essex CCG Statement of Financial Position

31 March 31 December 2017 2017

£000 £000 Non-current assets: Property, plant and equipment 25 13 Intangible assets 27 12 Other financial assets 0 0 Total non-current assets 52 25

Current assets: Trade and other receivables 5,368 4,729 Cash and cash equivalents 1 0 Total current assets 5,369 4,729

Total assets 5,421 4,754

Current liabilities Trade and other payables (28,960) (27,562) Borrowings (619) (666) Provisions (1,523) (782) Total current liabilities (31,102) (29,010)

Non-Current Assets less Net Current Liabilities (25,681) (24,256)

Non-current liabilities Trade and other payables 0 0 Provisions (1,320) (920) Total non-current liabilities (1,320) (920)

Assets less Liabilities (27,001) (25,176)

Financed by Taxpayers’ Equity General fund (27,001) (25,176) Other reserves 0 0 Total taxpayers' equity: (27,001) (25,176)

The CCG makes a payment run early in the month funded from the new cash drawdown received on the 1st of the month. The payments are accrued into the national financial system in the last few days of the previous month. For national cash flow purposes and for monitoring against the CCG's requirement not to overspend against the cash available - the payment has not left the CCG's bank account until the new month when the new cash drawdown is available. But the system (and the accounts at the year end) depict that the CCG is overdrawn on the last day of the previous month - reported in the Statement of Financial Position here as "borrowings".

86 Appendix H

NHS Mid Essex CCG Aged Debtors and Creditors

Aged creditors not yet authorised for payment - as at 31 December 2017

Overdue INVOICE AMOUNT £ Current 1-30 Days 31-60 Days 61-90 Days 90+ Days Grand Total NHS 2,334,796 563,515 441,396 240,399 1,466,424 5,046,531 Non-NHS 870,901 827,882 218,224 209,544 576,209 2,702,761 Disputed 270 270 270 201 96,665 97,675 Grand Total 3,205,967 1,391,667 659,890 450,144 2,139,298 7,846,967 Invoices within the above totals, 0 0 0 0 0 0 approved and pending payment Aged Creditors still awaiting approval 3,205,967 1,391,667 659,890 450,144 2,139,298 7,846,967

Position at 30 November 4,355,363 598,807 527,659 447,233 2,004,531 7,933,593

Overdue NUMBER OF INVOICES Current 1-30 Days 31-60 Days 61-90 Days 90+ Days Grand Total NHS 115 58 48 46 277 544 Non-NHS 239 86 48 40 219 632 Disputed 2 2 2 4 205 215 Grand Total 356 146 98 90 701 1,391

Position at 30 November 278 108 102 73 647 1208

Non-NHS Suppliers with Unpaid Invoices Aged 90+ Days Totalling £50k+ FRESENIUS KABI LTD £58,022.02 (made up of Update 9/1/18: Most of these invoices have been 6 different passed for payment. One invoice has been invoices) cancelled as it was duplicate. The only outstanding invoice is still waiting to be validated (Inv No. 900037962 dated 31/12/17)

Aged Debtors - as at 31 December 2017

Overdue INVOICE AMOUNT £ Current Aged 1-30 Aged 31-60 Aged 61-90 Aged 90+ Grand Total NHS 0 0 3,857 0 1,876 5,733 Non-NHS 0 12,698 0 2,161 8,454 23,313 Grand Total 0 12,698 3,857 2,161 10,330 29,046

Position at 30 November 12,881 2,161 232 5,380 15,098 35,751

Overdue NUMBER OF INVOICES Current 1-30 Days 31-60 Days 61-90 Days 90+ Days Grand Total NHS 0 0 3 0 2 5 Non-NHS 0 5 0 3 6 14 Grand Total 0 5 3 3 8 19

Position at 30 November 7 3 1 5 8 24

87 Appendix I

Mid Essex CCG CHC Retrospectives

Number of claims found eligible or part eligible 61 Number of eligible or part eligible cases where financial payment made or case transferred to another CCG 53 Number of eligible or part eligible cases where financial payment is still to be determined 8

Number of appeals as at 30 November 2017 43 Appeals resolved in December 2017 by local dispute resolution 0 Number of appeals received in December 2017 0 Total number of appeals in progress as at 31st December 2017 43

Number of claimants still eligible to appeal as at 30 November 2017* 15

Number of claimants still eligible to appeal as at 31st December 2017* 12

*Claimants have 6 months from date they are notified of the outcome to appeal the decision with Arden GEM. Thereafter further appeals can be made to NHSE and the Ombudsman - above figures reflect first stage appeals with Arden GEM

Amounts paid out* £000

2017/18 1,486 Apr-17 0 May-17 0 Jun-17 0 Jul-17 5 Aug-17 121 Sep-17 9 Oct-17 12 Nov-17 0 Dec-17 0

Totals paid out and reimbursed from the NHS England risk pool 1,633

Note: Financial settlement for 6 cases made year to date. Arden GEM on weekly progress updates following earlier confirmation all cases would be settled by the end of August 17

Remaining provision held by NHSE for 8 eligible/part eligible cases (excluding appeals) 456 Provision required from NHSE for current level of appeals (43) 777 1,233

* There is a delay of up to 6 months between eligibility decision (recorded above as completed) and redress payments being made due to time taken for claimants to collate the necessary evidence and the process of offers being made and accepted

88 Mid Essex CCG Appendix J 2017/18 Underlying Resource and Expenditure

Non Recurrent Total Recurrent Comments

(£000) (£000) (£000)

Baseline allocation including GPIT, CAMHS additional funding & BCF protection of 17/18 Published Allocation 451,727 451,727 social care funding Running cost allocation plus market rent adjustment (£7k) & N3 funding Running Cost Allocation 8,338 8,361 23 adjustment (£16k) Co-Commissioning Allocation - - - Identification Rules (-£6,770k), HRG4+ (£3,140k), Health and Justice (-£84k), further In-year Recurrent Adjustments (3,993) (3,993) Identification Rules adjustment (-£269k), ICD transfer (-£10k) NR: Return of Surplus/(Deficit) (21,903) (21,903) Co-Commissioning NR Allocation - - Other Non Recurrent Allocations 2,001 2,001 GP Receptionist training (£66k), Diabetes Transformation (£224k), GP Wifi (£155k), market rent (£68k), EAST paramedic rebanding (£165k), N3 funding (£217k), STP infrastructure (£248k), Cancer 62 days - pass through to MEHT (£334k), Urgent & Emergency Care (£153k), Perinatal tranche 1 (£117k), STP Communications (£50k), Chargeable Exempt Overseas Visitors (-£649k), Right Care Support (£65k), Transformation Funding (£400k), Safeguarding (£1k), Quality Premium (£189k), Winter Funding (£198k)

TOTAL ALLOCATION 456,072 (19,879) 436,193

Paramedic rebanding (£165k), Cancer 62 days (£334k), Chargeable Exempt Overseas Acute services 243,070 (350) 242,720 Visitors (-£649k) Mental Health services 34,711 117 34,828 Perinatal (£117k) tranche 1 Community Health services (main contracts) 40,024 40,024 Continuing Care services 29,891 29,891 Prescribing 56,872 56,872 Receptionist and Clerical training (£66k), Urgent & Emergency Care (£153k), GP WiFi Other Primary Care & Other Prescribing 15,114 374 15,488 (£155k)

Diabetes transformation (£244k), Property Services market rent (£68k), HSCN network Other Programme services 14,999 728 15,727 funding (£217k), Safeguarding (£1k), winter pressures (£198k) BCF Protection of Social Care Expenditure 8,398 8,398 HSCN network funding (£16k), Property Services market rent (£7k), Right Care funding Running costs 7,412 88 7,500 (£65k) Sustainability & Transformation Partnership (50) 298 248 STP central funding (£248k), STP Comms consultation funding (£50k) Other non recurrent mitigations 5,100 (5,100) - -

TOTAL APPLICATION OF FUNDS 455,541 (3,845) 451,696

CUMULATIVE (SURPLUS)/ DEFICIT (531) 16,034 15,503

In-Year (Surplus)/ Deficit (6,400) (Surplus)/ Deficit b/f: 21,903

89 Summary Ring-Fenced and Special Projects Reporting Position as at M9 (31 December 18)

Baseline YTD Non Rec or Funding Forecast Other Available Outturn Variance £000 £000 £000 £000

System Resilience (Winter Pressures) B 2,115 1,586 2,115 0 National Budget NR 198 149 198

Mental Health Emotional Well-being & Mental Health Transfomation (formerlyB CAMHS) 878 585 878 0 Eating Disorders B 187 125 187 0 Perinatal Mental Health Funding NR 235 176 235 0

Service Transformation Funding Bids Diabetes Treatment and Care Transformation Fund - Structured Education NR 86 0 86 0 - Treatment target NR 94 0 94 0

Other Ring-Fenced Allocations Primary Care Winter Access (16/17 funding) NR 122 0 122 0 Reception and clerical training - (Training Care Navigators and Medical Assistants) NR 66 0 66 0 GP WiFi NR 156 0 156 0

Infrastructure funding for STP - whole STP NR 248 186 248 0 HSCN Resource Limit funding received NR 233 174 233 0 Urgent & Emergency Care Centre - STP allocation - MECCG NR 153 0 153 0 Cancer 62 day target - MEHT pass through to MEHT NR 234 234 234 0

Estates and Technology Transformation IM&T Project Mobile working O - system 275 0 275 0 GPIT wifi O - system 402 0 402 0 GPIT video conferencing O - system 200 0 200 0 IT Procurement Project O - MECCG - 8 35 35 5k contriubtion to WEISF (Whole of Essex Information Sharing Framework) O - MECCG 5 0 5 0 Infrastructure System (Value TBA) O - MECCG 989 0 989 0

Estates Development of Witham Primary Care Reprovision Full Business Case O 200 22 200 0 Development of Maldon Healthcare Hub Full Business Case O 300 33 300 0 Chelmsford Urban Area feasibility O 114 0 114 0 Estates - Kelvedon&Feering Surgery Extension 175 0 0 -175

Other GP IT Investment - GPIT hardware refresh bid O - MECCG 185 0 185 0 - GPIT capital bid for infrastructure refresh O - MECCG 150 0 150 0 - GPIT Clinical Systems migrations bid O - MECCG 128 0 60 -68 - GPIT Digital dictation bid O - MECCG 135 0 135 0

90 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 10.5 Report Title: Primary Care Update – January 2018 Written by: Robert Evans, Debalina Gupta, Emma Doughty, Adrian Hayward, Martin Royal Purpose of Report: To provide the Board with an update on Primary Care matters Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services  Strategic Objective 4 To ensure there is full practice engagement informing  commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees N/A that have reviewed this document).

Patient & Public N/A Engagement: Significant Risks The key risks continue to be around the sustainability of identified: primary care / general practice, in particular around recruitment and retention of clinical staff. Recommendations and Members of the Board are asked to note the Primary Care decision/actions update. required by the Committee/Board:

PRIMARY CARE UPDATE

Submitted by: Viv Barnes, Director of Governance & Performance

Status: For noting ______

1. Introduction

This paper continues the process whereby regular updates are provided to the Board on the current work in Primary Care, main issues and concerns, progress towards achieving the GP Forward View requirements and the work that the Primary Care team is undertaking to support practices.

The paper should be read in conjunction with another paper on the agenda, which provides an overview of the Primary Care Foundations Programme upon which the CCG is embarking. Foundations focuses on developing and implementing a programme of work to support the resilience and sustainability of primary care / general practice in Mid Essex and will address a number of the issues and concerns that have been identified in this and previous primary care update reports. In taking this work forward, operational and transformational primary care will be managed and taken forward within different directorates under the new CCG structure but working very closely together.

Members are also reminded that the commissioning of and contracting for Primary Care services are currently undertaken on a shared basis between the CCG and NHS England (NHSE) under a Joint Commissioning arrangement.

2. List Closures

There are currently no practices within Mid Essex CCG that are operating a fully closed list arrangement. One application for closure was recently considered at the Joint Primary Care Commissioning Committee, but was refused. It is understood that a further application is likely to be submitted by this practice when guideline timetables allow and at least one further application for full closure is known to be being progressed by another practice for consideration by the Joint Primary Care Commissioning Committee.

From a position during 2017 where up to 12 practices were operating temporary list closures, there was an improvement in year to just 3 practices operating such an arrangement. However that position is now changing and there are currently 5 practices operating temporary restrictions on patient registrations. These are:

• Blyths Meadow Surgery, Braintree • Blandford Medical Centre, Braintree • Blackwater Medical Centre, Maldon • Longfield Medical Centre, Maldon • Coggeshall Surgery, Coggeshall

It is also anticipated that other practices will implement temporary restrictions in the near future to try and mitigate the operational pressures that they are experiencing.

The CCG Primary Care team has been regularly meeting with these practices and providing whatever support they can to facilitate a review of their positions. Opportunities of support

92 through the developing Primary Care Foundations have also been discussed and offered to these practices if it would help in them reviewing their positions and fully reopening their lists.

In addition to the above, joint meetings involving the CCG and NHS England contract managers are being held with these practices, to consider options around actions and possible support. At these joint meetings, it is ensured that practices are aware of the guidance that commissioners are following in relation to the management of these temporary arrangements and that appropriate actions and plans are being drawn up by practices to address the situation.

For information, the current number of patients registered with Mid Essex CCG GP practices was 390,039 as of October 2017, an increase of just under 1,000 from the previous quarter.

3. Retirements and Recruitments

Recruitment of GPs and other clinical staff continues to be a significant challenge to practices across Mid Essex, with the overall situation likely to deteriorate when known and anticipated retirements and / or reduction in current commitments and working arrangements become effective at some practices.

Mid Essex is involved in the Essex-wide EU GP Pilot with NHSE, and to date we have recruited 2 GPs through the scheme, one at Blyths Meadow and one at Blackwater. These two GPs are still in the training phase of their contract and both are due to re-take their simulated surgery assessments at the end of January.

Burnham Surgery has interviewed a GP from the scheme and will offer a position, dependent on the doctor passing her ILETS (English language) exams at the end of January. Mount Chambers are also interested in offering a position to a GP through the scheme, but are clarifying a few contract issues before confirming a start date. Other practices have expressed interest in the scheme and interviewed some potential candidates, but no offers of appointments have been made to date.

As the project itself will be ongoing for at least two years, with an aspiration to bring in around 40 GPs in total to Essex (10 of which will be for Mid Essex), opportunities will exist for other practices to participate over the project period.

In December NHSE announced a new international GP recruitment project across England, based on the Essex and Midlands pilots. This continues to support the stated aspiration to recruit 5,000 additional GPs to support primary care. On a Mid and South Essex basis, we have expressed an interest in recruiting a further 192 international GPs to support our primary care workforce gap. This is in addition to the current EU GP scheme referred to above and will be staggered over 3 years.

4. Primary Care Estates and IT

The team continues to work collaboratively with NHS England (NHSE) and practices, and is in discussion with local councils and developers, to produce and maintain an accurate premises inventory, pipeline of developments and planned developments and identify and benefit from sources of potential funding e.g. Section 106 Monies, Community Infrastructure Levies (CIL), and Primary Care Transformation Funding.

The main updates to make the Board aware of since the last primary care report are:

93 • Beacon Health Group have been identified as the occupant for the Beaulieu Site and are working with the developer to finalise the agreement to lease and document the details of the proposal.

• A project initiation document (PID) has been approved for a development between the Castle and Sible Hedingham practices of a single site, midway between the two main sites. This is conditional on Value for Money for the final scheme and on the basis that it will be operated as a single building.

• The Outline Business Case for a development at South Woodham Ferrers, moving the current three practices onto a single site along with community services has been approved. The Full Business case is scheduled to be delivered and approved before end of March with an estimated 12 months construction period thereafter.

• Work on the PID for the William Fisher Medical practice in Southminster has been put on hold for the time being pending further discussion on future practice and service configuration, with, once resolved, the proposal can be worked up fairly swiftly.

• Minor reconfiguration works have been completed at Whitley House.

• Options around optimising current clinical space at Braintree practices and future arrangements for utilisation of space dedicated for “health use” within the Manor St development are currently being reviewed and considered.

• An Outline Business case for Phase 2 of the Church Lane development has been submitted, this was always an integral part of the Church Lane development and the space is already leased.

• Lease issues on the branch surgery in Heybridge (pending delivery of the main Heybridge scheme) have been resolved.

• Current and former partners at the Blandford site have agreed a process to finalise lease arrangements to be concluded by March 2018.

Another key element of future developments / new builds of GP practices is the national drive for digital technology in Primary Care. This includes the NHSE Local Digital Roadmap (LDR) which is intended to demonstrate how each local health and care system will meet the ongoing requirement, set out in the Five Year Forward View, to maximise digital technology in order to improve the delivery of care to patients by 2020. One example of this is the digitising of paper medical records, a proposal for which is currently being considered by NHSE which would release some space in practice premises and may result in proposals to reconfigure that space.

The LDR has been updated and submitted for Essex CCGs and has gone through assurance. The CCG is currently refreshing its baseline with leads identified to take the 10 national priorities forward.

The online services requirement has increased in 2017/18 to 20% of all patients signed up for at least one online service (GP appointments and / or repeat prescriptions).

Mid Essex (overall) have achieved a 22% sign up rate, but there is significant variation across practices and there are 20 individual practices that have currently not achieved their 20% target (this is down from 26 practices in July, so progress, although slow, is being made).

Other information technology options and opportunities are also being explored as part of the “enabler” elements of our GP Forward View delivery plan and our Foundations Model, including areas such as:

• E-conferencing - we are exploring options for WebEx licences for localities and equipment to enable video conferencing,

• E-consultation – our proposal for use of the resource available to support this was submitted to NHS England December, the outcome of which is currently awaited.

• Digital Dictation – there is funding available to roll out digital dictation solutions to practices and a supplier engagement day is arranged before the end of January.

• I-plato messaging solution - has been trialled in 2 practices with improvements of 20% and 30% in DNA rates being experienced in the practices involved. Funds have been applied for to enable all practices to implement this technology if they are interested.

• Ardens, a clinical system support arrangement, is being made available to all practices currently using the TPP SystmOne clinical system, with similar arrangements being made available to other clinical system users across Mid Essex CCG.

• Insight Solutions have been commissioned to provide advice, support and training on workflow optimisation techniques and processes on a practice specific basis to every practice across Mid Essex.

• Wifi implementation is well under way, with BT working with practices to undertake audits to understand any issues or challenges that may need to be addressed prior to implementation.

• Signposting / Navigator training has been commissioned through Equip, through which an average of 2 receptionists per practice will be able to be trained. It is expected that the first training sessions will be held in March.

5. Estates and Technology Transformation Fund (ETTF)

ETTF approval was given last year for all the CCG’s estate bids and most of the IT related bids. The IT bids were similar to proposals from other Essex CCGs and the delivery programme is being managed on an Essex Wide basis by the Commissioning Support Unit (CSU).

As part of the IT funding, every practice in Mid Essex was provided with the facility to undertake remote working, with laptops rolled out to each practice. The CCG is working with practices to ensure that the equipment enhances ability to work with care homes and provide patient treatment on a remote basis, with use and activity being monitored centrally by the CSU.

The Essex CCGs are in a procurement process for a new ‘Health and Social Care Network’ (HCSN), this will provide secure connections for clinical / patient data and will replace the current N3 connection.

All practices will have a new network provider and practices with particularly narrow bandwidth will see upgrades and improvements over the first 12 months.

95 The Maldon development is still being progressed and is at the latter stages of the Outline Business Case process but cannot be progressed further until the new service model has been bench tested and consulted upon. Notwithstanding this, the CCG is progressing development of the business case on a no bed option and meetings are planned with Maldon District Council to agree the funding and procurement framework whilst the schedule of accommodation is being finalized with key stakeholders. The timescale for delivery of the completed OBC remains February.

The Heybridge development sees a PID in place and submitted to NHS England for their consideration. A further question raised about the status of the development, and whether or not the landowner or the developer would take primacy in the design and build of the new facility, will be discussed at a planned meeting with the landowner’s agent in January with the CCG and NHSE present.

The Witham development is progressing with indicative design and space requirements being developed for discussion and approval with the constituent practices. ARCADIS will be developing the business case for this financial year. This is contingent on securing the largest practice buy in to the scheme (Fern House). Their buy in is linked to the dispensing activity which they are considering, and the CCG will be meeting the practice before the end of January to fully understand their position.

It is proposed to defer the planned feasibility study for urban Chelmsford to identify estate requirements and the proposed works on the Kelvedon Health Centre site until 2018/19, due to the very limited time available to undertake this former in the current financial year and the lease issues which need resolving in the latter case.

It is possible that the ETTF process will be extended for another year.

6. Demand Management

Management of demand, both for hospital based activity and that being experienced within primary care, continues to be a significant focus for the CCG and its member practices.

The main focus of this work is the management of winter pressures demand, with general practices having to deal with unparalleled demands for patient appointments and home visits and exceptionally high volumes of A&E attendances and emergency admissions being experienced by all acute trusts locally and nationally. The situation is being further exacerbated due to high levels of staff sickness.

It is reassuring to note that uptake of flu immunisations across Mid Essex has shown a slight improvement on that achieved last year. Supplies of vaccine are still available and practices are being encouraged to continue vaccinating vulnerable people and other key patient groups who have not yet been immunised.

In December, NHSE made additional funding available to help address this increase in demand, with bids required within a very short timescale and covering a range of service areas. Following contact by the primary care team to every practice, bids were received from 7 practices who, subject to receiving the necessary funding support, could put arrangements in place to provide additional appointments over and above their core hours arrangements including some weekend appointments.

All these bids were approved by NHSE and funding of c £50,000 has been agreed to support these practice arrangements which will enable another 155 appointments (including a mix of

96 pre-bookable and book on the day appointments) to be made available each week between now and the end of March 2018.

Work is also ongoing with practices to more appropriately utilise the skills of the professionals that are available and aspects of this work, in particular around workflow optimization support and the introduction of Ardens clinical system support methodology, are outlined elsewhere in this report.

7. Primary Care Sustainability

The Board will know that sustainability of general practice base is a key priority for commissioners and the CCG is continuing to work with practices where there is most concern about their future sustainability with NHS England fully engaged and LMC involved as appropriate. As referred to in a separate report on the agenda, the Mid Essex CCG Primary Care Foundations Programme has been developed to address the current resilience and future / ongoing sustainability issues and concerns around general practice. This local approach is in addition to a range of support arrangements which are available through the NHSE Vulnerable Practice Fund, and the NHSE General Practice Resilience Fund.

A number of local practices have been supported through these funding streams in both 2016/17 and 2017/18. It has recently been announced that some further resilience funding has been identified centrally for 2017/18 and the primary care team is working with practices to identify and submit appropriate cases in a bid to access this funding. It has also been confirmed that the national resilience funding programme will continue for a third year in 2018/19 and further information is waited on process and the timeline for submitting bids.

8. Locality Development

Work is continuing with each of the 7 localities to develop and define their priorities, future working arrangements and delivery plans and locality meetings are continuing to take place at most of the localities.

Clinical and Practice management leads in 6 localities have been identified and they are attending locality meetings and working with the CCG to address issues affecting their locality.

There is a recognition that each locality is at a different stage in their development and organic changes are taking place within some localities.

Two localities are looking at adopting a virtual hub model to facilitate joint working between practices within the locality. Discussions are in the initial stages but it is anticipated that progress will be made for them to be able to test out some hub delivered services in the early part of 2018/19.

Chelmsford locality held a meeting in December where it was agreed that some projects needed to be identified to test and facilitate partnership working. Further work is now needed to take this forward.

Internal discussions between practices within and across localities are currently taking place and new partnerships and collaborations may well emerge in the next few months.

97 9. GP Forward View Update

The main focus of the GP Forward View is to support the resilience and sustainability of general practice / primary care to enable it to meet the current and future challenges of the NHS, implementing and delivering transformational change to provide improved access and enhanced quality to as broad a range of appropriate services as possible.

The key themes of the GP Forward View Delivery Plan are Access, Workforce, Workload, Infrastructure & Models of Care.

Work is progressing in each of these areas across MECCG, brief summaries of which are provided below:

Extended Access

• The national requirement is for 50% of patients to have extended access to primary care, including weekends, by 31st March 2018, increasing to 100% coverage by 31st March 2019.

• An Extended Access working group has been established within Mid Essex and a detailed project plan has been submitted to NHSE. The working group is meeting monthly and key messages will be communicated to all practices.

• It is proposed that the CCG will be delivering extended access as per the national requirement and in compliance of the identified 7 core requirements, for a third of its population by October 2018, followed by a further third in December 2018 and the remaining population by Feb 2019.

• It is envisaged that the entire mid Essex population will have extended access with on the day and pre-bookable appointments by the end of March 2019.

• It is not a requirement for every individual practice to offer extended access, proved that such access is provided / commissioned on behalf of its patients. Within MECCG it is proposed that this requirement is best achieved through the development and establishment of access hubs. A business case for the IT infrastructure to support these hubs has already been agreed.

• A workshop is being organised for all GP practices outlining the key requirements of Extended Access.

• A briefing on Extended Access is also being provided to the CCG’s Patient Reference Group at its January meeting.

• Taking forward, mobilising and delivering extended access across the CCG will be a key element of the Primary Care Foundation programme.

Workforce

• EU GP recruitment and the development of a Workforce Strategy across Essex are both examples of work that is progressing in this area.

98 • An STP wide workforce plan is also being finalised and a modelling tool to identify alternative skill / staff ranges and opportunities within practices has also been developed.

• A realignment of Community Education Provider Networks (CEPN), with Mid Essex now joining Southend and Castle Point & Rochford CCGs in forming a South East Essex CEPN, will also enable greater consistency and achieve improved economies across our STP area in this work.

• The main initial emphasis for use of CEPN resource will be the undertaking of audits, workforce analysis work and the identification of skill mix across member practices to inform decisions on training, development and recruitment strategies.

• Workforce is a cornerstone of the Primary Care Foundations Programme and as such programme leads will focus heavily on this area and in particular the opportunities of reviewing skill mix and introducing alternatives to the traditional models of sole GP and nurse provision of primary care services to patients.

• It is already known that a number of practices are already employing or looking at alternative skill mix arrangements to better enable them to meet the demands of their patients. These include the increasing use of Pharmacists in a broad range of relevant roles, physiotherapists and emergency care practitioners amongst others and these will be further developed and expanded as part of the foundations programme.

Workload

• Addressing increasing demands within limited capacity is an ongoing issue.

• To provide support and assistance to practices in addressing and identifying potential ways of improving matters a nationally developed programme of 10 High Impact Changes has been pulled together.

• Some of the suggested changes are already being taken forward within practices and a range of schemes and training events are now in place to ensure comprehensive awareness of and access to available support schemes.

• Examples of the work already ongoing include receptionist signposting / navigation training, development of options and plans around implementing e-consultations and the use of appropriate IT enabled applications (apps) to support patient information, self- care and appropriate access to services.

• In addition to the above, the CCG is also supporting practices / localities with work around workflow optimisation and there is increasing evidence of practices working collaboratively and availing themselves of efficiencies and improvements in overall capacity.

Infrastructure

Premises and IT are recognised as being key enablers to effective working in primary care. Much of the work taking place in these areas is reflected in sections 4 and 5 of this paper covering Primary Care Estates and IT and Estates and Technology Transformation Fund (ETTF) respectively.

99 There is also currently underway a full audit of GP IT with support from the CSU. This is to implement improvements highlighted from the review of the Wanna-cry virus and other possibly security threats, with improvements needed in equipment, systems, cabling, service speeds etc. in practices.

ETTF funds will enable the audit and hopefully the majority of the rectification work needed.

Models of Care

Whilst work is in hand and continuing to address changes in the models of care, including the requirements of extended access as referred to above, the main thrust of this work will now be taken forward as part of the Primary Care Foundations Programme which is the subject of a separate paper to the Board

12. Recommendation

The Board is asked to note the contents of this report.

100 Report to: Part 1 Board Meeting Date: 25 January 2018

Agenda No: 11.1 Report Title: Mid and South Essex STP CCG Joint Committee Chair’s Report Submitted by: Professor Mike Bewick (Chair, STP CCG JC) Written by: Viv Barnes (Interim Committee Secretary, STP CCG JC) Purpose of Report: To provide a report on the business conducted by the Joint Committee on behalf of the Mid and South Essex CCGs Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services  Strategic Objective 4 To ensure there is full practice engagement informing  commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees The minutes upon which this report has been based Various that have reviewed this have been approved by the STP CCG JC. document). Reports Submitted to Board only: Date signed-off by Executive Team. Standing (NB: With the exception of standing agenda items, all reports submitted to the Board must be agenda signed-off by the Executive Team) item Have any financial implications been signed Finance Officer signing off N/A financial consequences off by the Chief Finance Officer? 

Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: None

Patient & Public N/A Engagement: Significant Risks None identified: Recommendations and Members of the Board are asked to note the business decision/actions conducted by the STP CCG Joint Committee at its meetings required by Execs/ on 8 September, 19 October and 29 November 2017. Committee/Board:

101 Since the last update to the Mid Essex CCG Board, the Mid and South Essex STP CCG Joint Committee has met in public on three occasions and considered and addressed the following issues:

Meeting of 8 September 2017

• The appointment of Caroline Rassell as STPJC Lead Accountable Officer was noted. • An options paper for Ophthalmology services to support the continued shift of activity from an acute to a community setting, where clinically appropriate, was considered. STPJC members supported the option of reviewing current care pathways with existing providers with a view to promoting a consultant-led triage service alongside enhanced community provision.

Meeting of 19 October 2017

• The STPJC received a presentation on the Local Maternity Services Transformation Plan setting out the proposed changes to maternity services over the next 5 years to deliver the aims set out in the national maternity review ‘Improving outcomes of maternity services in England’. The plan was supported by STP JC members subject to linking it to the ‘For Thurrock in Thurrock plans, the provision of more information on the expectations around communication and information sharing, the inclusion of a section on substance misuse and consideration being given how to integrate the plan with other services such as social care, fire and police. • Members received an update on the STP Pre-Consultation Business Case (PCBC) and the timetable for agreeing whether to go out to formal consultation on these plans. • The Commissioning Intentions, setting out the commissioning priorities for the Mid and South Essex CCGs for 2018/19, were reported in public.

Meeting of 29 November 2017

• The STP JC received the final version of the PCBC, as signed off by NHS England, and a final draft of the consultation document on the proposed changes to hospital services across the Mid and South Essex STP. There were a number of questions from the public which were either addressed at the time or subsequently followed up in writing. Members were asked to agree to proceed to a public consultation on the planned changes to hospital services commencing on 30 November 2017 for a period of 14 weeks. Seven votes were received in support of the PCBC moving into a consultation period and 3 members abstained from voting.

Recommendation

Members of the Board are asked to note the business conducted by the STP CCG Joint Committee at its meetings on 8 September, 19 October and 29 November 2017 and to receive the minutes of these meetings.

102 Sustainability and Transformation Partnership Joint Committee (STPJC) Public Meeting 8th September 2017 2:00pm West Barn, High House Production Park, Vellacott Close, Purfleet, RM19 1RJ

Present: Dr Mike Bewick (MB) Independent Chair

Ms Caroline Rassell (CR) Lead Accountable Officer, STP JC

Dr Caroline Dollery (CD) Chair, NHS Mid Essex CCG

Ms Mandy Ansell (MA) Accountable Officer, NHS Thurrock CCG

Mr Ian Stidston (IS) Accountable Officer, NHS Southend and NHS Castle Point & Rochford CCGs

Mr John Leslie (JL) Accountable Officer, NHS Basildon & Brentwood CCG

Dr Anand Deshpande (AD) Chair, NHS Thurrock CCG

Dr Jose Garcia (JG) Chair, NHS Southend CCG

Dr Kashif Siddiqui (KS) Chair, NHS Castle Point & Rochford CCG

Dr Arv Guniyangodage (AG) Chair, NHS Basildon & Brentwood CCG

In Attendance: Ms Jayne Mason (JM) Commissioner, NHS Castle Point & Rochford CCG

Ms Rachel Webb (RW) Locality Director. NHS England

Ms Nicola Adams (NA) Head of Corporate Governance, NHS Thurrock CCG (minute taker)

Ms Maureen Henes (MH) Member of the Public, NHS Mid Essex CCG

Dr Donald McGeachy (DM) Mid Essex CCG Medical Director, attending as member of the public

Ms Lesley Buckland (LB) Thurrock CCG Deputy Chair, attending as a member of the public

Mr Mike Fieldhouse (MF) Save our NHS Southend, Member of the public

Mr Simon Ashley Cross (SAC) Save our NHS Southend, Member of the public

Mr Trevor Arnold (TA) Regional Director Partnerships – Siemens Healthcare, attending as Member of the public

Apologies: Ms Viv Barnes Director of Corporate Services, Interim STPJC Secretary, NHS Mid Essex CCG

103 1. Welcome and Apologies MB welcomed all to the meeting. There were no apologies noted from the membership. Apologies were received from Viv Barnes (Interim STPJC Secretary).

