Governing Bodies in Common Part 1 – In Public 21 July 2020, 14:00
1 Opening Actions
Title Lead Purpose Time B L MK 1.1 Welcome and Introductions Chair 2:00 1.2 Declarations of Interest Chair Requirement 1.3 Matters Arising Chair
1.4 Action Log Chair Discussion 2 Operational
Title Lead Purpose Time B L MK 2.1 Chair’s Report (Verbal) Chair Assurance 2:10
2.2 Accountable Officer’s Report Accountable Officer Assurance 2:15 3 Finance, Quality and Performance
Title Lead Purpose Time B L MK 3.1 Performance and Quality Chief Nurse / Director Assurance 2:20 Report of Performance and Governance 3.2 Recovery Plan Director for Assurance 2:30 Strategy, Planning & Population Health 3.3 NHS Response to Covid19 in Director of Assurance 2:40 Bedfordshire and Luton Performance and Governance 3.4 M2 Finance Report BLMK Chief Finance Officer Discussion 2:50 CCGs 4 Projects and Programmes
Title Lead Purpose Time B L MK 4.1 Draft BLMK CCG Constitution Director of Approval 3:00 Performance and Governance 4.2 Establishment of an Equality, Director of Approval 3:10 Diversity and Inclusion Performance and Committee Governance / HR Lead BLMK
5 Governance
Title Lead Purpose Time B L MK 5.1 Corporate Risk Registers Director of Assurance 3:15 Performance and Governance
5.2 Governing Body Assurance Director of Assurance 3:20 Frameworks Performance and Governance 5.3 Committee Minutes Committee Chairs Assurance 3:25 5.3.1 Audit Committee Committee Chairs Assurance BCCG • 30 April 2020 LCCG • 21 January 2020 • 17 March 2020 MKCCG • 5 March 2020 5.3.4 Bedfordshire and Luton Committee Chairs Assurance Joint Prescribing Committee • 26 February 2020. 5.3.5 Committee Chairs Assurance BCCG Patient and Public Engagement Committee • 6 February 2020 LCCG Health and Social Care Engagement Group • 28 January 2020
5.3.6 Primary Care Committee Chairs Assurance Commissioning Committee BCCG • 12 February 2020 MKCCG • 12 February 2020 5.3.7 Quality Committee Committee Chairs Assurance BCCG • 23 January 2020 LCCG • 27 February 2020 MKCCG • 10 March Quality Committee in Public BLMK • 9 June 2020 6 Closing Actions
Title Lead Purpose Time B L MK 6.1 Date of next meeting Chair Information 3:30
2 Please send an queries or comments to: [email protected] 1.4
Governing Bodies in Common in Public 21 July 2020
Title: Action Log
Author: Secretariat Contact Information: [email protected] Lead Executive: Committee Chair Which CCGs does this paper apply to?
Bedfordshire Y Luton Y Milton Keynes Y
Information
Which activity does this paper The tracker shows the outstanding actions of the Governing relate to? Bodies
How?
What is the Committee/ To discuss and provide updates for the trackers including new Governing Body being asked to action deadlines/reassigning action owners where appropriate. do? Action owners should be Executive or Senior Manager level. What are the financial N/A implications?
Set out the key risks and risk N/A ratings
Date to which the information N/A this paper is based on was accurate
Executive Summary
N/A
16/07/2020 Governing Bodies in Common Action Log
Governing Bodies in Common Action Log RAG KEY Escalated Escalated - items flagged RED for 3 subsequent meetings - BLACK Outstanding Outstanding - no actions made to progress OR actions made but not on track to deliver In Progress In Progress. Outstanding - actions made to progress & on track to deliver due date - Not Yet Due Not Yet Due COMPLETE: COMPLETE - GREEN Propose closure at next meeting CLOSED CLOSED (dd/mm/yyyy)
Action Meeting Date CCG Item Title Action Responsible Manager Past deadlines Current Deadline Current Position RAG No. (Enter full name) (Since Revised) (Add date action is agreed closed)
1 26/05/2020 BLMK 2.3 Action Logs Action logs to be taken offline to be finalised Michael Wuestefeld- 08/07/2020: Complete. COMPLETE: Gray Propose closure at next meeting 21/07/2020
2 26/05/2020 BLMK 4.1 Corporate Risk The three CCG’s Risk Registers and Assurance Frameworks to Geraint Davies / 08/07/2020: Complete COMPLETE: Registers be amalgamated and brought to the next Governing Body Michael Wuestefeld- Propose closure at Meeting. Gray next meeting 21/07/2020 3 26/05/2020 BLMK 4.3 Committee Minutes A consistent format for minutes and other meeting templates to Michael Wuestefeld- 08/07/2020: Complete. COMPLETE: be developed. It was accepted this will take time. Gray Propose closure at next meeting 4 26/05/2020 BLMK 4.3 Committee Minutes Set up a meeting to discuss communications and public Jane Meggitt / engagement going forward Alison Borrett
5 26/05/2020 BLMK 4.3 Committee Minutes Comments about the following to be added to the Risk Michael Wuestefeld- Register: Gray / Sanjay Sharma / • Black and Minority Ethnic (BAME) issues Chirag Bakhai / • Emergency Preparedness Resilience and Response (EPRR) Kathy French • Personal Protective Equipement (PPE) including for patients coming into primary care settings, (raised by SS) • workforce issues • Diagnosis and treatment of pathology being delayed and resulting in harm, (raised by CB) • Primary and community workforce capacity to re-initiate 'routine care' (which will invariably require prioritisation). (Raised by CB.) • Has the risk to the population been assessed as the IPC guidance is fundamentally changing everything, therefore patients will have considerable waits for treatment? (Raised by KF)
6 26/05/2020 BLMK 4.3 Committee Minutes The Chief Finance Officer to review the financial risks proposed Chris Ford to be added to MKCCG Board Assurance Framework, (page 216/219).
7 26/05/2020 BLMK 5.1A - Covid-19 Incident The Secondary Care Doctor (HTu) to have a discussion about Chris Ford / Response – Phase 2 secondary care pathways outside of the Governing Body Helen Turner Recovery Plan meeting. The discussion needs to be part of the recovery cell.
Page 1 of 5 16/07/2020 Governing Bodies in Common Action Log
Action Meeting Date CCG Item Title Action Responsible Manager Past deadlines Current Deadline Current Position RAG No. (Enter full name) (Since Revised) (Add date action is agreed closed)
8 26/05/2020 BLMK 5.1A - Covid-19 Incident Colleagues to respond to an email from Director of Strategy, All / Response – Phase 2 Planning and Population Health (MT) and The Chief Finance Mike Thompson / Recovery Plan Officer (CF) outside of the meeting. Chris Ford
9 26/05/2020 BLMK 5.1A - Covid-19 Incident The GP Member (CB) and Director of Communications and Chirag Bakhai / Response – Phase 2 Engagement (JM) to follow up on having a Communications Jane Meggitt Recovery Plan strategy about Covid-19 and risk.
10 26/05/2020 BLMK 5.2 One BLMK CCG The Programme Director, One Team Programme (MWo) to Maria Wogan 08/07/2020: An update is on the agenda for 21/07/2020 GBs in COMPLETE: Programme circulate an updated version of the One BLMK CCG Common Meeting Propose closure at Programme document previously circulated to the Governing next meeting Body. 21/07/2020
11 26/05/2020 BLMK 5.2 One BLMK CCG The Medical Director’s presentation to be shared after the Sarah Whiteman 27/05/2020 COMPLETE: Programme meeting. Presentation circulated immediately after the meeting. Propose closure 21/07/20
12 26/05/2020 BLMK 5.2 One BLMK CCG NP to send further details about appointments to clinical roles Nicky Poulain / Programme to the Governing Body and NP to meet with US. Usma Sarwar
13 26/05/2020 BLMK 5.2 One BLMK CCG GP Members who are interested in involvement in a rapid GP Members / 08/07/2020: COmplete COMPLETE: Programme discussion and action on how GP Members work to get in Geraint Davies / Propose closure at touch with GD, MWo and JM. Maria Wogan / next meeting Jane Meggitt 21/07/2020
14 26/05/2020 BLMK 5.2 One BLMK CCG The Governance Team to send out further meeting invites for Michael Wuestefeld- 04/06/2020: This has been completed until the end of 2020. COMPLETE: Programme Governing Body in Common meetings. Gray / Maryla Hart Propose closure 21/07/20
15 26/05/2020 BLMK 5.2 One BLMK CCG Re-establish members’ forums so various questions with Nicky Poulain / Programme regards to clinical recruitment can be discussed. Sarah Whiteman / Nicola Smith
GB22 21/11/2020 Bedfordshire Part EPRR Joint Training for AM commented that the Executives have individually been Geraint Davies / Mike Summer 2020 16.12.20: This will be arranged for the summer. 1 Executive Team trained in responding to incidents and put forward the Thompson suggestion that as the Executive Team is relatively new, it may be helpful to receive training as a collective Group.
Page 2 of 5 16/07/2020 Governing Bodies in Common Action Log
Action Meeting Date CCG Item Title Action Responsible Manager Past deadlines Current Deadline Current Position RAG No. (Enter full name) (Since Revised) (Add date action is agreed closed)
GB23 16/12/2020 Bedfordshire Part Long Term Plan Update GD and MT to give a briefing to the Governing Body once Geraint Davies / Mike Dependent on 02/03/2020: MT to lead on this. 1 & 2020/21 NHSE guidance is received, particularly focusing on financial Thompson NHSE guidance 07/05/2020: The CCGs submitted NHS Long Term Response. Commissioning Delivery functions. We are now reviewing the submission in the light of the Covid Planning/Operations 19 Incident and the requirement to submit Phase 2 Recovery Plan Plan on 7th May 2020. The CCG has worked with NHS partners to agree and submit a plan on 7th May 2020 and feedback will be provided on 14th May 2020. A report covering 51/19a 16/07/2019 Luton Part 1 LeDeR To add the LeDeR risk to the Board Assurance Framework Anne Murray 17/09/2019 12/09/2019 - A risk has been draft around LeDeR/Quality and COMPLETE: Patient Safety for discussion at a Development Board session Propose closure at 19/11/2019 - A risk has been drafted, ongoing work required next meeting 21/01/2020 - The LeDeR risk is not on the BAF 09/04/2020: Please can the GB advise who this action should 21/07/2020 be reassigned to 3/7/2020 LeDeR is now included as part of the LD transformation programme. Additional resources have been allocated and whilst still a challenging work plan progress has 13/20b 21/01/2020 Luton Part 1 BAF To review the BAF in four weeks time to ensure the work is David Kempson 18/02/2020 09/05/2020: . A updated BAF was part of the original Board COMPLETE: progressing and an up to date report is presented at the March papers, however was not reviewed at the March 2020 meeting Propose closure at 2020 Board meeting due to the change in content of the meeting due to the next meeting Coronavirus outbreak. 08/07/20: This action was completed some time ago and can 21/07/2020 be closed.
89/19b 19/11/2019 Luton Part 1 BAF To review the BAF to ensure the report accurately reflect the Michael Wuestefeld- 21/01/2020 21/01/2020 - MWG advised that he plans to work with the COMPLETE: risks have been reviewed and updated Gray individual risk owners and leads for the BAF and the Corporate Propose closure at Risk Register to ensure the right risks are registered, that they next meeting are up to date and staff understand how to correctly use the system 21/07/2020 12/03/2020 - update BAF on agenda 08/07/2020: Completed some time ago
06/20 21/01/2020 Luton Part 1 Patient records out of To get an update and progress report from Mike Thompson on Nicky Poulaine 17/03/2020 In Progress hours accessing patient records out of hours
30/19a 16/07/2019 Luton Part 1 Board to Board To schedule a Board to Board meeting with the L&D Patricia Davies 16/07/2019 16/07/2019 - To hold the meeting including BCCG by September 2019 11/09/2019 - This is being reviewed in light of the merger between BHT & L&D and changes within the CCGs. This may be better done with BCCG & BHT/L&D collectively and will be discussed with Chairs of BCCG & LCCG re the best approach to take. 19/11/2019 - Steps are being taken to hold a Board to Board with the Shadow merged L&D/BHT board and LCCG/BCCG in the new year. 21/01/2020 - The proposed Board to Board meeting with the Luton and Dunstable Hospital (L&D) is due to take place April 2020 18/02/2020 - update recieved - The proposed Board to Board meeting, which will include Bedfordshire CCG, is planned for the beginning of May 2020. 09/05/2020: Given that all public and board meetings have been suspended in terms of COVID, this has also been put on hold on in terms of any Board to Board Meetings.
Page 3 of 5 16/07/2020 Governing Bodies in Common Action Log
Action Meeting Date CCG Item Title Action Responsible Manager Past deadlines Current Deadline Current Position RAG No. (Enter full name) (Since Revised) (Add date action is agreed closed)
240919/9i 24/09/2019 Milton Keynes Part BAF It was discussed that a joint risk approach was required for Alison Joyner Jan-20 Update Nov 19: WIP In Progress v 1 Committees in Common.
240919/9i 24/09/2019 Milton Keynes Part BAF: Transformation changes to be included at the next board Alison Joyner Jan-20 Update Nov 19: WIP In Progress ii 1 meeting.
261119/5i 26/11/2019 Milton Keynes Part AO & COO report: Safeguarding - there continues to be a high level of reviews Anne Murray Jan-20 03/07/2020: This work is managed through the MK Safer COMPLETE: i 1 within Milton Keynes of 3 very sad cases where there has been Together Board which covers the safeguarding partnership Propose closure at a high level of media interest both locally and nationally. To be work. Any involvment or learning for health services is next meeting discussed further at the next Board. identified and acted upon. This has been concluded. 21/07/2020
240919/7i 24/09/2019 Milton Keynes Part Quality & Performance There was discussion on the outcome of the Getting it Right Geraint Davies Jan-20 Update Nov 19: Not easy to receive data and GIRFT data is In Progress ii 1 Report: First Time (GIRFT) stroke review of the Luton & Dunstable confidential. To be discussed at Stroke Strategy Group and Hospital Hyper acute unit and the short term unit at Milton outcomes fed to Board Keynes. It was noted that the final report will be presented to a Update Jan 20: GIRFT – Data has now been received from future board. both MK and L&D hospitals and is being reviewed at the Stroke Strategy Group. A report will be circulated following completion of this review.
261119/5i 26/11/2019 Milton Keynes Part AO & COO report: ICSTs - a patient experience update to be presented to a Jane Meggistt Mar-20 Outstanding 1 future Board.
261119/5 26/11/2019 Milton Keynes Part AO & COO report: MT to provide common themes/gaps to the Chair and look into Maxine Teffaniti, Jan-20 Outstanding v 1 what data is captured via the ‘LiveLife’ social prescribing Healthwatch service.
280519/1 28/05/2019 Milton Keynes Part Public Health Update: How to report outcomes, data and health check information to Muriel Scott, Bedford Jan-20 Update Jul 19: data requirements to be defined In Progress 7 1 be discussed outside of the meeting. Borough Update Sep 19: MS followed up with PD. Public Health to come up with data sets, getting clarity how to monitor output and ensuring the right people at the right level are targetted.
Page 4 of 5 16/07/2020 Governing Bodies in Common Action Log
Action Meeting Date CCG Item Title Action Responsible Manager Past deadlines Current Deadline Current Position RAG No. (Enter full name) (Since Revised) (Add date action is agreed closed)
240919/5i 24/09/2019 Milton Keynes Part AO & COO Report: Personal Health Budgets –this is starting to make a difference Richard Alsop Jan-20 09/05/2020: JWO gave the following update and requested In Progress i 1 to people’s lives. Referrals to ‘LiveLife’Social Prescribing have information from the Governing Body: continued to exceed service capacity and patient reported “As per NHSE guidance, all non-essential work gave way to outcomes remain positive. MKCCG is now established as a Covid work, and this falls into that consideration. However, PHB mentor to a number of other CCGs. JWo to report how please could the Governing Body clarify the following so this outcomes are being measured. work can continue if necessary at the appropriate time. Please can the GB reassign a deadline. • Are we talking about PHBs generally? • The PHB Mentorship is work for us, and income, and has no intrinsic benefits other than that income • I think this actually related to the personalisation agenda and ‘Live Lives’ in particular – more to do with the Social Prescribing ‘stuff’ that MK Together is doing. Is that correct? I am not involved in that work.
230719/1 23/07/2019 Milton Keynes Part BLMK Primary Care The Board agreed to receive a presentation on the Sarah Whiteman Jan-20 Update Sep 19: to come to next board Outstanding 5 1 Strategy Digitalisation strategy by the Chief Information Officer of BLMK Update Nov 19: deferred to next board ICS at a future Board, in order to understand what the strategy will be delivering. To also be presented to the Commissioning Delivery Group and the Primary Care Committee.
Page 5 of 5 2.2
Governing Bodies in Common in Public
21 July 2020
Title Accountable Officer’s Report
Author: Patricia Davies Contact Information: Lead Executive: Accountable Officer Which CCGs does this paper apply to?
Bedfordshire Yes Luton Yes Milton Keynes Yes
Information
Which activity does this paper This paper provides an update on the work being undertaken by relate to? the CCGs in the intervening period between May and July.
How? An update by the Accountable Officer, Patrricia Davies
What is the Committee/ To note the paper. Governing Body being asked to do? What are the financial N/A implications?
Set out the key risks and risk N/A ratings
Date to which the information 14 July 2020 this paper is based on was accurate
Executive Summary
The purpose of this paper provides is to provide Governing Body with an update on the work that has been undertaken by Bedfordshire, Luton and Milton Keynes Clinical Commissioning Groups since it was last convened in May.
Covid-19 Our work to tackle Covid-19 across Bedfordshire, Luton and Milton Keynes continues. We remain in an NHS Level 4 command and control incident and as a result, the cell structure that was established in March to manage the crisis remains in place. Our work with the Bedfordshire and Luton Resilience Forum and the Thames Valley Resilience Forum to manage issues arising remains in place to ensure continued joint up working across multi agencies. We are working closely with Public Health colleagues locally to monitor infections in our areas and take steps as required to manage patient flows. Our communications and engagement team continues to lead the communications for Covid-19 across the patch, working with partners, clinicians, local residents and councillors to get our message out. I would like to put on record my personal thanks to all our GP colleagues who have contributed to this effort, whether by undertaking media interviews, providing support in recording films in different languages or sourcing celebrities to participate in our campaigns, your input in providing a ‘trusted voice’ for our communities has been invaluable. Recovery We have submitted our plans for recovery through to NHSE and are working to develop these plans with system partners in the coming weeks. We expect to receive feedback from NHSE in August, when we will be able to provide more information to Governing Body on what our BLMK recovery plans will be. Bedford ‘Deep Dive’ For the last month, we have been working closely with colleagues in the Joint Biosecurity Centre, Public Health England, Bedford Borough Council and colleagues in Bedfordshire Hospitals Trust to unpick pillar one and two data around an increased Coronavirus infection rate in Bedford Borough. The interim report, which was published on 7 July reported that while infections were higher in Bedford, compared to other areas in the country, this is declining steadily and despite earlier concerns, Bedford does not pose the same level of concern as other towns and cities, like Leicester. The interim report identified that women aged 30-59 have been most affected by the disease and there is a higher prevelance of infections those who work in health and social care settings. A number of postcode areas have also been identified as areas that have the highest levels of Covid-19 and Jane Meggitt, Director of Communications and Engagement has been working with partners to communicate that message to affected communities. The report also identified a number of recommendations to improve testing facilities at Bedford Hospital and these measures have been put in place to boost testing capacity on site. The final report is expected this week and we will provide the findings to Governing Body to provide an update and assurance on the steps being taken to mitigate and reduce the spread of Covid-19 in Bedford Borough. One Team In May, we re-started the organisational change programme to become one single CCG by April next year. We are currently working through the process to put new staffing structures in place and will continue to align governance meetings and develop the new constitution for the single CCG.
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We are working to align policies and processes across the 3 CCGs building on the best of existing work - identifying best practice across teams and enhancing joint working to avoid duplication whilst recognising the four distinct places in BLMK. We have continued to engage with our GP Members and in the last month have undertaken three place Members Forums and one BLMK Members Forum to further conversations around the new organisation and define in greater detail how the new CCG will ensure there is a strong local voice in decision-making and deliver an enhanced local offer at ICP, local authority and PCN level. A final draft constitution, which incorporates their feedback, is being shared with the membership in July.
We have attended the Overview and Scrutiny Committees of Bedford Borough and Central Bedfordshire Council to share our proposals. Both scrutiny committees have provided recommendations for our Membership and the Governing Body to consider, as part of wider discussions about our new constitution.
There are more engagements taking place with Committees, Councillors, Leaders and MPs over the coming weeks and we will of course provide further details around this as we are able. Our intention remains to undertake a GP membership vote in August, before we seek approvals from our Governing Body in September and submit our formal application by 30 September.
Finally, I would like to put on record a most sincere thanks to our staff – both in the CCG and in the wider NHS for their hard work in responding to Covid-19 in the past five months. This has been a pandemic like no other we have seen in our lifetimes and the resilience and fortitude they have shown has been exceptional.
The same can also be said for our colleagues in social care, our Local Authoritiy colleagues, and emergency services teams who have played such an important role in keeping the most vulnerable in our society safe in extraordinary times.
In making these comments however, it is also important that I pay a formal tribute to our many colleagues who have paid the ultimate price and their lost their lives, while caring for our patients. I know the Governing Body will join me in sending our most sincere condolences to their families and to the families of the 834 people who have tragically lost their lives to Covid-19 in Bedfordshire, Luton and Milton Keynes.
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3.1
Governing Bodies in Common in Public
21 July 2020
BLMK Performance and Quality Report 2020/21 M1 - April 2020
Author: BLMK Performance Team Contact Information: [email protected] Lead Executive: Geraint Davies, Director of Performance and Governance and Anne Murray, Chief Nurse Which CCGs does this paper apply to? Information
Bedfordshire Luton Milton Keynes
Which activity does this paper Provides the latest performance data and shows the impact on relate to? the delivery of statutory performance targets.
How? By providing information around the latest position for key performance and quality indicators together with commentary around recovery actions. What is the Committee/ To receive assurance around mitigation for areas of Governing Body being asked to underperformance. do? What are the financial N/A implications?
Set out the key risks and risk Introduction and key messages are included at the front of the ratings report.
Date to which the information Report is predominantly Month 1 2020/21 (April 2020) – data for this paper is based on was month 1 published nationally on 11th June 2020. accurate
Executive Summary
The report provides an overview of progress against key performance indicators across Bedfordshire, Luton and Milton Keynes together with a consolidated view of BLMK. This is based on the latest available data which is primarily M1 unless stated within the report. The report highlights the current impact of the Covid-19 pandemic across BLMK and the effect at Month 1. There continues to be a number of provider data returns have been suspended and once these have resumed reporting will be enhanced to cover performance, quality and safety.
Highlights
Planned Care Cancer - The biggest impacts at M1 were on the 2 week wait and 62 day pathways with a 53% reduction in patients seen on the 2 week wait pathway following a GP referral, 81% reduction on the 2 week wait breast symptomatic referral pathway and 33% reduction on the 62 day for 1st treatment following a GP Referral pathway.
18 Weeks Referral to Treatment - There has been an increase of 5,157 (42.17%) patients waiting in excess of 18 weeks across BLMK however the overall size of the waiting list has fallen by 2,052 patients (2.96%). There has been an increase in 52+ week wait breaches from 11 in March to 65 in April.
Diagnostics - There has been a significant increase in the number of people waiting more than six week from 760 in March to 7679 in April. The majority of this increase was at Bedfordshire Hospitals Trust (5,662)
Urgent and Emergency Care Emergency admissions in Bedfordshire Hospitals Trust continued to decrease with Covid-19 contributing to the decrease in activity. While emergency admissions increased slightly in Milton Keynes the overall 6 month trend is showing a decrease. Bed occupancy in all hospitals fell sharply as a result the response to Covid-19 whereby significant numbers of patients were discharged to support the creation required capacity to cope with surges in activity. Regional improvements were seen in the ambulance response times across East of England Ambulance Service - EAST (Bedfordshire and Luton) and South Central Ambulance Service - SCAS (Milton Keynes). Both of the acute trusts had a reduction in ambulance arrivals
Adults Mental Health Most face to face activity and treatment have been suspended during the Covid-19 period. Clinicians have seen people in person if the patient’s need required it. As lockdown is starting to lift both CNWL and ELFT are reporting patients presenting with high acuity, and units are at capacity.
Children Mental Health 24/7 all age crisis lines established across BLMK. Triaging and prioritising high risk young people for intensive care and support. Some young people have become more unwell during the lock down and this has resulted in admissions to hospital. Community and voluntary sector organisations have been important in providing additional support and care Infection Prevention and Control (IPCN) During April a significant amount of actual/suspected positive cases were identified within the acute trusts and within care homes. There were significant issues with PPE procurement especially in some areas of social and primary care across the system and knowledge of correct use was not always optimal in the early stages of the pandemic, with national guidance changing very regularly. The IPC nurses for BLMK were consistently promoting Public Health England advice and guidelines which was changing several times a week
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BLMK Performance and Quality Report 2020/21 Month 1 April 2020 Contents
Introduction 3 Planned Care 16-22
Covid-19 Key Messages and 4-7 Urgent and Emergency Care 23-26 Impacts
Covid-19 8-11 Mental Health 27-34
Performance Dashboards 12-15 Quality and Safety 35-38
Definitions 39
2 Introduction
This report highlights the current impact of the Covid-19 pandemic across BLMK and the effect at Month 1 when measured against national indicators. There continues to be a number of provider returns that have been suspended. As these returns come back on line they will be included within the report.
Planned Care - Cancer - The biggest impacts at M1 were on the 2 week wait and 62 day pathways with a 53% reduction in patients seen on the 2 week wait pathway following a GP referral, 81% reduction on the 2 week wait breast symptomatic referral pathway and 33% reduction on the 62 day for 1st treatment following a GP Referral pathway.
18 Weeks Referral to Treatment - There has been an increase of 5,157 (42.17%) patients waiting in excess of 18 weeks across BLMK however the overall size of the waiting list has fallen by 2,052 patients (2.96%). There has been an increase in 52+ week wait breaches from 11 in March to 65 in April.
Diagnostics - There has been a significant increase in the number of people waiting more than six week from 760 in March to 7679 in April. The majority of this increase was at Bedfordshire Hospitals Trust (5,662)
Urgent and Emergency Care – In April emergency admissions in Bedfordshire Hospitals Trust continued to decrease with Covid-19 contributing to the decrease in activity. While emergency admissions increased slightly in Milton Keynes the overall 6 month trend is showing a decrease. Bed occupancy in all hospitals fell sharply as a result the response to Covid-19 whereby significant numbers of patients were discharged to support the creation required capacity to cope with surges in activity.
Adults Mental Health - Most face to face activity and treatment have been suspended during the Covid-19 period. Clinicians have seen people in person if the patient’s need required it. As lockdown is starting to lift both CNWL and ELFT are reporting patients presenting with high acuity, and units are at capacity.
Children Mental Health - 24/7 all age crisis lines established across BLMK. Triaging and prioritising high risk young people for intensive care and support. Some young people have become more unwell during the lock down and this has resulted in admissions to hospital. Community and voluntary sector organisations have been important in providing additional support and care 3 Covid-19 Key Messages and Impacts
Covid Confirmed Cases As at 30th June there had been 4,676 cases across BLMK which is 1.91% of total England cases.
Covid Cumulative deaths across all settings As at 26th June deaths (latest reported data) stood at 819 (17.59% of confirmed cases).
Cancer Performance has been adversely impacted by reduced capacity and this is likely to continue over the coming months. There is a recovery plan in place to ensure that services remain operational and provide mitigations for challenged services and or pathways. The focus of the recovery plan is on the reduction of surgery and endoscopy backlogs. Work includes using good practice to support the triage and management of patients awaiting treatment in conjunction with transformational work to support recovery of cancer services and overall performance.
Following a report published by Healthwatch, the CCG increased the information available to the public through; the ‘NHS is open for business’ campaign, production of a revised Covid-19 leaflet for 2 week wait referrals and greater consistency of patient information on GP practice websites.
4 Covid-19 Key Messages and Impacts
18 Week Referral to Treatment The Covid-19 pandemic has impacted heavily on secondary care and its ability to maintain services. Social distancing, infection rates and isolation, PPE requirements, the cancellation of routine elective care and the restrictions set out in national guidelines are all contributing factors. Referral pathways are now open and are being monitored.
Under Phase 2 work is underway to help the acute trusts plan to increase routine operations and treatment, while keeping the necessary capacity and capability to treat future coronavirus patients. Over the coming weeks patients who require planned procedures – including surgery – will begin to be scheduled for that care, with specialists prioritising those with the most urgent clinical need.
Diagnostics There has been a significant impact on Diagnostic waiting times with an increase in the number of people waiting more than six week from 760 in March to 7679 in April. Of the total breaches there were 5662 at Bedfordshire Hospitals Trust (73.77%), 575 at Milton Keynes (7.49% and 575 at Cambridge Community (4.79%) and 428 at East and North Hertfordshire (4.69%).
Over the coming months, recovery and supporting actions will aim to stabilise performance under reduced capacity conditions and increases in demand due to newly re-opened pathways.
Children Access to Mental Health Services Moving crisis care away from A&E, opening back up to self referral as soon as the workforce was available and making best use of digital technology to provide continuity of care. Eating Disorders Services have continued during the pandemic.
5 Covid-19 Key Messages and Impacts
Adults Mental Health • Both ELFT and CNWL have consolidated crisis and other teams to build resilience into the system. • Staffing was initially impacted by sickness and self-isolation (hence the consolidation of teams to bolster resilience), but this has stabilised and absence rates are now low. • Psychiatric liaison services in L&D, Bedford and MK hospitals have moved to facilities away from ED. 24/7 urgent care hubs have been created. These have been very quiet in terms of referrals from ED and direct walk-ins. • Crisis services in March and April saw a quiet period, with far fewer patients than usual seeking support. The Crisis Home Treatment Teams have been supporting people at home, helping to prevent admissions. • Both CNWL and ELFT set up isolation facilities for patients with Covid-19 symptoms or awaiting test results. The number of Covid-19 positive patients has been very low in both Trusts. • Memory assessment services have had to suspend assessments, but services are seeking means of reinstating using remote technology. ELFT would like to undertake assessments in GP surgeries but this is not currently possible. • IAPT services have been impacted significantly by Covid-19, with referrals and self-referrals much diminished against the same periods last year. All three services (CNWL, ELFT, Turning Point) have been providing treatment at all stages using technology, as well as holding online webinars and posting YouTube videos to support people with Covid-related anxiety. They have all been providing a support offer to NHS and care home staff, although take up appears to be low at present. The Covid-19 period will have a significant negative impact on access and recovery rates from March. • Mind BLMK has been providing a telephone crisis service throughout the Covid-19 period, and is looking at how soon they can re-open crisis cafes in Luton and Bedford. They continue to look for premises in Milton Keynes.
Serious Incidents There have been 16 serious incidents across BLMK, 4 in Bedfordshire, 2 in Luton and 10 in Milton Keynes. All SIs are accompanied with detailed learning/action plans which the CCGs monitor on a regular basis.
6 Covid-19 Key Messages and Impacts
Infection Prevention and Control (IPCN) During April a significant amount of actual/suspected positive cases were identified within the acute trusts and within care homes. There were significant issues with PPE procurement especially in some areas of social and primary care across the system and knowledge of correct use was not always optimal in the early stages of the pandemic, with national guidance changing very regularly.
The IPC nurses for BLMK were consistently promoting Public Health England advice and guidelines which was changing several times a week
Covid-19 (Coronavirus) – the IPCNs for BLMK were consistently promoting Public Health England advice and guidelines which was changing serval times a week over the whole of April 2020 and during this time the focus for IPC was predominantly around: • Ensuring updated guidance was communicated quickly and effectively • Ensuring adequate supplies of PPE were available to all health and social care provider organisations in conjunction with local resilience forums • Working with the local authority to advice and support care homes and other social care providers • Providing advice and support to primary care including setting up of red units/hot hubs • Ensuring consistent messages were being shared as national guidance was changing • Supporting outbreaks in care homes, gaining assurance on adherence to national guidance and safe practice • Providing education to care homes as required • Where necessary carrying out care home reviews and quality visits • Participating in national webinars and teleconferences to ensure we were consistently up to date • Supporting outbreak and incidents reviews in primary care to gain assurance on adherence to national guidance and capturing lessons learnt • Ensuring lessons learnt in all incidents and outbreaks were shared across the health system • Identifying risks and escalating as appropriate via the clinical cell
7 COVID-19
8 Covid 19 Dashboard
Bedford Central Milton Luton BLMK Measure Period Borough Bedfordshire Keynes
Cumulative Cumulative Cumulative Cumulative Cumulative
Covid-19 Cases 30-Jun 1242 1217 1366 851 4676
Hospital Deaths (All Causes) 26-Jun 435 670 505 542 2152
Hospital Deaths (Covid-19) 26-Jun 129 197 181 107 614
Care Home Deaths (All Causes) 26-Jun 260 341 196 309 1106
Care Home Deaths (Covid-19) 26-Jun 18 50 12 77 157
Other Place of Death (All Causes) 26-Jun 274 458 320 345 1397
Other Place of Death (Covid-19) 26-Jun 8 14 15 11 48
Pillar 1 testing - NHS swab testing for those with a medical need and the most critical key workers Pillar 2 testing - Commercial-swab testing for critical key workers in the NHS, social care and other sectors
9 Covid-19 Cases across Bedfordshire, Luton and Milton Keynes
Key messages: Cumulative cases to 30th June stood at 4,676. This is 1.91% of total England cases (244,246).
Cumulative cases include patients who are currently unwell, those who have recovered and those who have died.
Total Local Authority counts shown can occasionally go down as data is revised.
Data Source: Coronavirus (Covid-19) in the UK Dashboard https://coronavirus.data.gov.uk/#local-authorities
Note: The cumulative cases chart starts from 18-Mar, which is the date the number of cases across BLMK rose above 50.
8 COVID-19 Deaths across Bedfordshire, Luton and Milton Keynes
Hospital Deaths by Acute Trust – to 30th June 2020 All COVID 19 Deaths by Local Authority to 26th June 2020 Other communal Care home Elsewhere Home Hospice Hospital establishment All Causes Covid 19 All Causes Covid 19 All Causes Covid 19 All Causes Covid 19 All Causes Covid 19 All Causes Covid 19 Bedford 260 18 23 0 213 7 38 1 435 129 0 0 Central Bedfordshire 341 50 17 0 385 10 52 2 670 197 4 2 Luton 196 12 27 0 264 11 28 4 505 181 1 0 Milton Keynes 309 77 18 0 260 8 67 3 542 107 0 0
Data Sources: • Charts (Left): NHS Statistics https://www.england.nhs.uk/statistics/statistical-work- areas/covid-19-daily-deaths/ – data is subject to the following caveat: The most recent 5-7 days are likely to change and an accurate picture may not be available at the date of this report. The cumulative deaths chart starts at 29-Mar which is the date the number of deaths across BLMK rose above 50. • Table (above): Office For National Statistics (Deaths (numbers) by local authority and cause of death, registered up to the 12th June 2020, England and Wales) https://www.ons.gov.uk/ PERFORMANCE DASHBOARDS
Data is ragged Green if an indicator has been achieved or over-achieved, Amber if it has under-achieved within the agreed tolerance threshold and Red if it has under-achieved below the tolerance threshold. The arrows reflect the latest data compared to the previous month/quarter. Due to constraints within the national reporting timetable the Cancer monthly activity reflects validated data up to September 2019; October onwards shows the latest un-validated position.
Data is sourced from national statistics published by NHS England, NHS Improvement and NHS Digital, unless otherwise specific.
Due to the Covid-19 pandemic and the need to release capacity across the NHS to support the response, NHS England has suspended the collection and publication of some official statistics for data due to be submitted between 1 April and 30 June 2020. These indicators are greyed out in the dashboards and the report shows the last known position.
