Chorley and South Ribble CCG Governing Body - Part 1

27 March 2019 at 1.30 pm St Catherine's Hospice, Lostock Lane, Lostock Hall, PR5 5XU

Item Agenda Item Objectives/ Presented By Time No Desired Outcomes 1 Welcome and Apologies for Dr G Bangi 1.30 pm Absence Verbal

2 Declarations and Register of To provide Dr G Bangi 1.32 pm Interests (Pages 3 - 12) assurance Assurance

3 Minutes of Previous Meeting For group approval Dr G Bangi 1.35 pm (Pages 13 - 28) Approval

4 Matters Arising (Pages 29 - To provide Dr G Bangi 1.40 pm 32) assurance Assurance

Standing Items 5 Chair's Update To update the Dr G Bangi 1.45 pm group Verbal Board Assurance 6 Governing Body Assurance To provide Mr M Gaunt 1.50 pm Framework & Corporate Risk assurance Assurance Register (Pages 33 - 94)

Performance Update 7 Integrated Board Report & To update the Mrs H Curtis 1.50 pm Financial Performance Report group Discussion (Pages 95 - 198)

Quality and Governance 8 Constitution Update (Pages To update the Mr M Gaunt 2.05 pm 199 - 202) group Discussion

9 Replacement of the Local For group approval Mrs L Burton / 2.10 pm Safeguarding Children's Board Mrs L Elliott with Safeguarding Partnership Approval Arrangements & Development of a transformational safeguarding model ICP/ICS

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

(Pages 203 - 230)

Committee Updates and Minutes 10 Remuneration Committee For group approval Mr A Stuttard 2.25 pm Update and Terms of Approval Reference (Pages 231 - 244)

11 Audit Committee Update and To provide Mrs L Chivers Minutes (Pages 245 - 276) assurance Assurance

12 Joint Quality and Performance For group approval Mr A Stuttard Committee Update and Approval Minutes, and Terms of Reference (Pages 277 - 290)

13 Primary Care Commissioning To provide Mr A Stuttard Committee Update and assurance Assurance Minutes (Pages 291 - 298)

14 Patient Voice Committee To provide Mr G Update and Minutes (Pages assurance O'Donoghue 299 - 326) Assurance

Questions from the Public 15 Questions from the Public Dr G Bangi 2.35 pm Verbal Any Other Business 16 GBAF Risk Review Verbal Dr G Bangi 2.40 pm Verbal 17 Any other business Dr G Bangi 2.45 pm Verbal Date, Time and Venue of next meeting: Wednesday, 22 May 2019, 1.30 pm, The Presidents Suite, Lancashire Football Association, The County Ground, Thurston Road, Leyland, PR25 2LF

Agenda Chorley and South Ribble CCG Governing Body - Part 1 Meeting 27 March 2019 Agenda Item 2

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Declarations and Register of Interests Presented by Dr Gora Bangi, Chair Author Joanne Croasdale – Administrative Assistant Clinical lead N/A Confidential No

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

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

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

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

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

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

Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body Meeting Page 3 27 March 2019 Links to CCG Strategic Objectives SO1 Improve quality through more effective, safer services, which deliver a ☐ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☐ balance between in-hospital and out-of-hospital provision SO3 Be an integral part of a financially sustainable health economy ☐

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

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

This paper was last reported to 23 January Governing Body Governing Body on 23 January 2019 2019 Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these: N/A

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

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

Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body Meeting Page 4 27 March 2019

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

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

Name Role Declaration Date Mitigating Actions Ms Helen Curtis Director of Quality and NFPI - Daughter is Specialty Business 14.12.2018 This will be declared separately in any Performance, NHS Manager for Surgery at Lancashire meetings whereby this presents a conflict Chorley and South Teaching Hospitals NHS Foundation Trust to my decision making Ribble and NHS Greater - December 2018 Preston CCG NFPI - Son is a Social Worker in central Preston - Current Ms Patricia Governing Body Nurse, No Interests Declared 19.12.2018 Not applicable - no interests declared Hamilton NHS Chorley and South Ribble and NHS Greater Preston CCG Dr Eamonn Secondary Care Doctor, NFProI - Retired Consultant Anaesthetist 18.12.2018 Interest noted. Will be reviewed in line McKiernan NHS Chorley and South who worked at Lancashire Teaching with agenda items at committee meetings Ribble and NHS Greater Hospitals NHS Foundation Trust for 31 and procurement involvement. Where a Preston CCG years conflict emerges the individual will be NFPI - Oldest daughter is a social worker excluded from decision making. in Newcastle Upon Tyne - Current NFPI - Second daughter is a Psychiatrist

Page 5 Page Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Name Role Declaration Date Mitigating Actions researching and practicing in Cambridge - Current NFPI - Third daughter is Children's nurse in Stockport - Current NFPI - Son in Law training in Cardiology in Cambridge and Norwich - Current Vacant post GP Director, NHS Personal Chorley and South TBC Ribble CCG TBC Dr Lindsey GP Director, NHS NFPI - Sister in law works for LCFT as 12.12.2018 No direct involvement in commissioning Dickinson Chorley and South Team Manager for Mental Health - from contracts from LCFT Ribble CCG Dec 2018 Interest noted, will be reviewed in line with FI - GP Partner in The Chorley Surgery - agenda items at committee meetings and from 2016 procurement involvement. Where a FI - Shareholder in the Primary Care Prime conflict emerges the individual will be Vendor company - from Nov 2018 excluded from decision. FI – GP working for The Chorley Surgery providing primary medical care services for residents of NHS Chorley and South Ribble/Greater Preston CCG Mr Denis Gizzi Chief Accountable FI - The Den Recording Studio - Current 11.12.2018 Interest noted, will be reviewed in line with Officer, Chorley & South FI - Smart Sight Coaching - Current agenda items at committee meetings and Ribble & Greater Preston FI - Ndeed Consulting - Current procurement involvement. Where a CCG’s NFProI - Dr Alan Nye is a long-time conflict emerges the individual will be acquaintance from my time in Oldham - excluded from decision making Current NFPI - My partner is owner and MD for C&I Consulting - Current NFPI - Jackie Proctor, who is the CCG's

Page 6 Page Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Name Role Declaration Date Mitigating Actions anti-fraud specialist employed by MIAA, is a personal friend of mine - Current Dr Gora Bangi Chair, NHS Chorley and FI - GP Principal - Leyland Surgery and the 14.12.2018 Interest noted, will be reviewed in line with South Ribble CCG Surgery Chorley - Current agenda items at committee meetings and FI - Director of BAS group limited - Current procurement involvement. Where a FI - GP provider collaborative: - Current conflict emerges the individual will be Buckshaw Village Surgery excluded from decision making Adlington Medical Centre Eaves Lane Surgery Medicare Unit Leyland Surgery The Surgery Chorley FI - Leyland Surgery - Member of Leyland Network - Current FI - The Surgery Chorley - Member of Chorley Central Network - Current FI - Lancashire Care NHS Foundation Trust - Tenant in Leyland Surgery - Current NF ProI- NHS Clinical Commissioners Board Member - Current II - Wife is a nurse at Lancashire Teaching Hospitals Trust - Current II - Son is an Accountant at Deloitte UK - Current Ms Linda Chivers Lay Member, Chair of FI - Non-executive Director Bridgewater 18.12.2018 Interest noted, will be reviewed in line with Audit, NHS Chorley & Community Healthcare Foundation Trust agenda items at committee meetings and South Ribble CCG (Audit Chair) - 01.06.2018 procurement involvement. Where a NF ProI - Chorley and South Ribble CCG conflict emerges the individual will be Conflicts of Interest Guardian - Current excluded from decision making. if deemed appropriate member would also be

Page 7 Page Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Name Role Declaration Date Mitigating Actions excluded from any discussion prior to a decision. Mr Matt Gaunt Chief Finance & No Interest Declared 11.12.2018 No risk to decision making as no potential Contracting conflicts identified Officer,Deputy Accountable Officer, Chorley & South Ribble & Greater Preston CCG’s Dr Satyendra GP-Director Chorley & FI - GP Provider 21.12.2018 Interest noted, will be reviewed in line with Singh South Ribble CCG FI - GP Principal agenda items at committee meetings and NF ProI - LMC Member procurement involvement. Where a NF ProI - Member of Chorley- East conflict emerges the individual will be collaborative excluded from decision making NF ProI - Member of Central Lancashire GP Provider Group FI – GP working for Clayton Brook Surgery providing primary medical care services for residents of NHS Chorley and South Ribble/Greater Preston CCG Mr Alan Stuttard Lay Member, Vice Chair FI - Non Executive Director, Blackpool 22.12.2018 Interest noted, will be reviewed in line with - Governance, Chorley & Operating Company Ltd (wholly owned agenda items at committee meetings and South Ribble CCG company of Blackpool Council responsible procurement involvement. Where a for the Blackpool Sandcastle Waterpark) - conflict emerges the individual will be Jan 2018 - Present excluded from decision making NF PI - Volunteer Driver for the North West Ambulance Service NHS Trust - Nov 2017 - Present FI - Non Executive Director Bolton NHS Foundation Trust - Jan 2019

Page 8 Page Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Name Role Declaration Date Mitigating Actions

Mr Geoffrey Lay Member - NF PI - Co-opted Governor at Parklands 21.12.2018 Interest noted, will be reviewed in line with O'Donoghue Public,Patient Academy, Chorley - 17.12.2018 to Present agenda items at committee meetings and Engagement NF PI - Secretary to Chorley Sheds, procurement involvement. Where a Chorley South Ribble community group set up to alleviate conflict emerges the individual will be CCG isolation and improve individuals mental excluded from decision making. if deemed health and wellbeing - August 2018 to appropriate member would also be Present excluded from any discussion prior to a decision. Sue Stevenson Chief Operating Officer No Interest Declared 14.11.2018 for Healthwatch Lancashire Seeking Observer Status on the CCG Vancant post - Public Health Consultant, Public Health NHS Chorley and South Consultant Ribble CCG and NHS Greater Preston CCG Dr John Cairns GP Director, Chorley & NFProI - GP Partner at Library House 09.01.2019 Interest noted, will be reviewed in line with South Ribble CCG Surgery - Current agenda items at committee meetings and NFProI - Councillor West Lancs Council - procurement involvement. Where a Current conflict emerges the individual will be excluded from decision making

Dr Ann Robinson GP Director, NHS FI - GP partner at Withnell Health Centre - 21.01.2019 Interest noted, will be reviewed in line with Chorley and South Current agenda items at committee meetings and Ribble CCG FI - GP practice, Withnell Health Centre, procurement involvement. Where a offer extended access appointments as conflict emerges the individual will be

Page 9 Page Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Name Role Declaration Date Mitigating Actions part of the Chorley East Collaboration - excluded from decision making Current NFPI - Husband is a Secondary Care Consultant in diabetes and endocrinology and Chair of the Division of Medicine at Salford Royal - Current NFPI - Husband has private diabetes clinic at Beaumont Hospital - Current NFPI - Husband is the secondary care doctor for Ormskirk CCG - Current FI – GP working for Withnell Health Centre providing primary medical care services for residents of NHS Chorley and South Ribble/Greater Preston CCG Mrs Jayne Mellor Director of No Interest Declared 14.02.2019 No risk to decision making as no potential Transformation and conflicts identified Delivery Dr Anthony Reid LMC Representative Personal NHS Chorley and South IP - £1000 bond shareholder in Chorley Ribble CCG Medics Ltd PR - GP Appraiser for NHS England CL - Vice Chair of the Central Lancashire Local Medical Committee (LMC) Associated No interests declared

Page 10 Page Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Declarations of Interest Flowchart

Annual Declarations In Year Changes In a Meeting

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

Do you know what to include? You must provide details in Y You should writing, as soon as you become aware and no later complete a

than 28 days after becoming Declaration Is this on the You need to update aware to the Governing Body of interest Y N Y N Register of your declaration of Secretary Pro-Forma Interests? Interest Form

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

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

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

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

Page 11 Page Chair to refer to CCG Constitution Written notification of declarations made and P31 Clause 8.4.9-8.4.12 to course of action taken (using template) to be PUBLISH REGISTERS determine next steps submitted to Governing Body via GBS

This page is intentionally left blank Agenda Item 3

Governing Body Meeting – Minutes

Wednesday 23 January 2019 The Garden Room, St Catherine’s Hospice, Lostock Lane, Lostock Hall PR5 5XU

Present Dr Gora Bangi, Chair Mrs Linda Chivers, Lay Member for Finance and Audit Mrs Helen Curtis, Director of Quality and Performance Dr Lindsey Dickinson, GP Director Mr Matt Gaunt, Director of Finance and Contracting Mr Denis Gizzi, Chief Officer Dr Eamonn McKiernan, Secondary Care Doctor Mr Geoffrey O’Donoghue, Lay Member for Patient and Public Involvement Dr Ann Robinson, GP Director Dr Satyendra Singh, GP Director Mr Alan Stuttard, Vice Chair and Lay Member for Governance

In attendance Mrs Sarah James, Programme Director Integrated Care Partnership Ms Hollie Johnson, Governing Body Secretary (Minutes)

In attendance Mr Will Osborne, Moving Well Service iMSK, Patient Story to present

Members of the Ms Glenis Tansey, Engagement and Patient Experience Lead public Miss Harriett Fisher, KPMG Two members of the public attended the meeting

CSRGB Welcome and Apologies for Absence /190123-1 Dr Bangi welcomed everyone to the meeting. Introductions were made for the purpose of members of the public.

Apologies were received from Dr John Cairns, GP Director, Mrs Jayne Mellor, Director of Planning and Delivery and Mrs Tricia Hamilton, Governing Body Nurse.

A representative from Healthwatch or the Local Medical Committee did not attend the meeting.

CSRGB Patient Story /190123-2 Mrs Curtis introduced Mr Will Osbourne to the Governing Body. As the clinical lead for the Moving Well Service, Mr Osbourne had attended the meeting to provide an update with regard to how the service had responded to complaints surrounding waiting times.

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 13

Governing Body members heard about the implementation of the tele-physio service. Following a referral to the Moving Well service, patients were contacted by the tele-physio department at which time an assessment took place over the phone. Tele-physio ensured that patients were on the correct pathway for the referral into the integrated Muscular Skeletal (iMSK) Service and the positive effects had in terms of the reduction on waiting lists. Governing Body members were informed that the initial appointment arranged following a referral was kept in the instance that a patient required a face to face appointment after the tele-physio assessment.

Mr Osbourne provided an example of a positive patient experience by self-referral and use of the tele-physio service. Governing Body members heard how the patient had found it easy and convenient to complete the self-referral assessment online. The patient had been pleased to use the service on his own, noting that he was glad that he did not feel that he was wasting his GP’s time by needing an appointment to be referred. He had further been pleased that he could arrange the appointment around his shifts at work.

Governing Body members discussed how the option for a patient to self-refer into the service gave patients autonomy and promoted resilience for patients surrounding self-management. Mr Gaunt noted that it would be useful to monitor the effect had on patients who failed to attend their appointments as a result of the empowerment to self- refer.

Dr Bangi, on behalf of the Governing Body, thanked Mr Osbourne for attending the meeting.

CSRGB Declarations and Register of Interests /190123-3 Dr Bangi reminded Governing Body members of their obligation to declare any interest that they may have on any issues arising during the meeting which might conflict with the business of the Chorley and South Ribble CCG.

Mr Stuttard confirmed that his pending declaration as non-executive director at Bolton NHS Foundation Trust had now been confirmed.

Mr O’Donoghue noted the lack of attendance at Governing Body meetings by the representatives for the Local Medical Committee and Healthwatch. Mr Gaunt confirmed that he would liaise with the representatives outside the meeting with regard to their attendance.

Mrs Curtis referred to CSRGB/190123-13; the Safeguarding Annual Report on the agenda and advised that her son is a social worker, working in central Preston. On consideration of the report, she had not felt that it contained anything that would cause conflict. She further made the Governing Body aware that the Quality and

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 14

Performance Committee had noted the potential for conflict surrounding the presentation of the Integrated Board Report and that this needs to be addressed on an as needs basis.

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

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

The declarations and register of interests would be updated accordingly.

CSRGB Minutes of Previous Meeting /190123-4 The minutes from the meeting held on 28 November 2018 were presented for approval.

CSRGB/181128-2 A spelling error would be made in the second paragraph.

CSRGB/181128-9 The final sentence of the third paragraph would be amended to read ‘as only receiving funding 5-6 weeks before schemes to initiate successful schemes in the past had proved difficult due to the short space of time’.

CSRGB/181128-11 The fourth bullet point would be amended to reflect that an elective care board was being established.

CSRGB/181128-15 The third paragraph would be amended to note that changes to the constitution would require the approval of the Membership Council.

CSRGB/181128-16 A spelling error would be made in the first paragraph.

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

Resolved That the Governing Body accepted the minutes of the meeting held on 28 November 2018 as a correct record.

CSRGB Matters Arising /190123-5 Governing Body members noted the actions completed on the matters arising sheet provided. The following updates were provided for the outstanding matters arising:-

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CSRGB/180523-15 The terms of reference for the Quality and Performance Committee would be presented for approval at a future meeting.

CSRGB/181128-7a Content on the Our Health Our Care (OHOC) website was in the process of being updated. The Terms of Reference for the Integrated Care Partnership (ICP) Board would be published on the website as part of that update.

CSRGB/181129-10 An update surrounding the success of the winter plan would be presented to the Governing Body at its meeting in March 2019.

Resolved That the Governing Body noted the updates provided.

CSRGB Chair’s Update /190123-6 Dr Bangi welcomed Governing Body members to the meeting and provided an update on recent activities.

Our Health Our Care (OHOC) programme The OHOC Joint Committee met in public for the first time on 13 December 2018 to review the OHOC case for change document. Following a constructive discussion, the case for change was approved, subject to a minor revision.

The programme team is now working to develop the next steps, which will include a potential vision for a future model of care for how services could be arranged locally. The clinical vision and model will be developed incorporating feedback from clinicians and members of the public.

Prior to any consideration or development of potential options, the OHOC Joint Committee would need to approve this at a further meeting in public.

Integrated Care Partnership (ICP) shadow Board The ICP shadow Board for central Lancashire met on the 13 December 2018. It was agreed at the meeting that Mrs Curtis had been the ICP Executive Lead for Quality to help develop Quality Assurance and Improvement processes across the Integrated Care system (ICS). Mrs Mellor is the Better Care Fund (BCF) lead for the ICS.

Dr Bangi informed the Governing Body that a central Lancashire ICP Purpose Document was in development to articulate the ICP’s purpose and vision of the future, and explain the big seven strategic platforms. Scope documents were being developed for the enabler

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workstreams. It was agreed that organisational leads would be nominated for system-wide working groups for;

• Programme Management Arrangements • Continuous Improvement • Performance Reporting and Assurance • Communications • Public and Patient Engagement and Involvement • Governance Arrangements

The ICP board approved the platform brief for the Wellbeing and Health in Integrated Networks (WHINs), which is the first of the big seven platforms to be presented to the Partnership Board for approval.

The ICP board also supported the proposal surrounding how the voluntary care sector proposed to build capacity to enable them to better influence and engage with the ICP.

Long Term Plan Dr Bangi referred to the recent media coverage of the long term plan. He was pleased to report that a number of recommendations in the plan were already being implemented at the CCG. A staff away day had been arranged for February 2018, at which time discussions would be had surrounding how the CCG would implement the plan. Dr Bangi explained the expectation that the CCG engaged with our local populations on how we implement the long term plan. Th eCCG would work with ICS colleagues to deliver this.

Governing Body Members Dr Bangi informed the Governing Body that Mr Alan Stuttard had resigned from his position as the Governing Body Lay Member for Governance and Vice Chair to take up a role as a non-executive director at Bolton Hospital NHS Foundation Trust at the end of March 2019. Dr Bangi thanked Mr Stuttard for his work with the CCG over the past 12 months.

Mrs Chivers referred to the CCG staff away day on 13 February 2019 and noted that previously lay members had been invited to the same. Dr Bangi agreed with her that it was important for Governing Body members to be visible to staff. Governing Body members would be invited to the CCG staff away day.

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

CSRGB Governing Body Assurance Framework and Corporate Risk /190123-7 Register Mr Gaunt presented the Governing Body Assurance Framework

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(GBAF) that records the significant principle risks that could impact on the CCG achieving its strategic objectives. It should summarise the sources of control and assurance that are in place or are planned to mitigate the risks identified.

Mr Gaunt drew Governing Body members’ attention to the key changes made to the GBAF as outlined in the executive summary of the paper. The format of the GBAF had been updated following feedback from the Quality and Performance Committee, and changes that had been made to the GBAF were highlighted in red for attention and approval.

The GBAF had been presented to the Audit Committee and the Quality and Performance Committee meetings in January 2019. The Audit Committee provided scrutiny on the systems and processes used to manage the GBAF risks, at which time the committee received a ‘deep dive’ into GBAF02; Financial Sustainability.

Mrs Chivers welcomed the updated format of the GBAF. She informed the Governing Body of the deep-dive undertaken by the Audit Committee in January 2019 into GBAF02; Financial Sustainability and thanked Mr Gaunt for the excellent presentation. Mrs Chivers requested that the GBAF was amended to include the definition of the scores for impact and likelihood.

Governing Body discussed the following wording of a gap in control in GBAF03; Well Led, surrounding the OHOC programme; ‘the OHOC programme may not progress at pace or with the desired outcomes’. Governing Body members were in agreement with Mr Gizzi that the update should be re-worded to note that the programme needed to be managed with due diligence.

Mrs Chivers questioned what action was being taken surrounding the GP Director vacancy on the Governing Body. Mr Gizzi referred to the NHS long term 10 year plan, where it detailed that CCGs should consider the viability of mergers within the arrangements of the ICS. He further reminded the Governing Body that the CCG was required to reduce running costs by 20% by April 2020. Opportunities to recruit to the vacancy would be addressed as part of those considerations.

Mr Cherry raised concerns surrounding the delivery of the CCG’s strategic objectives. Governing Body members discussed the timing of the data within the GBAF presented at the meeting. Mr Gaunt confirmed that the information would be updated to detail the most up to date information at the time of Governing Body papers being published for the meeting.

Resolved

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That the Governing Body approved the changes made to the GBAF and CRR.

CSRGB Central Lancashire Integrated Care Partnership Update /190123-8 Mr Gizzi and Mrs James presented the Central Lancashire Integrated Care Partnership (ICP) update, detailing the progress made towards Integrated Care arrangements in Central Lancashire over the last month.

Mrs James drew Governing Body members’ attention to the updates in the report across the following areas:

• ICP Board business in December • ICP Mobilisation – Board and Leadership development • Movement towards place based regulation and assurance • The NHS long term plan and NHS planning guidance 2019/20 • Big Seven Strategic Framework – Platform Specific Updates • Looking ahead to the next period (January – February 2019)

The key messages and actions from the ICP Board meeting held in December were presented for Governing Body members’ information.

Mrs James drew Governing Body members’ attention to The NHS Long Term Plan Briefing that had been published on 7 January 2019. The briefing provided a short overview of the Plan, which set out the ambitions, commitments and priorities of the NHS for the next 10 years.

Mr Stuttard referred to the Big Seven Strategic framework, and made particular reference to OHOC Acute Sustainably. He felt that the title of the platform was not reflective of the OHOC Joint Committee of CCGs approval that a model of care needed to be developed for the whole health economy, from wellbeing and health to primary care and acute services. Mrs James explained that the rational was as part of the guidance when it came to consultation. She referred to the Wellbeing and Health in Integrated Neighbourhoods platform and detailed the interdependencies between each.

Mrs Chivers thanked Mrs James for the update and noted that she had found it clear and succinct. She expressed her concerns within the update surrounding the NHS long term 10 year plan and NHS planning guidance 2019/20, in particular the reference that it was likely that 2019/20 plans would be signed off by the ICP Board. Mrs James clarified that the Governing Body would have final approval of any CCG plan ahead of presentation to the ICP Board. Governing Body members were in agreement with Mr Gaunt for the need to ensure the synchronicity of the representative plans presented to the ICP Board. Mrs Chivers stated that she would seek to ensure that

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representative’s plans linked to and helped to deliver the CCG’s plan.

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

CSRGB Our Health Our Care Update /190123-9 Mr Gizzi presented an update on the Our Health Our Care (OHOC) programme, detailing progress and priorities of the acute sustainability workstream.

The OHOC Joint Committee approved the Case for change at its formal meeting on 13 January 2018, subject to decoupling the issues raised from explicit reference to the urgent and emergency care system.

The next step of the programme was planned as the presentation of the Model of Care to the OHOC Joint Committee on 13 March 2019, with update sessions for the Governing Body being presented informally on 17 January and 27 February 2019.

Resolved That the Governing Body noted the content of the OHOC updated provided.

CSRGB Integrated Board Report /190123-10 Mrs Curtis presented the Integrated Board Report (IBR). The IBR provides an overview of CCG business and performance across key national healthcare standards that the CCG is measured against. The IBR described the action taken by the CCG and service providers to tackle any concerns and drive improvements.

Mrs Curtis informed the Governing Body that the A&E 4 hour target performance remained below the STF trajectory and the national standard year-to-date.

An improvement had been seen in the referral to treatment times (RTT) target. There had been a significant increase in open pathways as a result of the implication of the moving well service. Mrs Curtis reminded Governing Body members of the requirement to ensure that the number of pathways open in March 2019 was no greater than it was in March 2018. She detailed the conversations had with NHS England surrounding how the figures in March 2018 would need to include the additional number of open pathways within the moving well service.

Governing Body members discussed performance over the winter period. Mrs Curtis outlined the need for focus to be placed on ensuring consistency over a 7 day period, and not 5. Mrs Curtis

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confirmed for Dr Bangi that there was evidence of recovery time following busy periods as a result of better embedded services.

Mrs Chivers referred to the contract performance notices that the CCG issued and noted her interest in the expected improvement period from the issue of the same. Mr Gaunt detailed how different notices had different consequences and explained the level of engagement required across different partners. Mr Gaunt explained how stroke was being reviewed at an ICS level, however LTHTR made local improvements by way of operational changes. The CCG continued to hold LTHTR to account in those areas.

Mrs Curtis provided details of the two never events that had occurred at LTHTR. Findings from a meeting that the CCG had with LTHTR and NHS England would be presented to the Quality and Performance Committee.

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

CSRGB Financial Performance Report /190123-11 Mr Gaunt presented the joint Financial Performance Report. The joint report sets out the combined financial position for NHS Chorley and South Ribble and NHS Greater Preston CCGs as at 31 December 2018. The report detailed the summary financial position, summary I&E, productivity and efficiency (QIPP) and net risks.

The CCGs were forecasting to achieve the planned breakeven position, although there were pressures resulting in a net risk of £0.3m across both CCGs against this forecast. The CCGs full year forecast reflected £5.8m of acute overspend against contract driven largely by non-elective cost pressures at LTHTR. The previously published QIPP shortfall of £2.7m and cost growth across out of hospital services, in particular drugs costs for eye treatments.

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

• Any expenditure above plan required to ensure the number of patients waiting for treatment was no higher at the end of March 2019 than it was in March 2018. The impact to the CCGs was estimated at £0.5m.

• The CCG had formally requested to retain the 0.5% non- recurrent system risk reserve and received approval for £1.8m of the £2.5m. In November 2018, a further £0.2m was approved as mitigation by NHS England and the Integrated Care System resulting in a shortfall of £0.6m. The shortfall was partially mitigated by an additional £0.5m benefit for 2017/18 quality premium award and the expectation of the

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2018/19 achievement. Mrs Chivers noted that this could put the CCG under pressure for the next financial year.

• In relation to Continuing Healthcare costs, there was emerging pressures due to an increase in retrospective packages of care. This was being scrutinised in detail to understand the increase in packages and the likely full year forecast outturn position.

Mr Stuttard outlined that he was pleased to hear that the CCG was forecasting a breakeven position.

Mr Gaunt confirmed for Mr Gizzi that ‘other community providers’ referred to in the report referred to Lancashire Foundation NHS Trust (LCFT). He explained how the variance was driven from contract variation over the course of 2018-19.

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

CSRGB EPRR – EU Exit Operational Guidance Update /190123-12 Mr Gaunt presented the EPRR EU Exit Operational Guidance Update. The EU Exit Operational Readiness Guidance which was developed and agreed with NHS England and NHS Improvement listed the actions that providers and commissioners of health and care services should take if the UK leaves the EU without a ratified deal or ‘no-deal’ exit, to ensure that organisations are prepared for, and can manage the risks in such a scenario.

Mr Gaunt drew Governing Body members’ attention to the requirements for commissioners and the action to be taken:

• To confirm Senior Responsible Officer (SRO) for EU Exit preparation to regional NHS England; Mr Gaunt is the SRO for EU Exit for the CCG. • To note nominated regional NHS lead for EU Exit; Jo Richardson, NHS England, is the required lead. • To restate the government message that UK health and social care providers should not stockpile additional medicines or medical devices beyond their business as usual stocks; following a meeting on 10 January 2019 with the relevant leads, communications will be sent to all primary care providers restating the government message • Undertake a risk assessment to address the seven key areas, potential increases in demand and locally specific risks; leads from East Lancashire CCG, CCG, LCFT and LTHTR will work collaboratively on local risks associated with EU Exit • Review business continuity plans; the CCG Corporate

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Governance Lead will review the CCG Business Continuity Plan by 31 January 2019 • Support providers in testing their business continuity plans; a meeting was held on 14 January 2019 with the relevant leads to gain assurance on steps taken against requirements of issued guidance.

The EU Exit Operational Guidance was available on request. Further guidance will be issued as more information becomes available from central government.

Mr O’Dongohue questioned how instances where patients stockpiled additional medicines could be evidenced. Dr Bangi explained that each patient on repeat medications had a yearly face to face review. Each request made for a repeat prescription was reviewed and only accepted in the instances that were reasonable. Dr Robinson added that the date of each prescription could be checked. GP Directors confirmed for Mr Gizzi that with regard to repeat prescriptions, each request required the approval of a clinician.

Resolved That the Governing Body noted the EPRR EU Exit Operational Guidance Update provided.

CSRGB Equality Annual Report 2018 /190123-13 Mrs Curtis presented the CCG’s Equality Annual Report 2018. The report demonstrated how the CCG met its statutory duties for equality, diversity and inclusion, and demonstrated legislative compliance with the Equality Act 2010 and its 2011 provision; the Public Sector Equality Duty.

The report highlighted a range of equality, diversity and inclusion evidence, and also included the CCG’s results of the annual Equality Delivery System (EDS) assessment. EDS is a national NHS England framework that the CCG assesses its delivery against a range of outcomes under four specific equality and diversity goals:

• Goal 1 – better health outcomes • Goal 2 – improved patient access and experience • Goal 3 – a representative and supportive workforce • Goal 4 – inclusive leadership

Mrs Curtis drew Governing Body members’ attention to the final results included in the report for Goals 1 and 2, with interim results currently included for Goals 3 and 4. She noted that Chorley and South Ribble CCG compared favourably when compared against other CCGs.

Mrs Curtis commended the work undertaken by Mrs Dawn Clarke as

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the lead for Equality and Diversity.

Mr Stuttard referred to the figures provided within the report surrounding the health profile for people in the community in December 2018, and questioned whether the figures were separate individuals or co-conditions. Mrs Curtis confirmed she would obtain that information.

Mrs Chivers noted the number of spelling mistakes within the report and the need for it to be proof read before being published.

Mr O’Donoghue noted his thanks to Ms Dawn Clarke for her hard work and input in compiling the report.

Resolved That the Governing Body approved the Equality Annual Report, subject to the final results being added for the Goal 3 and 4 EDS assessments and prior to it being published on the CCG website.

CSRGB CCG Safeguarding Annual Report 2017/18 /190123-14 Mrs Curtis presented the NHS Chorley and South Ribble CCG Safeguarding Annual Report 2017/18.

The report reviewed work undertaken over 2017/18, providing the assurance that the CCG had discharged its statutory responsibilities to safeguard the welfare of children and adults across health services it commissions. Information surrounding national changes and influences was included, alongside local developments and activity around how the challenges relating to safeguarding were being managed. Priorities for 2018/19 were outlined in the report.

Mrs Curtis informed the Governing Body that there had been a decrease of 11% compared to the previous year of children in Chorley and South Ribble that were subject to child protection plans. There had been an increase of 19% compared to the previous year in the number of Looked After Children in Chorley and South Ribble.

Mrs Curtis confirmed for Mr O’Donoghue that she would feedback to the next Governing Body meeting as to whether improvements had been seen surrounding the number of looked after children who received a health assessment.

Mrs Chivers sought assurance that all patients under Deprivation of Liberty Safeguards (DoLS) were being treated appropriately. She questioned the action taken to ensure that the CCG had the necessary capacity to address the increase of patients under DoLS. Mrs Curtis outlined that a number of Safeguarding Leads across Lancashire were working to address the issue. She confirmed that she would obtain further information surrounding this to feedback to

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the Governing Body.

Mrs Curtis confirmed for Mrs Chivers that Domiciliary Care Packages individuals in receipt of Continuing Healthcare was an area that had been brought to attention at ICS level.

Resolved That the Governing Body noted and approved the CCG Safeguarding Annual Report for 2017/18.

CSRGB Audit Committee Update and Minutes /190123-15 Mrs Chivers presented an update report on the work undertaken by the Audit Committee at the meeting held 4 January 2019. The minutes from the meeting held on 2 November 2018 were presented for information.

Mrs Chivers drew Governing Body members’ attention to the challenges experienced for the delivery of the internal audit plan. Mrs Chivers and Mr Ian Cherry, Audit Chair for Greater Preston CCG had met with KPMG and expressed their concerns surrounding the level of assurance and concerns. She confirmed that the meeting had been robust, and was pleased to report that KPMG had provided the assurance that they did not anticipate any significant findings as part of their review.

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

CSRGB Joint Quality and Performance Committee Update and Minutes /190123-16 Mr Stuttard presented an update report of the Quality and Performance Committee at its meeting held on 5 December 2018 and 9 January 2019. The minutes from the meeting held on 7 November 2018 were presented for information.

LTHTR attended the Quality and Performance Committee meeting in December to present updates on the Care Quality Commission (CQC) report, Quality Risk Profile and organisational culture. Mrs Curtis informed the Governing Body that the committee had felt that LTHTR had a greater level of confidence in the presentation they delivered than previously. She confirmed that there had been an acceptance that whilst significant progress had been made in some areas, there was still a significant amount of work to do in others.

Mrs Chivers referred to the minutes presented with regard to an ongoing matter arising for LTHTR to provide a business case for ophthalmology, following a presentation on the same. The committee had requested a copy of the business case in support of LTHTR. There had been a number of issues in receiving the same, therefore

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the action had been removed as a matter arising. Mrs Chivers noted her disappointment that the committee had not been met with openness and transparity, which did not contribute towards positive working relationships as part of an ICP across Central Lancashire.

Resolved That the Governing Body noted the update report provided.

CSRGB Delegated Commissioning Committee Update /190123-17 Mr Stuttard presented an update report on the activities of the Delegated Commissioning Committee at its meeting held in December 2018, at which time the committee discussed the following:

• Terms of Reference • Out of hospital Transformation update • Application to merge Gutteridge Medical Centre • Dr Wilson – request for additional rooms • Whittle surgery – protakabin/Chorley Medics building • Specification for atypical population • Prescribing Quality and Savings Scheme 2019

Going forward, the Delegated Commissioning Committee will be the Primary Care Commissioning Committee.

Mr Stuttard informed the Governing Body that both himself and Mrs Tricia Hamilton had requested a review by the Audit Committee into the systems and processes, as the Primary Care Commissioning Committee are often faced with approval requests without plans. Mrs Chivers confirmed that that feedback had been passed to KPMG, which would be addressed as part of planning for 2019/20.

Resolved That the Governing Body noted the update report provided.

CSRGB Clinical Effectiveness Committee Update /190123-18 Mr O’Donoghue presented an update report on the activities of the Patient Voice Committee at its meeting held on 10 October 2018 and 9 January 2019.

The committee received updates on the following:

• Individual Funding Requests (IFR) Annual Report 2018/19 Quarter 2 • RightCare • Evidence based interventions (EBI) • Clinical Policy Update • CQUIN Quarter 2 reconciliation • Medicine Management Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 26

Resolved That the Governing Body noted the update report provided.

CSRGB Lancashire Health and Wellbeing Board Minutes /190123-19 The Lancashire Health and Wellbeing Board minutes from 20 November 2018 together with the Boards forward planner were presented for information.

Mrs Chivers referred to the minutes of the meeting surrounding Children and Adult Mental Health Services (CAMHS) with regard to resource, and sought assurance that the Chorley and South Ribble population would not be at a disadvantage as a result of less resource. Mr Gaunt clarified that the CCG were investing in CAMHS in Central Lancashire and suggested that this could relate to a model used in Blackpool that was difficult and unaffordable to replicate.

CSRGB Risk Review /190123-20 Governing Body members discussed whether any changes were required to the risks on the GBAF, given the discussions had throughout the meeting.

Governing Body members were in agreement that the risk score of GBAF02; Financial Sustainability should be reduced, given the update provided and subsequent discussions throughout the meeting.

CSRGB Questions from the public /190123-21 One member of the public sought clarification around the reference Mr Gaunt had made in the Financial Performance Report to Continuing Healthcare (CHC) packages. Mr Gaunt confirmed that additional checks were being made with packages that exceeded £100ht to gain further visibility of the specifics and the assurance that the care provided was in line with expectations.

Dr Bangi confirmed for one member of the public that the Moving Well service would make a referral to the appropriate place based on the needs of a patient following the physiotherapy assessment.

There were no further questions from members of the public.

CSRGB Any Other Business /190123-22 There was no further business to discuss.

Date, Time and Venue of next meeting: Wednesday 27 March 2018 The Garden Room, St Catherine’s Hospice, Lostock Lane, Lostock Hall PR5 5XU

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 27

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

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 28

NHS Chorley and South Ribble CCG Governing Body - Matters Arising

Code Title Lead Status Due Date Comments CSRGB/180523-15 Annual Committee Terms of Reference Director of Quality and May 2019 Terms of reference for the Quality and Performance Review Performance Committee will be submitted for approval by the The terms of reference for the Quality and Governing Body in May. Performance Committee would be presented 4 Item Agenda to the Governing Body. CSRGB/181128-7a Central Lancashire ICP Update Programme Director March 2019 The terms of reference for the ICP Shadow Board The terms of reference for the ICP Shadow Integrated Care have been published on the OHOC website. Board would be published on the OHOC Partnership website. CSRGB/181129-1 Winter Plan Update Director of May 2019 An update surrounding the Winter Plan will be An update surrounding the success of the Transformation and submitted to the Governing Body in May. Winter Plan would be presented to the Delivery Governing Body in March. CSRGB/190123-3 Declaration of Interests Chief Finance and March 2019 The Healthwatch Representative and Local Medical The Local Medical Committee Contracting Officer Committee Representative have been contacted Representative and the Healthwatch surrounding their attendance at Governing Body Representative would be contacted with meetings. regard to their attendance at Governing Body meetings. CSRGB/190123-6 Chair’s Update Director of Quality and March 2019 Governing Body members were invited to the CCG Governing Body members would be invited Performance Staff away day that took place on 13 February 2019. to the CCG staff away day. CSRGB190123-07a GBAF/CRR Chief Finance and March 2019 The GBAF has been updated accordingly. The GBAF would be updated to include the Contracting Officer definitions of impact/likelihood scores

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Code Title Lead Status Due Date Comments CSRGB190123-07a GBAF/CRR Chief Finance and March 2019 The GBAF has been updated accordingly. The wording of GBAF03: Well Led would be Contracting Officer amended surrounding the delivery of the OHOC Programme. CSRGB190123-13 Equality Annual Report Director of Quality and March 2019 This work has been built into the work plan for Information would be sought surorunding the Performance. Equality and Diversity for 2019/20, outlining impact health profile for people in the community for more closely to the commissioning cycle. December 2018 as to whether the figures related to indivduals or co-conditions. CSRGB/190123-14a Safeguarding Annual Report Director of Quality and March 2019 There is considerable work ongoing regarding the Information surrounding the number of loked Performance performance around HAs review health after chidlren reciving health assessments assessments and a project commenced in October that had increase would be provided. 2018 working jointly with LCC to review, map the health assessment process and pathways. There were improvements as regards the timeliness of Review Health Assessments (not sustained) however less so with Initial Health Assessments. This work stream is ongoing with a planned findings meeting 1 Feb and redesign meeting planned 3 March 2019. Streamlining the steps in the process working more integrated from an administrative point of view will be a positive step forward, another positive which has already been agreed– is for social workers to attend the initial health assessment; we have been advised that this is imminent and training is being provided for the social workers around this.

CSRGB/190123-14b Safeguarding Annual Report Director of Quality and March 2019 The CSU team take responsibility in managing the Further information surrounding the Performance court of protection work and the team has been measures that were put in place to ensure recently expanded to support with managing CoP capacity due to the increase of DoLs would cases, however there is a business case in be provided. development to seek further resource to manage the increasing demand.

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Code Title Lead Status Due Date Comments

31 Page Matters Arising NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

This page is intentionally left blank Agenda Item 6

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Governing Body Assurance Framework and Corporate Risk Register Presented by Mr Matt Gaunt, Chief Finance Officer Author Mrs Sarah Mattocks, Corporate Affairs and Governance Manager Clinical lead N/A Confidential N/A

Purpose of the paper The purpose of this report is to provide an update to the Governing Body in respect of the Governing Body Assurance Framework (GBAF) and Corporate Risk Register (CRR). The risk scoring matrix has also been included at the start of this paper for reference.

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

The GBAF was submitted to the Audit Committee and the Quality and Performance Committee (QPC) this month. The Audit Committee has provided scrutiny on the systems and processes used to manage the GBAF risks, with the committee also receiving a ‘deep dive’ into GBAF 01.

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

GBAF01 - Quality, Safe and Effective Services - The Springfield Manor Gardens action has now been closed as this facility now has full CQC status. - A new action has been added (A9) to reflect the gap in assurance regarding the efficacy of the CQC action plan - Progress has been added against the other three open actions - Risk rating remains 4x4=16 - Target rating of 4x2=8 not met as this was set too high at the start of the year, and in year events have impacted on this such as the CQC assessments. The 2019/20 GBAF will incorporate more fore-casting for target risk ratings.

Governing Body Assurance Framework Update and Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 33 - All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. - The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation.

GBAF02 – Financial Sustainability - Risk rating has reduced from 4x4=16 to 3x1=3 due to an identified underspend in ICS pooled funds which will bridge the remaining gap - Due date for actions A4 and A5 have been extended to account for the operational plan to be finalised. - A new gap in control has been added regarding the lack of robust process for financial estimates of scheme delivery to reflect the open actions A4 and A5 - Action A6 has been closed as the gap has been mitigated. - The three open actions have been updated - Target rating of 3x2=6 has been met and impact scores are in line with what was predicted at the start of the financial year. - All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. - The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation.

GBAF 03 – Well Led - A new control has been added regarding Greater Preston CCG now having a new GP Director in post; leaving no clinical leadership vancancies in Greater Preston. This has resulted in the closure of action A3. - A new control has been added regadring establishing the OHOC Joint Committee. This has redulted in the closure of action A6. - A new control has been added regarding an OHOC risk register now being in place to manage the risks associated with the programme. This has resulted in the closure of action A5. - The risk score has been reduced from 4x3=12 to 4x2=8 meeting the target rating for this risk. The mitigation in place has reduced the risk scoring – particularly with regards to actions related to the OHOC programme. As there is a joint committee in place to facilitate robust decision making, regular development sessions have taken place with Governing Body members to engage them in the programme, and with a risk register in place to mitigate threats to the delivery of the programme, the risk score has been reduced. - Action A2 has been closed as both terms of reference have now been approved by the respective committees. - The one open action has been updated. - All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. - The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation.

GBAF04 – Service Transformation - A new control has been added regarding the Wellbeing and Health in Integrated Neighbourhoods (WHIN) Board in place.

Governing Body Assurance Framework Update and Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 34 - A new control has been added regarding the 10 year plan now being available. This has mitigated the gap in assurance around the CCG only being able to pre-empt the outputs from this guidance. - Risk has met target risk rating. The 10 year plan has now been released and the CCG pre-empted plans are in line with this. The 5 year plan indicates that the national requirements by 2021 are primary care network developments, commissioning of extended access services and care homes; all of which are already established in CCG plans. The GBAF for 2019/20 will need to incorporate the outputs from the 10 year plan and the commissioning responsibilities between ICS and ICP. - All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. - The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation.

Corporate Risk Register (CRR):

There is one new risk on the CRR. This risk is being reported to the Governing Body as it has been captured on the CCG risk registers with a score of 16. However prior to reporting this risk to the Governing Body it has been mitigated as the facility in question now has a full CQC registration and all planned actions have been completed. Therefore the following risk is now closed:

There is a risk that as the previous organisation (Spiral Health CIC) no longer exists, the new organisation (Springfield Manor Gardens ltd) is undertaking regulated activity without CQC registration due to the CQC application awaiting approval. This will leave the organisation without a CQC registration for a period of time.

There is also one ongoing risk on the CRR regarding Referral to Treatment times as follows (the update to this risk are highlighted in red text):

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

The full risk assessments for all corporate risks are included in this paper.

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

Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out of hospital provision

Governing Body Assurance Framework Update and Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 35 SO3 Be an integral part of a financially sustainable health economy ☒ SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒

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

NA

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

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

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

Governing Body Assurance Framework Update and Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 36 Appendix B : Risk Matrix

Quantitative Measure of Risk – Consequence Score

Consequence score (severity levels) and examples of descriptors

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

An event which impacts on a small number of patients

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

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

CCG Risk Scoring Matrix NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019 Page 37 Statutory duty/ No or minimal Breech of statutory Single breech in Enforcement action Multiple breeches in inspections impact or breech legislation statutory duty statutory duty of guidance/ Multiple breeches in statutory duty Reduced Challenging statutory duty Prosecution performance rating external if unresolved recommendations/ Improvement Complete systems improvement notice notices change required

Low performance Zero performance rating rating

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

Qualitative measure of risk – Likelihood score

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

CCG Risk Scoring Matrix NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019 Page 38

Quantification of the Risk – Risk score

Likelihood

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

CCG Risk Scoring Matrix NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019 Page 39

GBAF-01 - Quality, Safe and Effective Risk owner Next review date Current status Current trend Services Helen Curtis 30.04.2019

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

High Tolerance Low Confidence = Do not expend High Tolerance High Confidence = Take a balanced significant effort developing mitigations approach to how we expend effort developing mitigations Low Tolerance Low Confidence = Earliest possible Low Tolerance High Confidence = Always take all actions required to prevent risk rising available actions to mitigate risk Page 40 Page

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

Original risk Current risk Target risk

Impact Likelihood Rating Impact Likelihood Rating Impact Likelihood Rating

4 3 12 4 4 16 4 2 8

Existing assurance Existing controls Gaps in assurance Gaps in controls

Quality Accounts from Integrated Business Plan in ICP Performance Dashboard LTH CQC report published Providers are in line with the place which has been to be established to 17.10.18 with a continued regulations published by approved by Governing Body implement system wide rating of 'requires Department of Health & encompassing schemes which reporting and monitoring improvement'. Improvement Social Care will deliver better patient and support delivery of action plan needs to be experience, meet constitutional constitutional standards delivered. targets and financial across the patch. trajectories Action to address: A6 Action to address: A1 Care Quality Commission Integrated Performance and Efficacy of LTH recovery plan (CQC) inspection reports for all Improvement Group in place to can not be evidenced until providers have provided monitor Integrated Board completion and subsequent assurance on what is and is Report and organise onward CQC assessment not working well. Also reporting to Quality and establishment of an Performance Committee and Action to address: A9 Page 41 Page

GBAF01 NHS Chorley and South Ribble CCG Governing Body meeting 28 March 2019

Improvement Board following Governing Body latest inspection of Lancashire Teaching Hospitals (LTH) to monitor progress against CQC action plans. Patient experience data as Enhanced PMO function measured by friends and following successful family test informs what is recruitment to Senior and is not working well from Programme Manager role to patient perspective. ensure robust management of Integrated Business Plan Trend analysis from complaints Development of internal provides assurance on quality escalation process to raise to Quality and Performance awareness of performance Committee issues to ensure early actions are identified Annual review of compliance Serious Incident Review Group against the safeguarding to assess for improvements assurance framework to when serious incidents have ensure compliance taken place. Serious incidents are not closed down until the CCG receives confirmation from the Provider that all actions within action plan have been completed. Where themes are identified thematic reviews take place at the Quality and Performance Committee Health Watch local intelligence reports which are publically available provide external Page 42 Page GBAF01 NHS Chorley and South Ribble CCG Governing Body meeting

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assurance on key quality measures Safeguarding Toolkit in place for all providers provides assurance on a range of safeguarding quality standards. Right Care packs give Quality and Performance benchmarking information Committee monitor outcomes across the full clinical pathway and performance measures from referral to mortality, against the NHS Outcomes therefore providing more Framework and standards to outcome based information, as drive improvement, Provider opposed to just performance dashboards, CQUINS which based data (A4) are also built into contracts for Providers, effectiveness, advancing quality, mortality rates, schemes within the Integrated Business Plan and benchmarking All Acute providers, GP Provider recovery plans in practices and Care Homes place where constitutional have been Care Quality targets are not being met to Commission (CQC) assessed ensure a plan towards (A3). Inspection reports have delivery provided assurance on what is and is not working well LTH quality risk profile Primary Care Quality Contract completed (A2) which has in place to ensure key quality provided a baseline measures are monitored and assessment against Quality delivered

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and Safety standards

Results of NHS England’s A&E Delivery Board Sub Improvement and Group in place to review Assessment Framework outputs of Value Stream gave an overall CCG rating Analaysis workstreams and of ‘good’ associated risks, which are reported to A&E Delivery Board ‘Deep dive’ review presented Health economy wide to the Audit Committee in collaborative in relation to March 2019 to provide harm free care, i.e. falls, React assurance on progress of to Red, Care Homes to this risk towards mitigation identify themes and implement prevention methods. Health economy wide C Difficile review panel to identify themes and implement prevention methods. Quality Surveillance Group will identify themes and implement prevention methods. Contract performance notices allow CCG to hold providers to account (A5) Quality & Performance Committee members gained updates both in terms of

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progress and plan to move LTH towards a CQC rating of 'good' (A7).