All members introduced themselves and provided some background as to their role within the Sustainability and Transformation Partnership Joint Committee (STPJC).

MB welcomed members of the public and highlighted the importance of consulting with members of the public, particularly in the design of services to ensure that the NHS can deliver quality services that are safe and delivered in the most efficient manner.

2. Register of Interests MB presented the register of interests, noting that CR’s interests would now change and asked members to declare any interests other than those on the register. Members confirmed there were no further interests.

3. Questions from the Public MB welcomed any questions from members of the public.

SAC commented that the actual STP Plans for this area are very unclear and requested clarity on any other plans for the STP. CR was happy to send the latest version of the STP noting that it is a complex read.

ACTION: CR to circulate the STP Plan to Simon Cross.

SAC asked which Acute Hospital services will be transferred to central units rather than delivered locally. CR stated that the movement of any specialties is still work in progress but these plans will be shared at a Joint Committee meeting in October, which will be held in public.

SAC asked how community care would be implemented during the transition to the STP in light of GP shortages. CR stated that this runs to the heart of the 5 CCGs. The advantage of the STPJC focusing upon Acute Services is that it will allow the CCGs the capacity and the time to concentrate on local services. Each CCG is developing the delivery plan for local services in line with the goals of the STP

IS stated that all CCGs are looking at primary and community services to ensure there is a seamless transition between services and CCGs are focused on how to create a major transformation of services to support GP Practices, incorporating flexibility to provide the best services. IS offered a separate meeting with interested parties regarding Southend CCG specifically.

ACTION: IS to offer a separate meeting with members of the public from Southend regarding service design within Southend.

SAC raised concerns that over the last 22 years there has been a gradual reduction of Practices throughout Essex and Suffolk, noting that this area has the lowest number of GPs per head of population. It was also noted that there is a struggle in these areas to recruit. This is a real problem and therefore assurance over how this is to be managed would be welcomed.

MB stated that the primary focus is to ensure the there is sufficient service provision within the system and that this is what the STP is seeking to address.

MF raised a question regarding the Terms of Reference of the STP JC, noting that these required Committee members to make decisions on behalf of the 1.2 million STP population whereas the Health and Social Care Act required CCGs to commission services based on 104 assessing the needs of their local population. MF asked whether these aims were contradictory and, if so, whether it was appropriate for CCGs to approve the Committee’s Terms of Reference without a change to the primary legislation.

CR explained that the formation of the STPJC has been incorporated within CCGs’ constitutions, including the delegation of responsibilities to the STPJC to make decisions, i.e. planning of healthcare on a 1.2m population basis for areas where commissioning as one group provides greater control and influence over the Provider landscape. CCGs cannot delegate accountability and so they will still be accountable to the local population as per the Health and Social Care Act. Ultimately the CCGs are the accountable bodies, but the STPJC is making decisions for healthcare where this is appropriate and within their delegated remit of responsibility. All local services will still be decided locally, however where it makes sense to make decisions collectively, these will be made by the STPJC. MF asked whether this would create conflicts of interest. CR agreed that this was a complex area and that there may be times when members feel conflicted, but this will need to be worked through. . MB expressed the view that this is something that needed to be tested and the governance arrangements underpinning the STP JC will continue to be developed, but this is about working together across the 5 CCGs to get the best value and services for the needs of the public.

SAC stated that the differences in population made it impossible for ‘one size to fit all’. IS added that the STPJC provides a consistent thread for decision making. SAC agreed that the Consultant led diabetes scheme (STP decision) was a positive example of how this can work well in practice.

MF advised that he remained concerned about how this will work. MB agreed to provide a more formal considered response outside of the meeting.

ACTION: MB to formally respond to the question raised by MF.

4. Announcements and Items of Interest MB announced that CR has been appointed as the STPJC Lead Accountable Officer. The Committee noted the appointment.

MB also noted that the STPJC was not yet formally constituted but this should be completed by Friday 15th September 2017.

5. Minutes of the Last Meeting The minutes of the meeting held on 5th July 2017 were AGREED as an accurate record.

6. Matters Arising and Action Log STP Joint Committee Terms of Reference It was noted that the ToR had been reviewed by Accountable Officers and shared with CCG Chairs and that final changes have been made by NHS England. The document presented was the final approved version.

The Committee RECEIVED the Terms of Reference (ToR) of the Joint Committee.

7. Ophthalmology JM presented the proposal for Ophthalmology and provided background on the need to review ophthalmology pathways, including an ageing population and advances in technology. Currently services are reverting to Acute (a network review suggested that 50% of the activity doesn’t need to be seen in the hospital) and this is not sustainable. The Essex Plan for Ophthalmology has therefore been developed to support the continuing shift of activity from a hospital setting along with a need to transform service delivery. The intention is to work together as a health system to 105 use the resources available to ensure continued sustainability of quality services.

JM noted that there are approximately 20,000 referrals into Southend and 12,000 into Mid Essex hospitals.

Given the current capacity issues in the Hospital Eye Sector, the status quo was not considered sustainable. It was noted that a STP clinical network found that 50% of this activity could be safely managed in an alternative setting. However, to date, additional community capacity has been commissioned by CCGs on a piecemeal basis.

Three options were therefore appraised:

• Do nothing • Procurement of new service providers • Transformation of pathways with existing providers.

The proposal supported and recommended to the STPJC was option three, promoting a consultant led triage service alongside enhanced community provision.

The main barrier to this option is IT. There is a working solution for this within the plan. Training would be included within this. Lastly, there is a need to find premises for a consultant-led Multi- Disciplinary Team.

The STPJC were asked to approve option 3, commencing with the development of a project plan for the transformation programme.

JG welcomed the proposal and agreed that a full procurement isn’t the best option. It was noted the project plan would need clear timelines and goals.

ACTION: JM to provide a clear timeline for the Ophthalmology transformation programme to the STPJC.

IS stated that it is encouraging to see that this is being taken forward in this way and there should be recognition of the hard work it has taken to get to this stage. IS asked about capacity in the community to deliver this solution. JM responded that the ophthalmology committee is very engaged and keen to implement across the patch, particularly as it links to national resources. It was noted that there are 150 Practices across the patch so 10 appointments in each would be a good delivery. This would enable greater capacity and improve relationships with community providers.

CD congratulated the team, acknowledging that it is a huge piece of work. She noted that patients have struggled to book and to attend appointments and recommended working with patient groups to ensure the new service is accessible.

AG asked for assurance that the proposals had consultant body support and oversight. JM confirmed that the support does exist and that this is a clinically-led, bottom up solution with all actively engaged. JM also noted that there is a dedicated project manager from BTUH.

SAC shared that there was a potential solution to IT (Squeeze) used within a medical centre in Nottingham.

AD asked how this would fit with existing contracts for optometrists. It was noted that in South Essex they have started to commission local services using existing providers but a different pathway.

106 KS explained this is a very positive development from a primary care perspective which will reduce the number of direct GP referrals.

MB referenced Optical technologies and online reporting and asked if the service would be future proofed for patient self-monitoring. JM agreed to get a working group to look into this.

ACTION: JM to get a working group to look into future-proofing the Ophthalmology service.

MB asked for assurance regarding the governance for this proposal. JM stated that it had been shared with commissioners and with the clinical network, where questions were raised. Engagement with patient groups would be the next step. AG and JL agreed to review at pace when this had been considered by their CCG CR noted that when the STPJC is fully constituted the decision to proceed will come from the STP JC.

CD suggested that there should be a paper presented to CCG Boards to update them on progress with the STPJC and items of business.

MB summarised that the STPJC cannot agree the item today, but will do so when formally constituted. MB will present an information paper for CCGs to take to their Boards. This will include guidance to clarify governance processes for the Boards.

JG welcomed further clarity at the next meeting about how the governance works and what the procedure is for decision making at the STPJC and how it goes back to CCGs.

The Committee APPROVED in principle (to be ratified at the next meeting) Option 3 and the commencement of work with current providers on the transformation programme.

8 Questions form members of the public MF asked how decisions would be made if there was any disagreement between members.

CR confirmed that decisions by the STPJC are binding. Decisions will hopefully be by consensus, but if not, this will be by majority, with the Chair having a casting vote in the event of a split vote as set out within the STPJC terms of reference. CR added that the STPJC has more power working as one rather than five CCGs working separately. MF suggested that this was contrary to the founding principles of CCGs.

SAC commented that with regard to Ophthalmology; something is needed across the country and the decision made today is a step forward. This shows how well decisions at the STPJC can be done. However, the rationale for other decisions was not so obvious and it was important, therefore, that future decisions are informed by clinicians.

TA confirmed he was happy with transformation (for Ophthalmology) rather than procurement because this is in the spirit of collaboration. TA was interested to see potential savings being reinvested, but there is an assumed 20% saving. TA asked for an explanation of these assumptions as commissioning from primary care could be more costly. JM stated that it is a general principle to assume that a community service is cheaper, but that there was nothing to substantiate this. MB added that the proposal was intended to improve the quality of service and that savings, whilst important, were not the main driver for change.

9. Items for Decision There were no items for decision at the meeting because the STPJC had not yet been fully constituted. The recommendation in relation to Ophthalmology services will be ratified at the next meeting.

It was noted that in future any decision making items will be taken before further questions from

107 the public.

10. Items for Information The meeting etiquette principles were RECEIVED.

11. Any Other Business There were no items of any other business.

Close of Meeting The meeting closed at 14.56 pm.

Date of Next Public Meeting 2:15 pm on Friday 6th October 2017 in the Boardroom, Phoenix Place, Christopher Martin Road, Basildon SS14 3HG. [Subsequently rescheduled to 19 October 2017 at 9.30 am.]

MB noted that meeting venues are being rotated across the patch, but acknowledged that notification of meetings to the public needed to be imporoved. He also acknowledged the importance of public involvement and engagement.

SAC suggested that a suitably large venue.would be needed for the October meeting as there was likely to be a high public turnout for the discussion of the PCBC.

108 Sustainability and Transformation Partnership Joint Committee (STPJC) Public Meeting 19th October 2017 9:30am Boardroom, Phoenix Court, Christopher Martin Road, Basildon, Essex, SS14 3HG

Present: Dr Mike Bewick (MB) Independent Chair

Ms Caroline Rassell (CR) Lead Accountable Officer, STP JC

Dr Caroline Dollery (CD) Chair, NHS Mid Essex CCG

Ms Mandy Ansell (MA) Accountable Officer, NHS Thurrock CCG

Mr Ian Stidston (IS) Accountable Officer, NHS Southend and NHS Castle Point & Rochford CCGs

Mr John Leslie (JL) Accountable Officer, NHS Basildon & Brentwood CCG

Ms Lesley Buckland (LB) Deputy Chair, NHS Thurrock CCG, deputising for Dr A Deshpande.

Dr Jose Garcia (JG) Chair, NHS Southend CCG

Dr Kashif Siddiqui (KS) Chair, NHS Castle Point & Rochford CCG

Dr Arv Guniyangodage (AG) Chair, NHS Basildon & Brentwood CCG

In Attendance: Ms Viv Barnes (VB) Director of Corporate Services, Interim STPJC Secretary, NHS Mid Essex CCG

Ms Nicola Adams (NA) Head of Corporate Governance, NHS Thurrock CCG (minute taker)

Mr Alan Hudson (AH) Member of the Public, representing Thurrock PPG and Thurrock Commissioning Reference Group

Mr Mike Fieldhouse (MF) Save our NHS Southend, Member of the public

Ms Kathryn Whitehall (KW) PriceWaterhouseCoopers LLP

Ms Harriet Aldridge (HA) PriceWaterhouseCoopers LLP

Morven Wilson (MW) Member of the Public, Grunenthal

Anita Donley (ADo) Independent Chair, Mid and South Essex STP, attending as a Member of the Public

Matt Rangue (MR) Chief Nurse, NHS Southend CCG

Apologies: Dr Anand Deshpande (ADe) Chair, NHS Thurrock CCG

109 1. Welcome and Apologies MB welcomed all to the meeting. Apologies were noted from Dr Deshpande (NHS Thurrock CCG Chair), for whom Ms Buckland was deputising.

MB welcomed members of the public.

2. Register of Interests MB presented the register of interests. It was noted that further updates are required to complete the register.

MB asked if there were any declarations of interest, other than those held on the register, there were none.

ACTION: Members to email updates on their interests to VB.

3. Questions from the Public A member of the public (MF) explained concerns around the constitution of the STPJC. CR briefly explained the governance of the STPJC as a ‘joint committee’ and the decision making process as set out within the terms of reference of the STPJC.

ACTION: MB to provide a formal response to MF regarding decision making within the STPJC.

4. Announcements and Items of Interest There were no new announcements or items of interest.

5. Minutes of the Last Meeting The minutes of the meeting held on 8th September 2017 were AGREED as an accurate record.

6. Matters Arising and Action Log Action 08/09/2017-3ii – IS stated that there had been engagement with the patient group forum on the vision for out of hospital services in Southend and the next meeting of the group is planned for 19th October where there will be further discussions.

Action 08/09/2017-7i – The timeline for Ophthalmology transformation programme will be completed before the next meeting.

Action 08/09/2017-7ii – It was noted that a working group had been established and was operational.

7. Local Maternity Services Transformation Plan MR explained that the Local Maternity Services Transformation Plan was a good example of the CCGs working together across the STP alongside community provision and mental health. Maternity services were noted as ‘good’ across the STP, meaning that Mid and South Essex is a safe place for women to give birth, however there is always potential for improvement.

MR explained that all STPs were required to create a Maternity Transformation Plan. The plan sets out how the Mid and South Essex STP will work towards transformational change of maternity services to deliver the national aims identified with Better Births (2016) (Five Year Forward View of NHS Maternity Services in England). The Plan has been assessed by the NHS England Regional Team and while there are minor amendments required to the benchmarking data and finance sections, the overall assessment is that the plan meets the key lines of enquiry for a transformation plan able to deliver the aims within Better Births.

MR noted that the plan had been co-produced with local stakeholders and is supported by the LMS Steering Group. It also includes an assessment of local population and current services, 110 taking best and good practice from across the patch to mirror across the STP area so that all mothers receive the gold standard.

MR asked the STPJC Members to support the Mid and South Essex LMS Transformation Plan transition.

Questions were raised from Members as follows:

MB commented that the plan presented was very comprehensive. There were however some concerns around predictions on numbers of births and what this means for diseases going forward. However, it was noted that this would be a Public Health issue.

MA stated that there were opportunities to link this to the Thurrock CCG Estates Plan and into the hubs and the new-builds. It was also noted that Purfleet Care Centre will not exist in the future.

ACTION: MA and MR to liaise and link the Maternity Transformation Plan to the ‘For Thurrock In Thurrock’ plans.

CR ask for assurances that there has been consultation with the local authority with reference to weight/smoking in pregnancy and work around ‘pre-birth’. MR stated that this was comprehensive on the health side, but that social care may need more development. MR also stated that there was representation of Public Health (PH) in Essex on behalf of the three Local Authorities, but there was no cost against the PH section of the plan; this needs to be strengthened.

AG commented that the plan was comprehensive, but raised potential issues around communication and responsibilities of the different parties involved in the pathway. The need for a description of expectations around communication from providers etc was acknowledged. MR agreed this needed to be included, this is part of the digital agenda. The need for information sharing was noted and will be expanded in the proposal.

ACTION: MR to expand the maternity transition proposal to include more information on the expectations around communication and information sharing.

JG re-iterated the need to get communication right, particularly with the Acute Hospital and the need to ensure ‘standard’ care across the STP. MR highlighted that Helen Farmer at NHS Thurrock CCG is leading within childrens services and championing consistent standards.

IS commented that the plan was an essential document for the system that will link into transforming primary care and looking to Local Authority partnerships to implement the pathway. It was noted that although there is a section on Alcohol misuse, there was no section on substance misuse and that needs to be included. MR agreed.

ACTION: MR to include a section on substance misuse within the LMS Transformation Plan.

CD commented that the LMS was a very holistic, comprehensive plan. CD offered (as a member of the Mental Health concordat) to work with MR to integrate with other services (social care, fire, police etc.), building on current good practice, and how to influence consultants around mental health.

ACTION: CD to work with MR to integrate with other services on the LMS Transformation Plan.

MB summarised the item concluding that the most important areas were around social care and communication (developing digital processes); noting that the choice agenda is a challenge. The Plan was comprehensive at pulling all of this together. From a governance perspective it 111 was noted that the plan had been distributed to all of the AOs, but this was the first time presenting it to the STPJC.

Members were asked to support the Mid and South Essex LMS Transformation Plan transition.

Members APPROVED the Local Maternity Services Transformation Plan.

8 Meeting Dates Members were asked to note the proposed meeting dates for 2018.

CR questioned whether the dates were in line with the timetable for the PCBC and advised that the April meeting may need to be moved to March.

ACTION: CR / MB to review meeting dates and ensure they are in line with the timetable for the PCBC.

9. Update on Pre-Consultation Business Case CR updated Members on progress with the pre-consultation business case (PCBC), noting that it had been approved at the last meeting of the STPJC, but that there was an elongated timetable to enable engagement with colleagues and hospital clinicians, allow CCGs to further define local health and care models and to enable co-production of the document with partners and service users. A number of key milestones were noted as follows: . At the Regional Panel on 25th September it was agreed that the PCBC should progress to the national level. This was also agreed by the Oversight Group for Service change and Reconfiguration Panel on 2nd October. . Submission to the National Investment Committee on 4th October was positive, but some clarification on activity and finance was requested. The STPJC team and hospital teams have drafted a letter of clarification, which has now been provided to the committee. A decision is expected at the next meeting on 3rd November. . The Clinical Senate met and discussed specialised services at hospitals within the STP, it was noted that work was continuing around the stroke pathway, and presentations to the CCGs around stroke care are being planned. . Work is continuing on key documents to share with stakeholders and the public. The consultation document is being shared with CCGs, Local MPs and other stakeholders.

An STPJC meeting in being planned Mid-November to approve the PCBC to launch the consultation prior to the 22nd November deadline (this is the expected date for the Chancellor of the Exchequer to announce funding), and so the PCBC must be ‘out to consultation’ before it is announced, otherwise the STPJC would not be eligible for funding.

MB referred to a discussion (at the last STPJC meeting) around engagement with primary care and asked if any progress had been made. It was noted that clinical feedback had been obtained from the Clinical Senate.

IS stated that Southend Hospital have been engaging with primary care recognising the importance of engaging with consultants.

MB thanked CR for moving this forward within such a short timescale.

10 Commissioning Intentions It was noted that the STPJC Commissioning Intentions (approved by the STPJC on 15th September 2017) sets out the commissioning priorities for 2018/19. This has now been shared with relevant Providers and so can be reported publicly.

The paper presents the commissioning priorities for the 5 CCGs, looking at the whole of the

112 provision from community to acute, focusing on the integration of services.

The STPJC NOTED the Commissioning Intentions, acknowledging that these had been shared with each of CCG Boards.

11 Meeting Etiquette VB stated that the document had been updated to clarify processes for the STPJC, in particular for nominating deputies and attendance at meetings.

The STPJC NOTED the change in the meeting etiquette protocol.

12 Questions from Members of the Public AH acknowledged the progress on the PCBC to date, but stated that progress on technology so that machines and systems are inter-connected should be more prominent. It should also be acknowledged where some plans cannot move on until the technology is sufficient.

MB commented that nationally there is a digital strategy (which is trying to address information sharing problems), but we can do more locally, in particular looking at the means of communication. MB acknowledged that technology is one of the most important issues we are facing, noting that the new Director at NHS Digital is making this a priority. However, we need to ensure that we have this within all of our plans, whilst recognising the resourcing and implementation challenges that this involved.

IS noted that whilst there are problems, progress was being made, for example the majority of practices are using the same IT systems which supported greater integration and the provision of Out of Hours services.

CR, acknowledging that these are pertinent issues, suggested that Martin Callingham (Chief Information Officer for the three hospitals) be invited to attend a future meeting (Jan) to discuss connectivity within the hospitals and outside of hospital with primary care and community services. CD added that there are also problems with information sharing with Social Care and so inviting Local Authority colleagues would also be beneficial.

ACTION: Digital / technology to be included on a future agenda.

ACTION: Martin Callingham and a representative from Social Care to be invited to attend the STPJC to discuss technology.

12. Any Other Business There were no items of any other business.

Close of Meeting The meeting closed at 10.22 pm.

Date of Next Public Meeting 3rd November 2017 – Rayleigh

113 Sustainability and Transformation Partnership Joint Committee (STPJC) Public Meeting Wednesday 29th November 2017 3:45pm The Marconi Room, Chelmsford City Council, Civic Centre, Duke Street, Chelmsford CM1 1JE

Present: Dr Mike Bewick (MB) Independent Chair

Ms Caroline Rassell (CR) Lead Accountable Officer, Joint Committee and SRO Local Health & Care Accountable Officer, NHS Mid Essex CCG

Dr Caroline Dollery (CD) Chair, NHS Mid Essex CCG

Ms Mandy Ansell (MA) Accountable Officer, NHS Thurrock CCG

Mr Ian Stidston (IS) Accountable Officer, NHS Southend and NHS Castle Point & Rochford CCGs

Ms Lisa Allen (LA) Acting Accountable Officer, NHS Basildon & Brentwood CCG

Dr Anand Deshpande (AD) Chair, NHS Thurrock CCG

Dr Jose Garcia (JG) Chair, NHS Southend CCG

Dr Kashif Siddiqui (KS) Chair, NHS Castle Point & Rochford CCG

Dr Arv Guniyangodage (AG) Chair, NHS Basildon & Brentwood CCG

In Attendance: Mr Andrew Pike (AP) Director of Commissioning Operations (East), NHS England

Ms Viv Barnes (VB) Director of Corporate Services, Interim STPJC Secretary, NHS Mid Essex CCG

Ms Celia Skinner (CS) Chief Medical Officer, Basildon & Thurrock University Hospitals NHS Foundation Trust

Ms Nicola Adams (NA) Head of Corporate Governance, NHS Thurrock CCG (minute taker)

Ms Jo Cripps Chief Officer – STP Local Health and Care

Apologies: None

1. Welcome and Apologies MB welcomed all to the meeting. There were no apologies from the Membership.

MB welcomed members of the public. 114

2. Register of Interests MB asked members to declare any interest not already recorded in the Register of Interests. Members confirmed there were none, with the exception of KS who confirmed that he was not currently working for Spire Wellesley or conducting medical appraisals. His declared interests were therefore as a GP trainer and a GP partner at the Rushbottom Lane Surgery (which was also a member of the GP Healthcare alliance and Essex Clinical Research Network).

MB made a statement regarding recent media reports about ‘CareRooms’, to which he had been affiliated. MB advised that he had provided mentoring advice to Dr Harry Thirkettle (CareRooms Medical Director) through an NHS England scheme which supported the development of clinical entrepreneurs. There was no commercial or business arrangement in place for this, it was a voluntary role. MB had not declared this on the Register of Interests as it was not a pecuniary interest, although it had now been recorded. To ensure there was no further perception of a conflict, MB confirmed that he would be standing down from mentoring Dr Thirkettle.

CS was invited to comment on ‘CareRooms’ and stated that this was a model that might be considered for the future but was not being actively pursued at this time.

Declarations declared by members of the STP CCG Joint Committee are listed in Mid Essex CCG’s Register of Interests. The current and historic registers are available upon request via the Secretary to the Joint Committee.

Declarations of interest from sub committees

N/A.

Declarations of interest from today’s meeting

None declared.

2. Questions from the Public MB introduced this item confirming that the STP CCG Joint Committee was a meeting held in public, but was not a public meeting. Members of the public were able to observe the proceedings and were given the opportunity to ask questions under this agenda item. Normally questions would also be taken at the end of the meeting under agenda item 8. MB confirmed that with only one specific topic on the agenda - the decision whether to progress to public consultation on the proposed changes to hospital services in mid and south Essex - questions from members of the public would only be taken under agenda item 2, because if the recommendation was agreed there would be a formal consultation process to obtain public feedback and if it was not approved, there would be no further questions to answer at this point in time.

MB stated that a number of written questions had been received in advance. Members would endeavour to answer questions today, but some might need further enquiry and consequently might not be answered immediately. A written response would be provided for all written questions submitted in advance and any verbal questions to which a full response could not be given.

MB invited questions from the floor.

Alan Hudson (AH) (Thurrock patient representative). AH explained it was clear that change was required to A&E services because they were not sustainable. However he queried why the original proposal in relation to the configuration of A&E services had been amended if it had clinical support and asked what else had changed in the proposals now being presented to the STPJC.

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CS recognised that the local health economy was struggling and that the focus of the consultation was upon changes to acute services. However, the STP plan included primary and community care working alongside the Acute Hospitals so that patients did not present unnecessarily at A&E. This would provide a more efficient service and was vital to the success of the In Hospital strategy. CS also stated that in describing the network of hospitals, there were a number of designs in principle, some of which were separating emergency and elective care and to bring together specialised services under one umbrella to deliver improved patient outcomes.

CS also clarified that feedback from the public, stakeholders and staff was one of the reasons for the change in direction in relation to A&E services. It had become apparent that the three hospitals in the group were not ready for the proposed changes to the A&E ‘front door’, particularly Southend Hospital. Recruitment difficulties had also eased, so the hospitals were more confident they could continue to provide safe levels of emergency care. The interaction with Primary and Community care was important to ensure all groups were working together to help patients make the right choices before presenting at the front door of A&E.

Simon Cross (SC) (Save Southend). SC expressed his concerns over the pre-consultation business case, in particular the assumptions that were made about moving more services into a primary care setting. With high vacancies in primary care and many GPs planning to retire, SC said that he had significant concerns about the burden upon primary care and the impact on GP workload.

CS confirmed that primary care capacity issues and the potential impact on workload were recognised and that the Primary Care model might need to change in the future. Any changes to care pathways would focus upon ensuring patients received the right service at the right time.

CD commented that efforts were being made to work with local practices and the LMC, investing money, resource and skills in primary care. Practices were working together to develop wider teams that reflected local needs to serve their patient population.

SC accepted the wider model was reasonable, but expressed concern about the recruitment crisis. He was also concerned about the changes within the hospital model in terms of transporting patients between hospitals and the impact on hospital staff working across three sites.

CS advised that the hospital group saw approximately 900 patients a day, with 300 admitted. The PCBC was essentially a series of design conversations and high level planning assumptions. Within that high level plan of 900 patients, 15 might be required to travel to another hospital. For example under the stroke pathway, patients would attend their local hospital where they would be assessed and receive advanced imaging and/or be prescribed any necessary medication. They would then be moved to Basildon (where specialised stroke services were provided) for a 72 hour period of medical intervention. The joining of the specialised teams across the three hospitals meant that staff at the three locations could work as one team with shared protocols / ethos / rotas. This did not necessarily mean staff would be working at different sites all the time, in fact they were likely to stay where they currently worked, but they would have the opportunity to develop skills in other areas with a consequent upskilling of the overall team which would be advantageous to staff, patients and the hospital. Only a minority of staff would need to move across different sites and all staff would be consulted on any potential impact.

Pauline Amos (PA) (Support the NHS Halstead) PA said that she believed the messages in the consultation (PCBC) documents from NHS England/CCGs did not ‘pan out’. She provided examples of previous public engagement such as in Northumbria in 2013/14 where promises had not been kept about transport to other 116

hospital sites or that hospitals were not going to be downgraded. PA suggested that the STP’s plans were a precursor to the establishment of an Accountable Care Organisation and the privatisation of NHS services.

PA had provided written questions before the meeting as follows:

Q1 – Where in the PCBC does it say this is all leading towards the creation of an Accountable Care Organisation (ACO)?

CR stated that there had been discussions at the STP Programme Board, with a paper in October that looked at options available to the STP in terms of future organisational models. However, no decisions had been made because this would need a change in primary legislation. At the present time the STP was concentrating on building a strong primary care service, utilising CCGs as the route to deliver this, and working with the hospitals on the reconfiguration of acute services.

AP confirmed that the PCBC was not creating an ACO. AP reminded members and the public that the NHS operated in accordance with parliamentary and government policy, with clear mandates from NHS England. NHS services were and would remain free at the point of care.

Q2 – The consultation has not started … In the minutes from the last meeting, it states that funding [for the PCBC] is dependent on the consultation being launched by 22nd October, the date of the Autumn budget. What funding is this? And having missed the deadline will that now not be available?

CR confirmed that it was a requirement by 22nd November (the date of the national budget) that the PCBC had to be signed off by the national Investment Committee and there needed to be a plan in place to go out to consultation. On 3rd November the PCBC was approved in principle by the Investment Committee and this decision was confirmed in the budget. To get the capital funding, there was still a need to go out to consultation and to bid for available resources (a potential £118m).

Chris Gasper (CG) (patient representative, Southend) CG enquired how the consultation would take place, particularly in relation to the transport element. He also commented that there was too much detail in the PCBC and therefore care was needed how its messages were conveyed and communicated.

MB agreed that this was an important point and that the consultation must be robust and easy to understand. MB stated that a communications plan had been developed to support the consultation with a timetable of public events, user friendly documents and questionnaires, etc.

Dr Shan Newhouse (SN) (GP in Halstead) SN asked whether the renal dialysis service in Chelmsford was going to be closed down.

CS stated that the references to ‘renal’ within the PCBC related to inpatient beds and there were no plans to change dialysis provision which needed to be near patients’ homes. Out Patient services would continue as usual. Dialysis provision would not change, but the hospitals did want to develop a single specialist team.

SN went on to ask how seriously ill patients would be transported safely, noting that this required specialist staff and resources to keep patients stable.

CS stated that the STP investment plan included the provision of additional patient transport services. Discussions were being held with the East of England Ambulance Service NHS Trust about a partnership/in-house operation looking at patient numbers and their needs to ensure maximum clinical benefit and minimal waits. 117

Eric Watts (EW)

EW had submitted a written question before the meeting as follows:

How will the JCC ensure sufficient patient input into the planning of emergency care to ensure that patients receive appropriate treatment at their local hospital? (This applies to patients taken ill at home and not to accidents that may occur elsewhere.)

EW confirmed that the question had already been answered to some extent, but noted that there was still much more work to be done.

Cathy Trevaldwyn (CT) (Public Governor, EPUT)

CT had provided a written question before the meeting as follows:

Reference is made to the ‘STP Joint Committee will also play a role in decision making about Learning Disability Services within the existing pan-Essex arrangements’. In some of the Essex provision (South Essex) Autism services run alongside Learning Disability services, will the STP Joint Committee also play a role in the decision making within the existing pan-Essex arrangements for Autism in the same way?

CR confirmed that autism services would fall within the delegated decision making remit of the STP JCC.

Kate Sheean (KS) (Save Southend NHS) (not present at meeting)

KS had provided written questions before the meeting.

MB stated that KS’s first question in relation to CareRooms had been answered at the outset of the meeting. The other questions were technical in nature and so a comprehensive written answer would be provided in due course.

MB highlighted the importance of making change safe.

MB asked for any final questions.

PA commented that the 491 page PCBC was very long for people to read and digest and enquired whether the STP had looked at other evidence apart from UCL (a metropolitan service) regarding stroke. CS stated that a comprehensive evidence search, including evidence from services relevant to the Mid and South Essex STP, had been undertaken and this was detailed in one of the STP documents.

ACTION: CS to send the evidence reference document to PA.

3. Minutes of Previous Meeting The minutes of the public meeting held on 19th October 2017 were AGREED as an accurate record.

4. Action Log from Previous Meeting Members noted the update provided within the papers against each action. Verbal updates were provided as follows:

Action 08/09/2017-7i – The Ophthalmology timeline would be presented at the next STPJC meeting.

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Action 19/10/2017-2 – Updates to the register of interests had been provided and this action was now complete.

Remaining actions were in progress, but not yet due.

5. Matters Arising from last meeting (not on agenda) There were no matters arising from the previous meeting.

6. Public Consultation and Pre-Consultation Business Case (PCBC) CR introduced the PCBC noting that the briefing paper summarised the current status.