12 Key Performance and Quality Indicators
Bedfordshire 2020/21 2020/21 Milton 2020/21 2020/21 Measure Threshold Latest Data Trend Luton CCG Trend Trend BLMK Trend CCG YTD YTD Keynes CCG YTD YTD
Cancer Waiting Times - 2 Week Wait 93.00% Apr-20 84.39% ↓ 93.81% ↓ 88.17% ↑ 86.80% ↓ Cancer Waiting Times - 2 Week Wait (Breast 93.00% Apr-20 50.00% ↓ 50.00% ↓ 80.00% ↓ 55.56% ↓ Symptoms) Cancer Waiting Times - 28 Days Faster Diagnosis 70.00% Apr-20 56.16% 46.77% 78.71% 60.50% Standard Cancer Waiting Times - 31 Day First Treatment 96.00% Apr-20 98.22% ↓ 100.00% ↑ 94.32% ↓ 97.37% ↑
Cancer Waiting Times - 31 Day Surgery 94.00% Apr-20 90.24% ↓ 92.86% ↓ 96.00% ↑ 92.50% ↓
Cancer Waiting Times - 31 Day Drugs 98.00% Apr-20 97.30% ↓ 100.00% ↔ 92.86% ↓ 95.83% ↓
Cancer Waiting Times - 31 Day Radiotherapy 94.00% Apr-20 96.77% ↓ 100.00% ↑ 93.75% ↑ 97.12% ↑
Cancer Waiting Times - 62 Day GP Referral 85.00% Apr-20 67.42% ↓ 84.00% ↑ 79.55% ↑ 73.42% ↓
Cancer Waiting Times - 62 Day Screening 90.00% Apr-20 61.54% ↓ 92.86% ↑ 100.00% ↑ 79.31% ↓
Cancer Waiting Times - 62 Day Upgrade 90.00% Apr-20 66.67% ↓ 100.00% ↔ 100.00% ↑ 77.78% ↓
RTT Incomplete Pathway - Waiting Lists N/A Apr-20 31220 ↑ 14750 ↑ 21209 ↑ 67179 ↑
RTT Incomplete Pathway - 18 Weeks 92.00% Apr-20 76.51% ↓ 80.51% ↓ 66.17% ↓ 74.12% ↓
RTT Incomplete Pathway - 52 Week Waits 0 Apr-20 43 ↓ 6 ↓ 16 ↓ 65 ↓
Diagnostic Test Waiting Times 1.00% Apr-20 53.65% ↓ 55.73% ↓ 41.77% ↓ 52.86% ↓
Mixed Sex Accommodation Breaches 0 Feb-20 15 ↓ 0 ↔ 7 ↓ 22 ↓
C-difficile Infections N/A Apr-20 4 ↓ 4 ↓ 2 ↓ 10 ↓
MRSA Infections 0 Apr-20 0 ↔ 0 ↔ 0 ↔ 0 ↔
13 Key Performance and Quality Indicators
Bedfordshire 2020/21 2020/21 Milton 2020/21 2020/21 Measure Threshold Latest Data Trend Luton CCG Trend Trend BLMK Trend CCG YTD YTD Keynes CCG YTD YTD Ambulance Response Times - Category 1 - Mean (Local Data - EEAST - Bedfordshire & Luton; 7:00 Apr-20 7:10 ↑ 5:25 ↑ 6:00 ↑ SCAS - Milton Keynes) Ambulance Response Times - Category 1T - Not available at BLMK 90th Centile (Local Data - EEAST - Bedfordshire & 30:00 Apr-20 16:56 ↑ 13:10 ↑ 10:45 ↑ level Luton; SCAS - Milton Keynes) Ambulance Response Times - Category 2 - Mean (Local Data - EEAST - Bedfordshire & Luton; 18:00 Apr-20 19:13 ↑ 19:14 ↑ 11:07 ↑ SCAS - Milton Keynes) Estimated Diagnosis rate for people with 66.70% Apr-20 62.19% ↓ 69.70% ↓ 66.85% ↓ 64.71% ↓ dementia IAPT Access (Year to date) 19.75% Mar-20 20.47% ↑ 14.76% ↑ 19.32% ↑ 18.57% ↑
IAPT Recovery Rate 50.00% Mar-20 50.62% ↓ 51.16% ↑ 64.29% ↑ 54.22% ↑
IAPT Waiting Times - 6 weeks 75.00% Mar-20 97.70% ↓ 100.00% ↑ 90.70% ↓ 96.55% ↓
IAPT Waiting Times - 18 weeks 95.00% Mar-20 98.85% ↓ 100.00% ↔ 97.67% ↓ 98.85% ↓
IAPT in-treatment pathway waits 10.00% Mar-20 32.10% ↑ 14.29% ↑ 45.45% ↑ 32.02% ↑ Early Intervention in Pyschosis - 1st Treatment 56.00% Mar-20 81.00% ↑ 65.00% ↓ 87.00% ↓ 77.67% ↑ within 2 weeks (Rolling 3 months) SMI Physical Health Checks (Rolling 12 60.00% Q4 2019-20 25.34% ↓ 34.89% ↑ 28.27% ↑ 28.95% ↑ months) Learning Disabilities Health Checks 22.50% Q3 2019-20 15.50% ↑ 7.82% ↓ 7.82% ↓ 13.05% ↑
CPA 7-day Follow Ups 95.00% Q3 2019-20 90.55% ↔ 96.75% ↔ 96.43% ↔ 93.12% ↔ Children and Young People's Mental Health 34.00% Mar-20 51.75% ↑ 37.36% ↑ 41.75% ↑ 44.99% ↑ Services Access (Rolling 12 months) Perinatal mental health services - Access 7.10% Mar-20 39.51% ↑ 17.18% ↑ 41.84% ↑ 33.90% ↑ CYP Eating Disorders - Urgent (Rolling 12 95.00% Q4 2019-20 100.00% ↔ 66.67% ↓ 66.67% ↓ 84.21% ↓ months) CYP Eating Disorders - Routine (Rolling 12 95.00% Q4 2019-20 87.34% ↓ 75.86% ↓ 66.67% ↔ 79.59% ↓ months) Children's Wheelchairs 92.00% Q3 2019-20 96.67% ↓ 96.15% ↓ 84.00% ↓ 92.59% ↓ 14 Acute Providers Dashboard All patients Trust-wide
Milton Bedfordshire 2020/21 2020/21 Measure Threshold Latest Data Trend Keynes Trend Hospitals YTD Hospital YTD
Cancer Waiting Times - 2 Week Wait 93.00% Apr-20 85.51% ↓ 87.06% ↑ Cancer Waiting Times - 2 Week Wait (Breast 93.00% Apr-20 43.75% ↓ 83.33% ↓ Symptoms)
Cancer Waiting Times - 31 Day First Treatment 96.00% Apr-20 98.79% ↓ 96.63% ↓
Cancer Waiting Times - 31 Day Surgery 94.00% Apr-20 97.62% ↓ 100.00% ↑
Cancer Waiting Times - 31 Day Drugs 98.00% Apr-20 100.00% ↔ 97.06% ↓
Cancer Waiting Times - 31 Day Radiotherapy 94.00% Apr-20 NP NP
Cancer Waiting Times - 62 Day GP Referral 85.00% Apr-20 72.50% ↓ 71.70% ↓
Cancer Waiting Times - 62 Day Screening 90.00% Apr-20 95.74% ↑ 62.96% ↑
Cancer Waiting Times - 62 Day Upgrade 90.00% Apr-20 100.00% ↔ 64.86% ↑
RTT Incomplete Pathway - 18 Weeks 92.00% Apr-20 79.53% ↓ 64.10% ↓
RTT Incomplete Pathway - 52 Week Waits 0 Apr-20 49 ↓ 10 ↓
Diagnostic Test Waiting Times 1.00% Apr-20 53.11% ↓ 46.43% ↓
A&E 4hr Waits 95.00% Apr-20 Not Reporting 95.46% ↑
12hr Trolley Waits 0 Apr-20 0 ↔ 0 ↔
Mixed Sex Accommodation Breaches 0 Feb-20 17 ↓ 0 ↔
Cancelled Ops not rebooked within 28 Days 0 Q3 2019-20 12 ↓ 8 ↑
Urgent Operations cancelled for a second time 0 Feb-20 0 ↔ 0 ↔
C-difficile Infections N/A Apr-20 5 ↓ 1 ↓
VTE Risk Assessment 95.00% Dec-19 97.85% ↑ 96.86% ↓
NP = no patients 15 PLANNED CARE
16 Planned Care Dashboard
Bedfordshire 2020/21 2020/21 Milton 2020/21 2020/21 Measure Threshold Latest Data Trend Luton CCG Trend Trend BLMK Trend CCG YTD YTD Keynes CCG YTD YTD
Cancer Waiting Times - 2 Week Wait 93.00% Apr-20 84.39% ↓ 93.81% ↓ 88.17% ↑ 86.80% ↓ Cancer Waiting Times - 2 Week Wait (Breast 93.00% Apr-20 50.00% ↓ 50.00% ↓ 80.00% ↓ 55.56% ↓ Symptoms) Cancer Waiting Times - 28 Days Faster Diagnosis 70.00% Apr-20 56.16% 46.77% 78.71% 60.50% Standard Cancer Waiting Times - 31 Day Surgery 94.00% Apr-20 90.24% ↓ 92.86% ↓ 96.00% ↑ 92.50% ↓
Cancer Waiting Times - 31 Day Drugs 98.00% Apr-20 97.30% ↓ 100.00% ↔ 92.86% ↓ 95.83% ↓
Cancer Waiting Times - 62 Day GP Referral 85.00% Apr-20 67.42% ↓ 84.00% ↑ 79.55% ↑ 73.42% ↓
Cancer Waiting Times - 62 Day Screening 90.00% Apr-20 61.54% ↓ 92.86% ↑ 100.00% ↑ 79.31% ↓
Cancer Waiting Times - 62 Day Upgrade 90.00% Apr-20 66.67% ↓ 100.00% ↔ 100.00% ↑ 77.78% ↓
RTT Incomplete Pathway - Waiting Lists N/A Apr-20 31220 ↑ 14750 ↑ 21209 ↑ 67179 ↑
RTT Incomplete Pathway - 18 Weeks 92.00% Apr-20 76.51% ↓ 80.51% ↓ 66.17% ↓ 74.12% ↓
RTT Incomplete Pathway - 52 Week Waits 0 Apr-20 43 ↓ 6 ↓ 16 ↓ 65 ↓
Diagnostic Test Waiting Times 1.00% Apr-20 53.65% ↓ 55.73% ↓ 41.77% ↓ 52.86% ↓
17 Cancer
Cancer Two Week Wait Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire 86.39% 92.26% 85.38% 88.04% 93.67% 93.25% 94.28% 94.09% 94.77% 93.68% 95.30% 93.13% 84.39% 84.39% Luton 94.48% 94.19% 94.71% 93.73% 95.21% 95.07% 93.97% 93.90% 94.20% 91.86% 94.84% 94.64% 93.81% 93.81% Milton Keynes 95.63% 94.76% 91.12% 94.37% 95.06% 94.76% 92.70% 90.03% 90.89% 88.08% 91.34% 82.99% 88.17% 88.17% BLMK STP 90.36% 93.27% 88.63% 90.73% 94.35% 94.02% 93.80% 92.83% 93.58% 91.84% 94.10% 90.28% 86.80% 86.80%
Cancer Two Week Wait - Breast Symptomatic Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire 61.96% 85.54% 51.35% 78.85% 93.83% 88.89% 93.62% 93.51% 98.80% 91.25% 94.05% 90.57% 50.00% 50.00% Luton 95.65% 100.00% 87.50% 100.00% 96.77% 97.22% 96.67% 84.62% 97.73% 90.00% 97.22% 100.00% 50.00% 50.00% Milton Keynes 94.67% 97.70% 97.96% 95.18% 100.00% 100.00% 98.85% 91.36% 97.56% 91.53% 98.72% 93.10% 80.00% 80.00% BLMK STP 80.75% 92.96% 79.08% 87.79% 96.70% 94.97% 96.21% 91.30% 98.09% 91.12% 96.46% 93.66% 55.56% 55.56%
In the first half of 2019/20 there was a deterioration in 2 week The two week wait for breast symptoms standard was not waits, primarily at Bedford Hospital. This standard had been consistently achieved during 2019/20, primarily due to issues at achieved throughout 2018/19. Recovery in Q3 was followed by Bedford Hospital during Q1 and Q2. further deterioration in Q4 primarily at Milton Keynes Hospital. With the onset of the Covid-19 pandemic, the number of people The impact of the Covid-19 pandemic started to affect two week seen saw a decrease of 86% against the monthly average waits at the start of 2020/21. There were 1,288 people seen across 2018/19 and 2019/20, with 27 people seen in April 2020 during April compared with the monthly average over 2018/19 against the average of 196. and 2019/20 of 2,826 - a 54% decrease. 18 Cancer
Cancer 62 Day - GP Referral Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire 82.65% 74.50% 76.47% 73.23% 72.82% 74.34% 74.07% 72.97% 77.39% 72.58% 79.82% 77.37% 67.42% 67.42% Luton 81.48% 83.33% 77.14% 92.50% 88.24% 92.59% 89.74% 92.68% 93.33% 89.29% 82.76% 80.95% 84.00% 84.00% Milton Keynes 83.33% 80.00% 76.67% 66.67% 85.71% 82.69% 85.96% 76.36% 88.52% 81.13% 68.75% 76.36% 79.55% 79.55% BLMK STP 82.63% 76.92% 76.65% 74.78% 79.27% 79.17% 80.39% 77.78% 83.01% 77.07% 78.24% 77.78% 73.42% 73.42%
The 62 day standard for 1st treatment following a GP Referral has underachieved since 2018/19, with performance at Bedford Hospital and Milton Keynes Hospital impacting on the overall BLMK position.
The Covid-19 pandemic has affected the 62 day treatment pathway in April 2020, with 158 people treated against an average of the past two years of 204, a reduction of 23%.
19 18 Week Referral To Treatment
Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire 90.70% 90.12% 89.98% 89.47% 88.78% 88.49% 88.12% 87.35% 86.85% 86.49% 86.44% 83.95% 76.51% 76.51% Luton 92.12% 92.48% 92.51% 92.26% 90.90% 91.01% 91.60% 91.26% 91.18% 90.58% 90.36% 87.92% 80.51% 80.51% Milton Keynes 90.36% 89.55% 89.58% 87.57% 87.86% 87.11% 85.73% 82.42% 80.04% 80.19% 79.44% 75.90% 66.17% 66.17% BLMK STP 90.97% 90.55% 90.51% 89.70% 89.10% 88.81% 88.49% 87.22% 86.37% 85.76% 85.22% 82.34% 74.12% 74.12%
BLMK’s decision to suspend referrals as part of the national cancellation of elective care due to the Covid-19 response, may mask the total need for elective care across BLMK. Referral pathways have now reopened and will be monitored closely over the coming months by the Planned and Specialist Care Group.
A proportion of the increase in the waiting list can be attributed to Milton Keynes Hospital including appointment slot issues (where patients have yet to book their own appointment) in January 2020. This gives a more accurate position.
Recovery Actions: In April, the number of patients waiting more than 18 weeks for The wait list and RTT performance is likely to deteriorate over treatment across Bedfordshire, Luton and Milton Keynes the coming months as Trusts manage reduced capacity due to increased by 5,157 (42.17%), while the total waiting list fell by Covid-19 adjustments. Actions to support the recovery include: 2,052 (2.96%). The table below shows the total waiting list for • Commissioning a community Urgent Eye Care service the 4 specialties with the greatest number of extended waits, • Increased use and a standardised operating model for advice with a breakdown to show the number of patients still waiting at and guidance 26+ weeks and 39+ weeks. • Non-face to face activity / digital solutions • Review of the Procedures of Limited Clinical Value process Total Waiting and policies Treatment Function List 18+ Weeks 26+ Weeks 39+ Weeks • Prioritisation of long waiters, especially the 52 week Other 12090 2576 1020 180 Trauma & Orthopaedics 6059 2531 1452 439 breaches and waiting list validation Ophthalmology 9431 2348 803 119 • Utilising the nationally contracted Independent Sector Ear, Nose & Throat (ENT) 5739 1621 804 133 wherever possible 20 52+ Week Waits
Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire 0 1 1 0 2 2 1 1 0 0 2 8 43 43 Luton 1 1 1 4 1 2 2 2 2 1 1 2 6 6 Milton Keynes 0 0 1 0 2 2 1 1 3 1 2 1 16 16 BLMK STP 1 2 3 4 5 6 4 4 5 2 5 11 65 65
In April 2020 there were sixty-five 52 week breaches across Bedfordshire Luton and Milton Keynes, with the majority (38) in Trauma and Orthopaedics, which is reflective of the inability to undertake complex elective care during the Covid-19 pandemic. Of the remaining 27 breaches 12 were in the Other specialty, 4 in Urology, 4 in Plastic Surgery, 2 in Ophthalmology, 2 in ENT, 1 in Gynaecology, 1 in General Surgery and 1 in Neurology.
Of the total of 65 breaches, 34 occurred at Bedfordshire Hospitals NHS Trust and 9 were at Milton Keynes University Hospital NHS Trust. The remaining 22 were at multiple providers.
21 Diagnostics – 6 Week Waits
Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire 0.97% 0.97% 0.97% 1.08% 2.68% 2.06% 1.12% 0.90% 1.88% 1.39% 0.82% 5.19% 53.65% 53.65% Luton 0.98% 0.70% 0.80% 1.49% 3.28% 1.91% 0.66% 0.91% 1.37% 3.03% 1.32% 8.01% 55.73% 55.73% Milton Keynes 0.90% 1.15% 1.04% 0.94% 1.52% 1.33% 1.94% 1.44% 1.55% 1.49% 1.22% 4.60% 41.77% 41.77% BLMK STP 0.95% 0.97% 0.96% 1.12% 2.45% 1.80% 1.28% 1.07% 1.67% 1.79% 1.05% 5.88% 52.86% 52.86%
Recovery Actions:
The recovery actions aim to stabilise performance however, it is unlikely this target will be achieved in the coming months. Providers continue to adjust to Covid-19 constraints resulting in reduced capacity.
After closing routine referral pathways in March 2020, all Trusts reopened their diagnostic services in May. The accumulated demand coupled with Covid-19 adjustments will mean recovery is slow.
BLMK CCGs and Providers are developing their understanding In April more than half (7,679) of all patients on a diagnostic of capacity and demand to inform recovery plans. Initiatives to tests pathway waited for more than 6 weeks, however support recovery include: performance against the standard was slightly better than the England national position with 52.86% against 55.7%. The • Restarting Audiology services in line with national guidance number of people still waiting at 10 weeks was 1,144 and the • Review of Direct Access Diagnostics pathways number waiting for more than 13 weeks was 176. • Supporting the implementation of Endoscopy national guidelines • Utilising the nationally contracted Independent Sector wherever possible • Identifying additional community capacity
22 URGENT AND EMERGENCY CARE
23 Urgent and Emergency Care Dashboard
Bedfordshire 2020/21 2019/20 Milton Keynes 2020/21 2020/21 Measure Threshold Latest Data Trend Luton Trend Trend BLMK Trend Hospitals YTD YTD Hospital YTD YTD
A&E 4hr Waits (Provider Trustwide) 95.00% Apr-20 Not reporting 99.12% ↑
Emergency Admissions N/A Apr-20 3,813 ↓ 1,583 ↑ 5,396 ↑
Bed Occupancy - Total Open Beds 92.00% Apr-20 66.70% ↑ 49.30% ↑ 61.54% ↑
Ambulance Arrivals N/A Apr-20 3,456 ↑ 1,561 ↑ 5,017 ↑
2020/21 2020/21 Milton Keynes 2020/21 Measure Threshold Latest Data Bedfordshire CCG Trend Luton CCG Trend Trend YTD YTD CCG YTD Ambulance Response Times - Category 1 - Mean (Local Data - EEAST - Bedfordshire & Luton; SCAS - 7:00 Apr-20 7:10 ↑ 5:25 ↑ 6:00 ↑ Milton Keynes) Ambulance Response Times - Category 1T - 90th Centile (Local Data - EEAST - Bedfordshire & Luton; 30:00 Apr-20 16:56 ↑ 13:10 ↑ 10:45 ↑ SCAS - Milton Keynes) Ambulance Response Times - Category 2 - Mean (Local Data - EEAST - Bedfordshire & Luton; SCAS - 18:00 Apr-20 19:13 ↑ 19:14 ↑ 11:07 ↑ Milton Keynes)
In April emergency admissions in Bedfordshire Hospitals Trust Regional improvements were seen in the ambulance response continued to decrease with Covid-19 contributing to the decrease times across East of England Ambulance Service - EAST in activity. While emergency admissions increased slightly in (Bedfordshire and Luton) and South Central Ambulance Milton Keynes the overall 6 month trend is showing a decrease. Service - SCAS (Milton Keynes). Both of the acute trusts had a reduction in ambulance arrivals Bed occupancy in all hospitals fell sharply as a result the response to Covid-19 whereby significant numbers of patients Data Note: Bed Occupancy and Ambulance Arrivals data is were discharged to support the creation required capacity to cope taken from the regional UEC Dashboard Midlands & East with surges in activity. Region, designed and developed by the Emergency Care Intensive Support Team at NHSE/I. The data is obtained via the daily SITREP collection which is unvalidated and subject to change. 24 A&E 4 Hour Waits
Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire Hospitals 97.42% 93.50% Not reporting against the 4 hour wait standard Milton Keynes Hospital 93.44% 92.98% 92.90% 90.51% 92.67% 89.13% 84.97% 84.72% 82.52% 85.71% 88.45% 86.91% 95.46% 95.46% England 85.12% 87.96% 87.73% 87.84% 87.64% 86.71% 85.26% 83.29% 81.81% 83.51% 84.50% 85.78% 91.39% 91.39%
On 22nd May 2019 fourteen trusts, including Luton and Dunstable Hospital, began field testing new emergency care performance standards and as a result these providers are not required to report against the 4 hour wait target. Since June last year the 4 hour wait performance at the Luton and Dunstable Hospital has not been reported. The merger of the Luton and Dunstable Hospital and Bedford Hospital in April to form Bedfordshire Hospitals NHS Foundation Trust means that performance against this standard is not being reported for Bedford Hospital.
Before the Covid-19 pandemic, the average monthly A&E Attendances in 2019/20 across Bedfordshire, Luton and Milton Keynes was 33,470. This dropped sharply in March to 24,302, a decrease of 23.7%. In April the number of people attending A&E departments decreased further to 14,296, 55.1% lower than the M1 to M11 average last year.
25 Ambulance Response Times/Arrivals
Ambulance Response Times - Category 1 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire (EEAST) 7:07 6:58 7:27 7:52 7:09 7:26 7:44 7:55 7:44 7:03 7:12 7:20 7:10 7:10 Luton (EEAST) 6:07 5:39 6:07 5:56 5:45 5:52 5:42 6:03 6:05 5:23 5:45 5:53 5:25 5:25 Milton Keynes (SCAS) 6:12 5:58 6:25 6:14 5:35 6:08 6:15 6:38 6:39 6:10 6:38 7:44 6:00 6:00
Ambulance Response Times - Category 2 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 Bedfordshire (EEAST) 27:39 26:42 25:09 27:19 21:42 23:33 24:37 27:26 28:37 22:13 23:36 29:01 19:13 Luton (EEAST) 18:03 23:54 22:41 23:44 19:12 21:17 21:48 25:05 25:42 20:19 20:18 28:35 19:14 Milton Keynes (SCAS) 14:15 12:29 15:34 13:36 11:29 16:01 16:49 17:52 19:21 13:42 15:32 18:20 11:07
26 MENTAL HEALTH
27 Mental Health Dashboard
Bedfordshire 2020/21 2020/21 Milton 2020/21 2020/21 Measure Threshold Latest Data Trend Luton CCG Trend Trend BLMK Trend CCG YTD YTD Keynes CCG YTD YTD
Estimated Diagnosis rate for people with dementia 66.70% Apr-20 62.19% ↓ 69.70% ↓ 66.85% ↓ 64.71% ↓
IAPT Access (Year to date) 19.75% Mar-20 20.47% ↑ 14.76% ↑ 19.32% ↑ 18.57% ↑
IAPT in-treatment pathway waits 10.00% Mar-20 32.10% ↑ 14.29% ↑ 45.45% ↑ 32.02% ↑
SMI Physical Health Checks (Rolling 12 months) 60.00% Q4 2019-20 25.34% ↓ 34.89% ↑ 28.27% ↑ 28.95% ↑
Learning Disabilities Health Checks 22.50% Q3 2019-20 15.50% ↑ 7.82% ↓ 7.82% ↓ 13.05% ↑
CPA 7-day Follow Ups 95.00% Q3 2019-20 90.55% ↔ 96.75% ↔ 96.43% ↔ 93.12% ↔
CYP Eating Disorders - Urgent (Rolling 12 months) 95.00% Q4 2019-20 100.00% ↔ 66.67% ↓ 66.67% ↓ 84.21% ↓
CYP Eating Disorders - Routine (Rolling 12 95.00% Q4 2019-20 87.34% ↓ 75.86% ↓ 66.67% ↔ 79.59% ↓ months)
28 Improving Access to Psychological Therapies (IAPT)
Access Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 2019/20 YTD Bedfordshire 18.56% 1.69% 3.45% 5.05% 6.85% 8.46% 10.11% 11.95% 13.72% 15.04% 17.05% 18.79% 20.47% 20.47% Luton 9.47% 1.03% 2.24% 3.29% 4.62% 5.77% 7.10% 8.66% 9.89% 10.85% 12.25% 13.58% 14.76% 14.76% Milton Keynes 18.13% 1.57% 2.83% 4.34% 5.84% 7.28% 8.61% 10.44% 12.33% 13.86% 15.69% 17.45% 19.32% 19.32% BLMK STP 15.89% 1.47% 2.95% 4.37% 5.97% 7.40% 8.88% 10.64% 12.28% 13.56% 15.35% 16.98% 18.57% 18.57%
Providers have identified staffing and recruitment issues throughout the year as the root cause for underachievement. BLMK CCGs and providers are working to address these issues and an action plan has been agreed for the Luton service.
A wide programme of work aiming to improve access for people with Long Term Conditions continues, with IAPT therapists co- located within a number of services including Pain Management, Diabetes and Chronic Obstructive Pulmonary Disease. All IAPT services have seen lower levels of activity during the Covid-19 period. Providers are operating remote treatment, including digital offers and webinars. As part of the Covid-19 response all services are offering support to NHS and In March, 1,670 people entered treatment across Bedfordshire, care staff. Luton and Milton Keynes, giving a year to date total of 19,560 (18.57%) against the 2019/20 threshold of 20,806 (19.75%).
The Q4 threshold of 5.5%, to achieve a run rate of 22%, was not met. An underperformance in quarter of 5.01% gives a run rate of 20.04%.
The impact of Covid-19 on IAPT Access was minimal in March and the number of people entering treatment during March was higher than the monthly average across the previous two years 0f 1,505. 29 Dementia Diagnosis
Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020-21 YTD Bedfordshire 59.81% 60.30% 61.27% 62.61% 62.64% 63.26% 63.70% 63.60% 63.83% 63.47% 63.65% 63.41% 62.19% 62.19% Luton 69.11% 69.23% 69.89% 70.69% 71.14% 71.16% 69.63% 70.92% 70.60% 71.51% 71.45% 71.06% 69.70% 69.70% Milton Keynes 71.59% 71.35% 72.36% 73.25% 72.63% 72.53% 72.23% 71.60% 70.88% 70.42% 70.03% 70.14% 66.85% 66.85% BLMK STP 64.43% 64.66% 65.58% 66.71% 66.66% 66.99% 66.88% 66.91% 66.80% 66.65% 66.64% 66.46% 64.71% 64.71%
Face-to-face memory assessment services have been suspended during the Covid-19 period, but services are exploring ways of enabling initial assessments remotely.
At the end of April 2020 there were 6,037 people aged 65+ with a diagnosis of dementia across Bedfordshire, Luton and Milton Keynes giving a deteriorating position of 64.71%. There has been a further deterioration in May to 62.96%. This is primarily due to performance in Bedfordshire and a recovery action plan is in place.
In Bedfordshire there has been a consistent delivery of more than 63% during the second half of 2019-20 against averages of 61.5% in the first half of the year and 58.8% in 2018/19. A recovery action plan is in place with areas for development including increasing the number of appropriate referrals into the Memory Assessment Service (MAS) and further work with primary care to progress an increase diagnosis in Primary care.
As part of the dementia big 5 event organised by NHS England, BLMK CCGs are working together to improve diagnosis in primary care, including a mentorship offering from Milton Keynes memory assessment service.
30 Care Programme Approach (CPA) 7 Day Follow Ups
Q3 2018-19 Q4 2018-19 Q1 2019-20 Q2 2019-20 Q3 2019-20 2019/20 YTD Bedfordshire 93.80% 90.74% 92.46% 93.70% 90.55% 92.20% Luton 88.36% 89.02% 90.53% 93.10% 96.75% 93.36% Milton Keynes 100.00% 100.00% 91.30% 86.49% 96.43% 90.91% BLMK STP 92.16% 90.36% 91.67% 92.87% 93.12% 92.55%
Performance against the CPA 7 day follow up standard across Bedfordshire Luton and Milton Keynes has been consistently underachieved in the past two years primarily due to a high number of breaches in Bedfordshire.
In Q3 across Bedfordshire, Luton and Milton Keynes 436 patients on the Care Programme Approach were followed up with 30 breaching the 7 day follow up standard. The majority of the breaches were in Bedfordshire (24), all of which were at ELFT. However, on final review ELFT have confirmed that there were 21 breaches in Q3 and that the variation is due to a timing issue. 5 breaches were reported in Luton and 1 in Milton Keynes.
Due to the Covid-19 emergency response reporting against the CPA standard has been suspended and this section of the report will be developed further to include more detail of CPA breaches in Luton and Milton Keynes when reporting resumes.
31 SMI Physical Health Checks
Q4 2018-19 Q1 2019-20 Q2 2019-20 Q3 2019-20 Q4 2019-20 2019/20 YTD Bedfordshire 4.22% 8.44% 26.17% 25.46% 25.34% 25.34% Luton 4.06% - - 21.72% 34.89% 34.89% Milton Keynes 9.69% 9.38% 9.15% 23.42% 28.27% 28.27% BLMK STP 5.22% 8.69% 20.72% 23.79% 28.95% 28.95%
Figures for Q1 will be low due to Covid-19. BLMK commissioning sub-group will focus on improving targets, working with clinical leads.
For Bedfordshire Personal Medical Services (PMS) schemes have been agreed with Primary care to improve the number of health checks for 2020/21, although these have been delayed due to Covid-19.
Work is planned to raise the profile annual health checks with SMI and Learning disability patients virtually and to investigate ways of how to complete the physical aspects of the checks.
The national ambition is for 60% of people with a serious mental There are different Commissioning arrangements in place illness to receive an annual health check consisting of 6 across BLMK. In Luton, GPs provide health checks; in separate physical checks. During the 12 months to the end of Bedfordshire, ELFT is contracted to undertake them; and in Q4 2019/20, 2,021 people on the SMI register received the full Milton Keynes the GP Federation and some GP surgeries 6 checks, of whom 832 were in Bedfordshire, 755 in Luton and undertake checks. 434 in Milton Keynes. This is an upward trend in Luton and Milton Keynes.
In Q1 and Q2 2019/20 there was no submission from Luton due to data reporting issues. These have now been resolved.
32 Learning Disability Health Checks
Q3 2018-19 Q4 2018-19 Q1 2019-20 Q2 2019-20 Q3 2019-20 2019/20 YTD Bedfordshire 13.78% 24.31% 5.07% 10.33% 15.50% 30.90% Luton 14.15% 13.56% 9.44% 13.33% 13.89% 36.67% Milton Keynes 4.52% 12.19% 7.55% 8.98% 7.82% 24.35% BLMK STP 11.52% 18.50% 6.85% 10.75% 13.05% 30.65%
The national ambition is for 75% of people over the age of 14 on a GP learning disability register to have an annual health check (AHC).
In Q3 2019/20, 549 people with learning disabilities had an annual health check, of whom 312 were in Bedfordshire, 150 in Luton and 87 in Milton Keynes, giving a total of 1,289 year to date.
Work is due to be commenced to raise the profile and ability to complete AHC with LD patients virtually and how to complete the physical aspects of the check.
33 Children & Young People (CYP) – Eating Disorders
Urgent – Treated within 7 days (Rolling 12 months) Routine – Treated within 4 weeks (Rolling 12 months) Q1 2019-20 Q2 2019-20 Q3 2019-20 Q4 2019-20 Q1 2019-20 Q2 2019-20 Q3 2019-20 Q4 2019-20 92.31% 100.00% 100.00% 100.00% Bedfordshire Bedfordshire 90.63% 92.54% 89.06% 87.34% Luton 50.00% 75.00% 75.00% 66.67% Luton 88.89% 90.00% 80.95% 75.86% Milton Keynes 100.00% 75.00% 75.00% 66.67% Milton Keynes 83.33% 78.95% 66.67% 66.67% BLMK STP 88.24% 91.67% 90.48% 84.21% BLMK STP 89.36% 89.62% 81.74% 79.59%
There were 19 urgent patients treated across There were 147 routine patients treated with 30 Bedfordshire, Luton and Milton Keynes, with 3 breaches of the – 10 at Bedfordshire, 7 at Luton and 13 breaches of the standard – 1 at Luton and 2 at Milton at Milton Keynes. Keynes.
The children’s eating disorders provider teams are small and specialist and any change to the staff team impacts significantly on the capacity of the services.
There is a need to review the provision across BLMK and make recommendations for a model that will meet population needs and achieve the access and waiting time standards. Discussions have been initiated with the clinical network for how this might be supported by the regional team. A Task and Finish group will be established to take this work forward.
34 QUALITY AND SAFETY
35 Infection Control
C-Difficile Infections Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020/21 YTD Bedfordshire 8 8 8 14 3 6 3 9 4 7 6 2 4 4 Luton 2 3 2 1 7 3 1 5 3 3 2 0 4 4 Milton Keynes 1 5 0 3 1 1 3 4 3 1 2 0 2 2 BLMK STP 11 16 10 18 11 10 7 18 10 11 10 2 10 10 CCGs agree a ceiling for C-Difficile cases each year and the ragging in the above table is based on these numbers. The ceiling for 2020/21 is yet to be agreed. MRSA Infections Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 2020/21 YTD Bedfordshire 0 0 0 2 0 0 0 2 0 1 1 0 0 0 Luton 0 5 0 0 0 0 1 0 0 0 0 0 0 0 Milton Keynes 0 0 0 1 0 0 1 0 0 1 0 0 0 0 BLMK STP The0 national 5ambition is0 for 0 MRSA3 infections.0 0 2 2 0 2 1 0 0 0
National ambition is 0 MRSA infections
C-diff - In April there were a total of 10 cases of C-diff across Bedfordshire Luton and Milton Keynes – 4 in Bedfordshire, 4 in Luton and 2 in Milton Keynes. Of the 10 cases, 5 were acute apportioned and 5 were non-acute. All cases are reviewed by the relevant providers to identify any lapses in care that may have directly contributed to the infection
MRSA – there were no new cases of MRSA reported in April.
36 Safeguarding
CCG Type No. of cases Outcome/ Comments
Bedfordshire CCG Children – serious case reviews 4 - Briefing published 24/4 - On going TBC autumn - Report due Sept 20 (media interest) - On going thematic review report to be published late summer Child deaths in May (expected) 1 None in central Bedfordshire
Adults – Domestic Homicide review 2 - Pending Home office sign off before publication - Review commenced but paused due to change in court date
Adults – Safeguarding Adult reviews 2 - Related to self neglect - Related to unsafe hospital discharge Luton CCG Children – Child Safeguarding 2 - In partnership with Essex – awaiting author practice review - Luton case – awaiting author 1 pending - Awaiting decision re. meeting criteria Adults – Rapid review 1 - Mulberry court – Covid-19 deaths – rapid review supported by Adults – Safeguarding Adult reviews 4 Social Care Institute for Excellence. - SAR – related to Mulberry court - Published key findings SAR –Adult A - Pending publication and key findings - SAR agreed for complex patient Milton Keynes CCG Children safeguarding practice 5 - one serious case review related to gang and knife crime – reviews media interest / review not yet commenced Adults safeguarding practice reviews 3 Learning from reviews will be shared once reports have been Adult Local learning Reviews 1 cleared for publication. Action plans will be put in place for the Adult thematic review 2 services involved and monitored through MK Together assurance Domestic Homicide review 4 Board.
37 Serious Incidents and Never Events
Bedfordshire 2020/21 2020/21 Milton 2020/21 2020/21 Measure Threshold Latest Data Trend Luton CCG Trend Trend BLMK Trend CCG YTD YTD Keynes CCG YTD YTD
Serious Incidents 0 Apr-20 4 ↑ 2 ↑ 10 ↑ 16 ↑
Never Events 0 Apr-20 0 ↔ 0 ↔ 0 ↔ 0 ↔
Across Bedfordshire Luton and Milton Keynes, 16 serious incidents were reported in April 2020, with none meeting the criteria for a never event.
In Bedfordshire 4 serious incidents were reported, all in acute services.
Luton had 2 serious incidents reported, one in acute services and one in mental health services.
10 serious incidents were reported in Milton Keynes, with 8 occurring in acute services and two in mental health.
All SIs are accompanied with detailed learning/action plans which the CCGs monitor on a regular basis.
38 Definitions
Ambulance - Cat 1 - Immediately life threatening conditions emergency response within Cancer 62 day first treatment following referral from an NHS cancer screening an average time of 7 minutes counted at time of first responder service – Patients who receive first definitive treatment for all cancers within 62 days Ambulance – Cat 1T – As above however this is counted at time of emergency transfer following referral from an NHS cancer screening service. vehicle arrival 52+ Week RTT waits - The number of incomplete Referral to Treatment (RTT) Ambulance – IFT – Inter Facility Transfer - Emergency transfers prioritised on the basis pathways (patients yet to start treatment) of 52 weeks or more. of the treatment or intervention the patient requires or is highly likely to require when they A&E waiting times – total time in the A&E department - Percentage of patients who arrive at their destination, not the patient’s diagnosis. spent 4 hours or less in A&E. Ambulance - Cat 2 – Emergency calls average response time of 18 minutes. Mixed-sex accommodation breaches - The total occurrences of unjustified mixing in CPA follow up within 7 days of discharge from psychiatric in-patient care - people relation to sleeping accommodation. under adult mental illness specialties on CPA followed up (face to face contact or by Cancelled operations on or after day of admission and not offered another date phone discussion) within 7 days of discharge from psychiatric in-patient care. within 28 days - Number of patients not treated within 28 days of last minute elective Dementia Diagnosis – Diagnosis rate for people aged 65 and over, with a diagnosis of cancellation. dementia recorded in primary care, expressed as a percentage of the estimated Trolley waits in A&E over 12 hours - Total number of patients who have waited over prevalence based on GP registered populations. 12 hours in A&E from decision to admit to admission 18 Weeks Referral to Treatment – Incomplete pathway - Patients on a non-urgent Urgent Operations cancelled for a second time – The number of Urgent Operations consultant led pathway setting a maximum time of 18 weeks from the point of referral up Cancelled for the 2nd or more time to the start of any treatment necessary where it is clinically appropriate. Incomplete Psychosis treated with a NICE approved care package within two weeks of pathways are those where patients are still waiting for treatment. referral - People experiencing first episode psychosis or ARMS (at risk mental state) Diagnostics – Access to 15 key diagnostic tests within 6 weeks. that wait 2 weeks or less to start a NICE recommended package of care. Cancer 2 Week Wait Following Urgent GP Referral For Suspected Cancer – Patients IAPT Access Rate - Proportion of people that enter treatment against the level of need seen within two weeks of an urgent GP referral for suspected cancer in the general population Cancer 2 Week Wait for Breast Symptoms where cancer was not initially suspected IAPT - people who completed treatment and are moving to recovery – – Patients seen within two weeks of an urgent referral for breast symptoms where cancer Proportion of people who complete treatment who are moving to recovery. was not initially suspected IAPT waiting times - People that wait 6 weeks or less from referral to entering a course Cancer 31 day first treatment following a cancer diagnosis – Patients that receive of IAPT treatment and people that wait 18 weeks or less from referral to entering a first definitive treatment within 31 days of receiving a diagnosis for all cancers. course of IAPT treatment. Cancer 31 subsequent cancer treatments – Surgery – Patients that receive Improve access rate to Children and Young People’s (CYM) Mental Health subsequent treatment of surgery within a maximum waiting time of 31 days. Services (CYPMH) - Number of individual CYM under 18 receiving treatment by NHS Cancer 31 subsequent cancer treatments – Anti cancer drug regimens – Patients funded community services as a proportion of those with a diagnosable mental health that receive subsequent/adjuvant treatment of anti-cancer drug regimen within a condition. maximum waiting time of 31 days. Waiting times for Urgent and Routine Referrals to Children and Young People Cancer 31 subsequent cancer treatments – radiotherapy – Patients that receive Eating Disorder Services - Proportion of CYP with an Eating Disorder (urgent cases) subsequent/adjuvant radiotherapy treatment within a maximum waiting time of 31 days that wait one week or less from referral to start of NICE-approved treatment and including patients with recurrent cancer. proportion of CYP with an Eating Disorder (routine cases) that wait 4 weeks or less from Cancer 62 day first treatment following an urgent GP referral – Patients who receive referral to start of NICE-approved treatment. first definitive treatment for all cancers within 62 days following an urgent GP referral.