Action plan

Action Due date Assigned to Latest update Status

A1. Through the delivery 31.01.2019 Helen Curtis / Sarah 06.12.2018: In Open – current gap in of the shadow James Progress; There is now assurance Integrated Care an indication of the Partnership (ICP) agree contents of the arrangements for performance dashboard holding account for from ICS colleagues delivery of constitutional and work has targets commenced towards bringing this to the ICP Board in January. 08.02.19 In progress; A discussion paper was debated first at the ICP Senior Leaders meeting (21.01.19), and then at the ICP Board meeting on 28.01.19, through which the Board agreed some principles for system

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reporting. The proposal is being refined and it is hoped that these arrangements will be part of ICP Board Business from March 2019. A2. Baseline 30.11.2018 Helen Curtis 17.07.2018: In progress Closed – now an assessment against 30.08.2018: In progress assurance mechanism Quality and Safety 07.09.2018: Complete utilising Quality Risk for LCFT, LTH due Profile tool 13.09.2018 17.10.2018: LTH quality risk profile completed and submitted to Quality Improvement Board. A3. Monitor that CQC 30.11.2018 Helen Curtis 30.08.2018: All Acute Closed - now an assessments have providers, GP practices assurance mechanism taken place for all acute and Care Homes have providers, care homes now been CQC and GP practices assessed. A4. CCG to receive 30.08.2018 Helen Curtis 30.08.2018: CCG Closed - now an Right Care packs which receiving and utilising assurance mechanism give benchmarking this Right Care information across the information full clinical pathway from referral to mortality, therefore providing more outcome based information

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A5. CCG to utilise 30.08.2018 Helen Curtis 30.08.2018: Contract Closed – now a control contract performance performance notice mechanism notice process to hold process is in place and providers to account utilised to hold providers to account A6. Closely monitor LTH 31.03.2019 Helen Curtis 07.09.2018: Contract Open – current gap in recovery plan and notice in place and control escalate any concerns recovery plan received. with delivery The specialty level trajectory is being reviewed. 17.10.2018: Being monitored at fortnightly Referral To Treatment (RTT) steering group and then submitted to NHS England (NHSE)/NHS Improvement (NHSI) 09.01.2019: NHSE/NHSI System call took place on 11.12.2018 with CCG Accountable Officer and Acute Trust Chief Executive. The focus of this call was RTT, 52 week waiters, cancer and AED performance. Action due date extended from 31.12.2018 to

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31.03.2019 to reflect the target to deliver zero 52 week waiters and no more open pathways by end of March 2019 compared to 2018. 08.02.2019: A separate risk is on the Corporate Risk Register to manage the risks to the CCG regarding RTT and these will be reported to each Governing Body meeting until the risk rating reduces. A full action plan is in place on this risk assessment to mitigate the risk. Action to remain open on the GBAF until the corporate risk rating reduces to <15. A7. The CQC report 31.12.2018 Helen Curtis 15.11.2018: Closed – current published Nov 2018 Presentation arranged control mechanism reported an for QPC meeting in improvement in a December. In addition number of directorates, the Improvement Board however the Accident & will continue to run and Emergency Department the terms of reference and the Medical Division for this are under

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remain of concern. LTH review. to attend the CCGs 09.01.2019: LTH Quality & Performance attended the QPC Committee (QPC) in 05.12.18. Committee December to present members gained the CQC report and updates both in terms of corresponding action progress and plan to plan. move the organisation towards a rating of 'good'. This will be reported to the Governing Body in January. The CCG will continue to receive updates on the progress of this plan until subsequent CQC assessment. A8. Complete full 31.03.2019 Helen Curtis 08.02.2019 risk Closed separate risk assessment has been assessment of the completed, has been risks resulting from discussed at MET Springfield Manor 20.02.2019, Audit Gardens awaiting CQC Committee 01.03.2019 registration and report and will be presented this to the Governing to the Governing Body Body 27th & 28th March 2019. 07.03.2019 SMG now has full CQC registration therefore this is no longer a risk. All quality issues

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continue to be monitored by CCG chief nurse and will be escalated as needed. A9. Await CQC re- 31.12.2019 Helen Curtis 06.03.2019 action plan Open – current gap in assessment of both continues to progress, assurance providers to gain no date yet confirmed assurance that the for re-inspection. recovery action plan has addressed all concerns Progress

17.07.2018: New GBAF for 2018-19. Risk score 12. Existing assurance and controls established, gaps identified. Mitigations in place to address gaps. 30.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 07.09.2018: Risk reviewed following feedback from Quality and Performance Committee. An additional gap in assurance has been added regarding the recovery plan from LTH and an associated action has been added to mitigate this (A6). Progress updates have been added against actions A1, A2 & A3. 17.10.2018: Risk reviewed and action plan updated. Additional assurance added re LTH risk profiling. 15.11.2018: Risk reviewed following Audit Committee and Quality and Performance Committee - the completed actions have been mapped to the current controls and assurances (A2,A3,A4&A5). The risk rating has been increased from 4x3=12 to 4x4=16 resulting in this becoming 'high' risk. A new gap in assurance has been added regarding the release of a CQC report in Nov 2018 which showed a continued rating of 'requires improvement', this is linked to action A7. A new gap in control has been added regarding the need to establish an ICP performance dashboard which is linked to action A1. 06.12.2018: Risk reviewed and action plan updated. No changes to scoring or gaps. 08.02.2019: Risk reviewed. There are two key elements to this risk now which are RTT performance and the CQC registration of Springfield Manor Gardens (SMG). Separate operational risk assessments have been completed for these two areas and both feature on the Corporate Risk Register to manage the operational detail. These operational risks threaten this strategic objective so will therefore continue to be reported via the GBAF also.

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07.03.2019: Risk reviewed following Audit Committee and Quality and Performance Committee. All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation. The SMG action has now been closed as this facility now has full CQC status.

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GBAF-02 - Financial Sustainability Risk owner Next review date Current status Current trend Matt Gaunt 30.04.2019

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

High Tolerance Low Confidence = Do not expend High Tolerance High Confidence = Take a balanced significant effort developing mitigations approach to how we expend effort developing mitigations Low Tolerance Low Confidence = Earliest possible Low Tolerance High Confidence = Always take all actions required to prevent risk rising available actions to mitigate risk Page 52 Page GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

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

Original risk Current risk Target risk

Impact Likelihoo Ratin Impact Likelihoo Rating Impact Likelihoo Rating d g d d 3 3 9 3 1 3 3 2 6

Existing assurance Existing controls Gaps in assurance Gaps in controls

Grant Thornton have confirmed Clear Governance Lancashire Teaching Hospital Lack of robust process for through the Value for Money and decision represents the CCGs principle financial estimates of scheme conclusion that the CCG has proper making process, is partner, has a £46m deficit target delivery to ensure no over arrangements to secure economy, in place with clear in 2018/19 and has failed to agree estimates are made which efficiency and effectiveness. financial a control total with its regulator. leads to under delivery of delegations to The CCG has limited assurance QIPP tagert needed to achieve ensure regulation that the financial strategy pursued financial balance. of financial by the Trust will not adversely matters. impact on the CCG financial Action to address: A4 & A5 position.

Action to address: A1 NHS England have assured the CCG The CCG has as 'green' for financial arrangements agreed a financial through the CCG improvement and budget which Page 53 Page

GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

assessment framework (CCG IAF). delivers a break even position in 2018/19 which will enable the CCG to meet the NHS England financial delivery target for the CCG. Head of Internal Audit Opinion is that Financial forecasts the Governing Body can take are prepared substantial assurance that there is a quarterly and good system of internal control included within designed to meet the organisations regular reported objectives, and that controls are updates to the generally being applied consistently. CCG Governing Body to ensure Board oversight and early warning of financial position. In addition a monthly review of financial risks and opportunities supplements the quarterly forecasting review to ensure early identification of threats to delivery and associated mitigating P

age 54 age

GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

actions.

Deep dive review presented to the The CCG has a Audit Committee in January 2019 well established to provide assurance on progress programme of this risk towards mitigation management process to ensure that financial improvement and transformation schemes are properly resourced and managers and clinicians involved in their delivery are held to account to ensure the CCG meets its QIPP target. This has been strengthened through the recruitment of clinical advisors to supplement GP Director capacity. The financial position is reported bi-monthly to the Governing Body, and every month to the Quality and

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GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Committee to ensure Committee and Board oversight and early warning of financial position. ICP finance workshop taken place to agree ways to link all providers into the ICP finance plan which has improved visibility of susatinability issues The role of the Primary Care Commissioning Committee (previously Delegated Commissioning Committee (DCC)) has been strengthened with updated terms of reference which now clarify the remit of the committee and Page 56 Page

GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

include a wider role in signing off Primary Care investment proposals and strategy to ensure such proposals are future proof and support financial sustainability. (A2) Identified £0.5 million underspend in ICS pooled funds which will bridge the remaining gap (A6). Action plan

Action Due date Assigned to Latest update Status

A1. The CCG Chief Finance 31.03.2019 Matt Gaunt 17.07.2018: In progress Open – current gap in Officer (CFO) to work with LTH 29.08.2018: An ICP assurance Director of Finance (DOF) workshop has been through the Central Lancashire organised for 25th ICP to provide assurance that September and will be the ICP, CCG and Trust attended by the DOF for Leadership is aware of the both LTH and financial consequences of LTH Lancashire Care Page 57 Page GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

financial recovery strategy. Foundation Trust (LCFT)to agree ways to link into the ICP. 19.10.2018: ICP finance workshop took place 08.10.2018 to agree ways to link all providers into the ICP finance plan 06.12.2018: Action due date extended from 30.09.18 to 31.03.19 as this is ongoing work. The CCG CFO and Trust DOF have agreed the principles and are in the process of agreeing a final contract payment value for this financial year. 09.02.2019: In progress, status remains as last reported, aiming for completion 31.3.19 A2. A revised terms of 03.10.2018 Matt Gaunt 17.07.2018: In progress Closed – Now a control reference (TOR) will be 29.08.2018: Revised mechanism prepared for the DCC and TOR will be submitted to additional financial information DCC in October for will be provided to better inform approval. investment decisions. 19.10.2018: Revised TOR approved by DCC and will be submitted to

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GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Governing Body for ratification in November 06.12.2018: TOR ratified by Governing Body A3. Apply to ICS for 0.5% 01.10.2018 Matt Gaunt 06.09.2018: Process for Closed – Now that reserve monies this application of funds action A6 is complete has started. this is a control 19.10.2018: CFO has mechanism written to Director of Finance at NHSE Lancashire confirming that 0.5% reserve is required to meet CCG financial targets. This has still left the CCG with a gap - action A6 has been added to address this. A4. Review process for 31.03.2019 Matt Gaunt 06.09.2018: This will be Open – current gap in financial estimates of scheme built into the integrated control delivery to ensure no over business plan 2019/20 estimates going forward planning process. 19.10.2018: Status as above, action to remain open until the 2019/20 is approved. 06.12.2018: Status as above, action to remain open until the 2019/20 is approved. This is currently in draft form. 09.02.2019: action due

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GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

date extended from 30.11.2018 to 31.03.2019 as this action will be completed when the new operational plan is in place A5. Review planning process to 31.03.2019 Matt Gaunt 06.09.2018: Quality Open - current gap in ensure that cost saving checks will be built into control schemes that require a the contract planning contractual mechanism to process to ensure that if support delivery is built into required appropriate planning process. mechanisms are built into contracts. 19.10.2018: Status as above, action to remain open until the 2019/20 is approved. 06.12.2018: Status as above, action to remain open until the 2019/20 is approved. This is currently in draft form. 09.02.2019: action due date extended from 30.11.2018 to 31.03.2019 as this action will be completed when the new operational plan is in place

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GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

A6. CFO to engage system 31.12.2018 Matt Gaunt 14.11.2018: CFO has Closed – now a leaders at NHS England and organised to meet NHSE control mechanism the ICS to present a case for Director of Finance. additional ICS funds to bridge 06.12.2018: Agreement the gap in risk monies on further £250K from the ICS to the CCG to bridge the gap. A resolution for another £500k has been found. Remaining gap will be closed by review of accounts. Net risk position remains £0.8million. 09.02.2019: identified £0.5 million underspend in ICS pooled funds which will bridge the remaining gap. Progress

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GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

17.07.2018: New GBAF risk 2018-19. Risk score 9. Existing assurance and controls established, gaps identified and mitigating actions in place to address the gaps. 29.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 06.09.2018: 07.09.2018: Risk reviewed following feedback from Quality and Performance Committee. Target risk rating impact reduced from 4 to 3 to be in line with original and current risk rating. Gap in control added re QIPP gap. Gap in assurance added re securing mitigation monies. Current risk rating likelihood increased from 3 to 4 due to these gaps identified. Actions added re QIPP gap & securing mitigation monies (A3, A4, A5) 19.10.2018: Risk reviewed and action plan updated. QIPP target amended from £4.5 million to £2.7 million 14.11.2018: Risk reviewed following Audit Committee and Quality & Performance Committee - the completed actions have been mapped to the current controls and assurances (A1). The risk score has increased from 3x4=12 to 4x4=16 resulting in this becoming 'high' risk. This is due to the risk associated to achieving financial balance as a result of the reserve monies received being £1.8 million as opposed to the £2.5 million requested due to some funds being committed to addressing system risks, this is linked to action A6. 06.12.2018: Risk reviewed and action plan updated. No changes to scoring or gaps. 09.02.2019: Risk reviewed. Risk rating reduced from 4x4=16 to 3x1=3 as mitigation is now in place to bridge the financial gap. Target rating of 3x2=6 has been met and impact scores are in line with what was predicted at the start of the financial year. 06.03.2019: Risk reviewed following Audit Committee and Quality and Performance Committee. All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation.

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GBAF-02 – Financial Sustainability NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

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

Denis Gizzi 30.04.2019

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

High Tolerance Low Confidence = Do not expend High Tolerance High Confidence = Take a balanced significant effort developing mitigations approach to how we expend effort developing mitigations Low Tolerance Low Confidence = Earliest possible Low Tolerance High Confidence = Always take all actions required to prevent risk rising available actions to mitigate risk Page 63 Page GBAF-03 – Well Led NHS Chorley and South Ribble CCG Governing Body meeting

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

Original risk Current risk Target risk

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

Existing assurance Existing controls Gaps in assurance Gaps in controls

NHS England have assured the The CCG has The CCG staff are not clear how their Clinical leadership role remains CCG as 'good' through the initiated the creation role and objectives are aligned with unfilled; Chorley and South Ribble CCG improvement and of an Integrated the ICP agenda, and their particular CCG running with one GP Director assessment framework (CCG Care Partnership skill sets are used to best effect. vacancy. IAF), with quality of leadership and the ICP Board rated as 'green'. has agreed terms of Action to address: A4 Action to address: CCG reference , currently running with a governance process vacancy, any change in this and started to agree regard will be reflected on the priorities. This action plan evidences that the CCG is progressing system wide transformation Page 64 Page GBAF-03 – Well Led NHS Chorley and South Ribble CCG Governing Body meeting

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which is vital to lead the organistion into a sustainable health economy. Assurance has been The CCG identified with strong staff leadership team engagement, with the annual has well defined staff survey evidencing that objectives and the 87% feel they are equipped to resources in place do their job effectively. The to deliver them. possitive feedback from the Clinical leadership staff survery provides has been assurance that leadership is strengthened strong as the staff morale is through the relatively high. recruitment of GP advisors. 'Deep dive' presentation has All committee terms been made against this risk to of reference have the Audit Committee in been reviewed to September 2018 to provide ensure all are fit assurance on progress of for purpose and this risk towards mitigation able to deliver CCG business which will enable the organisation to evidence that it is well led . CCG assessment framework Mandatory training moved from 'requires package is in improvement' to 'good' in place for all staff several areas and monitored to Page 65 Page GBAF-03 – Well Led NHS Chorley and South Ribble CCG Governing Body meeting

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

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

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time of transformational change (A1) Updated Primary Care Commissioning Committee TOR in place with a new section to clarify the responsibilities the committee is to take with regards to primary care proposals and strategy (A2) Greater Preston CCG new GP Director started in role Jan 2019 leaving no clinical leadership vancancies in Greater Preston (A3)

OHOC Joint Committee established to facilitate a jointly lead sustainable secondary care programme that is Page 68 Page GBAF-03 – Well Led NHS Chorley and South Ribble CCG Governing Body meeting

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aligned to the Lancashire and South Cumbria Integrated Care System acute reconfiguration programme. (A6) OHOC risk register in place to mitigate the risks identified to the delivery of the OHOC programme (A5) Action plan

Action Due date Assigned to Latest update Status

A1. The CCG executive 31.08.2018 Jayne Mellor/ Matt Gaunt/ 17.07.2018: In progress Closed – now a control team are running a one Helen Curtis 30.08.2018: Staff mechanism day development session development session with all staff to bring taken place, further staff together ICS, ICP and engagement work to now CCG business objectives be undertaken. and to align skills to business need. This will inform a reset of individual and team objectives aligned to ICP/ICS deliverables

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A2. Quality and 30.11.2018 Matt Gaunt/Helen Curtis 17.07.2018: In progress Closed – now a control Performance Committee 30.08.2018: Reviews of mechanism and Delegated TORs in progress - DCC commissioning revised TOR will be Committee Terms Of submitted to the committee Reference (TOR) under in October for approval, review and subsequent ratification by the Governing Body in November. 19.10.2018: DCC TOR have been approved by DCC and will be submitted to Governing Body in November for ratification. Q&P TOR are being drafted for the next meeting and will be submitted to a subsequent Governing Body. 06.12.2018: Revised DCC TOR have been ratified by both Governing Bodies 28th & 29th Nov. QPC will be submitted to the committee and Governing Body for approval at a future date. 06.02.2019 Ongoing - a full terms of reference review will be reported to the Governing Body in May 2019

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06.03.2019 Complete – updated Quality and Performance Committee terms of reference have been approved by the committee and submitted to the Governing Body for ratification in March 2019. A3. Election of qualified 31.10.2018 Matt Gaunt 17.07.2018: In progress Closed – now a control GPs from the 30.08.2018: Expressions mechanism membership to GP of interest for both roles director vacancies will be closes 31.08.2018. completed. 07.09.2018: Expressions of interest have now been extended to 21.09.2018 due to insufficient submissions. 19.10.2018: Election closed 18.10.18, membership ratification of the process is taking place until 25.10.18, after which arrangements can be made for terms of office to begin. 15.11.2018: The election has now been ratified, HR work to be completed to issue offer letter and contract.

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06.12.2018 Chorley and South Ribble CCG running with one GP Director vacancy, the other post holder has commenced their third term of office. Greater Preston CCG new GP Director due to start Jan 2019. 08.02.2019 Greater Preston GP Director now in post leaving no vacancies. However a GP Director vacancy remains in Chorley & South Ribble CCG. A4. Scope staff 30.11.2018 Denis Gizzi 30.08.2018: In progress Open – current gap in engagement materials 07.09.2018: This work is assurance from local organisations underway, 'job1/job2' to implement a 'job1/job2' approach shared with staff approach at Team Brief in August. 19.10.2018: A further staff development session is being planned to bring together ICS, ICP and CCG business objectives and build on the 'job1/2 approach'. 06.12.2018: Staff away day planned for 13.02.2019 06.02.2019: Ongoing –

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awaiting outcome of staff away day 13.02.2019, feedback is currently being collated via survey monkey

A5. Develop a risk 31.01.2019 Denis Gizzi 06.12.2018: Draft risk Closed – now a control register to manage the register presented to mechanism risks to the OHOC OHOC Executive programme Oversight Group 05.11.2018, further amendments being made to finalise. Risk Register will be presented to the first Programme Oversight Group meeting once established 06.02.2019 Complete. Risk register now in place and held by the OHOC team. A6. Establish the OHOC 13.12.2018 Denis Gizzi 06.12.2018: TOR for the Closed – now a control Joint Committee to enable joint committee have been mechanism the CCGs to make approved by both decisions to progress the Governing Bodies. First OHOC programme meeting scheduled for 13.12.2018 06.02.2019 Complete committee is now established and held its first meeting 13.12.2018.

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Progress

17.07.2018: New GBAF risk 2018-19. Risk score 12. Existing assurance and controls established, gaps identified and mitigating actions in place to address the gaps. 30.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 07.09.2018: Risk updated following Audit Committee to include the deep dive presentation made. Progress updates have also been added against all actions. 19.10.2018: Risk reviewed and action plan updated. No change to risk scoring or associated gaps. 15.11.2018: Risk reviewed following Audit Committee - the completed actions have been mapped to the current controls and assurances (A1). 06.12.2018: Risk reviewed and action plan updated. Additional detail has been added to the risk regarding the progress of the OHOC programme. 06.02.2019: Risk reviewed and action plan updated. Risk rating remains 4x3=12. The target rating for this risk was set as 4x2=8 at the start of the financial year, since then the OHOC programme has gathered pace and therefore the current risk rating is 12. When the target risk ratings are refreshed in the 2019/20 GBAF the target risk score for this risk would increase. 06.03.2019: Risk reviewed following Audit Committee. The committee identified that the risk rating for this risk should be reviewed as the mitigation in place may reduce the risk scoring – particularly with regards to actions related to the OHOC programme. As there is a joint committee in place to facilitate robust decision making, regular development sessions have taken place with Governing Body members to engage them in the programme, and with a risk register in place to mitigate threats to the delivery of the programme, the risk score has been reduced from 4x3=12 to 4x2=8 meeting the target score for this risk. All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation.

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GBAF-04 - Service Transformation Risk owner Next review date Current status Current trend Jayne Mellor 30.04.2019

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

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

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

Original risk Current risk Target risk

Impact Likelihood Rating Impact Likelihood Rating Impact Likelihood Rating

4 2 8 4 2 8 4 2 8

Existing assurance Existing controls Gaps in assurance Gaps in controls

Link with the Integrated Board Milestones and key processes Lack of defined commissioning Report (IBR) is now in place have been set for the ICP to responsibilities between ICS which triangulates enable us to produce plans and ICP information relating to plan, which have been supported by performance and finance to all partners (Out of Hospital Action to address: A5 give overall picture of delivery and Urgent and Emergency of integrated business plan Care) and are therefore which is a key contributror appropriate for delivery to system transformation across the patch A 'deep dive' presentation has ICP Programme Board in place been made against this risk to to support delivery. ToR the Audit Committee in agreed with appropriate November 2018 to provide representation from partners assurance on progress of including Primary Care to this risk towards mitigation ensure system wide Page 76 Page

GBAF-04 – Service Transformation NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

representation and oversight

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

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GBAF-04 – Service Transformation NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

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

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A&E Delivery Board in place to oversee system stability. Associated sub group is in place with Programme Management Office support to review outputs of Value Stream Analaysis workstreams and associated risks, which are reported to A&E Delivery Board ICP representation on all ICS Commissioning Development Work streams to ensure that central lancashire transformation developments are in line with Lancashire and South Cumbria. Performance measures with targets for improvement for all schemes on all plans to monitor delivery Commissioning programme support in place to work and support ICS Director of Commissioning - to define process for agreeing commissioning framework at ICS/ICP level. (A2) Head of Primary Care and Head of Urgent Care now linked in to ICS commissioning Page 79 Page GBAF-04 – Service Transformation NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

framework, which will help to alleviate the lack of defined commissioning responsibilities between ICS and ICP Scheduled engagement events have now been completed to ensure system wide contribution to transformation (A1) Primary Care transformation is progressing with all practices now signed up to 7 day access and the establishment of integrated care teams Wellbeing and Health in Integrated Neighbourhoods (WHIN) Board in place to oversee this strategic platform of the ICP with a detailed driver diagram and associated action plan approved. Published 10 year plan to enable the CCG to form long term transformation plans (A3) Out of hospital and Acute reconfiguration programme groups established which will report to a Joint Clinical Oversight Group (COG) to oversee acute sustainability Page 80 Page GBAF-04 – Service Transformation NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

and new models of care (A4)

Action plan

Action Due date Assigned to Latest update Status

A1. Outcome of 30.11.2018 Jayne Mellor 17.07.2018: In progress Closed – Now a engagement events 06.09.2018: control mechanism regarding acute Engagement events sustainability and new scheduled for models of care to be 18/09/2018, 19/09/2018 taken through local and 20/09/2018 governance structure 10.10.2018: Scheduled engagement events have now been completed and feedback is being linked into the OHOC programme. A2. Appoint 30.08.2018 Jayne Mellor 30.08.2018: Post in Closed - Now a control commissioning place mechanism programme support from CSU to work and support ICS Director of Commissioning - to define process for agreeing commissioning framework at ICS/ICP level. A3. Await NHS 10 year 31.01.2019 Jayne Mellor 30.08.2018: In progress Closed - Now a plan which should 06.09.2018: 2019/20 control mechanism

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determine place based planning work has commissioning started, 10 year plan is expected to be released in November 2018 when this can be incorporated into the 2019/20 planning. 10.10.2018: 10 year plan is still awaited - however the early indications which have been released have been crossed referenced into local strategy. 06.12.2018: 10 year plan and guidance which was expected early December has been delayed. A meeting is being held 11.12.18 which is a clinical decision group of the ICS whereby the commissioning frameworks will be presented for consideration. Action due date extended from 30.11.18 to 31.01.19 to allow for the 10 year plan to be published.

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27 March 2019

15.02.19: 10 year plan has now been published along with a GP 5 year reform and guidance. This has been incroporated into the CCG transformational plan which will report into the Wellbeing and Health in Integrated Neighbourhoods (WHIN) Board, Clinical Oversight Group (COG) and ICP. The GBAF for 2019/20 will need to incorporate the outputs from the 10 year plan. A4. Establish out of 30.11.2018 Jayne Mellor 10.10.2018: Groups are Closed - Now a hospital and Acute in the process of being control mechanism reconfiguration established - the COG programme groups will be clinically led by which will report to a the Medical Director of Joint Clinical Oversight the OHOC programme Group (COG) to and the GP for primary oversee acute care from each CCG. sustainability and new 06.12.2018: Awaiting models of care confirmation of first meeting date and draft TORs. ICP platform brief which relates to out

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of hospital strategy (WHIN) is being presented to ICP Shadow Board on 13.12.2018 which will approve the governance arrangements. 15.02.19: WHIN Board in place which first met on 8th Feb and has cross organisational representatives. Terms of Reference for this are also in place. A5. ICP Board to 31.01.2019 Denis Gizzi 02.11.2018: Strategy Open – Current gap in develop an integrated being worked up assurance strategic plan 06.12.2018: Integrated Care Strategy is being reviewed following comments from partners and due to go back to ICP Board in January for approval. 15.02.19: work in progress Progress

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17.07.2018: New GBAF for 2018-19. Risk transferred over from last year and existing assurance and controls and gaps aligned to new risk description. Risk score 8. Actions determined to address gaps. 30.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 06.09.2018: Risk reviewed following feedback from Quality and Performance Committee. The risk description has been amended to be clear of it’s' remit. The following action has been removed as this is not directly part of this risk: 'JCCCG to review and agree recommendations from commissioning development work streams to establish commissioning responsibilities for ICS and ICP going forward'. Progress updates have been added against actions A1 and A4. 10.10.2018: Risk reviewed, additional controls added regarding CCG links into the ICS and engagement events taking place, and additional action added regarding programme groups being established. This risk will be the topic for the next audit committee GBAF deep dive. 02.11.2018: Risk reviewed following Audit Committee - the completed actions have been mapped to the current controls and assurances. Further detail has been added to the risk description, additional control added regarding the progress of primary care transformation, additional gap in control added regarding receipt and implementation of the 10 year plan. 06.12.2018: Risk reviewed and action plan updated. No changes to scoring or gaps. Once the 10 year plan is received and digested the action plan for this risk can be expanded. 15.02.2019: Risk reviewed and action plan updated. Risk has met target risk rating. The 10 year plan has now been released and the CCG pre-empted plans are in line with this. The 5 year plan indicates that the national requirements by 2021 are primary care network developments, commissioning of extended access services and care homes; all of which are already established in CCG plans. The GBAF for 2019/20 will need to incorporate the outputs from the 10 year plan and the commissioning responsibilities between ICS and ICP. 06.03.2019: Risk reviewed following Audit Committee. All controls and assurances have been reviewed to ensure that these are reported accurately and explain their role in mitigating/controlling the risk. The action plan has also been made more explicit to illustrate how actions link to gaps or current mitigation.

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GBAF-04 – Service Transformation NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Corporate Risk Register

Risk Owner Next Review Date Current RAG Status Direction of Travel

Helen Curtis 31-Mar-2019

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

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

Existing Assurance Existing Controls Gaps in Assurance Gaps in Controls 36+ week file received on Recovery action plan Awaiting outcome Lack of defined a weekly basis from LTH of ‘Four eyes’ measures which provides detailed Contractual framework – contract review into particularly insight into movement on performance notice in place theatre utilisation around waiting lists and an (A1) efficiency, for indication of RTT delivery Demand management schemes example theatre utilisation, and

Weekly Patient Tracking Deep dive analysis into referrals clinic start times List which provides a view and activity (A2) on the number of open pathways Fortnightly steering group ENT consultant meetings with LTH has been absent Root Cause Analysis which may have completed for every Monthly operational and contract an impact on patient who breaches 52 Board meetings ENT 52 week weeks, to date there has breaches (A4) been no evidence of harm Integrated Board Report which identified provides oversight of RTT Approximately trajectories and mitigating actions an additional 4000 open

Weekly Management Executive pathways have Team report tracking open been identified pathways from the IMSK service which

RTT position presented weekly to may affect the ‘Integrated Business Plan year end position Weekly Update Meeting’ (A5)

Remedial Action Plan in place (A3)

Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 86

Action Due Date Assigned To Latest Update Status 14.12.18 Four eyes work on going and report not yet complete 06.02.19 Four eyes A1. Receive outcome of work still ongoing In Progress – ‘Four eyes’ review into 31/3/19 Glenn Mather and not yet current gap in theatre utilisation complete, action assurance due date extended from 31/12/18 to 31/3/19 to allow for work to be completed. 14.12.18 Links to the above. Agreed at RTT steering group that Four A2. Agree efficiency eyes metrics will be measures with LTH in used to review order to instil oversight Glenn Mather efficiencies once In Progress – 14/04/19 and scrutiny of available current gap in efficiency of elective 06.02.19 Links to control services the above, action due date extended to allow for Four Eyes work to be completed. 14.12.18 This is a live document. An updated version was circulated last week and there will be further revisions following the RTT steering group

A3. Receive updated meeting next week. Complete – now a 30/11/18 Remedial Action Plan Update suggested control Glenn Mather that most mechanism specialities are on track against trajectory. ENT, Ophthalmology and Oral Surgery are specialties that are struggling to meet

Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 87 trajectory. Action to close as this has now been received and will continue to be submitted to the CCG. If any future versions prompt any further action this will be added to the risk. 06.02.18 action plan is in place and has been received by the CCG and will continue to be monitored. There are some specialty specific risks within this action plan, therefore a new action has been added regarding this. 06.02.19 ENT consultant currently absent who was due to see some patients approaching 52 week wait. All Glenn Mather patients have been offered an

appointment with In Progress – A4. Review Remedial another consultant, 28/02/2019 current gap in Action Plan however some control patients wanted to wait for current consultant to return which will impact on 52 week breaches. 15.03.19 ENT consultant has returned but reviewing impact on 52 week breaches. 06.02.19 liaising A5. Determine if the with NHSE to IMSK open pathways Glenn Mather determine this In Progress - will affect the year 28/02/2019 15.03.19 current gap in end position Conference call control with NHSE currently looking to

Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 88 resubmit data to allow for the inclusion of historical pathways

Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 89 The following risk is being reported to the Governing Body as it has been captured on the CCG risk registers with a score of 16. However prior to reporting this risk to the Governing Body it has been mitigated as the facility in question now has a full CQC registration and all planned actions have been completed. Therefore the following risk is now closed.

Corporate Risk Register

Risk Owner Next Review Date Current RAG Status Direction of Travel

Helen Curtis 31-Mar-2019

Risk Description There is a risk that as the previous organisation (Spiral Health CIC) no longer exists, the new organisation (Springfield Manor Gardens ltd) is undertaking regulated activity without CQC registration due to the CQC application awaiting approval. This will leave the organisation without a CQC registration for a period of time.

Original Risk Current Risk Target Risk Impact Likelihood Rating Impact Likelihood Rating Impact Likelihood Rating Target Date 4 4 16 4 4 16 4 1 4 31-03-2019

Existing Assurance Existing Controls Gaps in Assurance Gaps in Controls Multi agency approach to Voluntary suspension was support Springfield Manor supported on 14/12/18 to reduce the Gardens. number of beds by 4 to allow time for quality improvements and restrict Joint approach between the unit to two admissions per day to home and CCG to facilitate safe admission onto the development of action plan. Primrose suite.

Review of service Enhanced oversight - multi agency specification and admission meeting involving CQC, CCG, LCC, criteria Safeguarding and Springfield Manor Gardens taken place 16th November CQC registration confirmed 2018. (A1 & A3) Decision to suspend the intermediate care provision on the 18/01/19 due to multifactorial concerns and limited improvements made. The suspension means there are no admissions to the unit (currently 12 patients on unit on the 24 bedded unit).

Until CQC registration is confirmed, there is a suspension of admissions across all care provision.

Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 90 Following report of a further three safeguarding incidents on the 04/02/19, urgent multiagency meeting scheduled by CCG Lead Nurse on 06/02/19. Attendance from CQC, Lancashire Constabulary, CCG Quality and Safeguarding teams and LCC to determine next steps. Agreed suspension of all admissions to the provider until CQC registration status confirmed.

A QPIP is now being arranged which will be chaired by the CCG by which all quality improvement will be monitored by multi agency partners and the provider. This will run alongside the Rapid Action Plan (RAP) meeting which will lead on the safeguarding alerts.

Reviews will commence for all residents. CHC team will be informed along with CATCH to ensure no further admissions take place and all MDT's and arrangements for packages of care take priority on the primrose unit.

Agreed that each organisation (CCG, LCC & LCFT) will visit weekly on set days in order that we have constant oversight to support the home, monitor the improvements and ensure staffing remains safe.

Support to develop action plan in response to quality assurance visits from CCG and LCC, and regulatory inspection by CQC. Action plan being utilised as a working document to be update. Agreed at Multiagency meeting on 06/02/19 the CCG will keep the improvement plan up to date following visits and these will be shared with all partners to provide updates and assurances, this approach will reduce the burden on the provider to allow them to dedicate their time to quality improvements.

CCG SG team committed support to Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 91 walk round at unit, use real time examples with staff to demonstrate how theory is put into practice to safeguard patients. Actioned in January 2019.

Following report of three new safeguarding incidents on the 04/02/19, urgent multiagency meeting scheduled by CCG lead Nurse on 06/02/19. Attendance from CQC, Lancashire Constabulary, CCG Quality and Safeguarding teams and LCC to determine next steps.

Weekly support from CCG continues to review care documentation, risk assessments, daily observations.

CCG attended SMG 21/12/18, 11/01/19, 31/01/19, feedback given to service at time of visit and followed up in email. Concerns noted at both visits in terms of care documentation, care planning, risk assessments, daily monitoring. Latest visits on 31/01/19 + 07/02/19 note improvements in care documentation. Consistency now needed to provide assurance processes embedded.

All residents have been informed formally of the current CQC status, therefore reflecting patient choice to stay.

Safeguarding training has been completed with the clinical leads at the home from the CCG.

Safeguarding meeting held and assurances provided and all actions completed. Home now monitored via a QPIP process chaired by the CCG (A2).

New process agreed to ensure appropriate admissions (A4)

Action Due Date Assigned To Latest Update Status Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 92 Jane Brennan 15.02.19 CQC registration awaited. Provider registration A1. Ensure home Closed – now an interview with CQC progress CQC 31.03.2019 assurance is scheduled for 1st registration application mechanism March 2019 07.03.19 CQC registration confirmed Jane Brennan 15.02.19 incidents under investigation 07.03.19 safeguarding A2. Review outcome of meeting held and safeguarding assurances Closed – now a investigations and take 31.03.2019 provided and all control further action as actions mechanism needed. completed. Home now monitored via a QPIP process chaired by the CCG. 15.02.19 Action complete – meetings in place. CQC inspection manager has confirmed that Spiral Heath is still an active company

Jane Brennan and as long as it A3. Weekly meetings to exists on continue to ensure any Companies House risks are promptly and it is registered Closed – now an escalated to LCC & 08.02.2019 with CQC it is the assurance CCG who are holding relevant legal entity mechanism the risk. and is responsible for the regulated activity. Spiral Health is registered for Springfield Manor Gardens and so remains liable until and unless it cancels its own registration.

A4. Work-stream to Closed – now a determine learning 31.03.2019 15.02.19 incidents control opportunities from under investigation mechanism

Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 93 inappropriate 07.03.19 Meeting admissions held with CATCH, Jane Brennan SMG & CCG, new process agreed to ensure appropriate admissions. This will now be tested as the suspension has now been lifted and the home has been place on staggered admissions. The admission process will be reviewed following the first two admissions.

Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body meeting 27 March 2019

Page 94 Agenda Item 7

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Integrated Board Report Presented by Mrs Helen Curtis, Director of Quality and Performance Author Mr Glenn Mather, Associate Director of Performance and Effectiveness Clinical lead N/A Confidential No

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

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

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

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

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

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

Following discussions at the Quality and Performance Committee it was agreed that in presenting the Integrated Board Report to the Governing Body there should be a focus on a specific area each meeting. For this meeting there will be a focus on the CCG Improvement and Assessment Framework as the year end assessment for the CCG will have taken place on the morning of 27th March and it will be an opportune time to feedback to Governing Body members (see pages 40-41 of the Integrated Board Report).

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 95 27 March 2019 standards.

As well as these priority areas there has been an additional focus on the elective programme nationally centred on growth in incomplete pathways for RTT and long waits. Collectively, both CCGs have a variance of 4,258 pathways from plan in December. This increase in pathways is mainly as a result of the iMSK service being deemed as consultant-led by NHSI. The CCG has challenged this decision and a meeting to give a definitive decision on the status of the service is planned for early March.

Both Chorley and South Ribble CCG and Greater Preston CCG have met the 62 day cancer target, year to date to December 2018.

The A&E performance continues to remain below the STF trajectory and remains under the national standard year-to-date, despite a positive impact of the Winter Plan initiatives, which has improved performance in November by 3.5%, December by 7% and January by 6.6% on an underlying forecast position.

In Mental Health, the proportion of patients completing treatment moving to recovery was met by both CCGs; however, IAPT prevalence is below target for both CCGs in December. The 2 week psychosis target was not met by either CCG in December.

Two Never Events were reported in December both at Lancashire Teaching Hospitals, one was a misplaced nasogastric tube and the other related to wrong site surgery. Round table discussions have taken place in December 2018 with NHS England, NHS Improvement and LTHTR and the CCG to discuss incidents and develop an improvement plan.

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

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

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 96 27 March 2019

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

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

Assurance Assurance will continue to be delivered to the Quality and Performance Committee.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 97 27 March 2019 Chorley and South Ribble CCG Greater Preston CCG Integrated Board Report

February 2019

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 98 Contents Executive Summary ...... 1. Overview...... 1.1 Productivity and Efficiency Savings ...... 1.2 Quality and Performance...... 1.3 Improvement and Assessment Framework...... 1.4 Improvement and Assessment Framework Performance Exceptions ...... 2 Programmes ...... 2.1 Out of Hospital (Community and Primary Care)...... 2.1.1 Out of Hospital Referrals ...... 2.1.2 Out of Hospital Finance and Activity ...... 2.1.3 Out of Hospital Performance Exception ...... 2.1.4 Out of Hospital Integrated Business Plan ...... 2.2 Urgent Care...... 2.2.1 Finance and Activity ...... 2.2.2 Urgent Care Performance Exceptions ...... 2.2.3 Urgent Care Integrated Business Plan ...... 2.3 Elective Care ...... 2.3.1 Elective Care Referrals ...... 2.3.2 Elective Care Finance and Activity ...... 2.3.3 Elective Care Performance Exceptions ...... 2.3.4 Elective Care Integrated Business Plan...... 2.4 Mental Health and Learning Disabilities...... 2.4.1 Mental Health Referrals...... 2.4.2 Mental Health Finance and Activity ...... 2.4.3 Mental Health Performance Exceptions...... 2.4.4 Mental Health Integrated Business Plan ...... 2.5 Medicine Management ...... 2.5.1 Medicine Management Finance and Activity...... 2.6 Provider Quality Performance Exceptions ...... 3. RightCare ...... 4. Leadership ...... 4.1 Workforce ...... 4.2 Complaints ...... 4.3 Freedom of Information (FOI) requests ...... 5. Glossary......

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 99 27 March 2019 Introduction

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

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

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

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

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

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 100 27 March 2019 Executive Summary

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

As well as these priority areas, there has been an additional focus on the elective programme nationally centred on growth in incomplete pathways for RTT and long waits. Collectively, both CCGs have a variance of 4,258 pathways from plan in December. This increase in pathways is mainly as a result of the iMSK service being deemed as consultant-led by NHSI. The CCG has challenged this decision and a meeting to give a definitive decision on the status of the service is planned for early March.

Both Chorley and South Ribble CCG and Greater Preston CCG have met the 62 day cancer target, year to date to December 2018.

The A&E performance continues to remain below the STF trajectory and remains under the national standard year-to-date, despite a positive impact of the Winter Plan initiatives, which has improved performance in November by 3.5%, December by 7% and January by 6.6% on an underlying forecast position.

In Mental Health, the proportion of patients completing treatment moving to recovery was met by both CCGs; however, IAPT prevalence is below target for both CCGs in December. The 2 week psychosis target was not met by either CCG in December.

Two Never Events were reported in December both at Lancashire Teaching Hospitals, one was a misplaced nasogastric tube and the other related to wrong site surgery. Round table discussions have taken place in December 2018 with NHS England, NHS Improvement and LTHTR and the CCG to discuss incidents and develop an improvement plan.

Contract Notices

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

The CCG currently has a number of formal notices with different providers these are outlined below: LTHTR:

101 Page Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019

• CPN: 62 day Cancer issued 04/10/2017 – failure to achieve required performance for service users waiting from referral to first definitive treatment. • AQN: Major Trauma issued 27/02/2018 – issues around attribution of commissioner for activity with TARN score >8, possible duplication of payment – this is being worked through in conjunction with Specialised Commissioners. • CPN: Stroke Activity issued 11/06/2018 - non-achievement of stroke performance and five consecutive months of deteriorating performance. • AQN: Ophthalmology issued 20/07/2018 - significant increase in outpatient procedure activity relating to minor/intermediate retinal procedures and retinal tomography, meeting took place 1 August 2018 to discuss in more detail. • CPN: RTT issued 01/08/2018 - concerns that planned trajectories will not be met, delays in receiving RCAs and increasing number of 52 weeks breaches. Recovery Plan received from LTHTR. • CPN: Diagnostics issued 04/12/2018 performance under national standard.

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

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

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

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Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body 27 March 2019

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

Work Expected Issue Action stream Recovery

Urgent Percentage of A&E attendances Care admitted, transferred or discharged within 4 hours of arrival at an A&E Department Target 95% January data (Published): 81.36% Main issues remain in flow and breaches in waiting for bed and There are a number of schemes now in operation as a result of the winter plan with the aim of reducing delays in assessments. demand on the A&E department and improving flow within the hospital, these include;

Link to report • Reducing the number of patients conveyed to hospital by increasing the number of patients who are Reporting on the Winter Plan seen and treated in situ by the ambulance crews. schemes are included in the • Directing patients through the ambulatory care pathways where appropriate. detailed exception report. • Continuing the work on the discharge process. • An outlier team to reduce the number of medical outliers to reduce the length of stay for those patients. • A number of schemes under discharge planning to both reduce the number of breaches and the number of patients with a delay length of stay. Urgent Trolley waits in A&E no longer Care than 12 hours Target: 0

Main issue is insufficient capacity to move patients and accuracy of January data (Published): 57 reporting. March As above, with a focus on flow, streamlining the discharge processes and developing a minor injury 2019 Link to report stream will improve the 12hr breach position.

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

Link to report Page 103 Page

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body 27 March 2019

January data (Published) 7 mins: NWAS 00:07:51; CSR 00:09:22; GP 00:07:18

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

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

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

Link to report

January data (Published): Target 18 mins: NWAS 00:26:24; CSR 00:26:39; GP 00:23:26 Target 40 mins: NWAS 00:57:00; CSR 00:51:58; GP 00:49:15

Please see Category 1 Please see Category 1.

Urgent Category 3 - Urgent problem Care that requires treatment to relieve suffering and transport or assessment and management at scene with referral where needed within a clinically Page 104 Page appropriate timeframe

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

Target: 02:00:00 January data (Published): NWAS 03:04:09; CSR 02:24:30; GP 02:25:29

Link to report Please see Category 1. Please see Category 1.

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

Link to report January data (Published): NWAS 03:39:37; CSR 04:53:26; GP 04:28:03 Please see Category 1. Please see Category 1.

Urgent Ambulance Handover Delays Care Target: 0 Link to report

January data (Published): CSR (30-60mins) 4; (60mins+) 0 GP (30-60mins) 29; (60mins+) 9 Main issues affecting performance Improvement plans have included: are flow through the hospital and processes for rapid handovers. 1. Reducing Corridor Nursing: The Trust is working on new Rapid Assessment and Treatment work, Unclear protocols for clinical with capacity to assess 7 patients – this is now live. coordinator handover. 2. Time to First Assessment and Time to DTA: The Emergency Department (ED) clinicians are working with the acute physicians and specialty clinicians to design the pathways which are being tested currently using a Plan, Do, Study, Act (PDSA) approach. This includes direct streaming from the ambulance crews to ambulatory care and will include direct streaming from triage to ambulatory care over time.

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

Link to report January data (Published): 52.63%

Underperformance was largely due 1. The LTHTR business case in relation to additional specialist staffing for the stroke unit was not September to capacity issues the ring fencing successful and is currently being revised. 2019 of beds. 2. The CCG have requested and received a revised action plan as the 4hr target (to be seen on a stroke ward) is still not being achieved. This is being reviewed by the CCG.

3. A Getting it Right First Time – national review of stroke services is due to take place on the 1st March 2019. LTHTR and the CCG will be represented at this review.

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

Link to report

January data (Unpublished): CSR 87:8%; GP 88.3%

Capacity issues regarding Main actions to address poor performance include: workforce and beds affecting 1. Deep dive analysis on activity and demand for high volume specialities continues and has been fed performance. back to LTHTR. This will be used in join reviews of referral activity. 2. LTHTR are undertaking transformational work across a number of specialties including MSK and ophthalmology. 3. Remedial Action Plan ongoing actions centred on addressing capacity through recruitment and outsourcing, validating the waiting list and reducing demand in GP and other referrals. 4. Review of the consultant to consultant referral process. 5. RTT Steering Group monitoring of the LTHTR recovery plan routinely reported to NHSE. 6. Peer Review of neurosurgery pathway with specialist commissioners.