CR referred to the consultation document, confirming it was still in draft and several changes had been made to the version previously circulated to members. Further clarity has been provided on a small number of sections to ensure consistency between the PCBC and the consultation document. In particular, there had been clarification in relation to general surgical and gastroenterology services, which were proposed to be located at Broomfield Hospital. CR also noted that the plain text version of the consultation had now been enhanced by graphics and there had been contribution from all system partners to make the document more readable and explicit. The consultation document had been shared regularly during its development and there had been a high level of discussion. Following feedback and approval from the STPJC and provided that any further required changes were minor, a final version would be provided to NHSE to enable the consultation launch tomorrow.

CR noted that the case for change had been approved by the CCGs, highlighting the need to work in partnership with the three hospitals for sustainable acute services. In addition, the PCBC was required to enable access to funds for capital for investment to facilitate the changes within the hospitals.

The ‘Consultation Institute’ had been commissioned to review the document and dialogue was ongoing to reflect any proposals or suggested enhancements during the consultation period.

Public events had been organised and were detailed on page 13, which summarised the types of meetings and key dates for consultation across the STP and within each CCG area. The purpose of the events was to present the proposals and to note any key issues that needed to be taken into account.

CR confirmed that there were no major events/meetings planned in December to ensure that the engagement was effective, particularly as the PCBC was yet to be approved. Engagement activities included a Facebook page, hosting some live webchats in December, with larger engagement events thereafter. This would provide a more personal element to the consultation. Engagement was also planned with Patient Participation Groups (PPGs) within each of the CCG areas.

CR asked the STPJC to approve the PCBC for progression to consultation around the proposed changes to hospital services.

MB explained that part of the role of the STP was to gain assurance around equality and asked if this process would meet the Public Sector Equality Duty (PSED). CR confirmed that the PSED was considered in the PCBC and was one of the areas scrutinised by the Regional Assurance process. Discussions during the assurance process highlighted that, although it was clear that only small numbers of patients were potentially affected by the proposals, there was further work to be done to gather information on how the proposed service changes could affect members of the protected groups as identified by the Equality Act. It had been agreed with the regional assurers that this work would be undertaken as part of the consultation process with a report on

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progress at the next STPJC meeting.

MB stated that these plans had been developed over a long time and had been subject to a considerable degree of scrutiny. MB noted that the STPJC and CCGs had a duty to be transparent and open and emphasised the importance of everyone around the table sharing the plans with their local communities and making sure any concerns were voiced. MB also reminded members of the duty of candour and the duty to serve patients.

Questions were invited from Members:

KS referenced the different funding mechanisms and asked CR to elaborate on the detail included on page 185, paragraph 9.3 of the papers.

CR stated that one funding mechanism available to CCGs was the ‘LIFT’ companies who could develop premises and lease them back to the NHS. There had also been good partnership working between the Local Authorities (LAs) and CCGs in terms of funding smaller infrastructure with a number of developments funded by LAs in Thurrock, Mid Essex and Basildon. Public sector capital funding was not ruled out however it was fairly complicated to access. There would be other opportunities moving forward to enable CCGs to access resources for primary and community services. Some indicative figures of the funding required were provided in the PCBC and funding streams had been identified for these.

KS ask what current funding was set aside for CCGs. CR responded that for Mid Essex and Thurrock resources were available from LAs or third party developers. The resources required by other CCGs were currently under discussion and so there was no total figure yet for the entire STP footprint.

JG commented that the document lacked a clear commitment for investment outside of the hospital setting. An indicative investment of £118m had been identified for Acute services and JG stated that he would like there to be similar clarity regarding the investment required for primary care reconfiguration (GPs, Mental Health and Community Health Services).

CR gave a commitment to provide un update at the next STPJC Part II meeting in January in terms of each CCG’s plans for out of hospital (OOH) investment. All CCGs must ensure that robust primary care plans were established during the consultation period so that there was an overarching STP view of the primary care and OOH offer.

KS raised concerns that previous investment proposals for Primary Care had not been delivered. Whilst this was understandable because of pressures elsewhere in the system, the plan for A&E services depended on a robust primary care infrastructure (including Community and Mental Health).

AG noted the challenge for CCG JC members who remained accountable to their Boards and local population. In addition to the queries from Basildon and Brentwood CCG’s Board about OOH funding, concerns had also been raised regarding the funding allocated for transport to transfer patients between hospitals.

CS explained that the cost associated with non-resilient small Acute teams was not sustainable. Joining small number of specialists across the hospital group would support savings and achieve better patient outcomes. CS stated that the majority of care for the frail and elderly would be delivered locally and in the future would be delivered from primary care services, according to the needs of the patient. If there was a clinical need for a patient transfer, this would be arranged.

AD noted that the consultation was for the hospital strategy and was concerned that there was

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no equivalent strategy for primary care or recognition of the impact upon primary care.

CD emphasised the importance of presenting the Primary Care strategy in January to identify those impacts and consequent requirements.

KS stated that the plans in place for all CCGs were very good in terms of locality planning but were weakened by a lack of supporting resources.

AP reminded members that the recommendation was to consider and approve the PCBC to go out to public consultation; a decision was not being sought on the proposed changes to services as this would be undertaken at the end of the consultation period. The consultation process would consider the proposed changes, taking feedback from stakeholders, the public, CCGs and other partner organisations and using these to refine the overarching strategy. It was important to understand the OOH offer for each CCG, but this could be provided during the consultation period and AP offered NHS England’s support in reviewing these plans.

JG noted that the concerns raised were in relation to the primary care strategy, not the Acute elements of the strategy, on the basis that the two were mutually interdependent.

AP acknowledged the concerns raised and noted that the PCBC provided a clear, sensible vision about the overarching OOH strategy, however there was a need to ensure this vision was fully supported within CCG’s OOH plans. AP noted that all CCGs were making good progress in developing the OOH offer, but that more detail was required about how this would be delivered. This could be clarified during the consultation phase.

AD echoed the comments made by KS and JG regarding the lack of assurance about Primary Care investment.

MB clarified the recommendation to go out to public consultation for the Acute reconfiguration for a period of 14 weeks with feedback on the outcome planned for May / June. At that point, the STPJC would assess the support for the proposals and whether there were sufficient resources committed to approve it at that point.

MB went on to ask each CCG Chair to indicate how they intended to vote, in response to which KS, JG, AD, AG stated that they were considering abstaining from voting. MB then offered to pause proceedings to enable members to consider their positions.

Following a brief adjournment, MB asked each STPJC member to provide their vote and the reasons for their decision.

JG confirmed that he was speaking on behalf of the Southend CCG Board (clinicians and non- clinicians) and advised that he would abstain from voting not because he disagreed with the consultation proposals but because of concerns about the required Primary Care investment.

AD stated that Primary Care sustainability was also the main concern of Thurrock CCG’s Board and consequently he would also abstain from voting because of the lack of clarity about the accompanying Primary Care strategy.

AG confirmed that Basildon and Brentwood CCG’s Board was supportive of the consultation going forward and therefore he had decided upon reflection to vote in favour of the recommendation, but reiterated the need for clarity on the out of hospital approach.

KS (Castlepoint & Rochford CCG) thanked acute colleagues for their work on the PCBC, but noted that primary, community and social care services were a key component to these proposals and so he would abstain from voting.

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CD stated that there had been much debate at the Mid Essex CCG Board and with member practices about in and out of hospital care, however the CCG Board had concluded that there would be stagnation if the consultation did not proceed as the current system was not sustainable. CD would therefore vote in support of the recommendation.

LA agreed that it was important to open up the discussion and hear the views of the public and other stakeholders and advised that she was consequently voting in support of the recommendation.

IS stated that it was positive to have a debate around the OOH requirement and that investment was needed going forward to ensure delivery. This had been discussed with the Boards of both Southend and Castlepoint & Rochford CCGs, as a result of which IS was voting in support of the recommendation on behalf of both CCGs.

MA commented that this had been a difficult journey so far. There was a need for resources and discussions around pathways across acute and primary care, however it was appropriate to consult upon these proposals. MA would consequently support the recommendation.

CR confirmed her support for the recommendation in her capacity as Accountable Officer for Mid Essex CCG.

MB explained the governance around voting as set out within the STPJC Terms of Reference. MB explained that an abstention was classed as neither a ‘yes’ or ‘no’ vote and would therefore not count towards a majority decision. MB did however note that by abstaining from voting, members had sent a clear message regarding the issues that needed to be addressed during the consultation process.

The final vote was recorded as follows:

Member Organisation Vote CD, CCG Chair NHS Mid Essex CCG For KS, CCG Chair NHS Castle Point & Rochford CCG Abstain JG, CCG Chair NHS Southend CCG Abstain AG, CCG Chair NHS Basildon & Brentwood CCG For AD, CCG Chair NHS Thurrock CCG Abstain LA, Acting Accountable Officer NHS Basildon & Brentwood CCG For IS, Accountable Officer NHS Castle Point & Rochford CCG For IS, Accountable Officer NHS Southend CCG For MA, Accountable Officer NHS Thurrock CCG For CR, Accountable Officer NHS Mid Essex CCG For

Seven votes were received in support of the PCBC moving into a consultation period. Three members abstained from voting.

The STPJC APPROVED the decision for the PCBC to go out to consultation

CR outlined next stage of the process and asked members if there were any changes required to the current draft consultation document. LA confirmed that there were some minor wording changes proposed at the Accountable Officers meeting, otherwise there were no other changes required. The document would therefore be forwarded to NHS England for final assurance in order to commence the consultation tomorrow.

AG asked for clarification how the outcome would be notified to CCG Boards. CR stated that the decision should be noted at the CCG Boards and any feedback provided to the STPJC. IS noted that it should also be recorded at the clinical executive meetings. 122 8. Any Other Business

There were no items of any other business from the membership.

Members of the public asked whether any further questions could be raised. MB reiterated his earlier explanation that the PCBC was now approved for public consultation so any further questions could be raised during the consultation process itself.

Members of the public requested that action be taken to ensure that the STPJC meetings were more accessible, particularly for hard to reach groups. More visible name plates should be considered as well as arrangements for those with hearing difficulties (noting that one member of the public was lip-reading).

ACTION: Further consideration be given to the environment in which the public meetings are held to ensure that all members of the public (specifically hard to reach groups) were accommodated.

9. Close of Meeting The meeting closed at 6.22 pm.

10 Date and time of Next Joint Committee Meeting in Public: 3:15pm on Friday 2nd February 2018 at the Priory Suite, Southend CCG, Harcourt House, Harcourt Avenue, Southend on Sea, Essex, SS2 6HT.

123 Report to: Part 1 Board Meeting Date: 25 January 2018

Agenda No: 12.1 Report Title: Audit Committee Chair’s Update Report Written by: Head of Corporate Governance Purpose of Report: To provide the Board with a briefing on issues discussed at the Audit Committee meeting held on 18 December 2017. Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services Strategic Objective 6 To ensure the CCG has the necessary governance, capacity and  capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees N/A that have reviewed this document). Reports Submitted to Board only: Date signed-off by Executive Team. N/A (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: N/A Patient & Public Engagement: N/A Significant Risks The report sets out any significant risks reported to Audit identified: Committee on 18 December 2017. Recommendations and The Board is asked to note the content of this update report. decision/actions required by the Committee/Board:

124 Main Issues discussed at the Audit Committee meeting held on 18 December 2017

• The Chair welcomed Stephanie Beavis and Lawrence Newell, External Auditors from KPMG, to their first Mid Essex CCG Audit Committee meeting. It was noted that KPMG had received the necessary Letter of Etiquette from Ernst Young, the CCG’s former auditors. Arrangements had been made for KPMG to review EY’s files. • The External Audit Plan was submitted by KPMG and noted by the Committee. The Chair requested that although external audit needed to be consistent in reaching their Value for Money opinion, he would appreciate the CCG’s continued under-funding being recognised in their final report. • The Committee noted that the draft Procurement Governance audit report had been issued for management comment. • The Committee noted that the Lead Commissioner Governance audit had been completed and the draft audit report would be issued shortly. • The Local Counter Fraud Specialist (LCFS) advised that there had been no new fraud referrals and provided an update on current investigations. • It was noted that further security awareness training would take place on 17 January 2018, which would cover security of the building and personal security of CCG staff. • The Committee reviewed the Strategic and Corporate risk registers and raised queries on a number of risks. The risk register has been updated for the January 2018 Board meeting. • The Head of Contracts provided members with an update on the sign-off of contracts for 2017/18 and staffing difficulties currently being experienced by the Contracts Team were noted. • The Committee noted the minutes from the most recent meetings of Finance & Performance, Live Well, Quality & Governance and Primary Care Commissioning Committee meetings. • The Committee agreed revised Terms of Reference, which are included on the agenda of the January 2018 Board meeting for approval. • The Committee approved an amendment to the CCG’s Constitution to increase the number of elected GP members from four to five. • The Committee approved an amendment to the CCG’s Standing Orders to enable the extension of an elected member’s term of office in exceptional circumstances to a maximum of six months. • The Committee approved the draft revised Anti-Fraud and Bribery Policy. • The Committee received the quarterly Emergency Planning, Resilience and Response (EPRR) and Business Continuity Management (BCM) Assurance Report. Members noted that the Pandemic Flu Plan had been reviewed, a number of emergency planning exercises would take place in 2018 and an audit of BCM would commence on 19 January 2018. The number of trained loggists had been increased and further Strategic Command training for on-call managers would take place in February 2018. The Cyber-Attack action plan had mostly been completed. • The Committee approved a revised Incident Response Plan.

125 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 12.2 Report Title: Quality and Governance Committee Chair’s Update Report Written by: Acting Deputy Director of Nursing & Quality Purpose of Report: To inform the Board of the main actions arising from the Quality and Governance Committee held 12 December 2017 Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees that have reviewed this document).

Patient & Public Engagement: Significant Risks Risk Register is a Quality and Governance Committee standing identified: item. Recommendations and The Board are asked to Note the action points from the Quality decision/actions and Governance Committee meeting held on 12/12/2017 required by the Committee/Board:

126 Risk Register

Updates to the Risk Register were noted.

Information Governance (IG)

IG training is on track to meet the requirement for Level 2 of the IG toolkit. The Committee was made aware of the Data Protection Bill, which is due to be written into law during 2018.

Policies Approved

Please see separate Board paper for details

Infection Prevention and Control

Further MRSA bacteraemia have been reported and C difficile cases are going to exceed the ceiling figure in place by year end, as detailed in the Patient Safety and Quality report..

Mental Health

No report was submitted to Committee. This will be followed up to ensure that there is assurance of performance from the host commissioner, North East Essex CCG.

Safeguarding

Major concerns as to the level of child suicide within mid Essex were brought to the Committee’s attention, along with plans to understand the current position and to seek any common themes.

There has also been an increase in Domestic Homicide Reviews once investigations have been completed. The committee requested a deep dive to understand all outcomes and themes.

Patient Safety

Further Never Events were brought to the committee’s attention, bringing the year to date total to 4 from all acute providers:-

• 1 retained object • 3 wrong site surgery

127 Report to: Part 1 Board Meeting Date: 25 January 2018

Agenda No: 12.3 Report Title: Finance & Performance Committee Chair’s Update Report

Written by: Ruth Blake, Deputy Chief Finance Officer Purpose of Report: To provide the Board with a briefing on issues discussed at the F&P Committee meetings held on 26 September and 21 November 2017. Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services  Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity and  capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees that have reviewed this document). Reports Submitted to Board only: Date signed-off by Executive Team. N/A (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: N/A Patient & Public Engagement: N/A Significant Risks The report sets out any significant risks reported to F&P identified: Committee on 26 September and 21 November 2017 Recommendations and The Board is asked to: decision/actions required • Note the content of this update report. by the Committee/Board:

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The Finance & Performance Committees of 26 September and 21 November 2017 wished to draw to the Board’s attention to the following items:

26 September 2017

2017/18 Financial position (M5) and the Medium Term Financial Plan

The Committee noted the reported acute activity cost pressures due to very significant over-activity reported in non-elective admissions for M5. There continues to be a large volume of uncoded activity and other accounting and coding issues – largely due to implementation of the new patient recording system, Lorenzo, at MEHT. Intensive work was continuing to reconcile the data. The current expectation was that the Lorenzo issues would be resolved by September so that the November position utilising October data would show an accurate position. There were also continuing cost pressures within the adult CHC budgets. GP prescribing was forecast to overspend significantly due to the “No Cheaper Stock Obtainable” cost pressures.

QIPP slippage of £3m was reported in M5 against the £23.5m target. A further net risk of £2.6m QIPP delivery was reported. The Committee noted concerns around the QIPP Joint Delivery Board as future membership was uncertain due to restructuring at the 3 acute trusts. The Committee also noted that there was slippage on a number of key QIPP schemes for a variety of reasons including capacity within the CCG.

The Committee noted plans to continue work on the 2018-19 budgets with the CCG being required to deliver a £9.3m surplus in 2018/19. Concerns about the impact of the data quality issues on planning for 2018/19 were noted.

Transition to Joint Committee

There was a discussion regarding the implications of the move to Joint Committee arrangements for the CCG and the transition risks. The Committee noted the need for the split of responsibilities on the scrutiny of finance and performance issues between the Joint Committee and the CCG to be fully communicated and understood during and after the transition.

Performance

The Committee noted the Performance Report and areas of concern including A&E, Cancer, Referral to Treatment (RTT), IAPT and dementia. The number of 52+ week waiters has increased partly because breast reconstruction patients have been moved onto the RTT list and partly because of errors on the old patient information system that have now been validated. A recovery action plan is in place for all 52+ week waiters and the Trust reports a Harm Review dashboard to CQRG every month.

21 November 2017

2017/18 Financial position (M7) and the Medium Term Financial Plan

The Committee noted the M7 financial position of a year to date overspend of £1.8m with forecast break even against the £9m surplus control total. NHSE have not yet agreed to the CCG moving its forecast position away from a £9m surplus and as a result there is a £2.6m net unmitigated risk.

There continues to be reporting of significant non-elective overactivity at MEHT and increasing pressures on the CHC budget. GP prescribing continues to overspend as a result of an increasing number of items on the “no cheaper stock obtainable” list.

The Committee noted that work continues on the medium term financial plan with £16m of QIPP still to be identified for 2018/19 if the control total remains, as published, at £9.3m.

MEHT had not been able to resolve the Lorenzo data issues by the expected deadline of September and the Committee was very concerned about the ongoing impact for patients and for the CCG

129 forecasts and planning. The Committee requested that a formal letter be sent to Clare Panniker from the CCG outlining the concerns.

Transition to Joint Committee

The Committee emphasised the need for clarity regarding the governance arrangements once the Joint Committee is in place and wanted to understand the plans for supporting Committees/scrutiny functions to the Joint Committee as well as the governance around the cost implications of Joint Committee decisions for CCGs.

Performance

The Committee reviewed performance against targets and noted areas of concern as in the previous meeting. In addition, a significant drop in achievement against the RTT target (18 weeks) is being reported although analysis has backed up the assertion that this is largely a result of Lorenzo data issues.

Procurement

The Committee approved the following:

• The proposals to establish an Essex-wide IM&T ‘intelligent client’ function • Extension of the IRN framework by 12 months to expire in February 2019 in alignment with ECC’s contract expiry

The Committee recommended approval by the Board of the following:

• Delegation of the decision to award the IM&T procurement preferred bidder on the advice of the Procurement Programme Board to the AO and CFO • Delegation of contract award of the BI, HR & Financial Accounts procurement to the F&P Chair, AO and CFO on the recommendation of the Commissioning Support Services Steering Group and approval of the proposal for the contract to be hosted by MECCG as Caroline Rassell is the lead AO for the Joint Committee. (MECCG are only purchasing the BI element of the contract). • The proposal to undertake a new procurement process for GP Wi-Fi and delegation of the authority to approve the preferred supplier within the new procurement process to the AO and CFO.

130 Report to: Part 1 Board Meeting Date: 25 January 2018

Agenda No: 12.4 Report Title: Live Well Committee Assurance Summary Report Written by: Peter Wyatt, Head of PMO Purpose of Report: The Live Well Committee Chair reports key issues to each Board meeting Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services  Strategic Objective 4 To ensure there is full practice engagement informing  commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees N/A that have reviewed this document).

Reports Submitted to Board only: Date signed-off by Executive Team. Standing (NB: With the exception of standing agenda items, all reports submitted to the Board must be agenda signed-off by the Executive Team) item Have any financial implications been signed Finance Officer signing off N/A financial consequences off by the Chief Finance Officer? 

Patient & Public N/A Engagement: Significant Risks None identified: Recommendations and Members of the Board are asked to note the work of the Live decision/actions Well Committee at the meetings held on 3 October, required by Execs/ 7 November and 5 December 2017. Committee/Board:

131 The LiveWell Committee meetings considered and addressed the following issues.

Live Well Committee meeting of 3 October 2017

• The AposTherapy service specification was considered and approved, subject to some minor amendments. AposTherapy is a programme for knee and back pain, based on a foot-worn biomechanical device; • A presentation was received of the Essex Data Tool. It was agreed that a suitable project would be identified to trial the approach (subsequently agreed on 7 November 2017 to be Paediatrics); • Updates were received on a number of other issues, including procedures of limited clinical value and the outcomes of visits to GP practices.

Live Well Committee meeting of 7 November 2017

• An options paper for Paediatrics was discussed. It was agreed as a valuable study and that all options should be further explored with a view to developing a final proposal to come back to a future meeting; • The Committee approved a new Guidance and Referral form for Chronic Kidney Disease, subject to final checking with the relevant consultant; • The Committee considered the implications of a Regional Medicines Optimisation Committee statement on Freestyle Libre on the current service restriction policy. It was concluded that a detailed financial analysis for Freestyle Libre should be produced and presented to the Executive group; • Following an earlier paper on 3 October 2017, prescribing infant formula milks was further considered and it was concluded that Similac be taken back to the Medicines Management Committee for final sign off and the issue generally be considered further by the Live Well Committee when the Paediatric Network paper is published; • Updates were received on the RightCare Chronic Obstructive Pulmonary Disorder (COPD) project and the Primary Care Foundations programme for increasing resilience in primary care in 2018/19.

Live Well Committee meeting of 5 December 2017

• Revised Terms of Reference were agreed; • The Committee received updates on: o Dementia – Intensive Support Team; o Community Beds and Discharge to Assess project; o The rollout of the Ardens Clinical Decision Support system to GP practices. Live Well Committee meeting of 2 January 2018

This meeting was cancelled in light of anticipated winter pressures at the acute trust which were likely to require senior CCG support.

Recommendation

Members of the Board are asked to note the work of the Live Well Committee at the meetings held on 3 October, 7 November and 5 December 2017.

132 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 12.5 Report Title: Primary Care Commissioning Committee Chair’s Update Report Written by: Head of Corporate Governance Purpose of Report: To advise the Board of discussions held at Primary Care Commissioning Committee on 1 November 2017 and 10 January 2018. Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees that have reviewed this document).

Reports Submitted to Board only: Date signed-off by Executive Team. (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: N/A Patient & Public Engagement: Part I Primary Care Commissioning Committee meetings are held in public. Significant Risks identified: As outlined in the report. Recommendations and The Board is asked to note the Primary Care Commissioning decision/actions required Committee Chair’s update report. by the Committee/Board:

133 Key Issues Discussed at Primary Care Commissioning Committee, 1 November 2017

• In response to a query from the member of the public relating to the provision of GP services at the Beaulieu Park development, the Committee were advised that discussions with the contractor were still ongoing which were considered to be commercially sensitive and, therefore, confidential. • The Committee received the Month 6 Primary Care Financial Performance Report which showed an overspend of £25 against the budget, which was considered to be not far from a break-even position. However, there remained an overall cost pressure against the allocation of £1.076 million, which remained as a significant barrier to the CCG taking on responsibility for fully delegated primary care commissioning. • The Committee received the Estates and Premises update report. • The Committee received a summary of decisions taken at Part II PCCC meetings and Emergency Powers decisions that could now be reported at the publicly held Part I PCCC meeting.

Key Issues Discussed at Primary Care Commissioning Committee, 10 January 2018

• The Committee received the Month 8 Finance Report and noted there was a year-to-date pressure of £100k. • The Committee received the Estates and Premises update report. • The Committee received a summary of decisions taken at Part II PCCC meetings and Emergency Powers decisions that could now be reported at the publicly held Part I PCCC meeting. • The Committee received a briefing on the CCG’s revised management structure and noted that the Director of Clinical Transformation, Director of Governance & Performance and Head of Primary Care would be the key CCG representation on the Committee going forward.

134 Report to: Part 1 Board Meeting Date: 25 January 2018

Agenda No: 13 Report Title: Communications and Engagement Update Report Written by: Head of Communications and Engagement and Communications and Engagement Manager Purpose of Report: To update the Board on recent activity relating to communications and engagement Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe Strategic Objective 2 To meet the financial challenge through responsible use of resources Strategic Objective 3 To achieve transformation, innovation and integration of services 

Strategic Objective 4 To ensure there is full practice engagement informing  commissioning Strategic Objective 5 To ensure public confidence in commissioned services 

Strategic Objective 6 To ensure the CCG has the necessary governance, capacity and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees that have reviewed this document).

Quality Impact Assessment 

Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: N/A Patient & Public See report Engagement: Significant Risks None identified: Recommendations and The Board are asked to note the content of the report. decision/actions required by the Board:

135 Communications and Engagement report 15 September 2017 – 10 January 2018

Introduction

This communications and engagement report aims to demonstrate how Mid Essex CCG has been engaging, involving and informing people about key healthcare initiatives; the issues and key themes emerging from our patient and public feedback; and how the CCG is progressing with key work programmes.

The activity highlighted in this report covers the period from 15th September 2017 to 10th January 2018. If you would like to know more about this work or have feedback on the report, please get in touch with us by emailing [email protected].

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Campaigns and activity

The Communications and Engagement team has been closely involved in the launch of new projects and engagement activity during the reporting period, working with CCG colleagues and external partners and stakeholders. • We held our community Marvels of Mid Awards and Annual General Meeting on 28 September 2017, which saw the hard work of healthcare partners and volunteers from across mid Essex celebrated by our Board and partners. • The Dementia Intensive Support Service, or DISS, is a new one-stop service for people living with dementia and their families, developed to offer not only crisis support but early intervention and physical health care. The team led on communications for the service launch, encouraging people to self-refer or seek advice through a single telephone number. There have already been positive patient stories arising from it, some shared through BBC Look East. • Ahead of Christmas 2017, the team arranged, filmed and posted on the CCG website a series of ‘self-care Advent calendar’ movies offering a different tip each day for patients and the public to help them look after themselves during the winter. As well as receiving favourable media coverage, the campaign’s short films were watched more than 8,500 times. • The team arranged and ran our most successful GP Summit and Nurses’ Conference to date on 8 November 2017. The event focused on cancer care and early diagnosis, which brought approximately 250 clinicians and non-clinical GP practice staff together to learn about innovations in cancer care. Several GPs said it was the best such summit they had attended. • A local Over the Counter (OTC) medicine campaign in conjunction with our member practices provided signage and leaflets for local GP surgeries that enabled discussions with patients about purchasing common medication such as paracetamol over the counter in pharmacies and supermarkets rather than seeking it on prescription. The CCG is currently running an evaluation of this campaign. • Promotion among mid Essex GP practices of the dementia support services and training available to them, to ensure more joined up support for people in our area living with dementia. • Our Care Home Manual, a new resource for staff working in our local residential and nursing homes, was launched in October 2017. It was developed through close work with a wide range of clinical professionals and is intended to help care home workers at all levels for their residents. Homes across the area collected their manual at two launch events and the CCG delivered the rest during the autumn.

137

• A full programme of public engagement around the CCG’s Home First proposals led to some high quality feedback on both the support for and concerns around implementing such a discharge to assess model. Feedback from the engagement is included in the Home First report appearing elsewhere in this month’s Board papers. The team supported preparation of this and various other papers for Board and external partners. • The Mid and South Essex Sustainability and Transformation Partnership (STP) launched its public consultation on proposals for changes to acute services on 30 November 2017. The team has arranged consultation events in mid Essex including public meetings and supported publicity from STP communications staff. • The team supported an STP-wide and Asthma UK campaign called #Scarfie encouraging people with asthma and respiratory illness to wear scarves when the temperatures dropped. Local celebrities, clinicians, community groups, schools and council’s are all backing the ongoing campaign. • Working with local knitting groups, the team donated scarves to food banks for winter warm packs going out across the Braintree district. Outcomes of the #Scarfie campaign will be shared in the next report. • Winter messages have remained a key focus with the team. Newspaper adverts, online advice, social media promotion and leaflets were produced for every local practice and pharmacy to share with patients signposting NHS services available over Christmas and New Year. • The team is currently in the process of launching another initiative for local care homes, called the Red Bag scheme. This supports care home residents who need admission to hospital as all their belongings, medical records and prescribed medicines can travel with them and with agreed handover processes in place speed up their care as everything hospital staff need to care for them on a ward is readily available.

138

Engaging with our communities and our Patient Reference Group (PRG)

The Communications and Engagement team continues to produce the regular Engage e-newsletter for stakeholders. Three issues were produced in the current reporting period, with topics including:

• a number of the campaigns and activities mentioned in the previous section • promotion of self-care tools such as: o online Heart Age Calculator o Active 10 campaign o annual Stoptober anti-smoking drive • the current CCG Improvement and Assessment Framework result for Mid Essex CCG • a run-down of mental health and wellbeing support available in mid Essex, and coverage of the new Perinatal Mental Health Service in particular • coverage of the CCG receiving our Self Care Innovation Award for the Childhood Illness Booklet and associated workshops developed by the team • essential information on antibiotic use in support of a national Public Health England campaign around them • promotion of the #Scarfie campaign we are running in conjunction with Asthma UK, encouraging people with respiratory issues in particular to cover their nose and mouth with a scarf while outside during cold weather • a story celebrating the work our GP practices’ patient groups have been doing over the past year to help their communities to Live Well • publicising the NHS services available in mid Essex over the Christmas and New Year public holidays. You can find the current and previous issues of Engage online at http://bit.ly/2nr3lf7.

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The team also continues to organise, develop the agenda for and host PRG meetings, usually held every two months. The group – made up of community and voluntary representatives, patient group members and Healthwatch Essex – discusses commissioning priorities and current issues, feeding back on local healthcare and patient experience concerns.

The Lay Board Member for Public and Patient Engagement chairs the group and the Communications and Engagement team seeks Director-level attendance for each meeting whenever possible. At least one director attended every PRG meeting during 2017. Issues raised by group members that cannot be addressed at a meeting are shared with individual Directors for action and response and noted below for the Board’s reference. The PRG action log is available on the CCG’s website at http://bit.ly/2narKW7.

As well as meeting PRG members regularly, CCG directors and staff also attend events with other patient groups and stakeholders. Outcomes and actions from those meetings are recorded in our Engagement Log. The excerpt from the log below shows external engagement activity for the current reporting period alongside questions from PRG.