39 3.2
Governing Bodies in Common in Public
21 July 2020
Recovery Plan
Author: Mike Thompson Contact Information: Penny Emerson Lead Executive: Mike Thompson, Director fo Strategy, Planning & Population Health Which CCGs does this paper apply to?
Bedfordshire √ Luton √ Milton Keynes √
Information
Which activity does this paper • Strategic and Operational Planning relate to? • Statutory duties in respect of Emergency Preparedness, Resilience and Response How? The report is the narrative for the BLMK system Recovery Plan as submitted to NHSE/I on 18 June 2020
What is the Committee/ Receive assurance on the development of effective COVID-19 Governing Body being asked to recovery plans to NHSE/I requirements do? What are the financial The report highlights the financial requirements associated with implications? the BLMK system recovery plans
Set out the key risks and risk Key risks, issues and mitigations are set out in the report. The ratings relevant COVID-19 response and recovery risks are reflected in corporate risk registers and Board Assurance Framework Date to which the information As per the submission made on 18 June and feedback received this paper is based on was 20 June accurate
Executive Summary
As part of the ongoing system wide response to COVID-19 a submission was made to NHSE/I on 18 June setting out the key elements of the BLMK wide recovery plan. The attached document is the submitted narrative plus the NHSE/I feedback received on 20 June.
Key issues for the Governing body to note; • The narrative and associated detailed templates (finance, activity – detail not included in this report but summary tables are included within the narrative ) were as per NHSE/I regional guidance. • The submission was made by the CCG on behalf of the BLMK system, with the coordination of the recovery planning being led by the system ‘Health Cell’ and supported by the CCGs Recovery Cell. The CCG Programme Management Office (PMO) have been exemplary in coordinating the response. • The narrative summarises the capaital and revenue bids made in support of recovery plans, in particular acute and community providers. This is still subject to national discussions and no confirmation has yet been received on this. • It was acknowledged that for his submission the primary focus was on ‘health’ plans and this did not require, at this stage, wider system content e.g. social care, voluntary sector. This is being addressed in the next phase of planning (see below). • Feedback at this stage, noting the primary focus, was positive (see slides 23 and 24), noting that it was a well worked through system plan, with the Mental Health submission commended. The NHSE/I requirements at this stage were therefore met, with further detailed work to be undertaken.
Next Steps The national timetable for finalising plans has shifted with final plans expected to be submitted in September. National guidance is expected in July. A submission of further information (activity, updates to narrative) but not full plans is to be made on 16 July. The lntegrated Care System (ICS) central team will be leading the coordination of the 16 July and future submissions. It has set out a revised structure and processes for recovery planning and this is being discussed with system partners. The CCG will continue to support the process. In doing this the ICS will also draw into the BLMK plan the wider contributions and from social care, voluntary and community sector etc.. The Governing body are asked to note the report and receive assurance on meeting the CCG responsibilities in respect of recovery planning requirements.
2
1st Draft BLMK ICS Phase 3 Recovery Plan 18th June 2020 BLMK Recovery & Transformation Plan
Protect
Restore June 18th Submission: 1. BLMK system summary narrative 2. BLMK Recovery & Reassure Transformation Programme Plan v 10 3. NHSE Regional Waterfall template
BLMK 4. NHSE Regional Enable Finance template 5. Template A updated 6. Updated Surge Strategy 7. Mental Health
System Recovery Plan Recovery System Resource Recovery response
Transform Summary of submission
• The BLMK Covid-19 Health Cell continues to oversee the development and delivery of the Phases 2 & 3 Recovery Plan for BLMK. All partners are involved in developing the plans
• This submission builds on our previous 7th & 14th May submissions and specifically includes : – An update on progress made, together with an overview of the constraints we face both as a system, the solutions we are currently implementing and have planned, with their associated cost, and the resultant position this places us in respect of deliverable services and unmet need – Completed Waterfall and Finance templates to articulate our pre /post Covid bed capacity & activity, together with outlining our resulting financial position – An updated phase 2 template ( template A) – An updated Surge Strategy setting out our approach to management of future Covid incidents – Mental Health Recovery response – Latest version (10) Recovery & Transformation Programme Plan
• The key themes that emerge are as follows: – Clinical Priorities - Reducing harm – Inequalities - BAME Workforce / Population – Managing the gap and prioritising approaches – Capital - new position – Reduced capacity due to Covid constraints – Bed capacity ( e.g. at BHT) – Workforce ( e.g. provider workforce in the event of surge) Purpose
• Plans are be based on the principle of ‘system by default’ with shared priorities and objectives.
• The purpose of the BLMK system’s capacity and demand plan is:
– To be whole system, and address demand and capacity in all sectors – To be clinically and evidence led – To be widely owned across the system as the best way to deploy available resources for the benefit of local people – To optimise available capacity across the system – To effectively manage responses to increased Covid demand – To reshape and manage demand for services through best use of clinical evidence & guidance and through active management of waiting lists & access policies – To provide care in alternative settings, or in different ways, that either increase available capacity, or serve to reduce demand
• It should be a live plan, capable of adjustment to reflect the changing position on Covid-19 and agreed scenarios and assumptions. Principles : for managing the System demand and capacity gap
• A BLMK system wide approach will be taken involving all health care providers, local authorities and the voluntary sector.
• In doing the above, provide assurance that harm is being avoided by: – Tackling health inequalities – both existing & new (as a result of Covid-19) – Ensuring clinical oversight of back log position and prioritisation process, both in acute and community services. – Ensuring there is clarity on new pathways and alternative treatment pathways. – Ensuring adherence to infection prevention and control pathways and responsive reaction to reported concerns. – Ensuring effective multidisciplinary working for shielded patients enabling delivery of personalised plans. – Ensuring awareness of safeguarding concerns that will impact children, adults and families – Promoting responsive incident management and effective learning and change as required. – Ensuring a process of patient and public feedback is utilised to inform and respond accordingly. – Having awareness of the impact and resilience of staff and carers
• Check progress through undertaking EQIA assessment and ongoing monitoring. Progress since last submission
We have made good progress in further developing our System Recovery and Transformation plan since our last submission on 14th May. Further work has been carried out as detailed below:-
• Updated our Phase 2 ‘Step Up Clinical Services’ plan to indicate progress to date (see slide 7) • In response to a request from East of England Region reviewed and prioritised system gap schemes to identify duplication and opportunities to deliver at scale; and to agree overall approach within short delivery deadlines • Reviewed our system recovery assumptions, giving us a better understanding of the available system capacity and achievable delivery. These will continue to develop and evolve in the light of changing guidance and practice and as our system recovery plan develops. • Completed a System bed capacity analysis • Agreed a set of principles for managing the System demand and capacity gap, to include principles to support a cross system EQIA process, which has been approved via the Health Cell. • Developed a detailed Recovery Programme Plan to underpin delivery and monitoring of our System Recovery & Transformation Plan Phase 2 Actions – Progress Report RAG Rated Plan submitted
Status of BLMK implementation of Simon Stevens Phase 2 actions as at 17 June 2020
Green: 39 Amber: 4 Red: 0 Not applicable: 1
Exception Report
Reference No Action Provider Reason Red / Amber and Plan to deliver
12 Identify ring-fenced cancer BHT Dependency on ability to create better bio-secure diagnostic and surgical capacity areas particularly for colorectal also risk of patients not being able to isolate delaying procedures 22Other & 42 actions rated100% redprimary & amber care using digital BLMK Primary Digital consultations will be complete by 27/07/20 (duplicate actions) consultations Care Video consultations already 100% in place 33 Prepare for a possible longer- ELFT & CNWL ELFT & CNWL - dependency on funding being term increase in MH demand due available to recruit additional staff to pandemic, including by actively recruiting as per NHS LTP 34 Continue to complete annual ELFT Face to face annual health checks for people with a health checks for people with LD learning disability have commenced in primary care across BLMK, all practices are expected to have resumed health checks by end July. 36 Ensure you take into account ELFT & CNWL A BLMK wide MH equalities group has been inequalities in access to mental established to lead this work. This work health services, particularly for commenced before Covid and will continue beyond BAME communities the end of June. Assumptions for Capacity Planning
Whilst we have been able to develop a robust system approach to developing & managing our recovery and transformation, our agreed planning assumptions (summarised below) mean that there are a number of identified risks and constraints which will affect the successful delivery of our capacity gap solutions outlined in this return. Specifically these are shown on slide 10) Assumptions for Capacity Planning Risks & constraints
Whilst we have been able to develop a robust system approach to managing our recovery and transformation, there are a number of risks and constraints associated with delivery, some of which we outline below :
% of Reduction on % of Risk Reduction on Risk POD Risk / Constraint Total Risk / Constraint Total Acute Impacte Total Rating Total Acute Beds Rating Beds Activity d Activity Requirement for Productivity - 148 10% Moderate Moderate / Covid cohorting Impact of social 388,876 OP 28% High distancing Reducing bed bay Moderate capacity to facilitate 52 3% Reduced demand social distancing e.g. endoscopy for surveillance - FIT EL & Provision of 70,193 5% Moderate tests & Scanning, OP adequate space for 18 1% Low outpatients SOS PPE donning and refs doffing Reduced theatre Low 32,308 EL 2% Low Repurposed beds 16 1% utilisation Reduced bed NEL ITU ventilator 20,052 1% Low capacity & EL capacity limits 1% Low 9 (exclude anaesthetic Staff redeployment 12,000 OP 1% Low machines) Reduced staff Oxygen constraints 1% Low 6 (sickness, EL & at BH 6,741 0.5% Low shielding, OP Conversion to side 1% Low isolation) 12 rooms Laboratory and 6,200 EL 0.5% Low Removed of Ward 24 1% Low testing constraints 20 (MKUH) Workforce : There is a risk of not being able to recruit the 860 WTE identified thus far, however, work is underway to mitigate this via blended roles/ skill mix etc. . Solutions & mitigations
The following 2 slides provide examples of Acute, Community, MH & LD and Primary Care solutions to mitigate the constraints in Bed Capacity and Activity (greater detail is provided in the Finance Template to accompany this summary narrative):
Acute
Priority Area Solution / Mitigation Benefit Go-Live Strengthened 12 Weeks from 2 Storey Modular Ward (BHT) + 40 beds Urgent Care Approval + 40 beds 20 Weeks from Frailty Unit/Ward (BHT) Urgent Care Approval + 20 Theatre Identified RED/GREEN Hospitals - Two additional theatres, link to A&E and Sessions per Mar-21 Urgent Care emergency CT (BHT) Week Increased MDT 6 Weeks from Videoconferencing for cancer MDTs (BHT) Cancer capacity Approval 3rd CT scanner at L&D to reduce endoscopy and emergency general surgery + 163 Scans per Planned and Oct-20 demand (L&D) week Routine Care Reprovide ward beds for doffing and donning areas/reprovision of Ward 5 lost beds + 24 beds Mar-21 Urgent (L&D) + 4,800 OP Planned and Off site outpatient facility (L&D) Dec-20 Appointments Routine Care + 300 Scans per Planned and Imaging centre (diagnostic CT, MRI, ultrasound) (MKUH) Jan-21 week Routine Care Modular ward 50 beds - delivered within 12 weeks (MKUH) + 50 beds Dec-20 Urgent
+ 6 Beds + 20 2 additional endoscopy rooms and recovery space to increase screening and Planned and Theatre Sessions Dec-20 diagnostic capacity (includes additional scopes/stacks) Routine Care per week Solutions & mitigations
Community
Priority Area Solution / Mitigation Benefit Go-Live Strengthened Increased OOH Cardiovascular, Heart Long-term Condition Management and Hospital Admission Avoidance (CCS) Sep-20 capacity Attacks and Strokes Increased support to Integrated Discharge Hubs - Bedford and L&D Hospitals (ELFT) Already Live Community Care frail and vulnerable Community Hospital to increase the number of step down beds within the community Increased OOH Jun-20 Community Care (CNWL) capacity
Mental Health & Learning Disability
Solution / Mitigation Priority Area Benefit Go-Live Strengthened
Increased inpatient Mental Health, LD and 10% increase in MH services (CNWL) capacity and BAME Sep-20 access Autism
Increased inpatient Mental Health, LD and Strengthened Crisis Mental Health Services (ELFT) capacity and reduced Already Live inequalities Autism
Primary Care
Solution / Mitigation Priority Area Benefit Go-Live Strengthened Support practices as they begin to start to see more patients F2F Increased Primary Care Ongoing Primary Care Capacity Adaptions to premises to support infection control and social distancing measures, Increased capacity for Screening and Ongoing including enabling safe delivery of flu vaccination to high volumes of patients vaccinations Immunisations Video consultations, Remote monitoring and additional SMS activity Increased Primary Care Ongoing Digital Capacity Solutions & mitigations
We are also developing our comms approach to maintaining patient confidence as outlined below
Patient Communications
• We are undertaking a public survey, with Healthwatch and voluntary organisations, to understand patient perceptions and what is stopping them from using NHS services. The survey is just weeks in the field and to date, we have received more than 1200 responses from residents • Further focus groups will be held following analysis of the survey to understand perceptions within our local communities and this will be fed into the campaign to reassure local people • Work is underway with the business community to support people as they return to work. Videos have been delivered with CNWL and ELFT to provide tips on how people can manage anxieties as they return to work • A stakeholder newsletter has been developed, complete with key messaging for councillors and MPs, so they can provide advice to local people around the recovery of health services Residual gaps & next steps
Residual Gaps have been identified as follows :
• We will return to 100% of Non Elective and 80% of Routine care – this is further articulated in the accompanying Finance and Waterfall templates
Key next steps include :
• We recognise that the 18th June submission represents a point in time and there needs to be further granular work completed for the next submission around triangulation of activity, waiting lists, workforce and capacity • Iterate next draft phase 2/3 Recovery & Transformation plan ( 16 July submission) • Agree final phase 2/3 plan ( 13 August Submission) • Develop System Capacity and Demand plans ( including winter) • Develop and agree System Planning Framework & governance • Develop system level plan for responding to national ‘ask’ • Phase 4 - refresh of long term plans & 20/21 operating plan The Financial Impact of Recovery Plans
. In-Year additional CapEx at £125.4m . In-Year revenue implications are £74.8m . Recovery Plans are constituted of over a 100 schemes . Plans create capacity for: . 680 additional beds across various settings (gross) . 200 additional theatre sessions per week (gross) . Circa 1.3k additional scans per week . An additional 8.3k Outpatient Appts per week
The Financial Impact of Recovery Plans G&A and Critical Care Bed Capacity
Current plans deliver the following: . Critical Care Capacity increased by a net 9 beds on peak Covid (this is shown in waterfall), and +27 compared to pre-Covid baseline . G&A Bed Capacity has increased by a net 165 Beds. . In addition there are schemes for additional community capacity including the purchase of sub-acute beds; creating an additional net 159 beds .
The Financial Impact of Recovery Plans Capacity to undertake Activity
. In aggregate current plans provide capacity for the The Financial Impact systemof Recovery to treat near Plans or above assessed demand (with the LTP being used as the proxy for demand). . Submitted plans create the capacity to treat 12% more non-elective activity than the LTP baseline – additional capacity to is principally focused on the Bedford Hospital site. . Without capital and revenue investment the reduction is activity is significant: . -16% for NEL, -40% for ELDC, c-40% for Outpatients Activity Waterfalls
The Financial Impact of Recovery Plans Workforce
• Workforce requirements of our system gap plans have been identified by organisation, scheme, WTE & job role. Workforce capacity will need to increase by 860 WTE. This is a capacity gap of 3.9% above our planned workforce growth for acute, mental health and community services for 2020/21 from 1920/21 baseline position (2%). • Planning is in progress to identify supply via recruitment, deployment and bank/agency. Returner numbers are low in our system (26) and whilst retention plans are in place, this will not offer BLMK a substantial supply route. Deployment of existing staff will bring down the overall capacity WTE gap, however, may also negatively impact ability to resume services. • We continue to hold planning assumptions for 30% staff absence. We are developing a system report for monitoring absence across BLMK (national reports do not reflect entire system). • A workforce reset process is being led by the BLMK People’s Board, with transformation themes in development for Health & Wellbeing, Digital Evolution, Service Reset, Equality Diversity & Inclusion, Education & Up-skilling, and Workforce Supply & Demand- associated planning assumptions are being considered. • Innovative approaches to support workforce shortages within care homes & domiciliary care, developing a platform for on-going engagement of volunteers within health and social care services, engaging with Luton Airport to support entry into health and social care/council roles for redundant/furloughed staff and collectively commissioning a virtual education and up-skilling programme have commenced. System Service Planning Framework
BLMK LTP Response + (New) Local Priorities System Implement ation System Clinical Service Strategy Plans Medium- Long Term (Medium Long NHSE/I Term) Planning System Service Planning Environment Framework
Clinical Transformation CCG/ ICP / CVD/ Heart Urgent & routine Provider Attack & Stroke Surgery & Care Operational Plans MH/ Primary Cancer CYP Enablers: LD Care PHM/BI/ Analytics Workforce Digital Recovery Approach/ Delivery Structure Estates (Phase 3+4) Clinical Service delivery ICPs/ Providers plans Key delivery groups and interdependencies
System Cells
System DoFs Group : Health Cell Health & Maintain system Conduit for Social Care finance grip. system approach Cell ( B&L ) Milton Influence/implement to recovery & Coordinates Keynes new financial restoration. response & Equivalent planning framework Responds to recovery NHSE/I planning group or activities for working Organisational requirements & shared delivery of system ICC & relevant People’s Board responsibilities objectives & plans e.g. Care Homes Cells ( Ex LWAB) Oversight system workforce strategy. Joint mandate with NHSE/I/HEE to deliver local People’s Plan Existing & Proposed System Oversight Groups
System Population System Discharge Others Mental Health Health Grou Capacity & Planning Cancer (existing p Transformation demand Tactical Board groups to be Group Planning * Group reviewed) Wave 2 PHM Programme * To be established BLMK Feedback on system recovery plan – 18th June submission
20th June 2020 BLMK Summary of submission Solutions and mitigations th th • Well worked through whole system plan with a clear approach to answering the required four questions. Builds on 7 &14 The key solutions are summarised below. Solutions are heavily reliant on capital schemes however the proposed solutions can be implemented May submissions fully detailing progress to date/since last submission, risks/constraints, solutions/mitigations, and the level at pace as they are based on temporary builds (e.g. modular wards) and provision of additional equipment. of delivery (volume and %) of services, mitigated and unmitigated and residual unmet demand. LLOS 11% ambition not fully • Assume current financial support/investment to Local Authorities continues to 31/03/21 and no further reduction in financial support in included other areas • Waterfall template provides monthly phasing to March 2021 • Independent Sector provision and utilisation until 31/03/21 • System by default approach with whole system shared priorities, objectives and approach defined. • All remote/technical solutions continue to be utilised • Mental Health plans are truly system focussed and contain a fantastic level of detail. Strong on tackling health inequalities. • Communications programme to support and build patient confidence • Constraints solutions, costs and resultant position in terms of deliverable services and unmet need Capital schemes – Modular wards and additional diagnostic capacity. Primarily aimed at supporting reduction in capacity from socially • Plans as currently stated provide increased activity above baseline for non-elective activity and a small residual gap for distancing/infection control requirements. These schemes support 29% of baseline outpatient activity, 11% of baseline elective activity and 13% elective and outpatient activity. Assuming 69% increase in pre-covid critical care capacity and 11% increase in G&A bed of baseline non-elective activity capacity • 2 Storey Modular Ward (BHT) • Pre and post covid bed capacity and activity (mitigated and unmitigated) provided, surge strategy, detailed system recovery • Frailty Unit/Ward (BHT) and transformation plan, Mental Health recovery and response plans • Identified RED/GREEN Hospitals - Two additional theatres, link to A&E and emergency CT (BHT) Overall plan risk: • 3rd CT scanner at L&D to reduce endoscopy and emergency general surgery demand (L&D) • Reliance on capital and revenue funding: Plans to mitigate risk and constraints are heavily reliant on capital schemes. • Re-provide ward beds for doffing and donning areas/re=provision of Ward 5 lost beds (L&D) Schemes are appropriate and realistic however there is a need to assess lead times and the impact on activity plans. • Imaging centre (diagnostic CT, MRI, ultrasound) (MKUH) • Workforce capacity gap: Achieving workforce requirements • Modular ward 50 beds - delivered within 12 weeks (MKUH) • Some concern remains regarding deliverability of elective activity plans. This is due to: • 2 additional endoscopy rooms and recovery space to increase screening and diagnostic capacity - Significant increase in capacity from previous plans. Unclear which new elements are supporting this change. Virtual consultation - Supports 5.5% of baseline outpatient activity - Need to maximise IS capacity – there has been slow uptake to date (although improvement has been seen over the last two LLOS Improvement - Supports 5.5% of baseline non elective activity weeks) Diagnostic Hub – Supports 10% of baseline elective activity - Ensuring workforce can match need. Risk to securing additional staff to support plans is high. Out of hospital - solutions focus on increased bed capacity and admission avoidance, mental health crisis provision and video consultation and - Further work needed to understand whether assumptions have been built in for time lost to establishing these schemes. premises adaptation in primary care -Further information required regarding reduction in patient demand due to COVID concerns and isolation requirements. System require timely (by end of July at latest) confirmation of capital and revenue funding along with confirmation of continued system support • Further work is needed to understand how the plans presented take account of both backlog work and the resumption of to IS, and local authority provision etc to enable delivery of mitigation and solution schemes BAU activity in the period up until the end of March. • Reference is made to the recruitment initiatives including potential supply form Luton airport, this needs further exploration but would be a Risks and constraints possible solution. Top 5 constraints • the LWAB have progressed a joint employment charter for newly qualified students, a careers website to promote employment and learning • Requirement for Covid Cohorting – 10% reduction on bed availability (moderate risk) opportunities and have established strong working links with social care workforce leads which could will support the recovery workforce • Reducing bed bay capacity for social distancing - 3% reduction on bed availability (moderate risk) strategy. • Impact of social distancing on productivity – 28% reduction on acute activity (high risk) • Reduced demand e.g. endoscopy surveillance – 5% reduction on acute demand (moderate risk) • Reduced theatre utilisation – 2% reduction on acute activity (low risk) Residual gap and next steps The unmitigated position is: st • 19% acute bed stock at risk (6%Low risk / 13% moderate risk) linked to cohorting. Social distancing, PPE, repurposed beds, ITU • 84% of non elective activity, 60% of elective activity, 62% of 1 outpatient activity, 57% of FU outpatient activity ventilation, oxygen constraints, conversion to side rooms Without capital and revenue investment the reduction is activity is significant. After all mitigations are in included there is additional capacity • 38% total activity (largely outpatient & elective, 28% High/Medium risk, 5%high risk, 5% low risk) at risk due to social above baseline for non-elective and first outpatients and a small residual gap across elective and outpatient follow up. This equates to the distancing, decreased demand and theatre utilisation, bed capacity, staff redeployment, staff sickness etc, lab testing following: constraints • 112% NEL activity, 102.% 1st OP activity, 96% EL activity, 95% FU OP Further granular work to be completed to ensure triangulation of activity, waiting lists, workforce and capacity Other risks/constraints ( those equating to 1% or below reduction in beds or activity) • Laboratory and testing constraints Next Steps • Out of Hospital: OOA placements may increase due to lack of provision in BLMK • Workforce capacity gap of 860 WTE-delivery of this may be ambitious as it requires a combination of staff redeployment and significant • No point of care testing, testing approach: frontline staff to be tested every 7 days and patients 14 day pre procedure shielding. recruitment • Staff shielding and sickness are modelled at 30%, which is having a constraint on service recovery. • Further detail should be included in the final submission on the workforce training and upskilling strategy and supporting the workforce • Impact of trac and Trace is estimated to be significant but this has not been modelled redeployed and shielding back into their substantive roles. • PPE Donning and Doffing and social distancing have been highlighted as key constraints, the impact on workforce and reduced • Further work is required to assess the impact of staff shielding and sickness and the implications of Track and Trace as well as likely effect of productivity due to social distancing are a major constraint to recovery. additional demand through winter. • Mental Health workforce recruitment is highlighted as a major constraint, with significant recruitment identified on top of the • To maximise IS, management of backlog and resumption of BAU activity already ambitious growth forecast. • MH: Need to disentangle existing investment from new opportunities BLMK Activity Workforce Whilst BLMK have been able to articulate the workforce implications and have modelled the capacity • Pre and post covid bed capacity and activity (mitigated and unmitigated) provided, surge strategy, detailed system shortfall of workforce, further detail is required on how they will achieve this growth. recovery and transformation plan, Mental Health recovery and response plans • Recovery plan has estimated a capacity gap of 860 WTE which equates to 3.9% above the planned • Plans as currently stated provide increased activity above baseline for non-elective activity and a small residual gap for growth from 2019/20 position elective and outpatient activity. • Workforce demand has been articulated, supported by a recruitment and redeployment plan, The unmitigated position is: however delivery of this, staff wellbeing and supporting staff back into work requires further • 84% of non elective activity • 60% of elective activity detail,. • 62% of 1st outpatient activity • Further work is required to assess the impact of staff shielding and sickness and the implications • 57% of FU outpatient activity of Track and Trace as well as likely effect of additional demand through winter. Mitigated Position: After all mitigations are in included there is additional capacity above baseline for non-elective and first outpatients and a small residual gap across elective and outpatient follow up. This equates to the following: • Demand has been articulated, supported by a recruitment and redeployment plan, however • 112% NEL activity delivery of this, staff wellbeing and supporting staff back into work requires further detail, not • 102.% 1st OP activity presented in this return • 96% EL activity • Detail is provided on the WTE planned growth in the financial recovery plan for each service • 95% FU OP which is very positive, however, the timelines for recruitment appear ambitious particularly for • In aggregate current plans provide capacity for the system to treat near or above assessed demand (with the LTP being some areas where the WTE is high and specialty roles are required. For some roles such as ACPs used as the proxy for demand). which are likely to require a longer supply time due to any training or limited supply routes. • Submitted plans create the capacity to treat 12% more non-elective activity than the LTP baseline – additional capacity • Upskilling and training and training needs of the workforce needs consideration, along with to is principally focused on the Bedford Hospital site. supporting the redeployed and shielding back to their substantive roles • Planning for a 10% surge in activity at CNWL. Investment opportunities should be disaggregated to provide a better • Consideration has been given to possible supply routes and recruitment plans, using sources such understanding as Luton airport, however, it is acknowledged further work I required to fully evaluate these options. Capacity • Reference is made to modelling a 30% absence rate and the loss of acute activity equating to . Plans create capacity for: 6,741 episodes of care, however there is less detail about the strategy for supporting staff back to . 680 additional beds across various settings (gross) work or provisions for utilising staff that are shielding . 200 additional theatre sessions per week (gross) • Locally the LWAB have progressed a joint employment charter for newly qualified students, a . Circa 1.3k additional scans per week careers website to promote employment and learning opportunities and have established strong . An additional 8.3k Outpatient Appts per week working links with social care workforce leads which could will support the recovery workforce • 69% increase in pre-covid critical care capacity and 11% increase in G&A bed capacity strategy. • Critical Care Capacity increased by a net 9 beds on peak Covid (this is shown in waterfall), and +27 compared Finance to pre-Covid baseline) • G&A Bed Capacity has increased by a net 165 Beds. • Schemes for additional community capacity including the purchase of sub-acute beds; creating an additional net 159 In-Year additional Capital requirement of £126m (Total £137m) beds. In-Year revenue implications are £75m (Total £127m FYE) • Further diagnostic capacity of 1149 per week is provided through schemes to deliver a diagnostic hub, imaging centre Recovery Plans are constituted of 111 schemes and additional CT scanner, along with continued (and increasing) IS utilisation Key risks include: • Workforce capacity gap of 860 WTE, demand has been articulated, supported by a recruitment and redeployment plan, • Workforce availability, and reasonable recruitment costs however delivery of this, staff wellbeing and supporting staff back into work requires further detail, not presented in • PPE supply and availability this return. • Timing and scale of demand restoration Without capital and revenue investment the reduction is activity is significant: • • Promptness of capital funding approval . -16% for NEL, -40% for ELDC, c-40% for Outpatients 3.3
Governing Bodies in Common in Public
21 July 2020
Title: NHS Response to Covid19 in Bedfordshire and Luton
Author: Michelle Summers Contact Information: [email protected] Lead Executive: Geraint Davies, Director Governance and Performance Which CCGs does this paper apply to?
Bedfordshire Y Luton Y Milton Keynes Y
Information
Which activity does this paper This paper relates to the work that CCG has undertaken to relate to? respond to the Covid-19 pandemic across Bedfordshire, Luton and Milton Keynes. How? This paper sets out the response undertaken by Bedfordshire, Luton and Milton Keynes Clinical Commissioning Groups and the impact Covid-19 has had on local services. What is the Committee/ To receive assurance Governing Body being asked to do? What are the financial N/A implications?
Set out the key risks and risk N/A ratings
Date to which the information 14 July 2020 this paper is based on was accurate
Executive Summary
The purpose of this report is to provide the Governing Body with a ‘point in time’ update about the work that has been undertaken by NHS organisations and the Local Resilience Forum during the Covid19 pandemic.
1. Background
On 16 March 2020, NHS England called a Level 4 major incident around the Coronavirus pandemic and devolved its Category 1 responder powers to Bedfordshire Clinical Commissioning Group to respond to the emerging crisis.
A health incident room was established, the Local Resilience Forum (LRF) convened and military planners were brought in to support leaders in establishing a framework that would enable local agencies to respond to a crisis, which would run over a period of months and would look to build in resilience and capacity, should any one of the team become unwell with Covid19.
Pandemic plans, which are well established in Bedfordshire and had been exercised at regular intervals were rolled out in anger. Muriel Scott, Director of Public Health from Bedford Borough and Central Bedfordshire Council took the lead as Chair of the Strategic Control Group (SCG), from where the operation was led.
Vicky Head, Chief Officer Population Health from Bedford Borough and Central Bedfordshire Councils chaired the Tactical Control Group (TCG), which included partners from across the system who were responsible for delivering elements of the plan. Geraint Davies, Director Performance and Governance at Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group(s) took the health lead from across the system, working as Strategic Gold.
A number of cells that would manage the operation were set up and a ‘battle rhythm’ of meetings were established to ensure that the detail from the operation was fed into the control model, and decisions would be taken by the appropriate chain of command.
The cells included:
• Health cell • Mortality cell • Health and social care cell • Media cell • Management Information Cell (data gathering) • Councils cell (updates from three local councils)
On 23 March, the Prime Minister called a national emergency and encouraged those who could to work at home. The command centres and cells became virtual groups, meeting daily to respond to the growing crisis.
2. What’s the situation in Bedfordshire, Luton and Milton Keynes?
Mortality
Since the start of the pandemic, 834 people have tragically died from Covid19 in Bedfordshire, Luton and Milton Keynes [ONS data to 03/07/20, published 14/07/20]. This is an increase of 29 since 19th June.
• 162 in Bedford Borough; • 267 in Central Bedfordshire; • 209 in Luton; • 196 in Milton Keynes.
Confirmed Covid cases in acute settings
At the peak of the pandemic, which was 12 April 2020, highest peak at Bedford Hospital was 69 patients on 21 April and at the Luton and Dunstable Hospital 128 patients on the 15 April. The latest figures to 14 July show that there are 13 confirmed Covid inpatients at the Luton and Dunstable Hospital, 22 at Bedford Hospital and 3 at Milton Keynes Hospital.
2
Testing
In recent weeks, testing has steadily increased across the BLMK footprint and CCG staff have been redeployed from their day jobs to support testing in social care and key workers. Similarly, we have Mobile Testing Units (MTU’s) in place across the county (Bedford, Biggleswade, Leighton Buzzard and Luton Airport) and a Regional Test Centre in Milton Keynes, which provides swab testing for anyone who has symptoms of coronavirus, what their age.
49,528 tests have been carried out to 8 July, an average of 590 a day. This data has been populated from:
1. Steppingley Hospital this is being used as a base for East London Foundation Trust (ELFT) 2. The Acute Providers, although the data feed from the East of England ceased on the 4th June, as the data was no longer required regionally. 3. National - Milton Keynes RTC (Regional Test Centre) and Mobile Testing Units (MTU’s)
The following chart shows the steady increase in the number of swab tests carried from 16 April until 8th July.
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Support for care homes
In addition to providing testing for key workers, we have been working with ELFT to provide tests to staff and patients in social care. From April – 8th July, 3,171 (this figure is included in the overall figure above, 49,528) tests have been carried out in social care settings. This has allowed us to support staff in isolating symptomatic residents and preventing the spread of infection.
In addition to testing, redeployed staff from the CCG have been working closely with care homes to provide support around infection control. A webinar demonstrating how to ‘don and doff’ PPE was well attended by care home workers and this was followed up with a ‘Train the Trainer’ workshop, where 7 Infection Control Nurses and 22 volunteers from the CCG carried out training on how to reduce the spread of infection in care homes.
This was well received by the care homes, and we plan to roll this training out to domiciliary care providers through the winter months to build on the momentum and provide further support to the most vulnerable people in our community.
Personal Protective Equipment (PPE)
To date, the CCG has supplied the following PPE to Personal Healthcare Budget holders, primary care, dentistry, ophthalmology, pharmacy, social care providers, community services and acute hospitals by mutual aid arrangement:
• 135,400 pairs of gloves • 49,700 aprons • 68,400 Type IIR masks • 2470 FFP3 masks • 11,363 waste sacks • 2144 bottles hand gel • 14,353 Face shields
Due to changes in government guidance in March 2020, there was an increased need for PPE within care settings outside of our hospitals, including primary care, domiciliary care, residential care and pharmacy.
There were serious challenges with the supply and distribution of PPE in the early days of our response, in part due to supply chain issues. Establishing an effective supply chain was problematic due to changes in guidance and lead in times for supply, which could be up to 10 days for delivery.
There was an escalation process through the National Supply Disruption Response (NSDR) line, which aimed to deliver in 72 hours. However, this delivery timeframe was often not met, with providers often escalating to the CCG. Urgent stock deliveries were delivered through the Local Resilience Fora (LRF) in Bedfordshire and in Thames Valley, based on population size, caseloads and consumption rates.
In order to ensure the timely provision of PPE to Primary Care, the CCG agreed to centralise PPE procurement for primary care and Williams Medical Supplies, the largest supplier to general practice in the United Kingdom, agreed to open a ‘super-user’ or priority account for the CCG to enable the Primary Care Cell to order directly on behalf of all practices in Bedfordshire and Luton. Any shortfall was met by deliveries from the LRF stock delivery, which was used nationally to bridge gaps in equipment. This process worked well and limited the need for further escalation.
Due to the often joint nature of social care commissioning between both the Local Authorities and the CCG, a joint LA/CCG pathway was developed in Bedfordshire and Luton to support PPE provision in Care Homes. The pathway allows partner agencies to support each other in ensuring the timely provision of sufficient PPE to social care providers. Since being implemented, there has been a 100% reduction in escalation requests around PPE from social care.
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On 9 April, NHS England confirmed that the responsibility to supply PPE to holders of Personal Health Budgets (PHB) and their Personal Assistants was a delegated responsibility to the CCG. Since then, the CCG has worked to identify all holders of PHBs and has supplied packages of PPE directly to the identified individuals. A plan is currently being developed to ensure sustainability of supply as the national Covid-19 response shifts into Phase 2.
3. What impact has Covid19 had on NHS services?
As part of the Covid-19 Phase 1 incident response, non-Covid services were ‘stepped down’ at the end of March to maximise capacity to cope with the immediate emergency response.
This included some cancer treatments and non-urgent elective surgery. Outpatient appointments were conducted via telephone where possible to increase capacity at the hospitals and reduce infection risk on site.
Primary Care services were moved to telephone and video consultations to ensure the safety of the workforce, with only ‘low risk’ patients who needed face to face diagnosis attending surgeries.
GP surgeries remained open during Easter and May Bank Holiday weekends, to ensure that there was sufficient capacity in the system to care for patients if they became unwell during national holidays. This was promoted through a range of channels to ensure residents were aware that they could access help and advice, as necessary.
Whilst A&E continued to operate as normal during the outbreak, with Covid areas identified as part of standard infection control measures, attendances dropped significantly in the weeks leading up to and shortly after the Covid19 peak. This has however started to rise steadily throughout May and June.
The charts below show the number of patients attending A&E Departments at Bedford Hospital, Luton and Dunstable Hospital and Milton Keynes Hospital each week from the start of the year, and the gradual decline from mid-March, as infection rates increased and the Prime Minister introduced restrictions on movement.
BEDFORD HOSPITAL SOUTH WING
3,500
3,000
2,500
2,164 2,000
1,500 219 227 171 184 177 175 148
1,000 153 157 172 149 139 91 102 93 96 500 1115 979 1052 1041 1038 1035 1032 1028 899 881 826 813 750 723 687 666 0
Attendances (Type 1) Attendances (Type 3) Pre-Covid Average (Total Attends)
5
LUTON & DUNSTABLE HOSPITAL
3,500
3,000 3,025
2,500
2,000 732 503 436 543 364 406 326 449
1,500 266 302 324 216 234 220 141 129 1,000 158 1625 1609 1608 1570 1556 1542 1509 1434 1411 1324 1286 1281 1218 500 1214 1180 1124 1045
0
Attendances (Type 1) Attendances (Type 3) Pre-Covid Average (Total Attends)
MILTON KEYNES HOSPITAL
3,500
3,000 2,819 2,500
2,000 597 612 535 647 537 551
1,500 476 495 528 440 369 418 1,000 322 285 315 284 300 1496 1469 1412 1397 1387 1343 1330 1296 500 1258 1183 1145 981 967 840 817 801 716
0
Attendances (Type 1) Attendances (Type 3) Pre-Covid Average (Total Attends)
At this stage, we do not have the qualitative data to understand the reasons for the fall in attendances and whether this was as a result of fear or other factors. This will need to be downloaded from SUS data, which is currently unavailable – there is a two month lag. We will provide this information to members as soon as we are able, but it is reasonable to suggest that a number of factors including concern over infection risk and the fact that people were staying at home, contributed to the fall.
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Recovery and restoring services
With the number of confirmed cases of Covid and admissions starting to reduce, we are now working to restore NHS services.
In line with guidance received from NHS England at the end of April, we are looking to restore services through two phases:
Phase When? What? Phase 1 April – August Cancer, urgent elective surgery Phase 2 By March 2021 Near normal capacity levels
Initial plans have been completed, but work is on-going process to refine these over the next few weeks. As part of this work, consideration is being given to how services will need to operate in a ‘Covid’ environment – taking into account PPE requirements, testing capacity, workforce needs, estates and bed requirements.