Elective Zero tolerance RTT waits over 52 March Care weeks for incomplete pathways 2019 Target: 0

Link to report

January data (Unpublished): CSR 0; GP 1

As above, however, there are a Please see RTT section above for update. number of patients choosing a date past their breach point. Elective Percentage of Service Users Care waiting 6 weeks or more from referral for a diagnostic test Target: 1.00% Page 107 Page

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

Link to report January data (Unpublished): CSR 1.93%; GP 0.91%

The issues relating to The CCG issued a Contract Performance Notice (CPN) to LTHTR in early December to address the March underperformance are with underperformance. The CPN will be discussed in the fortnightly RTT steering group meetings. The main 2019 computed tomography (CT), points to address performance in the plan are: audiology assessments, echocardiography and endoscopy 1. Replacing CT scanners in April 2019. Mobile scanners will be used whilst the new ones are installed. 2. Endoscopy, initiatives including insourcing capacity, reviewing use of the suites and the structure of the estate. 3. Echocardiography – Bank cover for echo cardiographers, outsourcing clinics to the independent sector and upgrading capital.

Elective Percentage of service users on March Care Non Admitted pathways waiting 2019 no more than 18 weeks from referral (AHP @ LCFT) Target: 92% The issues are specifically related to relatively long waits for SALT January data (Published): CSR 94.9%; GP 99.8% and OT in Children’s Therapy Services The CCG is working with the assistant network director for the children’s and young person’s network on an action plan and trajectory to reduce the number of relatively long waiters for SALT and OT. This plan Link to report includes; 1. Teams monitoring their own performance weekly 2. Review of OT and SALT competency framework. 3. Reviewing triage processes for consistency in approach 4. Reviewing team working for a more integrated approach to therapy.

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

Link to report January data (Published): CSR 13,914; GP 15,872 Page 108 Page

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

Pathways have increased due to There are a number of actions outlined in the RTT section that will support the reduction in pathways. classification changes for iMSK However, this growth in pathways due to the introduction of the iMSK service requires specific actions: where these pathways are now 1. The decision to classify MSK referrals as consultant-led is being challenged by the CCG with NHSE. classed as consultant-led so are 2. Work with LCFT to support their conversations with NHSI on the classification of this activity. subject to RTT rules. This places both CCGs significantly above target, and even further above planned levels (which vary over the year) – the CCGs combined variance from plan is now 4,258 pathways. Elective Percentage of Service Users Care waiting no more than one month (31 days) from diagnosis to first definitive treatment for surgery Target: 94%

Link to report January data (Unpublished): CSR 100%; GP 95:45%

LTHTR is experiencing a large The CCG is working with LTHTR on the existing Remedial Action Plan for Cancer. Main actions ongoing increase in referrals on Cancer at present are; pathways especially in the Breast 1. Subcontracting breast care pathway clinics to Ramsay Euxton Hall and Upper GI pathways. 2. Appointing a new consultant for the upper GI pathway. 3. Increasing nurse endoscopist capacity.

Elective Percentage of Service Users Care with Breast Symptoms waiting no more than two weeks from urgent GP referral to first appointment. Target: 93% January data (Unpublished): CSR 91.49%; GP 87.10% Link to report Please see above Please see above

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

Link to report January data (Published): 27

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

Elective Sleeping Accommodation Care Breach Target: 0

Link to report

January data (Published) : Not available

Sleeping accommodation breaches 1. There was a previous issue regarding breaches in endoscopy which has now been resolved. continue to be reported due to 2. The deep dive is underway by LTHTR. more stringent timescales being applied to the critical care environment.

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

Mental Proportion of patients on (CPA) Health discharged from inpatient care who are followed up within 7 days Target 95%

Link to report January data (Published) : CSR 95.83%; GP 93.33% Chorley and South Ribble CCG Both patients have subsequently been followed up, with no further action for the second one. The trend has failed this target in for both CCGs is one of achievement. The low volume of patients means that one or two breaches can December, due to two breaches result in underperformance. All breaches are discussed at the monthly Mental Health Performance of this target, one patient who Effectiveness Group. DNA’d and one due to an admin error. Mental First episode of psychosis Health treated with a NICE approved care package with two weeks of referral Target: 53%

Link to report January data (Published): CSR 50.0%; GP 50% Reason for breaches are delays Actions to improve referrals pathways include: in referrals from other mental health services, increased 1. The service, in conjunction with commissioners, have looked for trends at CCG level, but with the demand on these services, and volume so low the overall conclusion is that there are no prominent trends at this level. patients choosing to wait longer to 2. Support is being sought from commissioners to share guidance for GP’s around symptom avoid an appointment over the identification to support timely referrals. Christmas period. 3. A SitRep process is in place to ensure that all service user pathways are tracked to monitor timely appointments. 4. On-going engagement work is continuing to review efficiency opportunities to support the capacity in EIS. 5. NHSi IST will work with the service to review Patient referral pathways and flow alongside considering how improving capacity can increase the carer’s support and family intervention offer.

Mental The percentage prevalence of Health people who have depression and/or anxiety disorder who receive psychological therapies (NEW KPI 2018/19) Page 111 Page Target: 1.54%

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

January data (Published): CSR 1.36%; GP 1.51% Link to report

The underperformance is caused 1. Review all job plans to ensure the capacity is available across all teams to meet the demand for March by a reduced number of referrals welcome calls coming into the service on a weekly basis due to recent clinical model change. 2019 received by the service to achieve 2. Increased communication and engagement with primary care to increase referrals and engagement the prevalence There are also with the service. some capacity issues within teams, and reduced referrals over the Christmas period.

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Quality Medication Errors (with harm) Target: 2

Link to report

January data (Published): 24

In December, 22 medication 1. A thematic review of all insulin incidents is planed to be undertaken by the diabetic team. errors with harm were reported 2. Two improvement actions are underway focussing on critical medications and classification of (19 were low harm, three caused medicine incidents. moderate harm). Two of moderate harms were in relation to the same incident.

Quality Serious Incidents Target: 0

Link to report

January data (Published): 5 Seven serious incidents were 1. Next Step and key actions to be published from round table event with NHSE, NHSI, CQC and reported in December (which LTHTR. included 2 Never Events). 2. LTHTR conducting a thematic review of all incidents to be presented to their Quality and Safety One diagnostic delay, two Committee in February. pressure ulcers, one slips, trips and falls, one sub-optimal care of the deteriorating patient.

Quality Never Events Target: 0%

Link to report

January data (Published): 0 Two Never Events were reported Please see Serious Incidents above. in December, one was a misplaced nasogastric tube and Page 113 Page the other related to wrong site

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

surgery.

Quality A&E FFT (% who would recommend) LTHTR Target: 85%

Link to report January data (Published): 86.22% Response rate decreased which 1. CCG will continue to monitor performance. may have affected overall 2. Workstreams under VSA are expected to positively impact on this target. performance.

Quality Pressure Ulcers Grade 3 Target: To be determined

Link to report January data (Published): 13 Pressure Ulcers Grade 4 Target: To be determined

Link to report January data (Published): 3 In December 2018, LCFT 1. All pressure ulcers have been reviewed and scrutinised by the LCFT Safety Senate to determine reported 13 Grade 3 pressure whether they were avoidable or unavoidable, and identify any learning to be shared. ulcers and 2 Grade 4 pressure 2. Working group to re-commence with LCFT, LTHTR, LCC and CCG to review thematic work to ulcers. understand what the priorities are for improvement work across the health economy.

As a health economy, there is a targeted focus to reduce the prevalence of pressure ulcers by increasing awareness of pressure ulcers, to reduce harm by enabling preventative interventions to be implemented at an earlier stage. Page 114 Page

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

Link to report January data (Published): 4 In December 2018, LCFT 1. Following a StEIS reportable incident, LCFT will undertake a Rapid Review (within 72 hours) and reported three serious incidents. submit this to the CCG. This has been received and notes immediate actions taken inclusive of duty of candour. The incidents all related to 2. A full RCA will be submitted to the CCG within 60 days. The investigative reports will then be duly pressure ulcers which were reviewed by the CCG SI Review group to determine if the incidents have been thoroughly potentially lapses in care. investigated and any lessons learnt cascaded across the health economy. 3. The CCG attends LCFT SI meetings where all SI cases are subject to a high level of scrutiny.

Quality Staff Friends and Family Test LCFT Target: As a place of work 58% For care and treatment 67% Link to report Staff friends and family test results remain poor. Assurance has been requested from LCFT of the steps being taken to address this. The 2018 NHS Staff Survey is due for publication at the end of February 2019, which will provide the trust and CCG with further oversight into staff morale.

Quality Mandatory Training LCFT Target: 85%

Link to report January data (Published): 83.46% Compliance against SG L3 has been identified as a hotspot. LCFT have reported an increase in the number of staff requiring L3 SG training following the changes in the intercollegiate document for safeguarding. Regular communication to staff to encourage completion, alongside enabling access to online training, is anticipated to increase compliance. CCG will request updates via contract meeting in March 2019.

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

Quality Ramsay Health Care – Complaints

Target: 0 January data (Published): 2 Link to report Two complaints at Euxton Hall • Euxton Hall investigated two patient concerns re post-operative pain. relating to concern with post- • Fulwood Hall experienced issues with their telephone system. operative pain and one complaint at Fulwood Hall relating to an issue with the telephone system.

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

1. Overview 1.1 Productivity and Efficiency Savings

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

As at the 31 January 2019, the year to date performance shows the plan is underperforming by £2.0m.

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

£000 £000 £000 £000 £000 £000

Out of Hospital 316 173 (108) (281) 1,510 1,194 Elective Care 3,810 2,866 2,197 (669) 3,402 (408)

Urgent Care 2,156 1,782 1,748 (34) 2,051 (105)

Mental Health and Learning Disabilities 527 439 439 0 527 0 Medicines Management 5,289 4,706 5,280 574 5,807 518 Other Programme 1,597 1,067 3,046 1,979 2,523 926

Sub total - assigned QIPP schemes 13,695 11,033 12,602 1,569 15,820 2,125 Unidentified QIPP 4,834 3,940 221 (3,546) 0 (4,835)

Total QIPP 18,529 14,973 12,823 (1,977) 15,820 (2,710)

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

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1.3 Improvement and Assessment Framework

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

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

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

106a Inequality Chronic - ACS & UC17-18 Q3 2,463  8/11 135/195 122c One-year survival from all ca 2015 72.6%  6/11 67/195 R 107a AMR: appropriate prescribin 2018 07 1.016  3/11 90/195 R 122d Cancer patient experience 2017 8.8  5/11 76/195 R 107b AMR: Broad spectrum prescri 2018 07 8.7%  9/11 103/195 R 123a IAPT recovery rate 18-19 Q1 57.1%  5/11 32/195 R 108a Quality of life of carers 2018 0.58  8/11 113/195 R 123b IAPT Access 18-19 Q1 4.1%  7/11 110/195 R 123c EIP 2 week referral 2018 09 42.5%  11/11 188/195

Sustainability Period CCG Peers England Trend 123d CYP mental health (not available) R 141b In-year financial performanc 18-19 Q1 Amber  123f MH - OAP (not available) R 144a Utilisation of the NHS e-referr 2018 07 128.4%  1/11 3/195 123e MH - Crisis care and liaison (not availab R 145a Expenditure in areas with ide 18-19 Q1 Red  123g MH - health checks (not available) 123h MH - cardio metabolic assessments (not

Leadership Period CCG Peers England Trend R 123i MH - investment standard Compliant 

R 162a Probity and corporate govern 18-19 Q1 Fully compliant  123j MH - DQMI (not available) 163a Staff engagement index 2017 3.74  10/11 128/195 R 124a LD - reliance on specialist IP 18-19 Q1 76  8/11 178/195

163b Progress against WRES 2017 0.11  6/11 83/195 124b LD - annual health check 2016-17 51.9%  5/11 74/195

164a Working relationship effectiv 2017-18 62.61  8/11 137/195 124c Completeness of the GP learn 2016-17 0.57%  3/11 39/195 166a CCG compliance with standar 2017 Amber  R 125d Maternal smoking at delivery 18-19 Q1 10.2%  4/11 88/195

R 165a Quality of CCG leadership 18-19 Q1 Green  125a Neonatal mortality and stillb 2016 2.0  1/11 5/195

125b Experience of maternity servi 2017 78.5  10/11 183/195

Key 125c Choices in maternity services 2017 64.8  3/11 37/195 R 126a Dementia diagnosis rate 2018 08 70.8%  2/11 67/195 Worst quartile in England 126b Dementia post diagnostic sup2016-17 82.6%  1/11 12/195 Best quartile in England 127b Emergency admissions for UC 17-18 Q3 2,278  6/11 95/195 Interquartile range R 127c A&E admission, transfer, dis 2018 10 83.2%  9/11 163/195 127e Delayed transfers of care per 2018 09 11.3  5/11 115/195 R 127f Hospital bed use following e 17-18 Q3 561.5  7/11 160/195

105c % of deaths with 3+ emergenc 2017 4.69%  1/11 44/195

R 128b Patient experience of GP serv 2018 87.2%  1/11 39/195

R 128c Primary care access 2018 08 96.0% 

R 128d Primary care workforce 2018 03 0.83  11/11 174/195 R 128e Primary care transformation 18-19 Q1 Green  1/11 1/195 R 129a 18 week RTT 2018 09 85.6%  9/11 124/195 130a 7 DS - achievement of standa 2016-17 2  R 131a % NHS CHC assesments takin 18-19 Q1 20.4%  10/11 150/195 132a Sepsis awareness 2017 Green  Page 130 Page R 133a 6 week diagnostics 2018 09 2.1%  6/11 131/195

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NHS Chorley and South Ribble CCG Governing Body 27 March 2019

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

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

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

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

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

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

Leadership Period CCG Peers England Trend R 123i MH - investment standard Compliant 

R 162a Probity and corporate govern 18-19 Q1 Fully compliant  123j MH - DQMI (not available) 163a Staff engagement index 2017 3.73  8/11 134/195 R 124a LD - reliance on specialist IP 18-19 Q1 76  10/11 178/195

163b Progress against WRES 2017 0.11  4/11 79/195 124b LD - annual health check 2016-17 38.2%  8/11 165/195

164a Working relationship effectiv 2017-18 67.45  6/11 102/195 124c Completeness of the GP learn 2016-17 0.41%  9/11 136/195 166a CCG compliance with standar 2017 Green  R 125d Maternal smoking at delivery 18-19 Q1 15.1%  9/11 153/195

R 165a Quality of CCG leadership 18-19 Q1 Green  125a Neonatal mortality and stillb 2016 5.2  6/11 132/195

125b Experience of maternity servi 2017 85.5  2/11 48/195

Key 125c Choices in maternity services 2017 63.3  3/11 53/195 R 126a Dementia diagnosis rate 2018 08 68.7%  4/11 91/195 Worst quartile in England 126b Dementia post diagnostic sup2016-17 80.5%  2/11 46/195 Best quartile in England 127b Emergency admissions for UC 17-18 Q3 2,370  4/11 104/195 Interquartile range R 127c A&E admission, transfer, dis 2018 10 83.1%  10/11 165/195

R 127e Delayed transfers of care per 2018 09 11.1  8/11 112/195

127f Hospital bed use following e 17-18 Q3 573.0  10/11 165/195 105c % of deaths with 3+ emergenc 2017 4.93%  3/11 57/195 R 128b Patient experience of GP serv 2018 82.8%  7/11 121/195 R 128c Primary care access 2018 08 100.0%  R 128d Primary care workforce 2018 03 0.91  4/11 129/195 R 128e Primary care transformation 18-19 Q1 Green  1/11 1/195 R 129a 18 week RTT 2018 09 85.6%  8/11 126/195

130a 7 DS - achievement of standa 2016-17 2   R 131a % NHS CHC assesments takin 18-19 Q1 15.0% 9/11 135/195 132a Sepsis awareness 2017 Green 

R 133a 6 week diagnostics 2018 09 2.2%  9/11 138/195 Page 131 Page

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1.4 Improvement and Assessment Framework Performance Exceptions

Improvement Assessment Framework (Better Health) IAF 105b – Personal Health Budgets (Number of Personal Health Budgets in place per 100,000 CCG population) Target: 200 CSR/240 GP Current Performance CSR CCG 201 GP CCG 86 PHBs by year end Q3 2018/19 Current Issues: A table top review of the use and potential of personal health budgets across Greater Preston, Chorley and South Ribble was completed in March 2018, the finding of which was accepted by the management executive team and work commenced in April 2018. It was clear from the review that it would not be possible to meet our NHSE trajectories through the use of personal health budgets within Continuing Health Care alone, and it would be necessary to explore other options. Personal wheelchair budgets were identified as an opportunity that would offer increased choice and control to citizens, whilst enabling trajectories to be met. As the lead commissioner for Lancashire Teaching Hospitals, who are the main provider of wheelchairs in Lancashire and South Cumbria, we brought together CCG leads from across the ICS and providers to a workshop and co-produced a set of principles and high level plan that Greater Preston, Chorley and South Ribble CCG’s led on mobilisation of, in partnership with Lancashire Teaching Hospitals and Southport and Ormskirk Hospital Trust (the provider in Chorley, South Ribble and West Lancashire). The CCG has been mentored in this approach by Hull CCG, who has had oversight of our action plans throughout. We have worked with people who have used the wheelchair service to develop the care and support plan and the processes and pathways have been trialed in both Trusts. The learning from which has been brought back to the implementation group and used to inform further improvements. The service went live on 01/10/2018 and this will be the standard offer for everyone referred into the service, using one of the three nationally agreed pathways: • Notional budget • Notional budget including third party top up • Third party

The trajectory for Chorley and South Ribble has been met. The trajectory for Greater Preston has not yet been met due to a backlog with this service; a plan is in place to achieve this.

Improvement Plans: There is a requirement for PHBs to be the default option for people in receipt of CHC living in their own home from April 2019, the ICS is working with the CSU about how this will be delivered, and a CCG based CHC lead has been appointed to support this and other work.

Improvement Assessment Framework (Better Health) IAF 107a AMR: Appropriate Prescribing Target: Current Performance CSR CCG 1.016 GP CCG 1.127 07/2018 Current Issues: The NHSE antibiotic volume target has been reduced from 1.161 per STAR PU (Specific Therapeutic group Age-sex Related Prescribing Units) to 0.965 per STAR PU. Prescribing volume across both CCGs continues to reduce but does not meet the required targeted by NHSE. https://www.england.nhs.uk/ccg-out-tool/anti-dash/https://www.england.nhs.uk/ccg-out- tool/anti-dash/ Improvement Plans: An annual antibiotic prescribing audit was completed in all practices in Sept/Oct. Individual feedback to practices ongoing. All practices written to with new targets and current position against targets. Antibiotic formulary reviewed and made available on net formulary. Antibiotic target is included in the quality contract. Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 132 Better Care Improvement Assessment Framework (Better Care) IAF 121a High Quality Care Acute Target: Current Performance CSR CCG 54 GP CCG 54 Q1 2018/19 Current Issues: Lancashire Teaching Hospitals have received an overall rating of ‘requires improvement’ in their latest CQC inspection. The main reasons for this are: 1. Insufficient improvements since last inspection in Urgent Care and Emergency and Medical Care - evidence of change but not embedded. 2. Despite improvements in appraisals, mandatory, life support and safeguarding training, still below target. 3. Lack of MCA and DOLS knowledge in front line staff. 4. Despite improvements in staffing, some areas did not have enough staff. 5. Some escalation areas unsuitable, such as MH facilities in ED. 6. Triage in ED not always timely. 7. Concern re Children’s pathway in ED at CDH - risks not fully mitigated. 8. Gaps in safe management of medicines. 9. Gaps in documentation. 10. Access and flow standards not met. 11. Medical services did not have a clear strategy and not all staff aware of wider Trust vision and strategy. 12. Lack of Trust-wide strategic plan or document, although recognised progress with long term strategy aligned to system. 13. Challenge with financial pressures. Improvement Plans: LTHTR have taken the following actions: 1. Enhanced leadership capacity and capability. 2. Embedded good governance; corporately and locally, ensuring standardisation of governance to the level of higher performing divisions. 3. Introduced Executive CQC ‘check and challenge sessions’ for Urgent and Emergency Care and Medicine Division. 4. Continued with staffing investment and recruitment. 5. Have improved their approach to patient safety by ensuring multi-disciplinary collaborations. 6. Improved management and mitigation of risk with associated KPI’s. 7. Developed a continuous improvement approach and function. 8. Developed a ‘Big Plan’ approach to connect strategy with front line. 9. Undertaken a cultural review with key actions as a result of this.

The CCG continue to monitor and work with LTHTR in the following ways: 1. Monthly contractual meetings, ensuring remedial action plans are in place where performance is below the expected target. 2. Key participants in the Central Lancashire Quality Improvement Board, which was implemented to ensure progress is made against the CQC inspection ‘should and must do’s’. 3. Continuous programme of CCG Quality Visits in order to understand any challenges that staff and patients are facing, but also to highlight any improvements that have been made. Recommendations from these reports are shared with the Trust.

The CCG instigated a round table event in relation to Never Events that have occurred in 2018-19. This was in partnership with LTHTR, NHS England, NHS Improvement and the CQC. Actions from this meeting included ensuring that a systems learning approach is taken in relation the learning from nasogastric tube incidents. This is being taken forward by NHS England. IAF 121c High Quality Care Adult Social Care Target: Current Performance CSR CCG 63 GP CCG 59 Q1 2018/19 Current Issues: Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 133 This indicator is based on an overall score indicative of the quality of care in a CCG area as determined by CQC inspection ratings, and then rated against an England average. This overall score is based on the ratings given at each site inspected in a CCG area against the five key questions i.e. “Is it safe?”, “Is it effective?”, and “Is it well-led?”, “is it caring?”, and “is it responsive?” The ratings for each question are scored as follows: outstanding = 3, good = 2, requires improvement = 1, inadequate = 0. This is then added up into a total score for each CCG, and compared against the total maximum score available for each CCG to give a rating score out of 100.

1. Themes across the regulated care sector identify areas of concern around medicines management, record keeping, and inconsistencies with leadership style across the care home sector and the need to focus on an appreciative leadership style. This is coupled with challenges due to retention of registered managers and the impact of inconsistency in practice amongst staff teams. Areas for development also include the need to strengthen risk assessment and management across the sector. The CCG safeguarding team continue to provide safeguarding leadership to those homes identified on Radar and the Quality, Performance Improvement Plan (QPIP) process. 2. Four nursing homes are being managed by the QPIP process; three of the homes are on a monitored staggered admission process. Action plans are in place and support is provided by health and social professionals to enable the homes to make the required improvements. 3. Nine homes remain on Radar and all have action plans in place and support visits planned. One home has been removed from the Radar. 4. Two domiciliary providers placed on Radar, with an agreement that no further placements are placed with 1 provider. The CCG is not able to implement a suspension or contract warning notice due to lack of contractual arrangements in place with domiciliary care providers. Improvement Plans: One home remains suspended to new admissions with a notice of decision to restrict admissions via CQC. The provider is proactively engaging with the support offered via the safeguarding partnership and is making progress with the improvement plan. The CQC have recently inspected and the report is due to be published following factual accuracies. Quality monitoring and support visits provided by the CCG continue both announced and unannounced.

Service Delivery: 1. The safeguarding champion model continues to be a successful initiative with good engagement from care home providers. The last workshop focused on consolidation of skills and knowledge, the requirements of the Adult Intercollegiate document which sets out learning requirements for safeguarding training requirements and an awareness session of the Persons in a Position of Trust (PIPOT) policy. 2. The domiciliary safeguarding champion continues to be well attended and the last workshop focused on staff understanding the requirements of the Mental Capacity Act (MCA) and implications for practice. 3. A self-neglect framework will be launched via the Lancashire Safeguarding Adults Board (LSAB) in March 2019 to support a multiagency response for services working with individuals who self-neglect where there is a risk of harm to individuals or others. 4. The LSAB MCA sub group will be working on a task group to support agencies to understand the requirements of the MCA Amendment Bill 2019 along with the introduction of the Liberty Protection Safeguards which will be replacing the Deprivation of Liberty Safeguards (DoLS).

Improvement Assessment Framework (Better Care) IAF 123f – Mental Health Out of Area Placement Target: N/A Current Performance CSR CCG 136.7 GP CCG 258.3 02/2018 Current Issues: There is a lack of in-patient beds due to high mental health acuity and this has led to an increase in OAP’s over the last 6-9 months (with a corresponding increase in bed days as per the target). Bed modelling demonstrates that there are enough treatment beds in the system if other resources are also in place, notably rehab/HDU beds and LD beds, but there are not sufficient beds without these specialist beds. The result is that non-acute cases have care delivered in acute MH treatment beds, preventing access to patients needing acute care. Additional pressure has been noted through the Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 134 absence of beds for the acute treatment of substance misuse associated presentations. There are flow issues particular to specific wards and these are being addressed with ECIST support.

Improvement Plans: Our health economy and the ICS plans are around ensuring we have more community services at the front end, to ensure individuals are able to access the correct mental health services at the right time. More complex individuals should receive an enhanced package of care which demonstrates their higher mental health acuity. Digital/tele-care approaches are being reviewed to aid compliance to medication regimes. Potentially, the change in the model of community mental health care should reduce the need for acute MH inpatient beds. ICS/local plans are currently in place around individuals with LD and/or Autism to ensure lengthy stays on MH wards are reduced as much as possible.

IAF 124a – Reliance on specialist inpatient care for Learning Disability/Autism (The number of inpatients for each CCG in the Transforming Care Partnership per million GP registered adult population in the Partnership). Target: N/A Current Performance CSR CCG 76 GP CCG 76 Q1 2018-19 Current Issues: The overarching aim for the CCGs is to support a discharge back to the community for all those individuals who are in hospital and prevent further admissions. The re-settlement programme monitored by NHS England should result in discharges taking place in line with each individuals own plan, with specific effort to discharge the pre 2014 cohort by 2019.

As at 26 February there were 11 patients in the Greater Preston CCG who met the Winterbourne criteria and 6 patients within the Chorley and South Ribble CCG.

Of the total 17 patients, 3 (2 for Greater Preston and 1 for Chorley & South Ribble) were from the original pre April 2014 cohort.

Reflected within these figures, 1 Greater Preston patient was discharged in January 2019.

The 2 admissions highlighted in brackets are patients who have stepped down from Secure services into CCG services. The 1 discharge highlighted in brackets is an individual who has been stepped up to Secure service.

1 April 2016 Admissions Discharges 26 February 2018 CCG Position (step down) (step up) Position Chorley & South Ribble 6 10 (1) 11 6 Greater Preston 6 18 (1) 13 (1) 11

Improvement Plans: 1. New community specification approved, and each provider gap analysis. 2. Financial Investment Options paper presented to CCB in February 2019. 3. Learning Disability and Autism Support risk register reviewed monthly. 4. Workforce developments – group continues to review the current actions. 5. Regular service user engagement using pathways via targeted meetings. 6. Consultation on in-patient provision underway by NHS England. 7. Operational Delivery Network developed inpatient bed model. 8. Learning process from Care and Treatment Reviews and the review of admissions meetings continue. 9. Specialist Support Team fully mobilised and engaging with community teams for full collaborative approach. 10. Greater focus in 2018/19 on children and transition, parity of esteem, increasing annual health checks and screening uptake, quality assurance, prevention of admissions by the Specialist Support Team and the crisis elements.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 135 Improvement Assessment Framework (Better Care) IAF 124b – Learning Disability receiving an annual health check (The proportion of people on the GP Learning Disability Register that have received an annual health check during the year). Target: N/A Current Performance CSR CCG 51.9% GP CCG 38.2% 2016-17 Current Issues: Not all patients with a Learning Disability (LD) on a GP Practice LD register have an Annual Health Check. Performance is based on behaviour within general practice in identifying and recording these patients – Greater Preston CCG was in the worst quartile nationally for this indicator last year. Performance at previous reporting period was CSR CCG 46.6%; GP CCG 30.3%, so a significant improvement has been seen.

Improvement Plans: The following two elements were included within the GP Quality Contract with effect from 2019/20:

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

2. The practice will invite all patients on the register for an annual health check and produce a health action plan.

These indicators are included within the annual Practice Variation review, looking at the number of patients on the register and those who have an annual health check. Work with the Public Health engagement lead at the Local Authority is underway to extend awareness of annual health checks. Improvement Assessment Framework (Better Care) IAF 125b – Women’s experience of maternity services Target: N/A Current Performance 2017 CSR CCG 78.5 GP CCG 85.5

Current Issues The National Maternity Survey 2018 was published in January 2019. The survey now rates the Trust as 12 out of 69 Trusts (the previous position was 36 out of 69 Trusts). This shows a significant improvement for our maternity services.

Improvement Plans: 1. The Maternity Voices Partnership (MVP) is thriving. Chaired by service users, the partnership has representation from the CCG and the Acute Trust. Service user representation continues to grow. Real-time service user experiences on specific topics are discussed at each meeting and are fed back directly to maternity service staff. Service users are also invited to walk round the maternity wards and give feedback based on their observations. Service users also have the opportunity to comment and input into the development of public facing service information leaflets and posters. 2. The CCG and the Acute Trust together with the MVP chairs are working across the Local Maternity System as part of the delivery of Better Births to improve Choice and Personalisation across the ICS. 3. Work will be undertaken to engage with minority groups to contribute to the MVP. 4. Investment has resulted in an increased staffing establishment, which has been recruited to. 5. A new bereavement suite is being developed. Consideration is being given to what the bereavement suite and bereavement team could be called, as there is recognition that this service may support families prior to suffering a loss e.g. babies born with a life limiting condition, therefore, the word bereavement may not be appropriate.

At LTHTR a group of midwives have come together to focus on home births and increase the home birth rates locally. Up to now, this work has included:

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 136 1. A home birth peer group being set up. 2. A Facebook group, which is used for mums to contribute their ideas. 3. Production of a home birth video, which will be edited and put to together as a series of podcasts. 4. Developing home birth boxes. 5. Designing ‘ask me about home birth’ badges for all midwives to wear (this is currently awaiting approval from infection control).

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

Improvement Assessment Framework (Better Care) IAF 125d – Maternal Smoking at Delivery Target: N/A Current Performance CSR CCG 9.67% GP CCG 9.75% Q2 2018-19 Current Issues: The CCG would like to see a further improvement in smoking rates at delivery. Notably, the overall position at the local acute Trust was 7.4% in November and 8.9% in December 2018. Improvement Plans: 1. The head of midwifery was instrumental in ensuring the Trust became a smoke-free zone. 2. LTHTR employ a public health midwife and a public health co-ordinator (for the Trust), who are both involved in the smoke-free policy and implementation of this scheme. 3. The public health midwife will be working with the service development midwife on a service improvement project around smoking in pregnancy in 2019. 4. The midwifery department have just had Nicotine Replacement Therapy (NRT) Patient Group Directives authorised this week so that staff can offer dual NRT for pregnant/postnatal women on the ward; training will begin for staff in 2019. 5. The public health midwife has just completed an audit against the Trust smoking in pregnancy policy. 6. An action plan will be devised once the data has been analysed. This will be shared with the CCG. 7. The CCG continue to monitor the monthly performance data around this indicator and work closely with midwifery colleagues at the acute Trust in order to ensure we are sighted on all improvement projects. Improvement Assessment Framework (Better Care) IAF 128d – Primary Care Workforce Target: N/A Current Performance CSR CCG 0.83 GP CCG 0.91 03/2018 Current Issues: This indicator is based on the number of full time equivalent GPs and Practice nurses per 1000 population. Chorley and South Ribble CCG is in the lowest quartile.

Improvement Plans:

1. The CCG worked closely with NHS England to submit a bid in November 2017 to recruit Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 137 additional GPs from abroad. All practices were contacted to scope interest around this scheme and a number of practices wish to be involved. This work is ongoing, with close involvement with NHSE and other CCGs in Lancashire and South Cumbria. Unfortunately, due to the current uncertainty around Brexit, no ongoing applications have been received to date.

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

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

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

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

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

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

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

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

Improvement Assessment Framework (Better Care) IAF 131a – Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting. Target: 15% or below Current Performance CSR CCG 20.4% GP CCG 15.0% Q1 2018-19 Current Issues: Number of NHS CHC full assessments in an acute hospital setting in the quarter as a percentage of Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 138 total NHS CHC full assessments carried out.

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

IAF 127f – Population use of hospital beds following emergency admission (total length of all Non elective Finished Consultant Episodes per 1000 population) Target: N/A Current Performance CSR CCG 561.5 GP CCG 573.0 Q3 2017/18 Current Issues: Both CCGs are in the lowest quartile for this indicator. The indicator is based on total length of Finished Consultant Episodes following a Non-Elective admission, per 1000 population. Current length of stay is not at an optimal level. Improvement Plans: 1. Following on from the VSA event a programme of work was agreed and KPI’s for each work stream established, which report to the A and E delivery board, where leads attend and held accountable for their work stream. 2. There are six work streams in this area: • Early intervention and prevention • 111 and 999 • Emergency Department • Rapid assessment and care coordination • Mental Health – unscheduled care • Paediatrics • Integrated therapies • Discharge 3. There is a detailed programme plan underpinning this work 4. Newton Europe has undertaken delayed transfers of care diagnostic and this is being aligned to the flow out of hospital VSA work stream plan. 5. The plan includes introducing ward based discharge co-ordinators; additional board rounds in the evening; standardised use of estimated discharge dates; one discharge planner document for each patient that also acts as a referral for any onward care; and a set of standards for discharge that will be delivered by each ward.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 139 2 Programmes 2.1 Out of Hospital (Community and Primary Care)

2.1.1 Out of Hospital Referrals

The cumulative position across both CCGs compared to the same period last year demonstrates an overall increase of 2.5% in GP referrals.

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 140 GP Referrals - Tier 2 | Community as at 31st December 2018

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

About Health 1,758 8% 553 3% -1,205 -68.5% Beacon Medical 1,809 8% 2,383 11% 574 31.7% Chorley Medics 3,251 15% 1,371 6% -1,880 -57.8% TICCS 2,097 10% 1,429 7% -668 -31.9% Community Health and Eyecare 832 4% 655 3% -177 -21.3% LCFT (GP Referrals) 11,794 55% 11,727 54% -67 -0.6% Moving Well 0 0% 3,648 17% 3,648 --

Chorley and South Ribble

Total 21,541 100.0% 21,766 100.0% 225 1.0% About Health 3,058 11% 740 3% -2,318 -75.8%

Beacon Medical 2,359 8% 2,704 10% 345 14.6% Chorley Medics 3,974 14% 1,675 6% -2,299 -57.9% TICCS 2,562 9% 1,746 6% -816 -31.9% Community Health and Eyecare 1,015 4% 801 3% -214 -21.1% LCFT (GP Referrals) 15,200 54% 15,942 57% 742 4.9% GreaterPreston Moving Well 0 0% 4,457 16% 4,457 --

Total 28,168 100.0% 28,065 100.0% -103 -0.4%

Beacon Medical has seen an increase of 345 referrals compared to 2017/18. The service mobilised in April 2017 and referrals into the service in the early months were slow. As the year progresses the variance is expected to reduce. The reduction in Tier 2 referrals can be attributed to several services ending in July and August due to the commencement of the new Central Lancashire Moving Well Service. The services which ended were the two physiotherapy providers: Chorley Medics and TICCs (Ascenti) and the previous MSK service provider, Virgin Care Services. Also, there is no data available on referral numbers for the community dermatology service, which is due to lack of training on the new electronic Referral Service (e-RS).

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 141 2.1.2 Out of Hospital Finance and Activity

Joint position both CCGs M10 YTD Budget Actual Variance Provider £000 £000 £000 Block / Grants Lancashire Care Foundation Trust 27,171 27,159 (12) Lancashire Care Foundation Trust - Central Lancashire Moving Well Service 3,403 3,358 (45) Hospices (grant agreements) 1,177 1,162 (15) Total 31,751 31,679 (72)

Block Contract

Lancashire Care Foundation Trust (LCFT) For year to date to Month 9 of the contract, overall activity is 3% under agreed baselines, within the +/- 10% tolerance level for the contract. For the CCGs within central Lancashire, Chorley South Ribble and Greater Preston are overall under the tolerance level at 3.3% below contracted activity. The CCG is working with Lancashire Care Foundation Trust on a revised approach to contract performance through Statistical Process Control as means to monitor variation in activity reporting and a more outcome based reporting approach.

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

Children’s Therapy Services The performance lead has met with the deputy network director to agree the final baselines before issuing to the associates for agreement. These baselines will reflect a revision in the approach to take account of present performance, reference cost calculations and leave allowances. The revised baselines will be issued for the next contract year 2019/20 after agreement with the associates to the contract.

Learning Disabilities Services The CCG is working with the service lead for LD services in Lancashire Care Foundation Trust to develop a more outcome based approach to contract reporting, which will better reflect the effectiveness of the service. The CCG continues to work with the service lead on increasing activity within the service lines partly as a result of recruiting to existing vacancies.

RIO rollout The performance lead in the CCG is working with the performance lead for LCFT on understanding the impact of the roll out of RIO to community services. The Change Management Process group is working to understand and identify the difference in activity reporting pre and post implementation to RIO.

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 142 During the first three months of the service going live, 1 July 2018 – 31 September, LCFT provided rheumatology, MSK and physiotherapy with pain and chronic fatigue going live from the 1 October 2018.

From the 1 October 2018 LCFT provides a fully integrated Moving Well Service incorporating rheumatology, MSK, physiotherapy, pain and chronic fatigue provision. The service also offers self-referral into the physiotherapy element of the service. Quarter 3 position reported 911 self-referrals into physiotherapy.

Beacon Medical (Community ENT) is a block contract with a 10% cap / collar agreement in place. Current cumulative performance is below the collar threshold by -447 (-9.4%). Activity at month 9 is 11.8% below planned levels. Invoices will be paid at the collar value of the contract until performance is at planned levels.

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

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 143 Chorley Medics, The Integrated Care Clinics and Virgin Care Services were decommissioned from 30 June 2018; therefore, no activity will be reported against budget for the remaining months of this financial year. MSK and physiotherapy were commissioned separately from the 1 July 2018 through the Central Lancashire Moving Well service provided by LCFT.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 144 2.1.3 Out of Hospital Performance Exception

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 145 2.1.4 Out of Hospital Integrated Business Plan

The Integrated Business Plan for 2018/19 is now closed. The projects on the plan with identified savings have been achieved. The focus is now on working up the Business Plan for 2019/20.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 146 2.2 Urgent Care 2.2.1 Urgent Care Finance and Activity

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

A&E Activity

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

A&E + Urgent Care Centre

Whilst local data flows are in place, appropriate contractual measures have been taken to ensure that Urgent Care Centre data is reported to the Secondary Uses Service (SUS+) dataset as this information flow has not yet been established.

Further steps are now being taken with both LTHTR and suppliers to determine how GTD can satisfy the new national Emergency Care Dataset (ECDS) for urgent and emergency care. Although GTD are not nationally mandated to be compliant until October 2018, this is a current contractual requirement. At the August 2018 Contract Review meeting GTD confirmed that testing, using their middleware supplier EMIS, was now ready to commence.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 147 Non Elective Activity

Non-elective activity levels are above plan by 683 and costs are above plan by £1.9m.

The main provider where over spend is observed is in LTHTR. This is primarily related to Respiratory Medicine and Geriatric Medicine as expected during winter periods.

The major trauma issue previously reported is now well underway to getting resolved, the reconciliation work has now concluded (for 2018/19) with interim values being agreed for the current financial year. The position for 2017/18 remains unresolved at this stage as NHS England Specialised Commissioning team are unwilling to enter into discussions – their stance being that 2017/18 positions are now closed. There is further ongoing discussion with specialised commissioners as they are now requesting a budget transfer from the CCGs in the region of £3.7m as they believe they are currently ‘not funded’ for major trauma, The CCG is currently reviewing its position based on the information held prior to any decision being made in relation to this.

Ambulatory care continues to be recoded as non-elective admissions to the unit, we are now able to distinguish ambulatory activity at both Preston and Chorley sites; further ongoing discussions are taking place between the CCG and LTHTR with a view to agreeing a local tariff for ambulatory activity as part of the 2019/20 contract planning round.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 148 2.2.2 Urgent Care Performance Exceptions Accident and Emergency IAF E.B.5 Percentage of A&E attendances where the Service User was admitted, transferred or discharged within 4 hours of their arrival at an A&E department (Trust) Target: 95% Current Performance 81.31% 12/2018 Current Issues: Performance in A&E showed a slight improvement in December from November’s position. The performance is significantly below the target figure; however it is above the predicted underlying performance figure.

Improvement Plans: There are a number of schemes now in operation as a result of the Winter plan with the aim of reducing demand on the A&E department and improving flow within the hospital, these include; • Reducing the number of patients conveyed to hospital by increasing the number of patients who are seen and treated in situ by the ambulance crews. • Directing patients through the Ambulatory Care pathways where appropriate. • Continuing the work on the discharge process. • An outlier team to reduce the number of medical outliers to reduce the length of stay for those patients. • A number of schemes under discharge planning to both reduce the number of breaches and the number of patients with a delay length of stay. The chart below describes the initiatives and the effect on performance for the Winter plan. The position shows that for October, November and December actual performance was above underlying performance by 5.8%, 3.5% and 7% respectively.

Link to summary E.B.S.5 Trolley waits in A&E no longer than 12 hours. Total number of patients who have waited over 12 hours in A&E from decision to admit to admission. (Trust) Target: 0 Current Performance 12 12/2018 Current Issues: Please see above. Improvement Plans:

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 149 Please see above.

Link to summary Ambulance Category 1 -Time critical and life threatening events (We aim to respond to these calls within an average time of 7 minutes.) Target: 00:7:00 Current Performance NWAS CSR CCG GP CCG 12/2018 00:07:41 00:09:05 00:07:24 Current Issues: Response time improvement requires operational reconfiguration of vehicle profile. Call volume remains high. Improvement Plans:

The CCG have now setup bi-monthly meetings to discuss specific performance concerns for central Lancashire. Following the first meeting NWAS have agreed to set local recovery trajectories that we can use to measure improvements against. A number of actions have commenced and improvements in performance can be expected in January. Actions include: 1. Auto clear, being piloted at RPH so ambulances are turned round more quickly. 2. Promoting alternative transport for patients into hospital. 3. An increased target for See and Treat. 4. Five additional vehicles (3 Preston, 1 Chorley, 1 Leyland). 5. Update of the staffing rotas.

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

Link to summary

Category 2 - Potentially serious conditions that may require rapid assessment, urgent on-scene clinical intervention/treatment and/or urgent transport (Respond to these calls within an average time of 18 minutes.) Target: 00:18:00 Current Performance NWAS CSR CCG GP CCG 12/2018 00:24:52 00:27:33 00:25:15

Current Issues: Please see Category 1 above.

Improvement Plans: Please see Category 1 above.

Link to summary Category 2 - Potentially serious conditions that may require rapid assessment, urgent on-scene clinical intervention/treatment and/or urgent transport (Respond to these calls within an average time of 40 minutes.) Target: 00:40:00 Current Performance NWAS CSR CCG GP CCG 12/2018 00:53:44 00:59:11 00:53:31 Current Issues: Please see Category 1 above. Improvement Plans: Please see Category 1 above.

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 150

Target: 02:00:00 Current Performance NWAS CSR CCG GP CCG 12/2018 02:50:34 02:53:12 02:46:18 Current Issues: Please see Category 1 above.

Improvement Plans: Please see Category 1 above.

Link to summary Category 4/4H/4HCP - Non urgent problem (not life-threatening) that requires assessment (by face to face or telephone) and possibly transport within a clinically appropriate timeframe We aim to respond to these calls within 180 minutes (3 hours) in 9 out of 10 cases. Target: 03:00:00 Current Performance NWAS CSR CCG GP CCG 12/2018 03:25:06 03:19:49 04:17:24 Current Issues: Please see Category 1 above. Improvement Plans: Please see Category 1 above.

Link to summary E.B.S.7a All handovers between ambulance and A&E must take place within 15 minutes with none waiting more than 30 minutes (Royal Preston / Chorley District) Target: 0 Current Performance CDH 4 RPH 50 12/2018 Current Issues: The number of over 30 minute breaches has reduced in December after the increase in November. Improvement Plans:

1. Reducing Corridor Nursing: LTHTR working on new Rapid Assessment and Treatment work, with capacity to assess seven patients. 2. Time to First Assessment and Time to DTA: The ED clinicians are working with the acute physicians and specialty clinicians to design the pathways which are being tested currently using a PDSA approach. This includes direct streaming from the ambulance crews to ambulatory care and will include direct streaming from triage to ambulatory care over time. 3. Maximised Use of Ambulatory Care: With the support of EY LTHTR has undertaken a comprehensive analysis of our ED attendance and calculated the ambulatory care potential to maximise patients being streamed to ambulatory care (note the national definition is patients who would have been expected to be admitted). The top ten pathways are now being designed to be implemented when the ambulatory care area reopens following the location back. The next focus is to extend the opening hours.

Link to summary

E.B.S.7b All handovers between ambulance and A&E must take place within 15 minutes with none waiting more than 60 minutes (Royal Preston / Chorley District) Target: 0 Current Performance CDH 0 RPH 30 12/2018 Current Issues: The number of over 60 minute breaches has increased in December at the Royal Preston Hospital (RPH).

Improvement Plans: Please see Ambulance handover time No. >30 mins (Royal Preston).

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 151 2.2.3 Urgent Care Integrated Business Plan

Following continued quality concerns, the category A bed procurement provision was formally suspended to all admissions on 06/02/19. The original provider of the category A bed procurement (Spiral Health CIC) no longer exists, the new organisation (Springfield Manor Gardens ltd) is awaiting approval of their CQC registration. This will leave the organisation without a CQC registration for a period of time. All patients and staff are fully aware. Multiagency weekly support is being provided to the provider to ensure patient safety is maintained.

The other project identified with risks was CHC, which is on the 2019/20 Business Plan.

The projects on the plan with identified savings have been achieved.

The Business Plan for 2018/19 is now closed and the focus will be on 2019/20.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 152 2.3 Elective Care

2.3.1 Elective Care Referrals

2017-18 2018-19

Market Share of Providers up to 31st December 2018 Market Market Referral Referral Referrals Referrals Share Share Variance Variance %

LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST 84,652 76.40% 83,938 76.18% -714 -0.22% RAMSAY HEALTHCARE UK OPERATIONS LIMITED 14,183 12.80% 15,150 13.75% 967 0.95% BLACKPOOL TEACHING HOSPITALS NHS FOUNDATION TRUST 4,050 3.66% 2,691 2.44% -1,359 -1.22% WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST 3,231 2.92% 3,417 3.10% 186 0.18% EAST LANCASHIRE HOSPITALS NHS TRUST 1,198 1.08% 1,101 1.00% -97 -0.08% SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST 802 0.72% 1,106 1.00% 304 0.28% UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST 650 0.59% 609 0.55% -41 -0.04% BOLTON NHS FOUNDATION TRUST 348 0.31% 440 0.40% 92 0.09% Grand Total 109,114 98.48% 108,452 98.42% -662 -0.06%

Overall referrals (GP, Hospital and Other) have reduced by 0.06% YTD. The GP referrals category has seen the biggest reduction including these specialties, trauma and orthopaedics, medical ophthalmology, ENT and pain management. GP and hospital referrals have reduced in December compared to the previous year as illustrated in the chart below.

2.3.2 Elective Care Finance and Activity

Activity Cost £'000 Elective Care as at 31st December 2018 Act Var Cost Var Plan Actual Variance Plan Actual Variance % % Inpatient Daycase 35,513 36,293 779 £26,621 £26,867 £247 2% 1% Inpatient Elective 6,058 5,886 -172 £18,603 £17,929 -£674 -3% -4% Outpatient First Attends 86,102 89,380 3,278 £12,723 £13,222 £499 4% 4% Outpatient Follow-up Attends 204,148 198,544 -5,603 £13,385 £13,019 -£366 -3% -3% Outpatient Procedure 46,403 47,333 931 £6,058 £6,403 £345 2% 6% Grand Total 378,224 377,437 -787 £77,390 £77,440 £50 0% 0%

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

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 153 Inpatient day case activity is over performing by 2%. This over performance is driven by specialties, colorectal surgery, ophthalmology and plastic surgery.