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Date Group / Event Attending from CCG “Well” People present Lead Purpose of meeting Feedback/Actions contact 18 Sep Beacon Health Dr Liz Towers Be Beacon Health Paul Share options around alternatives Continue to support future events 2017 Group PPG self- Well / Group patients Gilham to GP appointments and A&E visits run by the PPG as far as possible care event Stay and members of for minor ailments and self-limiting Well the local conditions community 19 Sep MECCG Patient Angela Bell, Ali Live Approx. 15 Viv Agenda available at As captured on PRG Action Log which 2017 Reference Connolly, Anne-Marie Well patient and Barnes http://bit.ly/2qkbumv can be found at Group (PRG) Garrigan, Viv Barnes, Healthwatch www.midessexccg.nhs.uk in the Get Rachel Harkes, Paul representatives Involved section Gilham, Dr Liz Towers, Paula Wilkinson 20 Sep Patient meeting Rachel Harkes Be Chairs of two Alison Discuss possible concerns around Amend materials in line with 2017 for Home First Well/ Maldon GP Connolly Home First, particularly as they discussions and respond to any engagement Stay practice patient relate to services at St Peter’s questions in writing not answered in Well groups Community Hospital full at meeting 28 Sep Mid Essex CCG All CCG executives and Live Approximately 70 Caroline Presentation of the year’s events, Media promotion of Marvels of Mid 2017 Annual General communications team Well members of the Rassell formal handover of CCG 2016/17 Awards (MOMA) results Meeting and members public and other Annual Report to Board and community stakeholders celebration of community awards contributions to helping mid Essex residents to Live Well 2 Oct Patient input on Rachel Harkes Be Three members Alison To shape materials for Home First Materials updated and verbal 2017 Home First Well/ of CCG Patient Connolly engagement programme based on responses offered to patient engagement Stay Reference Group patient feedback and answer any questions Well urgent questions 10 Oct Healthwatch Rachel Harkes Live Healthwatch Rachel To discuss priority areas and Support Healthwatch Essex 2017 Essex catch-up Well Essex Chief Harkes possible overlap of activity that campaigns through CCG comms Executive may enable cooperation where appropriate 22 Home First Caroline Rassell, Dr Be Members of the Alison To share ideas around Home First Recorded in Home First papers for Oct Engagement Caroline Dollery, Dr Liz Well/ public from Connolly model and seek feedback from Board – see

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2017 event Towers, Viv Barker, Stay Braintree area stakeholders as part of http://midessexccg.nhs.uk/about- Rachel Harkes Well and Friends of engagement programme us/ccg-board-meetings/board-papers Braintree Hospital for details members 23 Oct Home First Rachel Harkes Be Broomfield Alison To share seek feedback from Recorded in Home First papers for 2017 Engagement Well/ Hospital patients, Connolly stakeholders as part of Board – see drop-in session Stay their visitors and engagement programme http://midessexccg.nhs.uk/about- at Broomfield Well hospital staff us/ccg-board-meetings/board-papers Hospital for details 1 Nov Primary Care Anne-Marie Garrigan, Be Committee Viv Agenda and papers online at As minuted 2017 Commissioning Viv Barnes, Robert Well members and Barnes bit.ly/2wp30dq Committee Evans, Ruth Blake, members of the Sara O’Connor public 7 Nov Home First Caroline Rassell, Dr Be Members of the Alison To share ideas around Home First Recorded in Home First papers for 2017 Engagement Anna Davey, James Well/ public from Connolly model and seek feedback from Board – see event Wilson, Viv Barker, Stay Maldon area and stakeholders as part of http://midessexccg.nhs.uk/about- Rachel Harkes, Paul Well district council engagement programme us/ccg-board-meetings/board-papers Gilham representatives for details 8 Nov GP Summit and All CCG executives, Be 250 GPs, district / Dr Liz Share latest guidance and good Discussions around particular cancer 2017 Nurses’ clinical leads and Well practice nurses Towers practice on early diagnosis of sites led to a number of actions being Conference communications team and non-clinical cancer, survivorship and treatment identified to improve care pathways members practice staff pathways. 10 Burnham N/A Be Open letter sent Paul Letter raises concerns about a Response sent within two working Nov Surgery Patient Well to Paul Gilham by Gilham perceived reduction in the days of receipt setting out the range 2017 Participation PPG facilities and services provided at of services still available, their various Group the Burnham Clinic. providers and why there was a perception of change

14 Home First Dr Anna Davey, Rachel Be Members of the Alison To share ideas around Home First Recorded in Home First papers for Nov Engagement Hearn, James Wilson, Well/ public from Connolly model and seek feedback from Board – see 2017 event Alison Connolly, Viv Stay Chelmsford area stakeholders as part of http://midessexccg.nhs.uk/about- Barker, Rachel Harkes Well engagement programme us/ccg-board-meetings/board-papers for details

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15 Home First Caroline Rassell, Alison Be Members of the Alison To share ideas around Home First Recorded in Home First papers for Nov Engagement Connolly, Rachel Well/ public from Connolly model and seek feedback from Board – see 2017 event Harkes Stay Braintree area stakeholders as part of http://midessexccg.nhs.uk/about- Well and Friends of engagement programme us/ccg-board-meetings/board-papers Braintree Hospital for details members 18 Young People’s Carol Anderson, Jenna Stay Young people Emma To discuss patient experience of Feedback and questions captured by Nov Cancer Chapman, James Well with experience Chaplin cancer services with younger BTUH staff attending 2017 Workshop Sharp of cancer and (BTUH) people and their families, and offer their families advice on support available 20 Quality Quality staff Be Provide district Rachel To discuss patient experience of Recorded by CCG Nursing and Quality Nov assurance visit – Well nurses and their Hearn commissioned district nursing staff 2017 district nurses patients service 21 MECCG Patient Anne-Marie Garrigan, Live Approx. 15 Viv Agenda available at As captured on PRG Action Log which Nov Reference Viv Barnes, James Well patient and Barnes http://bit.ly/2qkbumv can be found at 2017 Group (PRG) Wilson, Rachel Harkes, Healthwatch www.midessexccg.nhs.uk in the Get Paul Gilham, Paula representatives Involved section Wilkinson 22 Home First Steve McEwen, Gillian Be Broomfield Alison To share seek feedback from Recorded in Home First papers for Nov Engagement Woodward, Paul Well/ Hospital patients, Connolly stakeholders as part of Board – see 2017 drop-in session Gilham Stay their visitors and engagement programme http://midessexccg.nhs.uk/about- at Broomfield Well hospital staff us/ccg-board-meetings/board-papers Hospital for details 22 Home First Carol Anderson, Dan Be Members of the Alison To share ideas around Home First Recorded in Home First papers for Nov Engagement Doherty, Alison Well/ public from South Connolly model and seek feedback from Board – see 2017 event Connolly, Rachel Stay Woodham Ferrers stakeholders as part of http://midessexccg.nhs.uk/about- Harkes Well and Dengie areas engagement programme us/ccg-board-meetings/board-papers for details 29 Mid and South Dr Caroline Dollery, Live Members of the Caroline Agenda and papers online at As minuted by Joint Committee Nov Essex CCG Joint Caroline Rassell, Viv Well public from Rassell bit.ly/2wUfU5c secretary 2017 Committee Barnes across STP area meeting

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30 Quality Quality staff Be Provide district Rachel To discuss patient experience of Recorded by CCG Nursing and Quality Nov assurance visit – Well nurses and their Hearn commissioned district nursing staff 2017 district nurses patients service 4 Dec Filming for BBC Paul Gilham Stay Maldon residents Ola News interview to discuss new Film aired three times on BBC Look 2017 Look East Well living with Williams Dementia Intensive Support East news bulletins and supported by dementia and Service BBC social media posts their families, EPUT and NELFT clinicians 5 Dec Healthwatch Rachel Harkes Live Healthwatch Rachel To follow up on 10 Oct meeting Consider next steps following 2017 Essex catch-up Well Essex Chair Harkes and discuss ideas for further third September CVS event sector engagement 12 Maldon Health Dan Doherty, Dee Be Project board Dan To receive updates and review Minuted by Maldon District Council Dec Hub Davey, Paul Gilham Well members Doherty progress of Maldon health hub 2017 Stakeholder including patient project Project Board representatives 12 Knit and Natter Rachel Harkes Be Group members Rachel Discussion with group around how N/A Dec Chelmsford Well Harkes their donations would support self- 2017 care across mid and south Essex 9 Jan STP Caroline Rassell, Dan Live Members of the Wendy To share ideas around STP Recorded in STP consultation log 2018 Consultation Doherty, Dr Donald Well public from Smith proposals and seek feedback from Public McGeachy, Rachel Chelmsford area stakeholders as part of Discussion Harkes and MEHT staff consultation Event 10 Jan Primary Care Anne-Marie Garrigan, Be Committee Viv Agenda and papers online at As minuted 2017 Commissioning Viv Barnes, Robert Well members and Barnes bit.ly/2wp30dq Committee Evans members of the public

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Media and press coverage of CCG activity

The team proactively promotes the work of the CCG through press releases, social media and direct contact with journalists. During the reporting period, we have worked with the media on 19 stories. The information below outlines the media and potential reach of the news we have shared:

No. of Publication or channel (with link Area of coverage Circulation / reach stories to website) 171,000 (based on RAJAR 3 BBC Essex Countywide quarterly listening figures) 400,000 (estimated – actual 1 BBC Look East Regional figure behind BARB paywall)

5 Braintree and Witham Times Braintree, Witham, Dunmow, Hatfield Peverel 7,494 (ABC audited)

Chelmsford urban centre and surrounding 48,000 (estimated – recent title 4 Chelmsford and Mid Essex Times villages change will require new audit) Chelmsford City, Maldon District, Braintree 1 Essex Chronicle / Essex Live 16,689 (ABC audited) District, Dunmow, Stanstead

2 Halstead Gazette Halstead and some Colne Valley 3,386 (ABC audited)

Maldon town and surrounding villages, Dengie 3 Maldon and Burnham Standard 5,415 (ABC audited) peninsula, South Woodham Ferrers, Danbury 19

Our self-care advent calendar, Home First engagement, community Marvels of Mid Awards and the new Dementia Intensive Support Service were among the topics covered.

A weekly summary of media coverage that mentions the CCG is also shared with staff, GP and Board members to keep them informed. As well as the above mid-specific media, during this reporting period we also secured news coverage in the following county or regional outlets:

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• East Anglian Daily Times, circulation 39,205 (ABC audited but the figure is considerable smaller across the area of mid Essex – largely Braintree District – that the Essex edition covers) • Heart Essex – Chelmsford and Southend, with a reach of 291,000 (based on RAJAR quarterly listening figures) • Radio Essex and Radio Essex DAB, with a combined reach of 68,000 (based on RAJAR quarterly listening figures) • Southend - Basildon - Canvey Echo, circulation 17,932 (ABC audited)

The team responded to 23 press enquiries during the 15 September 2017 to 10 January 2018 reporting period. The team also successfully corrected 2 stories relating to the CCG that appeared in the media with inaccuracies or misleading information. Media enquiries covered a wide range of issues including:

• GP practices’ temporary suspension of patient registration • diabetes prevalence in mid Essex • the future of Courtauld ward in Braintree Community Hospital • the availability of appointments in mid Essex primary care • key national NHS targets at Broomfield Hospital • primary care services in Burnham • service restriction policies.

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Digital Communications

Following on from feedback at the September 2017 Board meeting, we have been looking at ways to enhance our reporting on digital communication activity and provide an overview of our digital audience.

Over the next few pages you will see some headline statistics for both engagement with the CCG website as well as our primary social media platforms; Twitter, Facebook and Instagram. We have also suggested some next steps for the coming year to enhance our digital communication strategy; target specific audiences and grow our online conversation.

Headline Statistics

Social Media

• 669,848 total social media impressions (The number of times our social media posts have been seen) • 22,105 total social engagements with our accounts including likes, shares, retweets, mentions and comments • 1,530 website visits direct from social media – up 19% on previous reporting period • Females aged 25-34 are the largest demographic which we engage with on social media Website

• 16,989 unique users (The number of people who have viewed our website at least once)

• 72,975 pageviews (The total number of pages viewed. Repeated views of a single page are counted) • A typical user visited 2.4 pages and on each visit stayed on the site for 2:28 minutes • Most viewed webpage* was Health in Mind (IAPT) – 1,521 pageviews • Users accessing the website via mobile and tablet devices is up 3.2% and 2.4% respectively

*This is excluding the homepage, contact us, about us and intranet login pages.

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Social Media

Twitter Facebook Instagram

Engagement • 5,006 followers • 522 followers • 334 followers • 464,000 impressions • 205,848 impressions • 8,061 total engagements • 5,983 total engagements Instagram is a relatively new platform for the CCG and one which we are continuing to grow. (favourites, retweets and replies) (like, comments and shares) Reporting for Instagram is currently limited and therefore the same level of analytics is not available. However, we are looking into ways to report on this in future reports. Social Demographics Gender Gender Gender • 40% Male • 13% Male • 39% Male • 60% Female • 86% Female • 61% Female

Age Age Age • 7% 13-17 • <1% 13-17 • 2% 13-17 • 9% 18-24 • 4% 18-24 • 16% 18-24 • 41% 25-34 • 28% 25-34 • 41% 25-34 • 22% 35-44 • 29% 35-44 • 25% 35-44 • 17% 45-54 • 17% 45-54 • 10% 45-54 • 5% 55+ • 8% 55+ • 6% 55+

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Social Media Campaign: Video Advent Calendar

During December we launched a video advent calendar across our social media platforms. The idea behind the calendar was Total video views: 8,500 to help local people find out more about services available to them over the Christmas Total minutes watched: 1,100 period and into the New Year.

Each day from 1st December – different health and social care professionals across mid and south Essex fronted short videos providing tips on areas including:

• Flu

• Mental wellbeing • Healthy lifestyles – walking, alcohol and smoking awareness • Self-care

• Social isolation

• Germs and infection prevention

• Sexual Health • Childhood Illness • GP and pharmacy services over bank holidays

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Website Statistics

What device are people using to access our website? Profile of our web users

Our website is used by a wide range of patients, local residents and healthcare professionals. The largest audience of website users since September 2017

were those aged 35-44 (28.76%).

6.21% were under 18, 26.61% were aged 25-34, 17.90% were aged between 45 and 54 and 20.53% were aged over 55.

Mobile Tablet Desktop 62.3% of website users are female and 37.7% are male. 8.5% 21% 70.5% +3.2% +2.2% -5.4%

Analysis

The CCG has a good relationship engaging with the 55+ age group through our Patient Participation Groups and more traditional forms of communications including newsletters, newspapers and community engagement events.

Reviewing the digital analytics for this reporting period, it is clear to see that our primary digital audience (web and social) are females aged between 25 and 44. This shows that through investing time and resource into our digital communication strategy we are able to engage with a younger segment of our local population.

However, there is still work to be done. It is disappointing to see that we still have not able to engage with males and those aged between 18 and 24. Over the coming months, our ambition is to look at ways that we can use digital to reach out to both these audiences.

150 The CCG website continues to receive a steady flow of visitors. This reporting period we received 16,989 unique user visits to the website compared to 11,642 in the last reporting period – up 45.93%. A spike in web visitors occurred on 23rd November which can be correlated to the day the STP CCG Joint Committee papers were published.

Our Health In Mind (IAPT) webpage had the most page views (1,521) which we can pinpoint to our activity on social media around mental health and suicide awareness days. We also supported Men’s Mental Health Awareness Month in November, which included several posts around mental wellbeing. Other web pages which performed well this reporting period include the Board profiles (1,282), medicines optimisation (1,175) and Your Health Services (1,093) – all of these pages have increased views since the last reporting period.

Desktop is still the device which users are using the most to view the website; however this is down 5.4% compared to mobile and tablet devices which are up 3.2% and 2.2% respectively.

Digital engagement ambitions: Next steps (over next 12 months) …

• Continue to improve the user experience on the CCG website making sections such as Live Well more interactive and up-to- date with local services and initiatives • Include a sign-up form on the website for people to receive our patients and public newsletter – Engage • Continue to grow our public audiences through more creative digital marketing including the use of video and paid-for, targeted social media content • Develop ways to improve digital reach to males and those aged 18 to 24 • Introduce other digital engagement methods including mobile and tablet applications • Support our GP member practices with improving digital communication and using social media to talk to patients

151 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 14 Report Title: Policies and Procedures Update Written by: Head of Corporate Governance Purpose of Report: To request members’ approval of the following policies:

• MECCG002 – Health & Safety Policy • MECCG008 – Anti-Fraud and Bribery Policy • MECCG088 – Grievance Policy • MECCG095 – Maternity and Adoption Leave Policy

Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Board members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick ) Patient & Public Engagement: N/A Significant Risks identified: N/A Recommendations and The Committee is asked to approve the content of the above policies. decision/actions required by the Committee: The policies will then be submitted to the March Board meeting for formal adoption by the CCG.

152 POLICIES / PROCEDURES APPROVED BY QUALITY & GOVERNANCE COMMITTEE, 12 DECEMBER 2017

Ref No New or Title of Policy Lead Director Review Date Revised Policy MECCG002 Revised Policy Health & Safety Policy Director of January 2019 Corporate Services The purpose of this policy is to provide a healthy and safe environment for all staff, patients, contractors, volunteers and members of the public through the adoption of the CCG Health and Safety Policy, to ensure the CCG complies with all related health and safety legislation and to operate a system where the CCG is able to demonstrate, openly and effectively, the development and achievement of health and safety standards and codes of practice. MECCG088 Revised Policy Grievance Policy Accountable December 2019 Officer The organisation encourages open communication between employees and their managers to ensure that questions and problems arising during the course of employment can be aired and, where possible, resolved quickly and to the satisfaction of all concerned. The aim of this policy is to settle grievances as near to the point of origin as possible. It is also preferable that both employees and managers should try to resolve issues informally first, and to use the formal route where the informal route has been explored, but has been unsuccessful.

MECCG095 Revised Policy Maternity and Adoption Accountable December 2019 Leave Policy Officer This policy sets out the rights of employees to statutory and occupational maternity leave and pay.

POLICIES APPROVED BY AUDIT COMMITTEE, 18 DECEMBER 2017

Ref No New or Title of Policy Lead Director Review Date Revised Policy MECCG008 Revised Policy Anti-Fraud and Bribery Director of January 2019 Policy Corporate Services The Mid Essex Clinical Commissioning Group is committed to reducing fraud, bribery and corruption in the NHS and will vigorously investigate all allegations made. Furthermore MECCG will seek the appropriate disciplinary, regulatory, civil and criminal sanctions against persons who are convicted of fraud or bribery and where possible will attempt to recover losses.

153 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 15 Report Title: Assurance Framework and Risk Register Written by: Head of Corporate Governance Purpose of Report: To provide a report of the current strategic and operational risks facing the CCG, the action being taken to mitigate these risks and assurances regarding the effectiveness of current controls.

Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of  services Strategic Objective 4 To ensure there is full practice engagement informing  commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees Risks have been reviewed by the responsible Director or senior As per risk that have reviewed this manager with lead responsibility as part of the annual refresh of register document). risk registers. Quality & Governance Committee 12/12/17 Audit Committee 18/12/17 Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Board members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Patient & Public Not applicable. Engagement: Significant Risks As per Strategic Risk Register (Appendix A) identified: Recommendations and Members are asked to:- decision/actions required by the • Note the risks set out at Appendix A Board/Committee: • Advise of any additional risks, any risks recommended for closure or any additional mitigating actions for existing risks.

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ASSURANCE FRAMEWORK AND RISK REGISTER

Submitted by: Head of Corporate Governance Status: For noting ______

1. INTRODUCTION

This report provides the latest update on the risk position for Mid Essex CCG. The Strategic Risk Register/Assurance Framework is provided at Appendix A.

There are currently 41 open risks. The following table sets out the number of strategic and operational risks within each Directorate:-

RISK TYPE DIRECTORATE Strategic Operational Total

Accountable Officer 1 1 2 Clinical Commissioning 3 2 5 Corporate Services 5 4 9 Finance 5 5 10 Nursing & Quality 3 5 8 Primary Care & Resilience* 2 5 7 Total 19 22 41 *Primary Care & Resilience risks have been allocated to other Directors pending full implementation of the new CCG staffing structure. The interim lead directors for strategic risks are shown on the strategic risk register (Appendix A).

The implementation of the new staffing structure for the CCG and the Sustainability and Transformation Partnership Joint Committee (STPJC) will require a review of responsibility for existing Mid Essex CCG risks. A review of risks across the five STP CCGs will also be carried out to develop an STP-wide risk register.

Number of Risks Linked to Each Strategic Objective

The number of risks linked to each strategic objective is as follows:-

No Strategic Objective No of Risks Linked 1 Improve quality and outcomes and keep patients safe 27 2 Meet the financial challenge through responsible use of resources 20 3 Achieve transformation, innovation and integration of services 8 4 Ensure there is full practice engagement informing commissioning 5 5 Ensure public confidence in commissioned services 24 6 Ensure the CCG has necessary governance, capacity and capability to 13 deliver all duties and responsibilities

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2. STRATEGIC RISKS

The Strategic Risk Register, including sources of Board assurance, is set out at Appendix A. The total number of open strategic risks is 19 and the risk profile is shown in the following table:-

Month Extreme High Moderate Green Total (Red) (Amber) (Yellow) (Low) January 2018 13 5 1 0 19 December 2017 12 5 1 0 18 September 2017 10 4 0 0 14 August 2017 10 4 0 0 14 June 2017 11 2 0 0 13 31 May 2017 11 5 2 0 18 (Q&G Committee) 11 May 2017 7 4 2 0 13 (Audit Committee February 2017 6 4 3 0 13 January 2017 6 4 3 0 13

New Strategic Risks

The following new risks have been added to the Strategic Risk Register:

Risk Directorate Description of Risk Comments Ref 13 Clinical IF ambulance turnaround times are Risk rating increased from Commissioning not improved High/Amber to Extreme/Red (and THEN there is an associated risk to therefore escalated to strategic patient safety level) due to winter pressures and RESULTING IN non-achievement of poor performance. national targets and associated reputational risk. 73 Corporate IF a major outbreak of disease (e.g. Currently rated Extreme/Red Services pandemic flu) or a major incident (score 15). (such as a transport disaster or terrorist incident) occurs, THEN this could result in a mass casualty situation leading to local health care providers being significantly challenged in terms of their capacity to respond to the demands posed by the incident, RESULTING IN other multi-agency organisations in the region/nationally having to provide mutual aid and potential delays in treatment. 74 Accountable IF the CCG experiences Current rated Extreme/Red Officer capacity/resources issues as a result (score 16) of staff uncertainty due to the restructuring of the CCG, THEN the CCG may not be able to deliver 'business as usual' RESULTING IN loss of reputation and failure to deliver statutory requirements.

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75 Nursing & IF IPC standards in providers are not Currently rated Extreme/Red Quality met (score 20) THEN mandatory Health Care Acquired Infection (HCAI) reduction targets will not be met RESULTING IN reputational damage to CCG and providers and financial loss through penalties to the providers. 76 Clinical IF the transition to the new Lorenzo Currently rated Extreme/Red Commissioning Patient Administration System at (score 20) MEHT is not completed in an effective and timely manner, THEN there is a risk of patient care being delayed, patient information not being provided to the CCG (e.g. billing information) and key partner organisations (e.g. discharge summaries) in a timely manner RESULTING IN patient safety risks and reputational damage to MEHT and the CCG.

Changes to Strategic Risk Ratings

In addition to ID13 (Ambulance turnaround times) referred to above, risk ratings have been amended for the following strategic risks (the others remain the same):

Risk Directorate Description of Risk Comments / Change to Risk Ref Ratings 6 Finance IF capital expenditure is not No CCG capital requirement yet contained within approved limit, identified. THEN there is a risk that the CCG will receive a qualified Audit opinion Risk Rating reduced from RESULTING IN leading to High/Amber to Moderate/Yellow. reputational and regulatory risk. 10 Nursing & IF Colchester Hospital University CHUFT’s Care Quality Commission Quality Foundation Trust (CHUFT) is unable rating is now 'Requires to improve the safety, quality and Improvement'. Special measures effectiveness of its services, lifted. THEN there is a risk that the Care Quality Commission will continue to Risk Rating reduced from rate the organisation as 'Inadequate' Extreme/Red to High/Amber. RESULTING IN a lack of public confidence in Mid Essex CCG commissioned services.

Strategic Risks Recommended for Closure or De-escalated to Operational Level

There are no strategic risks recommended for closure at this time and no strategic risks have been de-escalated to operational level.

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Strategic Risks Where No Assurances Are Available

There is currently one strategic risk that does not have any assurances identified:

Risk Directorate Description of Risk Comments Ref ID26 Finance IF NHS Property Services charging The Chief Finance Officer has arrangements are not clarified and confirmed that there are currently agreed THEN there is a risk that no assurances available. revenue expenditure will not be contained within the approved Financial Plan RESULTING IN unaffordable expenditure

Strategic Risks where no additional controls are due to be implemented by MECCG.

Although the following strategic risks have not yet achieved their target risk rating, no additional action is due to be implemented by the CCG, other than ongoing implementation of existing controls, for the reasons provided below (last column).

Risk Directorate Description of Risk Rationale for no additional Ref controls to be implemented by MECCG at this time. 10 Quality & IF Colchester Hospital University No additional action currently Nursing Foundation Trust (CHUFT) is unable required by MECCG - Lead to improve the safety, quality and Commissioner is NEECCG. effectiveness of its services, THEN there is a risk that the Care Quality Commission will continue to rate the organisation as 'Inadequate' RESULTING IN a lack of public confidence in Mid Essex CCG commissioned services. 26 Finance IF NHS Property Services charging There are ongoing discussions arrangements are not clarified and with NHSPS to challenge the agreed There are ongoing funding allocation. discussions with NHSPS to challenge the funding allocation. There are ongoing discussions with NHSPS to challenge the funding allocation. THEN there is a risk that revenue expenditure will not be contained within the approved Financial Plan RESULTING IN unaffordable expenditure. 29 Finance IF the CCG does not have sufficient There will be two opportunities in cash available March 2018 to draw down THEN it will be unable to pay its additional cash if required. No creditors issues identified to-date and the RESULTING IN reputational damage, position continues to be closely restricted supply of goods/services, monitored. potential legal action and associated costs (i.e. interest charges/legal costs)

158 Risk Directorate Description of Risk Rationale for no additional Ref controls to be implemented by MECCG at this time. 42 Clinical IF Mid Essex Hospitals Trust (MEHT) No further controls to be Commissioning breach the NHS Constitution 62 implemented by MECCG at this cancer pathway standard, time as MEHT are responsible for THEN this will lead to patients not taking action to improve achieving appropriate care on a performance. timely basis RESULTING IN potentially poor outcomes for patients, and associated reputational risk for MEHT, and the possibility of the CCG being downgraded under the Assessment & Improvement Framework.

66 Primary Care & IF additional measures in relation to No further controls to be Resilience the provision of Pan Essex 24/7 MH implemented by MECCG at this crisis response pathway redesign time - Thurrock CCG are leading plan to meet the requirements of the on delivery of plan. Policing and Crime Act 2017 are not implemented THEN this could result in the CCG failing to meet its responsibilities under the Act RESULTING IN possible legal challenge, reputational risk, increased demand on A&E Departments, risk to relevant patients, non-delivery of core crisis care concordat requirements and financial risks associated with an increased need for S136 suites. 76 Clinical IF the transition to the new Lorenzo MEHT have responsibility for Commissioning Patient Administration System at implementation of Lorenzo. MEHT is not completed in an effective and timely manner, THEN there is a risk of patient care being delayed, patient information not being provided to the CCG (e.g. billing information) and key partner organisations (e.g. discharge summaries) in a timely manner RESULTING IN patient safety risks and reputational damage to MEHT and the CCG.

3. RECOMMENDATIONS

Members are asked to:

• Note the Strategic Risk Register, including sources of assurance, set out at Appendix A. • Advise of any additional risks, any risks recommended for closure or any additional mitigating actions for existing risks.

159 APPENDIX A MID ESSEX CCG - STRATEGIC RISK REGISTER - JANUARY 2018

ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 3 IF cost savings are not Dee Ruth 4 December 2017: Work Quality outcomes 25 25 5 In-house PMO to drive Regular reporting to Board, Work continuing to 31/03/2018 achieved, Davey Blake continues in order to and safety. projects and track progress. Savings Programme Board support project delivery. THEN it may not be possible to maximise delivery of the Savings Programme Board and Finance & contain revenue expenditure existing schemes and to Meet financial increasing its focus on Performance Committee within approved Financial Plan identify other financial challenge. project deliverability. for early identification of mitigations. The CCG is Continual process for slippage and recovery RESULTING IN escalation to continuing negotiations Transformation, exploring opportunities for actions and for identifying NHSE Regional Team and with MEHT regarding the innovation and additional savings. further savings potential qualification of position for 2017/18. integration. Short term external support opportunities. statutory accounts and loss of provided by BCG and PWC. Financial Controls audit autonomy. report 2016/17 provided 'good' assurance 75 IF IPC standards in providers Rachel Chris NEW RISK: 29 November Quality outcomes 20 20 3 Panel in conjunction with CCG engagement with Quarterly review of E coli 31/03/2018 are not met Hearn Patridge 2017: MEHT have and safety. North Essex HCAI Network HCAI investigation surveillance and THEN mandatory Health Care breached year end ceiling Group drive actions processes. learning, with actions Acquired Infection (HCAI) for C difficile and is unlikely Public indentified from learning to Provider IPC reports to identified as required. reduction to recover through use of confidence. reduce risk. CQRGs monthly or targets will not be met trajectory appeals North Essex IPC Scrutiny quarterly. RESULTING IN potential harm process. Panel in place to investigate to patients, reputational damage CCG has breached year HCAIs and agree appeals. to CCG and providers and end ceiling for C difficile. financial loss through penalties There is no process for to the providers. trajectory appeals for CCGs. Surveillance processes in place for E coli blood stream infections. Despite measures to reduce incidence of those infections amenable to intervention, failure to meet CCG 10% reduction target i lik l

160 APPENDIX A MID ESSEX CCG - STRATEGIC RISK REGISTER - JANUARY 2018

ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 76 IF the transition to the new James Sara NEW RISK: 2 January Quality outcomes 20 20 4 MEHT Lorenzo Recovery Intensive Support Team No further controls to be Lorenzo Patient Administration Wilson O'Connor 2018: An Executive to and safety. Plan. undertook a review of implemented by MECCG System at MEHT is not Executive meeting will take Weekly Steering Group Lorenzo implementation at this time as MEHT completed in an effective and place early January to Public overseeing recovery. (December 2017) = have responsibliity for timely manner, review risks and MEHT's confidence. negative assurance. implementation of THEN there is a risk of patient Lorenzo recovery plan. NHS Digital sign-off of 'Go Lorenzo. care being delayed, patient Governance, Live' for Lorenzoe (May information not being provided capacity and 2017). to the CCG (e.g. billing capability to information) and key partner deliver. organisations (e.g. discharge summaries) in a timely manner