We will seek to maximise capacity and to continuously improve working arrangements over the coming weeks. However, until providers have re-started services, it will be difficult to assess exactly how much non-Covid capacity can be returned and by when.
As well as restoring priority services, we are also working to understand how we can operate in a new normal, which will mean that there will be some longer term services transformation, which will build on innovative practice implemented during Phase 1.
These plans are complex and require involvement from a number of providers and partners. Plans are currently being worked up with NHSE to support overall recovery of NHS services and we will provide more information around this as soon as it becomes available.
4. Communicating through crisis
“Warn and Inform”
As part of our multi agency response, the “Warn and Inform” group, which comprises of the communications and engagement teams from health, local authorities and emergency services came together to provide consistent messaging to residents.
The Pandemic Communications Plan, which was developed as part of the LRF was enacted and in the immediate response phase, advice and guidance around “Stay home, save lives” messaging was promoted on:
- Heart FM and local/ community radio; - Waste disposal trucks; - Ad vans, which were positioned at beauty spots on Bank Holiday weekends; - Lamp posts, bus shelters; - Local parish publications and; - Facebook advertising
Joint broadcasts with Look East were planned and joint communications for Ramadan were produced to support our Muslim communities in celebrating safely.
With the easing of ‘lockdown’, a campaign to encourage people to use NHS services has begun. A series of GP videos were broadcast on Facebook and Twitter, which focused on GPs undertaking their day to day work. Posters and social media posts have also been used to encourage people to use our services.
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With an increase in infection rates in Bedford Borough, steps have been taken to support the Council in communicating messaging to residents and encouraging them to be cautious when outdoors. GP videos in different languages have been broadcast for Black Asian and Minority Ethnic communities, BSL has been used to engage with the deaf community and a video with Paula Radcliffe was produced to help get the message across.
We’re listening
With the emergency response being scaled back and more focus on the recovery of services, we are keen to listen to the views of people living in Bedfordshire.
Working with Healthwatch Bedford Borough, Central Bedfordshire, Luton and Milton Keynes, we put together a survey to ask people what services they accessed during the outbreak, what they thought about the services and how they feel about using our services now, with restrictions being lifted. A similar survey of our GPs was also run, to understand how our GPs felt about the changes during Covid.
The survey closed on 21 June and we received 1321 public responses and 199 GP responses. We are currently working through the findings which will be used to support commissioners as they ‘stand up’ services going forward. Local views will also form the evidence base for our communications going forward.
5. Next steps
The information in this briefing document provides a look in time at the work we have been doing to safeguard our public during these unprecedented times. The NHS and partners are still responding to the pandemic and as a result, not all statistics are available at this present time.
We remain committed to absolute transparency, providing Members with an overview of our work, as we work, under emergency powers to deliver NHS services locally.
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NHS Response to Covid19 in Bedfordshire and Luton
Geraint Davies Director Governance and Performance Dr Sanjay Sharma Wheatfield Road Surgery, Dunstable Purpose
• To provide Members with an overview of the Covid19 response by the NHS in Bedfordshire, Luton and Milton Keynes. Initial response
• Formed an incident room, joined forces with BLRF and TVLRF to deliver pandemic plan in anger; • Joined up all CCGs to create a single CCG approach to response; • Established a battle rhythm – managing issues arising including PPE, mortality, surge plans and communications. Overview • 834 people have tragically died from Covid19 in Bedfordshire [ONS data to 19/06/20, published 29/06/20]. This is an increase of 70 over the last 3 weeks. – 162 in Bedford Borough; – 267 in Central Bedfordshire; – 209 in Luton; – 196 in Milton Keynes. Number of confirmed cases in beds Cumulative number of swabs Impact on attendances BHT BEDFORD HOSPITAL SOUTH WING
3,500
3,000
2,500
2,164 2,000
1,500 219 227 171 184 177 175 148
1,000 153 157 172 149 139 102 91 93 96
500 1115 1052 979 1041 1038 1035 1032 1028 899 881 826 813 750 723 687 666
0
Attendances (Type 1) Attendances (Type 3) Pre-Covid Average (Total Attends) Impact on attendances L&D
LUTON & DUNSTABLE HOSPITAL
3,500
3,000 3,025
2,500
2,000 732 503 436 543 364 406 326 449
1,500 266 302 324 216 234 220 141 129 1,000 158 1625 1609 1608 1570 1556 1542 1509 1434 1411 1324 1286 1281 1218 1214 500 1180 1124 1045
0
Attendances (Type 1) Attendances (Type 3) Pre-Covid Average (Total Attends) Impact on attendances Milton Keynes
MILTON KEYNES HOSPITAL
3,500
3,000 2,819
2,500
2,000 597 612 535 647 537 551 476
1,500 495 528 440 369 418 322 1,000 285 315 284 300 1496 1469 1412 1397 1387 1343 1330 1296 1258 1183
500 1145 981 967 840 817 801 716
0
Attendances (Type 1) Attendances (Type 3) Pre-Covid Average (Total Attends) Recovery
• During the pandemic, some services changed to safeguard our workforce. • We are currently in the process of restoring services. • We will provide an update to Committee on any potential services changes, as complex plans start to be confirmed. 3.4
Governing Bodies in Common in Public
21 July 2020
Title M2 Finance Report BLMK CCGs
Author: CCG Finance Teams Contact Information: Deputy CFOs, BLMK CCGs Lead Executive: Chris Ford, Chief Finance Officer Which CCGs does this paper apply to?
Bedfordshire X Luton X Milton Keynes X
Information
Which activity does this paper The report summarises the financial performance of the three relate to? BLMK CCGs for Month 2 2020/21.
How?
What is the Committee/ For Assurance/Discussion/Information Governing Body being asked to do? What are the financial As set out in paper. implications?
Set out the key risks and risk Failure to meet statutory financial duties. ratings As per Finance Risk Register
Date to which the information 18th June 2020 this paper is based on was accurate
Executive Summary
In response to COVID-19, a temporary financial regime has been put in the place to cover the period 1 April 2020 to 31 July 2020. CCG allocations have been non-recurrently adjusted. CCGs are monitored against the adjusted allocation. Actual expenditure is reviewed on a monthly basis and a retrospective non-recurrent
adjustment is expected to be actioned for reasonable variances between actual expenditure and the expected monthly expenditure. As at Month 2, no retrospective allocations have been made - the CCGs report a combined £18.1m YTD deficit and £35.1m forecast deficit to allocation for Months 1-4.
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Month 2 Finance Report - BLMK CCGs Governing Body in Common Chris Ford Chief Finance Officer
21 July 2020 The Temporary Financial Regime for CCGs
. In response to COVID-19, a temporary financial regime has been put in the place to cover the period 1 April 2020 to 31 July 2020. . The principle of this approach is that during the period 1 April to 31 July 2020, CCGs are expected to breakeven on an in- year basis. To achieve this, CCG allocations will be non-recurrently adjusted for M1 to M4. . CCG allocations have been non-recurrently adjusted to reflect expected monthly expenditure. This has been modelled nationally and the calculation considers the impacts of the temporary financial regime – these impacts include: Block contracting arrangements with NHS Trusts and Foundation Trusts (‘NHS Trusts’); and National contracting of acute services from independent sector.
. CCGs have received an output from NHS England that calculates revised allocations based on projected monthly expenditure for the period 1 April to 31 July 2020. BLMK CCGs have set budgets for the four-month period 1 April to 31 July which match this position. . CCGs are monitored against the adjusted allocation position. Actual expenditure is reviewed on a monthly basis and a retrospective non-recurrent adjustment will be actioned for reasonable variances between actual expenditure and the expected monthly expenditure.
At the time of Month 2 reporting, no retrospective adjustments to allocations have been confirmed by NHS England. We anticipate that allocation adjustments will be confirmed in July. However, at this point, year-to-date and forecast (Month 1-4) deficit positions are reported for all three BLMK CCGs, reflecting the impact of prospective allocation adjustments and Covid expenditure incurred.
Arrangements for Months 5 to 12 are being finalised by NHSE/I and will be confirmed in due course.
2 Year to Date Financial Performance (1)
BEDFORDSHIRE LUTON MILTON KEYNES COMBINED
Year to Date Net Expenditure Year to Date Net Expenditure Year to Date Net Expenditure Year to Date Net Expenditure CCG EXPENDITURE ANALYSIS Plan Actual Variance Variance Plan Actual Variance Variance Plan Actual Variance Variance Plan Actual Variance Variance £m £m £m % £m £m £m % £m £m £m % £m £m £m %
REVENUE RESOURCE LIMIT (IN YEAR) 114.100 57.466 64.455 236.020 REVENUE RESOURCE LIMIT (CUMULATIVE) 114.100 57.466 64.455 236.020
Acute Services (ISFE) 62.280 69.156 (6.876) (11.0%) 30.377 30.279 0.098 0.3% 34.050 33.625 0.424 1.2% 126.707 133.060 (6.354) (5.0%) Mental Health Services (ISFE) 10.761 10.501 0.259 2.4% 7.184 7.276 (0.092) (1.3%) 5.616 5.886 (0.270) (4.8%) 23.561 23.664 (0.103) (0.4%) Community Health Services (ISFE) 7.662 7.175 0.488 6.4% 5.130 6.542 (1.412) (27.5%) 4.027 4.904 (0.878) (21.8%) 16.819 18.621 (1.802) (10.7%) Continuing Care Services (ISFE) 5.793 5.561 0.232 4.0% 1.314 1.393 (0.079) (6.1%) 4.208 4.325 (0.117) (2.8%) 11.314 11.279 0.035 0.3% Primary Care Services (ISFE) 12.930 13.288 (0.358) (2.8%) 5.841 6.012 (0.172) (2.9%) 7.015 7.713 (0.698) (10.0%) 25.786 27.014 (1.228) (4.8%) Prescribing 10.487 10.697 (0.210) (2.0%) 4.745 4.682 0.063 1.3% 5.702 6.065 (0.363) (6.4%) 20.934 21.444 (0.510) (2.4%) Primary Care Co-Commissioning (ISFE) 10.360 11.067 (0.708) (6.8%) 5.263 5.588 (0.325) (6.2%) 5.995 6.428 (0.433) (7.2%) 21.617 23.084 (1.466) (6.8%) Other Programme Services (ISFE) 2.883 8.293 (5.410) (187.7%) 1.674 2.116 (0.443) (26.5%) 2.673 3.860 (1.187) (44.4%) 7.230 14.270 (7.040) (97.4%) TOTAL COMMISSIONING SERVICES 112.669 125.042 (12.373) (11.0%) 56.782 59.207 (2.425) (4.3%) 63.583 66.743 (3.160) (5.0%) 233.033 250.991 (17.958) (7.7%) Running Costs (ISFE) 1.431 1.469 (0.038) (2.7%) 0.684 0.768 (0.084) (12.3%) 0.872 0.873 (0.001) (0.1%) 2.987 3.110 (0.123) (4.1%) TOTAL CCG NET EXPENDITURE 114.100 126.511 (12.412) (10.9%) 57.466 59.975 (2.509) (4.4%) 64.455 67.615 (3.161) (4.9%) 236.020 254.101 (18.081) (7.7%)
IN YEAR UNDERSPEND / (DEFICIT) 0.000 (12.412) (12.412) (100.0%) - (2.509) (2.509) (100.0%) - (3.161) (3.161) (100.0%) 0.000 (18.081) (18.081) (100.0%)
The three BLMK CCGs are reporting a £18.1m combined year-to date (YTD) deficit at Month 2.
Bedfordshire • The plan reflects the four month model issued by NHSE/I. • The CCG is reporting a year to date overspend against budget of £12.4m, of which £4.3m is Covid-19 costs. The main drivers for the residual £8.1m overspend are: The exclusion of allocation for independent sector (IS) contracts. A specific BCCG contract is not part of the national NHS agreement with the independent sector - allocation has been reduced in error and the CCG continues to make payments, £6.0m. NHSE/I are appraised of this issue. A year to date variance on the delegated Primary Care budget of £0.8m which has arisen because of the methodology used to calculate the 4 month budget. Other - including increased cost of short-stock drugs and slippage against QIPP programme, £1.3m. Year to Date Financial Performance (2)
Luton . The plan is based on the revised model issued by NHSE/I. . The CCG is reporting a £2.5m overspend YTD, with £2.1m of the variance caused by costs incurred in relation to the Covid-19 response. Excluding Covid, the CCG is reporting a £0.5m overspend, which can be attributed to three main areas: Pressures arising from joint commissioning of mental health patients with LBC, £0.1m Extended Access - where the programme has continued from 2019/20 but no allocation has yet been received, £0.2m Other programme services overspend of £0.4m which is due to QIPP schemes which have not been progressed due to Covid.
Milton Keynes . The CCG plan is based on the revised plan notified by NHSE/I. . The CCG is reporting a year to date overspend against budget of £3.2m, of which £2.5m is Covid-19 costs. . The residual gap of c.£0.6m relates to QIPP schemes which have not been progressed due to Covid and additional pressures in primary care. Forecast For Months 1-4 – BLMK Wide (1)
BEDFORDSHIRE LUTON MILTON KEYNES COMBINED
Forecast Net Expenditure Forecast Net Expenditure Forecast Net Expenditure Forecast Net Expenditure CCG EXPENDITURE ANALYSIS Plan Actual Variance Variance Plan Actual Variance Variance Plan Actual Variance Variance Plan Actual Variance Variance £m £m £m % £m £m £m % £m £m £m % £m £m £m %
REVENUE RESOURCE LIMIT (IN YEAR) 228.200 114.933 128.909 472.042 REVENUE RESOURCE LIMIT (CUMULATIVE) 228.200 114.933 128.909 472.042 228199.656 Acute Services (ISFE) 124.560 138.312 (13.753) (11.0%) 60.755 60.628 0.127 0.2% 68.099 67.219 0.880 1.3% 253.413 266.160 (12.746) (5.0%) Mental Health Services (ISFE) 21.521 21.003 0.519 2.4% 14.368 14.467 (0.099) (0.7%) 11.232 11.781 (0.549) (4.9%) 47.121 47.251 (0.129) (0.3%) Community Health Services (ISFE) 15.325 14.350 0.975 6.4% 10.261 12.425 (2.164) (21.1%) 8.053 9.449 (1.396) (17.3%) 33.639 36.224 (2.585) (7.7%) Continuing Care Services (ISFE) 11.586 11.122 0.464 4.0% 2.627 2.863 (0.236) (9.0%) 8.415 8.575 (0.160) (1.9%) 22.628 22.560 0.069 0.3% Primary Care Services (ISFE) 25.860 26.577 (0.716) (2.8%) 11.681 12.375 (0.694) (5.9%) 14.030 15.536 (1.506) (10.7%) 51.571 54.487 (2.915) (5.7%) Prescribing 20.974 21.395 (0.421) (2.0%) 9.491 9.818 (0.327) (3.4%) 11.404 12.412 (1.008) (8.8%) 41.868 43.624 (1.756) (4.2%) Primary Care Co-Commissioning (ISFE) 20.719 22.135 (1.415) (6.8%) 10.525 10.813 (0.288) (2.7%) 11.990 12.857 (0.867) (7.2%) 43.234 45.804 (2.570) (5.9%) Other Programme Services (ISFE) 5.766 16.586 (10.820) (187.7%) 3.350 4.169 (0.819) (24.4%) 5.346 7.751 (2.405) (45.0%) 14.462 28.506 (14.044) (97.1%) TOTAL COMMISSIONING SERVICES 225.338 250.084 (24.746) (11.0%) 113.566 117.739 (4.173) (3.7%) 127.165 133.168 (6.003) (4.7%) 466.069 500.991 (34.922) (7.5%) Running Costs (ISFE) 2.862 2.938 (0.077) (2.7%) 1.367 1.471 (0.104) (7.6%) 1.744 1.768 (0.024) (1.4%) 5.973 6.177 (0.205) (3.4%) TOTAL CCG NET EXPENDITURE 228.200 253.022 (24.823) (10.9%) 114.933 119.209 (4.276) (3.7%) 128.909 134.936 (6.027) (4.7%) 472.042 507.168 (35.126) (7.4%)
IN YEAR UNDERSPEND / (DEFICIT) - (24.823) (24.823) (100.0%) - (4.276) (4.276) (100.0%) - (6.027) (6.027) (100.0%) - (35.126) (35.126) (100.0%) CUMULATIVE UNDERSPEND / (DEFICIT) - (24.823) (24.823) (100.0%) - (4.276) (4.276) (100.0%) - (6.027) (6.027) (100.0%) - (35.126) (35.126) (100.0%)
. A four month forecast has been produced to align with the expected duration of the temporary financial regime for CCGs. . A deficit of £35.1m for M1-4 is forecast across the three BLMK; this covers direct Covid related expenditure and other cost pressures arising. . CCGs are monitored by NHSE/I against the adjusted allocation position. Actual expenditure is reviewed on a monthly basis and a retrospective non-recurrent adjustment is anticipated to be actioned for reasonable variances between actual expenditure and the expected monthly expenditure - it is therefore anticipated that the adverse variance forecast for the four month period will be offset by allocation from NHSE/I. At the time of Month 2 reporting, no retrospective adjustments to allocations have been confirmed by NHSE/I. . It is not yet clear if further top up funding will be available for the remainder of the year and formal guidance is still awaited to clarify the financial regime post-July. Covid 19 YTD Expenditure – BLMK Wide
NHS NHS NHS Bedfordshire Luton Milton Keynes Totals CCG CCG CCG £'000 £'000 £'000 £'000 Total Covid Expenditure Including HDP 4,268 2,071 2,511 8,850
Finance support is embedded within Incident Cells and supports the reporting of Covid related costs incurred. All NHS organisations, including BLMK CCGs, submit monthly information to NHSE/I in respect of additional Covid related costs. The CCG claim therefore does not include costs incurred by other NHS bodies.
The total YTD costs of Covid for 20-21 across the three CCGs is £8.9m, this includes the cost of the Hospital Discharge Programme.
Bedfordshire The CCG has incurred £4.3m extra costs YTD relating to Covid-19 and this is forecast to grow to £8.5m for the four month period. £1.6m of the forecast Covid-19 costs relates to re-imbursement to the Local Authority for associated hospital discharge costs.
Luton The CCG has incurred £2.1m extra costs YTD relating to Covid-19 and this is forecast to grow to £2.9m for the four month period.
Milton Keynes The CCG has incurred £2.5m extra costs YTD relating to Covid-19 and this is forecast to grow to £4.6m for the four month period. £0.8m of the Covid-19 costs relates to re-imbursement to the Local Authority for associated hospital discharge costs. 4.1
Governing Bodies in Common in Public
21 July 2020
Constitution of the BLMK CCG
Author: Michael Wuestefeld Gray, Interim Programme Manager for BLMK Governance Contact Information: [email protected] Lead Executive: Geraint Davies, Director of Performance and Governance Which CCGs does this paper apply to?
Bedfordshire X Luton X Milton Keynes X
Information
Which activity does this paper The development of the underpinning governance structure of relate to? BLMK CCG
How? All CCGs are required to have a constitution. A constitution has been drafted based on the model NHS England constitution template. What is the Governing Body To review the draft constitution, in particular the sections set out being asked to do? below, and approve the draft to go to the membership of the three CCGs for a confirmatory vote What are the financial None implications?
Set out the key risks and risk The Constitution must be approved by members across the three ratings CCGs in time to be included in the application to NHS England to establish the single CCG. Date to which the information 10 July this paper is based on was accurate
Executive Summary
All CCGs are required to have a constitution supported by: • Standing Orders; • A Scheme of Reservation and Delegation • Standing Financial Instructions • Prime Financial Policies The draft Constitution of the BLMK CCG sets out in particular how it will engage with its members, the powers and other roles members have, and how the Governing Body of BLMK CCG will be appointed. These have been the focus of discussion at recent members’ forums. The Standing Orders of the draft Constitution have been taken from Bedfordshire CCG, as these have been highlighted as an example of good practice. The Scheme of Reservation and Delegation is a combination of the three CCG’s current schemes, modelled loosely on that of Milton Keynes. The three CCGs had common standing financial instructions and prime financial policies and these have been incorporated in the draft Governance Handbook. These shall require further review by subject matter experts to ensure they remain appropriate and are internally consistent with the rest of the Constitution and its supporting Handbook. Finally the terms of reference of the BLMK CCG’s committees will be drafted with the support and input of the appropriate joint committee or committees in common. Attached to this paper are the following appendices: • A: Draft BLMK CCG Constitution • B: Draft Governance Handbook • C: Summary of what has changed
What is different?
Appendix C is a briefing note for members that sets out the key changes in the Constitution to what is currently done, and why. Key sections of the draft Constitution (at Appendix A) are also highlighted with blue boxes to help scrutiny by the membership of the three CCGs as part of the voting process. In addition, following discussion at the three CCG’s members’ forums in June and a special BLMK- wide members’ forum further comments and feedback has led to some further small changes.
What is happens next?
The draft Constitution shall be shared with members for further review and comment before being put to an online vote by each of the three CCGs for the week commencing 17 August. The outcome of this vote will be presented to the Governing Bodies in Common at its meeting of 22 September 2020
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DRAFT
NHS BEDFORDSHIRE, LUTON AND MILTON KEYNES CLINICAL COMMISSIONING GROUP
CONSTITUTION NHS Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group Constitution
Version Effective Date Changes V1 Aug 2018 Standard model V1.1 13 Nov 2019 First draft to amend standard model V1.2 31 Jan 2020 Updated to reflect feedback and BLMK shadow arrangements V2.1 21 May 2020 Second Draft V2.2 26 June 2020 Third draft including draft standing orders V2.3 8 July 2020 Fourth draft post members’ feedback, with SFIs and SORD
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CONTENTS
1 Introduction ...... 5 1.1 Name ...... 5 1.2 Statutory Framework ...... 5 1.3 Status of this Constitution ...... 6 1.4 Amendment and Variation of this Constitution ...... 6 1.5 Related documents ...... 6 1.6 Accountability and transparency ...... 7 1.7 Liability and Indemnity ...... 9
2 Area Covered by the CCG ...... 10
3 Membership Matters ...... 11 3.1 Membership of the Clinical Commissioning Group ...... 11 3.2 Nature of Membership and Relationship with CCG ...... 15 3.3 Speaking, Writing or Acting in the Name of the CCG ...... 15 3.4 Members’ Rights ...... 15 3.5 Members’ Meetings ...... 16 3.6 Practice Representatives ...... 16
4 Arrangements for the Exercise of our Functions...... 18 4.1 Good Governance ...... 18 4.2 General ...... 18 4.3 Authority to Act: the CCG ...... 19 4.4 Authority to Act: the Governing Body ...... 19
5 Procedures for Making Decisions ...... 20 5.1 Scheme of Reservation and Delegation ...... 20 5.2 Standing Orders ...... 20 5.3 Standing Financial Instructions (SFIs) ...... 21 5.4 The Governing Body: Its Role and Functions ...... 21 5.5 Composition of the Governing Body ...... 22 5.6 Additional Attendees at the Governing Body Meetings ...... 23 5.7 Appointments to the Governing Body ...... 23 5.8 Committees and Sub-Committees ...... 23
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5.9 Committees of the Governing Body ...... 24 5.10 Collaborative Commissioning Arrangements ...... 25 5.11 Joint Commissioning Arrangements with Local Authority Partners ...... 26 5.12 Joint Commissioning Arrangements – Other CCGs ...... 27 5.13 Joint Commissioning Arrangements with NHS England ...... 30
6 Provisions for Conflict of Interest Management and Standards of Business Conduct ...... 32 6.1 Conflicts of Interest ...... 32 6.2 Declaring and Registering Interests ...... 32 6.3 Training in Relation to Conflicts of Interest ...... 33 6.4 Standards of Business Conduct ...... 33
Appendix 1: Definitions of Terms Used in This Constitution ...... 35
Appendix 2: Committee Terms of Reference ...... 38 Audit Committee ...... 38 Remuneration Committee ...... 38 Primary Care Commissioning Committee ...... 38
Appendix 3: Standing Orders ...... 38
Appendix 4: Standing Financial Instructions ...... 47
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1 Introduction
1.1 Name
The name of this clinical commissioning group is NHS Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group (“the CCG” or “BLMK CCG”).
1.2 Statutory Framework
1.2.1 CCGs are established under the NHS Act 2006 (“the 2006 Act”), as amended by the Health and Social Care Act 2012. The CCG is a statutory body with the function of commissioning health services in England and is treated as an NHS body for the purposes of the 2006 Act. The powers and duties of the CCG to commission certain health services are set out in sections 3 and 3A of the 2006 Act. These provisions are supplemented by other statutory powers and duties that apply to CCGs, as well as by regulations and directions (including, but not limited to, those issued under the 2006 Act). 1.2.2 When exercising its commissioning role, the CCG must act in a way that is consistent with its statutory functions. Many of these statutory functions are set out in the 2006 Act but there are also other specific pieces of legislation that apply to CCGs, including the Equality Act 2010 and the Children Acts. Some of the statutory functions that apply to CCGs take the form of statutory duties, which the CCG must comply with when exercising its functions. These duties include things like:
a) Acting in a way that promotes the NHS Constitution (section 14P of the 2006 Act); b) Exercising its functions effectively, efficiently and economically (section 14Q of the 2006 Act); c) Financial duties (under sections 223G-K of the 2006 Act); d) Child safeguarding (under the Children Acts 2004,1989); e) Equality, including the public-sector equality duty (under the Equality Act 2010); and f) Information law, (for instance under data protection laws, such as the EU General Data Protection Regulation 2016/679, and the Freedom of Information Act 2000). 1.2.3 Our status as a CCG is determined by NHS England. All CCGs are required to have a constitution and to publish it. 1.2.4 The CCG is subject to periodic assessments of its performance by NHS England which has powers to provide support or to intervene where it is satisfied that a CCG is failing, or has failed, to discharge any of its functions or that there is a significant risk that it will fail to do so.
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1.2.5 CCGs are clinically-led membership organisations made up of general practices. The Members of the CCG are responsible for determining the governing arrangements for the CCG, including arrangements for clinical leadership, which are set out in this Constitution.
1.3 Status of this Constitution
1.3.1 This CCG was first authorised on [date of authorisation by NHS England].
1.3.2 Changes to this Constitution are effective from the date of approval by NHS England.
1.3.3 The constitution is published on the CCG website at www.[insert URL].
1.4 Amendment and Variation of this Constitution
1.4.1 This Constitution can only be varied in two circumstances.
a) where the CCG applies to NHS England and that application is granted; and
b) where in the circumstances set out in legislation NHS England varies the Constitution other than on application by the CCG. 1.4.2 The Accountable Officer may periodically propose amendments to the constitution which shall be considered and approved by the Governing Body unless: a) the changes are thought to have a material impact; or b) changes are proposed to the reserved powers of the CCG’s members; or c) At least half (50%) of all the Governing Body Members formally request that the amendments be put before the membership for approval 1.4.3 Any Constitutional amendments that may not be approved by the Governing Body as set out in paragraph 1.4.2 shall be presented for approval by the CCG’s members through either: a) a confirmatory vote from each member practice; or b) a confirmatory vote by attendees at the CCG’s members forum(s).
1.5 Related documents
1.5.1 This Constitution is also informed by a number of documents which provide further details on how the CCG will operate. With the exception of the Standing Orders and the Standing Financial Instructions, these documents do not form part of the Constitution for the purposes of 1.4 above. They are the CCG’s:
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a) Standing orders – which set out the arrangements for meetings and the selection and appointment processes for the CCG’s Committees, and the CCG Governing Body (including Committees).
b) The Scheme of Reservation and Delegation – sets out those decisions that are reserved for the membership as a whole and those decisions that have been delegated by the CCG or the Governing Body
c) Prime financial policies – which set out the arrangements for managing the CCG’s financial affairs.
d) Standing Financial Instructions – which set out the delegated limits for financial commitments on behalf of the CCG.
e) The CCG Governance Handbook which includes:
• the documents described at 1.5.1 (a) to (d) inclusive; • the terms of reference of the CCG’s Governing Body and its committees; • arrangements for the admission and removal of member practices; • how the CCG will maintain standards of business conduct and manage conflicts of interests 1.6 Accountability and transparency 1.6.1 The CCG will demonstrate its accountability to its members, local people, stakeholders and NHS England in a number of ways, including by being transparent. We will meet our statutory requirements to:
a) publish our constitution and other key documents including the documents lists in section 1.5 above
b) appoint independent lay members and non-GP clinicians to our Governing Body;
c) manage actual or potential conflicts of interest in line with NHS England’s statutory guidance Managing Conflicts of Interest: Revised Statutory Guidance for CCGs 2017 and expected standards of good practice (see also part 6 of this constitution); Commented [WM-NBC1]: Cross reference
d) hold Governing Body meetings in public (except where we believe that it would not be in the public interest);
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e) publish an annual commissioning strategy that takes account of priorities in the health and wellbeing strategy;
f) procure services in a manner that is open, transparent, non- discriminatory and fair to all potential providers and publish a Procurement Strategy;
g) involve the public, in accordance with its duties under section 14Z2 of the 2006 Act, and as set out in more detail in the CCG’s strategies and plans as published.
h) When discharging its duties under section 14Z2, the CCG will ensure that it acts in accordance with its published visions and values to create a culture that listens to, learns from and empowers patients.
i) comply with local authority health overview and scrutiny requirements;
j) meet annually in public to present an annual report which is published;
k) produce annual accounts which are externally audited;
l) publish a clear complaints process;
m) comply with the Freedom of Information Act 2000 and with the Information Commissioner’s requirements regarding the publication of information relating to the CCG;
n) provide information to NHS England as required; and
o) be an active member of the local Health and Wellbeing Board. 1.6.2 In addition to these statutory requirements, the CCG will demonstrate its accountability by: a) holding regular events to involve and engage patients, carers and voluntary and community sector groups about the work of the CCG;
b) providing information to the public at large about the work of the CCG;
c) holding regular involvement events for the CCG’s members
d) working alongside local medical committees regarding the provision, delivery and quality of primary care.
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1.7 Liability and Indemnity 1.7.1 The CCG is a body corporate established and existing under the 2006 Act. All financial or legal liability for decisions or actions of the CCG resides with the CCG as a public statutory body and not with its Member practices. No Member or former Member, nor any person who is at any time a proprietor, officer or employee of any Member or former Member, shall be liable (whether as a Member or as an individual) for the debts, liabilities, acts or omissions, howsoever caused by the CCG in discharging its statutory functions. No Member or former Member, nor any person who is at any time a proprietor, officer or employee of any Member of former Member, shall be liable on any winding-up or dissolution of the CCG to contribute to the assets of the CCG, whether for the payment of its debts and liabilities or the expenses of its winding-up or otherwise. The CCG may indemnify any Member practice representative or other officer or individual exercising powers or duties on behalf of the CCG in respect of any civil liability incurred in the exercise of the CCGs’ business, provided that the person indemnified shall not have acted recklessly or with gross negligence.
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2 Area Covered by the CCG 2.1.1 The area covered by the CCG is all of: a) the area covered by the Borough of Bedford unitary authority; b) the area covered by the Central Bedfordshire unitary authority; c) the area covered by the Borough of Luton unitary authority d) the area covered by the Borough of Milton Keynes unitary authority e) four additional lower-layer super output areas (LSOAs) comprising the two wards of Newton Longville and the two wards of Great Brickhill, both in Buckinghamshire and part of the Aylesbury Vale District Council and Buckinghamshire County Council areas.
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3 Membership Matters 3.1 Membership of the Clinical Commissioning Group 3.1.1 The CCG is a membership organisation. 3.1.2 All practices who provide primary medical services to a registered list of patients under a General Medical Services, Personal Medical Services or Alternative Provider Medical Services contract in our area are eligible for membership of this CCG. 3.1.3 The practices which make up the membership of the CCG are listed below.
Practice Name Address 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
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20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
12
49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77
13
78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
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3.2 Nature of Membership and Relationship with CCG
3.2.1 The CCG’s Members are integral to the functioning of the CCG. Those exercising delegated functions on behalf of the Membership, including the BLMK CCG Governing Body, remain accountable to the Membership.
3.2.2 How the CCG’s Membership may hold the those exercising delegated functions to account is set out in:
a) This Constitution;
b) the Scheme of Reservation and Delegation;
c) the terms of reference of the Members’ Forum(s).
3.3 Speaking, Writing or Acting in the Name of the CCG
3.3.1 Members are not restricted from giving personal views on any matter. However, Members should make it clear that personal views are not necessarily the view of the CCG.
3.3.2 Nothing in or referred to in this constitution (including in relation to the issue of any press release or other public statement or disclosure) will prevent or inhibit the making of any protected disclosure (as defined in the Employment Rights Act 1996, as amended by the Public Interest Disclosure Act 1998) by any member of the CCG, any member of its Governing Body, any member of any of its Committees or Sub- Committees or the Committees or Sub-Committees of its Governing Body, or any employee of the CCG or of any of its members, nor will it affect the rights of any worker (as defined in that Act) under that Act.
3.4 Members’ Rights
3.4.1 The rights of members shall be to:
a) call and attend a general meeting of the CCG’s membership;
b) to have the CCG’s Chair, Accountable Officer or their nominated deputies attend general meetings of the CCG’s membership
c) submit proposals for the amendment of the CCG’s Constitution
d) the nominate themselves or others to be the CCG Chair, or member representative on the CCG’s Governing Body
e) to participate in the process of appointment to these posts
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f) to ratify the appointment to these posts at a meeting of the CCGs’ membership
g) design with the CCG the Members’ Forum(s) or equivalent through which the CCG shall primarily engage with members.
3.5 Members’ Meetings
3.5.1 The CCG is obliged by Paragraph 6 of Schedule 1A of the NHS Act 2006 to secure effective participation by its members.
3.5.2 The CCG shall hold an annual general meeting to which members shall be invited.
3.5.3 The CCG shall establish at least one Members’ Forum that will meet regularly, either in person or remotely (or both) on a regular basis.
3.6 Practice Representatives
3.6.1 Each Member practice has a nominated lead healthcare professional who represents the practice in the dealings with the CCG.
3.6.2 It is for each Member to decide how its Practice Representative is appointed, to draw up any terms of office, including the grounds for removal from office and to decide on any notice period.
3.6.3 Each Practice Representative shall represent the Member that has appointed it at meetings of the Members’ Forum in accordance with the procedures set out in the Standing Orders. 3.6.4 A Practice Member may replace its Member Representative from time to time by notice in writing to the Governing Body.
3.6.5 Each Member shall authorise its Practice Representative to act on behalf of the Member as follows:
a) attend and receive notice of any meetings of the Members’ Forum;
b) vote at meetings of the Members’ Forum on behalf of the Member in accordance with this Constitution;
c) sign any written resolution on behalf of the Member;
d) receive any notices from the CCG on behalf of the Practice Member and any notice delivered by the CCG to the Member Representative shall be deemed to have been made or served on the Practice Member;
e) appoint a proxy; and
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f) approve or provide any consent required of the Practice Member by the CCG in respect
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4 Arrangements for the Exercise of our Functions.
4.1 Good Governance
4.1.1 The CCG will, at all times, observe generally accepted principles of good governance. These include:
a) undertaking regular governance reviews;
b) adopting standards and procedures that facilitate speaking out and the raising of concerns including the appointment of a freedom to speak up guardian;
c) adopting CCG values that include standards of propriety in relation to the stewardship of public funds, impartiality, integrity and objectivity;
d) the Good Governance Standard for Public Services;
e) the standards of behaviour published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’;
f) the key principles of the NHS Constitution;
g) relevant legislation including such as the Equality Act 2010; and
h) the standards set out in the Professional Standard Authority’s guidance ‘Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England’.
4.2 General
4.2.1 The CCG will:
a) comply with all relevant laws, including regulations;
b) comply with directions issued by the Secretary of State for Health or NHS England;
c) have regard to statutory guidance including that issued by NHS England; and
d) take account, as appropriate, of other documents, advice and guidance.
4.2.2 The CCG will develop and implement the necessary systems and processes to comply with (a)-(d) above, documenting them as necessary in this constitution, its scheme of reservation and delegation and other relevant policies and procedures as appropriate.
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4.3 Authority to Act: the CCG
4.3.1 The CCG is accountable for exercising its statutory functions. It may grant authority to act on its behalf to:
a) any of its members or employees;
b) its Governing Body;
c) a Committee or Sub-Committee of the CCG.
4.4 Authority to Act: the Governing Body
4.4.1 The Governing Body may grant authority to act on its behalf to:
a) any Member of the Governing Body;
b) a Committee or Sub-Committee of the Governing Body;
c) a Member of the CCG who is an individual (but not a member of the Governing Body); and
d) any other individual who may be from outside the organisation and who can provide assistance to the CCG in delivering its functions.
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5 Procedures for Making Decisions
5.1 Scheme of Reservation and Delegation
5.1.1 The CCG has agreed a scheme of reservation and delegation (SoRD) which is published in full [on the CCG’s website]
5.1.2 The CCG’s SoRD sets out:
a) those decisions that are reserved for the membership as a whole;
b) those decisions that have been delegated by the CCG, the Governing Body or other individuals.
5.1.3 The CCG remains accountable for all of its functions, including those that it has delegated. All those with delegated authority, including the Governing Body, are accountable to the Members for the exercise of their delegated functions.
5.1.4 The Accountable Officer of the CCG may amend, or delegate the amendment of, the SoRD except where:
a) the amendment would vary the powers of the CCG’s members as these amendments must be approved by the Membership; or
b) the amendment would vary the terms of reference of the Governing Body or its committees, as these amendments must be approved by the Governing Body.
5.2 Standing Orders
5.2.1 The CCG has agreed a set of standing orders which describe the processes that are employed to undertake its business. They include procedures also included in this Constitution for:
a) conducting the business of the CCG and how the Governing Body operates;
b) the appointment of members of the Governing Body and its committees;
c) the procedures for decision making; and
d) the provision to hold meetings in public.
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5.2.2 A copy of the Standing Orders is included for reference at Appendix 3 and form part of the CCG’s Governance Handbook Commented [WM-NBC2]:
5.3 Standing Financial Instructions (SFIs)
5.3.1 The CCG has agreed a set of SFIs which include the delegated limits of financial authority set out in the SoRD.
5.3.2 A copy of the SFIs is included for reference at Appendix 4 and form part of the CCG’s Governance Handbook Commented [WM-NBC3]:
5.4 The Governing Body: Its Role and Functions
5.4.1 The Governing Body has statutory responsibility for:
a) ensuring that the CCG has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the CCG’s principles of good governance (its main function); and for
b) determining the remuneration, fees and other allowances payable to employees or other persons providing services to the CCG and the allowances payable under any pension scheme established.