The most frequent ophthalmology procedure undertaken is phacoemulsification cataract extraction and lens implant, with CC score 0-1. For colorectal surgery it is ‘diagnostic colonoscopy with biopsy’, 19 years and over. For plastic surgery it is ‘minor skin procedures’, 13 years and over.

Outpatient First Attends

Both activity and cost are above plan by 4% as at month 9. The main areas of over performance are dermatology, cardiology, urology and paediatric trauma and orthopaedics.

Outpatient Follow up Attends

Follow-up activity and cost are both below planned levels by 3% at month 9. The main areas of underperformance are pain management, paediatric trauma and orthopaedics, and spinal surgery service.

Outpatient Procedures

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 154 Overall outpatient procedures are 2% above plan for activity whilst costs are 6% above plan at month 9. The specialties that are affected are ophthalmology, gastroenterology and general surgery.

Following the AQN issued in July 2018 around an observed increase in outpatient procedure activity relating to minor/intermediate retinal procedures and retinal tomography, a meeting took place on 1 August 2018 to discuss in more detail, however, no analysis had been undertaken. Following a number of discussions, the CCG wrote again in October outlining the case in more detail, subsequent discussions at the operational group in November highlighted the Trust were to revisit procedures and coding for ophthalmology and the change could have been as a result of some transformational work that had been undertaken. The CCG have requested a copy of the business case to review the plans, however, to date, this has not been received.

Elective Activity

Overall elective inpatient and day case activity is under plan by 3% and cost is under plan by 4%. Specialties over performing are general surgery, urology and interventional radiology.

Specialties underperforming against plan for activity and cost are trauma and orthopaedics, plastic surgery and gastroenterology.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 155 2.3.3 Elective Care Performance Exceptions Referral to Treatment E.B.3 Referral to Treatment RTT (Incomplete) Percentage of Service Users on incomplete RTT pathways (yet to start treatment) waiting no more than 18 weeks from referral. Target: 92% Current Performance 87.5% CSR 88.4% GP 12/2018 CCG CCG Current Issues: Both CCGs are under the 92% threshold and show a slight deterioration from November. LTHTR position has also deteriorated slightly and is now at 79.8%.

RTT 52 week breaches have reduced significantly from the November/December position, from a high of 65 in November to 28 as at 15 February, however the trend is slightly worse as the week before showed 22. This is a result of the work done to try to reduce breaches to 0 by December in line with the trajectory, i.e. a lot of breach patients were booked in December. However, a number of issues arose which resulted in a failure to achieve the trajectory levels, with some of these issues continuing into the new year: • A neurosurgery ward was shut due to D&V which impacted on the elective programme. • One of the ENT consultants is off sick, meaning long waiting patients cannot get treatment • A plastics consultant is also off sick • Capacity issues (staffing) within HDU leading to elective cancellations

Twenty of these breaches are in neurosurgery and with numbers waiting over 40 weeks also high (126) this specialty remains a problem. Seven of the remaining breaches are in ENT. The longest wait is 68 weeks (neurosurgery). LTHTR are still aiming to reduce to 0 by the end of March.

The pressures resulting in this level of performance are manifold – there are capacity issues across a number of specialties, a backlog of validation work, and increased growth in GP referrals in a small number of specialties (including urology, plastics and oral surgery), and growth in consultant initiated referrals in a number of other specialties. Improvement Plans: 1. Following the issue of a contract performance notice, the CCG has received and signed off a Recovery Action Plan (RAP) from LTHTR giving trajectories around reducing both waiting list numbers and 52 week breaches. The weekly RTT steering group, with key members from the CCGs and LTHTR, is continuing - this group is supporting timely action planning around long waits and RTT, as well as monitoring whether the RAP actions and trajectories are on track on a regular and frequent basis.

2. Transformational work is under way across a range of specialties including MSK and ophthalmology. Ophthalmology transformation should see LTHTR develop significantly more capacity for acute conditions and procedures.

3. Actions in the RAP to address specialty specific issues are usually themed around three areas: a) addressing capacity through recruitment, adding extra sessions (including Waiting List Initiatives) and outsourcing, b) validation and working through the validation backlog, and c) reducing demand in GP and Other referrals.

4. The CCG Deep Dive programme continues, with review meetings and actions set around ENT, ophthalmology, urology, colorectal and plastics. A presentation of deep dive data was given to LTHTR colleagues at the last steering group meeting, and it was agreed that the tool would be used to complete regular joint reviews of referral activity.

5. A process has been agreed to manage consultant initiated referrals (CIs) within LTHTR using a centralised process, which should help reduce growth in this area. However, the Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 156 introduction of this process has not progressed as quickly as expected. Further work to send inappropriate CIs back to the GP has been agreed by CCG SMT – LTHTR senior leadership team have now agreed this process.

6. A peer review of the neurosurgery pathway within LTHTR has been carried out by the SPEC COMM quality surveillance team, with CCG representation – the outcome of this will be actioned and monitored through the RTT steering group.

7. The CCG and SPEC COMM have facilitated a Neurology and Neurosurgery Workshop focusing mainly on flow and capacity.

8. The plan around ophthalmology, another pressured speciality where numbers are still increasing, is three fold: continue to use the private sector, implement the agreed transformation to increase capacity, and put on more WLIs to clear the backlog. The Trust have agreed to quantify the impact of these workstreams. 9. There is no plan to achieve RTT within this financial year with the focus remaining on reducing pathways and 52 week breaches.

Link to summary Referral to Treatment E.B.S.4 Zero tolerance RTT waits over 52 weeks for incomplete pathways Target: 0 Current Performance CSR CCG 1 GP CCG 5 12/2018 Current Issues: The numbers of breaches at CCG level have reduced significantly this month and are now in single figures for the first time since June. Although the latest in month LTHTR figure shows a slight increase from 22 to 28, this is significantly reduced from a high of 65 in December, (breakdown of these breaches is above in RTT section) - there is no exact correlation as the neurosurgery breaches are badged against NHS England rather than CCGs, and the position outlined above for LTHTR is an in-month figure in February (a ‘live’ position), whereas the figure here is the validated month end figure at end December – breaches only count towards the final end of month figure if they are still breaching at month end, i.e. they haven’t been treated at that point.

At Chorley and South Ribble there is one breach in ENT at LTHTR. Greater Preston have five breaches – two in ENT at LTHTR, two in cardiology at Blackpool, and one in plastics at Manchester University Hospitals NHS Trust.

Improvement Plans: As described in the RTT section, the levels of 52 week breaches have significantly decreased at both LTHTR and at CCG level. The CCG are managing LTHTR on a recovery plan specifically for long waits, total pathways and 52 week breaches, which includes choice alternatives for patients, local targets, and escalation procedures. Please see RTT section above for further actions.

Link to summary

E.B.4 Percentage of Service Users waiting 6 weeks or more from referral for a diagnostic test Target: 1.00% Current Performance CSR CCG GP CCG 12/2018 4.76% 7.90% Current Issues: The 6 week diagnostic target, which was already a concern, has deteriorated significantly at both CCGs. There were a total of 122 patients waiting over 6 weeks in December at Chorley and South Ribble, 100 of which were at LTHTR (with the majority of the other breaches at Ramsay (13). Greater Preston underperformance relates to 302 breaches, 295

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 157 of which were at LTHTR. This is reflected in underperformance at LTHTR at 6.91%, the fifth month in a row that the Trust has failed this target.

Improvement Plans: The main causes of the deterioration in December across both CCGs are Computed Tomography (CT), audiology assessments, echocardiography and endoscopy at Lancashire Teaching Hospital, and non-obstetric ultrasound at Ramsay Healthcare. The LTHTR remedial action plan states; • CT – The present scanners are ageing, have broken down frequently and require replacement. • Endoscopy – There is a capacity shortfall of 88 points per week. • Echocardiography – There is sickness/absence, increasing workloads and capital equipment issues.

A Contract Performance Notice was issued by the CCG in early December requesting a Remedial Action Plan from Lancashire Teaching Hospital. The CCG has subsequently received this plan. • CT scanners -The target for replacement is April 19. LTHTR will be using mobile scanners as there will be a 10 week turnaround to replace the scanners. • Endoscopy – Resolved through insourcing as well as reviewing patient pathways, endoscopy estate, the use of the suite by respiratory patients and maximising non- medical endoscopy capacity. • Echocardiography – Bank cover for echo cardiographers, upgrades to machines which have now been identified as part of the capital replacement scheme for 2019 and outsourcing of clinics to the independent sector as a subcontract.

The RTT steering groups, meeting fortnightly, will include diagnostics as an agenda item • The Remedial Action Plan will be formally monitored through the contractual processes. • This issue will be put on the CCG risk register. • Regular updates will be provided to the CCG Quality and Performance Committee , Governing Bodies and Trust Board.

A contract performance noticed was issued to Ramsay Healthcare in November for non- compliance against the diagnostic target for Euxton Hall Hospital. Ramsay have produced a Recovery Action Plan which is being monitored through the contractual process. Link to summary

Percentage of service users on Incomplete pathways waiting no more than 18 weeks from referral (AHP @ LCFT) Target: 92.00% Current Performance CSR CCG GP CCG 12/2018 91.6% 99.3% Current issues: The performance for Chorley and South Ribble CCG represent 75 patients waiting more than 18 weeks for a first appointment. The majority of these patients are in Children’s Therapy Services, namely waiting for Occupational Therapy (OT) and Speech and Language Therapy (SALT).

Improvement Plans: The CCG is working with the Assistant Network Director for the Children’s and Young Person’s Network on an action plan to address OT and SALT performance.

For OT performance • Teams are monitoring RTT weekly , hotspots are escalated in real time • Short fall in staffing are being mitigated in the short term by staff working extra hours and use of bank staff.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 158 • Recruitment is ongoing and is likely to be an issue for the next 6 months. • OT competency framework will allow the upskilling of some staff. • Triage processes are being reviewed to ensure consistency across the localities. • The ratio of clinical and non-clinical time is being reviewed to maximise patient facing time For SALT performance • The Trust is producing a detailed trajectory on how demand for these services will be met • Teams are monitoring RTT weekly , hotspots are escalated in real time • SALT competency framework will allow the upskilling of some staff • Clinical job plans are being reviewed to increase patient facing time. • Recruitment to vacancies is ongoing

Link to summary No increase of total Acute pathways from March 2018 figure

Target: 11215 (CSR) Current Performance CSR CCG GP CCG 13470 (GP) 12/2018 14,200 16,360 Current issues: There is a new target for CCGs and Trusts for 2018/19 to ensure that there is no growth in acute pathways (i.e. those on an incomplete RTT pathway) from the March 2018 position. The target levels above are the final March waiting list numbers at CCG level. As documented above in the RTT and 52 week sections, a Recovery Action Plan has been agreed with LTHTR, which includes trajectories to reduce 52 week breaches and total pathways back to target levels. The Trust is still significantly above this trajectory, with 32571 pathways (December position) against a 30762 target. However, the December position shows a reduction against the November position by 783 pathways, a significant improvement.

The CCG position increased in October due to commencement of the new Tier 2 iMSK service provided by Lancashire Care Foundation Trust. NHS England advised that this activity should be considered consultant-led, and therefore counts towards the RTT target, despite both the provider and the CCG challenging this position, due to the consultant-led element being approximately 10% of the total activity. As a result of this ruling, 4,600 patients were therefore added to the waiting list in October and these have remained through to the December waiting list. This places both CCGs significantly above target.

Improvement Plans: Please see above RTT section for RAP and other actions to address this target.

The decision to classify MSK referrals as consultant-led is being challenged by the CCG.

Link to summary Cancer Waiting Times E.B.9 Percentage of Service Users waiting no more than one month (31 days) from diagnosis to first definitive treatment for surgery Target: 94% Current Performance CSR CCG GP CCG 12/2018 92.00% 100% Current Issues: The performance at CSR CCG represents 2 breaches out of 25 patients on the pathway. The main reason for these breaches is inadequate elective capacity for gynaecology.

Improvement Plans: • A rise in 2 week referrals for the breast pathway has resulted in the Trust subcontracting

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 159 to Ramsay Healthcare at Euxton Hall for their triple assessment. • A new consultant for upper GI has recently been appointed. • Nurse endoscopists are being trained up, which has led to short term capacity, but will increase capacity in the long term. • There is a backlog of patients on the gynaecology pathway which LTHTR have sent to BMI Manchester as a subcontract for treatment. • The urology template biopsy equipment recently procured will assist in clearing the backlog in February and March. Link to summary

E.B.7 Percentage of Service Users with Breast Symptoms waiting no more than two weeks from urgent GP referral to first appointment Target: 93% Current Performance CSR CCG GP CCG 12/2018 100% 92.5% Current Issues: The performance in month represents 3 breaches out of 40 patients on the pathway. Two of the breaches were patients being treated at LTHTR, with the breach being for patient choice. The third breach occurred at Wigan, Wrightington and Leigh Acute Trust, we do not have a reason for the breach at this point.

Improvement Plans:

Please see E.B.9 above.

Cancelled Operations E.B.S.2 All Service Users who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the Service User's treatment to be funded at the time and hospital of the Services User's choice (Trust)

Target: 0 Current Performance LTHTR 11 12/2018 Current Issues: These occurred across a range of specialties. Only one patient is awaiting a date for their surgery. The main reason for underperformance in this area is due to capacity.

Improvement Plans: 1. The CCG 18wk RTT action plan continues to be monitored on fortnightly basis and as a result the performance for cancelled electives is expected to improve. 2. The CCG have requested an update in relation to the patients who are awaiting their date for surgery. 3. The CCG routinely request assurances that the affected patients are not waiting for cancer surgery and that no harms occur as a result of the cancellations. 4. The CCG have requested additional assurances around the actions being taken to reduce the number of cancellations that occur for non-medical reasons.

Link to summary EMSA E.B.S.1 Sleeping Accommodation Breach Target: 0 Current Performance CSR CCG 18 GP CCG 15 12/2018 Current Issues: Sleeping accommodation breaches continue to be reported, these are mainly attributable to the critical care unit. This month has seen a marked improvement in the number of breaches reported.

Improvement Plans: Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 160 1. The previous issue regarding endoscopy reporting have been resolved. 2. The patient flow team track the flow requirements of the critical care unit three times a day. 3. A further deep dive review is underway by LTHTR and will be shared with the CCG once complete. 4. No complaints have been received as a result of this position. 5. Steps are taken to protect the patient’s privacy and dignity when a breach occurs.

Link to summary

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 161 2.3.4 Elective Care Integrated Business Plan

The Integrated Business Plan for 2018/19 is now closed. The projects on the plan with identified savings have been achieved. The focus is now on working up the Business Plan for 2019/20.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body 27 March 2019 Page 162 2.4 Mental Health and Learning Disabilities

2.4.1 Mental Health Referrals

Mental Health / Learning Disability Referrals 400 350 300 250 200 150 100 50 0

Chorley & South Ribble Greater Preston 12 per. Mov. Avg. (Chorley & South Ribble) 12 per. Mov. Avg. (Greater Preston) The mental health referrals, which are a combination of Adult and Children’s Services at LCFT, appear to be relatively static over the previous 18 months.

2.4.2 Mental Health Finance and Activity

Lancashire Care Foundation Trust (LCFT) – Activity by service Data to 31st December 2018 Service Plan Actual Variance Var % ADHD Contacts 455 265 -190 -41.8% CMHT Adult Teams Contacts 16,499 16,166 -333 -2.0% CMHT Older Adult Contacts 5,109 5,319 210 4.1% CRHT Face to Face Contacts - 18 to 65 9,312 8,458 -854 -9.2% CRHT Face to Face Contacts - Below 18 328 389 61 18.6% CRHT Face to Face Contacts - Over 65 142 56 -86 -60.6% CRHT Telephone Contacts - 18 to 65 4,768 5,297 529 11.1% CRHT Telephone Contacts - Below 18 46 273 227 493.5% CRHT Telephone Contacts - Over 65 51 84 33 64.7% Criminal Justice Liaison - Contacts 839 1,367 528 62.9% Eating Disorder Service - Contacts 2,844 695 -2,149 -75.6% Hospital Liaison Contacts 692 623 -69 -10.0% MAS Teams - Contacts 5,995 6,922 927 15.5% RITT Contacts 3,960 4,315 355 9.0% Adult Ward Occupied Bed Days 9,243 10,910 1,667 18.0% Older Adult (Dementia) Ward Occupied Bed Days 1,728 2,613 885 51.2% Older Adult (Functional) Ward Occupied Bed Days 1,350 2,288 938 69.5% PICU Ward Occupied Bed Days 1,521 1,950 429 28.2% Year to Date 64,882 67,990 3,108 4.8%

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 163 27 March 2019 The CCGs are associate commissioners to the LCFT mental health contract, which is hosted by Blackburn with Darwen CCG.

The table above now includes the baselines. However, there may be further amendments to these due to Morecambe Bay, Fylde and Wyre and Greater Preston CCGs involvement in GP practice transfers.

2.4.3 Mental Health Performance Exceptions

Mental Health and Learning Disabilities Proportion of patients on (CPA) discharged from inpatient care who are followed up within 7 days Target: 95% Current Performance CSR CCG GP CCG 12/2018 90.91% 95.65% Current issues: Chorley and South Ribble CCG has failed this target in December, due to two breaches of this target. One of these patients had DNA’d twice, and the other was due to an admin error – the patient did not require follow up, however this was not communicated to the relevant team.

Improvement Plans: Both patients have subsequently been followed up, with no further action for the second one. The trend for both CCGs is one of achievement with the odd blip – the low volume of patients means that one or two breaches can result in underperformance. All breaches are discussed at the monthly Mental Health Performance Effectiveness Group.

Link to summary

Mental Health and Learning Disabilities Percentage of People experiencing a first episode of psychosis treated with a NICE approved care package with two weeks of referral Target: 53% Current Performance CSR CCG GP CCG 12/2018 0.00 % 0.00% Current issues: Both CCGs failed this target this month at 0%. Although this is very poor performance, with all patients seen outside the target timescale this month, the numbers of patients are low, with Chorley and South Ribble seeing four patients and Greater Preston one patient. The overall LCFT position has also failed at 46.7%.

Most delays in the service at the moment are usually due to delays in the referral process, as the clock for these patients starts when they have first contact with any LCFT service, even if psychosis is not initially suspected. Increased demand across most mental health services has had some impact on this service, as increased pressure will reduce the capacity for other mental health services to identify these patients in line with the target timescale. There have also been a number of patient choice breaches due to the Christmas period, as people chose to wait after the holidays. Improvement Plans: 1. The service, in conjunction with commissioners, have looked for trends at CCG level, but with the numbers so low the overall conclusion is that there are no prominent trends at this level. 2. Support is being sought from commissioners to share guidance for GP’s around symptom identification to support timely referrals, with a GP referral form being developed to support this process. 3. A SITREP process is in place to ensure that all service user pathways are tracked to monitor timely appointments.

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 164 27 March 2019 4. On-going engagement work is continuing to review efficiency opportunities to support the capacity in EIS. This has included a review of standard record keeping, activity to support staff wellbeing, review of procedures and environmental concerns related to staff safety. 5. NHSi IST will work with the service to review patient referral pathways and flow alongside considering how improving capacity can increase the carer’s support and family intervention offer.

Link to summary

Mental Health and Learning Disabilities The percentage prevalence of people who have depression and/or anxiety disorder who receive psychological therapies (NEW KPI 2018/19) Target: 1.58% Current Performance CSR CCG GP CCG 12/2018 1.16% 1.30% Current issues: The national IAPT prevalence target is 19% by quarter 4. Although the trajectory is staggered to increase every quarter (the target level above reflects this trajectory), at present this is an internal target as contractually LCFT are only mandated to deliver 19% in quarter 4 and 16.8% in quarters 1-3. In line with most Lancashire CCGs, Greater Preston has been consistently underperforming against both the trajectory and the contractual target. However, Chorley and South Ribble CCG are also failing this target in December, and in fact all Lancashire CCG’s except Blackburn failed in December.

The underperformance is caused by a reduced number of referrals received by the service to achieve the prevalence target. There are also some capacity issues within teams to complete the assessments due to a recent transition to individual welcome calls from group sessions.

Furthermore, all teams have had a lower number of referrals and assessment appointments in December. This is typical of previous years when self-referrals into the service are low and people ask for their appointments to be booked outside of the Christmas period.

Improvement Plans: • Review all job plans to ensure the capacity is available across all teams to meet the demand for welcome calls coming into the service on a weekly basis due to recent clinical model change. It has been identified that in some teams clinical and estate capacity is not balanced, and urgent work is under way to restore the balance and clinician staff are able to work to their job plans. This work is due to complete in February. • Increased communication and engagement with primary care to increase referrals and engagement with the service.

Link to summary

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 165 27 March 2019 2.4.4 Mental Health Integrated Business Plan

The Integrated Business Plan for 2018/19 is now closed. The projects on the plan with identified savings have been achieved. The focus is now on working up the Business Plan for 2019/20.

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 166 27 March 2019 2.5 Medicine Management

2.5.1 Medicine Management Finance and Activity Primary Care Prescribing Savings Schemes Over / (under) achievement to Annual Savings within Budget date CSR GPR Total CSR GPR Total £000 £000 £000 £000 £000 £000

Planned Work Programme M.O.T. workplan 222 276 498 15 60 75 Meds Opt in Care Homes (MOCH) 37 45 82 (12) (15) (27) Medicines coordinators 908 873 1,781 34 (44) (10) Scriptswitch 281 302 583 35 52 87 Woundcare products 15 19 34 0 0 0 PQSS Incentive Scheme 135 179 314 (1) (6) (6) 3rd party repeat prescribing waste 518 883 1,400 (19) (76) (95) Sub Total: Planned Work Programme 2,116 2,576 4,692 52 (29) 24

Fortuitous QIPP Pregabablin 313 417 730 82 98 180 Pharmaceutical Rebates 45 45 90 2 3 5 Patent Expiries 95 105 199 183 183 366 Sub Total : Fortuitous QIPP 452 567 1,019 267 284 551

Total PC Prescribing 2,568 3,143 5,711 319 255 574

Medicines Optimisation Team (MOT) workplan, Medicines coordinators and Scriptswitch The above values are based on January data. CSR MOT savings have continued to improve and are now ahead of plan. MOT work has predominately focused on key quality areas in the first part of the year, and savings have increased with the recent focus on financial savings areas. CSR Medicines Coordinators’ savings position has also continued to improve. There have been a number of staffing changes with medicines coordinators this year. There has been a focus on engagement with training sessions increased to accommodate new starters. The 2018/19 GP Quality Contract KPIs have been updated to include medicines coordinator engagement and an increased Scriptswitch acceptance rate.

Medicines Optimisation in Care Homes Although there has been some slippage on scheme start date, staff have now been recruited to these the two posts.

Woundcare products This central ordering initiative delivers reductions in item waste and an increase in the proportion of formulary compliance.

PQSS Incentive Scheme The current gainshare scheme’s twelve month term ended on 30 June 2018. The above savings are based on June data. Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 167 27 March 2019 Waste reduction - Third Party Repeat Prescribing: The above savings are based on data for April to October. Savings are measured for the first 12 months live in each practice and cumulatively the scheme has saved £1.5million over the two financial years. The first practices went live in April 2017 and there are now 49 of 56 practices live as at September 2018, with one more live in November.

Pregabalin and Patent Expiries are based on October data and reflect savings from tariff reductions. Pharmaceutical Rebates reflects rebates received on Seretide and Sitagliptin.

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NHS Chorley and South Ribble CCG Governing Body Page 168 27 March 2019 2.6 Provider Quality Performance Exceptions

Quality and Experience – Lancashire Teaching Hospitals NHS Foundation Trust Lancashire Teaching Hospitals - Admission to designated stroke ward within 4 hours of presentation Target: 90% Current Performance 52.17% 12/2018 Current Issues: Performance was 52.17 % in December. This is not in line with the improvement trajectory that has been agreed with the CCG. Underperformance remains largely due to capacity issues.

Improvement Plans: 1. The CCG are continuing to monitor the remedial action plan and progress against the improvement trajectory in relation to this indicator. 2. Monthly meetings continue with LTHTR and the CCG. 3. At LTHTR a weekly MDT 4 hour breach meeting continues. This is to gain a rapid understanding of any current issues and to ensure that improvement methodology principles are enacted where appropriate. 4. A briefing paper has been approved by LTHTR executives in relation to the consistent ring fencing of 6 acute beds and 2 assessment trolleys. This will ensure that stroke patients have timely access to the stroke unit. The aim is for the pilot to start in February 2019. 5. An additional stroke specialist nurse started in January 2019. Consultant recruitment is ongoing though international recruitment and through the British Medical Journal (BMJ). 6. The CCG is awaiting feedback from the LTHTR on the resubmitted business case following on from the Stroke Peer Review Action Plan. 7. A Stroke Strategy Group (chaired by the CCG) is also in place to ensure that progress is made that is in line with the Lancashire and South Cumbria Integrated Stroke Service Specification.

Link to summary

Lancashire Teaching Hospitals – Medication error with harm Target: 2 Current Performance 22 12/2018 Current Issues: Twenty two medication errors with harm were reported in December (19 were low harm, three moderate harm). Two of the moderate harm incidents related to the same episode of care so have been combined. A level two investigation is underway.

Improvement Plans: 1. A thematic analysis of all insulin incidents is planned to be undertaken by the diabetic team with the medicines safety officer. 2. Two improvement actions are currently underway by the medicines safety champions focussing on critical medications and the classification of medication incidents. 3. The medicines safety champion role continues to be promoted via the Harm Free Care Committee across LTHTR 4. The CCG continue to receive monthly medicine safety reports to ensure that further detail and assurances are received. This includes trends and themes of incidents reported. These reports are analysed and any queries are raised directly with the Trust.

Link to summary Serious incidents Lancashire Teaching Hospitals - Serious incidents (including Never Events) Target: 0 Current Performance 7 12/2018

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NHS Chorley and South Ribble CCG Governing Body Page 169 27 March 2019 Current Issues: Seven serious incidents were reported in December (which included two Never Events). One diagnostic delay, two pressure ulcers, one slips, trips and falls, one sub-optimal care of the deteriorating patient. Two Never Events were reported in December, one was a misplaced nasogastric tube and the other related to wrong site surgery.

Improvement Plans: • A second round table discussion has been convened in response to the reported Never Events. There was representation from NHSE, NHSI, CQC, CCG and LTHTR at this meeting. This meeting considered the current situation in order to identify next steps and key actions. • LTHTR are currently undertaking a thematic review of these incidents. The report will be presented at the Quality and Safety Committee in February before submission to the Board. • NHS Improvement has supported an external review into the rise in reported pressure ulcers. The CCG have requested that this is shared. • The CCG serious incident review panel continue to review all submitted StEIS reports in order to ensure that the action plans submitted in the reports reflect the learning that has been identified from the incident. • LTHTR continue to send lead clinicians to discuss their reports at the CCG Serious Incident Review Panel.

Link to summary

A&E FFT (% who would recommend) Target: 85% Current Performance 82.94% 12/2018 Current Issues: This is slightly below the required target which may be due to the time of year and a high level of patient attendances in the department. The response rate also decreased which may have affected overall performance.

Improvement Plans: • The CCG will continue to monitor this target. • A number of improvements are underway in relation to emergency and urgent care at the Trust (as part of the VSA work streams). It is envisaged that these will positively impact on this target.

Link to summary

Quality and Experience – Lancashire Care NHS Foundation Trust (LCFT) Lancashire Care NHS Foundation Trust (LCFT) - Pressure Ulcers Grade 3 and 4 Target: Current Performance: G3 – 13 (YTD 95) To be determined 12/2018 G4 – 2 (YTD 17) Current Issues: In December 2018, LCFT reported 13 Grade 3 pressure ulcers and two Grade 4 pressure ulcers.

As a health economy, there is a targeted focus to reduce the prevalence of pressure ulcers by increasing awareness of pressure ulcers, to reduce harm by enabling preventative interventions to be implemented at an earlier stage.

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NHS Chorley and South Ribble CCG Governing Body Page 170 27 March 2019 Improvement Plans: . All pressure ulcers have been reviewed and scrutinised by the LCFT Safety Senate to determine whether they were avoidable or unavoidable, and identify any learning to be shared and identify those that require StEIs reporting. . The CCG requested a thematic review in response to this, which has been received and was reviewed by the CCG Serious Incident Panel in November 2018. Four themes were identified based on the findings of the initial review, self-management/education, assessment, clinical record keeping and staff training. However, the incident remains open as further assurances have been requested. . The health economy wide Pressure Ulcer Prevention Group has reconvened to agree terms of reference for the group. LCFT senior nurse for nursing and quality has confirmed further dates have been scheduled for February and March 2019. . A working group is to re-commence with LCFT, LTHTR, LCC and CCG to review all thematic work undertaken to understand what the priorities are with regards to improvement work across the health economy. . React to Red training continues to be delivered to support staff to prevent pressure ulcers developing and deteriorating. LCFT continue to review all pressure ulcers via the safety senate to provide an enhanced level of scrutiny and rigour. Link to summary

Lancashire Care NHS Foundation Trust (LCFT) – Serious Incidents (SI) Target: 0 Current Performance: 3 YTD 25 12/2018 Current Issues:

In December 2018, LCFT reported three serious incidents.

The incidents related to pressure ulcers that were reviewed by the LCFT safety senate where it was determined there were potentially lapses in care that contributed to the development/deterioration of a pressure ulcer.

Improvement Plans: . Following a StEIS reportable incident LCFT will undertake a Rapid Review (within 72 hours) and submit this to the CCG. The rapid reviews have been received. . A full RCA in relation to each incident will be submitted to the CCG within 60 days. The investigative reports will then be duly reviewed by the CCG SI Review group to determine if the incidents have been thoroughly investigated and any lessons learnt cascaded across the health economy. . The CCG attends LCFT SI meetings where all SI cases are subject to a high level of scrutiny.

Link to summary Lancashire Care NHS Foundation Trust (LCFT) – Staff Friends and Family Test Target: Current Performance: Q2 Work 48.26% As a place of work 58% Care 66.64% For care and treatment 67% Current Issues Staff Friends and family test results remain below target.

Improvement Plans:

Although the percentage of staff who would recommend LCFT as a place of work and for care/treatment remains below target, the performance has improved over the last three quarters.

The release of the 2017 NHS Staff survey for LCFT highlighted a number of areas of Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 171 27 March 2019 concern that require improvement. In response to the staff survey, LCFT updated their People Plan and presented a comprehensive action plan which was presented to the CCG / Provider contract meeting in 2018. LCFT are participating in a retention project with NHSI to ensure there is a connection between the senior management team and the services. This will allow any key issues to be rectified in a timely manner. LCFT have also employed engagement leads to ensure staff feel that their voice is heard. This work will be managed as part of the CQC action plan, reported through the Oversight Group.

The CCG has requested further assurance of the steps being taken to improve FFT results and awaits the release of the 2018 National NHS Staff Survey published on the 26 February 2019, which will provide the CCG wi th greater oversight of staff feedback. Link to summary Lancashire Care NHS Foundation Trust (LCFT) – Mandatory Training (core staff) Target: 85% Current Performance: 82.65% 12/2018 Current Issues:

Overall compliance against the mandatory training target has deteriorated in month.

The Network is achieving the Trust target of 80% for overall training compliance, however, is short of the Trust’s tolerance target of 85%.

The review of mandatory training for the Trust was during quarter 3 and the new mandatory training profile was implemented on 4 December 2018. Alongside the mandatory training course review; a review of the course requirements against roles was also completed. The implementation of the changes has resulted in a reduction in the reported overall compliance percentage for the Trust and for each Network and has also resulted in an increase in the number of courses with a red RAG status.

Improvement Plans:

The Network is focusing on achieving the Trust’s target and tolerance target for its hotspots, particularly safeguarding children level 3, which affects all localities. Trajectories are being developed and progress against reported via Network Governance sub-group at locality level.

The CCG has requested LCFT share the trajectory to provide assurance of when the network plan to recover the compliance against safeguarding level 3. Link to summary Quality and Experience – Ramsay Health Care Ramsay Health Care – Complaints Target: 0 Current Performance 3 12/2018 Current Issues: Two complaints at Euxton Hall, one complaint at Fulwood Hall.

Improvement Plans: • Euxton Hall investigated two patient concerns re post-operative pain. One patient was issued an explanation, apology and further pain management and is now satisfied. The second was offered an informal meeting but has declined the invitation. • Fulwood Hall experienced issues with their telephone system. Following a patient complaint, this has been investigated and locally resolved temporarily until RHC can repair it completely. The CCG will seek assurance at the next contract meeting that this is fully resolved.

Link to summary

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 172 27 March 2019 3 RightCare

NHSE Update

The CCGs are still awaiting the publication of refreshed ‘Where to Look’ and ‘Focus’ packs, which were due to be disseminated to the CCGs from October 2018 onwards have not yet been received. The NHS England delivery partner advised these had been delayed and were expected early January 2019. However, to date, they have not been received.

RightCare areas of intervention – updated evaluation plans Following the submission of the evaluation plans in September 2018, the team met with the NHS England delivery partner and delivery fieldwork specialist to receive feedback. Further work on the plans was required, specifically linking schemes of work to the highlighted RightCare opportunities. The team were asked to resubmit the plans prior to Christmas 2018. This has now been completed. The CCGs are awaiting formal feedback on the refreshed plans.

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 173 27 March 2019 4 Leadership

4.1 Workforce

CSRCCG Integrated Board Report – HR – 31/01/201 Expected Rate Actual Rate Sickness 3% 3.15% Mandatory Training 100% 95.31% compliance Staff Turnover 0.92% 1.30%

Sickness The expected rate for monthly sickness absence is 3%, based on a widely used target throughout the NHS. Data for January 2019 showed that the monthly sickness rate was 3.15%. Sickness absence has increased since last reported for December 2018 (1.39%), and is slightly above the expected rate. The rolling sickness absence rate for the last 12 months is 2.93% (and 3.17% for the 2018/19 financial year). The CCGs’ in-house HR team continues to undertake random spot checks to ensure that managers are complying with the absence management policy by conducting return to work interviews within two working days of employees returning from sickness. Work continues in order to identify and understand any trends in sickness absences.

Turnover The CCGs are currently reporting a monthly turnover rate of 1.30% for January 2019. Turnover has decreased slightly since last reported for December 2018 (1.33%), and is slightly above the expected monthly rate of 0.92%. The national NHS average turnover is 11% over a twelve month period, and the CCG’s current rolling 12 month turnover rate is 11.31% (and 7.36% for the 2018/19 financial year). The CCGs monitor reasons for people leaving the organisation, with the main reasons over the past 12 months being due promotions.

Mandatory training The CCGs were below the 100% compliance rate for mandatory training in January 2019 with a rate of 95.31% completion. The figure is a combined compliance rate across Chorley and South Ribble CCG and Greater Preston CCG, inclusive of office holders. Compliance has increased since last reported in December 2018, when a combined compliance rate for both CCGs was 93.08%. Non-compliance mainly comes from individuals currently on maternity leave, off sick or on secondments with another organisation. The in-house HR team monitors compliance on a monthly basis and follows up with further requests to complete all outstanding mandatory training, or to provide the evidence to support where, for example, training has been completed in other organisations.

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 174 27 March 2019 4.2 Complaints

In January 2019, a total number of 12 complaints were received across both CCGs. This was one more than the previous month, as illustrated in table 1.

Table 1: Total number of complaints by CCG

December CCG January 2019 2018 CSR 7 8 GP 4 4 Total 11 12

Graph 1 illustrates the number of complaints received for the period January 2018 to January 2019, broken down by CCG, to provide a full year view.

Graph 1 Complaints received by CCG (January 2018 to January 2019)

Of the complaints received in January 2019, five were transferred to other organisations (as highlighted in table 2), one was locally resolved by the customer care team, and one remained open but was within the 28 day timeframe for response. Five complaints were logged for information only as they were already being dealt with by the provider, or the complainant was given advice as to how to raise the complaint directly with the appropriate provider.

Complaint topics in January related to clinical care, discharge processes, information recorded in patient records, and poor staff attitudes.

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NHS Chorley and South Ribble CCG Governing Body Page 175 27 March 2019 Table 2: Complaints transferred to other organisations

December January Provider 2018 2019 Lancashire Teaching Hospitals 1 1

Lancashire Care NHS Foundation Trust 0 2 Lancashire Care NHS Foundation Trust 0 0 – moving well service Ramsay 0 0

Out of area 1 0

Lancashire County Council 0 0

NHS England 0 2 North West Ambulance Service 0 0

GTD Healthcare 0 0

Other provider(s) 0 0

NHS 111 0 0

7.3 Freedom of Information (FOI) requests

A total number of 27 FOI requests were received in January 2019. This was 10 more than received in December 2018. Twelve requests remained open at the end of December. All of these are still within the statutory timeframe.

Across both CCGs there were no breaches and all responses were made within the statutory 20 working days timeframe. No response extensions were requested or applied in December 2018.

• A breach occurs when a response to a request for information under the FOI Act 2000 exceeds 20 working days.

• If a FOI request is complex, the CCGs can ask the requester for an extension in addition to the original 20 working days. A breach would not occur as long as the response was provided within the agreed extension period.

In January, across both CCGs, exemptions were applied to part of the response in respect of three FOI requests. There are a number of exemptions that direct the CCGs to withhold information from a requester. This could be due to the harm that would arise or would be likely to arise from disclosure. For example, if disclosure would be likely to prejudice a criminal investigation or prejudice someone’s commercial interests. An entire request can also be refused under the following circumstances:

• It would cost too much or take too much staff time to deal with the request. • The request is vexatious.

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NHS Chorley and South Ribble CCG Governing Body Page 176 27 March 2019 • The request repeats a previous request from the same person.

Topics for information requested this month included financial information relating to use of interpreters, details of staffing structures and spend on agency staff, and requests for information relating to the CCGs’ risk management systems.

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 177 27 March 2019 5 Glossary

A&E Accident & Emergency NHSI National Health Service Improvement AHP's Allied Health Professionals NICE The National Institute for Health and Care Excellence AMD Acute Macular Degeneration NWAS North West Ambulance Service ASD Autism Spectrum Disorder OHOC Our Health Our Care BP PC Better Payment Practice Code OPFA Outpatient First Attendances CC Complications and Comorbidities OPFUP Outpatient Follow Up CCG Clinical Commissioning Group OPPROC Outpatients Procedures CHC Continuing Health Care PDSA Plan Do Study Act CI Consultant Initiated PLCV Procedures of Limited Clinical Value CITNS Children's Integrated Therapy Nursing POD Point of Delivery Services CL Cash Limit QI Quality Improvement CPA Care Programme Approach QIPP Quality for Innovation, Productivity and Prevention CPN Contract Performance Notice RAP Recovery Action Plan CQUIN Commissioning for Quality and Innovation RAT Rapid Assessment and Treatment CSR Chorley South Ribble RCAs Root Cause Analysis CT Computed Tomography RHC Ramsay Health Care CYP Children and Young People RRL Revenue Resource Limit DC Day Case RTT Referral to Treatment DPH Director of Public Health SALT Speech and Language Therapy DToC Delayed transfer of care SLAM Service Level Agreement Monitoring ECDS Emergency Care Dataset SoFP Summary Statement of Financial Position EHH Euxton Hall Hospital StEIS Strategic Executive Information System EL Elective STF Sustainability and Transformation Fund EMSA Eliminate Mixed Sex Accommodation SUS Secondary Uses Service ENT Ear Nose Throat TARN Trauma Audit & Research Network EPACCS Electronic Palliative Care Coordination TCI To Come In System FFT Friends and Family Test TICCS The Integrated Care Clinics FOI Freedom of Information VSA Value Stream Analysis GP Greater Preston WLIs Waiting List Initiatives HCAI - Health Care Associated Infections - YTD Year to date CDIFF Clostridium Difficile HFC Harm Free Care HSMR Hospital Standardised Mortality rate IAPT Improving Access to Psychological Therapies IUCS Integrated Urgent Care Service IV Intravenous LCC Lancashire County Council LCFT Lancashire Care Foundation Trust LCSU Lancashire Commissioning Support Unit LTHTR Lancashire Teaching Hospital Trust MAP Main Access Point MAS Memory Assessment Service MH Mental Health MoD Ministry of Defence MRC Medical Research Council MRSA Methicillin-resistant Staphylococcus aureus MSA Mixed Sex Accommodation MSK Musculoskeletal NEC Not Elsewhere Classified NELSD Non-elective same day NELST Non-elective short stay

Integrated Board Report

NHS Chorley and South Ribble CCG Governing Body Page 178 27 March 2019

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Financial Performance Report Presented by Mr Matt Gaunt, Chief Finance and Contracting Officer Author Mrs Katherine Disley, Deputy Chief Finance Officer Clinical lead N/A Confidential No

Purpose of the paper The Joint Financial Performance Report sets out the combined financial position for NHS Chorley and South Ribble and NHS Greater Preston Clinical Commissioning Groups (CCGs) as at 28 February 2019. This report includes the summary financial position, summary I&E, productivity and efficiency (QIPP) and net risks.

Executive summary The CCGs are forecasting to achieve the planned breakeven position. The full year forecast reflects £5.3m of acute overspend against contract driven largely by non- elective cost pressures at LTH, the previously published QIPP shortfall of £2.1m and cost growth across tier 2 (out of hospital) services in particular drugs costs for eye treatments. These areas of overspend have been mitigated through the use of remaining CCG contingency, uncommitted budget and forecast underspends.

Recommendations The Governing Body is asked to note the financial position of the CCGs at the end of February 2019.

Links to CCG Strategic Objectives SO1 Improve quality through more effective, safer services, which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out-of-hospital provision SO3 Be an integral part of a financially sustainable health economy ☒

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

Financial Performance Report NHS Chorley and South Ribble CCG Governing Body Meeting Page 179 27 March 2019

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

N/A

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

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

Assurance

Financial Performance Report NHS Chorley and South Ribble CCG Governing Body Meeting Page 189 27 March 2019

Joint Financial Performance Report 2018/19 As at 28 February 2019 Forecast Outturn to 31 March 2019 Page 181 Page

Chorley and South Ribble CCG Greater Preston CCG

CCG Narrative - Joint position

The CCGs' statutory duty is to deliver a balanced financial position and separately support the Integrated Care System (ICS) proposed planning requirements which includes maintaining a 0.5% non-recurrent system risk reserve. This is consistent with the CCGs' strategic objective: “To be an integral part of a financially sustainable health economy.”

As at 28 February 2019 the CCGs are forecasting to achieve the planned breakeven position. The CCGs full year forecast reflects £5.3m of acute overspend against contract driven largely by non-elective cost pressures at LTH, the previously published QIPP shortfall of £2.1m and cost growth across tier 2 (out of hospital) services in particular drugs costs for eye treatments. These areas of overspend have been mitigated through the use of remaining CCG contingency, uncommitted budget and forecast underspends.

The CCG is continuing to work with its NHS partners to agree full year outturn values that will provide a balanced financial position across both CCGs, and which creates an equitable balance of risk across all partners. Agreement in principle has been reached with Lancashire Teaching Hospitals which equates to an over performance of £5.7m against 2018/19 contract values.

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CCG Summary Financial position - Joint position

Financial Duties Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key

Revenue Resource Limit On plan

Cash Limit Actions in place to achieve plan

Better Payment Practice Code NHS Miss to plan

Non NHS Information not available

Business Rules and Financial Performance Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key Messages

0% Revenue Surplus/(Deficit)

- The forecast is to achieve an in year break-even £0.0m. This is a 0.5% Non-Recurrent system risk reserve £0.0m variance to plan. - Efficiency and Productivity is performing £1.9m under plan. Efficiency and Productivity performance - 0.5% Non-recurrent system risk reserve is utilised as agreed by the Governing Body in September 2018. Running costs - Running costs are within budget. - Non-recurrent investments are in accordance with plan. Main Provider Performance - LTH - The CCGs are currently reporting a net risk position of £0.0m.

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Summary I&E - Joint

Annual Annual Annual Budget to Expenditure Variance to Annual Budget Forecast 2017/18 Outturn Date to Date Date Forecast Variance Outturn Variance

£000 £000 £000 £000 £000 £000 £000 £000 Favourable / Favourable / Favourable / (Adverse) (Adverse) (Adverse)

In-year Revenue Resource Limit 522,859 522,859 0 573,271 573,271 0 557,236 16,035

Total Revenue Resource Limit 522,859 522,859 0 573,271 573,271 0 557,236 16,035

Acute services Lancashire Teaching Hospitals NHSFT 189,862 190,583 (721) 207,740 210,884 (3,144) 203,051 (7,833) NW Ambulance service NHST 11,096 11,055 41 12,105 12,079 26 11,473 (606) Wrightington Wigan & Leigh NHSFT 6,832 6,570 262 7,461 7,304 157 7,427 123 Blackpool Teaching Hospitals NHSFT 4,638 4,824 (185) 5,060 5,431 (371) 5,080 (351) East Lancashire Hospitals NHST 2,960 3,035 (75) 3,233 3,291 (58) 3,131 (160) Ramsay 20,883 21,042 (159) 22,926 22,937 (11) 23,402 465 Other Acute service providers 15,816 19,239 (3,423) 15,990 17,933 (1,943) 24,430 6,496 Acute services 252,088 256,349 (4,261) 274,515 279,859 (5,344) 277,993 (1,866) Mental Health Services Lancashire Care NHSFT 36,949 37,411 (461) 40,065 40,569 (504) 38,837 (1,732) Other Mental Health providers 19,026 18,618 408 20,797 20,632 164 17,844 (2,788) Mental Health services 55,975 56,028 (53) 60,862 61,201 (339) 56,681 (4,520) Community Health Services Lancashire Care NHSFT 33,618 33,897 (280) 36,909 36,947 (38) 33,438 (3,509) Other Community providers 13,336 14,466 (1,130) 14,420 15,642 (1,222) 11,752 (3,890) Community services 46,954 48,364 (1,410) 51,329 52,589 (1,260) 45,190 (7,400) Other Programme: Continuing Care services 22,541 24,301 (1,760) 24,591 26,167 (1,576) 23,521 (2,646) Primary Care services 58,873 57,602 1,271 66,204 63,346 2,858 55,399 (7,947) Prescribing 51,686 51,156 530 56,574 55,995 579 59,994 3,999 Other Programme services 4,496 4,136 360 4,905 4,813 91 4,862 49 Corporate 6,258 5,622 635 6,841 6,295 546 4,486 (1,809) Reserves 16,384 12,059 4,325 19,153 14,868 4,285 13,565 (1,302) Healthcare Sub Total 515,255 515,617 (362) 564,974 565,134 (160) 541,692 (23,442)

Running Costs 7,604 7,243 362 8,297 8,136 161 7,922 (214)

Total Expenditure 522,859 522,859 0 573,271 573,271 0 549,614 (23,656)

Surplus/(Deficit) 0 0 0 0 0 0 7,622 (7,622)

Of which: CSR CCG Surplus/(Deficit) 0 0 0 0 0 (0) 3,370 (3,370) GPR CCG Surplus/(Deficit) 0 0 0 0 0 (0) 4,252 (4,252) * Outturn 2017/18 has been adjusted to reflect the boundary change for NHS Greater Preston CCG with effect from 1 April 2018.

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Productivity and Efficiency (QIPP) - Joint

Target QIPP 18,529

YTD Risk Net QIPP QIPP overview Plan YTD Plan Actual (Shortfall) / Adjusted (Shortfall) / as at 28th February 2019 Benefit FOT Benefit £000 £000 £000 £000 £000 £000

Out of Hospital 316 245 (44) (289) (14) (330) Elective Care 3,810 3,087 2,372 (715) 3,089 (721) Urgent Care 2,156 1,968 1,915 (53) 2,095 (61) Mental Health and Learning Disabilities 527 483 483 0 527 0

Medicines Management 5,289 4,992 5,863 871 6,215 926 Other Programme 1,597 1,333 3,968 2,636 4,533 2,936

Sub total - assigned QIPP schemes 13,695 12,108 14,558 2,450 16,445 2,750 Unidentified QIPP 4,834 4,334 0 (4,334) 0 (4,835)

Total QIPP 18,529 16,443 14,558 (1,884) 16,445 (2,085)

Month by month performance £000 3000

2000

1000

0 M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 Actual QIPP Planned QIPP

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Main Risks - Joint

Area Current position Action Owners Net risk

£000 QIPP Under-Delivery Operational Plan Savings Delivery The operational plan is underpinned by a detailed The Operational Plan Delivery meetings monitor actions and Jayne Mellor productivity, efficiency and service redesign programme. appropriate support and measures in place to improve the risk to delivery. The current gap is £2.1m. The reduction is due to the (2,085) utilisation of the remaining CCG contingency and uncommitted budget and forecast underspends.