RESULTING IN patient safety risks and reputational damage to MEHT and the CCG 4 IF the CCG experiences Dee Dee 4 December 2017: The Quality outcomes 15 20 5 £2.3 m (0.5%) contingency. Financial Controls audit Review of the issues 30/09/2017 31/10/2017 unplanned costs, Davey Davey issues associated with drug and safety. Increased level of report 2016/17 provided around prescribing costs THEN this will result in revenue pricing are continuing to monitoring of activity to 'good' assurance. and savings. expenditure not being contained escalate in line with the Meet financial identify in-year cost All discretionary within the approved Financial national position. This is challenge. pressures at an earlier expenditure to be approved Chief Pharmacist to work 31/03/2018 Plan, being discussed at a stage and expedite recovery by Executive Team before with Region on drug RESULTING IN escalation to national level. Transformation, responses. committed. pricing issues. NHSE Regional Team and innovation and Close monthly monitoring potential qualification of integration. and reporting to Finance & Ongoing implementation 31/03/2018 statutory accounts and loss of Performance Committee of financial controls. autonomy. and Board for early identification and monitoring of financial pressures. All discretionary expenditure submitted to Exec Team for approval.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 26 IF NHS Property Services Dee Dee 4 December 2017: As a Meet financial 16 16 5 Reconciliation of changes CFO has confirmed there No further action charging arrangements are not Davey Davey result of regular follow-up challenge. with the agreed property list are currently no required as there are clarified and agreed by the CCG with NHSPS, and resource funding assurances available. ongoing discussions with THEN there is a risk that there are outstanding allocation, particularly to NHSPS to challenge the revenue expenditure will not be queries that need to be cover move to market rents. funding allocation. contained within the approved responded by NHSPS. Ongoing discussion with Financial Plan The CCG continues to NHSPS to challenge the RESULTING IN unaffordable follow this up on a regular funding allocation. expenditure (see risk ID4). basis. Risk rating remains the same.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 41 IF attendances and admissions Daniel Kate 7 December 2017: The Quality outcomes 16 16 4 Demand management Reports to A&E Delivery Implementation of 31/03/2018 at A&E at Mid Essex Hospitals Doherty Butcher 95% standard continues and safety. schemes have all been Board. revised frailty, end of life, Trust (MEHT) continue to not to be met, however, reviewed and there is CQC Report on MEHT dementia pathways. increase, performance did improve Meet financial ongoing work to improve December 2016 - 'Good' THEN there is a risk that A&E over September and challenge. delivery of schemes (GP in assurance. Introduction of Primary 31/01/2018 patients will not receive timely October. There are system ED, frailty) and introduce Reports to Finance & Care streaming initiative care and elective care might wide recovery plans in Transformation, new schemes, i.e. Performance Committee. (building on GP in need to be postponed, place covering demand innovation and enhanced end-of-life, Audit of Minors and ED/redirection RESULTING IN in the risk of management, front door, integration. dementia intensive support Ambulance activity. schemes). MEHT not achieving the A&E flow and discharge to try team, Primary Care and elective care standards as and support recovery of the Public foundations schemes. Develop Business Case 31/03/2018 set out in the NHS Constitution, standard. System wide confidence. System wide PMO in place, for Urgent Care Centre the CCG being downgraded plans include delivery of 7 with system plans covering at Broomfield. (currently under the Improvement & Urgent and Emergency each key area of delivery on hold due to PCBC). Assessment Framework and Care priorities identified and exec level ownership associated reputational risk. nationally. Regular calls in across the system. place with NHSE to Area Team system-wide discuss recovery. support. Contract levers.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 72 IF the CCG and its IT Provider Viv Jackie 4 January 2018: A Quality outcomes 16 16 4 MECCG Cyber attack Assurance received that Improve communication 31/03/2018 does not have robust Barnes King proposal to perform an and safety. action plan. cyber-security is to GP practices during arrangements to prevent or audit of patch management CARECert Notifications adequately covered within an incident. respond effectively to a cyber- was stood down due to the Public received by Head of the IT procurement attack NELCSU recovery plan and confidence. Corporate specification. Obtain assurance from 31/03/2018 the corporate and GP IT Governance/Head of CARECert Bulletin updates GPs on their business THEN there is a potential that procurement, for which Governance, Accounts. provided by NELCSU to continuity plans. data will be compromised or NELCSU were capacity and Cyber Attack Operations NHS England and copied will become unavailable on a unsuccessfull. capability to and Communications to MECCG. temporary or permanent basis deliver. Playbook, Version 12, Via the Monthly MECCG IT A flowchart setting out October 2017. Review Group, the CCG RESULTING IN breaches in NELCSU and CCG actions seeks assurance from confidentiality of personal or upon receipt of notifications NELCSU re action being corporate information/ delays in from CareCERT has been taken to prevent further provision of clinical services and developed by the CCG and Cyber-Attacks. inability to deliver other implemented across the business critical functions. Essex CCGs. the Busines Continuity Plan will be updated to incorporate this flowchart. Communication with GP practices during a major incident has been developed by implementation of a WhatsApp group which most practices have now signed-up to. This has already been used successfully for communicating during loss of power/IT incidents within practices.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 42 IF Mid Essex Hospitals Trust James James 7 December 2017: 62 Quality outcomes 16 16 3 Contract levers. Cancer Alliance have No additional controls to breach the NHS Constitution 62 Wilson Wilson Cancer performance is and safety. Trajectory in place. inputted and reviewed be implemented at this cancer pathway standard, 74.6% for October (against Detailed action plan Cancer Action Plan. time as MEHT are THEN this will lead to patients 85% target). Public received. NHSI review of Cancer responsible for taking not achieving appropriate care confidence. Additional resource secured Action Plan. action to improve on a timely basis from Cancer Alliance Mid Essex Cancer Board performance. RESULTING IN potentially poor Supporting MEHT's has reviewed and outcomes for patients, and recovery. approved the Cancer associated reputational risk for Regular monitoring by CCG, Action Plan. MEHT, and the possibility of the including escalation via Mid CCG being downgraded under Essex Cancer Board. the Assessment & Improvement Framework.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 74 IF the CCG experiences Caroline Caroline NEW RISK: 24 November Quality outcomes 16 16 8 Relevant HR processes will Feedback from staff Obtain staff feedback on 01/12/2017 capacity/resources issues as a Rassell Rassell 2017: The CCG is and safety. be applied in relation to following consultation. proposed new CCG result of staff uncertainty due to currently out to consultation affected staff. structure. the restructuring of the CCG, with staff to restructure the Transformation, Support for staff from line THEN the CCG may not be able CCG to enable it to refocus innovation and managers and Human to deliver 'business as usual' on commissioning care out- integration. Resources. RESULTING IN loss of of-hospital care and Two week staff consultation reputation and failure to deliver streamlining processes and Public on new staff structure to statutory requirements. reporting. It is confidence. faciliate early consideration acknowledged that this will of staff views. be an unsettling period for Governance, staff and there is potential, capacity and therefore, that the capability to organisation could lose deliver. focus on key deliverables. There is also the risk that due to uncertainty regarding their future roles, members of staff might decide to seek alternative employment. The consultation period has therefore been limited to two weeks to facilitate early consideration of staff comments so that information can be provided to staff regarding their future roles in the new structure at the earliest opportunity.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 13 IF ambulance turnaround times James Adam 7 December 2017: Arrival Quality outcomes 12 16 4 Winter Surge Planning. CQC Inspections and CCG to work with MEHT, All actions are not improved Wilson Townsen to handover (within 15 and safety. Overall oversight at AO's Audits by Quality Teams. EEAST and system to are THEN there is an associated d minutes) at September Board. Monitoring provides look at mitigating actions ongoing. risk to patient safety 2017 was 40.3%. Public (Handover to Clear) assurance on current at ED front door if AtoH RESULTING IN non- Handover to clear at confidence. Regional SLA Meeting. levels of achievement. becomes an issue. achievement of national targets September (within 15 (Handover to Clear) and associated reputational minutes) was 26.7%. Operational performance CCG to ensure Director risk. Target is 100% for both Group (includes handover of Service is kept up-to- providers to complete delays) date with alternative care respectively in 15 mins. (Handover to Clear) Essex pathways. Later figures than Operational Locality September not available Meeting CCG to work with due to impact of (Arrival to Handover) Urgent EEAST and system Ambulance Response Care Oversight Group and partners to ensure Programme and adapting A&E Delivery Board. alternative care reporting to accommodate. Service review to highlight pathways are Risk rating increased from weaknesses to resolving communicated to crews High/Amber to turnaround as part of overall and crews educated on Extreme/Red due to winter change to contracting these. pressures and poor model to make fit for performance. purpose going forward in CCG to work with 2018/19. EEAST and system partners to monitor use of alternative care pathways.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 73 IF a major outbreak of Viv Jackie 12 January 2018: A local Quality outcomes 15 15 10 LHRP Mass Casualty Plan. CCG carries out exercises Local Mass Casualty 12/12/2017 12/12/2017 disease (e.g. pandemic flu) or Barnes King exercise took place on 12 and safety. EPRR and BCM Policies against its own Exercise. a major incident (such as a December 2017 to test the and procedures. EPRR/BCM plans. transport disaster or terrorist LHRP Mass Casualty Plan. Public Mandatory EPRR/BCM Assurance on CCG Consider 31/03/2018 incident) occurs, The Plan was validated confidence. training. arrangements is provided alternative/additional THEN this could result in a with minor amendments. Incident Co-ordination at each LHRP meeting. transport arrangements mass casualty situation The final plan will now go Governance, Centre familiarisation Internal Audit of Business for use in a mass leading to local health care to LHRP for approval next capacity and training with Loggists and Continuity due in February casualty situation. providers being significantly week. capability to On-call staff. 2018. challenged in terms of their deliver. CCG staff have attended Self-assessment against Review arrangements 31/03/2018 capacity to respond to the demands posed by the NEW RISK: 5 October Loggist Training. the NHS EPRR Core with private providers to incident, 2017: The Essex LHRP Integrated Strategic standards (full compliance provide mutual aid. RESULTING IN other multi- Mass Casualty Plan is Management health training = positive assurance). agency organisations in the being reviewed with multi- (Gold Command) for on-call LRF Mass Casualty 31/07/2018 region/nationally having to agency partners, staff. Exercise. provide mutual aid and specifically looking at NHS England Core EPRR potential delays in treatment. casualty distribution and Standards assurance Mass Casualty Health 31/03/2018 capability. There is a Local process. Exercise. Resilience Forum exercise NHS England monitoring of planned in July 2018. The terrorism threat level. CCG has requested that a Essex CCGs Emergency health mass casualty Planning Team. exercise is conducted in EPRR and BCM the early part of 2018. plans/policies and procedures stored on (Cross-referenced with Resilience Direct. LHRP Risk 7) Memorandum of Understand between Providers and CCGs re provision of mutual aid. Flu-Pandemic Plan. Mass Casualty Task and Finish Group formed to review plans and exercises.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 29 IF the CCG does not have Dee Dee 4 December 2017: There Meet financial 15 15 5 Cash flow reporting Financial Controls audit No further controls to be sufficient cash available Davey Davey will be two opportunities in challenge. undertaken in-house. report 2016/17 provided implemented at this THEN it will be unable to pay its March 2018 to call down Reporting to Finance & 'good' assurance. time. creditors additional cash if required. Performance and Board. RESULTING IN reputational No issues identified to-date damage, restricted supply of and the position continues goods/services, potential legal to be closely monitored. action and associated costs (i.e. interest charges/legal costs).

10 IF Colchester Hospital Rachel Rachel 4 December 2017: CQC Quality outcomes 16 12 4 CHUFT action plan Key Performance No actions currently University Foundation Trust Hearn Hearn report from visit in July and safety. monitored by Care Quality Indicators for Q&E and required by MECCG - (CHUFT) is unable to improve published. CHUFT rating Commission and North East cancer targets = Negative Lead Commissioner is the safety, quality and now 'Requires Public Essex CCG. assurance. NEECCG. effectiveness of its services, Improvement' with confidence. Quality Collaborative CQC Report, July 2017 progress against meetings with lead shows improvement. THEN there is a risk that the requirements noted. commissioner (monthly). Care Quality Commission will Special measures lifted. Formal contract continue to rate the organisation Risk rating reduced from management of key as 'Inadequate' Extreme/Red to contracts, ensuring High/Amber. formalised contractual RESULTING IN a lack of public monitoring (monthly) and confidence in Mid Essex CCG sanctions applied as commissioned services. appropriate. Partnership agreement with Ipswich Hospital NHS Trust.

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 40 IF the CCG does not have Viv Sara 4 December 2017: Governance, 15 12 6 Information Governance Internal audit of All CCG staff to carry out 31/12/2017 comprehensive information Barnes O'Connor Director of Corporate capacity and Training. compliance with IG Toolkit. an initial review of their governance (IG) and Services requested that the capability to Freedom of Information Level 2 compliance with IG files held on server. information technology (IT) rating was reduced due to deliver. process, including review of Toolkit. security procedures in place, face-to-face IG training, responses by Senior NEL CSU CCG IG Acting Director of 09/01/2018 THEN there is a risk that there including information on Information Risk Officer Assurance Report Nursing to undertake will be breaches of General Data Protection (SIRO). 2016/17. Caldicott Guardian confidentiality or failure to Regulations (GDPR) Data Flow Mapping. Training disclose information held in having commenced. Information Asset response to Freedom of Registers. Information Requests, Restricted access to IT RESULTING IN loss of public systems and folders. confidence and possible referral Essex-wide Information of the CCG to the Information Governance Team support. Commissioner's Office. Information Governance policies and procedures. NELCSU and CCG IT Security procedures. Appointment of SIRO (Director of Corporate Services) and Caldicott Guardian (Acting Managing Director).

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 7 IF the CCG does not consult Viv Rachel 4 December 2017: Draft Transformation, 12 12 4 Information Governance Communications & Deliver staff awareness 31/03/2018 and engage with the public, its Barnes Harkes template and guidance for innovation and Team monitor privacy Engagement updates to training on equality & partners and other Equality and Health integration. impact assessments. Board. diversity. stakeholders, or fails to conduct Inequalities Impact Quality & Nursing Team Equality & Diversity Annual appropriate impact Assessment being piloted Public monitor quality impact Report. Training for 31/03/2018 assessments (equality, quality within MECCG. Public confidence. assessments. Outcome of stakeholder commissioners on and privacy) when undertaking engagement on Home First Patient Reference Group. assessment against undertaking equality service changes, has commenced 9 October Communications & Equality Delivery System impact assessments. THEN this may lead to poor 2017 and will run until 15 Engagement Strategy. (EDS2). decision-making, possibly December 2017. Communications & Standardisation of EIA 31/01/2018 RESULTING IN poor service Consultation on the STP Engagement Plan for Five documentation/process provision/patient Pre-consultation Business Year Strategy. across Mid and South experience/breach of the Public Case commenced 30 Equality & Diversity Group Essex STP footprint. Sector Equality Duty/informatinn November 2017 and will monitor equality impact governance breaches and run until 9 March 2018. assessments. potential legal action, including Judicial Review, of the CCG

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ID Description Risk Lead Updates Principal Controls Assurance Action required to Due date Completed Owner Officer objectives implement further controls. (current) Risklevel Risk level (initial) level Risk Risklevel (Target) 2 IF the staff of the CCG and its Rachel Chris 4 December 2017: Risk Quality outcomes 9 9 3 Quality Surgery (weekly). Monitoring of complaints, Programme 31/03/2018 providers do not adhere to Hearn Patridge reviewed and no change and safety. Patient engagement. incidents/serious incidents. Management Office to national and professional made to risk rating. Proactive Patient Liaison & Thematic reporting to act as gatekeeper for patient safety guidelines Transformation, Advice Service. Quality & Governance quality and other impact THEN there will be an increased innovation and Quality Impact Assessment Committee of patient assessments. risk of adverse incidents, integration. process to assess plans. experience and Serious particularly during a time of Incidents. system transformation, Public QIAs reported to Quality & RESULTING IN an increase in confidence. Governance Committee. complaints, possible legal Audit of Quality challenge, and associated Governance = 'good' reputational risk. assurance.

6 IF capital expenditure is not Dee Mark 4 December 2017: The Quality outcomes 15 5 5 Capital expenditure Regular reporting to Board Work ongoing to ensure 31/03/2018 contained within approved limit, Davey Hogben CCG has no capital and safety. monitored monthly. and Finance & that ETTF approvals and THEN there is a risk that the requirement yet identified. Performance Committee any other identified CCG will receive a qualified Risk reduced to Meet financial for early escalation of capital funding Audit opinion Moderate/Yellow. challenge. issues. requirements are RESULTING IN leading to secured. reputational and regulatory risk.

174 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 17 Report Title: Home First Written by: Authors: Alison Connolly (Head of Planned Care) and Rachel Harkes (Head of Communications and Engagement) Sponsor: Caroline Rassell, Accountable Officer Purpose of Report: • Outline the feedback from the CCG’s engagement programme on Home First and plans for how feedback will be factored in to service modelling.

• Outline potential delay to originally planned March start date.

• Seek agreement to proceed with Home First, with delegation to the CCG’s Executive group for any further operational decisions, including risks and mitigation, timelines and review of impact assessments. To include oversight of the Home First / Braintree Community Hospital (BCH) Steering Group.

How does this issue link to the CCG’s Strategic Objectives? Please Tick  Strategic Objective 1 To improve quality and outcomes for all and keep patients  safe Strategic Objective 2 To meet the financial challenge through responsible use  of resources Strategic Objective 3 To achieve transformation, innovation and integration of  services Strategic Objective 4 To ensure there is full practice engagement informing  commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees that have reviewed this document).

Reports Submitted to Board only: Date signed-off by Executive Team. 11th Jan 2018 (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed off Yes No N/A by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment Under review Quality Impact Assessment Under review Privacy Impact Assessment Under review

175 Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: None

Patient & Public The feedback from the programme for public communication and Engagement: engagement is detailed within this paper. Significant Risks Potential slippage of timescales due to winter pressures and delays in identified: confirming arrangements for provision of personal care. Recommendations and • Note the feedback from the CCG’s engagement programme on decision/actions required Home First and plans for how feedback will be factored in to by the Committee/Board: service modelling.

• Note potential delay to originally planned March start date.

• Consider agreement to proceed with Home First, with delegation to the CCG’s Executive group for any further operational decisions, including risks and mitigation, timelines and review of impact assessments. To include oversight of the Home First/BCH Steering Group.

1. Introduction

In September 2017, a paper was presented to the Mid Essex CCG Board with regard to Home First. The paper:

a. Set the context and case for change; b. Outlined the Home First model and opportunities for Braintree ward; (As an aide-memoire, Appendix 1 provides information on the case for change and the Home First proposal) c. Outline and seek agreement to the programme of communication and engagement.

In response, the Board:

a. Noted the case for change; b. Agreed in principle the Home First model and opportunities for Braintree ward as the basis upon which to communicate and engage with the public; c. Agreed the proposed programme of communication and engagement.

This paper outlines the programme of public engagement that took place and the feedback received. It then proceeds to outline the model for Home First, including how public feedback has been incorporated. Indicative timescales for implementation are also discussed.

2. How Engagement Took Place and Emerging Key themes

Appendix 2 contains the summary of the engagement programme. So far, approximately 250 people have attended the public events; drop-in sessions or taken part in direct meetings to find out more about Home first and discuss the plans.

Appendix 2 also contains a summary of all Q&A’s from the public meetings and comments captured.

Appendix 3 contains the complete set of survey responses and visualisations for them.

Following feedback from attendees to the first public meeting at Braintree Baptist Church, the CCG changed its presentation to make it clear how many people could be using the service at any one time to address a misconception that the service would be available to many.

176 The presentation was also revised to make it clearer that this was an engagement exercise – not consultation - and to make it more obvious where patients and the public could have influence i.e. consideration of where to locate nursing home beds.

There has been a broad sense of support for the introduction of Home First in mid Essex during the engagement to date – see below some of the comments given:

• New proposal is excellent - it should have great benefit • The opportunity to come home from hospital cannot be underestimated - it's what patients and often loved ones want. The familiarity of being at home is beneficial for recovery and just a sense of wellbeing • The choice for most people to be able to come out of hospital and back home and be looked after in familiar surroundings and in an environment that helps their recovery. • Putting Braintree Hospital operating theatres to better use to resolve waiting lists for orthopaedic surgery. Patients generally want to go home as soon as possible so this process will support those needs • Relieve bed blocking. Happier patients being discharged earlier.

However, there are also several key themes that are emerging for the CCG to consider as part of the next steps, plans for which are outlined in Section 3 of this paper:

Theme - Level of staffing/resources to cope with demand This was the biggest theme to emerge during both public events and through commentary received via our online survey. People know that NHS services are stretched and there is concern that this model will need more resource than available regarding district nurses and community staff.

A snapshot of commentary below:

• Being cared for at home after discharge from hospital sounds ideal BUT is very much depends on the person’s needs and the support that can be reasonably given and expected. • I like the partnership between the CCG and Provide, however I am concerned that patients will not receive adequate support at home. I have no confidence that the current Govt will adequately fund the care as Mid Essex CCG is already underfunded compared to others in the county • I am strongly in favour of the move but have concerns about getting the necessary support from district nurses, matron, physiotherapists and doctors. Personal experience also says that the level of care that people need to assist them at home will delay getting people out of Hospital who are fit and well enough to go home. • This is only suitable if your home is suitable for your needs - this includes home safety and the availability of staff to identify risks in the home. There should be a procedure in place to identify and adapt needs in the patients home and a budget in place (either yours ie NHS or social care) to enable these to be installed prior to discharge.

Theme - Anxiety of increased workload on local GPs This issue was raised at all of our public events and via questions received directly from some of our member GP practices – a snapshot of questions/statements below:

• I am worried that this will increase the workload of our GPs who are already overstretched • Will my GP be expected to provide care to people at home and if yes, does this mean they will be unavailable in my surgery to other patients? • If this is expected of the family GP, how will this additional work be funded?

Theme - Transport links and increased transport costs for those caring for relatives/loved ones who cannot come home This was a particular issue for our Braintree population – below a snapshot of comments:

• It is an effort to care for someone when they are too far away and there are not good transport links here in Braintree - are you taking this into account when looking at the location of where these nursing home beds will be? 177 • This plan doesn’t feel very ‘caring’ towards families in Braintree. People are worried about how they would get to some of these other community hospitals if they had to visit family or neighbours • Can you think carefully about the location of the nursing home beds and have some here in Braintree to ease pressure of transport for some?

Theme - Impact on carers This was a particular theme during our Chelmsford meeting, at a specific meeting held with Action for Family Carers and one that has also emerged from responses to the survey. Some comments below:

• It's easier to look after my parents in their own home. It's cheaper for me as hospital car parking is expensive. However I would need assurance if care workers visiting as well to ensure recovery • Please make sure the carer/family is at the heart of the plan to discharge so that all agencies are aware and confident with what is happening • The carer is often the expert in the room – you need to make sure you listen to them as they often know the patient the best and what their needs will be • Talk to carers after launching the service to make sure it is working for them - they will tell you if it is successful or not

Theme - Future use of Braintree Hospital This was mainly an issue for the local people of Braintree as picked up during our public meetings and through our online survey. A sample of comments below:

• We want to keep the hospital for the people of Braintree – this plan will see others taking our beds • We will lose flexibility of where patients can go if we no longer have the option of community beds in Braintree • You need to make sure that you can staff the Orthopaedic ward properly with the right staff so that people have confidence in using it • I am concerned over the future of the hospital and what it will become as these plans detract from it remaining a ‘community hospital’ • I am in favour of using the facilities at Braintree for Orthopaedic use and welcome it • It makes sense to use the theatres better and to reduce waiting times – I’m just sad that we will lose flexibility of those beds but understand the rationale.

Survey feedback

After extensive local media coverage of the Home First discussion and active promotion by patient groups in Braintree and Maldon particularly, we had 49 people respond to the survey either online (the large majority) or on paper. Approximately 10 people or organisations sent individual responses. The large majority of survey respondents were aged over 50 and two thirds were women. The participants also included eight people with disabilities, six health and social care professionals and four people who identified as carers.

Approximately half of respondents welcomed Home First as a concept, with benefits for rehabilitation and patient flow. A number more gave cautious approval provided their concerns were met and there was broad agreement that appropriate resourcing, particularly staffing and care home bed availability, would be required to make the service effective. Some concern at the added pressure on unpaid carers and importance of keeping them informed of all the support available was also expressed.

Three questions in the survey focused on proposals for Braintree Community Hospital (BCH). Approximately half of respondents welcomed better utilisation of the BCH surgical theatres and changes resulting from that, while concerns from other respondents varied, mentioning reduction in intermediate care beds but also more general NHS services and funding issues.

The relatively small number of responses means there are few clear trends, but discussion of patient- focused care and the perception of beds as important for BCH are apparent and overall the CCG has

178 received some rich commentary in relation to how to take plans forwards and in relation to issues to consider.

N.B. Although there was a small degree of confusion between Home First proposals and the – unrelated - “CareBeds” scheme being discussed in the media during the time of the public engagement exercise, most respondents made no reference to it.

3. CCG Response to the Feedback

The CCG is planning to consider public feedback – as received via all engagement routes - in the following ways:

Theme 1 - Level of staffing/resources to cope with demand

The CCG and Provide are holding detailed discussions to look at the operational and logistical requirements needed for Home First. This includes careful mapping of staff resources, with contingency planning if any immediate gaps become apparent. Provide CIC is an established and experienced provider, used to the requirements of rapid discharge processes and delivery of personal health care across a wide geographical patch. We will be collectively drawing on this knowledge and expertise as we begin to firm up models and operational plans.

Furthermore, the CCG recognises the need to ensure all staffing requirements are in place prior to commencement – particularly in relation to personal care, which came out strongly in discussions with the public. Section 4 of this paper details the CCG’s preparedness to introduce phased implementation of the model in order to ensure that all staffing can be safely provided.

Theme 2 - Anxiety of increased workload on local GPs

The Home First model would look to provide care for up to about 20 patients at any one time, across the whole of mid Essex, and across a mixture of domiciliary and enhanced nursing home beds. The service is set up to be self-sufficient as much as possible. That said, for the very minimal number of patients returning to their own home setting, patients would likely form part of normal primary care caseload, as with any other patients managed in the community following an episode of care in the acute setting. To reassure, we would expect this to involve very low input – both in terms of number of patients per practice, and actual clinical intervention. In our audit of patients in community hospital beds, from where we identified the cohort for care in their own home, medical needs identified were only sodium monitoring and referral to outpatient specialty.

For those patients going to an enhanced nursing home bed, provision of routine medical oversight would be provided by the Care Home’s regular medical input, through temporary registration with the home’s GP. This would not represent an increased burden for the home’s medical support, as the number of patient on the Home First pathway would remain within the defined overall number of beds supported.

For patients being discharged to a community hospital bed, there would be no change to existing provision, whereby medical support of arranged by Provide through contracts for medical support specifically for the community wards.

With all of these pathways:

• There is primary care oversight for day to day issues Plus • Provide team delivering the wraparound care under Home First and/or as part of universal services Plus • Community consultant oversight of the Home First patient caseload – likened to how outpatient services are presently accessed for expertise, oversight and advice – with visits where deemed necessary, as directed by Provide staff and as part of scheduled and frequent ‘ward rounds’.

179 Theme 3 - Transport links and increased transport costs for those caring for relatives/loved ones who cannot come home

The CCG will now have more than one enhanced nursing home site (the original plan was for one), balancing this with other financial and practical considerations in provision of the service, which was also referenced in the engagement.

Transportation links will be one of the requirements, to ensure accessibility as much as possible. It is also worth emphasising that the hope is that many patients would be able to have their care in their own home, negating the need for travel at all.

With regards to provision of services across mid Essex and including in some of the rural areas, the main provider for Home First, Provide, are well versed in delivering domiciliary care for patients regardless of where they live. Travel time to remote areas will be factored into planning caseload management and where teams are based – just as it is now and has been for many years – and providers already have contingency plans for extreme weather conditions (e.g. arrangements with 4x4 vehicle services).

Theme 4 - Impact on carers

There is an intention to ensure the very real value of ‘informal’ carers is fully realised in Home First, including requirement to:

‒ Discuss care plans with informal carers before a person leaves hospital, and when looking at on-going and future needs - this will be stipulated as part of service specifications and in pathways, including the opportunity to be involved in MDTs (explained further under Theme 5). ‒ Provide comprehensive and clear information to carers regarding the service, keyworkers and ‘who to contact‘ if a carer beings to feel overwhelmed or in need of support and advice.

The CCG will also be looking to talk further with carers organisations regarding the service specification for home based delivery, to ensure ongoing consideration of factors for this key group.

Theme 5 – Process: How patients access Home First and are routinely monitored; Links with other services; Leaving the service

Patients will undergo an assessment whilst still in hospital to understand suitability for one of the pathways under Home First. As part of this, there will be identification of any equipment, adaptations, medication and immediate care needs, which would be put in place before the person is discharged from hospital. Providers and commissioners are in the process of working through referral pathways to ensure that the right factors are considered and acted upon at the right time, just as happens now with patients discharged home under the Stroke Early Supported Discharge service.

The Home First service is an integrated model. Although elements of Home First may be delivered by different services, there will be an overarching principle of Multidisciplinary Team (MDT) oversight of the patient, facilitated by a named keyworker for each and every patient under Home First. Section 4 outlines what this would look like as a delivery model, and also the function of MDTs and keyworkers.

Section 4 also illustrates the explicit inclusion of a ‘segment’ detailing links to other agencies and services. This would include mental health (such as the new Dementia Intensive Support Service), voluntary agencies and social care. With a proactive MDT and keyworker monitoring the needs of each patient and acting to refer to partners as early as need indicates, the CCG is confident that different services/providers will be able to build upon existing referral pathways and links to provide a comprehensive wraparound service which is based on individual need.

Furthermore, with routine involvement by social care and universal health providers in MDTs and patient discussions, there will be greater opportunity to start to implement early referral for those patients who may subsequently be in need of ongoing care, aiming to avoid undue delay once time in the Home First service draws to a close. Patients will not be discharged from Home First without confirmation that the next step is in place.

180 Theme 6 - Future use of Braintree Hospital

It is hoped that any anxieties expressed by the local population in the re-purposing of the Braintree ward will be allayed through successful implementation of Home First and reduced orthopaedic waiting times for the people of Braintree as well as patients across mid Essex.

Voluntary groups who play a vital role in the running of the ward are being encouraged to continue, e.g. through companionship to inpatients, so that it is still possible to protect the community feel of the site.

Theme 7 – NHS England conditions for bed closures Plans are expected to meet one of the following three criteria: • Demonstrate that sufficient alternative provision, such as increased GP or community services, is being put in place alongside or ahead of bed closures, and that the new workforce will be there to deliver it; and/or • Show that specific new treatments or therapies, such as new anti-coagulation drugs used to treat strokes, will reduce specific categories of admissions; or • Where a hospital has been using beds less efficiently than the national average, that it has a credible plan to improve performance without affecting patient care (for example in line with the Getting it Right First Time programme)

The CCG and providers are confident in being able to quantify the necessary staffing requirements to deliver care in people’s homes and enhanced nursing homes for a limited cohort of 20 people.

Existing staff resources are being mapped and any gaps identified, taking account of travel and other considerations associated with the model. Sufficient time is being factored in to the planned commencement dates to allow for management of any such risks.

The Home First model/approach is partly born from an element of the research conducted by BCG into the cost of our community beds and the comparison with the national average and further compelled by the waiting times for Orthopaedic treatments locally in mid Essex – the model demonstrates a desire by the commissioners to strive towards improving performance in Orthopaedic wait times and to continually demonstrate best value in the way we deliver care by reducing the costs of community beds.

4. Delivery Model for Home First and Indicative Timescales

The Delivery Model and Pathways Current delivery diagrams for Home First – both domiciliary and enhanced nursing homes – are detailed below. These diagrams take account of feedback from the engagement exercise and operational discussions to date. They also represent the integrated nature of the services, and how the components will be commissioned and delivered by a range of providers.

Funding arrangements Funding is available from the IBCF (Improved Better Care Fund) for the 2017/18 arrangement. Discussions are still progressing with Provide on the staffing model from both an operational and economic sustainability perspective.

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Timing of Implementation The plans and timings for Home First and re-purposing of Braintree Community Hospital are intrinsically linked. Throughout the engagement on Home First, the CCG and system partners have collectively and continuously assured the public that commencement of the changes would not happen until there is confidence in timely delivery against the service model and confidence in safe mobilisation.

A number of factors have now emerged that provide early indication that there may be some potential slippage to the original timescales. These factors include the impact of managing immediate winter pressures, both in terms of i) the re-focusing of staff to manage those rather than being able to focus on planning of Home First and BCH changes, and ii) the benefits in utilising existing community capacity as ‘known entities’, rather than attempting to embed a new service during a time of high demand. There are also delays in confirming arrangements for provision of personal care and associated staffing. Confirmation of revised timelines – if required – is being sought urgently with all partners. (Verbal update may be available at the Board meeting). There would, however, remain clear and strong commitment to the model and the associated benefit to patients.

Whilst recognition and management of any delays would be pragmatic and the safest approach, there may, however, be some challenges, namely around the impact on staff facing further delay to implementation and the impact on plans for St. Peter’s. It is hoped that staff could be supported through clear explanation of the rationale for this approach, continued discussion with our providers and on-going and open dialogue with staff. Furthermore, it is felt that all staff would themselves want to be assured of the deliverability of a service in which they will be working, and support a short delay in full implementation in order to achieve this, particularly if accompanied by clear confirmation of, and system agreement to, a more achievable date.

With regards to plans for St. Peter’s in Maldon, any delays in Home First are not expected to be significant, which should not, therefore, impact on the proposals for considering the future business case of the Maldon hub.

Weekly steering group meetings are in place to confirm any revision of timescales needed, ensure system progress to deliver against such timelines and/or mitigate where required.

5. Recommendations

The Board is asked to:

• Note the feedback from the CCG’s engagement programme on Home First and plans for how feedback will be factored in to service modelling. • Note explanation for potential delay to originally planned March start date. • Consider agreement to proceed with Home First, with delegation to the CCG’s Executive group for any further operational decisions, including risks and mitigation, timelines and review of impact assessments. To include oversight of the Home First/BCH Steering Group.

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Appendix 1: Background to Home First

Mid Essex CCG has reviewed the efficiency of existing rehabilitation offered to patients in hospital. Evidence shows an opportunity to deliver support and care either at home or in an alternative place of care, with benefit to the patient’s health outcomes and level of longer-term independence.

The CCG, along with our community services provider, Provide CIC, and Mid Essex Hospital Trust (MEHT), conducted an audit earlier this year to clinically review patients using all community hospital bed facilities in Braintree Community Hospital, Halstead Hospital and St Peter’s (excluding those in St Peters admitted for stroke rehabilitation which represent a slightly different patient group).

We wanted a greater understanding of the variety of patients in the beds and range of care required. We also wanted to consider whether, if there were a different model of care in place, one that promoted rehabilitation at home or another setting, patients would actually still require a community hospital bed in its traditional form.

The audit revealed that only 7% of the patients using the community hospital beds needed to receive on-going clinical care in a hospital bed whilst the remaining 93% of patients using the beds could have either gone home or to a nursing home with ‘wraparound’ care provided while they recover and rehabilitate.

We also discovered that patients currently using the community beds do not automatically go to the closest hospital to where they live - they are placed in a hospital which can best provide the care for their individual needs. For example, in Braintree, only 29% patients admitted between April 2016 and June 2017 were registered with a Braintree GP.

At the same time as understanding beneficial changes for patients who currently receive care in community hospitals, there is a further opportunity to support patients awaiting Continuing Healthcare (CHC) assessment or commencement of a CHC package.

Generally, the CHC process can take up to four weeks, which a significant amount of ime either awaiting CHC assessment or commencement of care package once approval is obtained. During this time, patients remain in – usually the acute - hospital, risking deconditioning and removal of independence that would otherwise promote effective rehabilitation. When the patient is subsequently assessed for CHC requirements, needs are consequently based on an “artificial” picture. This results in a care package that would arguably have been either fully or partly unnecessary, had there been less time spent in hospital. Whilst this results in limited resources being spent on such CHC packages, most importantly, it places the patient in a long-term state of dependence and the associated negative health outcomes.