5.4.2 The CCG has also delegated the following additional functions to the Governing Body which are also set out in the SoRD. These delegated functions must be exercised within the procedural framework established by the CCG and primarily set out in the Standing Orders and SFIs: Commented [WM-NBC4]:
a) leading the development of vision and strategy for the CCG;
b) overseeing and monitoring the quality and safety of commissioned services;
c) approving the CCG’s commissioning plans and the arrangements for consultation and engagement;
d) stimulating innovation and modernisation;
e) overseeing and monitoring the financial and contractual or operational performance of the CCG and commissioned services;
f) overseeing risk assessment and securing assurance actions to mitigate identified strategic and operational risks;
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g) promoting a culture of strong engagement with patients, their carers, Members, the public and other stakeholders about the activity and progress of the CCG;
h) ensuring good governance and leading a culture of good governance throughout the CCG. The detailed procedures for the Governing Body, including voting arrangements, are set out in the standing orders.
i) assure the delivery of the CCG’s operating and commissioning plans;
j) undertake any function that is not delegated from the Governing Body and also is not reserved to the members.
5.5 Composition of the Governing Body
5.5.1 This part of the constitution describes the make-up of the Governing Body roles. Further information about the individuals who fulfil these roles can be found on our website [link to website].
5.5.2 The membership of the CCG’s Governing Body shall be:
a) The Chair who will be a GP from a member practice
b) The Accountable Officer
c) The Chief Finance Officer
d) A Secondary Care Specialist;
e) An Independent Registered Nurse
f) A Lay Member who has qualifications expertise or experience to enable them to lead on finance and audit matters;
g) A Lay Member who has knowledge about the CCG area enabling them to express an informed view about discharge of the CCG functions
h) A Lay Member who shall support the CCG in the field of patient and public engagement who will also be the Vice Chair of the CCG
i) Seven clinicians from member practices who will represent the CCG’s membership on the Governing Body
j) The following Executive Directors: • The CCG’s Medical Director • The CCG’s Chief Nurse
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• The CCG’s Director of Primary Care • The CCG’s Director of Performance and Governance
5.5.3 The CCG shall maintain a Governing Body structure where clinicians have a majority of voting membership
5.5.4 The CCG from time to time may vary the responsibilities and remits of executive directors, and their role titles to reflect those changes, without changing membership of the Governing Body.
5.6 Additional Attendees at the Governing Body Meetings
5.6.1 The CCG Governing Body may invite other person(s) to attend all or any of its meetings, or part(s) of a meeting, in order to assist it in its decision- making and in its discharge of its functions as it sees fit. Any such person may be invited by the chair to speak and participate in debate, but may not vote.
5.6.2 The CCG Governing Body will regularly invite the following individuals to attend any or all of its meetings as attendees:
a) All other Executive Directors
b) One or more representatives of local healthwatch organisations
c) One or more representatives from local authorities in the CCG area.
5.7 Appointments to the Governing Body
5.7.1 The process of appointing member representatives to the Governing Body, the selection of the Chair, and the appointment procedures for other Governing Body Members are set out in the standing orders.
5.7.2 Also set out in standing orders are the details regarding the term of office for each role and the procedures for resignation and removal from office.
5.8 Committees and Sub-Committees
5.8.1 The CCG may establish Committees and Sub-Committees of the CCG.
5.8.2 The Governing Body may establish Committees and Sub-Committees of the Governing Body.
5.8.3 Each Committee and Sub-Committee established by either the CCG or the Governing Body operates under terms of reference and membership agreed by the CCG or Governing Body as relevant. Appropriate reporting
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and assurance mechanisms must be developed as part of agreeing terms of reference for Committees and Sub-Committees.
5.8.4 With the exception of the Remuneration Committee, any Committee or Sub-Committee established in accordance with clause 5.8 may consist of or include persons other than Members or employees of the CCG.
5.8.5 All members of the Remuneration Committee will be members of the CCG’s Governing Body.
5.9 Committees of the Governing Body
5.9.1 The Governing Body will maintain the following statutory or mandated Committees:
5.9.2 Audit Committee: This Committee is accountable to the Governing Body and provides the Governing Body with an independent and objective view of the CCG’s compliance with its statutory responsibilities. The Committee is responsible for arranging appropriate internal and external audit.
5.9.3 The Audit Committee will be chaired by a Lay Member who has qualifications, expertise or experience to enable them to lead on finance and audit matters and members of the Audit Committee may include people who are not Governing Body members.
5.9.4 Remuneration Committee: This Committee is accountable to the Governing Body and makes recommendations to the Governing Body about the remuneration, fees and other allowances (including pension schemes) for employees and other individuals who provide services to the CCG.
5.9.5 The Remuneration Committee will be chaired by a lay member other than the audit chair and only members of the Governing Body may be members of the Remuneration Committee.
5.9.6 Primary Care Commissioning Committee: This committee is required by the terms of the delegation from NHS England in relation to primary care commissioning functions. The Primary Care Commissioning Committee reports to the Governing Body and to NHS England. Membership of the Committee is determined in accordance with the requirements of Managing Conflicts of Interest: Revised statutory Guidance for CCGs 2017. This includes the requirement for a lay member Chair and a lay Vice Chair. Commented [WM-NBC5]:
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5.9.7 None of the above Committees may operate on a joint committee basis with another CCG.
5.9.8 The terms of reference for each of the above committees are included in Appendix 2 to this constitution and form part of the CCG’s Hanbook Commented [WM-NBC6]:
5.9.9 The Governing Body has also established a number of other Committees to assist it with the discharge of its functions. These Committees are set out in the SoRD and further information about these Committees, including terms of reference, are published in the CCG’s Governance Handbook. Commented [WM-NBC7]:
5.10 Collaborative Commissioning Arrangements
5.10.1 The CCG wishes to work collaboratively with its partner organisations in order to assist it with meeting its statutory duties, particularly those relating to integration. The following provisions set out the framework that will apply to such arrangements.
5.10.2 In addition to the formal joint working mechanisms envisaged below, the Governing Body may enter into strategic or other transformation discussions with its partner organisations, on behalf of the CCG.
5.10.3 The Governing Body must ensure that appropriate reporting and assurance mechanisms are developed as part of any partnership or other collaborative arrangements. This will include:
a) reporting arrangements to the Governing Body, at appropriate intervals;
b) engagement events or other review sessions to consider the aims, objectives, strategy and progress of the arrangements; and
c) progress reporting against identified objectives.
5.10.4 When delegated responsibilities are being discharged collaboratively, the collaborative arrangements, whether formal joint working or informal collaboration, must:
a) identify the roles and responsibilities of those CCGs or other partner organisations that have agreed to work together and, if formal joint working is being used, the legal basis for such arrangements;
b) specify how performance will be monitored and assurance provided to the Governing Body on the discharge of responsibilities, so as to enable the Governing Body to have appropriate oversight as to how system integration and strategic intentions are being implemented;
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c) set out any financial arrangements that have been agreed in relation to the collaborative arrangements, including identifying any pooled budgets and how these will be managed and reported in annual accounts;
d) specify under which of the CCG’s supporting policies the collaborative working arrangements will operate;
e) specify how the risks associated with the collaborative working arrangement will be managed and apportioned between the respective parties;
f) set out how contributions from the parties, including details around assets, employees and equipment to be used, will be agreed and managed;
g) identify how disputes will be resolved and the steps required to safely terminate the working arrangements;
h) specify how decisions are communicated to the collaborative partners.
5.11 Joint Commissioning Arrangements with Local Authority Partners
5.11.1 The CCG will work with its Local Authority partners to reduce health and social inequalities and to promote greater integration of health and social care.
5.11.2 Partnership working between the CCG and its Local Authority partners might include collaborative commissioning arrangements, including joint commissioning under section 75 of the 2006 Act, where permitted by law. In this instance, and to the extent permitted by law, the CCG delegates to the Governing Body the ability to enter into arrangements with one or more relevant Local Authorities in respect of:
a) Delegating specified commissioning functions to one or more Local Authorities;
b) Exercising specified commissioning functions jointly with one or more Local Authorities;
c) Exercising any specified health-related functions on behalf of one or more Local Authorities.
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5.11.3 For purposes of the arrangements described in 5.11.2, the Governing Body may: Commented [WM-NBC8]:
a) agree formal and legal arrangements to make payments to, or receive payments from, the relevant Local Authorities, or pool funds for the purpose of joint commissioning;
b) make the services of its employees or any other resources available to the relevant Local Authorities; and
c) receive the services of the employees or the resources from the relevant Local Authorities.
d) where the Governing Body makes an agreement with one or more Local Authorities as described above, the agreement will set out the arrangements for joint working, including details of:
• how the parties will work together to carry out their commissioning functions;
• the duties and responsibilities of the parties, and the legal basis for such arrangements;
• how risk will be managed and apportioned between the parties;
• financial arrangements, including payments towards a pooled fund and management of that fund;
• contributions from each party, including details of any assets, employees and equipment to be used under the joint working arrangements; and
• the liability of the CCG to carry out its functions, notwithstanding any joint arrangements entered into.
5.11.4 The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.11.2 above.
5.12 Joint Commissioning Arrangements with other CCGs
5.12.1 The CCG may work together with other CCGs in the exercise of its Commissioning Functions.
5.12.2 The CCG delegates its powers and duties under 5.12 to the Governing Body and all references in this part to the CCG should be read as the Commented [WM-NBC9]: Governing Body, except to the extent that they relate to the continuing liability of the CCG under any joint arrangements.
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5.12.3 The CCG may make arrangements with one or more other CCGs in respect of:
a) delegating any of the CCG’s commissioning functions to another CCG;
b) exercising any of the Commissioning Functions of another CCG; or
c) exercising jointly the Commissioning Functions of the CCG and another CCG.
5.12.4 For the purposes of the arrangements described at 5.12.3, the CCG may:
a) make payments to another CCG;
b) receive payments from another CCG; or
c) make the services of its employees or any other resources available to another CCG; or
d) receive the services of the employees or the resources available to another CCG.
5.12.5 Where the CCG makes arrangements which involve all the CCGs exercising any of their commissioning functions jointly, a joint committee may be established to exercise those functions.
5.12.6 For the purposes of the arrangements described above, the CCG may establish and maintain a pooled fund made up of contributions by all of the CCGs working together jointly pursuant to paragraph 5.12.3 above. Any such pooled fund may be used to make payments towards expenditure incurred in the discharge of any of the commissioning functions in respect of which the arrangements are made.
5.12.7 Where the CCG makes arrangements with another CCG as described at paragraph 5.12.3 above, the CCG shall develop and agree with that CCG an agreement setting out the arrangements for joint working including details of:
a) how the parties will work together to carry out their commissioning functions;
b) the duties and responsibilities of the parties, and the legal basis for such arrangements;
c) how risk will be managed and apportioned between the parties;
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d) financial arrangements, including payments towards a pooled fund and management of that fund;
e) contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.
5.12.8 The responsibility of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.12.1 above.
5.12.9 The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.12.1 above.
5.12.10 Only arrangements that are safe and in the interests of patients registered with Member practices will be approved by the Governing Body.
5.12.11 The Governing Body shall require, in all joint commissioning arrangements, that the lead Governing Body Member for the joint arrangements:
a) make a quarterly written report to the Governing Body;
b) hold at least one annual engagement event to review the aims, objectives, strategy and progress of the joint commissioning arrangements; and
c) publish an annual report on progress made against objectives. Commented [WM-NBC10]:
5.12.12 Should a joint commissioning arrangement prove to be unsatisfactory the Governing Body of the CCG can decide to withdraw from the arrangement, but has to give six months’ notice to partners to allow for credible alternative arrangements to be put in place, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months’ notice period.
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5.13 Joint Commissioning Arrangements with NHS England
5.13.1 The CCG may work together with NHS England. This can take the form of joint working in relation to the CCG’s functions or in relation to NHS England’s functions.
5.13.2 The CCG delegates its powers and duties under 5.13 to the Governing Body and all references in this part to the CCG should be read as the Governing Body, except to the extent that they relate to the continuing liability of the CCG under any joint arrangements. Commented [WM-NBC11]:
5.13.3 In terms of either the CCG’s functions or NHS England’s functions, the CCG and NHS England may make arrangements to exercise any of their specified commissioning functions jointly.
5.13.4 The arrangements referred to in paragraph 5.13.3 above may include other CCGs, a combined authority or a local authority.
5.13.5 Where joint commissioning arrangements pursuant to 5.13.3 above are entered into, the parties may establish a Joint Committee to exercise the commissioning functions in question. For the avoidance of doubt, this provision does not apply to any functions fully delegated to the CCG by NHS England, including but not limited to those relating to primary care commissioning.
5.13.6 Arrangements made pursuant to 5.13.3 above may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG.
5.13.7 Where the CCG makes arrangements with NHS England (and another CCG if relevant) as described at paragraph 5.13.3 above, the CCG shall develop and agree with NHS England a framework setting out the arrangements for joint working, including details of:
a) how the parties will work together to carry out their commissioning functions;
b) the duties and responsibilities of the parties, and the legal basis for such arrangements;
c) how risk will be managed and apportioned between the parties;
d) financial arrangements, including, if applicable, payments towards a pooled fund and management of that fund;
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e) contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.
5.13.8 Where any joint arrangements entered into relate to the CCG’s functions, the liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.13.3 above. Similarly, where the arrangements relate to NHS England’s functions, the liability of NHS England to carry out its functions will not be affected where it and the CCG enter into joint arrangements pursuant to 5.13.
5.13.9 The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning.
5.13.10 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the Governing Body.
5.13.11 The Governing Body of the CCG shall require, in all joint commissioning arrangements that the lead Governing Body Member for the joint arrangements make; Commented [WM-NBC12]:
a) make a quarterly written report to the Governing Body;
b) hold at least one annual engagement event to review the aims, objectives, strategy and progress of the joint commissioning arrangements; and
c) publish an annual report on progress made against objectives.
5.13.12 Should a joint commissioning arrangement prove to be unsatisfactory the Governing Body of the CCG can decide to withdraw from the arrangement but has to give six months’ notice to partners to allow for credible alternative arrangements to be put in place, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months’ notice period.
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6 Provisions for Conflict of Interest Management and Standards of Business Conduct
Commented [WM-NBC13]: Ensure management of COI 6.1 Conflicts of Interests and delivery of statutory duties are in AC’s duties under SORD 6.1.1 As required by section 14O of the 2006 Act, the CCG has made arrangements to manage conflicts and potential conflicts of interests to ensure that decisions made by the CCG will be taken and seen to be taken without being unduly influenced by external or private interests.
6.1.2 The CCG has agreed policies and procedures for the identification and management of conflicts of interests.
6.1.3 Employees, Members, Committee and Sub-Committee members of the CCG and members of the Governing Body (and its Committees, Sub- Committees, Joint Committees) will comply with the CCG policy on conflicts of interests. Where an individual, including any individual directly involved with the business or decision-making of the CCG and not otherwise covered by one of the categories above, has an interest, or becomes aware of an interest which could lead to a conflict of interests in the event of the CCG considering an action or decision in relation to that interest, that must be considered as a potential conflict, and is subject to the provisions of this Constitution and the Standards of Business Conduct Policy.
6.1.4 The Chair of the Audit Committee shall be the CCG’s Conflicts of Interest Guardian. In collaboration with the CCG’s governance lead, their role is to:
a) act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interests; b) be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to conflicts of interests; c) support the rigorous application of conflict of interest principles and policies; d) provide independent advice and judgment to staff and members where there is any doubt about how to apply conflicts of interests policies and principles in an individual situation e) provide advice on minimising the risks of conflicts of interests.
6.2 Declaring and Registering Interests
6.2.1 The CCG will maintain registers of the interests of those individuals listed in the CCG’s policy.
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6.2.2 The CCG will, as a minimum, publish the registers of conflicts of interest and gifts and hospitality of decision making staff at least annually on the CCG website and make them available at its offices upon request.
6.2.3 All relevant persons for the purposes of NHS England’s statutory guidance Managing Conflicts of Interest: Revised Statutory Guidance for CCGs 2017 must declare any interests. Declarations should be made as soon as reasonably practicable and by law within 28 days after the interest arises. This could include interests an individual is pursuing. Interests will also be declared on appointment and during relevant discussion in meetings.
6.2.4 The CCG will ensure that, as a matter of course, declarations of interest are made and confirmed, or updated at least annually. All persons required to, must declare any interests as soon as reasonable practicable and by law within 28 days after the interest arises.
6.2.5 Interests (including gifts and hospitality) of decision making staff will remain on the public register for a minimum of six months. In addition, the CCG will retain a record of historic interests and offers/receipt of gifts and hospitality for a minimum of six years after the date on which it expired.
6.2.6 Activities funded in whole or in part by 3rd parties who may have an interest in CCG business such as sponsored events, posts and research will be managed in accordance with the CCG’s policy to ensure transparency and that any potential for conflicts of interest are well- managed.
6.3 Training in Relation to Conflicts of Interest
6.3.1 The CCG will ensure that relevant staff and all Governing Body members receive training on the identification and management of conflicts of interests and that relevant staff undertake as a minimum the NHS England mandatory training.
6.4 Standards of Business Conduct
6.4.1 Employees, Members, Committee and Sub-Committee members of the CCG and members of the Governing Body (and its Committees, Sub- Committees, Joint Committees) will at all times comply with this Constitution and be aware of their responsibilities as outlined in it. They should:
a) act in good faith and in the interests of the CCG;
b) follow the Seven Principles of Public Life; set out by the Committee on Standards in Public Life (the Nolan Principles);
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c) comply with the standards set out in the Professional Standards Authority guidance - Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England; and
d) comply with the CCG’s Standards of Business Conduct, including the requirements set out in the policy for managing conflicts of interest which is available on the CCG’s website and will be made available on request.
6.4.2 Individuals contracted to work on behalf of the CCG or otherwise providing services or facilities to the CCG will be made aware of their obligation with regard to declaring conflicts or potential conflicts of interest. This requirement will be written into their contract for services and is also outlined in the CCG’s Standards of Business Conduct policy.
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Appendix 1: Definitions of Terms Used in This Constitution
2006 Act National Health Service Act 2006
Accountable Officer an individual, as defined under paragraph 12 of Schedule (AO) 1A of the 2006 Act, appointed by NHS England, with responsibility for ensuring the group: complies with its obligations under: sections 14Q and 14R of the 2006 Act, sections 223H to 223J of the 2006 Act, paragraphs 17 to 19 of Schedule 1A of the NHS Act 2006, and any other provision of the 2006 Act specified in a document published by NHS England for that purpose; exercises its functions in a way which provides good value for money.
Area The geographical area that the CCG has responsibility for, as defined in part 2 of this constitution
Chair of the CCG The individual appointed by the CCG to act as chair of the Governing Body Governing Body and who is usually either a GP member or a lay member of the Governing Body.
Chief Finance A qualified accountant employed by the group with Officer (CFO) responsibility for financial strategy, financial management and financial governance and who is a member of the Governing Body.
Clinical A body corporate established by NHS England in Commissioning accordance with Chapter A2 of Part 2 of the 2006 Act. Groups (CCG)
Committee A Committee created and appointed by the membership of the CCG or the Governing Body.
Sub-Committee A Committee created by and reporting to a Committee.
Governing Body The body appointed under section 14L of the NHS Act 2006, with the main function of ensuring that a Clinical
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Commissioning Group has made appropriate arrangements for ensuring that it complies with its obligations under section 14Q under the NHS Act 2006, and such generally accepted principles of good governance as are relevant to it.
Governing Body Any individual appointed to the Governing Body of the Member CCG
Healthcare A Member of a profession that is regulated by one of the Professional following bodies: the General Medical Council (GMC) the General Dental Council (GDC) the General Optical Council; the General Osteopathic Council the General Chiropractic Council the General Pharmaceutical Council the Pharmaceutical Society of Northern Ireland the Nursing and Midwifery Council the Health and Care Professions Council any other regulatory body established by an Order in Council under Section 60 of the Health Act 1999 Commented [WM-NBC14]: Include in JDs
Lay Member A Lay Member of the CCG Governing Body, appointed by the CCG. A lay Member is an individual who is not a Member of the CCG or a healthcare professional (as defined above) or as otherwise defined in law.
Primary Care A Committee required by the terms of the delegation from Commissioning NHS England in relation to primary care commissioning Committee functions. The Primary Care Commissioning Committee reports to NHS England and the Governing Body
Professional An independent body accountable to the UK Parliament Standards Authority which help Parliament monitor and improve the protection of the public. Published Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England in 2013
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Member/ Member A provider of primary medical services to a registered Practice patient list, who is a Member of this CCG.
Member practice Member practices appoint a healthcare professional to act representative as their practice representative in dealings between it and the CCG, under regulations made under section 89 or 94 of the 2006 Act or directions under section 98A of the 2006 Act.
NHS England The operational name for the National Health Service Commissioning Board.
Registers of Registers a group is required to maintain and make interests publicly available under section 14O of the 2006 Act and the statutory guidance issues by NHS England, of the interests of: the Members of the group; the Members of its CCG Governing Body; the Members of its Committees or Sub-Committees and Committees or Sub-Committees of its CCG Governing Body; and Its employees.
STP Sustainability and Transformation Partnerships – the Commented [WM-NBC15]: Is this referenced in the constitution anywhere? framework within which the NHS and local authorities have come together to plan to improve health and social care over the next few years. STP can also refer to the formal proposals agreed between the NHS and local councils – a “Sustainability and Transformation Plan”.
Joint Committee Committees from two or more organisations that work together with delegated authority from both organisations to enable joint decision-making
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Appendix 2: Committee Terms of Reference Audit Committee – to be defined Remuneration Committee – to be defined Primary Care Commissioning Committee – to be defined
Appendix 3: Standing Orders 1. Statutory Framework and Status 1.1 These standing orders have been drawn up to regulate the proceedings of NHS Bedfordshire Luton and Milton Keynes Clinical Commissioning Group (“the CCG”) so that the CCG can fulfil its obligations, as set out in the NHS Act 2006 (the “Act”) and relevant statutory guidance issued by NHS England. They are effective from [date].
1.2 The standing orders, together with the CCG’s scheme of reservation and delegation and the CCG’s detailed financial policies, provide a procedural framework within which the CCG discharges its business. They set out:
a) the arrangements for conducting the business of the CCG; b) the appointment of member practice representatives and other members of the governing body; c) the procedure to be followed at meetings of the CCG, the Governing Body and any committees or sub-committees of the CCG or the Governing Body; d) the process to delegate powers; e) the process for identifying, declaring and managing conflicts of interest and; f) the standards of business conduct. 1.3 CCG members, members of the Governing Body, members of the Governing Body’s committees and sub-committees, members of the CCG’s committees and sub-committees, employees, and persons working on behalf of the CCG should be aware of the existence of these documents and, where necessary, be familiar with their detailed provisions. Failure to comply with the standing orders, scheme of reservation and delegation and prime financial policies may be regarded as a disciplinary matter that could result in dismissal.
1.4 These standing orders apply to the members’ forum and any committees of the members, unless it is stated that they do not.
1.5 These standing orders apply to the governing body and any committees of the governing body unless it is stated that they do not.
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2. Scheme of Reservation and Delegation
2.1 The 2006 Act provides the CCG with powers to delegate the CCG’s functions and those of the Governing Body to certain bodies (such as committees) and certain persons.
2.2 The CCG has decided that certain decisions may only be exercised by the membership of the CCG in formal session. Members will transact matters reserved to the membership at meetings of the members known as The Members’ Forum. A list of reserved matters is detailed in the Scheme of Reservation and Delegation.
2.3 All other matters are delegated to the Governing Body, its committees, or the executive directors of the CCG. Full details relating to matter reserved and delegated are to be found in the CCG’s scheme of reservation and delegation which is published on the CCG website.
3 Composition of the Membership and the CCG’s Governing Body
3.1. Composition of membership
3.1.1. The CCG is a membership body comprised GP practices in the Bedfordshire area. Full details of the area covered and a list member practices is included in the constitution.
3.1.2 The nature of the membership and relationship with the CCG are set out in the constitution section 3.
3.1.3 Full meetings of the membership are to be known as The Members’ Forum.
3.1.4 Members are represented at the Members’ forum by the healthcare professional that they nominate to deal with the CCG on their behalf. This individual must be a healthcare professional as defined in the legislation. Each practice is free to determine how they select an individual who fulfils the requirements. For clarity, whilst it must be a healthcare professional it need not be a GP and it is also permitted for a practice to nominate an employee from another practice if they choose to do so.
3.2. Key roles and appointments to the governing body
3.2.1. The CCG’s Constitution sets out the composition of the CCG’s Governing Body.
3.2.2. Each role on the governing body is defined by a role description. A person specification is drafted at the point of recruitment to aid the selection process.
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3.2.3. Members of the governing body comprise individuals appointed to represent the membership, appointed members (including lay members) and executive members.
3.2.4. The chair will be appointed using the process set out for member representatives.
3.2.5. The vice chair will be the Lay Member for Patient and Public Engagement
3.2.6 All members of the governing body will fulfil the requirements set out in the CCG Regulations 2012.
3.2.7. All members of the Members’ Forum, Governing Body and all sub committees will abide by the seven principles of public life; the ‘Nolan Principles’ which are detailed in the Governance Handbook, and adhere to the Standards of Business Conduct Policy which includes information on Conflict of Interest and how these should be handled during meetings.
3.3. Members Representatives on the Governing Body
3.3.1. The Members of the CCG will play a key role in the appointment of seven individuals to the governing body to represent the voice of the membership.
3.3.2. The Members of the CCG will also play a key role in the appointment of an individual to be the Chair of the CCG.
3.3.3. Each role will be described in a role description and have an accompanying specification that describes the skills, experience and characteristics required to fulfil the role.
3.3.4. The Appointment Process the CCG will follow is as follows:
a. Application and Initial Assessment
• The CCG shall issue an invitation for expressions of interest in the role of member representative on the Governing Body to members. • Individuals who complete an expression of interest shall be assessed against: o statutory eligibility criteria; o any conflicts of interests they may have if they became a member representative. • Those that are eligible to become member representatives shall be assessed against the role description • The assessment shall be done by a panel made up of: o At least three individuals from members practices, excluding anyone who may have a conflict of interest in the assessment process (e.g. colleagues in the same Member practice as the applicant) o The Accountable Officer or any executive director the Accountable Officer nominates to undertake this task
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o The CCG’s lay Vice Chair o A person, either from the CCG or an outside organisation, with expertise that allows them to provide advice and guidance in recruitment processes and candidate selection o An independent GP from outside the CCG area • The panel shall decide which of the applicants the CCG may take forward as candidates to the next stage of the process
b) Interview and Formal Assessment
• The CCG shall arrange a process to interview candidates that shall at a minimum include a structured interview and a stakeholder panel made up of CCG Members. • The CCG shall ask candidates to undertake a formal assessment of their skills, aptitudes or any other factor important to successfully undertaking the role. • The CCG shall select the best qualified candidate based on this assessment and offer them the post of member representative.
c) Appointment
• The CCG’s appointment shall be ratified by a vote at the Members’ Forum • The appointment shall be for an initial three year term
d) At the End of the Member Representative’s Term
• At the end of the member representative’s first three year term the CCG may offer them a second term of up to three years, • The extension shall be ratified by a vote at the Members’ Forum • At the end of the member representative’s second term the full appointment process shall be followed, and if that person is reappointed it shall be as if it were to their first term.
3.4 Appointment of the CCG’s Clinical Chair
3.3.1 The process for appointing the CCG’s Clinical Chair shall be the same as the process for appointing member representatives.
3.5 Appointed Members of the Governing Body
3.5.1 The CCG shall appoint individuals to the roles of:
• Secondary Care Doctor; • Independent Registered Nurse; and • Lay Member (three).
3.5.2. The appointments will be made following an openly advertised application and assessment process
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3.5.3 Each role will be described in a role description and have an accompanying specification that describes the skills, experience and characteristics required to fulfil the role.
3.5.4 Application: Individuals will complete an application process which will include setting out their key characteristics against a published specification.
3.5.5 Assessment: An appointments panel appointed by the governing body and supported by suitably qualified and experienced advisers will assess the applications using, as a minimum, a paper-based screen and interview.
3.5.6 Eligibility and exclusion: Individuals will not be appointed unless they meet the requirements of the descriptions (including the exclusion criteria) set out in the CCG Regulations 2012.
3.5.7 Term of office:
• At the end of the appointed member’s first three year term the CCG may offer them a second term of up to three years, • At the end of the appointed member’s second term the full appointment process shall be followed, and if that person is reappointed it shall be as if it were to their first term.
3.6 Executive Members of the Governing Body 3.6.1 Executive members of the Governing body become members by virtue of their employment into a management role in the CCG. These roles include:
• The Accountable Officer • The Chief Finance Officer • The Medical Director • The Chief Nurse • The Director of Primary Care • The Director of Performance and Governance
3.6.2 Each role will be described in a role description and have an accompanying specification that describes the skills, experience and characteristics required to fulfil the role.
3.6.3 Executive members are appointed following a formal standard recruitment process during which competency against the defined specification is assessed.
3.6.4 The Accountable Officer appointment process is subject to requirements set out by NHS England and the process will include a CCG panel convened by
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the chair. The appointment is subject to formal ratification by NHS England following selection and nomination by the CCG.
3.6.5 Other executive members of the governing body are appointed by a panel convened by the Accountable Officer.
3.6.6 Membership of the governing body is terminated when an individual’s contract of employment is terminated.
3.7 Deputy Arrangements
3.7.1 Where any member of the Governing Body is unable to attend a meeting, they may appoint a deputy, who will subject to the agreement of the Chair in advance of the meeting be permitted to speak in place of that member to relevant agenda items.
3.7.2 Deputies will not contribute to the quorum and will not be permitted to vote.
3.8 Removal from Office
3.8.1 Members of the Governing Body and its committees shall vacate their office if any of the following occurs:
• If they fail to attend a minimum of 75% of the meetings to which they are invited. • If they are deemed to not been the expected standards of performance at their annual appraisal. • If they no longer fulfil the requirements of their role or become ineligible for the role as set out in The CCG regulations (2012) Schedules 4 and 5. • If they have behaved in a manner or exhibited conduct which has or is likely to be detrimental to the honour and interest of the Governing Body or the CCG and is likely to bring the Governing Body or the CCG into disrepute. This includes but it is not limited to: o dishonesty; o misrepresentation (either knowingly or fraudulently); o defamation of any member of the Governing Body (being slander or libel); o abuse of position; o non-declaration of a known conflict of interest; o seeking to manipulate a decision of the Governing Body in a manner that would ultimately be in favour of that member whether financially or otherwise. • Are subject to disciplinary proceedings by a regulator or professional body
3.8.2 Members will be suspended pending the outcome of an investigation if they are suspended or under investigation by a regulator or professional body.
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3.9 Notice Period 3.9.1 Executive members’ notice period is defined in their contract of employment.
3.9.2 For all other members a three-month notice period is required to be given in writing to the chair.
4. Meetings and Decision Making 4.1. Introduction and scope
4.1.1 The following applies to all meetings of the CCG, including the Members’ Forum, the Governing Body and all Governing Body committees.
4.2. Calling meetings
4.2.1 The CCG shall set out a calendar of meetings at the start of each business cycle which will include, but not be limited to, meetings of the Governing Body, Audit Committee, Remuneration Committee and all meetings that provide assurance to the Governing Body.
4.2.2 Meetings shall be held at such times and places as the CCG may determine.
4.2.3 The Chair of the CCG or the relevant meeting or committee may call an additional meeting at any time.
4.2.4 Fifty per cent of the CCG’s Members, the Governing Body or a relevant meeting may request a meeting in writing.c If the Chair refuses, or fails, to call a meeting within seven days of such a request being presented, the members signing the request may forthwith call a meeting.
4.3. Agenda and supporting papers
4.3.1 Items of business for inclusion on the agenda of a meeting need to be notified to the Chair at least 10 working days before the meeting takes place.
4.3.2 Agendas will be agreed between the chair and the relevant executive lead.
4.3.3 Supporting papers for agenda items must be accompanied by an agreed cover-sheet and submitted to the committee secretariat at least seven working days before the meeting takes place.
4.3.4 The agenda and supporting papers will be circulated to all members of a meeting and agreed circulation list at least five working days before the date of the meeting.
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4.3.5 Agendas and certain papers for the CCG’s Governing Body and other meetings that are held in public– including details about meeting dates, times and venues - will be published on the CCG’s website.
4.4. Petitions
4.4.1 Where a petition has been received by the CCG, the chair of the Governing Body shall include the petition as an item for the agenda of the next meeting of the Governing Body.
4.5. Chair of a meeting
4.5.1 If the nominated chair is absent from the meeting, the deputy chair, if any and if present, shall preside.
4.5.2 If the chair is absent temporarily, for example on the grounds of a declared conflict of interest, the deputy chair, if present, shall preside.
4.5.3 If both the chair and deputy chair are absent, or are disqualified from participating, another participating member of the relevant committee shall be chosen by the members present, or by a majority of them, and shall preside.
4.6. Chair's ruling
4.6.1 The decision of the chair of the Governing Body on questions of order, relevancy and regularity and their interpretation of the constitution, standing orders, scheme of reservation and delegation and prime financial policies at the meeting, shall be final.
4.7. Remote meetings
4.7.1 Use of video, telephone or other communication facilities to conduct meetings are permissible with the agreement of the prior agreement of the chair.
4.7.2 The chair will take into account the difficulties that might be posed to ensure proper access by the public should it be necessary to hold remote meetings and will make adjustments where possible.
4.8. Quorum
4.8.1. The quorum of the Members’ Forum will be 50% of the member practices represented.
4.8.2. The quorum of the Governing Body will be 50% of the members of the governing body. Vacant posts will not be included in the total number.
4.8.3. In addition, at the Governing Body, no business shall be transacted at a meeting unless the following are present:
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• At least three health care professionals, at least one of whom is a GP; and • At least one lay member; and • Either the Accountable Officer of the Chief Finance Officer; and • Either the Chair or Vice Chair.
4.8.4 The same quorum will apply to any decision requiring a governing body vote that is held outside of a meeting.
4.8.5 If members of a meeting are temporarily excluded due to a conflict of interest, with the agreement of the chair, they will not be counted in the total number for the purpose of quoracy.
4.8.6 If a group of members are temporarily excluded due to a conflict of interest, and this results in a failure to meet the requirements of paragraph 4.8.2 (or specific quoracy requirements set out in the relevant terms of reference) with the agreement of the chair the requirement for that category of member to be present will be relaxed.
4.8.7 For committees and sub-committees of the Governing Body, the details of the quorum for these meetings are set out in the appropriate terms of reference.
4.9. Decision making
4.9.1 The CCG’s Constitution, together with the scheme of reservation and delegation, sets out the CCG’s structure and the arrangements made by the CCG for the exercise of the CCG’s statutory functions.
4.9.2 It is expected that decisions will usually be reached by consensus. Should this not be possible then a vote will be required, the process for which is set out below:
4.9.3 Only members of the relevant committee or meeting may vote.
4.9.4 Eligibility to attend a meeting, or have speaking rights at a meeting, does not in itself confer a right to vote.
4.9.5 The vote will be determined by a show of hands of those present in the room or via ballot using electronic means subject to the agreement of the chair.
4.9.6 The majority necessary to confirm a decision will be a simple majority of votes cast.
4.9.7 In the case of an equal number of votes the person chairing the meeting shall have an addition, casting vote.
4.9.8 Should a vote be taken, the outcome of the vote, and any dissenting views, will be recorded in the minutes of the meeting.
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4.10. Emergency powers and urgent decisions
4.10.1 In an emergency, or for an urgent decision, the powers of the Governing Body may be exercised by the Chair and the Accountable Officer after having consulted at least one lay member and one member practice representative on the governing body. In such circumstances, reasonable effort will be made to communicate with and engage the wider membership of the governing body or committee. The exercise of such powers by the Chair and Accountable Officer shall be reported to the next formal meeting of the governing body session for formal ratification. Commented [WM-NBC16]:
4.10.2 In an emergency, or for an urgent decision, the powers of committees and sub-committees of the CCG may be exercised by the Chair and lead executive officer for that Committee after having consulted at least one other member of the committee. The exercise of such powers shall be reported to the next formal meeting for formal ratification. Commented [WM-NBC17]:
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4.11. Suspension of Standing Orders
4.11.1 Except where it would contravene any statutory provision or any direction made by the Secretary of State for Health or NHS England, any part of these standing orders may be suspended at any meeting of the CCG (including the governing body and its committees and sub committees and the members forum), provided 75% of the people eligible to vote at the meeting in question are in agreement.
4.11.2 A decision to suspend standing orders together with the reasons for doing so shall be recorded in the minutes of the relevant meeting.
4.11.3 The suspension shall be for an agreed period and not longer than six months in the first instance.
4.11.4 A separate record of matters agreed, approved, or taken for assurance during the suspension shall be kept. These records shall be made available to the Governing Body’ and presented to the first Audit Committee after the suspension has been lifted for review of the reasonableness of the decisions taken during the suspension period.
4.12. Record of Attendance
4.12.1 All minutes of meetings will include the full names of members present and, their title or role. If such a record is not taken, the minutes of that meeting may not be taken as a full and accurate record of the meeting and its shall not be deemed to have been quorate.
4.13. Minutes
4.13.1 The minutes of the proceedings of a meeting shall be drawn up within five working days and a draft agreed with the chair.
4.13.2 The draft minutes will be circulated within 10 working days to all members and regular attendees (as specified in the constitution or relevant terms of reference) along with a log of agreed actions.
4.13.3 Draft minutes will be submitted for agreement at the next meeting where if approved they shall be the formal record of the meeting.
4.13.4 No discussion shall take place upon the minutes except upon their accuracy unless the Chair deems discussion to be appropriate. Any matters arising and a review of the updated log of actions from previous meetings shall be addressed as a separate agenda item.
4.13.5 Minutes from all meetings held in public including, but not limited to the Governing Body will be published on Bedfordshire CCGs web pages.
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4.13.6 At the discretion of the chair, the CCG may choose to publish other, non- confidential meetings’ papers.
4.14. Admission of public and the press
4.14.1 Some meetings of the CCG (including but not necessarily limited to the Governing Body and Primary Care Commissioning Committee) are held in public and as such members of the public and representatives of the press may attend to observe meetings.
4.14.2 No-one other than the members of the relevant committee may address the committee or attendees unless specifically invited by the chair to do so.
4.14.3 All persons other than those that are members or invited attendees (as specified in the Constitution or relevant terms of reference) will be excluded from any meeting or part of a meeting where it is deemed that it is not in the public interest for them to attend. Such circumstances will be limited to discussions relating to a matter of a confidential nature regarding an individual, or small group of individuals, where their identity could be revealed or to a matter which may be commercially sensitive.