Other risks 0.5% non-recurrent risk reserve NHS England confirmed in October that the full 0.5% non- Discussions taken place to receive the full risk reserve balance recurrent risk reserve can not be fully utilised by the CCGs due in order to mitigate against the CCGs risks. to retention of a proportion of this funding by the Integrated (793) Care System (ICS).

Gross risk (before mitigations) (2,878)

Mitigations

Net Area Current position Action mitigation £000 Other mitigations Uncommitted budget and forecast underspends primarily 2,648 within primary care co-commissioning 0.5% non-recurrent systems Remaining balance of the 0.5% non-recurrent system risk The Integrated Care System (on behalf of NHS England) have confirmed a risk reserve reserve retained by NHS England. proportion of remaining risk reserve will be made available to the CCGs. 230

Total mitigations 2,878

Net risk position

Total net risk 0

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Financial Performance Report 2018/19 As at 28 February 2019 Forecast Outturn to 31 March 2019 Page 187 Page

CCG Summary Financial position

Financial Duties Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key

Revenue Resource Limit On plan

Cash Limit Actions in place to achieve plan

Better Payment Practice Code NHS Miss to plan

Non NHS Information not available

Business Rules and Financial Performance Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key Messages

0% Revenue Surplus/(Deficit) - The forecast is to achieve an in year break-even £0.0m. This is a £0.0m variance to plan. 0.5% Non-Recurrent system - Efficiency and Productivity is performing £1.1m under plan. risk reserve - 0.5% Non-recurrent system risk reserve is utilised as agreed by the Governing Body in September 2018. Efficiency and Productivity performance - Running costs are within budget. Running costs - Non-recurrent investments are in accordance with plan. - The CCG is currently reporting a net risk position of £0.0m. Main Provider

Page 188 Page

Financial Performance Duties

Revenue Resource Limit (RRL) Total YTD Notes £000 Movements in allocations / funding totals £12k. Programme 275,889

Admin (running costs) 3,912

Cash Limit (CL) Total YTD Notes £000

Total 273,656

Better Payment Practice Code (BPPC) Total invoices Year to Date Total invoices Target paid within performance YTD Trend Notes paid in year % target %

Volume 13,538 13,498 95.0% 99.7% The CCG is exceeding all BPPC target

Non NHS levels. Value (£'000) 80,931 80,843 95.0% 99.9%

Volume 2,209 2,169 95.0% 98.2%

NHS Page 189 Page Value (£'000) 156,104 155,712 95.0% 99.7%

Financial Management

2017/18 2017/18 Receivables past their Summary Statement of Financial Position (SoFP) YTD position as at 31 March YTD position as at due date 2018 31 March 2018 £000 £000 £000 £000 Total non-current assets - - NHS 562 207 Non NHS 180 431

Current assets: Total 742 638 Inventories - -

Trade and other receivables 4,720 1,644 Comments Other financial assets 0 0 Cash - the balance on the SoFP is the total of anticipated payments/receipts for the CCG bank account. The month end cash target Other current assets 0 0 has been met. Receivables past their due date - NHS relate to balances Cash and cash equivalents (156) 36 owed by Lancashire Teaching Hospitals, East Lancashire CCG and NHS England. Non NHS primarily relate to recharges owed by Lancashire County Total current assets 4,564 1,680 Council.

Total assets 4,564 1,680 Total receivables

NHS Non NHS Current liabilities: 3,000 Trade and other payables (15,187) (13,239) 2,000 Other financial liabilities 0 0 1,000 Other liabilities 0 0 0 (1,000) Borrowings 0 0

Provisions (1) 0

Total current liabilities (15,188) (13,239) Cash - achieving 1.25% month end cash balance

Balance % Target % Non-Current Assets plus/less Net Current Assets/(Liabilities) (10,624) (11,559) 1.40 1.20 1.00 Total non-current liabilities 0 0 0.80 0.60 0.40 0.20 Assets less Liabilities (10,624) (11,559) -

Total taxpayers' equity: (10,624) (11,559)

Page 190 Page

Summary I&E

Annual Annual Variance to Forecast 2017/18 Outturn Budget to Expenditure Date Annual Annual Variance Outturn Variance Summary Income and Expenditure Date to Date Budget Forecast

as at 28th February 2019 £000 £000 £000 £000 £000 £000 Favourable £000 £000 Favourable Favourable / (Adverse) / (Adverse) / (Adverse)

In-year Revenue Resource Limit 249,902 249,902 0 273,656 273,656 0 265,783 7,873

Total Revenue Resource Limit 249,902 249,902 0 273,656 273,656 0 265,783 7,873

Acute services Lancashire Teaching Hospitals NHSFT 88,209 88,763 (554) 96,527 98,607 (2,081) 93,935 (4,672) NW Ambulance service NHST 4,840 4,779 61 5,280 5,216 64 5,049 (167) Wrightington Wigan & Leigh NHSFT 5,705 5,463 241 6,229 6,095 134 6,182 86 Blackpool Teaching Hospitals NHSFT 1,709 1,835 (126) 1,864 1,974 (110) 1,826 (148) East Lancashire Hospitals NHST 1,404 1,439 (35) 1,534 1,469 65 1,483 14 Ramsay 9,968 10,127 (159) 10,944 11,118 (174) 11,258 140 Other Acute service providers 8,157 9,348 (1,191) 8,314 8,679 (365) 12,706 4,027 Total Acute services 119,991 121,754 (1,762) 130,692 133,158 (2,467) 132,438 (720) Mental Health Services Lancashire Care NHSFT 17,223 17,383 (160) 18,688 18,863 (175) 18,151 (712) Other Mental Health providers 8,928 9,036 (107) 9,760 9,873 (113) 8,535 (1,337) Total Mental Health services 26,152 26,419 (267) 28,447 28,736 (288) 26,686 (2,049) Community Health Services Lancashire Care NHSFT 16,062 16,292 (230) 17,630 17,621 8 16,088 (1,533) Other Community providers 6,617 7,219 (602) 7,162 7,792 (630) 5,545 (2,247) Total Community services 22,679 23,510 (832) 24,791 25,413 (622) 21,633 (3,780) Other Programme: Continuing Care services 11,795 13,005 (1,211) 12,867 13,846 (979) 11,911 (1,936) Primary Care services 27,146 26,500 646 30,534 29,762 772 25,849 (3,913) Prescribing 24,373 24,465 (92) 26,678 26,778 (100) 28,429 1,651 Other Programme services 2,166 1,924 242 2,363 2,267 96 2,284 17 Corporate 2,440 1,861 579 2,669 1,964 705 2,048 83 Reserves 9,575 7,060 2,515 10,703 7,903 2,800 7,391 (512) Healthcare Sub Total 246,317 246,498 (181) 269,744 269,828 (84) 258,669 (11,159) Running Costs 3,585 3,404 181 3,912 3,828 84 3,744 (84) Total Expenditure 249,902 249,902 (0) 273,656 273,656 0 262,413 (11,243)

Surplus/(Deficit) 0 (0) (0) 0 0 0 3,370 (3,370) Page 191 Page

Productivity and Efficiency (QIPP)

YTD Risk Net QIPP QIPP overview as at 28th February 2019 Plan YTD Plan Actual (Shortfall)/ Adjusted (Shortfall) / Benefit FOT Benefit

£000 £000 £000 £000 £000 £000

Out of Hospital 125 85 (73) (158) (60) (185)

Elective Care 1,770 1,441 1,099 (342) 1,425 (345)

Urgent Care 1,038 949 935 (14) 1,022 (16)

Mental Health and Learning Disabilities 311 285 285 0 311 0

Medicines Management 2,486 2,339 2,776 437 2,950 464

Other Programme 553 460 1,339 880 1,627 1,074

Total QIPP 6,283 5,559 6,362 803 7,275 992 Unidentified QIPP 2,205 1,903 0 (1,903) 0 (2,205) Total QIPP 8,488 7,462 6,362 (1,100) 7,275 (1,213)

Current position £000

YTD Actual

Plan

Page 192 Page - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000

Financial Performance Report 2018/19 As at 28 February 2019 Forecast Outturn to 31 March 2019 Page 193 Page

CCG Summary Financial position

Financial Duties Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key

Revenue Resource Limit On plan

Cash Limit Actions in place to achieve plan

Better Payment Practice Code NHS Miss to plan

Non NHS Information not available

Business Rules and Financial Performance Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key Messages

0% Revenue Surplus/(Deficit) - The forecast is to achieve an in year break-even £0.0m. This is a £0.0m variance to plan. 0.5% Non-Recurrent system risk reserve - Efficiency and Productivity is performing £0.8m under plan. Efficiency and Productivity performance - 0.5% Non-recurrent system risk reserve is utilised as agreed by the

Governing Body in September 2018. Running costs - Running costs are within budget. Main Provider - Non-recurrent investments are in accordance with plan. - The CCG is currently reporting a net risk position of £0.0m. Performance - LTH

Page 194 Page

Financial Performance Duties

Revenue Resource Limit (RRL) Total YTD Notes £000 Movements in allocations / funding totals £(10)k; Programme 300,336

Admin (running costs) 4,385

Cash Limit (CL) Total YTD Notes £000

Total 299,615

Better Payment Practice Code (BPPC) Total invoices Year to Date Total invoices Target paid within performance YTD Trend Notes paid in year % target %

Volume 13,230 13,206 95.0% 99.8% The CCG is exceeding all BPPC target

Non NHS levels. Value (£'000) 90,352 90,292 95.0% 99.9%

Volume 2,481 2,471 95.0% 99.6%

NHS

Page 195 Page Value (£'000) 169,911 169,792 95.0% 99.9%

Financial Management

2017/18 2017/18 Receivables past their due Summary Statement of Financial Position (SoFP) YTD position as at 31 March YTD position as at date 2018 31 March 2018

£000 £000 £000 £000

Total non-current assets - - NHS 309 66 Non NHS (1) 73

Current assets: Total 308 139 Inventories - -

Trade and other receivables 5,208 1,719 Comments Other financial assets 0 0 Cash - the balance on the SoFP is the total of anticipated payments/receipts for the CCG bank account. The month end cash Other current assets 0 0 target has been met for the last twelve months. Receivables past their Cash and cash equivalents (482) 42 due date - NHS relates primarily to monies owed by NHS England and East Lancashire CCG. Total current assets 4,726 1,761

Total assets 4,726 1,761 Total receivables

nhs non nhs Current liabilities: 2,500 2,000 Trade and other payables (17,806) (14,682) 1,500 Other financial liabilities 0 0 1,000 500 Other liabilities 0 0 0 Borrowings 0 0

Provisions 0 0 Total current liabilities (17,806) (14,682) Cash - achieving 1.25% month end cash balance

Balance as a percentage Target Non-Current Assets plus/less Net Current Assets/(Liabilities) (13,080) (12,921) 1.40 1.20 1.00 Total non-current liabilities 0 0 0.80 0.60 0.40 Assets less Liabilities (13,080) (12,921) 0.20 -

Total taxpayers' equity: (13,080) (12,921)

Page 196 Page

Summary I&E

Annual Annual Variance to Forecast 2017/18 Outturn Budget to Expenditure Date Annual Annual Variance Outturn Variance Summary Income and Expenditure Date to Date Budget Forecast

as at 28th February 2019 £000 £000 £000 £000 £000 £000 Favourable £000 £000 Favourable Favourable / (Adverse) / (Adverse) / (Adverse)

In-year Revenue Resource Limit 272,957 272,957 0 299,615 299,615 0 291,453 8,162

Total Revenue Resource Limit 272,957 272,957 0 299,615 299,615 0 291,453 8,162

Acute services Lancashire Teaching Hospitals NHSFT 101,653 101,821 (167) 111,214 112,277 (1,063) 109,116 (3,160) NW Ambulance service NHST 6,256 6,277 (21) 6,825 6,863 (38) 6,424 (439) Wrightington Wigan & Leigh NHSFT 1,127 1,106 21 1,233 1,209 24 1,245 37 Blackpool Teaching Hospitals NHSFT 2,929 2,989 (59) 3,196 3,457 (261) 3,254 (203) East Lancashire Hospitals NHST 1,556 1,596 (40) 1,699 1,822 (123) 1,648 (174) Ramsay 10,916 10,915 0 11,982 11,819 163 12,144 325 Other Acute service providers 7,659 9,892 (2,232) 7,676 9,254 (1,578) 11,723 2,469 Total Acute services 132,097 134,595 (2,499) 143,824 146,701 (2,877) 145,555 (1,146) Mental Health Services Lancashire Care NHSFT 19,726 20,027 (301) 21,377 21,706 (329) 20,686 (1,020) Other Mental Health providers 10,097 9,582 516 11,037 10,760 277 9,309 (1,451) Total Mental Health services 29,824 29,609 214 32,414 32,465 (51) 29,995 (2,470) Community Health Services Lancashire Care NHSFT 17,556 17,606 (50) 19,279 19,326 (47) 17,350 (1,976) Other Community providers 6,719 7,248 (529) 7,259 7,850 (592) 6,207 (1,643) Total Community services 24,275 24,853 (579) 26,538 27,176 (639) 23,557 (3,619) Other Programme: Continuing Care services 10,747 11,296 (549) 11,724 12,321 (597) 11,611 (710) Primary Care services 31,727 31,102 625 35,670 33,584 2,086 29,550 (4,034) Prescribing 27,314 26,692 622 29,897 29,218 679 31,565 2,348 Other Programme services 2,330 2,212 118 2,542 2,546 (4) 2,578 32 Corporate 3,817 3,761 57 4,172 4,331 (158) 2,438 (1,892) Reserves 6,809 4,999 1,810 8,450 6,965 1,485 6,174 (791) Healthcare Sub Total 268,938 269,119 (181) 295,230 295,306 (76) 283,024 (12,283) Running Costs 4,019 3,838 181 4,385 4,308 77 4,178 (131) Total Expenditure 272,957 272,957 0 299,615 299,615 0 287,201 (12,413)

Surplus/(Deficit) 0 0 0 0 0 0 4,252 (4,252) * Outturn 2017/18 has been adjusted to reflect the boundary change for NHS Greater Preston CCG with effect from 1 April 2018. Page 197 Page

Productivity and Efficiency (QIPP)

YTD Risk Net QIPP QIPP overview as at 28th February 2019 Plan YTD Plan Actual (Shortfall) / Adjusted (Shortfall) / Benefit FOT Benefit

£000 £000 £000 £000 £000 £000

Out of Hospital 191 159 28 (131) 46 (145)

Elective Care 2,040 1,646 1,273 (373) 1,664 (376)

Urgent Care 1,118 1,019 980 (39) 1,073 (45)

Mental Health and Learning Disabilities 216 198 198 0 216 0

Medicines Management 2,803 2,653 3,087 434 3,265 462

Other Programme 1,044 873 2,629 1,756 2,906 1,862

Total QIPP 7,412 6,549 8,196 1,647 9,170 1,758 Unidentified QIPP 2,630 2,431 0 (2,431) 0 (2,630) Total QIPP 10,042 8,980 8,196 (784) 9,170 (872)

Current position £000

YTD Actual

Plan

Page 198 Page - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000

Agenda Item 8

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Constitution update Presented by Mr Matt Gaunt, Chief Finance Officer Author Mrs Sarah Mattocks, Corporate Affairs & Governance Manager Clinical lead N/A Confidential N/A

Purpose of the paper The purpose of this paper is to provide the Governing Body with an update on the constitution review.

Executive summary The CCG undertakes an annual review of its constitution to ensure that it remains reflective of national guidance and is fit for purpose in order to govern the practice of the CCG.

The Governing Body received a report at the November meeting outlining the proposed changes in the revised constitution ahead of engaging with the membership. The Governing Body supported these changes.

This paper updates the Governing Body on the progress of this constitution review.

Recommendations The Governing Body are asked to note the progress with the constitution review.

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

Constitution update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 199 Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

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

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

Assurance All constitutional changes will be approved by the Membership Council and will be ratified by NHS England.

Constitution update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 200 1.0 Background

1.1 The CCG undertakes an annual review of its constitution to ensure that it remains reflective of national guidance and is fit for purpose in order to govern the practice of the CCG.

1.2 The Governing Body received a report at the November meeting outlining the proposed changes in the revised constitution ahead of engaging with the membership. The Governing Body supported these changes.

1.3 This paper updates the Governing Body on the progress of this constitution review.

2.0 Membership engagement

2.1 An update was provided to the membership council meeting in December advising that a constitution review was being undertaken and that an engagement questionnaire would be distributed to all practices. Members were encouraged to use this questionnaire to contribute towards the voting decisions that would be taken at a future meeting on constitutional changes.

2.2 A questionnaire was submitted to all practices in January 2019, which received a total of 33 responses across both CCGs (one respondent did abstain on some questions).

2.3 The questionnaire responses illustrated that there was no appetite to vote on the following items:

• Non-GP primary care clinical roles holding posts on the CCG Governing Body

• Number of clinical sessions a GP must be working to be eligible as a GP Director

• GP Directors from the same practice

• Locum GPs being eligible as GP Directors

3.0 Voting outcome

3.1 A verbal update will be provided regarding the voting outcome from the Membership Council on 20th March at the Governing Body meeting as at the time of writing this report the voting had not yet taken place. Voting will take place on the following items:

• Amendment to the scheme of delegation in line with the EU Procurement Thresholds

Constitution update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 201 • The following being added as a grounds for removal from office for the Chair and GP Director to be in line with the other Governing Body office holder roles:

The office holder fails to attend at least 75% of Governing Body meetings

• The following being added as a grounds for removal from office for all Governing Body roles:

The office holder fails to attend at least 75% of Governing Body meetings and associated committees

• The CCG’s Remuneration Committee may not make decisions, and instead make recommendations for the Governing Body approval

• Chair notice period – no more than six months/no less than three months confirmed in writing

• Approval of minor constitutional changes by the Accountable Officer

4.0 Conclusion

4.1 The new CCG constitution will be drafted based on the Membership Council voting results and will be submitted to NHS England for approval.

Constitution update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 202 Agenda Item 9

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements Presented by Louise Burton, Designated Lead Nurse Safeguarding Children and Lorraine Elliott, Designated Lead Nurse Safeguarding Adults and Mental Capacity Act Author Edwina Grant, Executive Director of Education and Children’s Services with revisions by the Designated Professional Lancashire and South Cumbria Network to allow presentation at CCG Governing Bodies Clinical lead Dr Anitha Rangaswamy Confidential

Purpose of the paper The paper outlines the proposed model for new safeguarding partnership arrangements recommended to replace the Local Safeguarding Children’s Board following new legislation.

Executive summary This report is being presented to the three Lancashire Councils, the Executive bodies of the CCGs and the Police and sets out the recommended option for the replacement of the Local Safeguarding Children's Board to comply with the new area children’s safeguarding arrangements.

CCG’s, local authorities and the local constabulary now have equal and joint accountability for children safeguarding responsibilities (Working Together 2018).

Adult responsibilities remain unchanged in line with the Care Act 2014.

Equality Impact & Risk Assessment Completed? A full Equality and Impact Risk Assessment cannot be completed until the final model for the Safeguarding Partnership Arrangements is agreed.

Financial Implications? It has been indicated during discussions with partners that the changes can be made within the present financial envelope but this has not been confirmed.

Recommendations The Governing Body is asked to review the content of the paper and to endorse the option as set out in the report, which has been agreed in principle with safeguarding partner agencies.

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 203 27 March 2019

Links to CCG Strategic Objectives SO1 Improve quality through more effective, safer services, which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out-of-hospital provision SO3 Be an integral part of a financially sustainable health economy ☒

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

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome Safeguarding Assurance Group 07.09.17 Update provided and support to progress Safeguarding Partnership arrangements

Safeguarding Assurance Group 29.08.18 Update provided and support to progress Safeguarding Partnership arrangements

Quality & Performance Committee 05.09.18 Update provided and support to progress Safeguarding Partnership arrangements

Cumbria arrangements for 25.09.18 Collaboration with Local safeguarding reforms Authority Police and Health (DoN Chief Nurse & Designated Professionals CCG)

Pan-Lancashire arrangements for 20.11.18 Discussions with Local safeguarding reforms Authorities (Lancashire, Blackpool and Blackburn with Darwen) Police and Health (Designated Professionals and NHSE) Designated Nurses and legal 29.11.18 Agreed to proceed with single support partnership approach Pan-Lancashire arrangements for 19.12.18 Collaboration with Local safeguarding reforms Authorities (Lancashire, Blackpool and Blackburn with Darwen) Police and Health (Designated Professionals and

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 204 27 March 2019 NHSE) Pan-Lancashire arrangements for 16.1.19 Collaboration with Local safeguarding reforms Authorities (Lancashire, Blackpool and Blackburn with Darwen) Police and Health (Designated Professionals and NHSE) Cumbria arrangements for 17.1.19 Collaboration with Local safeguarding reforms Authority Police and Health (Designated Professionals CCG) Pan-Lancashire arrangements for 24.02.19 Collaboration with Local safeguarding reforms Authorities (Lancashire, Blackpool and Blackburn with Darwen) Police and Health (Designated Professionals and NHSE) Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these:

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

Assurance N/A

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 205 27 March 2019 1.0 Introduction

1.1 Under the Children Act 2004, as amended by the Children and Social Work Act 2017, Local Safeguarding Children Boards (LSCBs) will be replaced. Under the new legislation, the three agencies identified as key safeguarding partners are Local Authorities (LAs), Chief Officers of Police and Clinical Commissioning Groups (CCGs). These organisations must make safeguarding partnership arrangements to work together with relevant agencies (as they consider appropriate) to safeguard and protect the welfare of children in the area. LAs, CCG’s, and Chief Officers of Police now have equal and joint accountability for children safeguarding responsibilities (Working Together 2018). Adult responsibilities remain unchanged in line with the Care Act 2014.

1.2 Also under the new guidance, two agencies (LA and CCGs) are identified as the child death review partners and must set up child death review arrangements. These will remain the Child Death Overview Panels but with no formal link to the new safeguarding arrangements.

1.3 The current Serious Case Review arrangements will be replaced by Child Safeguarding Practice Reviews, which may be conducted at local or national level. The National Child Safeguarding Practice Review Panel was established on 29 June 2018 and transitional guidance has been published setting out the responsibility of safeguarding partners when a serious incident occurs from that date onwards. This arrangement will remain until such time as the new safeguarding arrangements are implemented locally.

1.4 Working Together to Safeguard Children (July 2018), sets out the statutory guidance to which all new safeguarding arrangements must adhere. This guidance sets out specific detail of the functions to be carried out by new arrangements. Chief Officers/Executives of the new statutory partners (or their nominees) have reviewed these proposals and make the proposal outlined below to establish effective new arrangements and ensure specific compliance with the responsibilities set out in these guidance documents.

1.5 Under the guidance it is permissible for the new arrangements to cover more than one LA area. This report sets out proposals for the three Local Safeguarding Children Boards in Blackpool, Blackburn with Darwen and Lancashire to be replaced by new arrangements that will cover all areas. It is proposed that the new arrangements are called the Blackpool, Blackburn with Darwen and Lancashire Safeguarding Children Strategic Partnership Board.

1.6 Alongside the approval of the framework for the new arrangements by Blackpool, Blackburn with Darwen and Lancashire Councils full detailed arrangements for this partnership must also be approved by the governance boards of the eight CCGs, and by Lancashire Constabulary, as set out earlier in this report. Following agreement, arrangements for internal partnership governance and the business support functions will be completed by the chief officers of each of the named safeguarding partners as required.

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 206 27 March 2019 1.7 To inform these proposals, representatives from each council and representatives from other safeguarding partners have been in discussions through a working group. Other partners have been kept informed that discussions were ongoing but they do not have a decision-making role in how the arrangements are established.

1.8 The working group has considered proposals set out in this paper for the new arrangements based on:

• The parameters set out by the Children and Social Work Act 2017 and Working Together to Safeguard Children 2018

• Analysis of the effectiveness of outstanding Local Safeguarding Children Board functions reviewed by Ofsted

• Analysis of published reports of Multi-Agency Joint Targeted Area Inspections

• Concerns from partner agencies highlighting the current level of duplication and risk of inconsistent safeguarding responses that are present in the current LSCB arrangements

2.0 The Proposal

2.1 Geographical Area

2.1.1 The Blackpool, Blackburn with Darwen and Lancashire Safeguarding Children Strategic Partnership Board will co-ordinate safeguarding services and will act as a strategic leadership group across the unitary authorities and county. Activity by the partnership will include the identification of the needs of children and young people living in diverse urban and rural areas and ensuring that effective action is taken to safeguard them.

2.1.2 Driving forward effective local arrangements requires attention to the detail of what works and where improvement is needed. In order to achieve this level of detail across the diverse areas of need, the new arrangements will be supported by joint thematic sub groups and will include reporting and scrutiny of some key functions in particular geographical areas, or in themes, for example similar ward characteristics on deprivation.

2.1.3 The new arrangements will be subject of review and this will include analysis of future opportunities to build on existing practice which brings together a number of sub-groups where the effectiveness of the co-ordination and scrutiny of arrangements across the three geographical council areas can be sustained and improved.

2.1.4 The new arrangements will be supported by changes in the framework for health commissioning and greater collaboration of CCGs across the Integrated Care System (ICS) area.

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 207 27 March 2019 2.1.5 Each local authority will remain responsible for fulfilling its own statutory and legislative duties to safeguard and promote the welfare of children.

2.1.6 The District Councils will continue to have essential safeguarding responsibilities. In order to uphold their responsibilities for safeguarding arrangements will be developed for the District Councils to actively participate in their existing joint arrangements to co-ordinate their safeguarding duties.

2.1.7 These arrangements will not remove or detract from the partner organisational requirements laid down within legal and national guidance pertinent to that partner.

2.1.8 The statutory requirements do not allow for local authority boundaries to be split but every effort will be to ensure a collaborative approach with the new arrangements established for Cumbria given the health boundary extends into South Cumbria.

2.2 Independent Scrutiny and Role of Elected and Lay Members

2.2.1 The role of independent scrutiny is to provide assurance in judging the effectiveness of the multi-agency arrangements to safeguard and promote the welfare of all children in a local area, including arrangements to identify and review serious incidents and conduct child safeguarding practice reviews, (previously known as serious case reviews).

2.2.2 It is proposed that there is ongoing independent scrutiny delivered through the role of an independent chair of the Strategic Board. A key feature of effective LSCBs, the role of the independent chair will provide the opportunity for scrutiny across the three local authority areas with demonstrable independence and a sufficient degree of authority to ensure that the agencies respond positively and work to address areas of weaker practice.

2.2.3 The revised guidance reflects the requirement that young people and members of the community have an increased role in shaping service development across all agencies and contributing to the scrutiny processes that hold agencies to account. This will require an increased focus within the new arrangements.

2.2.4 There is a requirement within the new arrangements to consider the part played by existing partners and designate those with a crucial role as “relevant agencies”. The recommendation is that considerable benefit has been derived from the breadth of the existing Board membership and, while efficiencies can be gained by shared representation, a broad range of agencies should be nominated. It is also felt that there have been benefits from the presence of lead elected members and from lay members and that future arrangement should enable some continued involvement.

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 208 27 March 2019 2.3 Strategic Board

2.3.1 Strong leadership is critical for the new arrangements to be effective in bringing together the various organisations and agencies within the partnership. The statutory safeguarding partners across Blackpool, Blackburn with Darwen and Lancashire have equal and joint responsibility for local safeguarding arrangements.

2.3.2 In order to ensure that the responsibilities of the partnership are being effectively discharged, it is proposed that the Strategic Board includes representation from the following (including all areas covered by different organisations listed below):

• Blackpool Council • Blackburn with Darwen Council • Lancashire County Council • Lancashire and South Cumbria area CCGs • Lancashire Constabulary • Lancashire Police and Crime Commissioner • Chief Officers of the other relevant agencies (or their nominee)

2.3.3 The Strategic Board members will:

- speak with authority for the safeguarding partner they represent;

- take decisions on behalf of their organisation or agency and be empowered to commit them on policy, resourcing and practice matters;

- hold their own organisation or agency to account on how effectively they participate in and implement the local arrangements; and

- play an active role, facilitating and driving action beyond institutional constraints and boundaries.

2.3.4 In situations that require a clear, single point of leadership, all safeguarding partners will decide who would take the lead on issues that arise. The detailed governance arrangements will explicitly set out how this will be achieved, mindful of the ongoing responsibilities for each Director of Children’s Services for the safety of children in their area (as set out in section 18 of the Children Act 2004). The Chair of the Board will have a role as arbitrator if agreement cannot be reached.

2.3.5 The Strategic Board will:

− publish a plan setting out local arrangements and how they will be implemented; publish a Memorandum of Understanding to ensure that there are transparent governance arrangements and decision-making processes;

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 209 27 March 2019 − ensure that the new arrangements are implemented within the prescribed timescales and meet the requirements of national guidance;

− publish an annual report regarding the effectiveness of the implementation of the new arrangements, including the effectiveness of any sub groups

− publish a business plan and drive forward improvements in local safeguarding arrangements across the area;

− present the report on the effectiveness of local safeguarding arrangements to other public boards including Health and Wellbeing Boards, Safeguarding Adult Boards, Channel Panels, Improvement Boards, Community Safety Partnerships, the Local Family Justice Board and Multi-Agency Public Protection Arrangements (MAPPAs);

− respond to recommendations from local and/or national child safeguarding practice reviews;

− drive forward learning and organisational development to improve safeguarding arrangements.

2.4 Supports to the Strategic Board

2.4.1 The Strategic Board will establish its own arrangements within available budget to co-ordinate the business plan and ensure delivery of the work of the Board to improve safeguarding arrangements and to inform the Strategic Board. This will be via the establishment of a single business unit, which will also continue to support the work of the Safeguarding Adult Board functions across the three LA areas.

2.5 Tactical and Operational Area Based Groups

2.5.1 It is suggested that the Strategic Board is supported by three tactical/operational area based groups reflecting the following three geographical areas:

• Blackpool, Fylde and North Lancashire • Central and South Lancashire • Blackburn with Darwen and East Lancashire

2.5.2 This will ensure delivery of the Strategic Board objectives at a local level and ensure the Strategic Board’s work is also informed by more local issues or concerns. The footprint of these groups will also enable current cross- boundary issues and inconsistencies to be more easily addressed.

2.6 Established Sub Groups

2.6.1 A number of the existing sub-groups will remain but be extended to cover the whole Lancashire footprint. Considerable efficiencies and economies will be achieved by doing things once rather than three times as is often currently the

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 210 27 March 2019 case. Other groups may be added as required and are likely to be on a task and finish basis rather than standing sub-groups.

2.7 Timescale for publication of the plan

2.7.1 Safeguarding partners have up to 29 June 2019, to agree their local arrangements and published their arrangements but may do so at any time before the end of that period.

3.0 Implementation of the new arrangements

3.1 Following publication of arrangements, safeguarding partners have up to three months from the date of publication to implement the arrangements. The implementation date should be made clear in the published arrangements. All new local arrangements must have been implemented by 29 September 2019.

3.2 If the safeguarding partner arrangements are in place and ready to operate before the child death review partner arrangements for a local area, the safeguarding partners may begin work, without waiting for the child death review partner arrangements to begin.

3.3 Once the arrangements have been published and implemented, the three LSCBs in Blackpool, Blackburn with Darwen and Lancashire will cease to exist.

3.4 Consultations have taken place with key agencies as defined in the legal requirements and more broadly with existing members of the three LSCBs via their meetings.

4.0 Implications

This item has the following implications, as indicated

4.1 Risk management

4.1.1 There is a risk to child protection and safeguarding if the changes to these arrangements are not made effectively and to the reputation of the partner organisations if arrangements are not effective.

4.1.2 The safeguarding partnership will have to absorb the present risk registers of the present three safeguarding Boards and also take over the responsibilities for unfinished reviews and associated action plans. Transfer of the data ownership to the safeguarding partnership will also have to be resolved but will be mitigated by the present suggestion to arrange for a single supporting business unit that will be an amalgamation of the three present business units of the LSCBs.

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 211 27 March 2019 4.2 Financial

4.2.1 There may be efficiency savings going forward. The current budgets for the Boards are as set out in the budget for the three individual councils and the budgets of partner establishments. There has been no identified requirement for further monies to date.

5.0 Further Options

5.1 Further options were explored within the workshops which included single safeguarding arrangements for each LA. Whilst there was a benefit in terms of preserving the status quo with minimum change this option was considered as wasteful in terms of resources and efficiencies in addition duplication was necessary in some of the partner agencies to meet this option. Communication and consistency across the three LA areas was seen as beneficial and required and this arrangement was counterproductive to this happening.

5.2 A safeguarding partnership including South Cumbria was not possible due to the inability within the Act to allow for LA to split into two partnerships. It is envisaged that the tactical group of the Coastal region will allow for future transition / support close working links with Cumbria.

6.0 Health Governance to support the proposed arrangements

6.1 Meeting this arrangement will have some implications for the CCGs. Representation at the Safeguarding Partnership Board will potentially need a single representative on behalf of all of the CCGs across the Lancashire and South Cumbria footprint whilst still maintaining statutory responsibility and accountability. To this end a suggested Governance structure that would support this arrangement has been considered by the Designated Professionals and proposals have also received some legal scrutiny.

6.2 It is known that the role of the Director of Nursing and Care Professionals for NHS England and ICS has to ensure that the statutory roles held by NHS England can be discharged fully within the emerging ICS and collaborative arrangements. The responsibility of NHS England is to ensure that the health commissioning system as a whole is working effectively to safeguard and promote the welfare of children. NHS England also is accountable for the services it directly commissions (Working Together 2018).

6.3 CCGs are one of the statutory safeguarding partners and the major commissioners of local health services. They are responsible for the provision of effective clinical, professional and strategic leadership to child safeguarding, including the quality assurance of safeguarding through their contractual arrangements with all provider organisations and agencies, including from independent providers. They are also responsible for securing the expertise of the Designated Professionals (Working Together 2018).

Replacement of the Local Safeguarding Children's Board with Safeguarding Partnership Arrangements NHS Chorley and South Ribble CCG Governing Body Meeting Page 212 27 March 2019 6.4 Maintaining these mandated requirements within the emerging ICS structures and through the present arrangements of CCGs will be challenging but not impossible with a supportive governance arrangement. Likely health membership at the Safeguarding Partnership Board will include the Director of Nursing and Care Professional NHSE and ICS, a CCG representative and a Designated Professional Representative for the Lancashire and South Cumbria footprint .

6.5 It is proposed that a Health Safeguarding Executive group is formed which would allow senior/executive representation of all health agencies within the footprint. This would meet prior to the Safeguarding Partnership Board to allow for the Board representatives for health to be fully briefed and in a position to represent the views of health agencies into the Partnership Board.

6.6 In addition an operational level group, which would be a collaborative health forum at ICP level, would be the vehicle for representation from this Provider level. This collaborative would be chaired by the Designated Nurse relevant to that area and ICP to ensure a Governance chain through the Health Executive Group and onto the Safeguarding Partnership Board. There would be an element of assurance through this group of the process and arrangements at ground level and will create a conduit for highlighting gaps in provision and concerns within the system.

6.7 The outline of this arrangement is within this document in the attached genograms.

7.0 Child Death Overview Arrangements

7.1 For Lancashire the LSCB Chairs, Police, LA and Health representatives at the Safeguarding Partnership meetings have proposed that current arrangements and resource remain in place for Child Death Overview Panel (CDOP) until January 2020 and CDOP operates as a parallel group to the Safeguarding Partnership. It is recommended that during this time transition arrangements can be put in place to transfer accountability for CDOP to the Health and Well Being Board.

8.0 List of Background Documents

• Children and Social Work Act 2017 • Revised Working Together to Safeguard Children 2018 • Child Death Review and Operational Guidance 2018 • Care Act 2014

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Appendix 1

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Appendix 2

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Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Development of a transformational safeguarding model across the ICS / ICPs Presented by Lorraine Elliott, Designated Lead Nurse Safeguarding Adults and Mental Capacity Act and Louise Burton, Designated Lead Nurse Safeguarding Children Author Lancashire and South Cumbria Designated Nurses Network Clinical lead Dr Anitha Rangaswamy Confidential

Purpose of the paper This paper updates the Governing Body and requests endorsement of the Integrated Care System (ICS) Safeguarding programme and will inform of the vision for safeguarding going forward within the ICS. The paper outlines some clear options for how the safeguarding structure, governance and assurance would work. This modelling has taken into account the new legislative requirements for safeguarding and the changing health landscape.

Executive summary There is a requirement for the safeguarding children and adult system to respond to reforms whilst keeping safeguarding firmly embedded in the transformation agenda within the Health Service and new challenges following the introduction of the NHS Long Term Plan (January 2019).

In addition, new legislation has removed the statutory authority of local safeguarding children boards and has introduced new local safeguarding partnership arrangements for safeguarding and promoting the welfare of children.

CCG’s, local authorities and the local constabulary now have equal and joint accountability for children safeguarding responsibilities (Working Together 2018). Adult responsibilities remain unchanged in line with the Care Act 2014.

Lancashire and South Cumbria Safeguarding ICS Designated Professionals Network has been identified nationally as an area to support the development of a transformational model of safeguarding support within an ICS. It has been agreed that an ICS blue print will be developed that will report back to the National Safeguarding Steering Group.

A working group of Designated Professionals has been formed to develop the proposal for the change model within this paper and a subsequent implementation plan. There is a clear commitment that has emerged to a combined adult and children system wide approach to safeguarding support across the ICS.

The benefits of such an approach:

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 216 1. Will allow for greater consistency in the delivery of statutory functions, promote resilience, and enable the development of a sustainable and flexible safeguarding model.

2. The development of a transformational model is an opportunity to consider new ways of delivering the functions of the designated role across the ICS to maximise system expertise and improved outcomes.

3. Collaborative ways of working and avoiding duplication, streamlining systems and processes and utilising the expert resource more effectively across Lancashire and South Cumbria will bring significant benefit.

4. A more effective and efficient way of working that will facilitate an approach that promotes greater resilience for the safeguarding networks.

5. CCGs will be able to continue to meet statuary requirements and the governance structures recommended will allow for the ICPs to be supported, directed and assured by the designated role and function

Equality Impact & Risk Assessment Completed? A full Equality and Impact Risk Assessment is in development pending the determination of the final model. A risk and benefit appraisal has been undertaken for each suggested model within the options appraisal.

Recommendations 1. The Governing Body is asked to support a programme of work which will support movement to the preferred model (option 3) as set out in this high level options appraisal (appendix 1) for delivering safeguarding arrangements across the ICS in accordance with the new requirements of Working Together 2018, Care Act 2014 and the NHS Long Term Plan. This programme will commence on the 01.04.19.

2. The Governing Body is asked to support the recommendation that there is a secondment of a Designated Professional (from the existing Lancashire & South Cumbria CCG safeguarding resource) to work across the ICS to support the development and implementation of the transformational model. There will be collaborative Designated Professional cover for this resource implication.

3. Governing Body members are asked to note that as part of this next phase of work within the programme there will be the development of a Memorandum of Understanding and a Governance Framework for eight CCGs, NHSE and the ICS which will set out the details of the delivery model. These documents will provide assurance that CCGs will continue to meet their statutory duties and responsibilities for adults, children and looked after children. These arrangements will be subject of future papers to CCG Governing bodies in 2019 for formal decision making.

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 217 Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☒

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

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome Cumbria arrangements for 25.09.18 Collaboration with Local Authority safeguarding reforms Police and Health (DoN Chief Nurse & Designated Nurses CCG) Pan-Lancashire arrangements for 20.11.2018 Discussions with Local safeguarding reforms Authorities (Lancashire, Blackpool and Blackburn with Darwen) Police and Health (Designated leads and NHSE) ICS Designated Nurses and legal 29.11.18 Agreed to proceed with ICS support approach Development Market Position 14.12.18 Agreed to proceed statement for Lancashire Director of Nursing and Chief 11.12.18 Agreed in principal Nurses Meeting Pan Lancashire arrangements for 19.12.18 Collaboration with Local safeguarding reforms Authorities (Lancashire, Blackpool and Blackburn with Darwen) Police and Health (Designated leads and NHSE) Pan Lancashire arrangements for 16.01.19 Collaboration with Local safeguarding reforms Authorities (Lancashire, Blackpool and Blackburn with Darwen) Police and Health (Designated leads and NHSE) Cumbria arrangements for 17.01.19 Collaboration with Local Authority safeguarding reforms Police and Health (Designated Nurses CCG) Lancashire & South Cumbria ICS 06.02.19 Redirection to CCG Governing Board Bodies and further clarification requested

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 218

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

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

Assurance N/A

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 219 1.0 Introduction

1.1 There is a requirement for the safeguarding children system to respond to the reforms set out in Working Together (2018) which identifies CCG’s as a key organisation having increased responsibility and accountability in the future safeguarding system. In addition to this the NHS reforms to an Integrated Care System (ICS) approach of commissioning and delivery of services, has led to the need to review the present CCG safeguarding arrangements and the position of the designated role and function.

1.2 Lancashire and South Cumbria safeguarding network has been identified as an area to support the development of a transformational model of safeguarding across the ICS and for NHS England (NHSE). This will include governance arrangements for the revised safeguarding partners across Lancashire and South Cumbria.

1.3 The challenge for health is significant as the children’s reforms need to be implemented within the timescales set out in the revised Working Together Guidance, 2018. Significant work is ongoing in respect to the new safeguarding arrangements and a separate paper is available that outlines this work and recommendations in detail. These reforms are however required alongside a back drop of a changing health landscape, limited resources available and the necessity to ensure the children and adult’s safeguarding agendas are very closely linked.

1.4 The health safeguarding system needs to evolve to meet the new challenges following the introduction of the NHS Long Term Plan (January 2019), which outlines the establishment of Integrated Care Systems’ (ICS’s) by 2021 and the work of Ruth May, CNO which sets out four areas of nursing influence (professional pride, one voice, workforce and long term planning).

1.5 Lancashire and South Cumbria Chief Nurses and Designated Professionals determined that the most effective way of achieving these requirements was to develop a transformational model of safeguarding across the ICS. This approach has been recognised nationally and regionally by NHSE and NHSI and they have provided the resource of the Deputy Head of Safeguarding for NHSE for a day and a half per week to support this development. The Lancashire and Cumbria ICS safeguarding network has also been invited to be a key note speaker at the sixth NHSE Annual Safeguarding Conference on the 9th April 2019.

1.6 It is intended that this paper will inform the Governing Body of the designated leads vision for safeguarding going forward. The paper outlines some clear options for how the safeguarding structure, governance and assurance would work. This modelling has taken into account the new legislative requirements for safeguarding and the changing health landscape. These options include approaches that support the ICS and membership of Integrated Care Partnerships (ICPs) and the CCGs in fulfilling their statutory duties and responsibilities in respect to safeguarding.

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 220 2.0 Background

2.1 A paper was presented to the ICS Board in July 2018, which outlined the need to support and develop safeguarding partnership arrangements across Lancashire and South Cumbria. Working Together, 2018 mandates all areas to publish new multi-agency safeguarding arrangements by June 2019. The paper also set out the need to review the CCG safeguarding role and functions to meet the emerging ICS and NHS reforms and gave a mandate to commence this work and development of a future safeguarding model for the ICS.

2.2 The changes to legislation and statutory guidance provided an opportunity to review some aspects of the current safeguarding arrangements, which are less effective. It is recognised that there is strength in having a collaborative approach. The development of a transformational model of safeguarding leadership, assurance and delivery is integral to future safeguarding arrangements and also for the health service changes within the ICS.

2.3 A leadership group of the Designated Professionals endorsed by the CCGs and NHSE has been formed to develop the proposal and implementation plan. A clear vision has been identified which includes a combined adult and children system wide approach to safeguarding across the ICS. This will include equal priority being given to Looked after Children. The benefits of such an approach will provide greater consistency in the delivery of statutory functions, promote resilience and enable the development of a sustainable and flexible safeguarding model, providing a blue print for other ICSs.

2.4 There were four clear outcomes required from the leadership group:

• The health safeguarding system needs to evolve to meet the new challenges of the NHS Long Term Plan

• To develop a model for the health safeguarding arrangements across the Lancashire and Cumbria footprint going forward taking into consideration the new commissioning framework; ICP’s; resources; accountability and assurance; legal requirements; leadership and the prioritisation of safeguarding across adults, children and looked after children

• The model needs to incorporate governance arrangements to fulfil accountability requirements for the developing children’s safeguarding partnerships across Lancashire and South Cumbria footprint (this footprint is inclusive of eight CCG’s, four Local Authorities and two Constabularies)

• The model will have the flexibility to meet the needs of the emerging Child Death Review (CDR) processes across Lancashire and South Cumbria

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 221 3.0 New Local Safeguarding Arrangements Requirements

3.1 In Lancashire an agreement has been reached in principle for a single Blackpool, Blackburn with Darwen and Lancashire Partnership, closely linked to the Adults Board. The partnership will be underpinned by three geographical groups to allow for a degree of localism (East, Central and Coastal). A paper is being prepared by the Director of Childrens Services for Lancashire that will be shared in due course and will need to be agreed through the respective governance arrangements for the three statutory partners.

3.2 In Cumbria a similar model has been endorsed by the Partners and progression through appropriate Governance structures is underway.

3.3 Papers requesting endorsement by the CCGs to these new safeguarding arrangements are presently progressing through Governing Bodies of all eight CCGs across Lancashire.

4.0 Re-modelling of the designated roles and functions to meet requirements

4.1 The approach adopted in developing the model is outlined below:

4.2 The Designated Professionals have determined that the key functions of the designated role can be best discharged across the ICS to facilitate a whole system approach. These functions have been mapped against delivery across the ICS and ICP landscape.

4.3 Such a model would incorporate the ability to create a safeguarding structure aligned to the ICS commissioning framework, whilst ensuring CCG’s fulfil their statutory requirements for safeguarding within the ICPs.

4.4 A combined ICS adult and children model will align the functions of Designated Professionals, CCG resources and the new safeguarding

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 222 arrangements. The existing informal collaborative network of Designated Professionals will be formalised to facilitate greater flexibility to meet demands, challenges and risks, notwithstanding the challenge of working across the geographical boundaries of Lancashire and South Cumbria. It will also provide the opportunity to scope out the safeguarding resource required in each ICP area and to determine how this might be arranged going forward.

4.5 There is a need to continue to be able to work collaboratively but still maintain the local leadership and representation within the CCGs whilst ever they exist as legal entities. A hub and spoke model would best meet this need at this time which would be supported by a MOU between the CCGs to ensure robust and appropriate representation within safeguarding agendas.

4.6 A local offer of designated professional role and function would be available to all CCGs and the ICS through collaborative working within the present resource. The resource available from each CCG to the collaborative would need defining but the resource that allows the designated functions to be carried out would be necessary as a minimum.

5.0 A transformational model of safeguarding leadership, assurance and delivery across the ICS

5.1 The key opportunities envisaged from the proposed model are outlined below:

• Reduce duplication and unwarranted variation and acknowledge warranted variation commensurate with Leading Change Adding Value (2014) • Support contextual safeguarding with partners and building relationships using collaborative governance • Support ‘Think Family’ • Greater clarity around roles and expectations • Allows for more flexibility and innovation • System assurance at both ICS /ICP level • Clear leadership and co-ordination across the safeguarding system • Support the dissemination of learning to effect system wide change • Better position to respond to the increased accountability and responsibility for health as a key safeguarding partner • Governance structure that supports the new safeguarding arrangements • Development of a Safeguarding Health Executive Group • Development of a collaborative safeguarding health forum for each ICP • System wide portfolio model for safeguarding leadership • System leadership, promoting and building resilience

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 223 6.0 Leadership and Influence

6.1 The essential components outlined below will be achieved in the proposed ICS model:

• Key safeguarding partnership principles • Partnerships to underpin the executive development • A clear accountability and governance framework supported by Executive Leadership from the Director of Nursing NHSE across Lancashire and South Cumbria • Memorandum of understanding between the CCG’s / Designated Leads and the Director of Nursing NHSE • Appropriate influence across the entire commissioning cycle

7.0 Recommendations

7.1 The Governing Body is asked to support a programme of work which will support movement to the preferred model (Option 3) as set out in this high level options appraisal (Appendix 1) for delivering safeguarding arrangements across the ICS in accordance with the new requirements of Working Together 2018, Care Act 2014 and the NHS Long Term Plan. This programme will commence on the 01.04.19.