Together, with MEHT; Provide CIC, Essex County Council social care and Farleigh Hospice, the CCG has been developing a new care model – ‘Home First’.

Our plans to change some local services

Home First runs along similar principles to the Early Supported Discharge Service already operating for stroke patients in mid Essex and follows national guidance to develop more opportunities for care which is closer to home.

Under Home First, patients who have been assessed as ‘medically fit’ to leave hospital could go home with ‘wraparound’ care; to an enhanced nursing home or remain in a community hospital bed. Every patient would be assessed and placed according to their unique and individual needs, with an emphasis on promoting each person’s potential for rehabilitation.

The CCG wants to begin a Home First service on a very small scale in early 2018 – caring for approx. only 20 patients at any one time in this way.

Patients under Home First will have ‘wraparound’ care for up to 28 days as part of the NHS offer from suitably qualified NHS staff, delivered either in their own home or an enhanced nursing home. 184

Repurposing of beds at Braintree Community Hospital

Home First will allow for more people to be cared for at home or in an enhanced nursing home, therefore allowing the CCG to look at different ways of using some of our community hospital beds.

Braintree Community Hospital has two state-of-the-art theatres designed for Orthopaedic surgery that are not fully-used to capacity.

By repurposing the beds on Courtauld Ward to surgical beds, the theatres could be used for Orthopaedic surgery. Winter pressures are likely to compound this yet further, as ‘elective’ procedures are cancelled to cope with non-elective cases.

This will help improve surgery waiting times and reduce short notice cancellations. Currently, more than 500 people in mid Essex have been waiting more than 18 weeks (the national target) for Orthopaedic surgery

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Appendix 2

The Engagement Programme

• The CCG ran a 10 week period of engagement to talk to the public, GPs, health professionals and community and voluntary groups.

• The CCG launched its engagement on 9th October by emailing a Home First information booklet and details of how to give feedback to a wide range of stakeholders including more than 150 local organisations and groups; press and media; GP practices and patient groups; local MPs, district and parish councils.

• The materials went live on the CCG’s website, facebook page and Twitter account and were continually promoted throughout the 10 week period.

• Packs of information materials were distributed to all 46 practices and staff asked to display in main reception areas. The packs included a printed survey (the same version as online). Completed questionnaires that were submitted online were automatically received by the Communications team. Those sent through the post were inputted by a member of the team.

• Local media including the Braintree and Witham Times, Chelmsford and Mid Essex Times, Maldon and Burnham Standard and Halstead Gazette gave early coverage following the launch.

• The Braintree and Witham Times and Maldon and Burnham Standard have given continual coverage throughout the engagement period with reader’s letters published and commentary pieces.

• Social media has been well used throughout the engagement to prompt views and publicise how to get involved including sending out ‘live’ commentary during public events.

• The CCG has also been able to secure free advertising in many partner magazines; websites and social media accounts to widen the reach – including Chelmsford CVS; Braintree council; Provide; MEHT; Maldon council.

• A number of public events took place across mid Essex to encourage people to find out more about the plans; allow the CCG to explain in more detail how the Home First service will work and gather views from local people.

Below is a timetable of events:

Date Time Venue Tuesday 17th October 7.00pm to 9.00pm Braintree Baptist Church, Coggeshall Road, Blyths Meadow, Braintree, CM7 9DP Tuesday 7th November 7.00pm to 8.30pm The Plume Academy (main hall), Fambridge Road, Maldon, CM9 6AB Tuesday 14th November 6.30pm to 8.00pm Chapter House (main hall), Cathedral Walk, Chelmsford, CM1 1NX Wednesday 15th November 1.30pm to 3.00pm Braintree Town Hall, Market Place, Braintree, CM7 3YG Wednesday 22nd November 7.00pm to 8.30pm Club Woodham, 5-7 Baron Road, South Woodham Ferrers, CM3 5XQ

• In addition, the CCG held two public drop-in sessions in the atrium of Broomfield Hospital and offered and held bespoke meetings with other stakeholders to ensure we captured as many views as possible, including:

186 ‒ Met with local MPs to brief them directly and answer any queries or concerns ‒ Met with Healthwatch Essex to brief them directly and answer any queries ‒ Attended Braintree District Council’s Health and Wellbeing Committee to brief them directly and answer questions ‒ Met with the Friends of Braintree Community Hospital to listen to views and concerns ‒ Canvassed the views of more than 200 GPs in the mid Essex area ‒ Canvassed the views of organisations including Essex LMC; Action for Family Carers and Age UK (Essex) ‒ Met with representatives of patients groups who helped to promote meetings and the online survey within their local community and networks ‒ Responded to queries from members of the public; individual GP practices and other professional bodies where required ‒ Worked with staff at Braintree Community Hospital to canvass views of families/carers of patients using community beds

A summary of all Q&A’s from the public meetings and comments captured.

CCG Engagement event: Home First Date: 17th October 2017 Time: 7pm-9.30pm Venue: Braintree Baptist Church, Coggeshall Road, Blyths Meadow, CM7 9DB

Attendees: Approximately 85 members of the public from the Braintree area including staff working within Braintree Community Hospital; local Councillors; members of the Friends of Braintree Community Hospital

What is the primary driver behind this change? Our plans for Home First are driven by the fact that we believe this is about doing the right thing for patients – Home First reduces deconditioning (meaning that muscle strength and mobility decreases the longer people stay in a bed). Implementing Home First does however raise the question of how we best use those beds in Braintree, where they would no longer be required in the way they are now. We have lots of elective Orthopaedic operations that get cancelled every year when demand peaks, and the ‘freed up’ facilities at Braintree could increase the number of surgeries carried out and reduce waiting times and cancellations.

Doesn’t this plan mean we lose flexibility because patients no longer have option of community beds in Braintree? We want to be able to increase the variety of places where people can recover whether that be at home, in a nursing home bed or, we believe in a few cases, still within a community hospital. At the same time as starting a Home First service we plan to commission a number of beds within nursing homes – which could potentially be across mid Essex - where the environment is more restful and can aid rehabilitation. The nursing homes will have enhanced support from medical and therapy staff to care for patients while they get back to their normal health. It is also worth highlighting that at the moment, patients do not necessarily go to the community hospital that is closest to where they live. It is dependent on their clinical needs and available capacity.

If you start Orthopaedics at Braintree, will you have the right staff in place? We would be looking at patients with low risk coming to Braintree for treatment. At the moment these patients are going to a private hospital, Springfield Hospital, so that we can get waiting lists down. The current situation with waits for Orthopaedic treatment is dire – more than 500 patients in mid Essex alone are waiting for this type of surgery. These patients are in often in chronic pain and debilitating all of the time and some of them have had their surgery cancelled 3 or 4 times because the demand for urgent and emergency operations increases. Partners are looking at pathways and medical cover for the ward at Braintree so patients are looked after in the right way and we get this right.

Why are you looking at Home First now – why hasn’t this been done before? One of the reasons that we end up in crisis during periods of heavy demand for NHS services is because we haven’t invested in community care enough.

187 Home First is exciting because we are reinvesting into the community to make sure those services and support is there. Doing the same things year to year doesn’t work – we need to try something different.

At one time Braintree had about 140 long stay beds – is this the last move to get rid of any type of bed in Braintree? There will be beds in Braintree but we want to be able to maximise all of the facilities within the hospital and this includes the two state-of-the-art surgical theatres. At the same time we want to be able to offer more modern ways to deliver care and in the best environment for patients – which is why we are excited to develop Home First. In the past, receiving care in a bed was the only available option, but that is no longer the case and, in many situations, not the best for people.

This demand for long term care will increase – will it not be at breaking point in the near future. How can you keep up with demand? Providing enough services across the NHS is a massive challenge – we continue to work very closely with patients, their families and carers and many health and social care professionals because we recognise we don’t have lots of money. But we have to come back to what is right for the patient and if we find this doesn’t work then we will rethink the way we can provide care in future too.

How will you make sure that people receive the right care in their homes – will there be adequate change-overs between staff and agencies so that people are not ‘abandoned’ when they still need help? One of the areas we have invested in is working together and bringing people together. Our GP surgeries have meetings once a month where GPs; community worker; therapists etc all sit together to work out how we can support individual patients. We need families and community on board too – we absolutely need that support. In the process of planning for Home First, we will also be identifying and planning for how to ensure patient needs are regularly monitored and any issues flagged up.

Clearly the situation with waiting times at Broomfield needs sorting. Will Home First services be NHS or contracted out to agencies? The Home First service will be provided by our community teams as they currently rehabilitate people within community hospitals. We hope to be able to reinvest in these services to ensure we have the right level of care available.

I’m worried about our GPs and the future – how will you ensure you have the skilled staff you will need? There is currently a programme across Essex looking to recruit and retrain EU GPs to help support our local workforce and Anglia Ruskin has just announced a new medical school opening in September 2018. We will be growing our own GPs and other skilled health professionals so there is some hope for the future but we do need to get through the next few years and attract more existing staff to Essex.

Broomfield Hospital is a massive site and there are other NHS buildings with capacity for opening up more beds and offering treatment so why are we paying for private hospitals to give services. Where is the foresight – is anyone reviewing what all of these buildings/rooms are being used for? There is a much more cohesive way we could use buildings and space across the public sector. There is a lot of work going on at the moment across Broomfield looking at utilising staff and space – but it always comes back to the point that there has to be staff to safely use these spaces. There is an audit of the three hospitals across mid and south Essex going on at the moment to see what have we and what do we use it for – it will, for the first time, present us with an NHS overview of what we own and how we use it or not.

If you’re moving beds out of Braintree – where are you going to put our people? When we carried out a recent audit of people using beds in Braintree, Halstead and St Peter’s (although not the stroke beds) only 7% of people needed those beds – many could have received care at home or in a nursing home with therapists and rehabilitation support. We’re hoping that Home First will enable people to get home sooner after a spell in an acute hospital, so that they don’t actually need to access a bed in the way they do at the moment.

Is it true that the survey you did at Braintree was on one day? 188 Yes – it was a “snapshot audit”, although the patient cohorts we looked at had variable lengths of stay, so it represented a good picture of the type of patients that would routinely be on the wards. Furthermore, there was nothing extraordinary about that week that would suggest findings would be out of kilter with any other day.

Of the 400/500 patients currently on the waiting list for Orthopaedic surgery, how many of these are suitable to come to Braintree in the future? Firstly we would look at all the patients on the current waiting list and at who we could send to Braintree (who would be ‘low risk’). It is still a patient’s choice of where they would like their treatment to be offered and who carries out surgery but a high number of patients could use facilities at Braintree. There are enough patients to continually fill those beds from the Orthopaedic elective list currently waiting.

St Peter’s floor isn’t good and couldn’t support bariatric patients. Braintree has much newer facilities so why restrict? We wouldn’t allow bariatrics at St Peter’s but these patients could receive treatement at Halstead – there is a ground floor facility there which is well-suited to it. We will always only ever place and nurse patients where it is safe to do so.

What is the timescale for this? The plan is to now look at end of February to close the ward at Braintree for intermediate care/rehab beds; deep clean it; and start using the theatres and beds for operations from the beginning of March 2018. If the Home First service isn’t ready or the hospital space ready then we will not begin – it has to be safe. We are looking at how best to maximise the other community hospital beds – we need to work sensibly because winter is almost here and need to be pragmatic.

Where will the upgraded nursing home beds be located? That’s one of the things we want to talk to you about – where is it best to have them? Should we spread these beds across mid Essex or should we have them in one location? Do we need to place them in more rural areas to support people in rural areas or should they come into Braintree? Your views are important.

This isn’t a consultation – you seem to have made up your mind already? No, this isn’t a consultation – this is an engagement event. CCGs have a legal duty to involve the public in our plans and this is something that mid Essex CCG takes very seriously. We don’t have all the answers and we want to make this right for patients – hence we’re talking to you about how this could work and the aspects that matter most to you.

It is an effort to care for someone when they are too far away and there are not good transport links here in Braintree. Are you taking this into account when looking at the location of where these nursing home beds will be? We know there is a great community in Braintree and a lot of local support available to people through voluntary and community groups and projects and initiatives run by the district council. We need to think about how can we use these local networks better – if you have got good ideas please let us know.

Comments • Transport in Halstead isn’t great and sometimes St Peter’s facilities have issues with the building – last year you had to move some beds out of there. • When enhanced services are there and a new health hub in Maldon then we’ll be in a fantastic place but at the moment I feel unsure that this will work. • We cannot afford the elderly – no government has planned for the NHS to be able to provide the right sort of care the increased elderly population will need in future. Doctors and MPs are saying it. • Our older population is increasing and you want to pinch our beds and there’s no space for expansion at the Braintree hospital site – I don’t think you should be doing this. • The word you have used tonight is care – but this doesn’t feel very ‘caring’ towards families in Braintree. People are worried about how they would get to some of these other community hospitals if they had to visit family or neighbours.

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CCG Engagement event: Home First Date: 7th November 2017 Time: 7pm – 8.30pm Venue: Plume Academy School, Fambridge Road, Maldon, CM9 6AB

Attendees: Approx 70 member of the public including patient groups; health and care staff and district councillors and officers.

How many beds are you looking at for Home First and how many beds will there be in mid Essex? There are 24 beds at Braintree, 20 in Halstead and approx. 10 at St Peters (not including the stroke beds) currently available for patients needing rehabilitation and recovery. Home First will start with a model to look at caring for approx. 20 patients at home at any one time. We plan to keep the beds in Halstead and St Peters and look at purchasing up to 8 more beds in nursing homes to provide enhanced care under Home First.

Will there still be stroke beds at St Peter’s? At the moment there are discussions about the future of the hospital. We are looking at various options for a Maldon health hub – but the question is do we need beds in the future? Does this type of care model work?

So the change of beds at Braintree is to help increase capacity for orthopaedic surgery but why don’t you consider things like 7 day working – there are a lot of wards currently at Broomfield that have capacity and spare beds From an orthopaedic perspective, we have looked at lots of models operating across the country. All wards at Broomfield are staffed 7 days a week and we carry out elective work 7 days a week from the early morning to late evening. However, the fact remains that we still have many people in hospital beds that are waiting to be assessed. This impacts on bed capacity which again impacts on us being able to do as much surgery. At the same time, we have people still coming in who are acutely unwell and need emergency/unplanned surgery so those who are on a waiting list for a planned procedure wait longer. By using the facilities at Braintree, we would be able to protect more of those planned procedures and begin to reduce those waiting times and, by doing so, reduce the numbers of people presenting for emergency surgery or treatment.

I share the aspiration to give treatment at home but my worry is the journey of how you get there. Where is the evaluation? The Discharge to Assess model – which is what our Home First service is based on – is innovative and relatively new within the NHS so there is a limited base of evaluation to date. However, as a local health system, we have to look at new ways of delivering services and we do have patients in hospital beds that would benefit from receiving their care at home. Essentially, what the Cochrane report suggests is that this isn’t a risky thing to do for patients. Nationally, the NHS is being encouraged to look at different models of care and this is being clinically driven. We will not be sending patients home unless it is safe to do so.

Speaking as a long term carer - our CHC assessment took 5 months – will care be provided until this is in place for patients? The national framework for CHC says we have to assess within a 28 day period and so I am very sorry that it didn’t happen within this timeframe for you. Under Home First, all patients will be assessed before leaving hospital and a 28 day care package put in place for rehabilitation and recovery. A multi-skilled team will be providing this care and continual assessments and milestones will be in place. If the patient is likely to need CHC, this will be identified and needs assessed. Early and continued discussion between healthcare professionals involved in the patient’s care will help to enable early identification of needs and timely planning, reducing the chance of delays.

Where is the extra staff going to come from to provide Home First – aren’t you struggling to recruit anyway? 190 We are working with Provide - our community services provider – as it will be a challenge but this way of working can bring new opportunities and attract staff. On a more general note, we are working with our local universities too to attract more health workers into Essex and think innovatively about future job roles.

Everyone is talking about elderly but what about patients who are younger - what happens to them? We absolutely recognise that not all patients will be elderly and this model will work for younger patients too and so this is about being able to provide the right care for the person – whether that is at home, within a nursing home or community hospital.

I’ve heard from colleagues that district nurses are fed up with the added bureaucracy - they don’t have autonomy anymore and that’s why you are losing staff? We are doing lots of work in our own local areas to best use the resources we have within our workforce. We can always do more to try and reduce the paperwork and get more people out providing services and there is a lot of examples across our patch where there is good work going on. It is a challenge but we are aware of these challenges and continue to work with our staff to overcome them when we can.

How long is the current contract with Provide? If you’ve only got a few months left then what happens with this model afterwards? The current contract with Provide runs until the end of 2019 but they have been providing our community services for 10 years so there is an excellent partnership and we are looking to keep a long term future. The key to helping make this a long term model is also working closely with social care providers, voluntary groups and other health providers to make sure this service can work into the future.

Why can’t you get the money we deserve in mid Essex from the government and then we can get a better service for people in Maldon? There is a national formula and we do get less than any other CCG in Essex and have been trying to improve on this for the past couple of years – today, again, we met with Ministers to discuss health services in our area. The biggest voice is yours and we need your help to do this. We have two theatres at Braintree that are better than at Broomfield – it is within our gift to make better use of these. This is the third year of operation for the CCG and it’s the first time I’ve been able to say during a public meeting like this that we’re not restricting services – this is an opportunity to get things right for future care.

What is happening to local hospital – St Peters? There has been no mention of this tonight? We haven’t concluded the business cases for Maldon and we are still looking at various options. Do we still need beds or can we look at other alternatives?

Who takes responsibility of care provided under Home First – is this medical (ie hospital) or social care? Care provided when a patient leaves hospital, and for up to 28 days afterwards, will be organised and funded by health. After this, some patients will continue to have health funded care via CHC and others will need care provided by social care. We will be looking at the patient holistically to ensure they can recover to their optimum. This is also about understanding if patients want to be home and then mitigating the risks to be able to support that patient at home. We already provide this kind of care now for some patients. This isn’t taking patients out of hospital who are not safe to manage outside of hospital.

Who manages the patient and who manages the process? Does info get shared with all health and other professionals? The care is health-funded for 28 days and is the responsiblity of mid Essex CCG. The patients GP will continue to be involved in the process as will other health professionals like physiotherapists, senior medical staff and nurses.

Will there be appropriate resources? We are looking to start this with a maximum of 20 patients at any one time and will only begin when we know that there are enough resources in place to ensure that patients are safe. 191

Comments: • This model has not been fully evaluated and there is little evidence supporting the outcomes. We don’t have a fall-back position and this model is based on zero evaluation and relies on volunteer co-operation. • I understand the model but I’d like to make a few points: - When you are working with Essex university and training new nurses please can you get across that it’s the whole person to be considered - not all needs are medical - I come from Sutton Colfield and there is a ‘halfway house model’ in our area where people are supported to recover – I would recommend looking at that model - I had to choose nursing homes for my mum and so I was able to make the right choice but what happens to older people with no children or living relatives – how will you help get the person to the right place? • I hope this will be different to the current reablement service provided by ECC as this is not very good – my mum is 96 and I had to make sure I could go see her every day as the carers didn’t really have time with her • I reject the proposal of Home first as I don’t think the CCG or our health system has the money to do this properly. The ambulance procurement by the CCG was abysmal and so I have no confidence in this process • There must be beds still and, most importantly, these beds need to be as accessible as possible for local people here in the district of Maldon • Interesting that the CCG is pushing the view that Maldon doesn’t need beds in the future – but we do. We need beds and we need appropriate facilities so stop talking and get on and do it

CCG Engagement event: Home First Date: 14th November 2017 Time: 6.30pm – 8.00pm Venue: Chapter House (main hall), Cathedral Walk, Chelmsford, CM1 1NX

Attendees: Approx 5 members of the public – three with a focus on carers; CCG and hospital staff.

Summary of questions and answers and comments

Are you going to be fully funding the additional support that will be needed for Home First model? Yes, the model will be funded by health. We are working very closely with Provide (our current community services provider) to ensure that we have enough staff in place to be able to start a Home First model. To begin with, Home First will only support up to 20 patients at any one time so that we can be assured of providing affordable, safe, high quality care for those patients.

How much extra burden will be put on the GP? In looking at this clinical model, we will have community geriatricians as part of the team providing Home First and each patient will have an individual care plan. Anyone in the team involved in providing care for that patient will be able to tap into the clinical oversight provided by the geriatrician and the nursing staff will be prescribers. We don’t anticipate that GPs will be asked to provide any additional care above and beyond what they are already providing for their patients.

Have you planned for redundancy? We’re not looking at any redundancies. Provide have been discussing with staff any potential changes in their ways of working but there has been no talk of redundancies. There are nurses working at Braintree community hospital who may want to continue providing this type of care but we will also look to recruit too if needs be. We are looking at current capacity, redeployment of staff and new staff. We have to look at working smarter – using appropriate nurses for appropriate care. Some will be registered nurses, others healthcare assistants – we need to grow flexible workforces.

We all want this to happen but can you do actually do it? We plan to start small with this model – to be able to test this and feel confident that we are getting it right for patients. 192 Provide already have very good experience of caring for patients with complex needs in their own homes through the Stroke Early Supported Discharge Service. We want to try and extend this type of wraparound care to other types of patient.

My wife was in hospital and then ready to come home, but the hospital couldn’t find an agency to care for her. Will Home First address this? Within Home First we would cover all of the patient’s needs for up to 28 days while they rehabilitate. The team will be working to therapy and clinical care plans. We wouldn’t agree to take someone home unless we could support their care needs. Talking to the carer will be part of the patient assessment – finding out what works for them and if we need to take specialist advice we know where to get it from. If you’ve already got carers and have rapport but just need extra support we can layer that on - we need to be able to work with what is normal for them and you. After the 28 days, it may be a different type of care or support that is needed but this will be worked out through assessments.

Where will the enhanced nursing home beds be? At the moment the CCG has a quality framework with 13 homes across mid Essex — a group of homes that we contract with and oversee the quality of care provided. We are very keen that those beds will be provided by homes in that framework so that we have oversight of the quality of care. At this point in time, however, we have not yet confirmed the homes or locations and are keen to capture views through this engagement.

Comments • I have experienced problems with my husband being discharged from hospital when he has not been well enough to come home - it worries me that there will not be enough follow up under Home First • I wasn’t considered as an expert carer to my wife and wasn’t that involved in the discharge planning – I hope this improves under the new model • One thing I can see as a real positive is that when people are in their own homes, there are more people who can have a say on their care (ie family and friends) so that they can better manage in the longer term • If we take the idea of pharmacy - if we are sending patients home they need to have enough medication or specific discharge pack • Need to listen to carers and that all people are heard - need to listen as we are the expert • Communicate and involve the carer in the MDT team sorting out discharge from hospital – this is essential if you are going to get this right • A lot of people still don’t understand how to deal with a patient’s mental health - staff involved in Home First will need to know how to handle anxieties • New proposal is excellent - it should have great benefit • I favour spreading the enhanced nursing home places so that there are options for reasonable travelling distance

CCG Engagement Event: Home First Date: 15th November 2017 Time: 1.30pm to 3.00pm Venue: Braintree Town Hall, Market Place, Braintree, CM7 3YG

Attendees: Approx 20 members of the public, members of Save Our NHS Colchester, patient groups and Friends of Braintree Community Hospital.

Summary of questions and answers and comments

What is an enhanced nursing home? It will be one, or several, of our existing nursing homes that will have dedicated beds for Home First patients and additional care services provided within the home – such as therapy, nursing and medical care. We have approx 13 homes on a contract framework with the CCG which means we get the oversight of care and quality within the home. The enhanced nursing beds could be offered at one of these homes.

193

I’ve seen people go home who couldn’t cope and then go back into hospital again. How will Home First stop this? Home First will only care for about 20 patients at any one time and only people who can safely go home with services wrapped around them. The idea of Home First is that it will be for patients who do not need to be in hospital and can make good progress in their recovery at home. We will work with family, carers and all providers to support patients. If it’s not appropriate then they won’t go home.

Why do you have to change the beds at Braintree to Orthopaedic use - why not open up more beds in total? Braintree has two theatres that have been designed for more complex surgery, such as orthopaedics – and the wards would need to be converted to surgical wards for patients using the theatres. It is not possible to have a ward with mixed use – orthopaedics and rehab – due to the need to control the risk of infection. We are looking to have some additional ‘beds’ for rehabilitation through the nursing homes and, potentially, 20 people who would have been in hospital will receive their care at home or in one of these enhanced nursing beds under Home First, so overall there will be more capacity to care for people with these plans. We assess our Orthopaedic patients and give each person a grading from 1-4. Grade 1 being fit and well; grade 4 patients being those who would likely have more complex needs to consider as part of their treatment. . Only grade 1 and 2 patients will be treated at Braintree and the others will stay at Broomfield.

Will it be safe for people to go home? The Home First model will only work with the right staff and carers in place. Patients will not go home without the right care available to them - it has to be safe

For example, we visited an area in Surrey which has 18 patients at home with a very small team around them providing care. This model is possible and the right thing to do for some patients. We need to work to ensure we can get the right staff and service in place.

Where are you going to get the staff to grow these teams? At the moment, we recognise there is a shortage of nurses and staff to provide support. We will recruit and we are looking at what levels and types of care will be needed; the skills and capacity of current staff and how we can grow and develop this. There will be a plan for every person that is individual to them and this care will be provided by one team – so there will not be overlaps with services that, at the moment, are provided separately. We are positive about recruiting – some people like flexible working and the opportunity to work in different roles with a variety of responsibilities.

Where are you expecting to get all of these carers from? We are ensuring a good lead in time to allow us to identify and recruit the care staff to deliver the personal care aspects (such as feeding, bed-washing etc.) of Home First. We will be regularly monitoring progress of this, and thinking through plans and timings to allow for any potential issues that might emerge. We are already discussing care needs with other organisations in mid Essex to think smartly about how to mitigate any staffing risks. Other staff involved in Home First, such as therapists and nurses, are likely to be drawn from teams currently delivering care in the community hospital. The provider would arrange the service so that teams are generally allocated a particular geographical area, in order to reduce travel time. However, there would then also be flexibility within each team and between neighbouring teams to provide cover and support if there is sickness.

What about people at the end of life – will Home First support them? Home First is a model for people who are rehabilitating and recovering after an episode of illness – not those who are on an end of life pathway. However, across mid Essex, we are working with lots of services to be able to support people to die in their preferred place. This can be home, a hospice, hospital – choice is vital and we do our best to help offer this. 194

You mentioned only 20 people for Home First – is that only 20 or 20 during the 28 day period? We anticipate starting Home First with only 20 people at any one time being cared for in this way as we want to be sure that we can offer care in a safe and managed way that will support the patient.

Say, geographically, Maldon gets busy with Home First and then another area – how will this work? Depending on needs of the patient, we will move staff from one area to another to support those individuals - that’s why our model of staffing needs to be flexible.

How does that work in rural areas if and when the weather gets bad? We already have contingency plans that kick in when the weather gets bad – this includes links with a 4x4 service so that we can get to all patients. This has been tried and tested already with the care our district nurses provide across mid Essex.

If you’ve discharged people from hospital - how do you ensure they are ok – who checks on them? Just because the patient comes out of hospital – they are not out of the system. We continually assess patients and only when it’s right will the patients be discharged from hospital. Under Home First, patients would still be seen by healthcare professionals who would be able to continuously monitor their condition. For some patients we will know before they leave hospital that they need CHC in the future; others it won’t be obvious until they go home and others won’t need it at all. If a patient has social care needs instead of health needs then we will work with social care – we have been talking to ECC as part of the Home First plans and we hope to get better at working more closely together.

Is this plan just another way to save money in the NHS? This isn’t about saving money – we doubt Home First will save us money. This is about giving people the opportunity to recover in the right place for them and to help people maintain as much independence as possible and to reduce demand in the future.

Can you really offer a bespoke, individual care plan with a small team? This comes back to the point of having conversations with the patient; their carers and family to try and accommodate as much as possible their needs. We might have to offer a limited window of time for certain services but we can offer more choice than in the hospital.

I’m worried about the lack of district nurses to take this service forwards – how will you staff it? There are no less district nurses in mid Essex than a few years ago but yes demand for their skills is higher. We need to be wise about use of the skills and teams we have and so will look carefully at what the patient needs and how that support can be provided. Years ago, GPs did everything - now a patient has care from a much wider range of people - physiotherapists, prescribing nurses, pharmacists and healthcare assistants.

If staff will now be driving to get to patients – will they be spending more time driving rather than caring for patients? The last thing we want as a district nursing team or community team is to spend all of our time in a car. That’s why we carefully plan out the care and have teams centrally located so that more time is spent with patient.

Where will the nursing home beds be located? We haven’t decided on the final location of nursing home beds - we want to make them as accessible as possible but equally within a home that the CCG monitors in terms of quality of care. At the moment we have 13 homes on our framework for quality assessment and are considering having the beds in one of these homes. We will take into consideration the issues around travel and transport that have been raised too.

195 You’re being asked to cope with very dwindling budgets and yet still look at new ways to provide care – how? We have focused Home First on how to improve care and how to make things right for patients individually. We have squeezed money in the past from areas of the NHS locally but this engagement and plan is genuinely not about that. The CCG, Provide, Mid Essex Hospital Trust and many other partners that we work alongside want to be able to offer innovative care that leads to the best possible health for patients.

Will you hold your hands up if this doesn’t work? We will not go from 0-20 patients using Home First straight away – the service will start small and we will evaluate it as we go. We are not going to fix a date to start either so that we can still flex beds over the winter if they are needed and ensure we are in a position to safely commence Home First.

Why have beds been closed already when they are needed? Rehabilitation beds remain at Braintree, St Peter’s and Halstead so that we can cope with demand when needed – beds and staffing flex across the service depending on need.

What care will be at Braintree overnight for those who have had hip/knee surgery or treatment? We will have a skills mix of the staff working within the ward at Braintree including senior nurses and access to a hospital consultant and anesthetist overnight and during the day. If patients deteriorate there is also a direct route back to Broomfield.

Putting this in place is fantastic. When the CHC doesn’t come - what is the transition between this and social care? As commissioners we carry on paying for the care to allow social care to organise alternative services and support. We are planning to ensure early discussion with those agencies and providers who may be involved in a patient’s ongoing needs so that early planning can take place to avoid any undue delays in transition from Home First to those other services.

During the first meeting in Braintree, some nurses went away in tears. What has been done about this? We had already started speaking to staff about Home First and, as you will imagine, there were some anxieties about the changes and whether or not jobs will still be there. There has been no discussion about redundancies and staff have been spoken to at length – we want to develop the skills and abilities of community staff.

Comments: • Population getting older and people living longer - since 2010 the ability to live independently has decreased • Number of people with long term conditions has increased - could we encourage some of these people to do their own injections or a bit of self care? • There is a national shortage of NHS staff - we need healthcare assistants and nurses working in roles that are suitable and skilled • If you turn Braintree into Orthopaedic use only this makes it prime for private providers to want to take over the hospital • A lot of people in a caring role are older and can’t drive – you need to make sure you look at bus routes that are not going to be axed • There is community transport and a voluntary bus service that runs from Danbury but it only takes you one way – could you work with them to look at expanding the options? • We’ve heard some great things today - if it has worked somewhere else then you would be silly not to try it in our area

196 CCG Engagement Event: Home First Date: 22nd November 2017 Time: 7.00pm to 8.30pm Venue: Club Woodham, Baron Road, South Woodham Ferrers, Cm3 5XQ

Attendees: Approx 20 people including members of patient groups.

Where are the doctors coming from to cover new Orthopaedic ward at Braintree? Within Broomfield, we have an emergency, elective and step down wards - 14 consultants currently work across these. The vision is that one of the consultants will go to Braintree - a resident doctor and senior nurse will also be at the hospital so that we can develop a therapy area away from the acute site and away from the trauma/emergency cases. We are trying to look at ways to be innovative and better manage the care on offer to patients. This ward will be for patients who are fitter and can be further away from an acute hospital but who will still have access to skilled and specialist staff. Patients don’t want to have their procedures cancelled – it’s one of the single most important things they identify in feedback to us. We hope this development of the ward in Braintree will enable us to get our waiting list down eventually and hopefully get patients to treatment quicker e.g. 2 theatres and 8 people a day for hips and knees.

Who currently decides to cancel operations – GP or hospital? There is a pre-assesment phase where the hospital team see every patient referred by the GP to look at suitability for surgery. This team will decide on which elective procedures are postponed when we have sudden increases in emergency cases.