4.14.4 In such circumstances the Governing Body or committee will resolve that ‘representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’, Section 1(2), Public Bodies (Admission to Meetings) Act 1960
4.15. Appointment of Committees and Sub-committees
4.15.1 The CCG may appoint committees and sub-committees of the CCG. The Governing Body may also appoint committees and sub-committees.
4.15.2 Other than where there are statutory requirements, or requirements set out in statutory guidance by NHS England, the Governing Body (or Members’ Forum for committees of the CCG) shall determine the membership and terms of reference of its committees and sub-committees and approve the appointment of members.
4.15.3 The Governing Body (or Members’ Forum if appropriate) will receive and consider reports from its committees at the next appropriate meeting.
4.15.4 The provisions of these standing orders shall apply where relevant to the operation of the Members’ Forum, and Governing Body, and all committees and sub-committees unless stated otherwise in the relevant terms of reference.
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4.16. Terms of Reference
4.16.1 All committees and sub-committees of the CCG and its Governing Body will operate within a set of terms of reference.
4.16.2 The terms of reference of committees and sub-committees will be approved by and may be amended by the Members’ forum or the Governing Body as appropriate. Commented [WM-NBC18]:
4.17. Delegation of Powers by Committees to Sub-committees
4.17.1 Where committees are authorised to establish sub-committees they may not delegate executive powers to the sub-committee unless expressly authorised by the Governing Body. Commented [WM-NBC19]:
5. Non-compliance
5.1 If for any reason these standing orders are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Governing Body for action or ratification.
5.2 All members of the CCG and staff have a duty to disclose any non- compliance with these standing orders to the accountable officer as soon as possible.
5.3 All instances of non-compliance should be reported to the Audit and Risk Committee. Commented [WM-NBC20]:
6. Use of the Seal and Authorisation of Documents
6.1. CCG’s seal
6.1.1 The CCG has use of a seal for executing documents where necessary. The following individuals or officers are authorised to authenticate its use by their signature:
• the Accountable Officer; • the Chair of the Governing Body; • the Chief Finance Officer; • the Chief Operating Officer
6.1.2 The following individuals are authorised to execute a document on behalf of the CCG by their signature • the Accountable Officer • the Chair of the Governing Body • the Chief Finance Officer
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• the Chief Operating Officer.
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Appendix 4: Standing Financial Instructions 4.1 COMMISSIONING CONTRACTS AUTHORISATION LIMITS
Agreement of NHS funded contracts for NHS patient services Contract Variations to NHS funded contracts for NHS patient services
Accountable Chief Finance CCG Chief Delegated Accountable Officer Chief Finance CCG Chief Delegated Budget Officer (on behalf Officer or Chief Operating Officer Budget Holder, (on behalf of the Officer or Chief Operating Holder, including of the Gov Body) Operating Officer or an authorised including Locality Gov Body) Operating Officer Officer Locality Business or an authorised or an authorised Deputy Business or an authorised or an authorised or an authorised Managers (per list Deputy Deputy Managers (per list Deputy Deputy Deputy held by Finance) held by Finance)
Over Up to Up to Up to Over Up to Up to Up to NHS Trusts & NHS Foundation Trusts Local NHS Providers to the BLMK CCG £60 million £60 million £25 million £1.5 million £1.5 million £600,000 £300,000
Other NHS Trusts £12 million £12 million £6 million £1.5 million £1.5 million £1.5 million £600,000 £120,000 where BLMK CCG is Lead Commissioner
Other NHS Providers £12 million £12 million £6 million £1.5 million £1.5 million £1 million £600,000 £120,000 where another CCG is Lead Commissioners
Non NHS Providers
Providers of NHS £1 million £1 million £500,000 CHC Team £200,000 £200,000 £100,000 £50,000 funded care up to £2,000 p.w. for 12 week periods non-CHC £250,000
4.2 HEALTHCARE INVOICE AUTHORISATION LIMITS
Authorising Invoices for agreed Authorising all other commissioning expenditure outside the Commissioning Contracts Commissioning Contract Accountable Delegated Budget Officer (on Relevant CCG CFO or Relevant CCG Delegated Budget Holder, incl behalf of the Chief Operating Chief Chief Operating Holder, incl Locality Business Governing Officer or Deputy Operating Officer or Deputy Locality Business Managers (per list Body) CFO Officer CFO Managers ( per list held by Finance) or an or an held by Finance) authorised authorised Deputy Deputy
Over Up to Over Up to Up to Up to
NHS PROVIDERS BLMK CCG NHS Trust or FT £500,000 £500,000
Other NHS Trusts where BLMK CCG is lead £500,000 £500,000 commissioner
Other NHS Trusts where a non BLMK CCG £500,000 £500,000 is the Lead Commissioner Non Commissioned / £50,00 N/A N/A £200,000 £200,000 £100,000 Contracted Activity 0
NON NHS PROVIDERS
Providers of NHS Funded £100,000 £100,000 Care
Non Commissioned / N/A N/A Contracted Activity £200,000 £200,000 £100,000 £50,000
4.3 GOODS AND SERVICES CONTRACTS
Agreement of Good and Services Contracts following quotation Contract Variations to Good and Services Contracts following or tender process quotation or tender process
Accountable Chief Finance CCG Chief Delegated Accountable Chief Finance CCG Chief Delegated Officer (on Officer or Chief Operating Officer Budget Holder, Officer (on behalf Officer or Chief Operating Budget Holder, behalf of the Operating including of the Gov Body) Operating Officer or an including Gov Body) or an Officer or an Locality or an authorised Officer or an authorised Locality authorised authorised Business Deputy authorised Deputy Business Deputy Deputy Managers (per list Deputy Managers (per list held by Finance) held by Finance)
Over Up to Up Up to Over Up to Up to Up to to Good and Services £1 million £1 million £600,000 £10,000 £500,000 £500,000 £300,000 £5,000
Building and £1 million £1 million £600,000 £10,000 £500,000 £500,000 £300,000 £5,000 Engineering
Note The signatory of the contract for goods and service is not the person that has sought the tender or quotation or has been a participant in a procurement evaluation process
DRAFT
NHS BEDFORDSHIRE, LUTON AND MILTON KEYNES CLINICAL COMMISSIONING GROUP
GOVERNANCE HANDBOOK CONTENTS
1 Introduction ...... 3
2 Membership ...... 3
3 Members’ Rights, Roles and Responsibilities ...... 3
4 Governing Body Committees’ Terms of Reference ...... 3 4.1 Audit Committee ...... 3 4.2 Remuneration Committee ...... 3 4.3 Primary Care Commissioning Committee ...... 3 4.4 Finance and Performance Committee ...... 4 4.5 Quality and Performance Committee ...... 4 4.6 Patient and Public Engagement Committee ...... 4 4.7 Forums ...... 4 4.8 Other Groups or Meetings ...... 4
5 Committees of the CCG ...... 5 5.1 Governing Body ...... 5 5.2 Members’ Forum ...... 5
6 Roles and Responsibilities ...... 5 6.1 To be Populated once Terms of Reference are Complete ...... 6
7 Standing Orders ...... 6
8 Standing Financial Instructions & Detailed Financial Policies ...... 20
9 Scheme of Reservation and Delegation ...... 47
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1 Introduction
1.1 The Governance Handbook provides information to the CCG, its Governing Body, Membership and CCG workers about how the CCG will conduct its affairs.
2 Membership 2.1 The CCG is a membership organisation and is accountable to its Members. 2.2 The CCG’s Membership has a number of rights, roles and responsibilities that are also set out in this Handbook. 3 Members’ Rights, Roles and Responsibilities 3.1 The rights of the CCG’s Member Practices are set out in section 3 of the CCG’s Constitution 3.2 Powers reserved to the CCG’s Membership are set out in the CCG’s Scheme of Reservation and Delegation 3.3 The role and responsibilities of the CCG’s Membership are set out in the terms of reference of the CCG’s Members’ Forum
4 Governing Body Committees’ Terms of Reference
The CCG’s Governing Body has resolved to establish the following committees:
4.1 Audit Committee
The Audit Committee’s Terms of Reference are to be drafted by the three CCG’s equivalent committees. Because this Committee is a statutory Committee its terms of reference shall also be included in the Constitution as an appendix. 4.2 Remuneration Committee The Remuneration Committee’s Terms of Reference are to be drafted by the three CCG’s equivalent committees Because this Committee is a statutory Committee its terms of reference shall also be included in the Constitution as an appendix. 4.3 Primary Care Commissioning Committee The Primary Care Commissioning Committee’s Terms of Reference are to be drafted by the three CCG’s equivalent committees.
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Because this Committee is a statutory Committee its terms of reference shall also be included in the Constitution as an appendix. 4.4 Finance and Performance Committee The Finance and Performance Committee’s Terms of Reference are to be drafted by the three CCG’s equivalent Committee. 4.5 Quality and Performance Committee The Quality and Performance Committee’s Terms of Reference are to be drafted by the three CCG’s equivalent Committee. 4.6 Patient and Public Engagement Committee The Patient and Public Engagement Committee’s Terms of Reference are to be drafted by the three CCG’s equivalent Committee. 4.7 Forums 4.7.1 The CCG’s Governing Body may establish and disestablish forums that focus on key themes, strategies or deliverables.
4.7.2 The Governing Body has resolved to establish the following forums:
4.7.2.1 A Clinical Commissioning Forum that shall support the work of the Finance Committee
4.7.2.2 An Equality and Diversity Forum that shall support the work of the Governing Body
4.8 Other Groups or Meetings
4.8.1 The CCG’s Governing Body may also establish, or approve its committees to establish additional sub-committees or other groups.
4.8.2 No sub-committees or other groups shall be established without appropriate authorisation in line with the CCG’s Scheme of Reservation and Delegation.
4.8.3 Only a committee of the Governing Body may be named as a committee.
4.8.4 An indicative naming convention for these other meetings is set out below:
Name Status and Reporting Line Sub- a temporary or permanent group that has a general function Committee or power delegated to it from a Committee of the Governing Body, and reports to that Committee
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Joint a temporary or permanent group established jointly with one Committee or more other organisations and has a general function or power delegated to it from the CCG’s Governing Body and all other parties and reports to the Governing Body or a committee of the Governing Body. Working A temporary group established to perform a specific function Group or strategy and is tasked with the management or delivery of that function/strategy and is accountable to either the Executive Team, the Governing Body or a committee of the Governing Body. Board A temporary group established to oversee the delivery of a programme or project for assurance of successful delivery of that programme or project and is accountable to either the Executive Team, the Governing Body or a committee of the Governing Body. Meeting A permanent or temporary group with no formal powers but is convened to support the delivery of one or more operational functions. Meetings are accountable to the Executive Team or an individual Executive Director, or someone to whom the Executive Director has delegated accountability.
5 Committees of the CCG
5.1 Governing Body
5.1.1 The CCG has established a Governing Body whose membership, roles and responsibilities are set out in the CCG’s Constitution
5.1.2 The CCG’s Governing Body has reserved or delegated powers as set out in the CCGs Constitution.
5.2 Members’ Forum
5.2.1 The CCG has established a Members’ Forum whose membership, roles and responsibilities are set out in the CCG’s Constitution.
5.2.2 The Members’ Forum shall have a terms of reference that set out how it will function. These terms of reference shall be designed with and agreed wit hthe CCG’s Membership.
6 Roles and Responsibilities
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6.1 To be Populated once Terms of Reference are Complete
7 Standing Orders 7.1. Statutory Framework and Status 7.1.1 These standing orders have been drawn up to regulate the proceedings of NHS Bedfordshire Luton and Milton Keynes Clinical Commissioning Group (“the CCG”) so that the CCG can fulfil its obligations, as set out in the NHS Act 2006 (the “Act”) and relevant statutory guidance issued by NHS England. They are effective from [date].
7.1.2 The standing orders, together with the CCG’s scheme of reservation and delegation and the CCG’s detailed financial policies, provide a procedural framework within which the CCG discharges its business. They set out:
a) the arrangements for conducting the business of the CCG; b) the appointment of member practice representatives and other members of the governing body; c) the procedure to be followed at meetings of the CCG, the Governing Body and any committees or sub-committees of the CCG or the Governing Body; d) the process to delegate powers; e) the process for identifying, declaring and managing conflicts of interest and; f) the standards of business conduct. 7.1.3 CCG members, members of the Governing Body, members of the Governing Body’s committees and sub-committees, members of the CCG’s committees and sub-committees, employees, and persons working on behalf of the CCG should be aware of the existence of these documents and, where necessary, be familiar with their detailed provisions. Failure to comply with the standing orders, scheme of reservation and delegation and prime financial policies may be regarded as a disciplinary matter that could result in dismissal. 7.1.4 These standing orders apply to the members’ forum and any committees of the members, unless it is stated that they do not.
7.1.5 These standing orders apply to the Governing Body and any committees of the Governing Body unless it is stated that they do not.
7.2 Scheme of Reservation and Delegation 7.2.1 The 2006 Act provides the CCG with powers to delegate the CCG’s functions and those of the Governing Body to certain bodies (such as committees) and certain persons.
7.2.2 The CCG has decided that certain decisions may only be exercised by the membership of the CCG in formal session. Members will transact matters
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reserved to the membership at meetings of the members known as The Members’ Forum. A list of reserved matters is detailed in the Scheme of Reservation and Delegation.
7.2.3 All other matters are delegated to the Governing Body, its committees, or the executive directors of the CCG. Full details relating to matter reserved and delegated are to be found in the CCG’s scheme of reservation and delegation which is published on the CCG website.
7.3 Composition of the Membership and the CCG’s Governing Body
7.3.1. Composition of membership
7.3.1.1 The CCG is a membership body comprised GP practices in the Bedfordshire area. Full details of the area covered and a list member practices is included in the constitution.
7.3.1.2 The nature of the membership and relationship with the CCG are set out in the constitution section 3.
7.3.1.3 Full meetings of the membership are to be known as The Members’ Forum.
7.3.1.4 Members are represented at the Members’ forum by the healthcare professional that they nominate to deal with the CCG on their behalf. This individual must be a healthcare professional as defined in the legislation. Each practice is free to determine how they select an individual who fulfils the requirements. For clarity, whilst it must be a healthcare professional it need not be a GP and it is also permitted for a practice to nominate an employee from another practice if they choose to do so.
7.3.2 Key roles and appointments to the governing body
7.3.2.1 The CCG’s Constitution sets out the composition of the CCG’s Governing Body.
7.3.2.2 Each role on the governing body is defined by a role description. A person specification is drafted at the point of recruitment to aid the selection process.
7.3.2.3 Members of the governing body comprise individuals appointed to represent the membership, appointed members (including lay members) and executive members.
7.3.2.4 The chair will be appointed using the process set out for member representatives.
7.3.2.5 The vice chair will be the Lay Member for Patient and Public Engagement
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7.3.2.6 All members of the governing body will fulfil the requirements set out in the CCG Regulations 2012.
7.3.2.7 All members of the Members’ Forum, Governing Body and all sub committees will abide by the seven principles of public life; the ‘Nolan Principles’ which are detailed in the Governance Handbook, and adhere to the Standards of Business Conduct Policy which includes information on Conflict of Interest and how these should be handled during meetings.
7.3.3 Members Representatives on the Governing Body
7.3.3.1 The Members of the CCG will play a key role in the appointment of seven individuals to the governing body to represent the voice of the membership.
7.3.3.2 The Members of the CCG will also play a key role in the appointment of an individual to be the Chair of the CCG.
7.3.3.3 Each role will be described in a role description and have an accompanying specification that describes the skills, experience and characteristics required to fulfil the role.
7.3.3.4 The Appointment Process the CCG will follow is as follows:
a. Application and Initial Assessment
• The CCG shall issue an invitation for expressions of interest in the role of member representative on the Governing Body to members. • Individuals who complete an expression of interest shall be assessed against: o statutory eligibility criteria; o any conflicts of interests they may have if they became a member representative. • Those that are eligible to become member representatives shall be assessed against the role description • The assessment shall be done by a panel made up of: o At least three individuals from members practices, excluding anyone who may have a conflict of interest in the assessment process (e.g. colleagues in the same Member practice as the applicant) o The Accountable Officer or any executive director the Accountable Officer nominates to undertake this task o The CCG’s lay Vice Chair o A person, either from the CCG or an outside organisation, with expertise that allows them to provide advice and guidance in recruitment processes and candidate selection o An independent GP from outside the CCG area • The panel shall decide which of the applicants the CCG may take forward as candidates to the next stage of the process
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b) Interview and Formal Assessment
• The CCG shall arrange a process to interview candidates that shall at a minimum include a structured interview and a stakeholder panel made up of CCG Members. • The CCG shall ask candidates to undertake a formal assessment of their skills, aptitudes or any other factor important to successfully undertaking the role. • The CCG shall select the best qualified candidate based on this assessment and offer them the post of member representative.
c) Appointment
• The CCG’s appointment shall be ratified by a vote at the Members’ Forum • The appointment shall be for an initial three year term
d) At the End of the Member Representative’s Term
• At the end of the member representative’s first three year term the CCG may offer them a second term of up to three years, • The extension shall be ratified by a vote at the Members’ Forum • At the end of the member representative’s second term the full appointment process shall be followed, and if that person is reappointed it shall be as if it were to their first term.
7.3.4 Appointment of the CCG’s Clinical Chair
7.3.4.1 The process for appointing the CCG’s Clinical Chair shall be the same as the process for appointing member representatives.
7.3.5 Appointed Members of the Governing Body
7.3.5.1 The CCG shall appoint individuals to the roles of:
• Secondary Care Doctor; • Independent Registered Nurse; and • Lay Member (three).
7.3.5.2 The appointments will be made following an openly advertised application and assessment process
7.3.5.3 Each role will be described in a role description and have an accompanying specification that describes the skills, experience and characteristics required to fulfil the role.
7.3.5.4 Application: Individuals will complete an application process which will include setting out their key characteristics against a published specification.
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7.3.5.5 Assessment: An appointments panel appointed by the governing body and supported by suitably qualified and experienced advisers will assess the applications using, as a minimum, a paper-based screen and interview.
7.3.5.6 Eligibility and exclusion: Individuals will not be appointed unless they meet the requirements of the descriptions (including the exclusion criteria) set out in the CCG Regulations 2012.
7.3.5.7 Term of office:
• At the end of the appointed member’s first three year term the CCG may offer them a second term of up to three years, • At the end of the appointed member’s second term the full appointment process shall be followed, and if that person is reappointed it shall be as if it were to their first term.
7.3.6 Executive Members of the Governing Body 7.3.6.1 Executive members of the Governing body become members by virtue of their employment into a management role in the CCG. These roles include:
• The Accountable Officer • The Chief Finance Officer • The Medical Director • The Chief Nurse • The Director of Primary Care • The Director of Performance and Governance
7.3.6.2 Each role will be described in a role description and have an accompanying specification that describes the skills, experience and characteristics required to fulfil the role.
7.3.6.3 Executive members are appointed following a formal standard recruitment process during which competency against the defined specification is assessed.
7.3.6.4 The Accountable Officer appointment process is subject to requirements set out by NHS England and the process will include a CCG panel convened by the chair. The appointment is subject to formal ratification by NHS England following selection and nomination by the CCG.
7.3.6.5 Other executive members of the governing body are appointed by a panel convened by the Accountable Officer.
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7.3.6.6 Membership of the governing body is terminated when an individual’s contract of employment is terminated.
7.3.7 Deputy Arrangements
7.3.7.1 Where any member of the Governing Body is unable to attend a meeting, they may appoint a deputy, who will subject to the agreement of the Chair in advance of the meeting be permitted to speak in place of that member to relevant agenda items.
7.3.7.2 Deputies will not contribute to the quorum and will not be permitted to vote.
7.3.8 Removal from Office
7.3.8.1 Members of the Governing Body and its committees shall vacate their office if any of the following occurs:
• If they fail to attend a minimum of 75% of the meetings to which they are invited. • If they are deemed to not been the expected standards of performance at their annual appraisal. • If they no longer fulfil the requirements of their role or become ineligible for the role as set out in The CCG regulations (2012) Schedules 4 and 5. • If they have behaved in a manner or exhibited conduct which has or is likely to be detrimental to the honour and interest of the Governing Body or the CCG and is likely to bring the Governing Body or the CCG into disrepute. This includes but it is not limited to: o dishonesty; o misrepresentation (either knowingly or fraudulently); o defamation of any member of the Governing Body (being slander or libel); o abuse of position; o non-declaration of a known conflict of interest; o seeking to manipulate a decision of the Governing Body in a manner that would ultimately be in favour of that member whether financially or otherwise. • Are subject to disciplinary proceedings by a regulator or professional body
7.3.8.2 Members will be suspended pending the outcome of an investigation if they are suspended or under investigation by a regulator or professional body.
7.4 Notice Period 7.4.1 Executive members’ notice period is defined in their contract of employment.
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7.4.2 For all other members a three-month notice period is required to be given in writing to the chair.
7.5 Meetings and Decision Making 7.5.1 Introduction and scope
7.5.1.1 The following applies to all meetings of the CCG, including the Members’ Forum, the Governing Body and all Governing Body committees.
7.5.2 Calling meetings
7.5.2.1 The CCG shall set out a calendar of meetings at the start of each business cycle which will include, but not be limited to, meetings of the Governing Body, Audit Committee, Remuneration Committee and all meetings that provide assurance to the Governing Body.
7.5.2.2 Meetings shall be held at such times and places as the CCG may determine.
7.5.2.3 The Chair of the CCG or the relevant meeting or committee may call an additional meeting at any time.
7.5.2.4 Fifty per cent of the CCG’s Members, the Governing Body or a relevant meeting may request a meeting in writing. If the Chair refuses, or fails, to call a meeting within seven days of such a request being presented, the members signing the request may forthwith call a meeting.
7.6 Agenda and supporting papers
7.6.1 Items of business for inclusion on the agenda of a meeting need to be notified to the Chair at least 10 working days before the meeting takes place.
7.6.2 Agendas will be agreed between the chair and the relevant executive lead.
7.6.3 Supporting papers for agenda items must be accompanied by an agreed cover-sheet and submitted to the committee secretariat at least seven working days before the meeting takes place.
7.6.4 The agenda and supporting papers will be circulated to all members of a meeting and agreed circulation list at least five working days before the date of the meeting.
7.6.5 Agendas and certain papers for the CCG’s Governing Body and other meetings that are held in public– including details about meeting dates, times and venues - will be published on the CCG’s website.
7.7 Petitions
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7.7.1 Where a petition has been received by the CCG, the chair of the Governing Body shall include the petition as an item for the agenda of the next meeting of the Governing Body.
7.8 Chair of a meeting
7.8.1 If the nominated chair is absent from the meeting, the deputy chair, if any and if present, shall preside.
7.8.2 If the chair is absent temporarily, for example on the grounds of a declared conflict of interest, the deputy chair, if present, shall preside.
7.8.3 If both the chair and deputy chair are absent, or are disqualified from participating, another participating member of the relevant committee shall be chosen by the members present, or by a majority of them, and shall preside.
7.9 Chair's ruling
7.9.1 The decision of the chair of the Governing Body on questions of order, relevancy and regularity and their interpretation of the constitution, standing orders, scheme of reservation and delegation and prime financial policies at the meeting, shall be final.
7.10 Remote meetings
7.10.1 Use of video, telephone or other communication facilities to conduct meetings are permissible with the agreement of the prior agreement of the chair.
7.10.2 The chair will take into account the difficulties that might be posed to ensure proper access by the public should it be necessary to hold remote meetings and will make adjustments where possible.
7.11 Quorum
7.11.1 The quorum of the Members’ Forum will be 50% of the member practices represented.
7.11.2 The quorum of the Governing Body will be 50% of the members of the governing body. Vacant posts will not be included in the total number.
7.11.3 In addition, at the Governing Body, no business shall be transacted at a meeting unless the following are present:
• At least three health care professionals, at least one of whom is a GP; and • At least one lay member; and • Either the Accountable Officer of the Chief Finance Officer; and • Either the Chair or Vice Chair.
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7.11.4 The same quorum will apply to any decision requiring a governing body vote that is held outside of a meeting.
7.11.5 If members of a meeting are temporarily excluded due to a conflict of interest, with the agreement of the chair, they will not be counted in the total number for the purpose of quoracy.
7.11.6 If a group of members are temporarily excluded due to a conflict of interest, and this results in a failure to meet the requirements of paragraph 4.8.2 (or specific quoracy requirements set out in the relevant terms of reference) with the agreement of the chair the requirement for that category of member to be present will be relaxed.
7.11.7 For committees and sub-committees of the Governing Body, the details of the quorum for these meetings are set out in the appropriate terms of reference.
7.12 Decision making
7.12.1 The CCG’s Constitution, together with the scheme of reservation and delegation, sets out the CCG’s structure and the arrangements made by the CCG for the exercise of the CCG’s statutory functions.
7.12.2 It is expected that decisions will usually be reached by consensus. Should this not be possible then a vote will be required, the process for which is set out below:
7.12.3 Only members of the relevant committee or meeting may vote.
7.12.4 Eligibility to attend a meeting, or have speaking rights at a meeting, does not in itself confer a right to vote.
7.12.5 The vote will be determined by a show of hands of those present in the room or via ballot using electronic means subject to the agreement of the chair.
7.12.6 The majority necessary to confirm a decision will be a simple majority of votes cast.
7.12.7 In the case of an equal number of votes the person chairing the meeting shall have an addition, casting vote.
7.12.8 Should a vote be taken, the outcome of the vote, and any dissenting views, will be recorded in the minutes of the meeting.
7.13 Emergency powers and urgent decisions
7.13.1 In an emergency, or for an urgent decision, the powers of the Governing Body may be exercised by the Chair and the Accountable Officer after having consulted at least one lay member and one member practice representative on the governing body. In such circumstances, reasonable effort will be made
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to communicate with and engage the wider membership of the governing body or committee. The exercise of such powers by the Chair and Accountable Officer shall be reported to the next formal meeting of the governing body session for formal ratification.
7.13.2 In an emergency, or for an urgent decision, the powers of committees and sub-committees of the CCG may be exercised by the Chair and lead executive officer for that Committee after having consulted at least one other member of the committee. The exercise of such powers shall be reported to the next formal meeting for formal ratification.
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7.14 Suspension of Standing Orders
7.14.1 Except where it would contravene any statutory provision or any direction made by the Secretary of State for Health or NHS England, any part of these standing orders may be suspended at any meeting of the CCG (including the governing body and its committees and sub committees and the members forum), provided 75% of the people eligible to vote at the meeting in question are in agreement.
7.14.2 A decision to suspend standing orders together with the reasons for doing so shall be recorded in the minutes of the relevant meeting.
7.14.3 The suspension shall be for an agreed period and not longer than six months in the first instance.
7.15.4 A separate record of matters agreed, approved, or taken for assurance during the suspension shall be kept. These records shall be made available to the Governing Body’ and presented to the first Audit Committee after the suspension has been lifted for review of the reasonableness of the decisions taken during the suspension period.
7.15 Record of Attendance
7.15.1 All minutes of meetings will include the full names of members present and, their title or role. If such a record is not taken, the minutes of that meeting may not be taken as a full and accurate record of the meeting and its shall not be deemed to have been quorate.
7.16 Minutes
7.16.1 The minutes of the proceedings of a meeting shall be drawn up within five working days and a draft agreed with the chair.
7.16.2 The draft minutes will be circulated within 10 working days to all members and regular attendees (as specified in the constitution or relevant terms of reference) along with a log of agreed actions.
7.16.3 Draft minutes will be submitted for agreement at the next meeting where if approved they shall be the formal record of the meeting.
7.16.4 No discussion shall take place upon the minutes except upon their accuracy unless the Chair deems discussion to be appropriate. Any matters arising and a review of the updated log of actions from previous meetings shall be addressed as a separate agenda item.
7.17.5 Minutes from all meetings held in public including, but not limited to the Governing Body will be published on Bedfordshire CCGs web pages.
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7.17.6 At the discretion of the chair, the CCG may choose to publish other, non- confidential meetings’ papers.
7.18 Admission of public and the press
7.18.1 Some meetings of the CCG (including but not necessarily limited to the Governing Body and Primary Care Commissioning Committee) are held in public and as such members of the public and representatives of the press may attend to observe meetings.
7.18.2 No-one other than the members of the relevant committee may address the committee or attendees unless specifically invited by the chair to do so.
7.18.3 All persons other than those that are members or invited attendees (as specified in the Constitution or relevant terms of reference) will be excluded from any meeting or part of a meeting where it is deemed that it is not in the public interest for them to attend. Such circumstances will be limited to discussions relating to a matter of a confidential nature regarding an individual, or small group of individuals, where their identity could be revealed or to a matter which may be commercially sensitive.
7.18.4 In such circumstances the Governing Body or committee will resolve that ‘representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’, Section 1(2), Public Bodies (Admission to Meetings) Act 1960
7.19 Appointment of Committees and Sub-committees
7.19.1 The CCG may appoint committees and sub-committees of the CCG. The Governing Body may also appoint committees and sub-committees.
7.19.2 Other than where there are statutory requirements, or requirements set out in statutory guidance by NHS England, the Governing Body (or Members’ Forum for committees of the CCG) shall determine the membership and terms of reference of its committees and sub-committees and approve the appointment of members.
7.19.3 The Governing Body (or Members’ Forum if appropriate) will receive and consider reports from its committees at the next appropriate meeting.
7.19.4 The provisions of these standing orders shall apply where relevant to the operation of the Members’ Forum, and Governing Body, and all committees and sub-committees unless stated otherwise in the relevant terms of reference.
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7.20 Terms of Reference
7.20.1 All committees and sub-committees of the CCG and its Governing Body will operate within a set of terms of reference.
7.20.2 The terms of reference of committees and sub-committees will be approved by and may be amended by the Members’ forum or the Governing Body as appropriate.
7.21 Delegation of Powers by Committees to Sub-committees
7.21.1 Where committees are authorised to establish sub-committees they may not delegate executive powers to the sub-committee unless expressly authorised by the Governing Body.
7.22 Non-compliance
7.22.1 If for any reason these standing orders are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Governing Body for action or ratification.
7.22.2 All members of the CCG and staff have a duty to disclose any non- compliance with these standing orders to the accountable officer as soon as possible.
7.22.3 All instances of non-compliance should be reported to the Audit and Risk Committee.
7.23 Use of the Seal and Authorisation of Documents
7.23.1. CCG’s seal
7.23.1.1 The CCG has use of a seal for executing documents where necessary. The following individuals or officers are authorised to authenticate its use by their signature:
• the Accountable Officer; • the Chair of the Governing Body; • the Chief Finance Officer; • the Chief Operating Officer
7.23.1.2 The following individuals are authorised to execute a document on behalf of the CCG by their signature • the Accountable Officer • the Chair of the Governing Body • the Chief Finance Officer
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• the Chief Operating Officer.
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8 Standing Financial Instructions & Detailed Financial Policies 8.1 INTRODUCTION
8.1.1 These Detailed Financial Policies build on the CCG’s Prime Financial Policies and shall have effect as if incorporated into the Prime Financial Policies and thereby the CCG’s Constitution.
8.1.2 The Prime Financial Policies and Detailed Financial Policies identify the financial responsibilities which apply to everyone working for the CCG and its constituent organisations.
8.1.3 Any contractor or employee of a contractor who is empowered by the CCG to commit the CCG to expenditure or who is authorised to obtain income shall be covered by these Detailed Financial Policies. It is the responsibility of the Accountable Officer to ensure that such persons are made aware of this.
8.1.4 Failure to act in accordance with the CCG’s Constitution and its appendices, including these Detailed Financial Policies can in certain circumstances be regarded as a disciplinary matter that could result in dismissal (see the CCG’s Disciplinary Policy for further information).
8.1.5 The user of these Detailed Financial Policies should therefore be familiar with and comply with the provisions of the CCG’s constitution, including its appendices, and use these Detailed Financial Policies in conjunction with the Operational Scheme of Delegation.
8.1.6 The Detailed Financial Policies provide detailed procedural direction and should any difficulties arise regarding the interpretation or application of any of the CCG’s financial policies then the advice of the Chief Finance Officer must be sought before acting.
8.1.7 Where any procedures set out in the Prime Financial Policies and thereby the Detailed Financial Policies are undertaken by a Shared Service provider, the Service Level Agreement with the Shared Service provider should specify adherence to the CCG's financial policies.
8.1.8 All Detailed Financial Policies must be approved by the Chief Finance Officer.
8.1.9 These Detailed Financial Policies will be published and maintained on the CCG’s website at [url] and the Chief Finance Officer will review them at least annually to ensure they remain relevant.
8.1.10 Overriding Prime Financial Policies – if for any reason these Detailed Financial Policies are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be
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reported to the next formal meeting of the Audit Committee for referring action or ratification. All members of the Governing Body [Board] and staff have a duty to disclose any non-compliance with these Detailed Financial Policies to the Chief Finance Officer as soon as possible.
8.2 INTERNAL CONTROL
POLICY – the CCG will put in place a suitable control environment and effective internal controls that provide reasonable assurance of effective and efficient operations, financial stewardship, probity and compliance with laws and policies
8.2.1 The Governing Body is required to establish an Audit Committee with terms of reference agreed by the Governing Body and set out in this handbook.
8.2.2 The Accountable Officer has overall responsibility for the CCG’s systems of internal control.
8.2.3 The Chief Finance Officer will ensure that:
8.2.3.1 financial policies are considered for review and update annually;
8.2.3.2 a system is in place for proper checking and reporting of all breaches of financial policies; and
8.2.3.3 a proper procedure is in place for regular checking of the adequacy and effectiveness of the control environment.
8.2.4 Any employee or officer discovering or suspecting a loss of any kind must inform the Chief Finance Officer. Where a criminal offence is suspected, the Chief Finance Officer must immediately inform the police if theft or arson is involved. In cases of fraud and bribery or of anomalies which may indicate fraud or bribery, the Chief Finance Officer must inform the Local Counter Fraud Specialist and any other party in accordance with the Losses and Special Payments Policy.
8.2.5 The Chief Finance Officer shall maintain a Losses and Special Payments Register for each statutory organisation in which write-off action is recorded. No special payments exceeding delegated limits shall be made without the prior approval of NHS England. All losses and special payments must be reported to the next meeting of the Audit Committee. For further information see the Losses and Special Payments Policy.
8.3 AUDIT
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POLICY – the CCG will keep an effective and independent internal audit function and fully comply with the requirements of external audit and other statutory reviews
8.3.1 In line with the Terms of Reference for the governing body’s Audit Committee, the person appointed by the CCG to be responsible for internal audit and external audit will have direct and unrestricted access to Audit Committee members and the Chair of the governing body, Chief Officer and Chief Finance Officer for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity.
8.3.2 The person appointed by the CCG to be responsible for internal audit and the external auditor will have access to the Audit Committee and the Chief Officer to review audit issues as appropriate. All Audit Committee members, the Chair of the governing body and the Chief Officer will have direct and unrestricted access to the Head of Internal Audit and external auditors.
8.3.3 Where the Audit Committee considers there is evidence of ultra vires transactions, evidence of improper acts, or if there are other important matters that the Committee wishes to raise, the Chair of the Audit Committee should raise the matter at a meeting of the governing body and with the appointed auditor. Exceptionally, the matter may need to be referred to NHS England. Consideration should also be given to section 4 below and the requirements of the Anti-Fraud and Bribery policy.
8.3.4 The minutes of Audit Committee meetings shall be formally recorded by the CCG and submitted to the governing body. The Chair of the Committee shall draw to the attention of the governing body any issues that require disclosure to the governing body, or require executive action.
8.3.5 The Committee will report to the governing body annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the risk management process, the completeness and integration of risk management and the governance arrangements in place in the CCG.
8.3.6 The Chief Finance Officer will ensure that:
8.3.6.1 the CCG has a professional and technically competent internal audit function; and
8.3.6.2 the governing body’s Audit Committee approves any changes to the provision or delivery of assurance services to the CCG.
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8.4 FRAUD AND BRIBERY
POLICY – the CCG requires all staff to always act honestly and with integrity to safeguard the public resources they are responsible for. The CCG will not tolerate any fraud perpetrated against it and will actively chase any loss suffered
8.4.1 The governing body’s Audit Committee will satisfy itself that the CCG has adequate arrangements in place for countering fraud and shall review the outcomes of counter fraud work. It shall also approve the counter fraud work programme.
8.4.2 The governing body’s Audit Committee will ensure that the CCG has arrangements in place to work effectively with NHS Counter Fraud Authority.
8.4.3 In line with their responsibilities, the Chief Officer and Chief Finance Officer shall monitor and ensure compliance with Directions on fraud and bribery issued by the Secretary of State for Health or NHS England as well as any statute law, such as The Fraud Act 2006 and The Bribery Act 2010.
8.4.4 The CCG shall nominate a suitable person to carry out the duties of the Local Counter Fraud Specialist (LCFS) as specified by the NHS Counter Fraud and Corruption Manual and guidance.
8.4.5 The Local Counter Fraud Specialist shall report to the CCG Chief Finance Officer and shall work with staff in the NHS Counter Fraud Authority in accordance with the NHS Counter Fraud and Corruption Manual.
8.4.6 The Local Counter Fraud Specialist will provide a written annual report and further periodic update reports to the Audit Committee on counter fraud work within the CCG.
8.4.7 Any governing body member, member of staff or agent of the CCG should raise any concerns regarding bribery, fraud and conflict of interest immediately with the Local Counter Fraud Specialist, Chief Finance Officer or use NHS Counter Fraud Authority’s independent Fraud and Corruption Reporting Line.
8.4.8 The Chief Finance Officer must notify NHS Counter Fraud Authority and the External Auditor of all frauds.
8.4.9 For losses apparently caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the Chief Finance Officer must immediately notify the governing body and the External Auditor.
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8.5 EXPENDITURE CONTROL
8.5.1 The CCG is required by statutory provisions1 to ensure that its expenditure does not exceed the aggregate of allotments from NHS England and any other sums it has received and is legally allowed to spend.
8.5.2 The Accountable Officer has overall executive responsibility for ensuring that the CCG complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money.
8.5.3 The Chief Finance Officer will:
8.5.3.1 provide reports in the form required by NHS England;
8.5.3.2 ensure money drawn from NHS England is required for approved expenditure only is drawn down only at the time of need and follows best practice; and
8.5.3.3 be responsible for ensuring that an adequate system of monitoring financial performance is in place to enable the CCG to fulfil its statutory responsibility not to exceed its expenditure limits, as set by direction of NHS England.
8.6 ALLOTMENTS2
8.6.1 The CCG’s Chief Finance Officer will:
8.6.1.1 periodically review the basis and assumptions used by NHS England for distributing allotments and ensure that these are reasonable and realistic and secure the CCG’s entitlement to funds;
8.6.1.2 prior to the start of each financial year submit to the governing body for approval a report showing the total allocations received and their proposed distribution including any sums to be held in reserve; and
8.6.1.3 regularly update the governing body on significant changes to the initial allocation and the uses of such funds.