7.2 The Governing Body is asked to support the recommendation that there is a secondment of a Designated Professional (from the existing Lancs & South Cumbria CCG safeguarding resource) to work across the ICS to support the development and implementation of the transformational model. There will be collaborative Designated Professional cover for this resource implication.

7.3 Governing Body members are asked to note that as part of this next phase of work within the programme there will be the development of a Memorandum of Understanding and a Governance Framework for eight CCGs, NHSE and the ICS which will set out the details of the delivery model. These documents will provide assurance that CCGs will continue to meet their statutory duties and responsibilities for adults, children and looked after children. These arrangements will be subject of future papers to CCG Governing bodies in 2019 for formal decision making.

Development of a transformational safeguarding model across the ICS / ICPs NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 224 Appendix 1

Option 1 Benefits Risks Safeguarding resources remain within The informal partnership approach currently The MOU needs to be robust and agreed CCG’s (ICP’s) but formalise a virtual Pan in place across the pan-Lancashire footprint Lancashire and Cumbria network with in- will be formalised through an MOU No tangible resource and leadership would move reach into the ICS (Portfolios) to the ICS and loss of opportunity to influence the The portfolio arrangement would promote current intractable safeguarding risks efficiency, resilience and lean working Established structures will remain with the inability to influence the changing NHS Perceived benefit to partners and providers landscape and strategic safeguarding partnership as the current system remains unchanged meetings Inequitable resource and skill mix will remain across Lancashire and South Cumbria CCGs. Unwarranted variation will continue due to inequity in resource

Less potential for clear leadership and co- ordination across the safeguarding system strategic leadership

Is not aligned with present children’s commissioning framework

Lack of clarity/ inconsistent roles and responsibilities

Less flexibility in responding to changes required within the refreshed Accountability and Assurance Framework and NHS England Long Term Plan Page 225 Page

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28 March 2019

Option 2 Benefits Risks The whole current CCG resource is This is a lift and shift model which could be The MOU needs to be robust and agreed transferred to the ICS with portfolio easily mobilised responsibility and the operational Inequitable resource and skill mix will remain safeguarding framework continues to be System leadership / Portfolio development / across Lancashire and South Cumbria CCGs. delivered at ICP level will promote and build resilience Unwarranted variation will continue due to System wide portfolio model for safeguarding inequity in resource leadership Agreement may not be reached re mobilisation of Some CCGs currently commission enhanced resources from CCGs safeguarding resource from providers this could be re-designed to cover the ICP Transition arrangements for safeguarding will footprints need to be considered during the transformation of the health agenda Supports effective system wide change and appropriate influence across entire Safeguarding leadership removed visibly from commissioning cycle Local footprints / would need to have strong ICP Health Safeguarding Forums and strong in-reach Governance structure to support new support safeguarding arrangements underpinned by MOU Potential for local need not to be fully recognised and prioritised particularly in the non-unitary LA areas

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NHS Greater Preston CCG Governing Body meeting 28 March 2019

Option 3 Benefits Risks Designated and Deputy resource will be MOU will allow for leadership and incorporated into one single team hosted representation within all of the CCGs whilst Clear governance structure would need to be in by one CCG to deliver the designated their legal entity remains. Accountability of place as CCG’s retain safeguarding functions across the health system in the CCGS will be supported whilst allowing accountability supported by MOU response to population need for resource to work collaboratively and efficiently MOU would need to be robust and agreed Structure the team with a Designated Lead role for Adults, Children and Looked System wide strategic overview will be Clear plans in place for transition in order that After Children (secondment from the achieved current resource is not destabilised existing CCG safeguarding resource) who would take a Safeguarding leadership Direct leadership and accountability will be Transfer of safeguarding resources to a host role within the ICS structure and directly provided under a clear governance structure CCG will need to be agreed by all report into NHS England to the ICS/ICP/NHSE/CCG

Designated Professionals will be aligned Dedicated health safeguarding expertise into to ICP footprints and locality safeguarding the ICS and the ability to oversee transition partnership groups; including portfolio arrangements in line with the NHS long term responsibilities for the ICS footprint plan

Aligns with the safeguarding partnership model and also provides strategic leadership into the emerging model and CDOP developments

There are benefits for multi-agency partners to have a collective health voice

System wide portfolio model for safeguarding leadership and increase collaboration to deliver on functions

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Better able to disseminate learning to effective system wide change and influence the current intractable risks

Consistency in approach and reduces unwarranted variation, allowing warranted variation, doing things once to drive efficiency

Flexibility of resource and allows redesign to reflect future transformation

Supports effective system wide change and appropriate influence across entire commissioning cycle whilst raising profile to embed safeguarding

Can establish a virtual model in shadow form to support transition Page 228 Page

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This page is intentionally left blank Agenda Item 10

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Remuneration Committee Update Presented by Mr Alan Stuttard, Remuneration Committee Chair Author Mr Alan Stuttard, Remuneration Committee Chair Clinical lead N/A Confidential No

Purpose of the paper The purpose of this paper is to provide an update of recent activities of the Remuneration Committee since last reported to the Governing Body in November 2018.

Executive summary The Remuneration Committee meets on an ad-hoc basis and will normally meet a minimum of twice per year in accordance with the Terms of Reference.

The key decisions made at meetings held on 17 January and 21 February 2019 are presented in this report. The full details of the papers and minutes cannot be shared with the Governing Body meeting as the Remuneration Committee is a private meeting not held in public.

The Governing Body is asked to ratify the Remuneration Committee terms of reference, which have been approved by the committee following guidance released by NHS England with the new model constitution which states that Remuneration Committees should only make recommendations to the Governing Body, rather than make decisions.

Recommendations The Governing Body is asked to: 1) note the contents of this report; and 2) ratify the revised Remuneration Committee Terms of Reference.

Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☐ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☐ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☐ Remuneration Committee Update

NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 231 SO4 Ensure patients are at the centre of the planning and management of ☐ their own care and their voices are heard SO5 Be seen as a well-run clinical commissioning group and the system ☒ leader

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

N/A

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

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

Assurance The Remuneration Committee consists of lay members only to ensure that decisions are fair and impartial.

Remuneration Committee Update

NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 232 1.0 Introduction

1.1 The Remuneration Committee is responsible for approving the remuneration, fees and other allowances for employees and for other persons providing services on behalf of the Clinical Commissioning Group (CCG). Following guidance from the Secretary of State for Health, each Committee is responsible for considering the appropriateness of pay awards, agreeing remuneration packages and redundancy packages for VSM staff.

1.2 The Committee meets with Greater Preston CCG Remuneration Committee as a meeting in common. Meetings are chaired by the Chorley and South Ribble CCG Vice Chair as staff are employed by Chorley and South Ribble CCG and seconded to Greater Preston CCG.

1.3 Since the last Remuneration Committee update report to the Governing Body on 28 November 2018, two meetings have taken place on 17 January and 21 February 2019. The outcomes of the meetings held on 17 January and 21 February are provided in this report.

2.0 Meeting held on 17 January 2019

2.1 The following agenda items were discussed at the meeting on 17 January 2019. HR advice and support was provided at the meeting by the HR Business Partner, MLCSU. Remuneration Committee Terms of Reference

2.2 The committee terms of reference have been reviewed following guidance released by NHS England with the new model constitution which states that Remuneration Committees should only make recommendations to the Governing Body, rather than make decisions. Therefore a full review of the terms of reference has been completed to this effect and the committee approved the updated terms of reference subject to the following clarification points.

• What decisions should be made by Remuneration Committee and Governing Body. For example, HR policies to the Remuneration Committee, and Terms and Conditions to Governing Body. • That the terms of reference should be more explicit around its report to the Governing Body annually on its work in support of the Annual Governance Statement and submit details of senior manager remuneration as required for the annual report, and include whether Governing Body Part 1 or Part 2 meetings and on an ‘ad hoc’ basis. • Some aspects of the terms of reference needed to be more explicit.

2.3 There was a consensus that the committee should follow the new national guidance for this meeting as the Governing Body had yet to ratify the new terms of reference. If the Governing Body does not ratify the revised terms of reference then the Remuneration Committee would need to review them again.

Remuneration Committee Update

NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 233 2.4 Remuneration Committee members were mindful of the risk of Chorley and South Ribble and Greater Preston Remuneration Committees making a different decision for VSMs, GP Directors and CCG Chairs. It was agreed that the process would be for Greater Preston Remuneration Committee to make recommendations to Chorley and South Ribble Remuneration Committee, then Chorley and South Ribble Remuneration Committee to make recommendations to the Governing Body.

VSM Remuneration

2.5 The Chorley and South Ribble CCG Chair attended the meeting to provide the rationale behind a proposal for VSM remuneration as part of the annual review process by the Chief Officer who asked if there should be a consistent approach between Agenda for Change and VSM contracts. The committee requested more detail around the rationale behind the pay awards given in recent years and to relate the information to the Agenda for Change for current posts for the next three years. The committee agreed to meet again to consider the detail which it requested.

VSM Contract Review

2.6 The committee agreed to re-issue all VSM and CCG Chairs’ contracts using a standardised contract template and which would reflect the changes to VSM accountability which had been approved by the Remuneration Committee in July 2018.

Update on Agenda for Change Pay Deal

2.7 The committee received an update on the NHS Terms and Conditions of Service contract refresh 2018 following implementation of the Agenda for Change Pay Deal. The committee noted that from 1 April 2019 the automatic incremental pay steps would no longer be used for new staff and would be phased over a period of time for existing staff. CCGs are asked to ensure that robust appraisal systems are in place to support this change.

3.0 Meeting held on 21 February 2019

3.1 The following agenda items were discussed at the meeting on 21 February 2019. HR advice and support was provided at the meeting by the HR Business Partner, MLCSU.

Remuneration Committee Terms of Reference

3.2 The committee received and approved an updated terms of reference following the request for more detail at the meeting held on 17 January. The Remuneration Committee terms of reference are appended to this report for Governing Body ratification.

Report on Performance of Executive Directors (excluding the Chief Officer)

3.3 The committee received a report on the performance of Executive Directors (excluding the Chief Officer) to assure itself of the performance levels of VSMs and Remuneration Committee Update

NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 234 that Executive Directors are meeting expectations before any pay increase is awarded. The Chief Officer attended for this item to provide assurance of the performance of Executive Directors (excluding the Chief Officer).

3.4 The committee accepted that future reporting of performance reviews for Executive Directors would include a summary with a trajectory of any changes to give assurance to the committee around the performance of Executive Directors and that any areas of concern are addressed.

Report on Performance of the Chief Officer

3.5 The committee received a report on the performance of the Chief Officer in accordance with the terms of reference for the Remuneration Committee. The Chorley and South Ribble CCG Chair attended for this item and provided a summary of the performance of the Chief Officer.

Non Agenda for Change Pay Deal – Very Senior Managers

3.6 In light of the new guidance released by NHS England with the new model constitution which states that Remuneration Committees should only make recommendations to the Governing Body, the committee agreed that a recommendation to a Governing Body Part 2 meeting should be made with regard to approval of VSM remuneration.

Non Agenda for Change Pay – GPs

3.7 In light of the new guidance released by NHS England with the new model constitution which states that Remuneration Committees should only make recommendations to the Governing Body, the committee agreed to recommend an uplift which gives parity against the uplift for VSMs.

Social Media Policy

3.8 The committee approved a revised Social Media policy following a review and addition of a specific section about the use of social media during a major incident in line with the CCGs’ emergency preparedness incidents policy and response plan.

Mr Alan Stuttard Remuneration Committee Chair March 2019

Remuneration Committee Update

NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 235

TERMS OF REFERENCE

REMUNERATION COMMITTEE

Document Reference: CSR/TOR/RC Document Title: Terms of Reference – Remuneration Committee Version: 4 Supersedes: 3.1 Author: Mrs Sarah Mattocks Authors Designation: Corporate Affairs and Governance Manager Consultation Group: Remuneration Committee Date Ratified: Review Date:

Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

Page 236 REMUNERATION COMMITTEE TERMS OF REFERENCE

1.0 Introduction

1.1 The CCG’s Governing Body has established a Committee to be known as the Remuneration Committee (the Committee) to carry out the duties as set out in clause 6.6.5(b) of the constitution.

1.2 Except as outlined in these Terms of Reference, meetings of the Committee shall be conducted in accordance with the provisions of Standing Orders, Reservation and Delegation of Powers and Prime Financial Policies approved by the Governing Body and reviewed from time to time. The Committee is authorised by the Governing Body to investigate any activity within its Terms of Reference which has delegated functions connected with the Governing Body’s main function.

1.3 The Committee, which is accountable to the CCG’s Governing Body, is responsible for making recommendation on the remuneration, fees and other allowances for employees and for other persons providing services on behalf of the Clinical Commissioning Group (CCG). All recommendations regarding remuneration will be submitted to the Governing Body for approval.

1.4 The Governing Body has approved and keeps under review the terms of reference for the Committee, which includes information on the membership of the Committee.

1.5 The Committee has responsibility to assure itself and the Governing Body that the CCG is compliant with guidance from NHS England, the Department of Health, and any other relevant public sector in reference to Remuneration.

1.6 Both Chorley and South Ribble CCG and Greater Preston CCG Committees may hold their meetings together as a ‘Committee in Common’ unless there are any agenda items which are pertinent or confidential to one particular CCG, on which occasions the committees will meet separately.

1.7 The Remuneration Committee will provide an opinion to the Governing Body on the adequacy of controls and assurances available with respect to those matters set out in the Remuneration Committee’s Terms of Reference.

1.8 The Committee will be the ratifying body of all employment and staff related policies.

1.9 The Director of Quality and Performance will be responsible for ensuring that FOI requirements in relation to the Committee’s minutes and reports are met. The chair of the committee will seek the advice of the Director of Quality and Performance in relation to any matters where an exemption as defined within the Freedom of Information Act 2000 is believed to apply.

Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

Page 237

2.0 Membership

2.1 The Committee shall be appointed by the CCG from amongst the lay members of its Governing Body Members. The Committee should not include employees.

2.2 The Committee shall consist of not less than 3 members:

• Vice Chair of the Governing Body;

• Two Lay Members of the Governing Body;

2.3 In addition:

• additional members should be appointed at the discretion of the Governing Body;

• The CCG’s Human Resources Business Partner should attend every meeting;

• the composition of the Committee should be recorded in the annual report.

2.4 The meeting will be Chaired by the Vice Chair of Chorley and South Ribble CCG Governing Body. Chorley and South Ribble CCG hold the contracts of employment for all staff except those staff specifically employed to work for Greater Preston CCG. All employees are seconded to Greater Preston CCG on a part time basis under joint arrangements from Chorley and South Ribble CCG, unless a contract states that they are specifically employed to work for Chorley and South Ribble CCG.

3.0 Voting

3.1 Where a vote is required to agree on the recommendation being made to the Governing Body which relates to a contractual/remuneration issue for a Chorley and South Ribble CCG employee, Greater Preston CCG Committee members should make a recommendation to Chorley and South Ribble CCG Committee members who will then agree the recommendation made to the Chorley and South Ribble Governing Body. Likewise where a vote is required which relates to a contractual issue for a Greater Preston CCG employee, Chorley and South Ribble CCG Committee members should make a recommendation to Greater Preston CCG Committee members who will then agree the recommendation made to the Greater Preston Governing Body. Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

Page 238

3.2 Where voting decisions are taken and there is an even split in voting, the casting vote will be awarded to the Chair.

3.3 Recommendations will be made to the Governing Body of the respective CCG holding the contract of employment of the staff groups concerned. The CCG to which this does not pertain to will receive the outcome of the Governing Body decision for information.

3.4 No member should be involved in considering and making recommendations on their own remuneration.

4.0 Attendance

4.1 Only members of the Committee have the right to attend Committee meetings. However, other individuals such as the Accountable Officer, appropriate HR professional, CCG Officers or external advisers may be invited to attend for all or part of any meeting as and when appropriate.

5.0 Quorum

5.1 Quorum shall be 2 members from each CCG (4 members in total).

5.2 A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee on behalf of the Governing Body.

6.0 Frequency and Notice

6.1 The Committee shall normally meet at least twice a year, but additional meetings may be required and the Chair will be advised of this in advance. The Chair may also ask for a meeting to be convened.

6.2 Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Committee, and other persons required to attend no later than five working days before the date of the meeting. Supporting papers shall be sent to Committee members and other attendees as appropriate, at the same time.

7.0 Purpose

Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

Page 239 7.1 The committee will make recommendation on determinations about allowances under any pension scheme that the group may establish as an alternative to the NHS pension scheme.

7.2 From June 2015, a responsibility was placed on CCG Remuneration Committees to assure themselves that CCG executive remuneration is necessary and publicly justifiable. The Committee will seek the views of NHS Improvement and NHS England before making appointments to NHS Boards with a salary threshold higher than the Prime Minister’s. HMT guidance on “off-payroll” appointments must be rigorously followed, and it is the Secretary of State for Health’s expectation that there should be no significant difference in the terms and conditions of senior leadership teams.

7.3 Any actions taken by the Committee must be publicly defensible. The Committee should bear in mind the need for properly defensible remuneration packages, which are linked to clear statements of responsibilities and with rewards linked to the measurable discharge of those responsibilities.

7.4 In all of their decisions and recommendations the Committee should also remain aware that the group is corporately responsible for ensuring that its pay arrangements are appropriate in terms of Equal Pay requirements and other relevant legislation.

7.5 The Committee and CCG Governing Body, to which they report, are public bodies. As such they must at all times:

• observe the highest standards of propriety involving impartiality, integrity and objectivity in relation to the stewardship of public funds and the management of the bodies concerned;

• maximise value for money through ensuring that services are delivered in the most efficient and economical way, within available resources, and with independent validation of performance achieved wherever practicable;

• be accountable to Parliament, to users of services, to individual citizens and to staff for the activities of the bodies concerned, for their stewardship of public funds and the extent to which key performance targets and objectives have been met;

• comply fully with the principles of the Citizen's Charter and the Code of Practice on Access to Government Information, in accordance with Government policy on openness;

• bear in mind the necessity of keeping comprehensive written records of their decisions, in line with general good practice in corporate governance;

Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

Page 240 • seek independent advice when making recommendations on the remuneration of Governing Body members. NB independent advice could be in the form of expert Human Resources advice;

• invite independent representatives to scrutinise decision-making where the removal of members with a conflict of interest would make the meeting no longer quorate;

• scrutinise systems for identifying and developing leadership and high potential; and

• scrutinise plans for orderly succession of appointments to the Governing Body and of senior management, in order to maintain an appropriate balance of skills and experience.

8.0 Duties

8.1 The Committee shall:

• make recommendations on determinations about pay and remuneration for employees of the Clinical Commissioning Group and people who provide services to the Clinical Commissioning Group. The Committee will also make recommendations on allowances under any pension scheme it might establish as an alternative to the NHS pension scheme;

• seek assurance from the CCG Chair regarding the performance of the Accountable Officer, and assurance from the Accountable Officer regarding the performance of those staff on Very Senior Manager contracts.

• make recommendations on annual salary awards, if appropriate for those staff on Very Senior Manager contracts, after having received assurance regarding performance of those staff.

• consider the severance payments of the Accountable Officer and usually of other senior staff, seeking HM Treasury approval as appropriate in accordance with the guidance ‘Managing Public Money’ (available on the HM Treasury website).

• The Committee Chair may wish to seek external advice on any of the above matters.

8.2 All aspects of salary will be considered by the Committee, including:

• performance-related elements and bonuses;

• provisions for other benefits, including pensions and cars;

Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

Page 241 • arrangements for termination of employment and other contractual terms (decisions requiring dismissal shall be referred to the Governing Body)

8.3 The Committee will also consider the following issues for submission to NHS England Remuneration Committee:

• severance payments to Accountable Officers and Senior Managers;

• termination payments requiring Treasury approval;

• redundancy / early retirement payments to Very Senior Managers, or costing over £50,000.

8.4 The Committee will apply best practice in all elements of its decision making processes in the recommendations that it makes, for example, when considering individual remuneration the Committee will:

• comply with current disclosure requirements for remuneration;

• on occasion seek independent advice about remuneration for individuals; and

• ensure that decisions are based on clear and transparent criteria.

• The Committee Chair will provide guidance, if required, to the Clinical Chair on matters relating to arrangements in place for GP Director absence should this be anticipated to exceed the attendance levels laid out in the terms of reference for the committees on which the GP Director is a member.

8.5 The Committee will have full authority to commission reports or surveys or seek the advice it deems necessary to fulfil its obligations.

8.6 The Committee will seek assurance that for every interest declared to it, either in writing or by oral declaration, arrangements are in place and have been implemented to manage the conflict of interests or potential conflict of interests, to ensure the integrity of the Committee’s decision making processes.

8.7 The Committee will be the ratifying body of all employment and staff related policies.

8.8 The committee has a responsibility to manage conflicts or potential conflicts of interest when these are declared in the meeting by following the Managing Conflicts of Interest Policy. The committee’s minutes will record the steps taken to manage any identified conflicts of interest in accordance with the requirements of the CCG policy and constitution.

Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

Page 242 8.9 The committee has the responsibility to approve all policies within its remit. However where an item of business comes to the committee that effects terms and conditions of a staff member, such as approval of a VSM salary, the committee will make a recommendation to the Governing Body, which will approve this decision. These discussions will take place in Part 2 Governing Body meetings unless it is identified that the item should be discussed in a public domain.

9.0 Reporting

9.1 The minutes of Committee meetings shall be formally recorded and a summary submitted to the CCG Governing Body after each time the committee has met.

9.2 The Committee will also submit an annual report to the Governing Body on its work in support of the Annual Governance Statement and submit details of senior manager remuneration as required for the annual report.

10.0 Monitoring and Compliance

10.1 The Committee shall submit an annual report to the CCG Governing Body, incorporating progress, reporting arrangements, frequency of meetings and membership attendance.

11.0 Review of Terms of Reference

11.1 The Terms of Reference of the Committee shall be reviewed by the CCG Governing Body at least annually.

Remuneration Committee Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019

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This page is intentionally left blank Agenda Item 11

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Audit Committee Update Presented by Mrs Linda Chivers, Audit Committee Chair Author Mrs Linda Chivers, Audit Committee Chair Clinical lead N/A Confidential No

Purpose of the paper The paper provides an update from the Audit Committee meeting held on 1 March 2019 and on any work undertaken by committee members outside of the meeting.

Executive summary The minutes of the meeting held on 4 January 2019 are attached for information. The key points from the meeting on 4 January were presented to the Governing Body on 23 January 2019.

The report on the meeting held on 1 March 2019 outlines the key decisions made, the assurances sought and any key risks that were identified.

The Audit Committee would like to draw attention to the points highlighted in the report requesting that: 1. That the Governing Body approve the addition of a risk to the Corporate Risk Register relating to Springfield Manor Gardens. 2. The Audit Chair reviews the finalised submission of the Data Security and Protection Toolkit prior to sign off by the CCG Chair and submission for 31 March 2019. 3. The Governing Body receive and approve the Annual Report from the Freedom to Speak Up Guardian.

Recommendations The Governing Body is asked to note the report.

Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☐ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☐ balance between in-hospital and out of hospital provision

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 245 SO3 Be an integral part of a financially sustainable health economy ☐ SO4 Ensure patients are at the centre of the planning and management of ☐ their own care and their voices are heard SO5 Be seen as a well-run clinical commissioning group and the system ☒ leader

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

N/A

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

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

Assurance This committee is an assurance committee. Additional assurances are provided through Internal Audit reviews, the Head of Internal Audit Opinion and External Audit Report and findings.

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 246 1.0 Introduction

1.1 The Governing Body papers include the approved minutes of the meeting held on 4 January 2019. The key points from the meeting on 4 January 2019 were reported on at the Governing Body meeting on 23 January 2019. This report covers the meeting held on 1 March 2019.

2.0 Decisions

2.1 The Committee received the proposed reviewed Audit Committee Terms of Reference as required annually and and approved them for recommendation to Governing Body for ratification. There were no recommended changes to the terms of reference, therefore they remain unchanged. The reviewed Terms of Reference will be submitted to the Governing Body for ratification in May 2019 as part of a suite of CCG Committees Terms of Reference.

2.2 The Committee approved the process used to manage the Corporate Risk Register and recommends that the Governing Body approves the one addition to the register which relates to Springfield Manor Gardens Ltd, which replaces Spiral Health CHC, which no longer exists. This recommendation is included in the GBAF and Corporate Risk Register within Governing Body papers.

2.3 The Committee received the Information Governance (IG) Update and the IG Annual Report. The reports provided updates on progress made on the CCG Annual Data Security and Protection (DSP) toolkit submission and the CCG compliance for data protection and GDPR. The CCG was confident that outstanding evidence would be submitted in time to secure a 100% compliance rating. The final sign off would be carried out by Audit Chairs prior to CCG Chairs.

2.4 The committee approved the Internal Audit Annual Plan for 2019/20. As the initial outline plan has indicated a significant increase in time and cost it was agreed to focus reviews on the key areas of priority risk and if necessary, draw 6 days from 2020/2021. On the advice of KPMG a number of proposed audits were removed from the plan. These related to Management Costs; Governing Body Effectiveness and Remuneration Committee. It was agreed to keep in the plan Contract Management for MLCSU as Continuing Health Care costs could be significant.

2.5 The Committee received the Freedom to Speak Up Guardian Annual Report No concerns have been reported to the Guardian. A copy of the report is attached for information. The report is recommended to the Governing Body for approval. The committee acknowledged that the Greater Preston CCG Freedom to Speak Up Guardian would provide the role for Chorley and South Ribble CCG from 1 April 2019 until the vacancy for Chorley and South Ribble CCG Vice Chair is filled.

2.6 The Committee approved the Anti-Fraud work plan for 2019/20.

2.7 The committee approved the Audit Committee Annual Report, a copy of which is included with Governing Body papers for ratification.

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 247 2.8 The committee noted that there have been no new entries on the CCG Corporate Registers since last reported to the Governing Body.

3.0 Assurances

3.1 The Committee received a ‘deep dive’ presentation by Mrs Helen Curtis, Director of Quality and Performance on GBAF01 ‘Quality, Safe and Effective Services’. Audit Committee members considered how the CCGs have seen a diminishing of powers to ensure our providers deliver the services which the CCG commissions, and that the only areas where the CCG is able to withhold money is for Commissioning for Quality and Innovation (CQUINS).

3.2 The committee was disappointed to note an increase in risk scoring for two of the risks following the outcome of two Care Quality Commission (CQC) Inspections at to Lancashire Care NHS Foundation Trust which “requires improvement”. The two inspections were related to mental health services and staffing issues at Longridge Community Hospital. Another CQC Inspection at Lancashire Teaching Hospitals NHS Foundation Trust has led to a rating of “requires improvement” with regard to A&E and Emergency Medicines. The committee noted that the Referral To Treatment Times target risk, which is recorded on the Corporate Risk Register, is linked to quality and performance management and forms part of the broader transformation work for the Integrated Care Partnership.

3.3 The Committee was concerned that the CCG is focusing on external (CQC) expectations rather than measuring outcomes and patient experience and suggested that for the next GBAF for 2019/20 we should focus on quality and safety rather than the performance of our providers. The committee also noted that the risks could changes, for example stroke services and failures around performance data, yet there is no patient harm or poor patient outcome. It may be that the patient was treated in the wrong place but has come to no harm.

The Committee agreed that the risk should be renamed to reflect the function of CCGs - “failure to commission safe and effective services resulting in poor outcomes and experiences”.

3.4 The Committee noted progress with regard to the Governing Body Assurance Framework (GBAF), which has been updated to reflect the changes made since last reported to the Governing Body. Audit Committee members felt that the reduction in GBAF 02 Financial Sustainability was a ‘one-off’ benefit and that this risk should be linked to the three year plan and we should measure likelihood of the outcome based on past performance. With regard to GBAF 03 Well Led, the committee felt that there should be a balance of the various elements of the Corporate Risk Register including Our Health Our Care presented to Governing Body members.

3.5 Grant Thornton colleagues provided an update on progress in delivering responsibilities as external auditors and reported that there were no issues. The Committee received the External Audit Plan for 2019/20 and a Sector

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 248 Update which provided an opportunity for Audit Committee members to consider the key issues facing CCGs. Mr Kelly, Engagement Lead, Grant Thornton has put forward our CCGs to NHS England to reflect the innovation of our Stand Up Friday work.

3.6 KPMG colleagues provided an update on progress against the internal audit plan for 2018/19. Four final reports were presented to the Committee. Key issues from those reviews were presented at the meeting. Recommendations included that a formal process needs to be in place for financial management of hosting arrangements as the risks are not included in the risk management process. Another recommendation related to GBAF risk assurances and how Governing Bodies can keep track of actions and accountability if the Integrated Care Partnership does not deliver its plans.

3.7 Assurances were received in relation to the following audits: Partnership Working and Contract Management: Hosted Arrangements – Significant assurance with minor improvement opportunities; Privacy Diagnostics (GDPR) Review of Governance, Risk, Training and Incident Management – Significant assurance; Data Security and Protection Toolkit – Phase One – Partial assurance with improvements required. The outcome of a strategic advisory review on ICP Governance was also presented confirming good levels of engagement

3.8 The committee received the draft Head of Internal Audit Opinion which gave “significant assurance with minor improvement opportunities” on the overall adequacy and effectiveness of the CCGs’ framework of governance. The full Head of Internal Audit Opinion will be presented to the committee on 3 May 2019.

3.9 The committee received an action plan which will address concerns raised through the recent survey on the effectiveness of Internal Audit, which Audit Committee, Management Executive Team and direct reports took part in. The actions related to wider input into the annual planning process for 2019/20 and sharing additional benefits of any training sessions which would be useful to Audit Committee or Governing Body members.

3.10 The committee received the Anti-Fraud Progress Report which gave an update on progress against the annual work plan. .

3.11 Following the number of outstanding overdue declarations of interest reported to the Governing Body in November 2018 in relation to GP member representatives, letters were issued from Conflicts of Interest Guardians to each member who had not completed their declaration. Since then the position has improved.

3.12 The committee was pleased to note the compliance rating of 100% for conflicts of interest training for those members and employees, including GP Clinical Advisors, who are required by NHS England to undertake annual conflicts of interest training.

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 249 3.13 The committee received for information the accounting policies to be included with the 2018/19 financial accounts and noted a potential impact for CCGs from next year with regard to CCGs lease of buildings in primary care.

4.0 Audit Committee Chair Update

4.1 The Audit Committee Chairs reported on their recent activities which included attendance at ICS meetings and a Mersey Internal Audit Agency event on ‘understanding strategic finances’.

4.2 Committee members agreed after the meeting that they were satisfied with the outcomes and decisions made.

Mrs Linda Chivers, Audit Committee Chair Chorley and South Ribble CCG March 2019

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 250

Chorley and South Ribble CCG Audit Committee Minutes Friday, 4 January 2019, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 9.30 am

Present Mrs Linda Chivers, Audit Committee Chair Mr Geoffrey O'Donoghue, Lay Member Patient and Public Involvement Mr Alan Stuttard, Lay Member Governance

In Attendance Mr Ian Cherry, Audit Committee Chair Greater Preston CCG (Chair) Mrs Debbie Corcoran, Lay Member Patient and Public Involvement Greater Preston CCG Mr Matt Gaunt, Director of Finance and Contracting Mrs Lynne Johnstone, Audit Manager, Grant Thornton Mr Gareth Kelly, Engagement Lead, Grant Thornton Mrs Amanda Latham, Head of Internal Audit, KPMG Mrs Sarah Mattocks, Corporate Affairs and Governance Manager Mr Paul Richardson, Lay Member Governance Greater Preston CCG Mrs Anne Whittle, Corporate Business Manager (minutes)

1 Introduction Mr Cherry welcomed everyone to the meeting, wishing everyone a happy new year. He introduced Mrs Lynne Johnstone, Audit Manager, Grant Thornton.

2 Apologies for Absence Apologies for absence were received from Ms Harriet Fisher, Manager, KPMG.

3 Declarations and Register of Interests The Register of Interests was presented for information. Mr Cherry reminded committee members of their obligation to declare interests they have against the agenda which might produce a conflict. He asked if there were any new declarations in relation to the agenda. None were received, however it was noted that Mr Stuttard’s declaration of interest has since been updated to reflect that he has a non-executive director role at Bolton NHS Foundation Trust, and that his son no longer works for North West Ambulance Service. This has been reflected in an updated declaration of interest proforma that Mr Stuttard has submitted to the governance team and requires no management in this meeting.

4 Minutes of Previous Meeting Both Audit Committees reviewed the minutes of the Audit Committee meeting held on 2 November 2018. These were accepted as a correct record, subject to the following amendment.

Introduction – Mr Gareth Winstanley’s title should read ‘Engagement Manager’.

Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 4 January 2019 NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 251 Resolved That the minutes from the meeting held on 2 November 2018 were accepted as a correct record, subject to the above correction.

5 Matters Arising Audit Committee members accepted those items which were identified as complete and updates where actions are not complete. The committee accepted the following additional update:

180522-03 External Audit Findings Report Mr Gaunt confirmed that there was a change to the way we do our reporting. He would pick this up with Mr Kelly in relation to bringing visibility to this committee including how we receive value against the CCGs’ Better Care Fund contribution. This action was now complete.

181102-08 Annual Review of the Effectiveness of External Audit Mr Kelly stated that the key issue from the outcome of the annual review of external audit services was in relation to Grant Thornton’s communication / presentation of output. He suggested an informal briefing with Audit Committee members would help this and would look to complete this later this year. This action was now complete.

Resolved That the Committee noted the updates provided and approved the closing of all actions assessed as complete.

6 GBAF 02 Financial Sustainability Deep Dive Mr Gaunt gave a presentation on GBAF02 Financial Sustainability, including risk definition and attitudes to risk and a review of assurance and controls. Mr Gaunt described the three levels of financial sustainability within statutory financial frameworks and asked Audit Committee members to consider the current level of risk appetite, which was high tolerance and high confidence and whether this was consistent with how we feel at this stage in the year and in line with discussions we had at the Governing Body and other fora. He felt there were significant changes to reporting over the last 9 months in the way we address gaps and controls.

Mr Gaunt asked Audit Committee members how we go about framing our partnership assurances in future as the next three to four years will look different. He asked for views on potential issues with regard to future income as discussed by the Primary Care Commissioning Committee, with long standing commitments using recurrent funding and that risks can only be mitigated by the CCG in areas where the owner has control. Hence the comment “unable to deliver system side transformation as directed by the Integrated Care system (ICS) and Integrated Care Partnership (ICP). Comments made by the committee included:

• With regard to the impact of failure, whether in-year or in future years, the committee would normally expect to see zero based budgeting over a three year span. However this was not the method adopted by the CCG therefore impact tends to be over marginal areas of investment on an annual basis. • That we receive an indication of the use of non-recurrent funding to support recurrent programmes of work which could affect the risk rating going

Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 4 January 2019 NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 252 forward. • We tend to increase the risk rating with the difficulty of execution rather than the likelihood of occurrence and would expect the risk rating to be lower the closer towards the year end we were assessing likelihood. • That the CCG takes a balanced approach to risk, however at year-end we feel an increase in financial pressure and move to low tolerance, low confidence, which is reflective of our lead provider’s performance. • That assurances and gaps which occur through statutory routes for CCGs relate to reduced Consultant to Consultant activity and increased growth in A&E activity at Lancashire Teaching Hospitals. • There was concern that if nationally CCGs are required to provide additional financial resources to support hospitals which are in a deficit position this would affect our financial controls, and that NHS England will ‘come down’ on CCGs not achieving financial sustainability. • That Primary Care and Continuing Health Care are two areas of risk which could be given more focus by the Governing Body. Primary Care programmes use 10% of CCG budget yet this should be more as we try to move patient care into the community. • That the risk profile does not seem to reflect patient outcome. Rather than trying to deliver our strategy we are trying to ‘balance our books’. • The Committee drew comparison between Lancashire Teaching Hospitals and Wrightington, Wigan and Leigh Hospital, which performs better in managing A&E. • There were strong levels of assurance around financial sustainability from external and internal auditors.

Overall the Audit Committee was satisfied with the way which the CCG manages financial sustainability and has confidence in the CCG achieving financial balance.

Resolved That the Committee noted the update provided from the deep dive into GBAF02 Financial Sustainability.

7 Governing Body Assurance Framework and Corporate Risk Register Mrs Mattocks presented an update in respect of the Governing Body Assurance Framework (GBAF) and Corporate Risk Register, which has been updated to reflect the changes made since last reported to the Governing Body. Good progress has been made across the risks included in the GBAF. The committee noted that the Quality and Performance Committee were satisfied that actions were being delivered by Lancashire Teaching Hospitals following recommendations from the Care Quality Commission report which concluded that the Trust “requires improvement”. The committee noted that assurance is dependent on delivery by the provider and that we should only reduce the risk when we see improvement.

Comments received included:

• That the Quality and Performance Committee has received updates that actions to mitigate the gaps are being delivered and that there has been an improvement in performance since the CQC report was published. • That increased staffing was one of the improvements at Lancashire Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 4 January 2019 NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 253 Teaching Hospitals. • That the Our Health Our Care Joint Committee has discussed the case for change at LTH, which supports GBAF 01.

Resolved That the Committee noted the progress with the GBAF for 2018/19 and approved the process used to manage the Corporate Risk Register and recommends the Governing Body approves the new risk to the Corporate Risk Register.

8 External Audit Progress Report Mrs Johnstone presented a report which provided an update on progress in delivering responsibilities as external auditors and reported that there were no issues. The report included a summary of current issues facing the NHS.

Mrs Johnstone met with Mr Gaunt in November 2018 to discuss audit plans and they agreed that there were no issues which required the attention of the Audit Committee. With regard to the Audit Deliverables report the committee noted that the planned date for this report was January 2019. The report would be circulated to Audit Committee members via Mrs Whittle. An interim Financial Statements Audit report will be provided to the March 2019 meeting.

In reply to a question about whether Grant Thornton have any concern about timescales for internal audit reports as several reports will be received at year end and will be needed for external audit assurance. Mr Kelly confirmed that this fits in with external audit work, however he would liaise with KPMG to dovetail the process.

The report included a summary of national issues and developments that may be relevant to CCGs and a number of challenge questions in respect of those emerging issues as a tool that the committee may wish to consider. Mr Kelly highlighted in particular the links to documents relating to prevention and innovation. Grant Thornton had taken key themes around leadership and culture and what is relevant to Chorley and South Ribble and Greater Preston CCGs.

Audit Committee members noted the information contained within the report.

Resolved That the Committee noted the content of the report.

9 Internal Audit Progress Report and Health Sector Update Mrs Latham provided an update on progress against the internal audit plan. Those reports which have yet to be finalised in time for year-end would be brought to the March 2019 Audit Committee meeting. As this would be too late for the committee to influence assurance levels, at the meeting in private after the Audit Committee meeting it was agreed that the Audit Chairs would meet with KPMG colleagues to discuss the final reports. Audit Chairs would then consider whether an extra ordinary Audit Committee meeting would need to be convened before March to review final internal audit reports.

With regard to the Delegated Commissioning Audit, the committee noted that there was one recommendation rather than two as reported in the report. A correction would be made to the name of the committee in the report. With regard

Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 4 January 2019 NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 254 to the Financial Reporting Audit more detail was requested and clarity in the final paragraph on page 89 of committee papers.

There was follow up work to be completed with regard to the list of actions outstanding from audits completed by for the previous internal auditors, Mersey Internal Audit Agency. Mr Gaunt was confident that all actions had been completed but would liaise with Mrs Betts, Corporate Governance Manager to seek assurance that all actions were closed.

The Key Performance Indicators showed 50% of management responses received within 10 working days of draft reports being issued. Mr Gaunt would take this back to Management Executive Team. Mrs Latham explained that this was due to specialist staff on leave and in future any delays would be escalated to the Audit Committee.

Audit Chairs would in future receive final audits before these are shared with the Audit Committee.

Resolved That the Committee noted the content of the report.

10 Annual Review of the Effectiveness of Internal Audit Mrs Mattocks presented a report which outlined the outcome of a recent survey which has been undertaken to support the review of the effectiveness of internal audit services. Overall the results provided a satisfactory level of assurance to the Audit Committee. Where there were areas which respondents scored with low levels of assurance, KPMG colleagues would produce an action plan to address these areas.

Respondents to the survey included Audit Committee members, Management Executive Team (MET) and Direct Reports to MET. As it was difficult to see which sectors had issues with internal audit services it was agreed that work would be done to split the results into two sectors, Audit Committee and MET, and Direct Reports, then send this information to Audit Chairs and KPMG, for KPMG to produce a response plan.

In reply to a question about the way we report in future, Mrs Latham would liaise with Mrs Mattocks and Mrs Betts to put an action in place to address any issues which had arisen as a result of the survey.

In reply to comments made in the survey that respondents were not aware of any additional benefits or training events that internal auditors can provide, KPMG colleagues agreed to promote this information more widely.

Resolved That the Committee noted the content of the report.

11 Emergency Planning, Resilience and Response Mrs Mattocks presented the Emergency Preparedness Resilience and Response (EPRR) Annual Submission. The standards have undergone major revamp which it does every three years and includes new criterion not previously covered. The submission was based on the thresholds for the overall EPRR assurance rating

Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 4 January 2019 NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 255 sent by NHS England. Chorley and South Ribble and Greater Preston CCGs have both declared “substantially compliant”. Audit plans are in place where recommendations were made and CCG colleagues were confident that the CCGs would be fully compliant next year. In addition both CCG providers Lancashire Teaching Hospitals and Lancashire Care also reported a “substantially compliant” rating. Where either provider or the CCG were not compliant with a specific standard and action is in place to address this within the next 12 months.

Resolved That the Committee noted the content of the EPRR Annual Submission.

12 Information Governance (IG) Update Mrs Mattocks presented an update report which summarised the work undertaken by the Information Governance (IG) Team. The committee noted that as part of the new IG framework a newly developed Employee Privacy Notice is now available on the CCG’s website. The committee discussed the data flow mapping as referred to on page 166 of committee papers. There are several draft data flows which have been delayed. The IG Team is working with the Unscheduled Care Team, where the delays are to ensure these are complete.

In reply to a question about the MEAM as referred to on page 152 of committee papers, Mr Gaunt was not aware of any escalators and would ask what the expectation is.

A request was received that dates in the ‘date issue logged’ column of the Caldicott Log are placed in chronological order.

Resolved That the Committee noted the content of the report.

13 Corporate Registers Mrs Mattocks provided an update report on each of the CCG Corporate Registers. The committee:

- noted there have been 0 new entries on the Hospitality, Sponsorship and Gifts Register

- noted there have been 0 new entries on the Tender Waivers Register

- noted there has been 1 new entry on the Procurement Decisions Register. The addition was for the Haven Community Crisis / Recovery Café contract award. There was an amendment to the register which related to the value of the GP Online Consultation Services contract. This was an administration error which has not had any financial impact on the CCG; however Mrs Mattocks would check the value over three years and the financial figures.

- noted there have been 0 new entries on the Losses, Write Offs and Special Payments Register

Resolved

Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 4 January 2019 NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 256 That the Committee noted that there was 1 new entry and 1 amendment to the Procurement Decisions Register and that there were no new entries on the Hospitality, Sponsorship and Gifts Register, Tender Waivers Register or the Losses, Write-Offs and Special Payments Register.

14 Chairs Update The Audit Committee Chairs reported that other than the Our Health Our Care pre consultation meetings (which all had attended) into Acute and Emergency Service redesign there have been few meetings to attend since the last Audit Committee meeting.

Resolved That the Committee noted the update provided.

15 Any Other Business There was no further business to discuss.

16 Outcomes from the Meeting Audit Committee members took time after the meeting to consider the outcomes and reflect on the decisions made at the meeting and consider what went well and not so well.

Date of next meeting: Friday 1 March 2019, 9.30am in the Bowman Room, Chorley House

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

Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 4 January 2019 NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 257 Freedom to Speak Up Guardian Annual Report

1.0 Introduction

1.1 Following the ‘Freedom to Speak up Review’ by Sir Robert Francis, it was recommended that all NHS organisations foster a culture of safety and learning in which staff feel safe when raising concerns.

1.2 One of the recommendations to this effect is for the organisation to appoint a ‘Freedom to Speak up Guardian’. This Guardian acts as a support to the organisation in becoming a more open and transparent place to work, where all staff are actively encouraged and enabled to speak up safely.

1.3 There is also a national Guardian who provides leadership and advice for local Guardians based in NHS organisations.

1.4 Evidence contained in this report will be reported to the Clinical Commissioning Group Governing Body and will be used to support the content of the CCG Annual Governance Statement and CCG Annual Report.

2.0 Role profile of the Freedom to Speak up Guardian

2.1 The diagram below illustrates the characteristics expected of the guardian and what staff can expect when approaching them with concerns:

Freedom to Speak Up Guardian Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 258 2.2 Chorley and South Ribble CCG and Greater Preston CCG are separate statutory organisations and have appointed their own Freedom to Speak up Guardians. However due to the joint management arrangements between the two organisations staff have access to either of the Guardians.

2.3 The Guardians are :

Chorley and South Ribble CCG – Alan Stuttard, Vice Chair Governance Greater Preston CCG – Paul Richardson, Vice Chair Governance

The contact details and role of the Guardian are contained on the CCG Website.

3.0 Activity in the last 12 months

3.1 No concerns have been reported to the Guardian in the last 12 months.

3.2 A whistle blowing ‘lunch and learn’ session was delivered on 22 November 2018. This session was made available to all staff in order to raise awareness of the guardian role and processes surrounding whistleblowing. In addition a further session was delivered to the Medicines Management Team on the 19 March 2019.

4.0 Conclusion

4.1 The CCG has established the role of Freedom to Speak up Guardian in accordance with the recommendations of the Francis Report. Although no concerns have been raised by staff in 2018/19 the role has been publicised through the CCG website and the delivery of learning sessions to staff across the organisation.

Freedom to Speak Up Guardian Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 259 Audit Committee Annual Report 2018/19

1.0 Introduction

1.1 The Audit Committee (the Committee) has prepared this report to the Governing Body. It provides information about actions taken by the Committee to provide assurance that it complied with its Terms of Reference (TOR) in the financial year 1 April 2018 to 31 March 2019.

1.2 Evidence contained in this report will be shared with the Clinical Commissioning Group Governing Body and will be used to support the content of the CCG Annual Governance Statement.

1.3 The Committee meets in common (with the Audit Committee of Greater Preston CCG) and met seven times during the period 1 April 2018 to 31 March 2019.

2.0 Background

2.1 The NHS Codes of Conduct and Accountability and the NHS Audit Committee Handbook require that an Audit Committee is established as a non-executive Committee of the Governing Body to provide an independent and objective view on its financial systems, financial information and compliance with laws, guidance and regulations governing the NHS. The establishment and constitution of an Audit Committee is mandated by the Constitution of the CCG. The Audit Committee has oversight of the CCG’s integrated governance, risk management and systems for internal control, and seeks assurance that these are operating effectively.

3.0 Governance, Establishment and Duties

3.1 Members of the committee are appointed by the Governing Body from amongst the Lay Members of the CCG. The TOR were reviewed and updated by the committee in March 2019 but this resulted in no changes to the core membership. There must be at least three members on the committee, one of whom is appointed by the Governing Body to chair the Committee. This is the lay member for audit, finance and conflicts of interest. The chair is a qualified accountant and also holds the role of the conflicts of interest guardian.

3.2 The committee’s TOR state that the Chief Finance and Contracting Officer, representatives of internal and external audit, and counter fraud will normally attend meetings. Other directors and CCG officers are invited to attend, as needed, for the discussion of specific items of business or recommendations arising from reports. The Accountable Officer attends the meeting in May each year to discuss assurances relating to the Annual Governance Statement. The revised TOR will be submitted to the Governing Body for ratification at its May 2019 meeting.

3.3 The committee receives support from the CCG Governance Team based within the Finance and Contracting Directorate. The committee’s regular meeting schedule

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 260 also allows for private meetings between committee members and representatives from internal and external audit and counter fraud. These meetings provide an opportunity for committee members and the auditors to discuss matters without any other persons being present and allow the Committee to check that relationships between internal and external audit are effective. These meetings were held in 2018/19.

3.4 The Audit Committee TOR were submitted to the committee for approval in March 2019 as per the requirement within the TOR to review these annually. No significant changes were requested at this review.

3.5 The committee is authorised by the Governing Body to investigate any activity within its TOR. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any reasonable request made by the committee. The committee is authorised by the Governing Body to obtain reasonable outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

3.6 The minutes of the committee are formally recorded by a member of the Governance team and are provided to all members of the Governing Body. A summary report is also provided to the Governing Body at each meeting, this is prepared by the committee chair. The report draws to the attention of the Governing Body any issues that require disclosure to the full Governing Body, or issues that require further discussion or executive action.