I went to opening of the Braintree hospital and it is lovely – very clean and modern - but I’m amazed this hasn’t been used properly before? Braintree hospital is being used but not for the type of surgery we would want to carry out there – we want to fully utilise the theatres and improve things for patients across mid Essex.

My concern with Home First is our GPs – this will place an additional burden on them. Most practices are over-subscribed and, locally, we are planning for more homes in Southminster, Althorne and Burnham. How can they support more people at home? Quite often patients coming home from hospital need support from their GP. We will be wrapping care around the Home First patients - specialist services provided by district nurses and physiotherapists – so they won’t require any more support from their GP. We want to create a virtual ward in the community with Home First – a service where we can monitor the needs of each person and co-ordinate care accordingly. Already we are trying to grow our workforce skills in practices in this area – we have a pilot to develop practice nurses; we have a new model helping patients at home that were keen to try out and a rapid response team that can see someone within 2 hours. Our GP colleagues have helped design this service – Home First - so that there isn’t additional burden on primary care.

Some of the areas surrounding South Woodham are quite rural ie Southminster and Althorne – how are you going to support these people at home? We have already got a support service at home for stroke patients and it works now – we do get nurses and services out to rural areas and plan for this so that we can ensure all patients can be cared for at home.

Will the patients know these people ie nurses/carers or will it be different staff every day? We always try to keep continuity of care and have a small team of community staff so the likelihood is that a patient will get to know them

What happens at the end of 28 days? Will patients still receive care? On average, we believe that Home First patients will have had the rehabilitation they need to recover within this timeframe but there will be a conversation going on during this time about how patients are managing and they will have milestones in their recovery. If the patient needs care beyond the 28 days

197 we will be assessing needs and helping to source the next care package if those needs are primarily health-related. The care package could come from CHC or social care. We already work with integrated discharge teams to look at what long term needs are for patients and Home First will keep this assessment and planning process going - working with social services is vital.

Will any of this team be taken away from what they are doing now? It could be different staff providing the care under Home First. We want to have a specific team that will take the patients out of hospital and start rehabilitation as soon as possible and oversee their time to recover at home. We are not going to be forcing people to do this - going home has to be right for the patient but we do know that rehabilitating people at home can give better health outcomes and help people recover their independence.

Has there been research into this model of Home First? Not formal research but there are quite a few areas of the country that are already running Discharge to Assess models of care. Sheffield is one and we have been to look at their model. Likewise, we’ve been more locally to Yarmouth as they are doing something similar.

Remind me of what sort of numbers for home first? We are only looking to have 20 patients at any one time on the Home First service - we aim to start with a small number to make sure that we can provide support and care.

20 sounds small - what if there’s 30 people suitable? We’re testing a theory - if this works we will expand it but need to start small so that we know we can provide the service.

Will they be selected randomly? No - based on suitability and need. We don’t want to take patients and they then go back into hospital – the so-called yo-yo effect. We want to make sure patients are suitable to be at home.

How will you manage this? The Home First service will be delivered by Provide who currently deliver most community services cross mid Essex and are very experienced at doing so. The CCG will manage the contract with Provide and oversee the process.

Things in the NHS are constantly reorganised and then it doesn’t work - how long will people be around to monitor it? We do get things wrong and reflect on that to make sure we learn lessons for the future but we also gets things right too – our current stroke service in the community has won awards.

Will you take into account people’s homes? In terms of if their home is adaptable/suitable and if the patient needs certain types of equipment then yes we will.

Are you checking bus routes/travel options before deciding which nursing homes to have beds in for Home First? We will take into account how accessible places are for relatives and carers – this has been talked about at other meetings.

What happens if you have opted for knee surgery at Springfield? We want to take some of the work from Springfield to Braintree so this could be an option for some patients but it is always a patient’s choice.

Comments: • People don’t want to be isolated and so it’s really important that they do go home with support • Majority of people want to be at home, things have got to change so totally buy into the change • I like the principles and idea of Home First but am worried it will not have staff to make it work • I worry that this is being funded by commissioners and your funding is always at risk but I can see that this will give patients benefit in the long term 198 • The hospital will get more room by doing this – that’s a good thing. It will free up some of our beds as a lot of patients need those elective operations • If you don’t try this you will never know – I support it • As someone who has used Braintree hospital it is lovely and I’d rather go there than Broomfield • Could I just say that everything was fantastic for my wife last year when she was in hospital and I wish people would congratulate the staff • My mum had palliative care at home and it was really the right thing for her – the care was first class and the district nurse team was brilliant

Appendix 3

Full Home First engagement survey results

Question 1 (49 responses)

Question 2 (49 responses)

199 Question 3 (49 responses)

Question 4 (49 responses)

Question 5 (49 responses)

200 Question 6 (42 responses)

2 4 1 3

1. I have recent or current experience of hospital discharge to a community bed in mid Essex 2. I am a carer or family member of someone who has used or is using a local community bed 3. I work for a provider and am directly involved in managing community beds and/or reablement 4. I am a health or social care professional not directly involved in these areas 5. I do not have any direct interest in this matter but wish to share my view 6. If you have a different interest in this subject, please state: I live in Writtle, am active on the Writtle Patient Group and have had an interest in healthcare (end of life, specialist, complex acute and dementia care homes) since 2001 I am a carer for a person with dementia. Transferred from my area due to lack of beds in the Tendring area I am married to a transplant patient who may well have issues in the future and I myself have heart issues and may need support in the future to come home from hospital Recent bad experience of the 'Fast track' discharge scheme. My Mum passed away in Broomfield Hospital in October 2017 but was due to go home under the 'Fast Track' discharge scheme. I am a primary care manager Community Champion for Braintree Carer for 3 people over 78 years of age, all in one home. Member of Blackwater PPG Previous experience of discharge to community hospital Maldon Town Council represent the interests of residents of Maldon I was, for many years, the manager of the housing team in BDC environmental health dept. I was responsible for the provision of disabled facility grants and worked closely with the OT in providing adaptions to suit client needs. I know the limitation of budgets and the practical difficulties in providing a timely response to meet urgent needs of potential hospital discharge. Liaison is a must. NHS Supporter I have received various minor surgical procedures over the years involving in-patient admissions I am a family member of people who have regular hospital treatment

Question 7 (11 responses)

201 Question 8 (2 responses)

Question 9 (10 responses)

Question 10 (34 responses) Please give us your views about Home First and how you think people who need ongoing care after they are discharged from hospital should receive it It sounds ideal for those for whom it is suitable, but given the current financial pressures is it possible to fund these changes, and care at home, to a good enough standard? People are currently discharged without adequate care/reablement packages and hence they are then re- admitted. I think Home First offers a solution to this It seems a very good idea to move people from a fully equipped hospital bed to a less highly specified location. Concerns that "local means local" and not just somewhere in Mid Essex. This is like reinventing the wheel, insofar as in the not too distant past we had convalescent homes/cottage hospitals, which with the march of progress were decried and closed. Now we are being asked to consider this radical idea of cheap rate convalescence care. It always was a good idea until acountants ruled the roost and did not listen to practitioners. If operated correctedly and not just a cheapskate solution, then I would fully support the resurrection of the convalescent ideal. The mental health community services need to be involved in aftercare quicker to avoid readmission and waste of bed space in the hospital My mum lives in the West Midlands and she has recently had good experience of a 'half way house' - an independent room with a shared use of kitchen/dining room. This really helped give her confidence to come home - this was not a nursing home though and I wonder if something like this could be available in midEssex? Being cared for at home after discharge from hospital sounds ideal BUT is very much depends on the persons needs and the support that can be reasonably given and expected. From our experience as relatives the current support given by care agencies is hugely insufficient in terms of skilled staff and resources. Currently staff spend large amounts of time in their cars and not with patients - care agencies don't pay great wages so staff are less skilled than they should be and agencies don't recompensate staff for travel

202 expenses. From our experience, being cared for at home after discharge from hospital sounds ideal BUT it very much depends on the persons needs and the support that can be given and expected. From our experience and for the relatives, the current support offered is insufficient in terms of skilled staff and resources. Currently care and nursing staff spend lots of their time in cars instead of with patients. Often care agencies use staff that are not skilled and don't pay them very well or proper rates for their travel expenses. I believe that some home care is needed I write after hearing and being reassured that the stroke ward at St Peters will not be affected by Home First. I like the partnership between the CCG and Provide however I am concerned that patients will not receive adequate support at home. I have no confidence that the current Govt will adequately fund the care or that Mid Essex CCG is already underfunded compared to others in the county. I also have concerns that this may place pressure on relatives and infrastructure may limit the mobility of staff delivering services at home i.e. traffic/travel time

My experience is of the Reablement programme. It was sold to us in exactly the same way you are describing Home First - assessment in your own home, therapies delivered in the community, care workers who will support and encourage mobility and a return to independence. The reality of the programme was a shambles. The uncertainty of carers times and visits made my mum anxious, frustrated and confused. The therapeutic input was good but entirely insufficient and none of the carers had the ability to support any programme. There was no continuity of any programme or progress of recovery. While I applaud this idea I do not believe it will be funded appropriately - especially in rural areas I am a full time carer and recently has a stay in hospital, but once I was discharged, I was at first see in out patients, till such time any additional treatment was through my GP. I can safely say this system works, I see Home First as an extension/progress of this system, I have personal experience through my volunteer work of people recovering quicker at home with the right support then staying in Hospital. The biggest challenge will be the system meeting the needs of the individual, especially if they have very or no little family/friends network to support them. There is an education required that people need to take a level of responsibility for their care, encourage them to be involved in deciding their care plan. Care providers need to be fully aware of the complex needs of patients with long term multiple conditions, especially understanding their emotional needs At home if possible. Lack of suitably trained/qualified staff will result in a vulnerable level of service to the patient. An intermediate care facility should be available for those patients who require equipment/alterations to their home without which the treatment/care cannot be independent. through community matrons and district nurses with the support of the gp only if the patient is fit for discharge Provision should be made before they are discharged. Reablement doesn't see to work properly. I need to know more about how this works out in reality. I'm not happy that everything IS IN place to carry this forward right now. Looking at other Trusts and probably copying what they do, might not work in our area. The demographics and support for that area needs addressing first. It appears to me that in theory on paper it will work, not sure about it in reality and one person let down is one too many. What and where are the people to carry out this service being recruited from? According to their need I am strongly in favour of the move but have concerns about getting the necessary support from district nurses, matron, physiotherapists and doctors. Personal experience also says that setting up the commercial rehabilitation needs to assist the patient at home will delay getting people out of hos[ital who are fit and well enough to go home. I think Home First is a good idea so long as it does not detract from the care already being given at Braintree Community Hospital. Home First could be detrimental to people in my position. Its all very well sending professionals to the home but who is going to provide the care in between those professionals visit? The ethos is sound but I cannot see how it will be adequately funded or staffed. I have grave concerns that the neccessery staffing levels will be sufficiant. The presentation was good and if it can be made to work could be very good. I cannot see how it will work properly though without investment and how will enough staff be recruited? There is a chronic shortage now so I am cynical that it will work. The overriding feeling I got from the meeting was that we still need beds in Maldon. Present shortage of carers and District nurses very stretched to cover existing calls make this idea virtually impossible. Too few doctors also under pressure and shortage of physios make this unviable unless a large increase in staff which is unlikely to happen. People will be left with no help Maldon Town Council is very concerned that a town of this size has insufficient provision of recuperation beds available locally. Given the lack of adequate public transport links to Braintree and Halstead. This must be detrimental to the health of local residents and patient recovery 203 This is only suitable if your home is suitable for your needs - this includes home safety and the availability of staff to identify risks in the home. There should be a procedure in place to identify and adapt needs in the patients home and a budget in place(either yours ie NHS or social care) to enable these to be installed prior to discharge. 1. I take issue with the omission of reference to the underlying aim of discharging patients earlier than perhaps would be appropriate/usual if beds and staffing were available, in order to free up beds in a setting where the number of available beds has been deliberately and dramatically reduced since 2010. 2. Rehabilitation and recovery from treatment should be given by appropriate and medically trained staff until such time the clinician/consultant is satisfied (not under pressure) to sign off the patient as being at a stage where no further hospital medical input or monitoring is required. If the patient can manage independently at home, then ongoing care would be follow-up appointments with the Consultant or GP to monitor recovery. If the patient is in need of care and medical input, which can be provided outside a hospital setting, a well resourced, adequate support system has to be in place before they are discharged home. If the level of care needed cannot be given in the home, then the person should be placed in an appropriate, qualified convalescence/care provider setting, where a GP/Consultant continues to have oversight. I’m a big advocate of Home First. My 85 years old father received the NI equivalent of Home First after receiving hospital care for an aneurism. The speed of his recovery when he was discharged to his home took us by surprise; we couldn’t believe how quickly he returned to his former baseline after leaving hospital. The timing of the risk assessment as well as the assessment itself is very important in my view. It occurred to me after I witnessed my father’s recovery whether the risk assessment could have happened earlier, but the amount of improvement he made over a relatively short time was so dramatic, I’m not sure anyone could have predicted it. I believe people should have a choice to have care in a community hospital or at home in the community but those services are over stretched as it is and would need more capacity. At home is best as long as the carers attend at a time that is acceptable for the care the people require Not at 11 am to assist with dressing and breakfast as some re-ablement carers do if they turn up at all. Home First would benefit patients who may not be able to access local out-patient facilities The reason we used the hospital was because the care needed for my family member could not be provided at home due to his home being very old with low ceilings and small rooms so equipment could not be provided to accommodate his needs plus the hospital provided nurses and therapists and a doctor which would not be possible to get at home in the same way. There was a long waiting time to see a community therapist once he did get home Eee France already have this type of system as my parents have experienced it who live their. I think its a fanrastic idea especially where elderly peoe are concerned who are vulnerable. As long as the system is put in place properly and with no staff shortages. As speaking to several friends who are occupational therapists, cost cutting is already causing lots of problems. I think speaking to these people whonare on the front line and obtaing their first hand experiences would be so beneficial. Get them home asap they will recover better there - but ensure there are district medical staff to check regularly on them and their care. If not able to be at home them discharge to community hospital

Question 11 (35 responses) What do you think are the positives of a Home First service? People can be assessed at home in a less stressful environment. Ward beds are not always required or necessary for the process of recovery or for the full length of someone's care journey. Home First is a good solution but not the only one. Free up highly specified hospital beds and nursing staff. Patients to received more focussed care and attention in a less stressful area. Cost savings to a degree. Would hope this gave better turnaround and space for those in need of specialised attention, and free experienced and qualified staff from routine care duties.

Link to property and ownership of your own home without spending NHS reserves on hospitalisation If patients are genuinely OK to be on their own for a large part of the day then this will be great - it will help unblock beds but home first should not be the default for everyone - only those who can be supported The opportunity to come home from hospital cannot be underestimated - it's what patients and, often, loved ones want. The familiarity of being at home is beneficial for recovery and just a sense of wellbeing

The choice for most people to be able to come out of hospital and back home and be looked after in familiar surroundings and in an environment that helps their recovery. To help the person to rehabilitate For the CCG and hospitals this model will reduce the so-called bed-blocking 204 I understand wanting to make the best use of the wards at Braintree and the machinery that is there but this also begs the question - why were they built and not been used properly for the past 10 years? More relaxed patients returning home sooner which seems to be most patients primary driver. Accurate assessment of aids and adaptions required. Increased mobility and uptake of normal daily life. people will recover quicker at home at in an environment set up for more for after care then first/front line care Being in home environment. With family. No need to travel to hospital or nursing / care home to visit. It should encourage better working arrangements with the social care service to ensure that the patient does not return to hospital. the only positive I can think of is that patients do tend to recover quicker at home If it works well then it would be positive, but at the moment there are too many unanswered questions for my liking. The freeing up of hospital beds and from the patients perspective the comfort and security of being treated in the familiar surroundings of their own home. Putting Braintree Hospital operating theaters to better use to resolve waiting lists for orthopedic surgery. Patients generally want to go home as soon as possible so this process will support those needs. Good that people can be in their own homes and with their family That patients do not become 'institutionalised' and they have the comfort of home. Everyone likes to be at home and that must help with recovery For someone in my position I struggle to imagine any positives. A convalescence type service sounds excellent. It could ease up Hospital beds quicker. Relieve bed blocking. Happier patients being discharged earlier. Might work if properly staffed but not at present More effective use of existing surgical facilities to reduce waiting lists I think there is little doubt that in most instances the best place to recover is at home. however the home has to be suitable, safe and adapted as necessary IF AND ONLY IF a well resourced, well organized infrastructure was in place (which it isn’t) then for people who would rather not be in hospital, and it is safe to discharge them, to home/small hospital/care home environment it may a preferred option. If the care supporting the risk assessment is available, the patient can make a dramatically accelerated recovery Faster rehabilitation as individuals are within their own environment. Family and friends can provide support to reduce costs but they need the support from qualified professionals to ensure safe and effective care. People are at home so are rehabilitated to their own requirements in their own environment, more realistic rehabilitation Probably a more stress free environment on a 1 to 1 basis. Eee People can recover in home surroundings. People generally will recover more quickly in their own homes

205 Question 12 (36 responses)

Other (please specify) If HF includes a stay in a facility outside of a hospital ward but with access to consultant/nurses then it will be a huge step forward in improving patient outcomes Distance relatives may have to travel and really should not incurr greater travel time and expense Are there enough staff resources? There will always be a need for community beds near to patients home or close by for relatives. Will there be economic pressure to discharge early because hospital needs beds? Does this pave the way for privatisation of more NHS services? Sorry - most of the above and fear that, over time, companies like Virgin Care will privatise the service, reduce care and eventually suck any money from the NHS at the expense of patients I cannot see how it will be possible to provide care and treatment in the community. We have a large rural community across the mid Essex patch and you would need a larger number of staff to deliver services at home. We were told at the meeting I attended that staff would be those currently employed in Courtauld Ward. Logistically that will not be sufficient. The dividing line between treatment (NHS) and care (ECC) is blurred for older people with mutiple needs. How will you demonstrate the ability to work together? Contracts with providers need to watertight especially in conflicts around performance failures, avoiding lengthy and costly litigation sessions. the impact on general practice Making sure the right gender of person is acceptable to the patient. Plus language and cultural issues need addressing. adequate provision of necessary physiotherapy and medication by the district physiotherapist and geriatric specialist. In practical terms, to ensure that a town of this size has sufficient provision of recuperation beds available locally, given that it is impractical for patients and carers to travel to Halstead or Braintree using public transport, and the detrimental impact on the health of local residents and patients Aftercare is stated as being free for 28 days under the NHS. Then an assessment takes place, and funding is applied for. Your booklet does not explain whether the assessment includes means testing for funding. If this is the case, I have grave concerns that people who do not qualify, could face long term financial distress or forfeit their health/quality of life by going without rehabilitation/recovery support. The timing of the risk assessment that determines when the patient can be discharged from hospita Adequate capacity and staffing of all the multidisciplinary team involved. If after surgery complications are evident, it may require re-admission which could have been diagnosed and remided during an outpatient visit. Funding and how this will be staffed, ESSDAR has been a huge mistake, staff employed reluctant to visit puts, cherry pick there visits and are not well managed, total waste of NHS money None

206

Question 13 (22 responses) If you think Home First will impact on you, someone you care for or another family member, please tell us how Yes, access to a facility as detailed on page 12 on your booklet will free up ward beds, increase efficiences and save money whilst delivering better care solutions Distance to visit and the quality of the care and accommodation provided. The Community Mental Health Team is overstreatched and underfunded, and employes the people who cannot be properly used because the Home First scheme does not work with them. How will the service be managed and what will the impact be on GPs and practices? You can't expect our already overworked GPs to take on more responsibility for these patients. For example, Church Lane Surgery is staffed by Locum GPs who are not familiar with the district; services; patients or the local NHS procedures! This could be a huge burden on already stretched resources if not managed properly or executed properly. Not sure if this is a solution created by politicians who have removed many LA-funded care home places that used to exist 5 years ago. Having closed these homes to reduce costs involved, this proposal is now looking at caring for people at home which must be more expensive? This will be a service that only caters for a small number of people but could be quite expensive.

Not at the moment Home first may impact if situation arises where a medical condition develops needing major adjustments to the home set up, use of Home First whilst things etc are set up/provided. Not applicable. There is a risk that the patient will be off-loaded onto relatives who are not conversant with the patient's needs and may cause harm. No impact on me personally at the moment. Will wait and see if and when I need this sort of service before being able to answer this question. As a health care professional I am concerned that we are already struggling to provide adequate care in the community and I have not heard anything about where the extra manpower resources are going to be coming from to provide this service Could put an added impact on the Carer. As previously described. I am generally concerned that all home first patients will not get the care they need and may be inappropriately accommodated with inadequate care. Not yet !!! Lack of carers and physios will leave vulnerable people without support for up to 22 hours a day. The breadwinner working full time with a heart condition, diabetes, and mental health problems. If the condition deteriorates, or a heart attack occurs, the spouse already needs to work to live and would not be able to provide care at home. The family home is not a rental. What if the main breadwinner should require long term recovery care.... would funding be denied because they have a house (not mortgage free), will they lose their home? My father recovered a lot quicker at home. Knowing he was well and contented put my mind at rest. I think it will affect my family members confidence being on their own most of the day We will be expected to provide 24 hour care at home with only limited nursing and therapy input unlike a hospital which is ideally set up to get people recovered and on their feet and able to cope with their home environment before they come home Eee It's easier to look after my parents in their own home . It's cheaper for me as hospital car parking is expensive. However I would need assurance if care workers visiting as well to ensure recovery

Question 14 (32 responses) Please give us your views about our plans for the beds at Braintree Community Hospital I would be pleased to see a reduction in waiting times for surgery as posited by this proposal. Very happy with the plans - forward thinking; saving money and delivering better care solutions If it can be demonstrated that the change in practice will improve care results then that is fine. Using the theatres effectively is a good idea but you must not displace rehab beds for strokes etc or maternity beds that are still needed at St Peters.

Broomfield is overstretched and needs more resources - this needs addressing first surely? 207 I think the plans are taking away from the original intentions of William Julian Courtauld who very much saw this as a hospital for local people and to benefit local people ie those living in Braintree. It now seems the NHS want to change the ward to the detriment of local people and to remove the legacy that William Courtauld left.

It is very helpful to recover from Orthopaedic surgery and I like the idea of having this type of surgery available in braintree I support plans to use BCH in a way which increases use of specialist equipment that is already in the hospital Good idea proactive approach, concretration of resources a effective a positive outcome No view This seems a good idea. The beds that were for rehabilitation should be provided within the other centres of care and not in an elderly persons home. Sounds a good idea if it can be properly staffed without cutting somewhere else we have an aging population - older children of elderly parents if you use the beds differently this will put add strain on families. Well I am far from happy that 10 beds have already been removed from the hospital and sent to Maldon. This was supposed to be a phased transfer up to February 2018. I believe that Provide own the beds and therefore they may have the right to remove them. However, that then takes the available beds away and the hospital capacity reduced. This is NOT acceptable, it is a waste of resources which could still be being used until actually needed in 2018. I have no problem with the theatres being used - but as of yet, they are not being used to their full capacity. More public involvement and consultation should have occurred before decisions were taken. It is, afterall OUR NHS - the public are being denied services due to contracting out to private organisation for profit. The planned changes make sense. totally in favour Again, so long as this does not impact on care and treatment that is already being given in the Braintree Community all should be well. They seem right We should not lose rehabilitation beds in any area, in fact there should be more rehab beds. This is fine as long as those needing rehabilitation get the same level of care as they have at Braintree. Good if it works Surely recovering from surgery is rehabilitation It is sensible to use these beds more effectively, providing there is no knock-on impact of withdrawing them on patients in other areas such as Maldon I can see no real issue with losing the rehabilitation beds at the hospital provided that suitable, safe alternatives can be assured in the local vicinity. There needs to be local transport in rural areas as this is poor 1. This is a way of further isolating Acute & Emergency care from other forms of care. Farming out responsibility, and normalising the intent of the government to only be responsible for providing the bare minimum, life threatening health care. Once isolated and normalised, the next step will be to give the contract for elective surgery to a private sector company. Final step will be withdrawal of elective surgery under NHS. 2.The immediate effect is it reduces the number of beds available for convalescence/aftercare - further diminishing the already skeleton support system which needs huge financial commitment to adequately resource before launching Home First. I'm not sure I have any valuable opinion to offer other than I trust in the professionals making these decisions. Excellent idea for those people who are not ready for discharge or need further physio or nursing care. It makes sense to utilise the ward and theaters to their full potential. as long as in the case of emergency the equipment is available quickly Good idea. Brings local treatment / recovery facilities into the community We need community beds for patients in crisis in the community that are not best placed in an acute hospital, for our palliative puts, dementia puts, ect currently there is nowhere for these puts but a long an inappropriate wait in A and E, bad enough getting rid of RAU, now we have no other options to send the dying, confused and vulnerable to meht Very unhappy. The ward is vital for care of people recovering from illness. Halstead and Maldon are too far away Speaking to people who work their, NOT A GOOD IDEA. The hospital ward needs to be used in the best cost effective way to serve patients . If this is the best way then I would have no objection

208 Question 15 (23 responses)

Other (please specify) none These services must be kept in the NHS and not privatised in any way. You need to have the resources to do the job though so we need more money coming into local NHS The use of the hospital at the weekends. My assumption is that the change in the use of beds is to provide elective surgery at Braintree on a Monday to Friday basis. My mum used braintree for rehabilitation but fell on a Friday while there and had to spend all day Saturday at A&E just for an x-ray using an ambulance to get there too - just seemed a waste of hospital resource. Concerns that the change is used as a means to reduce the number of properly staffed rehabilitation beds in the area. We are underfunded here in Essex along with many other areas of UK. I think the CCG should camapaign along with other CCGs for fair funding whilst at the same time use the funds you do have do have wisely. impact on general practice and community services Not enough consultation with the people of Braintree per se no intensive care at Braintree in case of emergencies. the CCG needs to ensure that sufficient resources are put in place to make the initiative a success to adequately support patients in their homes, if this is what they want The scheme proposed seems, in part, to be dependent on other things like budget and available funds eg if a patient needs to be discharged but their own property requires adaptations you will be reliant on social services or LA to fund this. So will an assumption be made, or funding provided by you so that necessary work can be carried out prior to discharge? The drip, drip approach to the depletion of services as you pull the wool over their eyes, with logos and other devices to pretend it is all still the NHS. MEHT say they own Braintree Community Hospital, but InHealth and Arkanum (TPP) run the services as far NHSChoices say. I object strongly to any changes/projects/initiatives which involve depletion of services that should be provided through a publicly funded NHS ...... OUR NHS.

Question 16 (15 responses) If you think these plans may have any impact on you, someone you care for or another family member, please tell us how Yes - a very positive impact for friends and family in mid Essex and hopefully quicker time to treatment There need to be localised Essex services organised to provide aftercare in the community where a person owns their property. My knees will need replacing before long and I need reassurance re the type of service being offered at Braintree and the calibre of surgeon. From information I have managed to gather, the beds from Courtauld ward (rehabilitation) are moving to Maldon! This will involve more travel for relatives and carers (who are often elderly) and more financial cost; parking charges or longer waiting for park and ride schemes. In relation to home care, I have real doubt as there are not many good CQC rated agencies or homes in our area. You are struggling to recruit enough people with the skills and cannot train/retain fast enough to provide the level of care needed for this type of scheme to really be beneficial and rolled out to a much wider

209 audience. Not applicable n/a Many of us are getting old and will no doubt require NHS services till we die. These plans or similar will impact on us at some point. The Home Choice options seem good on the surface but I cannot see how it can be implemented without funding and it is the CCG's responsibility to campaign for the funding required to see it through. We have all paid our taxes for years and will not be duped by this, or any other government. I use the hospital for out-patient appointment. I have never been an in-patient (so far).So can't really give a personal opinion of what is good about the proposed services. Added burden of work in looking after an invalid. Discharge home too early. May get sent home too quick Lack of staff will leave vulnerable people without support As stated in comment box at Q13. This affects everyone. It will be nice to have the facility to have ops near to home but will the beds be full of patients from further afield too, Broomfield has a lot larger catchment area than Mid Essex it will take beds away from the older people who really need these facilities and I think that is discrimination. The big hospital at Broomfield should have plans to manage the number of operations needed

Question 17 (24 responses) Is there anything else we could do to support people ready for discharge from hospital who require ongoing NHS care? Widen the use of step down beds in care homes for acute consultant and nurse-led care. There is more capacity with guide at Broomfield Hospital who operate the facility next to the hospital To ensure that the comprehensive care package is in place and that the family are consulted about the ramifications of the earlier discharge from hospital. Not, a here is Uncle Joe, just get on with it. More funding for CPNs and district nurses Have more nurses and nursing support at GP practices and in the community Provide more NHS or LA-funded care homes for people to convalesce in. Where are they all? Closed by politicians trying to avoid their responsibility to the public. having gained city status in Chelmsford - how many extra beds are there compared to the extra houses/people that are being built in the area? More home care services Create convalescent homes Plan more carefully for discharge right at the start of treatment involve families in discharge planning and meetings that support discharge so that everyone knows what the plans are Adopt 'the team around the child' approach - more MDT planning with families and professionals could help. Time spent planning could make a much more effective ending and this doesn't have to be led by NHS staff Ensure everyone involved in providing NHS Care with Home first commit to the change. Yes. Get things in place as quickly as possible but you need to make sure that families are involved in the process throughout. Make it clear to the patient and family what is happening. Communication is key; you need to provide clear information and options at all times, preferably with one named person as the point of contact. My experience of 'Fast Track' discharge scheme as Broomfield Hospital was extremely poor and makes me wonder how well 'Home First' would work in practice. There was no clear line of communication and a bewildering range of people / departments appeared to be involved but it was never made clear who they were or what their role was in the overall scheme of things. There needs to be adequate resources in place (staff and funding) to make this work. Are these resources in place? Increase the number of qualified community nurses working in the community and liaising with the hospital discharge teams and social care staff. you could make sure that they are really ready for discharge instead of sending them out too early. YES - work more closely with Social Services and make sure that there is joined-up acceptable provision, which the recipient is happy with. Have in place a 'hot line' that could react quickly to emergency situations and reassure the person being cared for where there are concerns or anxieties. Involve carers in the multi-disciplinary team preparing for patient discharge. Blood tests, regular appointments. More District Nurses, domicillary physiotherapists and Occupation Therapists and Care Assistants. I have read of a suggested scheme whereby patients are discharged into a strangers home for rehabilitation - so called Carebnb - an appalling thought! Lobby parliament to stop killing OUR NHS. Shout "NO WE WON'T" when told to chant by NHSE / NHSI / Jeremy Hunt et al. Lobby parliament to fund social care and health care sufficiently. Lobby parliament to reinstate the nurses bursary, and to give a decent pay rise to public sector workers. Challenge the Secretary of State for Health and the government on their excuses about there being no

210 money! There is and always will be enough money, but it is being misdirected. Philip Hammond actually said last week that money could not be wasted on nugatory thing like the NHS..... NUGATORY!! I am disgusted, and I hope you are too. Discharge planning prior to admission. Hospital discharge information booklet with information about expected recovery progress and signposting to other useful organisations after discharge. Proper and timely social support. Possible nursing beds with rehabilitation input. To keep GP informed who may have made the appointment to see a Consultant. Yes MORE staff, address recruitment and retention of staff, yes keep the hospital beds in Braintree for their use More frequent contact

Question 18 (15 responses) Please add any other comments you would like to make Congrats to MEHT, CCG and Provide for being solutions-focused in looking at options for delivering care for mid Essex residents. Bravo! The Tendring District has a very large community of mental health patients and elderly people. Care is overstretched, underfunded and does not work. The NHS is the heart of our nation. The government should review rates on properties better. It is disgraceful that we keep getting reorganisations and new policies to fit the government of the time ie St Peters is a prime example of this - going on for too long!