1 See section 223H of the 2006 Act, inserted by section 27 of the 2012 Act
2 See section 223(G) of the 2006 Act, inserted by section 27 of the 2012 Act.
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8.7 COMMISSIONING STRATEGY, BUDGETS, BUDGETARY CONTROL AND MONITORING
POLICY – the CCG will produce and publish an annual commissioning plan3 that explains how it proposes to discharge its financial duties. The CCG will support this with comprehensive medium term financial plans and annual budgets
8.7.1 The Accountable Officer will compile and submit to the governing body a commissioning strategy which takes into account financial targets and forecast limits of available resources. The plan will contain a statement of the significant assumptions on which the plan is based and details of major changes in workload, delivery of services or resources required to achieve the plan.
8.7.2 The Accountable Officer will approve consultation arrangements for the CCG’s commissioning plan4.
8.7.3 Prior to the start of the financial year the Chief Finance Officer will, on behalf of the Accountable Officer, prepare and submit budgets for approval by the governing body. Such budgets will be in accordance with the aims and objectives set out in the commissioning plan; accord with workload and manpower plans; be produced following discussion with appropriate budget holders; be prepared within the limits of available funds; identify potential risks.
8.7.4 The Chief Finance Officer will devise and maintain systems of budgetary control in order to monitor financial performance against budget and plan. These systems will include:
8.7.4.1 Periodic financial reports to the Governing Body in a form approved by the Governing Body.
8.7.4.2 The issue of timely, accurate and comprehensible advice and financial reports to each budget holder, covering the areas for which they are responsible.
8.7.4.3 Investigation and reporting of variances from financial, workload and manpower budgets.
8.7.4.4 Monitoring of management action to correct variances.
3 See section 14Z11 of the 2006 Act, inserted by section 26 of the 2012 Act.
4 See section 14Z13 of the 2006 Act, inserted by section 26 of the 2012 Act
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8.7.4.5 Arrangements for the authorisation of budget transfers.
8.7.5 The Accountable Officer may delegate the management of a budget to permit the performance of a defined range of activities. This delegation must be in writing. Delegated budget holders must not exceed the budgetary total or virement limits set by the governing body. Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Chief Officer, subject to any authorised use of virement.
8.7.6 Each Budget Holder is responsible for ensuring that:
8.7.6.1 Any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the governing body.
8.7.6.2 The amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised, subject to the rules of virement.
8.7.6.3 No permanent employees are appointed without the approval of the Accountable Officer other than those provided for within the available resources and manpower establishment as approved by the governing body.
8.7.7 Non-recurring resources should not be used to finance recurring expenditure without the authority in writing of the Accountable Officer, as advised by the Chief Finance Officer.
8.7.8 The Accountable Officer is responsible for ensuring that information relating to the CCG’s accounts or to its income or expenditure, or its use of resources is provided to NHS England as requested.
8.7.9 The Chief Finance Officer has a responsibility to ensure that adequate training is delivered on an on-going basis to budget holders to help them manage successfully.
8.7.10 The general rules applying to delegation and reporting shall also apply to capital expenditure. (The particular applications relating to capital are contained in section 18 of these Detailed Financial Policies).
8.8 ANNUAL ACCOUNTS AND REPORTS
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POLICY – the CCG will produce and submit to NHS England accounts and reports in accordance with all statutory obligations5, relevant accounting standards and accounting best practice in the form and content and at the time required by NHS England
8.8.1 The Chief Finance Officer will ensure the CCG:
8.8.1.1 prepares a timetable for producing the annual report and accounts and agrees it with external auditors and the governing body’s Audit Committee;
8.8.1.2 prepares the accounts according to the timetable approved by the governing body’s Audit Committee;
8.8.1.3 complies with statutory requirements and relevant directions for the publication of annual report;
8.8.1.4 considers the external auditor’s management letter and fully address all issues within agreed timescales; and
8.8.1.5 publishes the external auditor’s management letter on the CCG’s website.
8.8.2 The CCG’s accounts must be audited by an auditor appointed by the CCG in line with the Terms of Reference for the governing body’s Audit Committee.
8.8.3 The CCG will publish the audited annual report and accounts, in accordance with guidelines on local accountability, and present it at a public meeting.
8.9 INFORMATION TECHNOLOGY
POLICY – the CCG will ensure the accuracy and security of the CCG’s computerised financial data
8.9.1 The Chief Finance Officer is responsible for the accuracy and security of the CCG’s computerised financial data and shall:
8.9.1.1 devise and implement any necessary procedures to ensure adequate (reasonable) protection of the CCG's data, programs and computer hardware from accidental or intentional disclosure to unauthorised persons, deletion or
5 See paragraph 17 of Schedule 1A of the 2006 Act, as inserted by Schedule 2 of the 2012 Act.
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modification, theft or damage, having due regard for the Data Protection Act 1998;
8.9.1.2 ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;
8.9.1.3 ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment; and
8.9.1.4 ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the Chief Finance Officer may consider necessary are being carried out.
8.9.2 In addition the Chief Finance Officer shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.
8.10 ACCOUNTING SYSTEMS
POLICY – the CCG will run an accounting system that creates management and financial accounts
8.10.1 The Chief Finance Officer will ensure:
8.10.1.1 the CCG has suitable financial and other software to enable it to comply with these policies and any consolidation requirements of NHS England; and
8.10.1.2 that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.
8.10.2 Where another health organisation or any other agency provides a computer service for financial applications, the Chief Finance Officer shall periodically seek assurances that adequate controls are in operation.
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8.11 BANK ACCOUNTS
POLICY – the CCG will keep enough liquidity to meet its current commitments
8.11.1 The Chief Finance Officer will:
8.11.1.1 review the banking arrangements of the CCG at least annually and when changes occur to ensure they are in accordance with Secretary of State directions6, best practice and represent best value for money;
8.11.1.2 manage the CCG's banking arrangements and advise the CCG on the provision of banking services and operation of accounts; and
8.11.1.3 prepare detailed instructions on the operation of bank accounts, which must include:
8.11.1.3.1 the conditions under which each bank account is to be operated; and
8.11.1.3.2 those authorised to sign cheques or other orders drawn on the CCG’s accounts.
8.11.2 The Chief Officer shall approve the banking arrangements.
8.11.3 On an ongoing basis the Chief Finance Officer is responsible for:
8.11.3.1 Ensuring payments made from the CCG’s bank accounts do not exceed the amount credited to the account.
8.11.3.2 In the unlikely event that an overdraft facility is required, all such arrangements made with the CCG’s bankers must be reported to the governing body.
8.11.3.3 Monitoring compliance with direction from NHS England on the level of cleared funds.
8.12 INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS.
6 See section 223H(3) of the NHS Act 2006, inserted by section 27 of the 2012 Act
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POLICY – the CCG will: • Operate a sound system for prompt recording, invoicing and collection of all monies due • Seek to maximise its potential to raise additional income only to the extent that it does not interfere with the performance of the CCG or its functions7 • Ensure its power to make grants and loans is used to discharge its functions effectively8
8.12.1 The Chief Financial Officer is responsible for:
8.12.1.1 designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, and collection and coding of all monies due;
8.12.1.2 the appropriate recovery action on all outstanding debts, with income not received dealt with in accordance with losses procedures. Overpayments should be detected (or preferably prevented) and recovery initiated.
8.12.1.3 establishing and maintaining systems and procedures for the secure handling of cash and other negotiable instruments;
8.12.1.4 approving and regularly reviewing the level of all fees and charges other than those determined by NHS England or by statute. Independent professional advice on matters of valuation shall be taken as necessary; and
8.12.1.5 for developing effective arrangements for making grants or loans.
8.12.2 All employees must inform the Chief Finance Officer within 10 working days of money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements and other transactions.
8.12.3 The Chief Finance Officer is responsible for the management and timely recovery of all debts and may wish to engage an independent firm of debt collectors to speed up the process of debt collection. This responsibility includes:
8.12.3.1 the monthly review of a summary debtor position and the periodic report to the governing body;
7 See section 14Z5 of the 2006 Act, inserted by section 26 of the 2012 Act.
8 See section 14Z6 of the 2006 Act, inserted by section 26 of the 2012 Act.
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8.12.3.2 the production of a detailed aged debt report of all debtors over £100,000 outstanding for more than 6 months should be submitted to the Audit Committee; and
8.12.3.3 ensuring that income not likely to be received is dealt with in accordance with losses procedures.
8.13 TENDERING AND CONTRACTING PROCEDURE
POLICY – the CCG: • Will ensure proper competition that is legally compliant within all purchasing to ensure we incur only budgeted, approved and necessary spending • Will seek value for money for all goods and services • Shall ensure that competitive tenders are invited for: o the supply of goods, materials and manufactured articles; o the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the Department of Health); and o for the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens) for disposals
8.13.1 In all contracts entered into, the CCG shall endeavour to obtain best value for money. The Accountable Officer shall nominate an individual who shall oversee and manage each contract on behalf of the CCG.
8.13.2 The CCG shall maintain lists of approved firms, to include all firms who have applied for permission to tender and as to who’s technical and financial competence the CCG is satisfied. All suppliers must be made aware of the CCG’s terms and conditions of contract.
8.13.3 The CCG shall ensure that the firms / individuals invited to tender (and where appropriate, quote) are among those on the lists of approved firms or where necessary a framework agreement. Where in the opinion of the Chief Finance Officer it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Accountable Officer or the CCG’s governing body.
8.13.4 The governing body may only negotiate contracts on behalf of the CCG, and the CCG may only enter into contracts, within the statutory framework set up by the NHS 2006 Act, as amended by the NHS 2012 Act. Such contracts shall comply with:
8.13.4.1 the CCG’s Standing Orders;
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8.13.4.2 the Public Contracts Regulation 2006, any successor legislation and any other applicable law; and
8.13.4.3 take into account as appropriate any applicable NHS England or NHS Improvement guidance that does not conflict with (b) above.
8.13.5 Unless the exceptions set out in 13.6 or 13.7 apply, the CCG shall ensure that invitations to tender are sent to a sufficient number of firms/individuals to provide fair and adequate competition as appropriate, and in no case less than three firms/individuals, having regard to their capacity to supply the goods or materials or to undertake the services or works required.
8.13.6 Formal tendering procedures need not be applied where the estimated expenditure or income does not, or is not reasonably expected to, exceed £50,000 (contract life cycle) or where the supply is proposed under special arrangements negotiated by NHS England in which event the said special arrangements must be complied with.
8.13.7 Where it is decided that competitive tendering is not applicable and should be waived, the fact of the waiver and the reasons should be documented and recorded in an appropriate CCG record signed by the Accountable Officer or Chief Finance Officer and reported to the next Audit Committee meeting. Formal tendering procedures may be waived in the circumstances set out below:
8.13.7.1 In very exceptional circumstances where the Accountable Officer or Chief Finance Officer decides that formal tendering procedures would not be practicable or the estimated expenditure or income would not warrant formal tendering procedures, and the circumstances are detailed in an appropriate CCG record;
8.13.7.2 where the requirement is covered by an existing contract;
8.13.7.3 where NHS Purchasing and Supply Agency (PASA) or equivalent agreements are in place and have been approved by the governing body;
8.13.7.4 where a consortium arrangement is in place and a lead organisation has been appointed to carry out tendering activity on behalf of the consortium members;
8.13.7.5 where the timescale genuinely precludes competitive tendering, but failure to plan the work properly would not be regarded as a justification for a single tender;
8.13.7.6 where specialist expertise is required and is available from only one source;
8.13.7.7 when the task is essential to complete the project, and arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate;
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8.13.7.8 there is a clear benefit to be gained from maintaining continuity with an earlier project, however in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering;
8.13.7.9 for the provision of legal advice and services providing that any legal firm or partnership commissioned by the CCG is regulated by the Law Society for England and Wales for the conduct of their business (or by the Bar Council for England and Wales in relation to the obtaining of Counsel’s opinion) and are generally recognised as having sufficient expertise in the area of work for which they are commissioned (the Chief Finance Officer will ensure that any fees paid are reasonable and within commonly accepted rates for the costing of such work); or
8.13.7.10 where allowed and provided for in the Capital Investment Manual.
8.13.8 Written quotations should be obtained from at least two firms/individuals based on specifications (expenditure £10,000 - £20,000) or three firms/individuals based on specifications (expenditure £20,001 - £50,000) or terms of reference where formal tendering procedures are not adopted and where the intended expenditure or income exceeds, or is reasonably expected to exceed £10,000. These quotations are then subject to the following requirements:
8.13.8.1 The Accountable Officer, or person nominated by the Accountable Officer, should evaluate the quotation and select the quote which gives the best value for money. If this is not the lowest quotation if payment is to be made by the CCG, or the highest if payment is to be received by the CCG, then the choice made and the reasons why should be recorded in a permanent record.
8.13.8.2 No quotation shall be accepted that commits expenditure in excess of that which has been allocated by the CCG and which is not in accordance with Detailed Financial Policies except with the authorisation of either the Accountable Officer or Chief Finance Officer.
8.13.9 Items estimated to be below the limits set in these Detailed Financial Policies for which formal tendering procedures are not used which subsequently prove to have a value above such limits shall be reported to the Accountable Officer, and be recorded in a single tender waiver form.
8.13.10 Where tenders have been invited:
8.13.10.1 As soon as practicable after the date and time stated as being the latest time for the receipt of tenders, they shall be opened by two senior officers or managers designated by the Accountable Officer and not from the originating department.
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8.13.10.2 A register shall be maintained by the Accountable Officer, or person nominated by the Accountable Officer, to show for each set of competitive tender invitations despatched that includes the following:
8.13.10.2.1 the name of all firms individuals invited; 8.13.10.2.2 the names of firms individuals from which tenders have been received; 8.13.10.2.3 the date the tenders were received and opened; 8.13.10.2.4 the persons present at the opening; 8.13.10.2.5 the price shown on each tender; 8.13.10.2.6 a note where price alterations have been made on the tender and suitably initialled.
8.13.10.3 Each entry to this register shall be signed by those present.
8.13.10.4 If for any reason the designated officers are of the opinion that the tenders received are not strictly competitive (for example, because their numbers are insufficient or any are amended, incomplete or qualified) no contract shall be awarded without the approval of the Accountable Officer.
8.13.10.5 Where only one tender is received and a contract is to be awarded, the Accountable Officer and Chief Finance Officer shall, as far practicable, ensure that the price to be paid is fair and reasonable and will ensure value for money for the CCG.
8.13.10.6 Tenders received after the due time and date, but prior to the opening of the other tenders, may be considered only if the Accountable Officer or his/her nominated officer decides that there are exceptional circumstances e.g. despatched in good time but delayed through no fault of the tenderer. Only in the most exceptional circumstances will a tender be considered which is received after the opening of the other tenders and only then if the tenders that have been duly opened have not left the custody of the Accountable Officer or his/her nominated officer or if the process of evaluation and adjudication has not started. While decisions as to the admissibility of late, incomplete or amended tenders are under consideration, the tender documents shall be kept strictly confidential, recorded, and held in safe custody by the Accountable Officer or his/her nominated officer. Accepted late tenders will be reported to the Audit Committee.
8.13.10.7 The lowest tender, if payment is to be made by the CCG, or the highest, if payment is to be received by the CCG, shall be accepted unless there are good and sufficient reasons to the contrary. It is accepted that for professional services such as management consultancy, the lowest price does not always represent the best value for money. Other factors affecting the success of a project should be taken into account. Where other factors are taken into account in selecting a tenderer, these must be clearly recorded and documented in the contract file, and the reason(s) for not accepting the lowest tender clearly stated.
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8.13.10.8 No tender shall be accepted which will commit expenditure in excess of that which has been allocated by the CCG and which is not in accordance with these Detailed Financial Policies except with the authorisation of the Accountable Officer.
8.13.10.9 All tenders should be treated as confidential and should be retained for inspection.
8.13.11 Providing all the conditions and circumstances set out in these Detailed Financial Policies have been fully complied with, formal authorisation and awarding of a contract may be decided by the following staff to the value of the contract as listed in Appendix 4 and Appendix 6.
8.13.12 Competitive tendering or quotation procedures shall not apply to the disposal of:
8.13.12.1 any matter in respect of which a fair price can be obtained only by negotiation or sale by auction as determined (or pre-determined in a reserve) by the Chief Officer or his nominated officer;
8.13.12.2 obsolete or condemned articles and stores, which may be disposed of in accordance with the supplies policy of the CCG;
8.13.12.3 items to be disposed of with an estimated sale value of less than £2,000;
8.13.12.4 items arising from works of construction, demolition or site clearance, which should be dealt with in accordance with the relevant contract;
8.14 COMMISSIONING
POLICY – working in partnership with relevant national and local stakeholders, the CCG will commission certain health services to meet the reasonable requirements of the persons for whom it has responsibility
8.14.1 The CCG will coordinate its work with NHS England, other Clinical Commissioning Groups, local providers of services, the local authority, including through Health & Wellbeing Boards, patients and their carers and the voluntary sector and others as appropriate to develop robust commissioning plans.
8.14.2 In considering its approach to the commissioning of and contracting for healthcare services the CCG will comply with legislation and nationally published guidance by
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NHS England, Cooperation and Competition Panel and other equivalent bodies. Where the CCG decides not to open a new service to the market by way of tender, the reason for this will be reported to the governing body. Where the CCG decides tender services, section 13 of these Detailed Financial Policies will apply.
8.14.3 The Accountable Officer will establish arrangements to ensure that regular reports are provided to the governing body detailing actual and forecast expenditure and activity for each contract.
8.14.4 The Chief Finance Officer will maintain a system of financial monitoring to ensure the effective accounting of expenditure under contracts. This should provide a suitable audit trail for all payments made under the contracts whilst maintaining patient confidentiality.
8.14.5 Agreements with providers of NHS commissioned healthcare services shall be drawn up in accordance with the relevant Health and Social Care Act and administered by the CCG. Agreements with NHS Trusts are not contracts in law and are not enforceable by the courts. However, a contract with a Foundation Trust is a legal document and is enforceable in law.
8.14.6 The Accountable Officer is responsible for ensuring the CCG enters into suitable contracts for healthcare services. The Accountable Officer shall nominate officers to commission standard contract agreements with providers of healthcare in line with a commissioning plan approved by the governing body. All funding should aim to implement the agreed priorities contained within the commissioning plan and wherever possible, be based upon integrated care pathways to reflect expected patient experience. In discharging this responsibility, the Accountable Officer should take into account:
8.14.6.1 the standards of service quality expected;
8.14.6.2 the relevant national outcome frameworks;
8.14.6.3 the provision of reliable information on cost and volume of services; and
8.14.6.4 that contracts build where appropriate on existing Joint Commissioning Plans.
8.15 RISK MANAGEMENT AND INSURANCE
POLICY – the CCG will put arrangements in place for evaluation and management of its risks
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8.15.1 The Accountable Officer will ensure that appropriate risk management and assurance framework processes are in place that adequately support the CCG’s Risk Management Strategy and assure the governing body that risk is being managed effectively across all areas of the CCG. The risk management programme and the assurance framework processes will be evaluated regularly monitored by the governing body’s Audit Committee. The programme of risk management shall include:
8.15.1.1 a process for identifying and quantifying risks and potential liabilities;
8.15.1.2 engendering among all levels of staff a positive attitude towards the control of risk;
8.15.1.3 management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;
8.15.1.4 contingency plans to offset the impact of adverse events;
8.15.1.5 audit arrangements including; internal audit and health and safety review;
8.15.1.6 a clear indication of which risks shall be insured; and
8.15.1.7 arrangements to review the risk management programme.
8.15.2 The governing body will approve arrangements for risk sharing and or risk pooling with other organisations (for example arrangements for pooled funds with other Clinical Commissioning Groups or pooled budget arrangements under section 75 of the NHS Act 2006).
8.15.3 The Chief Finance Officer will ensure that:
8.15.3.1 the process for recording, evaluating and reporting risk is communicated across the CCG in order to manage risk at an appropriate level;
8.15.3.2 the process for recording, evaluating and reporting risk is reviewed annually; and
8.15.3.3 risk is reported on a regular basis to the governing body’s Audit Committee.
8.15.4 The governing body will approve insurance arrangements through the risk pooling schemes administered by the NHS Litigation Authority or self-insure for some or all of the risks covered by the schemes. Any decision by the governing body not to use the risk pooling schemes for any of the risk areas (clinical liability, property/employers/third party/products liability and professional indemnity) covered by the scheme should be reviewed annually
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8.15.5 Commercial insurers should generally not be used except in the following specific circumstances – insuring motor vehicles including insuring third party liability arising from their use, where the CCG is involved in jointly commissioned service where other members of the consortium require commercial insurance arrangements and where income generation activities take place, especially where the general public is involved.
8.16 PAYROLL
POLICY – the CCG will put arrangements in place for an effective payroll service
8.16.1 The Chief Finance Officer will ensure that the payroll service selected:
8.16.1.1 is supported by appropriate (i.e. contracted) terms and conditions;
8.16.1.2 has adequate internal controls and audit review processes; and
8.16.1.3 has suitable arrangements for the collection of payroll deductions and payment of these to appropriate bodies.
8.16.2 In addition the Chief Finance Officer shall set out comprehensive procedures for the effective processing of payroll.
8.16.3 Appropriately nominated managers and Senior Management Team members have delegated responsibility for:
8.16.3.1 submitting time records, and other notifications in accordance with agreed timetables; 8.16.3.2 completing time records and other notifications in accordance with the Chief Finance Officer's instructions and in the form prescribed by the Chief Finance Officer; and
8.16.3.3 submitting termination forms in the prescribed form immediately upon knowing the effective date of an employee's or officer’s resignation, termination or retirement. Where an employee fails to report for duty or to fulfil their obligations in circumstances that suggest they have left without notice, the Chief Finance Officer must be informed immediately.
8.16.4 The Chief Officer is responsible for ensuring that all employees are issued with a Contract of Employment in a form approved by the governing body and which complies with employment legislation and dealing with variations to, or termination of, contracts of employment.
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8.17 NON-PAY EXPENDITURE
POLICY – the CCG will seek to obtain the best value for money goods and services received
8.17.1 The CCG’s governing body will approve the level of non-pay expenditure on an annual basis and the Accountable Officer will determine the level of delegation to budget managers.
8.17.2 The Accountable Officer shall set out procedures on the seeking of professional advice regarding the supply of goods and services.
8.17.3 The Chief Finance Officer will:
8.17.3.1 advise the CCG’s governing body on the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in the Scheme of Reservation and Delegation;
8.17.3.2 set out the list of managers who are authorised to place requisitions for the supply of goods and services, the maximum level of each requisition and the system for authorisation above that level;
8.17.3.3 be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable; and
8.17.3.4 be responsible for the prompt payment of all properly authorised accounts and claims. Payment of contract invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.
8.17.4 Any requisitioner, in choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the CCG. In so doing, the advice of the CCG's adviser on supply shall be sought. Where this advice is not acceptable to the requisitioner, the Chief Finance Officer (and/or the Accountable Officer) shall be consulted.
8.17.5 Prepayments are only permitted where exceptional circumstances apply. In such instances:
8.17.5.1 Prepayments are only permitted where the financial advantages outweigh the disadvantages (i.e. cash flows must be discounted to NPV using the National Loans Fund (NLF) rate plus 2%).
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8.17.5.2 The appropriate officer member of the Senior Management Team must provide, in the form of a written report, a case setting out all relevant circumstances of the purchase. The report must set out the effects on the CCG if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments;
8.17.5.3 The Chief Finance Officer will need to be satisfied with the proposed arrangements before contractual arrangements proceed;
8.17.5.4 The budget holder is responsible for ensuring that all items due under a prepayment contract are received and they must immediately inform the Accountable Officer or Chief Finance Officer if problems are encountered.
8.17.6 No contract or other form of order shall be issued for any item or items to any firm which has made an offer of gifts, reward or benefit to directors, employees or agents of the CCG, other than isolated gifts of a trivial character or inexpensive seasonal gifts such as calendars or conventional hospitality such as lunches in the course of working visits. For further guidance see the CCG’s Conflicts of Interest Policy and declare as necessary in the Gifts and Hospitality register.
8.17.7 No requisition/order is placed for any item or items for which there is no budget provision unless authorised by the Chief Finance Officer on behalf of the Accountable Officer.
8.17.8 Orders must not be split or otherwise placed in a manner devised so as to avoid the financial thresholds set out in these Detailed Financial Policies or the Operational Scheme of Delegation.
8.17.9 Goods are not to be taken on trial or loan in circumstances that could commit the CCG to a future uncompetitive purchase.
8.18 CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS
POLICY – the CCG will put arrangements in place to manage capital investment, maintain an asset register recording fixed assets and put in place polices to secure the safe storage of the CCG’s fixed assets
8.19.1 The Accountable Officer will:
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8.19.1.1 ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon plans;
8.19.1.2 be responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost;
8.19.1.3 shall ensure that the capital investment is not undertaken without confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges; and
8.19.1.4 be responsible for the maintenance of registers of assets, taking account of the advice of the Chief Finance Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.
8.19.2 For every capital expenditure proposal the Accountable Officer shall ensure that a business case is produced setting out:
8.19.2.1 an option appraisal of potential benefits compared with known costs to determine the option with the highest ratio of benefits to costs;
8.19.2.2 the source of capital funding and where appropriate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector;
8.19.2.3 appropriate project management and control arrangements; and
8.19.2.4 that the Chief Finance Officer has certified professionally to the costs and revenue consequences detailed in the business case and involved appropriate CCG personnel and external agencies in the process.
8.19.3 The approval of a capital programme shall not constitute approval for expenditure on any scheme. The Accountable Officer shall issue to the manager responsible for any scheme:
8.19.3.1 specific authority to commit expenditure;
8.19.3.2 authority to proceed to tender; and
8.19.3.3 approval to accept a successful tender (see overlap with paragraph 13.11 of these Detailed Financial Policies).
8.19.4 The Chief Finance Officer shall issue procedures governing the financial management, including variations to contract, of capital investment projects and
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valuation for accounting purposes. These procedures shall fully take into account any CCG delegated limits for capital schemes.
8.19.5 Whilst each employee and officer has a responsibility for the security of property of the CCG, it is the responsibility of governing body and Senior Management Team members and senior employees in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the governing body. Any breach of agreed security practices must be reported in accordance with agreed procedures to the Chief Finance Officer (email [email protected] or call 01908 278763 / 07920 253658) and the Local Security Management Specialist (LSMS).
8.19.6 The Chief Finance Officer will prepare detailed procedures for the disposals of assets. Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where sold).
8.19.7 When it is decided to dispose of a CCG asset, the Head of Department or authorised deputy will determine and advise the Chief Finance Officer of the estimated market value of the item, taking account of professional advice where appropriate.
8.20 RETENTION OF RECORDS
POLICY – the CCG will put arrangements in place to retain all records in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance
8.20.1 The Accountable Officer shall:
8.20.1.1 be responsible for maintaining all records required to be retained in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance;
8.20.1.2 ensure that arrangements are in place for effective responses to Freedom of Information requests; and
8.20.1.3 publish and maintain a Freedom of Information Publication Scheme.
8.20.2 Records shall only be destroyed at the express instigation of the Chief Officer. Detail shall be maintained of records so destroyed.
8.21 TRUST FUNDS AND TRUSTEES
42
POLICY – the CCG will put arrangements in place to provide for the appointment of trustees if the CCG holds property on trust
8.21.1 The Chief Finance Officer shall ensure that each trust fund which the CCG is responsible for managing is managed appropriately with regard to its purpose and to its requirements.
43
8.22 CONTRACTING, PURCHASING & BUSINESS CASE APPROVAL LIMITS
Tendering and Contracting – Financial limits (limits quoted are inclusive of VAT, and are for the total value of an individual requisition for the total term of the agreement)
Scenario estimated to cost range
A minimum of 2 written competitive quotations must be £10,000 to £20,000 (a) obtained for • all building and engineering works, • goods, • equipment, and • services
(b) A minimum of 3 written competitive quotations to be £20,001 to £50,000 obtained for • all building and engineering works, • goods, • equipment, and • services • (c) A minimum of 3 written competitive tenders from firms on £50,001 to £125,000 approved lists to be invited for • all building and engineering works, • goods, • equipment, and • services
A minimum of 5 written competitive tenders from firms on over £125,000 approved lists to be invited for • all building and engineering works, (d) • goods, • equipment, and • services
44
8.23 Revenue (excluding Commissioning related services)
Authority to incur revenue expenditure or to accept revenue income, by placing an order or accepting a quotation or a tender shall be exercised as follows:
Any designated budget holder, including Locality Business Up to £10,000 Managers £10,001 to £25,000 Deputy CFO or Chief Operating Officer
Deputy CFO and Chief Operating Officer £25,001 to £50,000
Accountable Officer or CFO Over £50,000 (on behalf of the Governing Body)
In the case of capital expenditure or income, prior approval from the CFO is required for all schemes/purchases
45
8.24 EU Procurement Rules (January 2018)
Under the public contracts Directive (2014/24/EU) and the UK Public Contracts Regulations public sector organisations that wish to let contracts which exceed certain financial thresholds in accordance with prescribed procedures contained within the Regulations.
The thresholds (exclusive of VAT) set out by the EU directives and which are updated from time to time, cover the purchase of goods, services and buildings, valid for the period commencing
SUPPLY, SOCIAL AND OTHER WORKS SERVICES AND SPECIFIC SERVICES CONTRACTS DESIGN CONTRACTS (note 3) (note 2) (note 1)
CENTRAL £615,278 £118,133 £4,551,413 GOVERNMENT €750,000 €144,000 €5,548,000 (note 4)
OTHER £181,302 £4,551,413 £615,278 CONTRACTING €750,000 AUTHORITIES €221,000 €5,548,000
£65,630 £820,370 n/a SMALL LOTS €80,000 €1,000,000
Notes
(1) With the exception of the following services which have different thresholds or are exempt: a. Social and other specific services (subject to the light touch regime) Article 74 b. Subsidised services contracts specified under Article 13 c. Research and development services under Article 14 (specified CPV codes are exempt) (2) With the exception of subsidised works contracts specified under Article 13 (3) As per Article 74 services listed in Annex XIV (4) Schedule 1 of the Public Contracts Regulations lists in the central Government bodies subject to the WTO GPA. These thresholds will apply to successor bodies
8.25 Authority to approve Business Cases for proposed service developments*
Up to £20 million: Executive Management Team Over £20 million: Governing Body * based on total proposed investment for duration of contract, including capital
8.26 COMMISSIONING CONTRACTS AUTHORISATION LIMITS
Agreement of NHS funded contracts for NHS patient services Contract Variations to NHS funded contracts for NHS patient services
Accountable Chief Finance CCG Chief Delegated Accountable Officer Chief Finance CCG Chief Delegated Budget Officer (on behalf Officer or Chief Operating Officer Budget Holder, (on behalf of the Officer or Chief Operating Holder, including of the Gov Body) Operating Officer or an authorised including Locality Gov Body) Operating Officer Officer Locality Business or an authorised or an authorised Deputy Business or an authorised or an authorised or an authorised Managers (per list Deputy Deputy Managers (per list Deputy Deputy Deputy held by Finance) held by Finance)
Over Up to Up to Up to Over Up to Up to Up to NHS Trusts & NHS Foundation Trusts Local NHS Providers to the BLMK CCG £60 million £60 million £25 million £1.5 million £1.5 million £600,000 £300,000
Other NHS Trusts £12 million £12 million £6 million £1.5 million £1.5 million £1.5 million £600,000 £120,000 where BLMK CCG is Lead Commissioner
Other NHS Providers £12 million £12 million £6 million £1.5 million £1.5 million £1 million £600,000 £120,000 where another CCG is Lead Commissioners
Non NHS Providers
Providers of NHS £1 million £1 million £500,000 CHC Team £200,000 £200,000 £100,000 £50,000 funded care up to £2,000 p.w. for 12 week periods non-CHC £250,000
8.28 HEALTHCARE INVOICE AUTHORISATION LIMITS
Authorising Invoices for agreed Authorising all other commissioning expenditure outside the Commissioning Contracts Commissioning Contract Accountable Delegated Budget Officer (on Relevant CCG CFO or Relevant CCG Delegated Budget Holder, incl behalf of the Chief Operating Chief Chief Operating Holder, incl Locality Business Governing Officer or Deputy Operating Officer or Deputy Locality Business Managers (per list Body) CFO Officer CFO Managers ( per list held by Finance) or an or an held by Finance) authorised authorised Deputy Deputy
Over Up to Over Up to Up to Up to
NHS PROVIDERS BLMK CCG NHS Trust or FT £500,000 £500,000
Other NHS Trusts where BLMK CCG is lead £500,000 £500,000 commissioner
Other NHS Trusts where a non BLMK CCG £500,000 £500,000 is the Lead Commissioner Non Commissioned / £50,00 N/A N/A £200,000 £200,000 £100,000 Contracted Activity 0
NON NHS PROVIDERS
Providers of NHS Funded £100,000 £100,000 Care
Non Commissioned / N/A N/A Contracted Activity £200,000 £200,000 £100,000 £50,000
8.29 GOODS AND SERVICES CONTRACTS
Agreement of Good and Services Contracts following quotation Contract Variations to Good and Services Contracts following or tender process quotation or tender process
Accountable Chief Finance CCG Chief Delegated Accountable Chief Finance CCG Chief Delegated Officer (on Officer or Chief Operating Officer Budget Holder, Officer (on behalf Officer or Chief Operating Budget Holder, behalf of the Operating including of the Gov Body) Operating Officer or an including Gov Body) or an Officer or an Locality or an authorised Officer or an authorised Locality authorised authorised Business Deputy authorised Deputy Business Deputy Deputy Managers (per list Deputy Managers (per list held by Finance) held by Finance)
Over Up to Up Up to Over Up to Up to Up to to Good and Services £1 million £1 million £600,000 £10,000 £500,000 £500,000 £300,000 £5,000
Building and £1 million £1 million £600,000 £10,000 £500,000 £500,000 £300,000 £5,000 Engineering
Note The signatory of the contract for goods and service is not the person that has sought the tender or quotation or has been a participant in a procurement evaluation process
9 Scheme of Reservation and Delegation Area Activity Delegated/Reserved to: Note
Commissioning Approve the CCG's annual commissioning strategy or Governing Body plan Commissioning Approve contracts for commissioning support Governing Body
Commissioning Approve arrangements for the discharge of the CCGs Governing Body statutory commissioning functions Commissioning Approve arrangements for joint commissioning with NHS Governing Body England and/or other CCGs and/or local authorities Commissioning Exercise clinical commissioning decisions as they relate Primary Care to primary care Commissioning Committee Commissioning Exercise clinical commissioning decisions as they relate Quality Committee to services other than primary care Commissioning Primary care contract procurement Accountable Officer
Complaints Approve arrangements for handling complaints Accountable Officer
Estates and Ratify proposals for the acquisition or disposal of property Finance Committee Facilities Finance Approve detailed financial policies Governing Body
Finance Approve arrangements for funds held on trust Accountable Officer
Finance Ratify any failures to comply with the standing Governing Body Also reviewed by Audit Committee for orders/temporary suspension of the standing orders Assurance Finance Approve financial resources allocated to local Governing Body commissioning priorities Finance Approve business cases for capital investment that are a Finance Committee variation of the strategic plan
Finance Recommend budgets to the Governing Body Chief Finance Officer
Finance Approve recommended budgets Governing Body
Finance Approve variations of budgets where that variation has a Governing Body material impact Finance Approve banking arrangements Finance Committee
Finance Approve arrangements for the discharge of the CCG's Governing Body statutory financial duties Finance Approve systems for internal control Governing Body
Finance Approve contracts for corporate support Governing Body
Finance Approve arrangements for managing exceptional funding Governing Body requests Finance Approval of exceptional funding requests Accountable Officer
Governance Approve any application to NHS England to make Governing Body changes to the CCG's Constitution Governance Approve the CCG's constitution Membership
Governance Approve terms and reference of or membership of Governing Body Governing Body or its Committees Governance Approve Standing Orders Governing Body
Governance Approve Prime Financial Policies Governing Body
Governance Receive declarations of interests from Governing Body Governing Body members Governance Receive declarations of interests from member practice Accountable Officer With the power to delegate representatives Governance Receive declarations of interests from CCG workers Accountable Officer
Governance Receive reports from committees Governing Body
Governance Approve terms of reference of committees Governing Body
Governance Ensure members, the Governing Body and CCG workers Accountable Officer comply with statutory duties Governance Approve the procedures for declarations of hospitality Accountable Officer
Governance Decide who has authority to sign documents Governing Body
Governance Appoint the Chair of the Governing Body Membership
Governance Remove the Chair of the Governing Body Membership
Governance Appoint a Vice Chair of the Governing Body Governing Body
Governance Remove the Vice Chair of the Governing Body Governing Body
Governance Create or remove committees, or members of Governing Body Some committees are required in law committees, of the Governing Body Governance Approve the process for the recruitment and removal of Remuneration Committee non-elected Governing Body members Governance Approve the process for identifying and recruiting the Governing Body Based on recommendation from Accountable Officer Remuneration Committee Governance Identify and manage key strategic risks Accountable Officer
Governance Receive annual report and accounts including internal Governing Body Audit Committee makes recommendations to and external auditors' reports the Governing Body Governance Approve the Scheme of Delegation Governing Body
Governance Approve counter fraud arrangements Accountable Officer
Governance Approve risk management arrangements Audit Committee
Governance Approve arrangements for risk sharing or risk pooling Governing Body Audit Committee makes recommendations to the Governing Body Governance Approve arrangements for business continuity and Accountable Officer emergency planning Governance Approve arrangements for information governance and Accountable Officer information security Governance Approve arrangements for Freedom of Information Accountable Officer
Governance Approve appointment of internal and external auditors Governing Body
Human Appoint and dismiss employee members of the Governing Body Resources Governing Body Human Note the proposals of the Remuneration Committee Governing Body Resources Human Approve individual compensation payments Governing Body Based on recommendation of the Resources Remuneration Committee Human Approve HR Policies Accountable Officer Resources Human Approve the terms and conditions, remuneration and Remuneration Committee Resources allowances for Governing Body members Human Approve the terms and conditions, remuneration and Accountable Officer Resources allowances for CCG employees Human Approve disciplinary arrangements Accountable Officer Based on recommendation of the Resources Remuneration Committee Human Approve arrangements for the discharge of the CCG's Accountable Officer Resources statutory duties as an employer Member Appoint and remove member practice representatives Membership engagement Member Determine arrangements by which members approve Accountable Officer engagement decisions reserved to the membership Other Any actions or activity not otherwise covered in the Accountable Officer Except where there is a conflict of interests, Scheme of Delegation in which case it shall be the Chair
Other Approve organisational structures Accountable Officer
Other Exercise the powers of the Governing Body in an Accountable Officer In consultation with two other Governing emergency or for very urgent matters Body members; must then be presented to next public Governing Body meeting Other Approve proposals for action on litigation against or by Accountable Officer the CCG Other Approval of QOF/QIPP schemes Accountable Officer
Policy Approval of policies not covered elsewhere Accountable Officer
Quality and Approve proposals for quality and clinical governance in Quality Committee Safety services commissioned by the CCG Quality and Approve policies relating to Quality and Safety Quality Committee Safety Quality and Approve arrangements to support NHS England secure Governing Body Safety improvements in quality and safety Strategy Define the vision, values, strategic aims and objectives of Governing Body the CCG
The BLMK CCG Draft Constitution
The draft BLMK CCG Constitution has a number of important elements that the CCG wishes to highlight for comment and review. These are set out below with an explanatory note to help understand the key parts of the Constitution and why they have been drafted that way. The draft Constitution highlights these sections in blue so you can review the specific wording. There are different types of sections, so they have been coloured as follows:
Members’ powers and the CCG’s accountability How the CCG will engage with members How the CCG, its Governing Body and the members forum will operate Things to note Further changes based on members’ feedback
You can comment on and make suggestions on any of these areas, or any other part of the Constitution. Please note this draft Constitution is a combination of: three existing constitutions; elements required by law and the regulator NHS England; and examples of good practice nationally.