3.7 The committee has retained its duties for the management of conflicts of interest and reviewed its process in line with the release of new guidance from NHS England (Managing Conflicts of Interest: Revised Statutory Guidance for CCGs) in June 2017 and as such approved an updated policy for the management of conflicts of interest at the September 2018 meeting.

4.0 Audit Committee Effectiveness

4.1 There were seven committee meetings during the year. All meetings were quorate and internal and external audit, and counter fraud regularly attended the meeting. Attendance can be summarised as follows:

Committee members

4 May 22 May 6 July 7 Sept 2 Nov 4 Jan 1 Mar

Lay Y Y Y Y Y Y Y Member for Finance, Audit & Conflicts of Interest

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 261 (Chair)

Vice Chair Y Y Y Y Y Y Y

Lay Y N Y Y Y Y Y Member for Patient and Public Involvement

Committee attendees

4 May 22 May 6 July 7 Sept 2 Nov 4 Jan 1 Mar

Chief Y Y Y Y N Y N Finance and Contracting Officer

Internal Y N Y Y Y Y Y auditors

External Y Y Y Y N Y Y auditors

Counter Y N N Y Y N Y fraud (not required for every meeting)

4.2 The committee has a cycle of business, which is ordered around its TOR. The cycle of business ensures that the committee receives the reports and assurance it needs to report to the Governing Body in a timely manner. The cycle of business allows for planning for standing items alongside flexibility to deal with emerging risks.

4.3 The committee has also conducted an effectiveness review of its own performance which was reported to the committee in September 2018. A series of statements were issued in a questionnaire to seek to understand how members of the Audit Committee and those who work with the Audit Committee are assured in terms of the effectiveness, efficiency and performance of the committee. Respondents were asked to use ratings from a range of 1 to 5 (1 being disagree, 3 being neither agree

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 262 nor disagree and 5 being agree). Overall the results showed that respondents were in agreement with the statements provided, with 23 of the statements receiving more than 80% agreement, and 14 of the statements receiving more than 90% agreement.

5.0 Governance, Risk Management and Internal Control

5.1 The Audit Committee supported the Governing Body by critically reviewing governance and assurance process on which the Governing Body places reliance. As such the committee reviewed the establishment and maintenance of the systems of governance, risk management and internal controls across the whole of the CCG activities.

5.2 During the year much emphasis has been placed on embedding the new Internal Audit providers (KPMG) and ensuring clarity on the expectations of the CCG and Audit Committee on the Internal Audit function. Work will continue during 2019/20 to maintain progress in this regard and ensure that target dates for completion of audits are achieved. The committee will focus its attention on areas of partial or no assurance identified high level actions and exception reporting. The following table outlines all audits completed by KPMG during 2018/19:

REVIEW TITLE PLANNED ASSURANCE Commentary Q1 Q2 Q3 Q4 LEVEL Core Reviews to inform Head of Internal Audit Opinion

Risk Management and √ Draft TBC – draft report stage GBAF Financial Systems √ Fieldwork ongoing. TBC – fieldwork ongoing. Financial Reporting √ Significant There are robust Assurance with processes in place for Minor Improvement producing monthly Opportunities financial reporting which can support the Governing Body in effectively monitoring financial performance as well as providing assurance against the GBAF Financial Sustainability risk. There are four low priority recommendations which relate to minor improvements the CCGs can make to enhance reporting. Mandated Reviews

Conflicts of Interest √ Draft TBC – draft report stage (added to the plan due to new additional training requirement from NHS England) Delegated √ Substantial Audit work has resulted Commissioning Assurance in one low priority recommendation being made. There was no record of patient engagement in the report presented to the

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 263 Committee. Risk Based Reviews

Partnership Working and √ Significant Audit work has identified Contract Management Assurance with two medium risks and Minor Improvement one low risk. There was Opportunities no formalisation of the roles and responsibilities in relation to the cancer alliance hosted service; The cost of providing the financial monitoring and processing for hosted arrangements was not captured or recognised; Similarly, the risks to the organisations were not recognised in the risk management process at present.

GDPR Preparedness √ Draft TBC – draft report stage DSP Toolkit √ Draft TBC – draft report stage Cyber Security Maturity √ Significant Audit work has resulted Assessment assurance with in two medium priority minor improvement recommendations being opportunities made. There were no formalised regular reporting mechanisms for known or new cyber security risks, both to the CSU and the Senior Information Risk Owner (SIRO). There were currently limited mechanisms in place to document and communicate effectively the CCGs cyber security risks between the lines of defence.

ICP Arrangements √ n/a – strategic KPMG presented their advisory review work in relation to ICP Governance as an advisory report and to ensure that our corporate governance remains fit for purpose. Given the developing nature of ICP governance arrangements, it was felt not be appropriate to offer a formal assurance rating at this stage. As part of the work, it found there to be a good level of engagement in the ICP process from both CCG management and partners and evidence that positive progress is being made to give the ICP a more formal structure and encourage joint decision making amongst partners. It also found from meeting observations that there are consistent messages

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 264 communicated to those present.

5.3 The Audit Committee seeks assurance on behalf of the Governing Body in relation to the Information Governance Toolkit. The committee has achieved this by receiving policies and procedures throughout the year for approval which provide key evidence for toolkit compliance. In addition the committee has received regular update reports in July 2018, November 2018, January 2019 and March 2019 to provide progress against toolkit compliance in key areas such as security audits, training, and spot checks. This also provides an opportunity to escalate any potential issues or risks for toolkit compliance to the committee.

5.4 All CCGs are required to maintain an effective Governing Body Assurance Framework (GBAF). The purpose of the GBAF is to provide the Governing Body with a tool for the effective and focused management of the risks that threaten the delivery of the strategic objectives. The Audit Committee supports the Governing Body to discharge its duties regarding the management of the GBAF by seeking assurance on the processes used to manage the risks on the GBAF at each meeting. The committee has consistently received the GBAF prior to submission to Governing Body throughout 2018/19, and has provided direction where further information should be provided to the Governing Body.

5.5 Furthermore the Audit Committee has received a ‘deep dive’ presentation into each of the GBAF risks throughout the year, with the executive owner attending the meeting to present this. These presentations have provided the committee with an insight into how each of the risks has been managed by the officers and the wider implications of these risks on CCG business. This has provided the committee with assurance on the risk management processes followed internally prior to the risks being presented at committee and Board level. The deep dives were received in- year as follows:

 September 2018 ‘GBAF 03 – Well Led’, presented by Denis Gizzi, Chief Officer  November 2018 ‘GBAF 04 – Service Transformation’, presented by Jayne Mellor, Director of Transformation and Delivery  January 2019 ‘GBAF 02 – Financial Sustainability’, presented by Matt Gaunt, Chief Finance and Contracting Officer  March 2017 ‘GBAF 01 - Quality, Safe and Effective Services’, presented by Helen Curtis Director of Quality and Performance

5.6 The Audit Committee received reports on registers of interests. Updates have been provided to the committee throughout 2018/2019. The CCG has a statutory requirement to keep and maintain a Register of Interests for the organisation with regard to actual or potential interests declared by; Governing Body members, Membership Council members, members of Sub Committees of the Governing Body, and employees of the CCG. The register is a standing item on all statutory Committee agendas. The register is for information purposes and allows members to challenge any potential conflicts against agenda items. This item also allows members and attendees to declare any additional interests against agenda items prior to the main body of the meeting. The CCG also has a responsibility to ensure

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 265 that the registers are published on its website as specified in the Managing Conflicts of Interest policy.

5.7 The committee has also scrutinised the registers for interests, hospitality, sponsorship and gifts, and procurement, and received assurances in respect of tender waivers and standing orders, Losses, Write-offs and Special Payments. NHS England on line training in relation to Conflicts of Interest training for CCGs was made available in March 2017. All designated CCG staff have attended this training as follows (those highlighted in yellow are due to expire in March and the governance team have started to alert these staff members):

Governing Body Members and Governance Employees (as outlined requiring this training)

Name Compliant (Yes/No) Expires on (date)

Gora Bangi Yes 4 April 19

John Cairns Yes 24 May 19

Lindsey Dickinson Yes 20 March 19

Ann Robinson Yes 26 April 19

Satyendra Singh Yes 24 May 19

Linda Chivers Yes 7 March 20

Geoff O’Donoghue Yes 21 March 20

Alan Stuttard Yes 13 April 19

Sumantra Mukerji Yes 5 April 19

Brigid Finlay Yes 23 May 19

Hari Nair Yes 23 March 19

Praphul Methukunta Yes 13 July 19

Sandeep Prakash Yes 26 April 19

Anitha Rangaswamy Yes 31 January 20

Eamonn McKiernan Yes 23 March 19

Tricia Hamilton Yes 12 July 19

Ian Cherry Yes 5 Feb 20

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 266 Debbie Corcoran Yes 4 April 19

Paul Richardson Yes 21 March 20

Sarah Mattocks Yes 21 Sept 19

Stephanie Betts Yes 29 March 20

Joanne Sherborne Yes 5 April 19

Matt Gaunt Yes 3 April 19

Jayne Mellor Yes 30 April 19

Helen Curtis Yes 18 April 19

Denis Gizzi Yes 16 April 19

GP Clinical Advisors (all have completed the training, however none are yet involved at decision making for procurements as yet and therefore the training is in anticipation rather than a current requirement).

Name Compliant (Yes/No) Expires on (date)

Richard Kelsall Yes 27 Aug 19

Joegy Shah Yes 8 Oct 19

Lesley Atherton Yes 14 Aug 19

Mahtab Siddiqui Yes 3 Feb 20

Partha Ganguli Yes 24 June 19

Jane Shaw Yes 27 Dec 19

Alicia Speller Yes 27 Dec 19

6.0 Financial Reporting

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 267 6.1 The committee reviews the annual report and financial statements before submission to the Governing Body. The committee will review the unaudited accounts, draft annual report and draft letters of representation alongside the annual governance statement at the meeting in May 2019 and assure itself that the systems of financial reporting to the Governing Body were robust.

7.0 Internal Audit

7.1 The committee ensures that the CCG has an effective internal audit function that meets mandatory NHS internal audit standards and provides appropriate independent assurance to the Audit Committee, Chief Officer and Governing Body. The scope of internal audit is the systematic review and evaluation of risk management, control and governance procedures that are put in place to achieve the principal objectives of the CCG.

7.2 The internal auditors for the CCG are KPMG who took over this contract from 1 April 2018. This was following a competitive tender process. The table in section 5.2 details the areas of work where internal audit provided an opinion in 2018/19 which has been the first year of appointment from KPMG. The committee has followed up all issues raised by these audits and gained satisfactory assurances.

7.3 In August 2018 NHS England introduced a new mandatory requirement for all CCGs to have an internal audit of their delegated commissioning arrangements. These requirements are set out in the NHSE publication “Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups”. The overall objective of the audit framework is to evaluate the effectiveness of the arrangements put in place by CCGs to exercise the primary medical care commissioning functions of NHS England as set out in the Delegation Agreement under the following four functions:

• Commissioning and procurement of services • Contract Oversight and Management Functions • Primary Care Finance • Governance (common to each of the above areas)

In 2018/19, the internal auditors reviewed the Commissioning and procurement of services function, including governance arrangements in place for commissioning and procurement. The audit provided the CCG with ‘substantial assurance’ and noted that the CCG’s current arrangements around delegated commissioning were clear and in line with both the NHSE’s Policy and Guidance Manual and other CCGs.

8.0 Counter-Fraud

8.1 A work plan for 2018/19 was approved by the committee which outlined core activities to be undertaken by the Local Counter Fraud Specialist (LCFS) during the financial year and related resources expected to enable such tasks as detailed in the plan to be delivered and completed successfully. The objectives of the counter

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 268 fraud plan are divided into the following four areas; strategic governance, inform and involve, hold to account, and prevent and deter. The LCFS attended the CCGs on 28 November 2018 to present fraud awareness training for staff

9.0 External Audit

9.1 The CCG external auditors for 2018/19 were Grant Thornton. The scope of work for external audit is set out in the guidance issued by the National Audit Office. The Code requires auditors to satisfy themselves that "the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources". The guidance confirmed the overall criterion as: "in all significant respects, the audited body had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people". The three sub criteria for assessment to be able to give a conclusion overall are: •Informed decision making •Sustainable resource deployment • Working with partners and other third parties Findings will be available in the Audit Findings Report and give our Value For Money Conclusion by the deadline in May 2019.

10.0 Priorities 2019/20

10.1 The key priorities for 2019/20 will include: • Review of the GBAF/CRR to ensure that these remain fit for purpose and support the CCG through forth-coming strategic changes • Conflict of Interest on-line training for staff • Ensuring that the CCG complies with all its statutory and legal obligations as outlined in the strategic objectives • Ensuring the internal Audit Programme addresses the key strategic risk areas of the CCGs

11.0 Summary

11.1 In summary the Audit Committee has satisfied itself that the CCG system of risk management is adequate in identifying risks and allowing the Governing Body to understand the appropriate management of those risks. It has received assurances from sources that are complete and has been assured on the integrity of those assurances where provided and there are no outstanding issues or areas of significant omission that have come to the committees attentions. To this end a self- assessment has been completed as per Appendix 1 of this report.

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 269 Appendix 1: Self-Assessment Checklist

1=must do 2=should do 3=could do

Status Issue Yes No Comments / Action 1 Does the Audit Committee have √ ToR was last ratified by the written terms of reference that Governing Body in May 2018. The adequately define the Committee’s Audit Committee will review an role in accordance with Department updated ToR in March 2019 and of Health/Monitor guidance? subject to further amendments will be ratified by the Governing Body in May 2019. 1 Have the terms of reference been √ The latest TOR was ratified by the adopted by the Board? Governing Body in May 2018, the latest TOR will be presented to the Governing Body in May 2019. 1 Are the terms of reference reviewed √ ToR are updated annual and taking annually to take into account into account governance governance developments (including developments and the remit of integrated other Committees within the governance principles) and the remit organisation in year. This is of facilitated via the annual calendar other committees within the of business. organisation? 1 Has the Committee been provided √ All members are non-employees with and there is sufficient membership, sufficient membership, authority and authority and resources to perform resources to perform its role its role efficiently and effectively independently with lay member and independently? representation and internal and external audit representation. 2 Are changes to the Committee’s √ The Governing Body ratify the current and future workload committee TOR which outline the discussed and approved at Board work and duties. There is an level? approved annual Audit Committee Forward Plan and calendar of business. 1 Are Committee members √ The membership consists of the independent of the management lay member responsible for team? Finance & Audit, the Governing Body Vice Chair who is a lay member, and the lay member responsible for patient and public involvement. 1 Does the Committee report regularly √ A committee update report is to the Board? presented by the Audit Committee Chair at each Governing Body along with the last ratified minutes 1 Has the Chair of the Committee a √ This is mandated in the prior understanding of, or received Constitution, the chair is a qualified training in, finance and internal accountant control or other relevant expertise? 1 Are new members provided with √ All new members are introduced to appropriate induction? key staff within Corporate Services who administer the meeting, and

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 270 are introduced to the Committee. 1 Does the Board ensure that members √ The Committee receives the have sufficient knowledge of the corporate risk register and GBAF organisation’s business to identify prior to each Governing Body key risk areas and to challenge both meeting, to provide challenge on line management and the auditors on the processes followed to manage critical and sensitive matters? these risks. The strategic and operational plans are developed with the full involvement of Governing Body members. Committee members have also been provided with training which has covered a number of key CCG areas of business. 1 Does the Committee prepare an √ This is the report which this self- annual report on its work and assessment is appended to performance in the preceding year for consideration by the Board? 1 Does the Committee assess its own √ Via this self- assessment process effectiveness periodically? and the annual governance statement. The Committee also undertook an effectiveness review and considered the results at its September meeting. In addition the committee conducts effectiveness reviews of its’ services (internal audit, external audit and counter fraud) 1 Has the Committee established a √ The committee has a plan of matters to be dealt with comprehensive work plan drawn across the from the TOR and guidance from year? NHSE Audit Committee Handbook. The agenda is developed from this plan to ensure that all key areas are covered in year. 1 Does the Committee meet sufficiently √ The committee meets bi-monthly, frequently to deal with planned and will meet more often where matters and is enough time allowed required. for questions and discussion? 1 Does the Committee’s calendar meet √ An additional meeting is scheduled the Board’s requirements and in May to approve the annual financial and governance calendar? report and accounts prior to these being submitted to Governing Body 2 Are Committee papers distributed in √ Committee papers are published 7 sufficient time for members to give days prior to the meeting taking them due consideration? place 2 Are Committee meetings scheduled √ Bi-monthly meetings allows for a prior to important decisions being regular programme of meetings made? taking place throughout the year. There are in year examples of papers submitted to the committee for consultation such as; information governance updates, and the annual report and accounts 2 Is the timing of Committee meetings √ Meetings are organised to ensure discussed with all the parties that the timing suits the core involved? membership to ensure consistent quoracy of meetings

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 271 1 Does the Committee review √ The committee will recommend assurance and regulatory compliance where assurance needs to be reporting processes? onward reported 3 Has the Committee formally X This has not been a formal assessed whether there is a need for process, although the the support of a ‘Trust/Company administration support to the Secretary’ role or its equivalent? committee meets its requirements 2 Does the Committee have a √ Via updates from CCG staff, mechanism to keep it aware of internal and external audit, and the topical, legal and regulatory issues? NHS Audit Chairs Forum which the audit chairs attend or will receive the notes and presentation from if appropriate. 1 Has the Committee formally √ The functions of all committees are considered how it integrates with considered in the annual other committees that are reviewing governance statement. Also this risk – for example, risk management has been included in the risk and clinical governance? management strategy which the committee approves. In this year the committee has sought to receive assurance on clinical governance through the Chair of the Quality and Performance Committee as a standing element of the item considering the GBAF. 1 Has the Committee formally √ Via this annual report, the considered how its work integrates committee forward planner, and with wider performance management the TOR and standards compliance? 1 Has the Committee reviewed the √ The GBAF is reviewed and robustness and effectiveness of the discussed at every meeting. In content of the organisation’s addition the committee has Assurance Framework? received a ‘deep dive’ presentation on each GBAF risk. 1 Has the Committee reviewed the √ The AGS will be submitted to the robustness and content of the draft Audit Committee prior to Governing Statement on Internal Control before Body. it is presented to the Board? 2 Has the Committee reviewed whether √ This is managed via the annual the reports it receives are timely and planner and monthly meetings have the right format and content to between the Audit Committee enable it to discharge its internal chairs and CCG Officers who will control and risk management review the agenda before each responsibilities? meeting.

1 Has the Committee reviewed the √ All reports presented to the robustness of the data behind reports committee containing data should and assurances received by itself and outline where this information has the Board? been sourced from. Members have a role in scrutinising all reports submitted 1 Is the Committee satisfied that the √ Via the AGS and annual reporting Board has been advised that assurance reporting is in place to encompass all the organisation’s responsibilities? 1 Is the Committee’s role in reviewing √ As per the TOR and annual plan and recommending to the Board the annual report and accounts clearly

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 272 defined? 1 Does the Committee consider the √ As per the annual plan External Auditor’s report to those charged with governance including proposed adjustments to the accounts? 1 Does the Committee review √ As per the TOR and annual plan management’s letter of representation? 1 Is there clarity over the timing and √ As per the annual plan content of the assurance statements received by the Committee from the Head of Internal Audit? 1 Is there a formal ‘charter’ or terms of √ Section dedicated to internal audit reference, defining internal audit’s in the TOR objectives, responsibilities and reporting lines? 1 Are the terms of reference approved √ At least annually. This is facilitated by the Committee and regularly via the calendar of business. reviewed? 2 Are the key principles of the terms of √ As declared in the AGS reference set out in the Standing Financial Instructions? 1 Does the Committee review and √ As per the annual plan approve the internal audit plan at the beginning of the financial year? 1 Does the Committee approve any √ As per minutes as and when material changes to the plan? changes occur 2 Are audit plans derived from clear √ The plan is evident of the CCG processes based on risk assessment priorities with clear links to the Assurance Framework? 1 Does the Audit Committee receive √ As per the committee papers periodic reports from the Head of Internal Audit? 1 Do these reports inform the Audit √ Updates are provided regarding Committee about progress or delays the progress of audits and any in completing the audit plan? delays. Additional meetings have been held during 2018/2019 as the new Internal Auditors embed their work programme. 3 Has the Committee established a √ Members have the opportunity to process whereby it reviews any make in year changes to the material objection to the plans and internal audit plan which is signed associated assignments that cannot off by the committee be resolved through negotiation? 2 Does the Committee effectively √ Auditors follow up with managers monitor the implementation of on actions from audits which is management reported to the committee actions arising from audit reports? 1 Does the Head of Internal Audit have √ Yes as per the TOR a direct line of reporting to the Committee and its Chair? 2 Is internal audit free of any scope √ Freedoms from restrictions raised restrictions and, if not, what are they at private meetings between and who establishes them? internal audit and audit committee members 2 Is internal audit free from any √ The CCG utilises the services of

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 273 operating responsibilities or conflicts Auditors for this function. Staff of interest that could impair its operating in this capacity have objectivity? been asked to provide details of any conflicts of interest for record 2 Has the Committee determined the √ Via the development of regular appropriate level of detail it wishes to update reports receive from internal audit? 1 Does the Committee hold periodic √ This is detailed in the TOR and private discussions with the Head of takes place on an annual basis Internal Audit? 2 Does the Committee review the √ The results of this were presented effectiveness of internal audit and the to the January 2019 meeting. adequacy of staffing and resources within internal audit? 2 Has the Committee evaluated √ The head of internal audit opinion whether internal audit complies with provides this assurance the NHS Internal Audit Standards (or Government Internal Audit Standards in an FT)? 3 Has the Committee agreed a range of √ These are the standing items in the internal audit performance measures update report from internal audit to be reported on a routine basis? which has been agreed by the committee 1 Does the Committee receive and √ On an annual basis review the Head of Internal Audit’s annual report and opinion? 2 Is there appropriate cooperation with √ Assurance is provided by the the external auditors? external auditors on the annual report and accounts which are presented at the committee. Internal audit are also asked to comment in the effectiveness review for external audit to provide another view point. 2 Are there any quality assurance √ The plan for internal audit is procedures to confirm whether the approved by the committee and work of the internal auditors is reviewed in year. In addition an properly planned, completed, effectiveness review of internal supervised and reviewed? audit services is completed each year. 1 Do the external auditors present their √ On an annual basis and update audit plans and strategy to the reports provided in-year against Committee for approval? progress 2 Has the Committee satisfied itself √ The content of the plan is amended that work not relating to the financial each year to include current statements is adequate and priorities for the CCG. appropriate? 2 Does the Committee receive and √ Auditors follow up with managers monitor actions taken in respect of on actions from audits. The prior years’ reviews? committee seek assurance for this 1 Does the Committee review the √ These are shared in the committee External Auditor’s annual audit letter? papers 1 Does the Committee review the √ The Value of money conclusion is External Auditor’s use of resources considered by the committee conclusion? 1 Does the Committee hold periodic √ These have occurred in year via private discussions with the external private meetings auditors? 2 Does the Committee assess the √ An effectiveness review of external

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 274 performance of external audit? audit services is completed each year and was last presented to the committee in November 2018. 3 Does the Committee require X This has not been assessed in- assurance from external audit about year the policies for ensuring independence and compliance with staff rotation requirements? 3 Does the Committee review the X This has not been assessed in- nature and value of non-audit work year but no non-audit work has carried out by the external auditors? been undertaken 1 Does the Committee review and √ On an annual basis approve the counter fraud work plan at the beginning of the financial year? 1 Does the Committee satisfy itself that √ Via approval of the plan the work plan adequately covers each of the seven generic areas defined in NHS counter fraud policy? 1 Does the Committee approve any √ Any changes to plan are submitted material changes to the plan? to the committee for approval 2 Are counter fraud plans derived from √ Assurance is provided against the clear processes based on risk formulation of the plan when it is assessment? presented to the committee 1 Does the Audit Committee receive √ On a regular basis, and the LCFS periodic reports from the Local attends regularly Counter Fraud Specialist? 2 Does the Committee effectively √ Key management actions would monitor the implementation of form part of the committee matters management actions arising from arising counter fraud reports? 1 Does the Local Counter Fraud √ They are in regular contact and the Specialist have a right of direct private meetings provide a format access to the Committee and its for this also Chair? 1 Does the Committee review the √ An effectiveness review of internal effectiveness of the local counter audit services is completed each fraud service and the adequacy of its year and includes the counter fraud staffing and resources? service 1 Does the Committee receive and √ On an annual basis review the Local Counter Fraud Specialist’s annual report of counter fraud activity and qualitative assessment? 1 Does the Committee receive and √ NHS Protect updates discuss reports arising from quality inspections by CFSMS? 1 Is the Committee’s role in the √ As per the TOR approval of the annual accounts clearly defined? 2 Is a Committee meeting scheduled to √ The committee reviews the discuss proposed adjustments to the accounts before they are submitted accounts and issues arising from the to the Governing Body audit? 1 Does the Committee specifically √ All policies of this nature would be review: submitted to the committee for . Changes in accounting policies? approval – the audit chair is a . Changes in accounting practice due qualified accountant to changes in accounting

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 275 standards? . Changes in estimation techniques? . Significant judgements made? 3 Does the Committee review the draft X The committee receives the draft accounts before the start of the accounts after they have been audit? submitted externally 1 Does the Committee ensure it √ These are reviewed by the receives explanations as to the committee prior to submission to reasons for any unadjusted errors in Governing Body the accounts found by the external auditors? 1 Does the Committee receive and √ Now the annual governance review a draft of the organisation’s statement Statement on Internal Control? 2 Does the Committee receive and X NA for CCGs review the evidence required to demonstrate fitness to register with the Care Quality Commission? 2 Does the Committee receive and √ The committee receives the draft review a draft of the organisation’s and the final draft before it is annual report? submitted to Governing Body 3 Has the Committee considered the √ As part of the annual accounts costs that it incurs: and are the costs appropriate to the perceived risks and the benefits? 2 Has the Committee reviewed its √ Via this report and the performance in the year for effectiveness review carried out in consistency year with its: . Terms of reference? . Programme for the year? 3 Does the annual report and accounts √ This is included in the template of the Authority/Trust include a description of the Committee’s establishment and activities?

Audit Committee Annual Report NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 276 Agenda Item 12

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Joint Quality and Performance Committee Update Presented by Mr Alan Stuttard, Lay Member Author Mrs Helen Curtis, Director of Quality and Performance Clinical lead N/A Confidential No

Purpose of the paper

This report provides an update from the Quality and Performance Committee meetings held on 6 February and 6 March. The minutes of the January and February meetings are attached.

Executive summary

The February meeting focussed on quality visits to Ramsay Health Care, Royal Preston Hospital, Go To Doc and in addition there was a progress update on the year-end assessment against the CCG Improvement and Assessment Framework.

The Quality and Performance team visited Euxton Hall Hospital at Ramsay Healthcare. Patient stories were complimentary and although there had been several changes in Hospital Manager a new permanent General Manager has been in post from September 2018 and improvements in staff development and operational changes had been made. Assurance was sought regarding blood products being available for patients and the provider confirmed standard operating procedures and revised protocols for provision had been put in to place.

The Royal Preston Hospital visit was to the areas of Ward 2A,B and C (Neurosurgery) and Ward 15 (Vascular Surgery). Patient stories were positive and staffing levels for Neurosurgery had improved in recent months with staff also feeling supported by Consultants. On the day of the visit approximately one third of the Neurosurgery beds were occupied by sleep out patients which caused concern as there were a high number of patients waiting to be treated. The Team received positive feedback from patients and staff on Ward 15. The ward had undertaken practice improvement projects which had also been rolled out across the Trust. Therapy staff had raised an issue of not being able to see post-operative patients within three days due to them covering chest therapy and discharges. Both Neurosurgery and Ward 15 experienced issues regarding repatriation of patients.

Go To Doc patient stories were positive although some comments were received regarding waiting times. There had been some improvement with regard to the

Joint Quality and Performance Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 277 reliance on agency staff and a Medical Director had been appointed making a positive impact. It was noted that sharing learning and cascading of incidents could be improved along with working relationships across both sites. Assurance had been requested around monitoring of safety and deteriorating patients within the adult waiting area. Confirmation had been given of an agreed pathway for paediatrics attending the Urgent Care Centre at Chorley Hospital to transfer to Royal Preston Hospital.

The Committee received a presentation regarding the end of year Improvement and Assessment Framework (IAF) review for 2018/2019 and the expectations of NHSE. It was confirmed a process was in place to monitor all IAF key performance indicators throughout the year and ensure actions were in place to improve those that were underachieving. At the time off the meeting the main concerns were RTT/elective, diagnostics and ensuring that the committee understood all areas of underperformance had actions in place to mitigate these.

The March meeting was a full business meeting and also included discussion on a revised set of terms of reference for the Committee.

Quality Visit reports were received for Brindle Ward and Rookwood B. Both wards were extremely busy and did not have the full complement of staff. Brindle Ward had very few discharges over the weekend as the co-ordinator only worked Monday to Friday and seven day ward rounds are not in place. Previous recommendations for Rookwood B had been put in to place. Student nurse experience had improved and they felt supported. Skill mix on the ward had improved as had the administration of drugs. There was no clear dissemination of learning from incidents as staff meetings were often cancelled. The ward also experienced issues around DTOC as some patients were not accepted back to their original care setting and were experiencing a delay in nursing home assessments.

Ramsay Healthcare quality visit was to Fulwood Hall Hospital where the team received positive feedback from patients and staff. The experience for student nurses was positive and 1:1’s to support staff was improving.

A number of serious incidents had been reported for both Lancashire Teaching Hospital Trust and Lancashire Care Foundation Trust. Lancashire Teaching Hospital Trust have accepted an offer from another Trust to investigate some serious incidents in order to improve further learning from these incidents.

Recommendations

The Governing Body is asked to note the content of the report.

Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☒ better patient experience

Joint Quality and Performance Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 278 SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☒ SO4 Ensure patients are at the centre of the planning and management of ☒ their own care and their voices are heard SO5 Be seen as a well-run clinical commissioning group and the system ☒ leader

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome Quality and Performance 06/03/2019 A number of actions were Committee agreed at the meeting in relation to the various agenda items. Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No x If conflicts of interest were identified what were these: Yes as identified in the declaration of interests submissions to the Committee.

Implications Quality/patient experience Yes ☒ No ☐ N/A ☐ implications? (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☒ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☒ N/A ☐ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk ☒ ☐ ☐ register? Yes No N/A If yes, please include risk GBAF01 description and reference number

Assurance

Assurances will continue to be provided on delivery to the Quality and Performance Committee.

Joint Quality and Performance Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 279

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Quality and Performance Committee Minutes Wednesday, 6 February 2019, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 10.30 am

Present Mrs Linda Chivers, Lay Member - NHS Chorley and South Ribble CCG Mrs Helen Curtis, Director of Quality and Performance - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Dr Brigid Finlay, GP Director - NHS Greater Preston CCG Mr Matt Gaunt, Chief Finance and Contracting Officer - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Dr Eamonn McKiernan, Secondary Care Doctor - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Jayne Mellor, Director of Planning and Delivery - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Paul Richardson, Lay Member - NHS Greater Preston CCG (Chair) Mr Alan Stuttard, Lay Member for Governance - NHS Chorley and South Ribble CCG

In Attendance Ms Ruth Bond, PA Quality and Performance Team - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Ms Jane Brennan, Chief Nurse - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Sam James, Head of Performance - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Glenn Mather, Evidence and Effectiveness Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG

1 Welcome and Apologies for Absence

Mr Richardson welcomed the Committee Members and confirmed apologies from: Mr Ian Cherry, Lay Member – NHS Greater Preston CCG (attending ICS Board) Mrs Tricia Hamilton, Governing Body Nurse - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG

2 Declarations of Interests

There were no conflicts of interest outside those noted in the routine submission. Mrs Curtis advised her daughter is a Manager at Lancashire Teaching Hospital

Minutes of Quality and Performance Committee 6 February 2019 Page 281 Trust, no decisions or voting were required at this meeting.

3 Minutes of Previous Meeting

Minutes of the previous meeting were accepted as a true record.

4 Matters Arising

20191003/6 Dates to be circulated once agreed.

5 Quality Visit - Euxton Hall Hospital

The Euxton Hall Hospital quality visit report was presented to the Committee. Patient stories were very complimentary of the care being received, advising that the hospital felt very private with a calm and pleasant environment.

There had been several changes in Hospital Manager. However, since September 2018 a new permanent General Manager had been in post and was forthcoming in working with team leaders in supporting the staff through professional development and operational changes.

There had also been staffing changes within the booking teams and booking processes had been inconsistent. Specific assurance around management of the referral to treatment (RTT) pathway was sought and the CCGs received assurance that all staff now in post had been fully trained internally in all booking pathway processes. It was noted the provider’s RTT compliance at December 2018 was 98%.

DNA rate for December was reported as 2.3% in December 2018.

The team were assured that systems in theatre were safe and patient care good. The implementation of the WHO checklist was noted.

Some assurance was sought regarding blood products being available when patients require them and that transport arrangements for routine and urgent samples were in place. The provider has instigated standard operating procedures and revised protocols for blood product provision.

A question was raised regarding clinical supervision and competencies. It was agreed the wording around clinical supervision required clarification.

Following the visit, the matron has departed. The ward manager is acting up as interim and has sourced mentorship from the matron at Fulwood Hall.

Areas where additional assurances are required will be discussed with the hospital Matron and where appropriate, in contract meetings.

The committee requested that future reports include recommendations for commissioner and provider organisations.

6 Quality Visit - Royal Preston Hospital

The Royal Preston Hospital quality visit focussed on Ward 2A,B,C (Neurosurgery) and Ward 15 (Vascular Surgery). Patient Stories obtained were positive. Staffing levels for the

Minutes of Quality and Performance Committee 6 February 2019 Page 282 neurosurgical wards had improved in recent months and nursing staff felt supported by Consultants, Ward Manager and Divisional Nurse Director. Health and wellbeing initiatives were also in place to support staff.

The ward experienced a high number of medical and surgical sleep outs which caused concern as there were a high number of patients waiting to be treated. On the day of the visit approximately one third of the neurosurgical beds were occupied by sleep out patients.

The Committee discussed issues for junior doctors and their ability to view CT scans from other areas/Trusts. There was initially a workaround although this presented an IG breach. Although the issue for junior doctors has been escalated there would be no easy resolution due to the high turnaround of trainees. The Quality and Performance Manager committed to follow this up with the provider.

Ward 15 had positive feedback from patients and staff. There was open and transparent communication across all staff levels. The ward had undertaken practice improvement projects which have also been rolled out across the Trust.

Therapy staff did raise an issue of not being able to see post-operative patients within three days due to them covering chest therapy and discharges.

Both ward areas experienced issues regarding repatriation of patients.

7 Quality Visit - GTD

The Committee received the quality visit report for Go To Doc. There were positive patient stories although some comments were received regarding waiting times. Although staffing was an ongoing issue there had been some improvement from the reliance of agency staff. A Medical Director had been appointed and had made a positive impact.

The DVT services were under performing due to the availability of scan slots. GTD had also advised the paperwork received for patients from primary care was not at its optimum.

Sharing learning and cascading of incidents could be improved along with working relationships across both sites.

Further monitoring of safety and deteriorating patients within the adult waiting area is required and further assurance is to be given.

There is an agreed pathway for paediatrics attending the Urgent Care Centre at Chorley Hospital to transfer to Royal Preston Hospital.

The latest CQC rating for GTD is ‘good’. It was confirmed that the CCG does not share issues as with other services although a report is submitted to Quality Assurance where CQC have a representative.

Mrs Mellor provided an update in relation to the availability of DVT scan slots. Mrs Curtis committed to future quality visit reports being shared with the Transformation and Delivery team ahead of the submission to the Committee to ensure the most current position is reflected.

Minutes of Quality and Performance Committee 6 February 2019 Page 283 8 Year End Assessment and Progress

Mr McAllister gave a presentation to the Committee regarding the end of year Improvement and Assessment Framework (IAF) review for 2018/2019 and the expectations of NHSE.

A process is in place to monitor all IAF KPIs throughout the year and to ensure actions are in place to improve against any that are underachieving. The end of year process is initiated in early January, ensuring a comprehensive briefing is in place by the time the review meeting in late March.

There are a number of areas of underperformance across the CCG’s which have been reported to the Committee throughout the year, some of which will be difficult to improve over a short period of time. Nine areas have improved from quarter 3 2017/2018 and seven have deteriorated for the same period.

Chief concerns at this time include RTT/elective, diagnostics and ensuring that we fully understand all areas of underperformance and have actions in place to mitigate this.

The Committee acknowledge that the assessment framework has been included in the IBR but focus has been on finance, cancer rates and RTT figures. It was agreed the IBR summary would include the assessment framework areas in future.

9 Any other business

The Committee were informed that this would be the last Quality and Performance Committee for Sam James as he was moving on to Liverpool CCG. The Committee thanked Sam for his contributions.

Date of next meeting: Wednesday, 6 March 2019

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

Minutes of Quality and Performance Committee 6 February 2019 Page 284 Agenda Item 13

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Primary Care Commissioning Committee Update and Minutes Presented by Mr Alan Stuttard, Lay Member Author Mrs Lina De Burgh, Service Transformation Coordinator Clinical lead Dr Lindsey Dickinson, GP Director Confidential No

Purpose of the paper This paper is intended to provide the Governing Body with a summary of key decisions made by the Primary Care Commissioning Committee.

Executive summary The Primary Care Commissioning Committee met in December 2018. The meeting was held in public. The minutes of that meeting have not yet been ratified.

The items considered at the meeting included:- • GP Quality Contract • Future GP Merger applications • Quarterly Contract changes

The ratified minutes of the meeting held in October 2018 are attached.

Recommendations The Governing Body is asked to receive the minutes and update.

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

Primary Care Commissioning Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 285 Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

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

If conflicts of interest were identified what were these: N/A

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

Assurance An annual report will be presented to the next Primary Care Commissioning Committee to review its business over the last financial year.

Primary Care Commissioning Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 27 March 2019 Page 286 r

r L:bj Chorley and South Ribble Cllnlc.-il Commlnlonlng Group

Chorley and South Ribble CCG Primary Care Commissioning Committee Minutes Wednesday, 5 December 2018, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 2.30 pm

Present Mr Alan Stuttard, Lay Member for Governance, NHS Chorley and South Ribble CCG Dr Eamonn McKiernan, Secondary Care Doctor Mr Matt Gaunt, Chief Finance and Contracting Officer Mrs Helen Curtis, Director of Quality and Performance Mr Denis Gizzi, Chief Officer

In Attendance Dr Hari Nair, GP Director Mrs Jayne Mellor, Director of Transformation and Delivery Dr Gora Bangi, Chair of NHS Chorley and South Ribble CCG Dr Sumantra Mukerji, GP Director Mr Paul Richardson, Lay Member Governance, NHS Greater Preston CCG Mr Ian Cherry, Lay Member Finance and Audit, NHS Greater Preston CCG Ms Donna Roberts, Head of Primary and Elective Care Ms Sarah Danson, NHS England Mrs Jill Truby, Committee Secretary Mrs Nicola Schaffel (item 5) Dr J Cairns (item 5)

Members of the Public There were 4 members of the public present

1 Welcome and Apologies for Absence As Chairman of the meeting, Mr Paul Richardson welcomed everyone to the meeting in common of the Primary Care Commissioning Committees of Chorley and South Ribble I i CCG and Greater Preston CCG.

Apologies for absence received from Dr Lindsey Dickinson, Mrs Linda Chivers and Mrs Tricia Hamilton.

Quorum The meeting was quorate. ._ 2 Declarations of Interest Mr Richardson reminded committee members of their obligations to declare any interest thev mav have on anv issues arisina at committee meetinos which mioht conflict with the business of the CCGs.

Page 287 Ralified Minutes NHS Chorley and South Ribble CCG Delegated Commissioning Committee Meeting held on 5 December 2018 1,.

Declarations made by member of the Primary Care Commissioning Committee are listed in the CCGs' Register of Interests. The Register is available either via the secretary to the governing body or the CCGs' websites at the following link: http://chorleysouthribbleccq.nhs.uk/about-chorleysouthribbleccg/who-we-are/our- governing-body/

Declarations of interest from today's meeting pertinent to the agenda: Item (8) Whittle Surgery - Mrs Curtis declared that she was a patient of the practice. Item (7) Gutteridge Practice - Dr Muke i declared that he was in the same network Item (10) Atypical populations - Mr Richardson declared that family members were patients at this practice

It was agreed that these declarations were not deemed to have a potential impact on any decision making and therefore it was agreed that all could participate in full for these items.

Chorley and South Ribble Primary Care Commissioning Committee resolved: • Declarations of Interests were noted

3 Minutes of Previous Meeting The minutes of the meeting held on 3 October 2018 were agreed as an accurate record.

4 Matters Arising There were no matters arising.

5 Terms of Reference Members received a verbal update from Mr Matt Gaunt following the Governing Bodies receiving the Terms of Reference at their recent meetings. There was one further amendment from the Governing Body which was to amend the Lay member for Patient and Public Involvement from attendee to member with voting rights.

In the absence of a revised copy, it was agreed that Chair's action be taken in respect of adopting the new terms of reference.

Chorley and South Ribble Primary Care Commissioning Committee resolved: • Agreed to a Chair's action in respect of adopting the new terms of reference

6 --O-ut-of-H-os-pit-al -Tra-ns-fo-rm-at-ion ------1 Mrs Donna Roberts presented an update on progress for information. This follows the sign off by the Committee in October 2018 of the proposal for delivery of national and local requirements in regards to developing Networks and the investment of the £4 per head of population.

All Networks have been established with a lead GP, nurse and practice manager identified to sit on the leadership team. Lancashire Care NHS Foundation Trust (LCFT) are also in the process of identifying their lead representative and a request is being submitted to LCC asking them to identify theirs. Networks are also inviting other partners such as councillors and third sector representatives.

Key achievements to date include: • Agreement on achievement aim for each of the six themes for 2018/19 I I • Delivery..o dersbip..and.Corporate-Governanc inJts...er:1tir.ety-as-0ur-firs------priority . ._ •_ Delivery of "Care Teams and Clinical Governance" as our second priQ_ritY,_ -

Page 288 Ratified Minutes NHS Chorley and South Ribble CCG Delegated Commissioning Committee Meeting held on 5 December 2018 ,

• A group is being established to include the Network lead GP and practice managers to deliver a number of options for the utilisation of the £2 per head of population to deliver a scheme which will deliver improved patient outcomes benefits elsewhere in the system.

Next steps: • Development of the annual plan template • Completion of the plan for 2018/19 in order to achieve the required progress towards level 2 and release of the associated £1 per head of population • Agreement on the assessment and planning process to inform the 2019/20 plan.

Chorley and South Ribble Primary Care Commissioning Committee: • Noted the progress.

7. Application to merge Gutteridge Medical Centre (Dr Verra) and Gutteridge Medical Centre (Dr Chakrabarti)

Mrs Sarah Danson presented the report. Ors Yerra and Chakrabarti have applied to merge practices and terminate the practice code P81763 with effect from 6 February 2019, resulting in one contract continuing under the practice code P81647.

The practices feel that the merger will give them the opportunity to achieve significant efficiencies in relation to patient care. The practices are currently based in the same building and will continue to operate from the same premises, with the same appointment booking system. They have identified that patients will have access to a wider range of specialist services due to a wider skill mix across the two teams.

Each practice currently holds a GMS contract and there are no additional financial consequences of the proposed merger.

Extensive patient engagement had been undertaken, including a practice merger open day where practice staff were available to meet patients form both practices to offer information.

Greater Preston Primary Care Commissioning Committee: • Approved the application and terminate practice code P81763

8. Dr Wilson - request for additional rooms Mrs Donna Roberts presented the paper which informed the Committee of the request by Dr Wilson and Partners for an increase in rooms to be occupied in their current premises and an increase in associated notional rent.

The practice wish to occupy 3 x clinical rooms formerly occupied by Dr Rossall (Medicom) who has relocated to ISSA Medical Centre on a temporary basis pending the completion of primary care premises on Garstang Road, Preston.

If Dr Wilson and Partners are granted permission to occupy the rooms an increase in their notional rent allocation will be required.

In response to a query on the timescale, Mrs Roberts reported that Dr Rossall would not be moving back into the premises. The rooms had been void for two weeks.

"h e-practlce-lTacl-put lrr mr apptlcattorrvia--e-ff rtt,extenrn r-re existlng building IToweve . _ _. _th_i_s _may now be reduced. They will still continue with the application via ETTF.

Page 280 Ratified Minutes NHS Chorley and South Ribble CCG Delegated Commissioning Committee Meeting held on 5 December 2018 '

Mr Gaunt voiced concerns relating to funding and that there was no funding identified in the current financial year to cover this cost. He emphasised the importance of building a 'pipeline' of estates changes so that the organisation was sighted on 100% of all likely requests prior to the start of each financial year so that adequate budget provision could be made for the associated rent changes.

A vote followed with a majority vote in favour of approving the application by Greater Preston Primary Care Commissioning Committee.

Greater Preston Primary Care Commissioning Committee resolved: • To approved the application for a further 3 x clinical rooms for Dr Wilson and Partners at the Health Centre, Flintoff Way and to increase the required notional rent for the premises.

9. Whittle Surgery - portakabin/Chorley Medics Mrs Curtis declared that she was a patient of the practice and would therefore not vote on the recommendation.

Mrs Donna Roberts presented the paper which was a request by Whittle Surgery for a proposed alternative to its current temporary portakabin premises. The alternative premises are a contingency in the event that planning permission for the portakabin is removed by Chorley Borough Council. The alternative premises will require an increase in notional rent allocation to the practice.

Mrs Roberts explained that the portakabin was fully kitted out for clinical use.

Chorley and South Ribble Primary Care Commissioning Committee resolved: • To approve the application to relocate in the event of a revocation of planning approval and the additional notional rent for the premises.

10. Specification for atypical populations (University Practice)

Mrs Donna Roberts presented the specification for Atypical Populations (University Practices) to the Committee.

In 2015/16 Greater Preston Clinical Commissioning Group reviewed all its PMS Contracts. At the time the Committee agreed to defer the decisions for Penwortham St Mary's Practice until the Carr Hill Formula had been revised taking into account the differences in population for a University. The PMS Review Panel held in November 2015 agreed to defer any funding withdrawals form Penwortham St Mary's due to pending changes to the national funding formula for special populations (including student populations) which were to take effect from April 2017.

This review resulted in guidance notes being published by NHS England in December 2016 on practices serving Atypical Populations to assist Clinical Commissioning Groups and NHS England to commission services recognising Atypical Populations. This guidance identified three characteristics that serve to place significant additional demands on a GP practice that make them Atypical, this includes University populations.

Greater Preston Primary Care Commissioning Board resolved: • To approve the specification for Penwortham St Mary's to recognise the I additi0nal-work-asseciateEl-with-lJAi ver-sity-J3e f31:1latien s-whieh--are -not ------­ identified in the current Carr Hill Formula and consequently remove the -- P-MS Premium from the Contract. Page 290 Ratified Minutes NHS Chorley and South Ribble CCG Delegated Commissioning Committee Meeting held on 5 December 2018 .. I'

11. Prescribing Quality and Savings Scheme 2019 ------

Mrs Nicola Schaffel and Dr John Cairns presented a proposed prescribing quality and savings scheme for approval.

POSS for 2018 achieved significant savings in prescribing costs. The Joint Medicines Management Group recommended that a new scheme, based on the same principles be as those for 2018, approved for 2019.

The paper outlined the potential savings available through implementation of a POSS scheme.

In response to a query Mr Gaunt responded that the budget had not yet been set for next year that would include these savings.

Dr Bangi confirmed that the scheme was monitored by each practice.

Dr Nair reported that he was totally in favour with the scheme.

Chorley and South Ribble Primary Care Commissioning Board resolved: • Approved the proposed 2019 POSS scheme for GP practices in Chorley ---- and South Ribble. - 12. Any other business There was no further business.

The meeting closed at 3:30 pm.