My experience of caring for a 96-year-old relative and having seen the care he has received at Broomfield and Braintree Hospital, I can only praise all of those staff working hard on the wards. I wish I could say the same about the level of GP services and the way these are being run - it is a total disaster! I have written to our local MP, the provider (Virgin Care) and the honesty is that they are just playing politics with people's care. I am hoping to have a knee operation soon and would love for this to be in Braintree as I live very close by. Has the CCG already determined to go ahead with 'Home First'? It is interesting, or possibly worrying, that this is termed a public engagement rather than a consultation. Is this merely an information or tick box exercise on your part? Provide evidence on a regular basis of the impact of this scheme and ensure that the level of care is enhanced and not diminished. I understand fully the rationale behind this move but in reality have you really thought about the impact on patients and their families and of course the pressure that any problems will bring to doctors in general practice? All the above For this sort of decision to be made on Home First the decision makers at the CCG should come and live the life of a Carer for a few days to experience just what it is like. Maldon Town Council is very concerned that a town of this size has insufficient provision of recuperation beds available locally. Given the lack of adequate public transport links to Braintree and Halstead. This must be detrimental to the health of local residents and patient recovery The scheme seems largely reliant on the availability of spaces and staff being available at care homes. Have spaces and suitable care homes been secured? Care homes are not going to leave rooms empty while waiting on possible discharged patients... Existing difficulties in recruiting care staff - how will this be addressed? Very concerned regarding the CareRooms idea which is being mooted. This proposal is in my opinion totally irresponsible. Safeguarding issues alone must make it so. My goodness, have Mid & South Essex Joint STP gone mad??? Strangers being paid for room and board for recovering, probably frail/vulnerable patients!! Whatever next?! Improved communication on all levels. If an individual is involved in all aspects of their care and recovery they will feel a part of that process, they will be informed and know what to expect and take ownership of their rehabilitation. I intend to visit the Drop In session at Braintree Town Hall, on Wednesday 15th November at 1.30pm.

211 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 18 Report Title: Primary Care Foundations Written by: Robert Evans, Head of Operational Primary Care Viv Barnes, Director of Governance & Performance Dan Doherty, Director of Clinical Transformation Purpose of Report: To provide the Board with an overview of the locally developed Primary Care Foundations programme, outline the main areas that the programme seeks to address, provide an update on the work already undertaken and future plans and identify the resource assumptions and funding opportunities underpinning delivery. Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of  services Strategic Objective 4 To ensure there is full practice engagement informing  commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees N/A that have reviewed this document).

Reports Submitted to Board only: Date signed-off by Executive Team. (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: Not applicable Patient & Public N/A Engagement: Significant Risks The key underlying risks associated with this paper are: identified: • There are no clear or credible alternatives currently

212 identified to the programme proposed, to achieve the outcomes required. • Finalising the detailed costing and resource implications may indicate financial pressures that are not currently known / identified.

Inability to gain full engagement by member practices will result in a less than optimal outcome and limit the improvements achievable. Recommendations and Members of the Board are asked to: decision/actions required by the Committee/Board: • Approve the principles of the Primary Care Foundations programme and its proposed funding streams; • Note the work that is ongoing to deliver the programme; and • Request further progress updates on the implementation of the programme at regular intervals.

213 PRIMARY CARE FOUNDATIONS

Submitted by: Viv Barnes, Director of Governance & Performance Dan Doherty, Director of Clinical Transformation

Status: For Decision ______

Purpose

The purpose of this paper is to provide the Board with an overview of the locally developed Primary Care Foundations programme, outline the main areas that the programme seeks to address, provide an update on the work already undertaken and future plans and identify the resource assumptions and funding opportunities underpinning delivery.

Background

Mid Essex CCG and its member practices are in an area / health economy which is one of the most financially challenged in the country, is facing a significant increase in population particularly across the elderly age groups, with a consequent increase in care needs associated with frailty, vulnerability and long term conditions. In addition there is a history of significant challenge in recruiting and retaining traditional care professionals (GPs and nurses) and where the current workforce (on average) is one of the “oldest” in the country with a high number of retirements and leavers expected over the next few years.

Notwithstanding the above, the standard of general practice across the area is generally good. However the ongoing increases in demand, reducing capacity and other challenges being faced are leading to significant concerns about current resilience and future sustainability.

This is reflected in the chart below, which is taken from research by The Kings Fund and which shows a 10% increase in list sizes and a 15% increase in face to face and telephone contacts with practice clinical staff over the last 5 years.

214

The role that primary care / general practice plays in maintaining healthcare and managing system demand is also worth noting as is exemplified by the statistic that Mid Essex Hospitals NHS Trust (our main local acute hospital) sees around 300 A&E attendances per day whilst across our General Practice base there are an average of around 8,200 appointments provided each day.

What we are Trying to Achieve

The aim of the programme is to develop and implement a support package across all our 45 GP practices to lay the “foundations” of a resilient and sustainable primary medical service for our population from which we can further develop and transform the way in which primary care (in its broader sense) is delivered across Mid Essex.

We want to create a modern, fit for purpose, resilient and sustainable primary care service across Mid Essex with general practice at its heart, that everyone working in it can be proud of, that our patients are pleased and happy with and to which other Primary Care Organisations will aspire.

Whilst the programme is focused directly and specifically on the Mid Essex CCG area, it is a model that has been shared across the Mid & South Essex Sustainability and Transformation Partnership (STP) and is referred to in the STP workforce strategy with the underlying / underpinning workforce modelling tool being adopted by other CCGs in the STP.

The key organisations involved and affected by the change programme are the member practices of Mid Essex CCG and the CCG itself, who are all stakeholders in this work.

The work is also informing plans in other areas across the STP and by working collaboratively with our local LMC, it is anticipated that outcomes from our work will be shared widely to support transformation across a broader geographical base.

Where are we now?

Much work is already under way in a number of areas to develop resilience and support the sustainability of general practice across mid Essex. This work is reflected in the Primary Care Update report which is a separate item on today’s agenda. The Foundations Programme builds upon this work and signals a significant cultural change in the way that the CCG engages with and supports its member practices pulling together a variety of strands into a strategy which transforms the primary care / general practice landscape to deliver the outcomes that we want.

Work that is identified within the foundations programme and which is already under way or agreed include:

• Identifying and sharing information on the 10 High Impact Changes, resulting from the “Releasing Time for Care” work undertaken by NHS England and making available training in key areas for practice staff. • The provision of CCG commissioned support, development and training (on a practice specific basis) on “workflow optimisation” processes and other means of becoming more resilient and sustainable for the longer term.

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• Work on the key themes of the GP Forward View Delivery Plan on Access, Workforce, Workload, Infrastructure & Models of Care as identified in the Primary Care Update report.

Work is also ongoing to review existing arrangements around locally commissioned enhanced services and the use of the locally generated Primary Care Sustainability, Development & Transformation Fund (PCSDT) to ensure that available resource is deployed as effectively as possible to meet local needs. The outcome of this work is being used to inform primary care commissioning intentions and local investment of available resource for 2018/19 and thereafter, as outlined in the finances and resourcing section below.

A significant amount of work has been undertaken already in drafting and developing our proposals and plans. An outline of the programme, direction and aspiration is attached at Appendix 1 for information.

What exactly is being proposed

 New delivery models

We are developing an innovative, comprehensive and fully integrated approach to delivering primary care for the future, focusing upon the concept of Primary Care Foundations.

This concept recognises primary care as the bedrock of the health care system and that as such it needs to be strong and solid enough to serve as the base from which we can build upon our vision for transformational change.

The Primary Care Foundations programme will:

• Ensure that every practice has trained care navigators • Identify opportunities and support the diversification of the workforce • Facilitate the training and upskilling of staff • Optimise the use of IT and the digitalisation of primary care provision • Introduce improved systems and pathways • Deliver extended access and a broader range of services to our entire population

A key enabler to all of the above will be our approach in “Activating Primary Care” by arranging funded shut downs and time to learn sessions, arranging and facilitating the provision of independent advice and expertise to practices, and providing space, time and support to allow practices to explore collaborative options amongst themselves, to identify and implement solutions and services that are right for their local areas and for their patients.

Through the above we will ensure that there are comprehensive and integrated services in place to support our patients through all of the life stages, staying loyal to our agreed and overarching “Live Well” strategy, examples of which include : • Start Well - Paediatric ESDAAR, Focus on needs of Children & Young People in our extended access plans and service specification, High Impact Pathways • Be Well - Cancer Vague Symptoms, Pre-Operative Checklist, Care Navigators

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• Stay Well - Prescribing – MOLES, Prescribing – Waste Management, APOS Therapy, Ophthalmology, SIM (Serenity Integrated Monitoring) • Age Well - Frailty, Dementia Intensive Support Service (DISS), Home First • Die Well - Enhanced Hospice at Home Service, Enhanced telephone advice line, Link worker as part of MEHT palliative care team, Project ECHO

Elements of the Foundations work are already being piloted, with others still in the discussion and specification stage, and progress against these will be reported to the Live Well Committee.

Links to other work streams and priorities

In addition to the links with the Live Well agenda as outlined above, the Foundations Programme will also build on other strategies and work programmes being developed and taken forward across the CCG, including:

 Neighbourhood working

Members will know that across the CCG there are currently seven localities, most of these are formed around natural communities and fairly discrete geographies. The demography of Mid Essex is mixed with large urban areas and a significant number of rural communities, with varying levels of deprivation and disadvantage. The area has 45 GP Practices, varying from single handed practices to multi partner practices. The actual needs of each practice will therefore vary significantly.

Through the Foundations Programme, further development and future configuration of localities can, where appropriate and based on practice preferences, be determined by the practices themselves and they will be pivotal in determining the service configuration and means of delivery that is best suited to their local demographics and patient needs.

The programme will ensure that there is equity of service provision, for example, around extended access, and will work with each locality / practice configuration to localise services that are commissioned by them and on their behalf and in facilitating relationships with other partner organisations including social services, district councils, community providers, voluntary sector, etc.

In addition, there are possible arrangements emerging around potential mergers, super partnerships and other options and opportunities around collaborative working between practices, which again will be something that the Foundations Programme will seek to support.

 Workforce and role substitution

Workforce is the cornerstone of the Primary Care Foundations Programme and as such programme leads will focus heavily on this area and the opportunities for reviewing skill mix and introducing alternatives to the traditional models of GP and nurse-led primary care provision.

Mid Essex CCG has developed a tool / model whereby it can support practices in identifying possible alternatives of structuring their staff base to take advantage of the broader range of skills that are available to provide services that are effective,

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appropriate and safe in meeting the health care needs of their patients. Through application of this model, it is hoped that a more diverse and potentially more appropriate skill mix will be deployed across the area which will help in addressing the difficulties that are currently being experienced in both recruiting and retaining the traditional mainstay of practices e.g. doctors and nurses, and in managing the increasing demands that practices are experiencing.

 Extended Access

There is a national requirement whereby extended access to general practice / primary care is made available to all patients by the end of March 2019. This does not mean that every practice has to provide extended access, but that the CCG has to ensure that such access is provided / commissioned on behalf of its patients. A separate working group has been established to lead on this for the CCG and the development of access hubs in appropriate locations and for defined populations is currently being proposed. More work in refining and defining the model and supporting specification is currently taking place, but through implementation of the Foundations Programme and the recruitment of the additional clinical staff envisaged, delivery of the extended access requirement will also be enabled and achieved.

How will we achieve this?

In addition to continuing with the schemes already in place, and for which successful bids for national funding have been secured, such as the recruitment of EU GPs, we will provide support, training and development opportunities to all practices.

This will include, but will not necessarily be restricted to:

• Improvements and enhancements to available technology – including on line access • Support with clinical system optimisation (e.g. Ardens) • Assistance with understanding and updating practice specific operating processes (Insight Solutions) • Training and development of staff (e.g. signposting /navigation – upskilling nurses, etc.). • Access to independent specialist advice on practice configurations and opportunities around collaborative working.

We will also, by application of the aforementioned workforce modelling tool, aim to recruit an additional 80 clinical members of staff of various clinical professional backgrounds and skills, to supplement and support the existing practice staff base and enable the extended access requirement to be delivered.

Financing and Resources

Implementing and delivering the foundations programme will have to be appropriately resourced.

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Initial estimates of likely costs and potential sources of funds have been identified from which the overall affordability has been assessed and agreed.

The programme will be funded from a variety of sources, including dedicated funding from NHS England in support of the GP forward View Programme, reallocation of some current CCG Primary Care budgets and use of extended access funding, the first tranche of which will be made available to the CCG in 2018/19.

Further, more detailed work on the funding streams will now be undertaken and an update on the resources available and overall costs reported to the Board at its March 2018 meeting.

Every effort will be made to access other sources of funding that may become available to support this work and partnership working will be embraced to achieve further economies and efficiencies wherever appropriate.

How will the work be taken forward?

Leadership of the change programme will be the responsibility of the Director of Transformation, a post that has been established as part of the CCG’s staff restructure.

In support of the work, there will be a programme team, comprising of a number of people across a range of disciplines and organisational backgrounds, including GPs, Practice Managers, CCG Officers and Senior Finance staff, some of whom will be participating in the Transformational Change through System Leadership (TCSL) programme run by NHS Improvement.

Following a successful application, the CCG has been offered an opportunity to participate in the Primary Care Leadership Collaborative. This is a joint venture sponsored and supported by EAHSN (Eastern Academic Health Science Network), RCGP (Royal College of General Practitioners – East Anglia Faculty) and NHS HEE (Health Education England) and delivered in partnership with NHS England and the East of England Leadership Academy.

It is described as an exciting development opportunity, enabling people from across different professions within Primary Care in the East of England to enhance their leadership and improvement skills. Each collaborative will be leading initiatives, interventions or programmes of work which support the delivery of high quality, effective, compassionate care and improved health outcomes for communities, perhaps through the delivery of new models of integrated care.

It is hoped that involvement in this programme will provide participants with the concepts, tools and techniques required to radically change the way health and social care is delivered, together with the necessary skills and abilities to take the CCG’s plans forward and deliver the transformational change required.

Other staff within the CCG and across our practice base will be available to support specific elements of the work and maintain ongoing engagement and involvement with member practices.

219 Through the Director Lead, the group will be directly accountable to the CCG Board for the delivery of the transformational change programme.

Recommendations:

Members of the Board are asked to:

• Approve the principles of the Primary Care Foundations programme and its proposed funding streams; • Note the work that is ongoing to deliver the programme; and • Request further progress updates on the implementation of the programme at periodic intervals.

220 APPENDIX 1 Childhood Illness Work Intergenerational Care Project Maternity Voices Connect Well Self-Care OTC Campaign Tier II Weight Management

START WELL BE WELL Awareness Health Mental

i. An enhanced telephone advice line • Paediatric ESDAAR • ED Front Door Focus for patients and professionals with capacity • Cancer vague Symptoms • Health Navigators As per West Essex Model for up to 1500 call a month • High Impact Pathways To develop the shortest and safest route To health coach patients who have presented Extended CCN (8am to 8pm 7/7) ii. A communications campaign to promote the Bronchiolitis to cancer diagnosis, especially for patients as inpatients. Health coaches actively train Rapid response but not urgent response advice line further, as well as the other services our Gastroenteritis with non-specific vague symptoms patients to self-care Referrals from GP/ED/Children’s Ward hospice offers Fever • Pre-Operative Checklist iii. A new innovative approach to information sharing, Systm 1 fitness for surgery checklist education, case management and support to Initial Pilot in Witham Group surgeries professionals- Project ECHO. This is a tele-mentoring system which will allow for the hospice to spread its specialist skills and knowledge. iv. An enhanced hospice at home service, including a campaign respiratory #SCARFIE

rapid response service for end of life patients. Additional staffing in the service will allow for more • Prescribing MOLES patients and care hours to be delivered by the service. Medicines optimisation supporting patients The enhanced service will run 8am-8pm 7 days a to optimise usage of their prescribed week. The new service will also provide in-reach to medications to improve quality, outcomes support prompt discharge MEHT; end of life support to Workforce Diversification and costs DIE WELL DIE Upskill staff patients in care homes and access to booking of Marie • Prescribing – Waste Management Care Navigation To fund and support recruitment of an Review of repeat prescription requests to Curie night hours for patients on the H@H service innovative, diverse workforce into Primary Care. We will train 45 practice staff as caseload. We intend to train 90 front-of- This would include, nurses, physios, independent prescribers to support reduce wastage of medicines v. A link worker to be part of the MEHT palliative care house practice staff as care pharmacists, counsellors and others. GPs • APOS Therapy navigators. These staff will allow team, creating an integrated team that can work We will also train 45 practice staff in Physiotherapy delivered alternative patients to be directed to the most We will recruit 80 WTE additional frontline

enhanced clinical reasoning skills to WELL STAY together to improve the identification of patients at appropriate services both within personnel intervention to knee and hip surgery. ConnectWell manage same day emergencies or end of life. practices and within communities. Pilot trial to assess efficacy. This will require a significant workforce Long Term Conditions Can reduce the need for surgery for Staff will have backfill resourced recruitment drive for mid Essex Staff will have backfill resourced appropriate patients

Improved Systems Digitalisation Activate Primary Care Frailty We will provide decision We will ensure free patient WiFi access is We will provide funded shut-downs, • Opthalmology i. Identification via the Electronic Frailty Index allowing support software (e.g. available in all of our GP surgeries independent advice and expertise Connect Well Connect Taking certain, appropriate ophthalmic all frail patients at risk to be identified to practices. ARDENS) to all practices that and off-site accommodation to would like it This will facilitate increased opportunities for facilitate practices to explore appointments and providing them closer Increasing utilisation of the Information About Me online consultations, online booking and collaborative options amongst to patients in high street settings

(IAM) forms and patient care plans. We will provide workflow records management and prescription Pilot Back Witham Pain themselves. • SIM (Serenity Integrated Monitoring) Needs practice rollout but could be facilitated by optimisation tools to all management. practices who want it Embedding a specially trained police officer Ardens decision support software into our Community Mental Health Team to ii. Central Point of Access (CPA) to become a single manage High Intensity Users, typically with contact number for patients and clinicians to join personality disorders (PD)

services to needs. We need to increase the utilisation and increase the connectivity of services, especially social care and

mental health Dementia Intensive iii. Active Case Management. How are practices Support Service (DISS) Home First managing patients identified as Frail? We will ensure there are co-ordinators working in practices to The DISS provides joined-up physical and mental health and People are discharged from hospital, once medically fit, to either

facilitate multi-disciplinary case management. This is social care for people living with dementia in mid Essex home, an enhanced nursing home or a community hospital bed – Waste Medicine facilitated by the Enhanced Primary Care Workforce whatever is the most appropriate place for that person – to The service, also for people with suspected dementia, offers: initiative. enable their best recovery A 24-hour helpline, rapid support for people with dementia who iv. Crisis Response Support by a range of NHS healthcare services will be available – are in crisis, intensive treatment at home, help with dementia which could include therapists, nurses and doctors – for up to 28 CARE HOMEMANUALROLLOUTCARE The Frailty Assessment Unit (FAU) will provide diagnosis and signposting to further advice and support comprehensive geriatric assessment of frail patients days after leaving hospital. At the end of this period, if the presenting to hospital person has ongoing healthcare needs they would still be able to Campaign We need to maximise usage of the ESDAAR service have a CHC assessment but this would be based on a more Creation of the frailty SILVER phone for practice accurate understanding of the person’s abilities and needs.

advice and guidance. AGE WELL 221 DISS promotion Connect Well Age Well Workshops and Handbooks Braintree DC Age Well / Stay Safe Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 19 Report Title: 2018/19 Financial Plan Written by: Dee Davey, Chief Finance Officer Purpose of Report: To provide an update on the financial planning process and delivery of the financial control total. Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe  Strategic Objective 2 To meet the financial challenge through responsible use of resources  Strategic Objective 3 To achieve transformation, innovation and integration of services  Strategic Objective 4 To ensure there is full practice engagement informing commissioning  Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity and  capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees The Finance & Performance Committee and Board receive a regular that have reviewed this update on the Medium Term Financial Plan. document). The Board will be required to formally approve the 2018/19 Budget at its March meeting. The Savings Programme Board receives information on the overall savings target, progress with developing and implementing savings plans and the expected impact upon delivering the financial plan.

Have any financial implications been signed off Yes No N/A by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Board members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Patient & Public Engagement: N/A

Significant Risks identified: Controlling expenditure within approved resources is a key requirement of the CCG. Ability to achieve the NHSE set financial control total will determine the nature of the performance monitoring and management intervention arrangements applied to the CCG. Service performance is monitored against national and regional targets. The NHS constitution sets out rights and pledges for patients and the public which the CCG is required to fulfil. Recommendations and To note the emerging issues relating to the updating of the decision/actions required: Medium Term Financial Plan and the development of the 2018/19 Budget.

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1. Headline Messages

1.1 As referred to in the 2017/18 Finance Report on today’s agenda, the CCG’s 2018/19 control total challenge has reduced from a requirement to deliver a £9.3m in-year surplus, to a revised target of delivering a £3m in-year surplus. Given all the financial pressures within the health system, this still represents a substantial management challenge. The challenge for MECCG is exacerbated by the CCG’s relatively low funding per head and the fact that the CCG is funded below target funding.

1.2 Publication of the 2018/19 Planning Guidance has been delayed. However, the financial “business rules” for 2018/19 were outlined in the 2017/18 guidance.

2. Allocations, Control Totals and Business Rules

2.1. The MECCG Baseline Resource Limit uplift for 2018/19 is currently expected to be £11.1m (2.5%). MECCG population is forecast to increase by 0.7%. With an increasing age profile, the demands on services are expected to increase at a faster rate.

2.2. NHS provider organisations are expected to again be eligible for System Transformation Funding subject to certain conditions and the delivery of in-year service and financial targets. To avoid “double jeopardy”, NHSE is therefore expected to again significantly restrict the fines and penalties that can be applied to provider organisations for failing to achieve key performance metrics.

2.3. The CCG is again required to hold a 1% Transformation Reserve. As for 2017/18, the CCG is permitted to develop plans to invest half of the reserve. The CCG must hold the remaining half as a risk reserve until further notice.

2.4. The table below sets out the anticipated requirements in order to deliver the expected 2018/19 Business Rules:

Metric Performance 1% Transformation Reserve £4.588m 0.5% Contingency £2.294m Demonstrate a 2.5% increase in expenditure MH Parity compared to 2017/18 expenditure Emotional Health & Well-being MH Total of £1.247m to be invested in eating disorders Services (EHWMHS) Investment and transforming children and young persons services. £3 per head non-recurrent Primary £500k in 2017/18 and the £674k balance to be Care Transformation investment invested in 2018/19 It is likely that the CCG will need to budget to clear the accumulated backlog above target performance. RTT However MEHT data quality issues are delaying the assessment of the financial cost pressure. Plan to be submitted in line with control total - but Achivement of NHSE Control Total the CCG savings plans are not yet sufficient to deliver the required target. Work ongoing.

2.5. As covered elsewhere on today’s agenda, the CCG is expecting to be able to access significant additional funding for primary care investment in 2018/19.

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3. Cost Pressures

3.1. All cost pressure assumptions continue to be reviewed and refined in the light of emerging information.

3.2. Both NHS and private providers are flagging cost pressures in excess of the uplift currently provided in the net national tariff uplift. It is not clear whether national tariff uplift assumptions will be adjusted to reflect the final national pay award or the continued financial pressures being experienced by providers and the deteriorating financial positions of the acute sector.

3.3. Current year activity increases have been significantly distorted by changes in national reporting rules across a number of acute providers. At MEHT, activity reporting is further distorted by changes in pathway/recording arising from changes in the Emergency Village and from different reporting treatments and implementation data quality issues arising from the new Lorenzo system. This reduces the quality of the information available to the CCG in planning for 2018/19 activity and costs.

3.4. CCGs have been advised to assume that the significant prescribing cost pressure from supply issues (“No Cheaper Stock Option”) will not reoccur in 2018/19.

3.5. The 2017/18 position is supported by a number of non-recurrent benefits, which increases the pressure on the baseline position.

4. Savings/Cost Mitigations

4.1. A £3m surplus is currently expected to require savings/mitigations of £19.4m (4.2%).

4.2. Work on opportunities has been underway for a number of months. CCGs are working across the STP in order to share ideas and approaches and to streamline resource requirements to mobilise opportunities.

4.3. Identified solutions are still significantly short of the required total and work is continuing.

5. Capital

5.1 The CCG is expecting to require only a small CCG capital allocation for 2018/19. GP IT capital expenditure is accounted for by NHS England. The CCG usually also has access to Estates & Technology Transformation Funding (ETTF) towards some GP premises project work and a share of transformation funding to progress primary care mobile working. ETTF expenditure is accounted for by NHSE.

6. Deficit Repayment

6.1 Section 16 of the 2017/18 Finance Report sets out the assumptions on the closing 2017/18 if the CCG is able to deliver a £6.4m in-year surplus in 2017/18 and the CCG is allowed to retain the benefit of the unspent 0.5% risk reserve. The table below reflects those assumptions and assumes that the 2018/19 Control Total can be delivered.

224 Required Accumulated In-Year Surplus/ Deficit Deficit Repyment at 31 March £m £m

7 Recommendation

The Board is requested to note the emerging issues relating to the development of the 2018/19 Financial Plan.

225 Report to: Part I Board Meeting Date: 25 January 2018

Agenda No: 20 Report Title: Revised Committee Terms of Reference Written by: Head of Corporate Governance Purpose of Report: To ask the Board to approve an amendment, in line with NHS England Statutory Guidance for CCGs on the Management of Conflicts of Interest, to the Terms of Reference of the Audit Committee, Finance & Performance Committee, Live Well Committee, Quality & Governance Committee, Primary Care Commissioning Committee and Remuneration Committee.

In addition, to seek Board approval to various amendments to the Terms of Reference of the Individual Funding Requests (IFR) Panel. Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe Strategic Objective 2 To meet the financial challenge through responsible use of resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees Each Committee has reviewed its own Terms of Reference that have reviewed this prior to submitting them for approval document). Reports Submitted to Board only: Date signed-off by Executive Team. (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick )  Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment  Quality Impact Assessment  Privacy Impact Assessment  Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick )  Declarations of Interest: N/A Patient & Public Engagement: N/A Significant Risks identified: N/A Recommendations and The Board is asked to approve the amendment to the Terms of decision/actions required Reference of the above-mentioned Committees and Panels. by the Committee/Board: 226

Amendment of Committee Terms of Reference in line with revised CCG Conflict of Interest Guidance

Paragraph 30 of the NHS England statutory guidance on the management of conflicts of interest states:

CCGs should ensure that their ……. committee terms of reference ………. are reviewed to ensure that they enable the CCG to take appropriate action to manage conflicts of interest robustly and effectively in such circumstances.

The Chairs of the CCG’s main committees (Audit, Finance & Performance, Quality & Governance, Live Well, Primary Care Commissioning Committee and Remuneration Committee) were therefore asked to include an additional paragraph within committee Terms of Reference as follows:

MANAGEMENT OF CONFLICTS OF INTEREST

Members of the Committee will be required to declare any relevant interests to the CCG in accordance with the CCG’s Conflicts of Interest Policy (MECCG003).

A register of Committee members’ interests and CCG staff and staff from other organisations/Auditors* who regularly attend Committee meetings will be produced for each meeting. Committee members will be required to declare interests relevant to agenda items as soon as they are aware of an actual or potential conflict so that the Committee Chair can decide on the necessary action to manage the interest in accordance with the Conflicts of Interest Policy.

* Auditors included within the Audit Committee Terms of Reference only.

IFR Panel Terms of Reference

The IFR Panel is a sub-committee of the CCG Board and has delegated authority to make decisions in respect of funding for individual cases. Under its current Terms of Reference the IFR Panel reports directly to the CCG Board, hence the following amendments to its Terms of Reference are being submitted to the Board for approval. Going forward, it is recommended that the IFR Panel reports to the Quality & Governance Committee in line with the CCG’s other clinical sub-committees.

The following amendments are proposed to the IFR Panel’s Terms of Reference:

Membership Patient Experience Manager removed from membership.

Frequency of meetings An ‘extraordinary’ IFR meeting can be convened comprising a senior Public Health professional, nominated by the Director of Public Health, and a Clinical or equivalent, the Chair and either Chief Pharmacist or nominated GP as a minimum membership.

Accountability

The minutes of the IFR Panel will be approved by the Chair of the Panel. The IFR Panel is accountable to the CCG Board Quality & Governance Committee. 227 Reporting and Monitoring The IFR Coordinator will produce an annual report which will be approved by the IFR panel and considered by the CCG Board Quality & Governance Committee.

The Terms of Reference of the IFR Panel will be reviewed annually and any changes agreed by the CCG Board Quality & Governance Committee.

Patient’s right to appeal Section added as follows:

If a patient or clinician wishes to appeal an IFR Panel decision, they may do so by requesting a review of the IFR process in writing to the IFR Coordinator of the CCG within 20 working days of the date of the outcome letter. Mid Essex CCG appeal hearings are carried out by NEECCG …. The appeal hearing will only consider the case in terms of whether or not due process was followed; it does not reconsider the case on its merits.

RECOMMENDATION

Board members are asked to approve the above amendment to the Terms of Reference of the:

• Audit Committee • Finance & Performance Committee • Live Well Committee • Quality & Governance Committee and • Primary Care Commissioning Committee • Remuneration Committee • IFR Panel

228 Report to: Board Meeting Date: 25 January 2018

Agenda No: 21 Report Title: Emergency Powers Decisions Written by: Director of Corporate Services / Head of Corporate Governance Purpose of Report: To advise the Board of Emergency Powers decisions taken since the Board meeting held on 28 September 2017. Please Tick How does this issue link to the CCG’s Strategic Objectives?  Strategic Objective 1 To improve quality and outcomes for all and keep patients safe Strategic Objective 2 To meet the financial challenge through responsible use of  resources Strategic Objective 3 To achieve transformation, innovation and integration of services Strategic Objective 4 To ensure there is full practice engagement informing commissioning Strategic Objective 5 To ensure public confidence in commissioned services  Strategic Objective 6 To ensure the CCG has the necessary governance, capacity  and capability to deliver all our duties and responsibilities Approval Route: Group/Committee Date (List Groups/Committees that have reviewed this document).

Reports Submitted to Board only: Date signed-off by Executive Team. (NB: With the exception of standing agenda items, all reports submitted to the Board must be signed-off by the Executive Team) Have any financial implications been signed Yes No N/A off by the Chief Finance Officer? (Please Tick ) Have the following Assessments been carried Yes No N/A out? (Please Tick ) NB: Members may request a copy of the relevant Assessment from the Head of Corporate Governance, if required. Equality Impact Assessment Quality Impact Assessment Privacy Impact Assessment Procurements Only: Has the Procurement Yes No N/A Checklist been completed? (Please Tick ) Declarations of Interest: Dr Caroline was not eligible to vote in relation to the amendment to the Constitution to extend the term of office of an elected GP in exceptional circumstances. Patient & Public N/A Engagement: Significant Risks N/A identified: Recommendations and The Board are asked to note the Emergency Powers decisions decision/actions required taken since the Board meeting held on 28 September 2017. by the Committee/Board:

229 EMERGENCY POWERS DECISIONS TAKEN SINCE THE BOARD MEETING HELD ON 28 SEPTEMBER 2017

Commissioning Support Services

On the recommendation of Finance & Performance Committee, the Chief Finance Officer sought and was given approval for Mid Essex CCG to host the Local Provider Framework contract for commissioning support services on behalf of itself and the other Mid and South Essex CCGs.

Amendment to the CCG’s Constitution

Paragraph 2.2.2 of the CCG’s Standing Orders (SOs) states that elected GP Board members can ‘serve for a period of two or three years, for a maximum of two terms’ and that elected members ‘will not be eligible to stand again if they have completed two terms of two or three years (to a maximum of six years) without a one year break’. Dr Caroline Dollery, Chair of the CCG, is reaching the end of her second term of office and the other GP Board members are reaching the end of their first term of office, with all appointments ending on 31 March 2018.

To maintain stability during the implementation of the new staffing structures for the CCG and the outcome of the consultation upon the mid and south Essex STP plan, the Director of Corporate Services sought and was given approval for Mid Essex CCG to amend Section 2.2.2. of Standing Orders as follows:

“In exceptional circumstances an elected member’s term of office may be extended beyond the initial agreed length for a maximum period of six months. Any such extension will be subject to the support of the Local Medical Council and the agreement of the CCG’s Remuneration and Terms of Service Committee”

This amendment was also supported by the Chief Executive of the Local Medical Committee.

The CCG’s Remuneration and Terms of Service Committee subsequently agreed at its meeting on 21 December 2017 to extend Dr Caroline Dollery’s term of office as an elected GP Board member and Chair of the CCG by six months when it expires on 31 March 2018.

Amendment to the CCG’s Standing Orders

Elections for elected GP Board members will commence in January 2018 with appointments being made with effect from 1 April 2018. To enable Dr Dollery to provide support and mentorship to the ‘designate Chair’ who will take on the role of Chair at the end of Dr Dollery’s extended six month term, the Director of Corporate Services sought and was given approval to increase the number of elected GP Board members from four to five on a temporary basis during Dr Dollery’s extended term of office.

Section 6.8.2. of CCG’s Standing Orders have therefore been amended to reflect the increase in elected GP Board members.

230