Signed as an accurate record ...... Date ...... 7:.?.-:. 3

Ratified Minutes NHS Chorley and South Ribble CCG Delegated Commissioning Committee Meeting held on 5 December 2018 Page 291

t t 1 f r . i /[ j }

t,. Agenda Item 14

Governing Body Meeting

Date of meeting 27 March 2019 Title of paper Joint Patient Voice Committee update Presented by Mr Geoffrey O’Donoghue, Lay Member for Patient and Public Involvement Author Ms Rebecca Stafford, Customer Care and Patient Experience Officer and Committee Secretary Clinical lead N/A Confidential No

Purpose of the paper This paper provides an overview and summary of the themes discussed and areas scrutinised at the Joint Patient Voice Committee (PVC) meetings held on 29 January 2019 and 6 March 2019. The ratified minutes for the meeting held on 7 November 2018 and 29 January 2019 are also attached. The minutes of the 6 March meeting will be ratified at the 1 May 2019 Committee meeting and brought to the Governing Body meeting that follows.

Executive summary The Joint Patient Voice Committee on 29 January 2019 was updated on the activity for communications and engagement for the Our Health, Our Care transformation programme. The Committee also received the customer care activity report for quarter three 2018/19 and discussed the interim position for ‘goals 3 and 4’ – workforce and leadership outcomes in relation to the Equality Delivery System (EDS). Standing items for the meeting were also received and reviewed, including the quarterly patient involvement and assurance report.

What follows is a summary of some key topics covered during the 29 January meeting.

Our Health, Our Care (OHOC)

The Committee received an update on the OHOC programme and heard that the communications and engagement element was currently in ‘phase 7’, that will run through to mid-March 2019 until Purdah commences due to local elections taking place.

The Committee was updated on a piece of work that the Transformation Unit (TU) had commenced in relation to market research, which had involved a targeted telephone survey and other face-to-face fieldwork. Members heard that the TU also ran focus groups in relation to market research insights and information gathering.

The Committee reviewed a plan of future targeted engagement activity with seldom heard and vulnerable groups of people, and was informed that this piece of work was

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 293 27 March 2019 being led by the CCGs’ Equality and Diversity lead. Members also received and reviewed a copy of a document that outlined the Equality Impact Assessment methodology for the programme specifically to support any potential options development stage for the programmes.

The Committee discussed the draft independent review report completed by Pickersgill Consultancy and Planning, Market Research consultants and commissioned to offer a review of the effectiveness of the work between September 2016 and September 2018. It was agreed that the report should be reviewed and reframed if possible to better meet the original brief as the current report was not fit for purpose.

Customer care activity report – quarter three 2018/19

The Committee was presented with an overview of the CCGs’ customer care service for the period of 1 October 2018 to 31 December 2018 (quarter 3, 2018/19).

Committee members were informed that there had been an 18% (46) decrease of complaints received when compared to the previous quarter. The total number of contacts received had decreased by 5% (313) when compared to the previous quarter. This included a decrease of 41% (71) in Freedom of Information (FOI) requests. Trends were discussed, and the areas of the complaints reviewed.

Patient involvement and assurance report

The Committee received an overview of CCG-led patient engagement and involvement. Key activity included the Patient Advisory Group (PAG) members reviewing a Care UK patient information leaflet and receiving an additional presentation from GTD Healthcare, delivered in the style of ‘you said, we did’.

PAG members received the OHOC case for change and had the opportunity to ask some questions about it.

The Committee heard that the ‘Young People’s Health Advocates’ (YPHAs) have potentially been given an opportunity to work with a GP practice to help develop a campaign to encourage more young people to get involved with their practice’s patient participation group.

What follows is a summary of some key topics covered during the 6 March meeting.

Joint Committee Effectiveness report

The Committee discussed the process, content and survey questions from previous effectiveness reports, and agreed that the report structure should remain the same, with survey questions in the supporting PVC member survey focused on the Committee’s impact.

Improvement and Assessment Framework – ‘patient and community engagement’ indicator

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 294 27 March 2019 Committee members received an update on the CCGs’ submission for the ‘patient and community engagement’ indicator for NHS England’s (NHSE) Improvement and Assessment Framework. The update outlined the action plan and detailed the process timeframe in order to provide assurance that a robust review and assessment process had been followed.

Members welcomed the draft submission, agreeing it was an impressive and thorough piece of work and recognised that several of the descriptors offered evidence of outstanding practice. The Committee was informed that following extensive feedback from CCGs, and other partners, NHSE had agreed that the same reviewer will be allocated to joint CCGs and other organisations that have websites that ‘mirror’ each other, to support consistent evaluation.

Our Health, Our Care (OHOC) The Committee was updated on the OHOC programme and was informed that a draft ‘model of care’ had now been developed, and will be reviewed at the OHOC Joint Committee meeting on 13 March 2019.

The Committee received updates on the communications and engagement activity for the programme, that included summary notes and action logs from the previous two OHOC Stakeholder Panel meetings, and the OHOC Communications and Engagement Steering Group, and progress updates on CCG-led seldom heard group targeted engagement activities.

Committee members heard that the results and final report from the market research work that the TU had undertaken, would be available soon.

The Committee expressed its concern in relation to unapproved draft materials containing incorrect information being used for some market research focus groups, and sought assurance, from a public perspective, that this matter had been dealt appropriately and asked what measures had been put in place to ensure it did not happen again.

Members heard from Mrs Curtis, Director of Quality and Performance, that this matter had been addressed, as it was not acceptable for any materials to be issued unless they have been approved and signed off by the CCGs. Committee members were reassured to hear that measures had been put in place and that all materials must be approved before use via one of these routes:

• OHOC Communications and Engagement Steering Group • Programme Oversight Group • The CCGs’ Senior Management Team

Members supported this and agreed that material should be prepared well in advance to ensure it is presented at one of the above meetings for approval.

Recommendations The Governing Body is asked to note the contents of this report and the associated minutes.

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 295 27 March 2019

Links to CCG Strategic Objectives SO1 Improve quality through more effective, safer services, which deliver a ☐ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☐ balance between in-hospital and out-of-hospital provision SO3 Be an integral part of a financially sustainable health economy ☐

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

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

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

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

Assurance Assurances on delivery in this area will continue to be provided by the Patient Voice Committee to the Governing Body.

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 296 27 March 2019

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 297 27 March 2019

DRAFT Patient Voice Committee Minutes 12.45pm – 2.45 Wednesday 7 November 2018 Boardroom 2, Chorley House, Leyland PR26 6TT

Present Mrs Dawn Clarke, Equality and Diversity Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Debbie Corcoran, Patient and Public Involvement Lay Member – NHS Greater Preston CCG (Chair) Mrs Rosemary Cowell, Quality and Performance Mental Health Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Ms Janet Ince, Mental Health Transformation Manager – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Clare Moss, Head of Medicines Optimisation – Midlands and Lancashire Commissioning Support Unit Mr Geoffrey O’Donoghue, Patient and Public Involvement Lay Member – NHS Chorley and South Ribble CCG (Vice Chair) Ms Erin Portsmouth, Head of Communications and Engagement – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Kerry Prescott, Projects Manager – Healthwatch Lancashire Mrs Glenis Tansey, Engagement and Patient Experience Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG

In Attendance Ms Rebecca Stafford, Customer Care and Patient Experience Officer, NHS Chorley and South Ribble CCG and NHS Greater Preston CCG (minute taker)

1 Welcome and apologies for absence Mrs Corcoran opened the Patient Voice Committee (PVC) by welcoming everyone to the meeting. Introductions were not required on this occasion.

The following apologies for absence were given: • Mr Lionel Barker, Chair – Patient Advisory Group. • Mrs Helen Curtis, Director of Quality and Performance – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG. • Ms Stephanie Purcell, Effectiveness and Innovation Specialist (Clinical) – Midlands and Lancashire Commissioning Support Unit.

2 Declarations of interests Mrs Corcoran explained that following guidance released at the end of last year by NHS England, the CCGs only need to provide registers for statutory committees. As the Patient Voice Committee (PVC) is an assurance committee,

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 298 a register of interests was not warranted.

Declarations of interests would, however, remain as a standing agenda item to ensure that people have the opportunity to declare any interest they may have on any issues arising at committee meetings that might conflict with the business of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG.

Mrs Corcoran asked if any members of the PVC had anything further to declare.

There were no additional declarations made.

3 Minutes of previous meeting – 5 September 2018 The Committee checked the minutes of the 5 September 2018 meeting and agreed that the minutes were an accurate reflection of the discussions.

4 Matters arising The Committee appraised the matters arising log and agreed to the closure of the items identified as complete.

Ms Portsmouth provided the Committee with an update on the two remaining outstanding matters arising, which both related to the attendance of a Healthwatch Lancashire representative at key CCG meetings.

Ms Portsmouth advised that there had been a lot of changes recently at Healthwatch Lancashire and the CCGs have been reviewing at their meetings and Terms of References for Governing Body and statutory meetings. Ms Portsmouth met with Kerry Prescott from Healthwatch Lancashire to discuss representation by Healthwatch at the most appropriate meetings.

Currently Healthwatch are listed on the Terms of Reference for the Delegated Commissioning Committee, however, the connection with the Patient Voice Committee and the Patient Advisory Group is more relevant, and also the connection with the Our Health, Our Care (OHOC) stakeholder panel.

Ms Portsmouth informed the Committee that the CCG Chief Officer Denis Gizzi wants to ensure that the Healthwatch connection is linked back to the Governing bodies. Following the recent changes at Healthwatch Lancashire, a meeting has been scheduled with it’s new Chief Executive, David Blacklock.

Items related to duties and assurance 5 Mental Health – update Mrs Corcoran explained that the mental health update has been re-scheduled to today’s meeting.

Mrs Cowell provided an overview of the mental health presentation that had been sent out to Committee members ahead of the meeting. The Committee heard that Blackpool and Preston share 21% of all suicide deaths across the Integrated Care System (ICS). In 2015/16 Preston was ranked as having the highest suicide rates nationwide, however, this has improved slightly and Preston is now ranked fourth, with Blackpool being ranked in seventh place nationwide.

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 299

Mrs Cowell advised that mental health breaches across the CCGs’ health economy are currently lowest in the Lancashire and South Cumbria Integrated Care System (ICS), however, the CCGs cannot afford to get complacent.

Mental health is currently under a lot of pressure, and the CCGs are working hard with other organisations and providers to commission and develop services differently to ensure that they are clinically effective, safe and able to cope with demand. In turn, the new services should reduce demand on other organisations and services such as, emergency services, whilst providing a better patient experience.

Committee members heard that three new mental health services were in the process of being commissioned by the CCGs with a focus on early intervention and prevention, improved mortality rates for individuals with serious mental illness, and an integrated community crisis café/hub.

Mrs Cowell informed the Committee that six additional mental health practitioners had been recruited to work within primary care GP practices, and have been in post for approximately two to three months. The Committee had a discussion in respect of the integration of the practitioners into primary care. Mrs Cowell commented that there had been some setbacks. However, since the additional posts had been put in place, the waiting time for a mental health assessment has decreased dramatically from 26 weeks. If a patient requires an assessment, they can now be seen the following week or earlier.

Mr O’Donoghue asked if this would be expected to continue. Mrs Cowell confirmed that it was expected and explained that the CCGs are monitoring the team on a monthly basis via the contracting process.

Mrs Corcoran asked if the service was for adults only and Mrs Cowell advised that it was for anyone aged 16 years and above. Mrs Cowell went on to say that there was a Child and adolescent mental health services (CAMHS) redesign currently being undertaken.

The Committee heard that within the first month of this service running there has been a 7% reduction in crisis referrals, and a 25% reduction to secondary care mental health services. Mr O’Donoghue made a comment in relation to the fact that very little mental health performance data was reported to the governing bodies, and feels that this makes it difficult for members to appreciate how these services are performing for the local communities.

Mrs Cowell advised that performance data is received on a monthly basis, so there was no reason why the team could not provide a regular update to the governing bodies.

Mrs Cowell commented that the CCGs have invested heavily in mental health services, and it would be helpful to promote the work that the CCGs have actioned for the local health economy.

Mrs Corcoran suggested that it may be useful for someone to speak to Helen

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 300 Curtis or Denis Gizzi to establish whether it would be appropriate to hold a development session for the Governing Body, to understand how mental health services join up.

Mrs Cowell delivered the rest of the presentation, which included information in respect of a new team being developed to address the issues around monitoring physical health in serious mental illness. Mrs Cowell informed Committee members that non-compliance of medication plays a major role in contributing to individuals diagnosed with schizophrenia being admitted, and that evidence shows these individuals have an increased rate of dying 15 to 20 years earlier than the rest of the population.

The Committee was advised that an integrated community crisis café/hub is in the process of being procured. The aim of the crisis café is to provide a safe and supportive place where people can go before the onset of a crisis. The successful provider is due to be announced soon, with a plan for the service to go live in May 2019.

The crisis café will be open 12 hours a day, 365 days of the year, and it will offer a full range of services by a number of organisations, and will be open to anyone aged 16 years old and above.

Mr O’Donoghue asked if he could meet up with Mrs Cowell outside of the meeting, as he is involved in setting up ‘Chorley Sheds’. At this point, Mr O’Donoghue commented that he should have declared an interest at the beginning of the meeting, as he is the secretary to Chorley Sheds.

ACTION POINT • Mrs Corcoran to liaise with Mrs Curtis in respect of a Governing Body development session in relation to mental health.

Chair’s summary The presentation was welcomed by Committee members. It was helpful to have a better understanding of where things are up to with new developments, and it would be good to tie this in with the information provided to the Governing Bodies.

6 NHS England involvement guidance - update

Ms Portsmouth provided a brief overview of the context behind the paper being presented, explaining that the self-assessment was made in relation to two pieces of key national guidance on the CCGs’ responsibilities and role in patient and public engagement and involvement. Following the closure of the self- assessment for the previous financial year, a new self-assessment for the 2018/19 financial year was being presented for review today.

The Committee heard that some areas of the self-assessment indicators had improved, moving from ‘green’ to ‘purple’, meaning that the CCGs are now excelling in these areas.

The purple ‘excelling’ improved areas are:

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 301

• Involve the public in governance – Ms Portsmouth commented that the CCGs actually do more than the indicator description in the constitution, as the PVC, PAG, Young People’s Health Advocates (YPHAs) and Stakeholder Panel are all linked to extensive engagement and embedded into the CCGs’ governance.

• Promote and publicise public involvement – The Committee was informed that the pages on the CCGs’ websites provide more information on how people can get involved, than what is detailed in this indicator.

• Hold providers to account – The CCGs use the standard contract arrangements accordingly, and work collaboratively with providers in particular with the communications work - The CCGs also assist GP practices in relation to their engagement and work with providers on specific engagement CQUINS (Commissioning for Quality and Innovation).

A discussion took place in relation to the above improvements.

Committee members heard that indicator number 2 (Explain public involvement in commissioning plans / business plans) of this section had moved from green to amber in anticipation of the new NHS England 10 year guidance. The CCGs and the local Integrated Care Partnership will need to revise the commissioning plans to ensure that public involvement duty is more embedded. Ms Portsmouth commented that she does not envisage this being amber for much longer.

Mrs Corcoran and Mr O’Donoghue commented that as it stands this indicator is still green due to the fact that the 10 year guidance has not yet been released, and therefore asked Ms Portsmouth to amend the colour to green.

The Committee discussed indicator number 6 (Feedback and evaluate) and Ms Portsmouth commented that the CCGs provided face-to-face feedback effectively, in particular, in relation to procurement of services. However, there was further work to be done in relation to some of the ‘you said, we did’ information on the CCGs’ websites.

Mrs Tansey commented that a ‘you said, we did’ section is now being reported in the patient involvement and assurance report.

Continuing the ‘you said, we did’ discussion, and in relation to indicator 12 (Publicise and promote personal health budgets) Mrs Tansey informed the Committee that she was involved in a review of patient experience in relation to Personal Health Budgets (PHB). Mrs Tansey further commented that the whole Continuing Healthcare (CHC) process is extremely complex and hopes to get some good feedback on the PHB element, and confirmed that she will present feedback and developments to the Committee upon completion. Committee members had a discussion in relation to Personal Health Budgets (PHB), and Mrs Tansey advised that a review of how patients use PHBs is currently taking place. Mrs Tansey further advised that there is approximately 30 people within the CCGs’ locality who currently have a PHB.

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Mrs Clarke commented that a workshop has also been scheduled for the Patient Advisory Group to discuss PHBs.

The Committee heard that the CCGs need to increase the uptake of PHBs whilst acknowledging that it is a huge responsibility for people to purchase their own healthcare.

Ms Portsmouth informed Committee members that further work needs to be done in relation to indicator number 16 (Assure themselves that providers are involving people in their own health and care to an acceptable standard). She commented that the CCGs have launched ‘fit for surgery’, and Dr Matthew Orr, Clinical digital lead for the CCGs is undertaking a piece of work around the digital elements.

ACTION POINTS • Ms Portsmouth to amend indicator number 2 from amber to green. • Ms Portsmouth to provide the Committee with a further update in six months’ time.

Chair’s summary The Committee welcomed the update and was assured that work is ongoing to ensure that the CCGs’ responsibilities are being met, and look forward to receiving a further update in six months’ time.

7 Customer care and complaints policy – refresh Mrs Tansey presented the refreshed policy to the Committee for ratification. The draft policy has been circulated to a number of people, listed in the policy, for comments and feedback, and the changes had been made to reflect this. Mrs Tansey advised that the main changes to note are:

• Updated legislation (GDPR) • Updated consent forms • Updated contact details

Mrs Corcoran commented that she had noted in the policy that the customer care team endeavour to prevent a complaint from escalating into to formal complaint, which she acknowledged was good practice. Mrs Corcoran queried how assurance was provided that themes and trends are being captured to improve learning.

Mrs Tansey explained that complaints are reported back to the PVC and the Quality and Performance Committee through the customer care activity and assurance report, and also, all formal complaints are reported quarterly to NHS digital via a KO41a return that all health organisations have to complete on a quarterly basis.

Mrs Corcoran also wanted to know the volume of patients that have been classed as persistent, habitual and unreasonable complainants. Mrs Tansey confirmed that although the CCGs have regular contact from a handful of patients, this element of the policy has only been enacted once in four years. She further

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 303 explained that the regular callers are also well known to other health organisations.

Chair’s summary The Committee noted the changes and feel that the updates have been based on best practice and builds on experience of what works well and what doesn’t. It is a fair, clear and balanced approach to handling complaints, and the Committee is happy to ratify the refreshed policy.

8 Customer care activity report – quarter 2, 2018/19 Mrs Tansey presented the Committee with an overview of the CCGs’ customer care service for the period of 1 July 2018 to 30 September 2018 (quarter 2, 2018/19).

Committee members heard that there had been a 57% (57) increase of complaints received when compared to the previous quarter, with 42% (22) being transferred to other organisations. The Committee heard that the total number of contacts received had increased by 20% (331) when compared to the previous quarter. This included an increase of 14% (120) in Freedom of Information (FOI) requests received.

Mrs Tansey commented that two FOI response extensions had been requested and granted in this quarter, due to the complexity of the requests. All other FOIs that had been received were closed within the 20 working days timeframe.

The Committee was informed that the report now included examples of the kind of compliments that are received. Mrs Corcoran commented that it was nice to hear from patients in their own words.

Mrs Tansey advised that some of the complaints received this quarter were in relation to the new central Lancashire ‘moving well’ service, mainly regarding the issues experienced with the transfer of data from one large organisation to another. She confirmed that as a result of this the customer care team has created an issues log to capture any feedback that come through about the service, which Mrs Tansey presents back to the provider via weekly face-to-face meetings. As a result of this action the provider can look to make on-going improvements in relation to patient experience.

Chair’s summary The Committee welcomed the report and was given assurance that the range of contacts is captured accordingly, and that customer care data is fed back to the appropriate teams both within and external to the CCGs in order to help improve services.

9 Equality Delivery System - results Mrs Clarke informed that Committee that the grading of goals 1 and 2 of the Equality Delivery System had taken place on 16 October 2018. Despite the confirmation of attendance from twelve patients, only three were in attendance.

Mrs Clarke explained that due to the poor attendance, a further grading session

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 304 took place at the Patient Advisory Group on 30 October 2018, which 20 patients participated in.

All the results have been collated and Mrs Clarke confirmed that the CCGs had maintained the grades from 2017.

Mrs Clarke advised that grading of ‘goal 3’, a represented and supported workforce and ‘goal 4’, inclusive leadership, will take place during December 2018. Results of these goals will be presented at the Governing Bodies in January 2019.

Mrs Corcoran confirmed that she would be happy to directly engage in the process by attending the grading, and Mr O’Donoghue also agreed.

ACTION POINT • Mrs Corcoran and Mr O’Donoghue to provide Mrs Clarke with dates of their availability throughout December.

Chair’s summary The Committee welcomed the results, and the news that they had remained the same, and thanked everyone who had been involved in the process.

10 Patient involvement and assurance report Mrs Clarke presented the Committee with the report, advising that it provides an overview and assurance of all key engagement and involvement that is taking place. She explained that the report covered the period of 21 August 2018 to 31 October 2018.

Mrs Clarke informed the Committee that the CCGs have undertaken a piece of work with Lancashire and South Cumbria and Healthwatch Lancashire to identify targeted community groups to engage with in relation to digital technology. One of the groups was a black Caribbean group called Windrush, however, the planned engagement event had to be cancelled due to unforeseen circumstances amongst the group.

Mrs Prescott further commented that Healthwatch Lancashire had also engaged with a learning disability group called ‘Voice for all’.

The Committee heard that recruitment to the Patient Advisory Group (PAG) continues, and three additional people were recruited this quarter.

Committee members heard that the PAG had received a presentation from GTD Healthcare in relation to the urgent care service at both local hospital sites. The Committee was informed that moving forward the provider will deliver themed quarterly updates on urgent care at the PAG meetings, and will provide responses to any questions that PAG members may have asked at the previous meeting, as agreed in its CQUIN (Commissioning for Quality and Innovation).

Mrs Clarke advised that she had been working with Brothers of Charity, and had taken part in an interview for a customer service excellence award that Brothers

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 305 of Charity had been nominated for. She commented that a board member for Brothers of Charity highly appreciated her assistance.

Mrs Tansey confirmed that a ‘you said, we did’ section had been incorporated into the report as agreed at the previous PVC meeting, and the example in this report was in relation to the new central Lancashire ‘Moving Well’ service.

The Committee heard that the Maternity Voices Partnership (MVP) is gathering momentum and the development of a local policy to formalise job roles and budgets is currently in progress. The policy will be based on the NHS England patient participation policy and will be shared across the local maternity services for other CCG areas to adopt and/or adapt.

Mrs Tansey commented that the MVP Terms of Reference state that the role of the Chair is for a period of two years. The role will then go out for expressions of interest.

Mrs Tansey informed the Committee that she was working with commissioning colleagues to embed maternity-related work into the CCGs’ operational plans.

Chair’s summary The Committee welcomed the report and the assurances it provided.

11 Our Health, Our Care (OHOC) Ms Portsmouth provided the Committee with an update on the OHOC programme in relation to the level of pre-consultation engagement that had taken place. Some of the activities included 25 public engagement events, online surveys and extensive face-to-face conversations and ongoing relationship building with seldom heard groups and people with protected characteristics.

The Committee was informed that an independent ‘look back’ review was being undertaken in respect of what communication and engagement had been done so far. Evidence-based documents have been submitted to the Centre for Health and Communications research for review.

Ms Portsmouth explained that she has also been doing some work around the governance of the programme and commented that there used to be an OHOC programme board that evolved into the integrated care shadow board. The Terms of Reference (ToRs) for the previous programme board have been revised to form a new ‘Programme Oversight Group’ which will report into the central Lancashire Integrated Care Partnership (ICP).

Senior officers that are responsible for the different work streams, including the communications and engagement workstreams, will be able to report in to the Programme Oversight Group, and the group can then ensure that all the work is integrated. Ms Portsmouth advised that the revised ToRs will be presented to the ICP board for approval and meetings will be set up.

Ms Portsmouth confirmed that the OHOC Joint Committee ToR has now been ratified and the ICP board will be making recommendations and endorsements for

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 306 the OHOC joint Committee to make decisions on.

The Committee heard that the OHOC Stakeholder Panel was now up and running and embedded into the CCGs’ engagement and governance framework. This panel is a sub-group of the Patient Voice Committee. The PVC Chair and Vice Chair are members, as is the Chair of the Patient Advisory Group.

The work stream for communications and engagement has been re-set and now has a revised membership on its steering group, which includes an NHS England communications lead. Ms Portsmouth commented that a Communications and Engagement working group has also been set up.

The Committee heard that a lot of work has been taking place to re-set the programme timeline.

Ms Portsmouth commented that four appendices were attached to the paper, those being: • Stakeholder panel Terms of Reference – being considered by the PVC for approval today. • Approved stakeholder minutes – it was agreed that these would be brought to the PVC to ensure that it is reflected in the published Governing Body papers and summary sheets from the Patient Voice Committee. • Engagement statistics overview presentation. • Programme governance chart.

The Committee was informed that there had been a slight amendment to the governance chart since the paper was published. Another box had been added above the ICP box, called ‘organisational boards / Governing Bodies’.

Ms Portsmouth advised the Committee that she has a presentation that talks about the legalities of duties to involve and consultation process and change, which may be useful.

Mr O’Donoghue left the meeting at this point.

ACTION POINT • Ms Portsmouth to circulate the presentation on legalities of duties to involve and consultation process and change to PVC members.

Chair’s summary The Committee approved the Stakeholder Panel Terms of Reference and welcomed the update that was presented. Members agreed that it was a ‘work in progress’ programme, and look forward to receiving further updates.

Items for Information 12 Healthwatch Lancashire update Mrs Prescott apologised for the lack of Healthwatch Lancashire representation at some of the previous PVC meetings, and explained that there had been a lot of organisational changes recently, that included being taken over by a new provider.

Draft minutes v0.3 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 7 November 2018 Page 307 Mr O’Donoghue returned to the meeting at this point.

Mrs Prescott echoed the comments that Ms Portsmouth had made in the ‘matters arising’ section of the agenda, confirming that she will liaise with David Blacklock to ensure representatives for the Governing Body and PAG meetings. She will continue to represent Healthwatch Lancashire at the PVC meetings.

The Committee heard that Healthwatch Lancashire had been working on three major projects, and one of them was with the Integrated Care System (ICS) on a digital technology project. A report is currently being produced and Mrs Prescott suggested that she presents the findings at the next PVC meeting. Committee members were in agreement with this.

Healthwatch has also been working with the NHS in relation to increasing the update of cervical and breast screening for women within the learning disability community. Mrs Prescott advised that there is another substantial phase of engagement to complete this project, and she will provide the Committee with further updates as soon as possible.

Committee members heard that Healthwatch has supported the transformation team on the ‘Thrive’ model of care developments in relation to children and young people’s, mental health. The first phase of this project has been concluded.

ACTION POINT • Mrs Prescott to update the Committee with the findings of the digital technology project at the 15 January 2019 PVC meeting.

Chair’s summary The Committee welcomed Mrs Prescott back to the meeting and noted the updates on the work that Healthwatch Lancashire has been involved in, and look forward to receiving future updates.

13 Any other business There was no further business to discuss.

14 Reflections of the meeting Mrs Corcoran welcomed any comments from the Committee on the meeting.

Ms Portsmouth commented that it was a good meeting, however, she was slightly disappointed that there was no clinical representation. She also commented that it was good to have Healthwatch back at the meetings.

Mr O’Donoghue commented that the Chair had done well to keep the meeting to schedule, and felt that there had still been a good level of conversation that did not feel constrained.

Date of next meeting: Tuesday 15 January 2019, 12.45pm – 2.45pm Boardroom 2, Chorley House, Lancashire PR26 6TT

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Patient Voice Committee Minutes 12.45pm – 2.45pm Tuesday 29 January 2019 Boardroom 2, Chorley House, Leyland PR26 6TT

Present Mr Lionel Barker, Chair – Patient Advisory Group Mrs Kate Burgess, Commissioning Delivery Manager – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Dawn Clarke, Equality and Diversity Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Debbie Corcoran, Patient and Public Involvement Lay Member – NHS Greater Preston CCG (Chair) Mrs Helen Curtis, Director of Quality and Performance – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Geoffrey O’Donoghue, Patient and Public Involvement Lay Member – NHS Chorley and South Ribble CCG (Vice Chair) Ms Erin Portsmouth, Head of Communications and Engagement – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Suzanne Penrose, Medicines Optimisation pharmacist – Midlands and Lancashire Commissioning Support Unit Mrs Glenis Tansey, Engagement and Patient Experience Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG

In Attendance Ms Rebecca Stafford, Customer Care and Patient Experience Officer, NHS Chorley and South Ribble CCG and NHS Greater Preston CCG (minute taker) Mrs Kerry Prescott, Projects Manager – Healthwatch Lancashire

1 Welcome and apologies for absence Mrs Corcoran opened the Patient Voice Committee (PVC) by welcoming everyone to the meeting and introductions were made.

Mrs Penrose advised that she had to attend another meeting at 2.00pm so she would need to leave the meeting a couple of minutes before that time.

No other apologies given and the meeting was quorate.

2 Declarations of interests Mrs Corcoran explained that following guidance released at the end of last year by NHS England, the CCGs only need to provide registers for statutory committees. As the Patient Voice Committee (PVC) is an assurance committee, a register of interests was not warranted.

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 309 Declarations of interests would, however, remain as a standing agenda item to ensure that people have the opportunity to declare any interest they may have on any issues arising that might conflict with the business of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG.

Mrs Corcoran asked if any members of the PVC had anything further to declare.

There were no additional declarations made.

3 Minutes of previous meeting – 7 November 2018 The Committee reviewed the minutes of the 7 November 2018 meeting and agreed that they were an accurate reflection of the discussions.

4 Matters arising The Committee appraised the matters arising log and agreed to the closure of the items identified as complete.

Ms Stafford advised that at the time of publishing the meeting papers, the two actions relating to Healthwatch Lancashire were still in progress. However, the meeting had now taken place as planned, therefore, the Committee agreed that these actions could now be closed.

In relation to matters arising action number PVC181107-05, Mrs Corcoran updated the Committee, explaining that there had been a couple of patient stories presented at the Governing Body meetings with a mental health theme to support understanding in this priority area. The first one was in relation to perinatal mental health, which was very powerful. The second patient story was delivered by Sam Tyrer, founder of ‘Change Talks’, which is a voluntary community sector organisation that champions mental health issues.

Mrs Curtis advised that a report had also been presented to both governing bodies, however, she was not sure how long ago it had been, therefore, an additional update would be worthwhile updating on the approach to this area at the Integrated Care System (ICS) level, to highlight how things are moving forward in terms of what has been commissioned locally.

Mrs Corcoran commented that a paper had been presented by the ICS forum at the Joint Committee of Clinical Commissioning Groups (JCCCG) in December 2018, which was in relation to the commissioning framework for adult mental health. She suggested mapping what is already being done locally in relation to mental health, and seeing how it aligns with the commissioning framework.

Mrs Corcoran suggested that the action remained as ‘in progress’ to keep it on the radar, and she will liaise with Mrs Curtis to see if there are any opportunities moving forward to table something more formal around mental health in the future.

ACTION POINT • Ms Stafford to update matters arising number PVC181107-05 as ‘ongoing’.

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 319 Items related to duties and assurance 5 Improvement and Assessment Framework – Update on ‘patient and community engagement’ indicator

Ms Portsmouth informed the Committee that as part of the assurance work for the CCGs’ Improvement and Assessment Framework (IAF), there is an indicator called ‘indicator 57’, which is about statutory requirements around patient and public participation in commissioning services. Ms Portsmouth advised that this was a national process carried out by NHS England (NHSE) for all CCGs.

Ms Portsmouth commented that the framework and criteria within the indicator had not changed as of the last financial year. However, following the last assessment, NHSE received extensive feedback from CCGs and other partners that were involved, and based on this feedback new guidance has been developed for this financial year.

The Committee heard that the last assessment had been based purely on NHSE assessors reviewing the CCGs’ websites over a specific period of time. The process, however, appeared to be flawed as both CCGs were scored differently despite both websites having identical content.

Mrs Tansey informed Committee members that NHSE had held a series of webinars to assist CCGs with their submissions. The CCGs had been provided with a template to signpost NHSE to the evidence. In addition, it is the intention that the same assessor will be assigned to both CCGs.

The deadline for submission is 8 March 2019, and the CCGs’ Lay Members for Patient and Public Involvement will have an opportunity to review and provide feedback on the draft evidence templates before they are submitted.

Mrs Tansey also confirmed that she is working with a member of the CCGs’ Patient Advisory Group (PAG) and Healthwatch Lancashire to complete the templates.

ACTION POINT Mrs Tansey to circulate the completed template for comments, ahead of final submission to: • CCG (PPI) Lay Members • Director of Quality and Performance • Head of Communications and Engagement

Chair’s summary The Committee noted the update and feel that it is positive that the process is changing, and that NHSE has offered more support and clarity for the CCGs.

6 Equality Delivery System (EDS) grading results Mrs Clarke informed Committee members that this update was focusing on ‘goals 3 and 4’ workforce and leadership outcomes. She explained that the CCGs had undertaken a staff survey this year, which was inclusive of all staff and office holders of the CCG.

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The initial outcome of the survey shows that the CCGs are achieving the goals. Mrs Clarke advised that unfortunately it had not been possible to get a grading panel together yet due to grader’s availability. A panel will be undertaken during February and the survey results moderated and published on the CCG websites accordingly.

The Committee heard that interim results show that the CCGs are achieving every outcome, however, it was noted, that this could change for goals 3 and 4 depending on the outcome of the panel when it meets.

Ms Portsmouth commented that in addition to the survey that office holders and staff completed, additional questions relating to harassment and bullying were added to the annual CCG staff survey. Although the survey does not include embedded Commissioning Support Unit (CSU) staff, the results provided more evidence than received previously in relation to this specific indicator within the EDS process.

Mrs Corcoran commented that the world café style approach that was used for goals 1 and 2 was very positively received, and although she is conscious that it is a big investment of time for those involved with the process, she feels that it would be useful to use this kind of approach again.

Mrs Corcoran further commented that she had noted that two indicators had changed from purple (excelling) to green (achieving), and asked if there was a specific reason for that. Ms Portsmouth stated that it is a subjective process with different grades each year, so fluctuation is to be expected. Mrs Clarke replied that this could change again once the evidence has been produced following the panel.

Mrs Corcoran asked that the leadership team particularly look at the results if they are below where they were last year, to see if there is a specific reason for this.

Mrs Curtis commented that it would be worth triangulating the EDS results with the cultural survey results to see what the overall results show, as the cultural survey also includes the embedded CSU staff members.

Ms Portsmouth agreed this would be useful and commented that there could be a change in the results due to the fact the CCGs are in a different kind of landscape at the moment.

Mrs Corcoran advised that the equality and diversity action plan had been circulated to both governing bodies, and wanted it noting that although the action plan provided lots of value, Greater Preston members would like further information and understanding around any specific groups that struggle to access commissioned services.

Ms Portsmouth agreed that this is a worthwhile piece of work and has briefly discussed with Mrs Clarke as to how this can be built into the workplan for next year.

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 312 ACTION POINTS • Mrs Clarke to arrange a date for the grading panel to take place and provide the Committee with an update of the results when they are available. • Mrs Clarke to look at the triangulation of equality and diversity across access to commissioned services.

Chair’s summary The Committee noted the positive position for goals 1 and 2 and thanked the Patient Advisory Group again for their input and support and welcomed the interim position for goals 3 and 4 and look forward to receiving the final report. Members discussed the development of future approach in relation to commissioning and access of services to be included in next year’s framework.

7 Customer care service report – quarter 3 2018/19 Mrs Tansey presented the Committee with an overview of the customer care service report. She told the Committee that contacts to the service has decreased this quarter, however, GP enquiries had slightly increased. There was also a slight increase in compliments and further narrative has been included within the report. The customer care team continues to share data with the relevant CCG teams, in particularly the quality team. Committee members heard that themes this quarter mainly related to the district nursing service and continuing healthcare communications.

Mrs Tansey informed the Committee that because continuing healthcare is a regular theme, the customer care team is undertaking a piece of work to dig a little deeper into the complaints in order to better understand exactly where the issues are and what the solution may be. She further commented that the team produces issues logs for most services so that the team can feedback information. An example of this is when the ‘Moving Well’ service was mobilised. The team collated the issues and shared high level themes with the Moving Well, contracting and commissioning representatives, and dealt with the issues as source, and asked the provider to put the appropriate steps in place.

Mr O’Donoghue asked if there was anything that could distinguish between the characteristics of the contacts received from emails and telephone, as this form of contact appears to be the most common. For instance, age and gender.

Mrs Tansey explained that due to the nature of a lot of the telephone calls, patients may be distressed, upset or angry and as such, it may not be appropriate to ask for this information. The customer care team does encourage complainants to provide feedback via a link to a survey, which is included in the response letter/email.

A discussion took place around the type of telephone calls that are received. Mrs Tansey explained that the calls were varied, and due to the complexity of some of the complaints patients had been offered the opportunity to feedback their comments face-to-face. Examples will be provided in the next report.

Mr O’Donoghue asked if the team went out to meet patients to gather this

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 313 information. Mrs Tansey commented that this has not been done to date, however, it could be considered dependant on the patient’s needs. Ms Portsmouth advised that it was about making sure that the process worked for individuals, ensuring that safeguarding measures are in place for members of the team and the patient. Mrs Tansey commented that if the patient came into the CCGs to talk, there would always be two members of staff present.

The Committee was informed that this process was also about how the CCGs can learn from the issues that have been raised to improve services and pathways moving forward. Mrs Tansey advised that patients are also given the opportunity to share their stories with governing bodies.

Ms Portsmouth commented that is it sometimes difficult to show direct correlation between feedback and action.

Ms Portsmouth left the meeting at this point.

Mrs Prescott commented that Healthwatch Lancashire has the same challenges when it comes to reporting certain types of information and informed the Committee that rather than a ‘you said, we did’ section, they have a section called ‘you said, we listened’.

Ms Portsmouth returned to the meeting at this point.

Members had a conversation in respect of the triangulation of information and how it could potentially be presented through the report in a more visual way to show what the CCGs have done about the issues raised. Ms Portsmouth commented that further thought was required as to how the information could be reported and commented that the PVC may not be the correct meeting for this. Mrs Tansey suggested it could be in a ‘you said, we considered’ format.

Mrs Corcoran commented that she had noted that MP enquiries had increased this quarter and asked if there was anything specific as to why this may be.

Ms Portsmouth replied that there could be several reasons for this. Some of them could be constituent specific and the MP is acting as an advocate for them. Others may be based on pre-thinking, depending on what the MP potentially wants to campaign for. Ms Portsmouth explained that the CCGs work with the parliamentary team at NHS England, so if local MPs put a question forward, the CCGs can provide the relevant information. She continued to explain that MPs have regular briefings with the CCGs’ Chief Officer, Denis Gizzi and Karen Partington, Chief Executive for Lancashire Teaching Hospitals.

ACTION POINTS • Mrs Tansey to look at ways of reporting triangulated data and outcomes. • Mrs Tansey to include examples of patient complaints that had been reported face-to-face in the next quarterly customer care service report.

Chair’s summary The Committee welcomed and received the report for assurance and noted the

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 314 trends and current position.

8 Patient involvement and assurance report Mrs Clarke presented the Committee with the report, advising that it provides an overview and assurance of all key engagement and involvement that is taking place. She explained that the report covered the period of 7 November 2018 to 14 January 2018.

Mrs Clarke informed the Committee that the PAG meeting had not taken place ahead of the PVC papers being published, therefore, an update of the meeting will be provided in the next quarterly report.

Committee members heard that some of the key activity this quarter had included PAG members reviewing the Care UK patient information leaflet, and they had also been given the opportunity to attend the ‘bereaved by suicide support pathway’ focus group. PAG members also received the ‘Our Health, Our Care’ case for change.

Mr Barker commented that Mrs Boampang, Associate Director for Communications, Engagement and Marketing for the Transformation Unit, received a lot of challenging questions from PAG members following her presentation of the case for change.

PAG members also received an additional presentation from GTD that was in the style of ‘you said, we did’. The presentation focused on answering the questions that PAG members had presented to GTD at the previous PAG meeting. Mr Barker advised that this was received very well by PAG members.

Mrs Tansey advised that following requests at previous meetings to identify some outcomes of the young people’s health advocates (YPHAs) engagement opportunities, a template has been produced to capture this information.

Mrs Tansey commented that the YPHAs have been presented with an opportunity to potentially work with a GP practice to develop a campaign to encourage more young people to get involved with their practice’s patient participation group.

The Committee heard that Matthew Tetlow, Engagement Officer for the CCGs is leading on this piece of work and further updates will be presented at future PVC meetings.

Mrs Penrose asked what age group was classed as ‘young people’. Mrs Tansey confirmed that it was under 25, and briefly explained about how YPHAs first started.

Mr O’Dongohue asked if the focus group for ‘bereaved by suicide’ was linked with the new appointment of the North West regional suicide prevention officer.

Ms Portsmouth replied that the suicide support pathway was being led by the Integrated Care System and NHSE was also linked with this piece of work.

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 315 ACTION POINT • Mrs Tansey to provide feedback on the young people’s involvement in relation to the PPG work.

Chair’s summary The Committee welcomed and noted the updates and thanked those involved in producing the report, and look forward to receiving further updates on the PPG work that the YPHAs are undertaking.

9 Our Health, Our Care (OHOC) Ms Portsmouth provided the Committee with an update on the communications and engagement activity for the Our Health, Our Care (OHOC) transformation programme.

Ms Portsmouth explained that the communications and engagement element of the programme was currently in ‘phase 7’, which commenced at the beginning of December 2018 and will run through to mid-March 2019, at which point all engagement will need to be paused as we enter a stage of Purdah due to local elections taking place. She advised that work on other areas of the programme will continue.

Committee members were presented with a series of appended documents and advised that they were for information. The first appendix was an ‘interim market research results report’ that the Transformation Unit (TU) had undertaken on behalf of the OHOC programme. This involved a targeted telephone survey and other face-to-face fieldwork.

Ms Portsmouth advised that this piece of work was approximately half way through with at least a further 250 conversations to take place. She commented that the TU is also running focus groups in relation to market research insights and information gathering, and that an update would be brought to the next Committee meeting.

The second appendix was a plan of upcoming targeted engagement activity for the programme that was broken down by protected characteristics and is being led by Mrs Clarke, Equality and Diversity lead for the CCGs.

Mrs Clarke explained that engagement had already commenced, and she has gathered some interesting information that can be fed back into the programme.

Ms Portsmouth continued to present the remaining appended documents advising that the third was a TU document to show the Equality Impact Assessment methodology for the programme specifically to support the options development stage.

The Committee heard that the final appendix was a draft of the independent review report that the CCGs asked to be undertaken in relation to the communications and engagement activity that had taken place for OHOC to date.

Committee members discussed the targeted engagement plan and agreed that it

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 316 was a positive piece of work. Mrs Corcoran wanted assurance that engagement with the protected characteristic groups was consistent with other engagement, and asked how the gathered information would link it into programme and feed back to the stakeholder panel.

Mrs Clarke commented that she follows a guide template that covers the OHOC work and the digital work. She will also be providing a report on the information gathered to the stakeholder panel. The report will also be in line with the work that the TU is doing.

Ms Portsmouth added that the work that Mrs Clarke is doing is in line with the programme to ensure that the information gathered is relevant to what is being worked on. This will influence the programme work to come, along with all previous involvement work. The stakeholder panel will receive this information along with the market research results which will feed into the programme team and will also inform the overall Equality Impact Assessment.

Mrs Penrose left the meeting at this time.

Committee members were asked to comment on the draft independent review report. All Committee members agreed that the report was not as robust as they had expected it to be and felt that it was more of a summary rather than a review.

Mr O’Donoghue commented that he felt it was difficult to see what value it added.

Committee members agreed with this comment and Mrs Corcoran added that she had expected the report to provide assurances around the value of engagement and that best practice had been followed. She also felt that it should add more rigour in order to show the public exactly what the CCGs had learned, and what had been put in place as a result of this. The Committee felt that there was a lack of context and the report wasn’t as constructive as it could be.

The Committee discussed the report further and agreed that the report needed to be reframed before it was presented to the governing bodies or other groups, because as it stands it does not meet the original brief. Mrs Corcoran asked if there was still a need and a value for this piece of work, and if so, what should be done next.

Overall, Committee members felt that the report was not as evidence-based as it could be, that it didn’t meet the brief, and needs to be a more in-depth evaluation. The team was asked to look at re-framing the brief with a view to a new review being carried out.

Mrs Corcoran commented that once the next engagement stages are clear for the programme, it would be helpful to have a gant chart that clearly outlines the timeline of next steps. Mrs Curtis confirmed that there would be a full spreadsheet outlining all the relevant stages of the programme.

ACTION POINTS • Ms Portsmouth to provide an update of the OHOC market research results

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 317 at the next Committee meeting. • Ms Portsmouth to look at re-framing the OHOC communications and engagement brief with a view to a new review being carried out.

Chair’s summary The Committee welcomed the update and the opportunity to provide vital feedback in relation to the targeted engagement plan and also the independent review report, and look forward to hopefully receiving a reframed report that delivers what is needed.

Items for Information 10 Healthwatch Lancashire - digital technology project update Mrs Prescott explained that unfortunately there had been a delay in the digital technology project report being published, however, she provided members with a printed handout that provided an overview of the work that had been undertaken and the reasoning behind it. The full digital report will be published tomorrow.

Mrs Prescott advised that this piece of work was undertaken by the Healthwatch collaborative alongside Healthier Lancashire and South Cumbria, to support their digital work stream in terms of how the public currently engage and wish to engage in the future. She continued to explain that this had been a large piece of work that also included 38 ‘chatty van’ engagement events. The CCGs had also supported the work by undertaking some targeted engagement with local groups.

Members heard that the team had also undertaken a survey where they had spoken to over 1,000 people. A large proportion of the work was undertaken through focus groups with diverse communities to ensure that everyone including people from protected characteristic groups had a voice on how they would like to engage.

Mrs Prescott explained that it would be useful if Committee members could read the final report and provide some feedback at the next PVC meeting.

Mrs Corcoran agreed this would be helpful and asked the Committee to do a mini audit of the report and reflect on the recommendations to see if the CCGs are doing any of them currently or how they could possibly be embedded.

Mr O’Donoghue left the meeting at this point.

Mrs Corcoran requested that members provide Mrs Prescott with their feedback at the next PVC meeting, which in turn will provide the Committee with the assurance that when good practice and learning is received, it is being taken on board and implemented.

Mr O’Donoghue returned to the meeting at this point.

Mrs Tansey commented that this could be a great project for young people who are technology-minded to get involved in, and could be used with the PPG work that YPHAs are involved with.

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 318 Ms Portsmouth commented that Mrs Clarke was involved in the Integrated Care System digital engagement work, and is also part of the central Lancashire digital group that the CCGs are leading, so this piece of work will link in with them.

ACTION POINTS • Mrs Prescott to provide Ms Stafford with the link to the digital report for distribution to Committee members. • Mrs Clarke and Mrs Tansey to co-ordinate a mini audit of the Healthwatch digital report and link in with the ICS and central Lancashire digital work.

Chair’s summary Committee members welcomed the update and look forward to reading the full digital report when it is published. Members will provide feedback at the next PVC meeting.

11 Any other business Mrs Corcoran asked if PVC meeting dates had been set for 2019/20 financial year.

Ms Stafford confirmed that they had and would be shared with the Committee members at the next PVC meeting on 6 March 2018.

12 Reflections of the meeting Mrs Corcoran welcomed any comments from the Committee.

Mr O’Donghue commented that he was conscious that everyone is very busy at the moment and asked if it made good use of Mrs Penrose’s time to attend the meeting.

Ms Stafford explained that representation from the relevant teams were listed in the PVC Terms of Reference, and that the agenda is sent to the Head of Medicines Optimisation, who then decides who is best placed to attend the meeting.

Ms Portsmouth commented that it was also about building knowledge and awareness of the PVC with representatives from other teams. She suggested that it may be useful to look at what efficiency plans are coming up for the next financial year, and then decide at the Committee pre-meet if there is anything specific that needs particular representation from teams.

Ms Portsmouth explained that the PVC Terms of Reference states that quoracy means at least one of the three representatives from medicines optimisation, planning and delivery or quality and performance attend, however, as it stands, the rest of the named members are now part of the quality and performance team. She commented that there are constitutional reviews currently underway, so it would also be a good opportunity to review the Terms of Reference ahead of the new financial year.

Final minutes v1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 29 January 2019 Page 319 Date of next meeting: Wednesday 6 March 2019, 12.45pm – 2.45pm Boardroom 2, Chorley House, Lancashire PR26 6TT

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