Section Page Note 1.4.3 6 Sets out that the CCG’s members approve the CCG’s Constitution
Substantive means anything that has a material impact such as changing the number of voting members of the Governing Body. An examples of something that is not substantial is changing the portfolios and job titles of the executive members. 1.6.2 6 Describes the CCG’s accountability to its members 3.1.3 11 A list of member practices must be included by law 3.2 12 Sets out the relationship between the CCG and its members 3.2.2 15 Clarifies where members’ roles and powers are set out 3.4 12 Sets out members powers. This is a new section, which is part of the current CCG Constitution template. These are being set out in this way for the first time. 3.5.2, 3 13 The CCG will establish meetings with its members. 3.6 13 This is a combination of what practice representatives may do on behalf of their member practice from all three CCGs. 5.1.3 16 Sets out the accountability of the CCG to its members 5.1.4 16 Sets out the CCG may not vary its scheme of reservation and delegation of it would change the powers of members. 5.5.2 18 The CCG’s Chair will be a GP 5.5.2i 18 It is proposed that there will be seven member representatives as voting members on the CCG’s Governing Body. They will be clinicians with:
• Two from Milton Keynes • Two from Luton • Three from Bedfordshire
These numbers align well with PCNs 5.5.3 22 Sets out that the Governing Body shall always have clinicians holding a voting majority. 5.6.2 23 Clarifies additional attendees at the Governing Body 5.7.2 23 Highlights the terms f office and process for appointment and removal for Governing Body members SO 2.2 35 The CCG will delegate powers and the transaction of some formal business to one or more members forums 5.6.2b 19 Additional attendees at the Governing Body are to be finalised. SO 3.2.3 36 Composition of the Governing Body SO 3.3 36, 37 Sets out the role of the membership in the appointment of the CCG Chair and the member representatives on the CCG’s Governing Body.
See the graphic below that explains why the three CCGs are proposing appointment over election to these roles SO 4.8.1 41 Is 50% too high a proportion of the 98 practices that will make up the new CCG’s membership? *SO means standing orders
What has changed for the membership of the three current CCGs? The draft Constitution contains a number of provisions relating to the CCGs’ membership, and how it will work with the membership. These are a combination of the powers and functions of the membership of the three CCGs. This means that the membership of the proposed single CCG share the combined powers and functions that were held by the membership of the three current CCGs – and nothing has been removed. In addition the draft Constitution contains for the first time clear provisions relating to the membership and their rights.
Why can’t members appoint remove all Governing Body members? The CCG’s membership have a key role in the selection and appointment of the Chair and the member representatives on the CCG’s Governing Body because these are selected from among the membership. The executive directors are, unlike other Governing Body members, employees of the CCG and the CCG cannot delegate its legal liabilities as an employer. This also means the membership cannot be held liable for the CCG’s actions. Instead the CCGs are proposing stronger links with and accountability to the single CCG’s members’ including inviting the CCG’s executive directors and others to meetings of the membership to discuss and scrutinise activity and action plans in specific areas.
Why is the CCG proposing appointment of the Chair and member representatives of the Governing Body? When a CCG puts up candidates for elections to posts its members are being asked to select from people the CCG has preselected. Quite often in CCG elections there is only one candidate, which makes the election moot. In order to give members a greater role in deciding who fills these roles if they are involved in candidate selection from the start, and ratify the appointment of the most qualified candidate at the members’ forum. Election
Members choose The CCG's CCG seeks CCG review from the CCG's choice(s) go to candidates candidates preferred election candidates
This is the only point members are involved Appointment
Members The Members' Members ratify CCG seeks review choices go to the appointed candidates candidates interview/panel candidates
Members are involved throughout 4.2
Governing Bodies in Common in Public 21 July 2020
Establishment of an Equality, Diversity and Inclusion Committee
Author: Emma Richards, Corporate Services & Workforce Lead, NHS Milton Keynes CCG / HR Lead BLMK Contact Information: [email protected] Lead Executive: Geraint Davies, Director of Performance and Governance
Which CCGs does this paper apply to?
Bedfordshire x Luton x Milton Keynes x
Information
Which activity does this paper The establishment of a formal sub-committee of the Governing relate to? Body for the monitoring of BLMK Commissioning Collaborative’s performance in relation to equality and diversity. How? The attached paper describes the process undertaken to establish the committee and the attached draft ToR describe the terms under which the Committee will operate. What is the Committee/ The Committee is asked to : Governing Body being asked to • Approve the establishment of the Committee do? • Approve the draft Terms of Reference What are the financial The Committee itself shuld not incur financial costs. It is implications? recognised that individual pieces of work may incur costs. Approval for these will be sought through appropriate governance mechanisms. Set out the key risks and risk It is good practice for employers to be aware of and mitigate ratings against any form of discrimination; consideration and positive action should be taken in terms of equality, diversity and inclusion. To not support a formal committee and dirve forwards a strong agenda may impact negatively on staff morale and CCGs reputation. It may also lead to legal claims and challenges if cases arise and positive action on this agenda has not been taken. Date to which the information 13th July 2020 this paper is based on was accurate
Executive Summary
Please ensure you do not use acronyms, technical terms or jargon without clarifying what they mean If you are referring to data or attachments please help the reader by highlighting specifically where they can cross reference that information
1. Background
As part of its work to establish one CCG, BLMK Commissioning Collaborative is seeking ways in which it can work in a more aligned manner. Equality, diversity and Inclusion has been a focus for each CCG individually, but with the onset of Covid the 3 CCGs were driven to find more collaborative approaches. The collaborative would like to continue this work by creating a united agenda and focus. To progress a united approach, the Collaborative feels there should be a single committee of the Governing Body focused on equality, diversity and inclusion. The collaborative is passionate about this area of work and wants to show staff that it is very committed.
2. Purpose of the Equality, Diversity & Inclusion Committee
The Equality, Diversity and Inclusion (EDI) Committee’s purpose is to monitor the BLMK Commissioning Collaborative’s performance in relation to equality and diversity. The Equality, Diversity and Inclusion Committee will provide proactive support, evidence-based feedback, guidance, assurance and governance to the Governing Body to enable it to carry out its responsibilities for the Equality and Diversity Agenda and provide strategic direction, leadership and support for promoting and maintaining equality, diversity and human rights issues across the BLMK CC. The work of the Committee will not only include tasks related to statutory frameworks such as Workforce Race Equality Standards, Equality Act 2010, Equality Delivery System 2 and Workforce Disability Standard but will also discuss equality, diversity and inclusion improvements, updates and issues and develop a workplan.
3. Establishing an Equality, Diversity & Inclusion Committee
The journey in establishing an Equality, Diversity & Inclusion Committee, whilst following due process, has also been inclusive with staff representation being sought.
2
When establishing the Equality, Diversity and Inclusion Committee the CC felt strongly that it was important the Committee represented our diverse workforce. With this in mind, the CC voiced its intention to staff to make a real commitment to Equality, Diversity & Inclusion and invited staff to join the Committee.
As a sub-committee of the Governing Body, a Chair is required. It is noted that the 3 CCGs are still separate statutory organisations. The Chair of the Committee is required to lead on behalf of the 3 CCGs. This authority requires delegated approval from Luton and Milton Keynes CCGs. Initial work completed to date has been to finalise the membership, including the chair and develop draft Terms of Refeerence. An inaugural meeting was held on 2nd July. The CCG has also secured specialist Equality, Diversity and Inclusion resource.
4. Next Steps
Having established the Equality, Diversity and Inclusion Committee the Commissioning Collaborative will now:
• Seek approval of the Terms of Reference from the Governing Body • Seek delegated authority for the position of Committee Chair from Luton and Milton Keynes CCG • Develop an Equality, Diversity & Inclusion workplan
5. Recommendations for the Governing Body
The Governing body are asked to: • Approve the establishment of the Committee • Approve delegated authority for the position of Committee Chair to lead on behalf of all 3 CCGs; and • Review and approve the proposed Terms of Reference for the Equality, Diversity & Inclusion committee (See Appendix A)
3
Subject: Establishment of an Equality, Diversity & Inclusion Committee
Meeting: Governing Bodies in Common
Date of Meeting: 21st July 2020
Report of: Emma Richards, Corporate Services & Workforce Lead Geraint Davies, Director of Performance & Governance
Is this document Commercially Sensitive N
1. Background
BLMK Commissioning Collaborative is dis-establishing 3 CCGs and re-establishing one CCG with effect from April 2021. The Commissioning Collaborative is currently seeking ways in which it can work in a more aligned manner to improve ways of working for its workforce and the commissioning of services for the general public.
The current BLMK Commissioning Collaborative (BLMK CC) has both a diverse workforce across its 3 sites and equally a diverse patient population. It is important that the Commissioning Collaborative recognises this in its work, whether internally focused on staffing matters or externally in the commissioning of services.
Whilst equality, diversity and inclusion has been a focus for each of the 3 CCGs individually, the onset of Covid-19 and the risks highlighted for various groups as a result of this disease has driven the Collaborative to work in an aligned way to address these matters, for example BAME and PPE, risk assessments etc This work has highlighted that further improvements could be achieved if the 3 CCGs were to work together more in respect of equality, diversity and inclusion. To support this work, it is strongly believed by the Commissioning Collaborative that not only should there be a real focus on equality and diversity both internally to BLMK CC and externally, but there must also be a dedicated committee of the Governing Body to oversee this important area of work, evidencing BLMK CC’s commitment in this area to its workforce and the general public.
As a result, the Commissioning Collaborative now feels that there should a single committee established to focus on equality, diversity and inclusion. The collaborative is passionate about this area of work and wants to show staff that it is very committed.
2. Purpose of the Equality, Diversity & Inclusion Committee
The Equality, Diversity and Inclusion (EDI) Committee’s purpose is to monitor the BLMK Commissioning Collaborative’s performance in relation to equality and diversity. This means 1
monitoring the BLMK CC’s performance in creating an organisation where healthcare provision is accessible, responsive and appropriate to people, irrespective of their personal characteristics and where all CCG employees can fully contribute, develop and flourish at work, irrespective of their personal characteristics. The Equality, Diversity and Inclusion Committee has been set up to provide proactive support, evidence-based feedback, guidance, assurance and governance to the Governing Body to enable it to carry out its responsibilities for the Equality and Diversity Agenda and provide strategic direction, leadership and support for promoting and maintaining equality, diversity and human rights issues across the BLMK CC.
The Equality, Diversity and Inclusion Committee will:
• Implement the Equality Act 2010. The general and specific duties of the Public Sector Equality Duty, in line with CQC guidance on Equality and Human rights and NHS Constitution. • Implement the Accessible Information Standard. • Manage the Equality Delivery System (EDS2) and the subsequent actions falling out of EDS2. • Implement the Workforce Race Equality Standard in line with NHS England guidance. • Prepare the organisation for the introduction of the Workforce Disability Standard and subsequent standards.
Ensure equality and diversity improvements, updates and issues are discussed and an agreed work plan/schedule is actioned. The work plan/schedule will consist of priorities that link to BLMK Commissioning Collaborative’s strategic direction, workforce plan and the wider development of services
3. Establishing an Equality, Diversity & Inclusion Committee
The journey in establishing an Equality, Diversity & Inclusion Committee, whilst following due process, has also been inclusive with staff representation being sought.
When establishing the Equality, Diversity and Inclusion Committee the CC felt strongly that it was important the Committee represented our diverse workforce. With this in mind, the CC voiced its intention to staff to make a real commitment to Equality, Diversity & Inclusion and invited staff to join the Committee. As this is a formal sub-committee of the Governing Body, staff were asked to provide a short narrative as to why they might like to join the Committee and what value could they bring. This resulted in 9 very positive responses from staff members who, through their narrative, demonstrated a real interest and passion for Equality & Diversity.
Having made the decision to initiate an Equality & Diversity Committee the following steps have been taken: • Comprehensive Terms of Reference have been drafted and reviewed by the Governance team for compliance and organisational standards. These Terms of Reference are also comparable to those of similar organisations. Approval of the Terms of Reference is required by the Governing Body. • A provisional clinical lead has been appointed to lead the Committee – Dr Roshan Jayaleth. As a sub-committee of the Governing Body, a Chair is required. It is noted that the 3 CCGs are still separate statutory organisations. The Chair of the Committee is required to lead on behalf of the 3 CCGs. This authority requires delegated approval from Luton and Milton Keynes CCGs. 2
• An Executive lead has been appointed – Geraint Davies • 9 staff members have been appointed who have an interest in Equality, Diversity & Inclusion • Other key members have also been nominated to represent Safeguarding, Communications & Engagement and Human Resources • The Commissioning Collaborative recognises that specialist Equality and Diversity experience would greatly support the work of the Committee and has secured additional resource in this area. To start by August. • Held its inaugural meeting with all members on 2nd July 2020
4. Next Steps
Having established the Equality, Diversity and Inclusion Committee the Commissioning Collaborative will now:
• Seek approval of the Terms of Reference from the Governing Body • Develop an Equality, Diversity & Inclusion workplan
5. Recommendations for the Governing Body
The Governing body are asked to approve the establishment of the Committee and review and approve the proposed Terms of Reference for the Equality, Diversity & Inclusion committee (See Appendix A)
Attachment:
Appendix A – Terms of Reference for Equality, Diversity & Inclusion Committee (Draft)
3
Equality, Diversity and Inclusion Committee
Terms of Reference
July 2020
Page 1 Equality Diversity and Inclusion Committee Terms of Reference Draft V 1.0
PURPOSE
The Equality, Diversity and Inclusion (EDI) Committee’s purpose is to monitor the Bedfordshire, Luton and Milton Keynes Commissioning Collaborative’s (BLMK CC) performance in relation to equality and diversity. This means monitoring the BLMK CC’s performance in creating an organisation where healthcare provision is accessible, responsive and appropriate to people, irrespective of their personal characteristics and where all CCG employees can fully contribute, develop and flourish at work, irrespective of their personal characteristics. The Equality, Diversity and Inclusion Committee is the formal mechanism by which the BLMK CC can oversee its processes to eliminate discrimination on the basis of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.
The Equality, Diversity and Inclusion Committee has been set up to provide proactive support, evidence-based feedback, guidance, assurance and governance to the Governing Body to enable it to carry out its responsibilities for the Equality and Diversity Agenda and provide strategic direction, leadership and support for promoting and maintaining equality, diversity and human rights issues across the BLMK CC.
The Equality, Diversity and Inclusion Committee will:
• Implement the Equality Act 2010. The general and specific duties of the Public Sector Equality Duty, in line with CQC guidance on Equality and Human rights and NHS Constitution. • Implement the Accessible Information Standard. • Manage the Equality Delivery System (EDS2) and the subsequent actions falling out of EDS2. • Implement the Workforce Race Equality Standard in line with NHS England guidance. • Prepare the organisation for the introduction of the Workforce Disability Standard and subsequent standards. • Ensure equality and diversity improvements, updates and issues are discussed and an agreed work plan/schedule is actioned. The work plan/schedule will consist of priorities that link to BLMK Commissioning Collaborative’s strategic direction, workforce plan and the wider development of services.
The Equality, Diversity and Inclusion Committee will not monitor relevant activity and performance in commissioned services and / or supporting CCG members. The Equality, Diversity and Inclusion Committee will not represent individual CCG issues as there are policies and procedures already in place to support CCG staff.
Page 2 Equality Diversity and Inclusion Committee Terms of Reference Draft V 1.0
DUTIES/RESPONSIBILITIES
The objectives of the Committee are to implement, facilitate, inspire and make it easy for line managers/clinical leads.
The EDI Committee will:
Take a strategic overview of equality, diversity and human rights issues taking account of changing legislation, best practice evidence and patients and staff feedback and to set the BLMK CC’s strategic agenda in this area as follows:
• Agree an annual work schedule/plan based on: • Legislation • Workforce Requirements • National Service Frameworks • National and Local Strategies • Healthcare Strategy • Staff Surveys • Patient Surveys • Equality Impact Assessments • Respond to Healthcare Commission Guidelines • Work within Equality and Human Rights Commission Guidelines and codes of practice. • Ensure all proposed plans are discussed with internal and external stakeholders. • Respond to social care strategies. • Monitor, on behalf of the Governing Body, progress against a range of Equality Objectives as set out in the Equality, Diversity and Inclusion Strategy and action plans to ongoing development. • To provide assurance to the Governing Body and its subcommittees that the BLMK CC is fulfilling the legislative and regulatory requirements relating to equality, diversity and human rights agenda, including the PSED2 and publication of equalities information. • To oversee the design, implementation and period review of the BLMK CC’s equality objectives (at least every 3 years), to review and if necessary prioritise action plans to reflect national guidance (such as the NHS Equality Delivery System EDS2, NHS Workforce Race Equality Standard, Workforce Disability Standards). • To provide a forum for discussion and ensure liaison and where appropriate joint working with the BLMK’s partners, patients and the public. • To create sub-committees and/or working groups to complete work delegated to it from the Committee, This could include the following, agreeing the direction, activity and output of the groups/sub-committees which will enable the diversity
Page 3 Equality Diversity and Inclusion Committee Terms of Reference Draft V 1.0
of the staff groups to influence the effective implementation of action plans.To report the BLMK CC’s progress to the Governing Body. • To assess risks associated with Equality Diversity and Inclusion and provide guidance to the Executive Team and/or risk owner. • To receive and sign off for reports on Equality and Diversity. • Identification and recommendations of Positive Action Initiatives to address inequality and meet the relevant standards. • Bring to the table any other new equality objectives as may be required by NHS Equality, Diversity Council or new legislation. • Considering the above, there will be focus on implementation of the above to three main areas: o Operational (service) Issues o Employment Issues o Patient Focused Activity
EXTERNAL RELATIONSHIP
• To promote, recognise and value the diverse nature of communities across the BLMK region and internal staff networks. • To engage with community groups, including seldom heard voices and emerging communities to assist the organisation in carrying out assessments and grading procedures, i.e. EDS2. To implement the Public Sector Equality Duty. • To ensure that all sections of the community, including strategic partners can access appropriate policies and procedures, for example, the complaints and compliments process and for these processes to be transparent and straightforward. • To ensure that local communities and strategic healthcare providers identify the organisation as being equality focused, diversity driven and inclusion minded. • To delivery appropriate and patient focused services taking into account cultural requirements to meet the needs of our diverse communities and ensure accessibility.
MEMBERSHIP
The membership of the EDI Committee will consist of members with specific responsibilities for equality and diversity – as reflected in their job description and/or annual objectives – and members well-placed to provide feedback to the Committee in relation to the CCG’s equality and diversity commitments and responsibilities regarding equality. In order to ensure that the EDI Committee is effective the representatives will include:
Page 4 Equality Diversity and Inclusion Committee Terms of Reference Draft V 1.0
• Chair – GP Governing Body Member (delegated authority to be provided by the CCGs where the GP is not a GB member) • Deputy Chair - Director of Performance and Governance • BLMK CC Medical Director • HR Representative/Equality, Diversity and Inclusion Manager • Communications and Engagement Representative • Safeguarding Representative • Representatives of the CCG staff from all three areas – Bedfordshire, Luton and Milton Keynes
All of the above members are entitled to one vote. Deputies and delegates for the above will equally be entitled to one vote when representing the member. However, the member should ensure that the deputy / delegate has sufficient information/knowledge to attend and make an informed decision in regards to any vote.
The Chair of the committee may not nominate a deputy/delegate. Where the Chair is absent the Deputy Chair will fulfil the role of Chair.
EXTERNAL STAKEHOLDERS/CRITICAL FRIENDS (as appropriate)
This group will invite other key management and stakeholder representatives for specific items. However, this will be organized taking regard of the needs of the CCG.
OTHER WORKING GROUPS
BLMK CC Specialist Diversity Groups – these will be formulated as and when required to address any inequalities as deemed necessary.
ROLES OF MEMBERSHIP
• To regularly attend meetings of the Committee, and when not available, to make arrangements for a nominated person or deputy to attend. In circumstances where a nominated person or deputy cannot attend, then the member should send their input/contributions together with an apology. • To contribute fully to enabling the group to comply with its Terms of Reference, once agreed.
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• To undertake duties assigned by the group. • To focus decision making on the principles of modernisation, staff/patient centred roles, improving the work environment for staff, improving services for patients, flexibility and building effective teams. • To act as advocates of the Equality, Diversity and Inclusion Committee and the broader equality and diversity agenda within their profession and organisation. • To ensure that the work of the group and the broader equality and diversity agenda is communicated widely, through existing forums and communication channels. • To effectively bring to the Committee, the views of the staff, professional group and/or other organisations to which they belong and give informed opinions on related disciplines not represented. • To ensure the Committee is informed of progress, risks, etc on specific actions/projects or areas of work that relate to the EDI agenda.
ATTENDANCE
When a member cannot attend they should arrange for a fully briefed nominiated person or deputy to attend on their behalf who is able to feedback and contribute. In circumstances where a nominated person or deputy cannot attend, then the member should send their input/contributions together with an apology.
Members will be required to attend a minimum of 3 meetings per calendar year.
QUORUM
A quorum of 4 members is required to be present to enable the Committee to undertake its function. This is to include the Chair or Deputy Chair (or another CCG Director) plus 3 others.
Deputies / delegates will be counted under quoracy terms with the exception of the Chair as described above (See Membership section).
If an apology is provided and information / contribution is provided from a member in advance of the meeting, this will not count for quoracy.
In order to maximise the participation of members and to achieve quoracy, individual members may be deemed to be ‘present’ via Skype, Video Conferencing, telephone or other communications technology which the Chair deems appropriate to enable their full participation in the meeting.
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FREQUENCY
The Committee will meet at least 4 times a year, however meeting frequency could increase and this would be subject to discussion and agreement by members
ACCOUNTABLE TO:
The Committee is accountable to the Governing Body for monitoring the BLMK CC’s performance in relation to equality and diversity, both in relation to the provision of services to the public and in the employment of its staff.
The action notes of the Equality, Diversity and Inclusion Committee shall be formally recorded and submitted to Governing Body. The Chair / Deputy Chair of the Equality, Diversity & Inclusion Committee shall draw to the attention of the Governing body any issues that require disclosure to the Governing Body, or require executive action.
ADMINISTRATION
An administrator will be appointed to the EDI Committee to manage the meetings diary, taking notes, formulating and agreeing the agenda with the Chair and Equality Lead and sending out papers.
Agendas, reports and papers will be issued to members at least 5 calendar days prior to the meeting.
Action notes will be taken at each meeting and will be circulated within 2 weeks of the date of the meeting.
BUDGET
A budget will be allocated annually to help support activities/set objectives.
EFFECTIVENESS
The Committee’s effectiveness will be monitored through:
• Annual audit of attendance • Publishing an annual equalities report. Page 7 Equality Diversity and Inclusion Committee Terms of Reference Draft V 1.0
• Progress against the CCGs equality objectives.
REVIEW OF TERMS OF REFERENCE
An evaluation of the effectiveness of the Equality, Diversity and Inclusion Committee and a review of its Terms of Reference and frequency of meetings will take place annually, or beforehand in light of any system, procedural or organisational change and will be approved by the Governing Body.
Version Date Revision Author Approver 1.0 June 2020 E. Richards
MONITORING
Compliance with these Terms of Reference will be monitored by the Audit Committees in Common as part of the annual review of the terms of reference and annual report.
EQUALITY STATEMENT
Equality, Diversity, Inclusion and Human Rights encompass all our aims, objectives and actions addressing inequalities and promoting diversity in healthcare and employment. The key principle of Diversity and Inclusion is that it belongs to everyone and that every individual has the right to be treated with respect and dignity as aligned to our core values.
BLMK Commissioning Collaborative aims to design and implement policy and processes that meet the diverse needs of our services, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the current UK legislative requirements, including the Equality Act 2010 and the Human Rights Act 1998, and promotes equal opportunities for all, ensuring that no- one receives less favourable treatment due to their personal circumstances, i.e. the protected characteristics of their age, disability, sex (gender), gender reassignments, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Appropriate consideration has also been given to gender identity, socio-economic status, immigration status and the principles of the Human Rights Act.
In carrying out its functions, BLMK Commissioning Collaborative must have due regard to the Public Sector Duty (PSED2) and remain focused on equality of
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outcome and equality of opportunity. This applies to all the activities for which BLMK Commissioning Collaborative is responsible.
REVIEW DATE
These terms of reference will be reviewed annually.
Agreed and Signed by:
…………………………………………………………………………………..
Date:……………………………………………………
Chair
GP Governing Body Member
Page 9 Equality Diversity and Inclusion Committee Terms of Reference Draft V 1.0 5.1
Governing Bodies in Common in Public
21 July 2020
Corporate Risk Registers
Author: Michael Wuestefeld-Gray, Interim Programme Manager for BLMK Governancce Contact Information: [email protected] Lead Executive: Geraint Davies, Director of Performance and Governance Which CCGs does this paper apply to?
Bedfordshire X Luton X Milton Keynes X
Information
Which activity does this paper Assurance of effective corporate level risk mangement at the relate to? three CCGs
How? The CCGs now have a combined risk register, and legacy risks from the three local risk registers have been reviewed and uodated. What is the Governing Body To receive assurance that there is effective risk management at being asked to do? the three CCGs, and work to develop aligned risk management systems is progressing. What are the financial As set out in the individual risks. implications?
Set out the key risks and risk N/A ratings
Date to which the information 8 July 2020 this paper is based on was accurate
Executive Summary
Each CCG maintains a corporate risk register that includes risks escalated from different workstreams and activities. As part of the move to a single CCG a common risk management system is being rolled out across the three CCGs and in preparation for that a single, shared corporate risk register has been developed. This currently is collated manually but the single system will collate risks and produce reports automatically. The risk register enclosed as Appendix A attempts to replicate the look and feel of that report but there are variations among the three CCGs that currently cannot be aligned until the automated system is in place. Timings for next steps are dependent on the capacity of the CCGs and the provider of the system to be able to roll it out and provide training In addition risks have been grouped under key areas to help the Governing Bodies review and compare risks. The number of risks varies by CCG significantly, and this is partly due to the closedown of 2019/20 related risks which is still ongoing in some places.
Risks
A summary of the risk register is set out in the table below. There are 186 risks across the three CCGs broken down as follows: Area Bedford- Luton Milton Total shire Keynes Children, young people, safeguarding & maternity 0 11 8 19 Corporate strategy 0 2 15 17 Financial 0 13 8 21 Mental health, CHC and learning disabilities 1 0 7 8 One BLMK CCG Programme 0 1 34 35 Primary care 2 5 15 22 Services 0 20 9 29 STP/ICS 0 4 1 5 Urgent and emergency care 0 1 3 4 Workforce 0 5 0 5 Planned care, community/commissioned services 0 21 0 21 Total 3 83 100 186
2
Numbers of risks vary across the CCGs for a range of reasons: • A significant proportion of Bedfordshire’s risks related to 2019/20 and equivalent risks for 2020/21 have not yet been defined. • Some risks on the risk register for Luton and Milton Keynes relate to 2019/20 and risk leads are being asked to identify and close them. • Milton Keynes CCG hosts the risks relating to the BLMK-wide programme to develop a single CCG. • Priorities and challenges at individual CCGs will vary. • Thresholds for escalation to the corporate risk register vary from CCG to CCG. For example, a number of Luton’s risks are green rated both before and after mitigation. • There will be some duplication of risks between CCGs and a single BLMK risk may be a more appropriate reflection of the risk the three CCGs face. To further align risks and risk management across the three CCGs next steps include: • The definition of a common risk management strategies for the three CCGs. • Rolling out consistent risk management systems across the three CCGs. • Working with the joint committees and committees in common for the three CCGs to define the appetite for and tolerance of risk in different areas (which will define common threshold for escalation). • Working with risk leads and subject matter experts to eliminate duplication and define common strategic risks.
3
BLMK Corporate Risk Register
Children, Young People, Safeguarding and Maternity
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton CYP S2 - COMPLEX PATIENTS As a result of a lack of a co- I = 3 L Appointed to 2 joint posts with Local I = 3 L Programme of work has been created, programme Hannah 30 Nov I = 2 L Kenyes 8 Access & Owner: Richard Alsop ordinated system wide = 5 Authority to deliver a programme of work = 3 plan in place Pugliese 2020 = 2 Quality Risk Lead: Hannah response to meet the 15 aimed at addressing this risk. 9 4 Pugliese needs of children with Last Updated: 09 Jun complex and challenging Children's commissioner working across Outcome of case 2020 behaviours, there is a risk health and social care to identify potential conferences available upon Latest Review Date: that children with complex longer-term solutions and also to improve request, but contains 09 Jun 2020 needs do not have those systems working around individual Patient Identifiable Data. Latest Review By: needs fully addressed, and children and young people with current Joyce Baskerville a large amount of staff needs. capacity is used in attempting to address needs on an ad hoc basis. Resulting in children with complex needs experiencing poor outcomes of care, and a large amount of staff capacity is inefficiently used in attempting to address individual needs of children Milton CYP S2 - CYP IN CAMPBELL As a result of CNWL I = 4 L There is a dedicated space which has I = 4 L CNWL is now part of the east of England Provider Hannah 30 Sep I = 2 L Kenyes 7 Access & CENTRE querying how appropriate it = 3 been designed for CYP in the Campbell = 2 Collaborative, and there is a plan and time frame Pugliese 2020 = 2 Quality Owner: Richard Alsop is for CYP to be admitted to 12 Centre and through custom and practice 8 for devolving responsibilities to local provider 4 Risk Lead: Hannah the Campbell Centre which CNWL have been providing this facility collaborative to deliver admissions avoidance, bed Pugliese is an adult mental health in- and it is described within an operational management and crisis beds. Use of the Campbell Last Updated: 09 Jun patient unit, there is a risk policy. Information secured that Centre bed (or an alternative provision) is being 2020 that they may cease to previously funding was provided for this considered as part of this plan. Delays due to Latest Review Date: make this provision provision. Covid 02 Mar 2020 available, resulting in poorer outcomes for CYP as they will need to spend significant periods of time in A&E awaiting an age appropriate bed in an adolescent unit. Milton CYP S3 - COMMISSIONING Due to limited capacity in I = 3 L Process for prioritisation of Regular (monthly) review of I = 2 L Build capacity and capability in with the tier 3 Hannah 28 Aug I = 2 L Kenyes 2 Financi al PRIORITIES the Children's = 5 commissioning intentions was a workplan. = 4 restructure Pugliese 2020 = 4 Sustain Owner: Richard Alsop Commissioning Team and 15 transparent and robust process 8 8 ability Risk Lead: Hannah a large number of completed in line with the CCG agreed Pugliese competing priorities, there prioritisation matrix is a risk that not all areas of Work plan for team in place which is work will be prioritised for reviewed each month by the programme action, resulting in 2 board and reprioritisation of projects can potential impacts: missed be undertaken and agreed if pressures opportunities for doing emerge. things better, situations LMS work now funded through the LMS may escalate before transformation budget. Team restructure commissioners become approved - 2 joint posts agreed with the aware. council.
Milton CYP S2 - BCG SERVICE As a result of CNWL giving I = 3 L Pathway is under development, and new I = 2 L New pathway under development. Joint TB and Hannah 31 Jul I = 2 L Kenyes 9 Access & Owner: Richard Alsop notice on providing a BCG = 5 provider has been identified. = 5 BCG business case being finalised for resources Pugliese 2020 = 1 Quality Risk Lead: Hannah immunisation service for 15 10 to deliver the services. Delays due to Covid 2 Pugliese over 1's as this is no longer Last Updated: 09 Jun viable as they have been 2020 decommissioned from providing the school based universal immunisation programme by NHSE, there is a risk that children requiring immunisations wont be identified resulting in a poor coverage in MK. Milton CYP S2 - MATERNITY RECORDS As a result of midwives and I = 5 L Client held records are being used. Further action is required to I = 5 L Monitor local interoperability scheme (SystmOne / Hannah 28 Aug I = 3 L Kenyes 3 Access & Owner: Richard Alsop GPs not being able to = 3 Some midwives have access to GP confirm that the mitigating = 2 eCare), and ensure input from the clinical team and Pugliese 2020 = 1 Quality Risk Lead: Hannah access each others clinical 15 system factors are sufficient 10 commissioning when required. 3 Pugliese records, important assurance to manage the Last Updated: 09 Jun information will not be risk. ArdenGEM undertook an options appraisal for a Hannah 28 Aug 2020 available when providing digital solution for the development of personalised Pugliese 2020 Latest Review Date: patient care, resulting in care planning records, however as the 09 Jun 2020 patient safety being recommendation has been to pause the Latest Review By: compromised. programme following a national information Joyce Baskerville standards notice, plan to develop a paper-based Last Review Comments: personalised care plan. Paper-based record (final Updated draft) signed-off Jan 2020, being launched imminently.
Milton CYP S2 - QUALITY OF MATERNITY Due to a lack of choice and I = 4 L A large programme of work is being Local Maternity System I = 4 L Specific activity undertaken in the context of Covid Hannah 31 Jul I = 4 L Kenyes 1 Access & SERVICES a perception that care is = 3 undertaken across BLMK in response to action plan evidences that = 2 - Co-produced maternity pathways Pugliese 2020 = 1 Quality Owner: Richard Alsop not personalised to them, 12 the Better Births publication. This this action plan is being 8 - Co-produced prenatal mental health pathways 4 Risk Lead: Hannah there is a risk that women includes co- production of personalised undertaken. - Enhanced virtual breastfeeding offer Pugliese will have a poor experience care plans, the opening of a new Last Updated: 09 Jun of care at Milton Keynes midwifery-led birthing unit at MK, 2020 maternity department, introduction of continuity of carer models. Deliver and monitor transformation programme Hannah 31 Dec actions (establish shared learning and quality Pugliese 2020 Latest Review Date: resulting in poorer improvement across BLMK STP LMS, inc.: Shared 09 Jun 2020 outcomes for the health SI panels, perinatal mortality reviewing tool, and Latest Review By: and wellbeing of new local learning system.) through LMS Business and Joyce Baskerville mothers and their babies. Quality quarterly meetings. Milton CYP S3 - SYSTEM WIDE As a result of system wide I = 3 L Quality Impact Assessments to be I = 3 L System wide issue. Monitor impact of financial Hannah 28 Aug I = 2 L Kenyes 4 Financi al FINANCIAL PRESSURE financial pressure, = 3 undertaken for any significant proposed = 3 reductions as they occur factoring in any additional Pugliese 2020 = 2 Sustain Owner: Richard Alsop C,YP&M services across 9 changes 9 pressure from Covid. 4 ability Risk Lead: Hannah MK will find it increasingly Providers can raise through contractual Pugliese difficult to provide the mechanisms pressures within services expected services and/or Last Updated: 09 Jun 2020 the quality of service may diminish, resulting in patients not receiving the care, or quality of care, that they did previously. May be further impacted by the consequences of Covid Milton CYP S2 - Delayed consent Iintial As a result of delays in the I = 4 L A number of controls are in place; 1.The attachments of actions I = 3 L Children in care without consent: CNWL LAC Mandy Park 30 Apr I = 3 L Kenyes 13 Access & Health Assessment (IHA) CNWL LAC health team = 4 director of children and families services plans and draft strategy = 3 health team are escalating monthly the names of 2020 = 2 Quality Owner: Linda Chibuzor receiving valid consent 16 and head of corporate parenting within which includes a new 9 children with delayed consent and therefore not 6 Risk Lead: Mandy Park from children's social care children's Social are aware of the risk and process timeline and having an IHA. Foster carers are obliged to register Last Updated: 03 Apr there is a risk that looked the DN has written to the senior Terms of Reference to the the child with a GP Practice, and SystmOne IT 2020 after children coming into management team in CSC (email to head LAC forum which reviews records will follow the child, this will support care will not have an Initial of service 8th July 2019) requesting a all issues for Looked after mitigation of concern as health information should Health Assessment, and current position and trajectory of Children in MK. be available to the GP. Therefore any on-going the IHA will not be within expected improvement in compliance. prescriptions or clinical risks will have primary care the statutory time frames. 2.On a monthly basis the LAC health oversight. This would mean that team escalate the names of all children children coming in to care who have not had an IHA due to delayed Latest Review Date: may have clinical health consent to the Heads of Service. 03 Apr 2020
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BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
03 Apr 2020 risks due to a lack of 3. Workshops are in place to review the All children coming into care: SC and partners to Mandy Park 30 Jun Latest Review By: identification and sharing of processes of children coming in to care review the processes to ensure statutory time 2020 Mandy Park information relating to their to assist in expediting consent. scales are achieved. This along with actions Last Review Comments: health needs. 4.Admin from both CSC and LAC health discussed remain in place, however there is 3/4/20 Due to Covid-19 the meet weekly to review CSC records as to greater co- ordinated oversight from the DN implementation date has why consent is delayed - outcomes will MKCCG, DoN CNWL and Service Manager within been postponed to June be sent to CSC SMT. CNWL. These actions will be longstanding due to 2020. Full oversight of LAC 5.there are plans for CSC to educate the number of processes/changes in place. processes remains by the family and friends around consent and 3/4/20 Due to Covid-19 the implementation date Designated Nurse to the need for children to be brought in for has been postponed to June 2020. Full oversight ensure looked after their IHA (when consent has been of LAC processes remains by the Designated children are receiving gained). 6.Regulation 24 processes Nurse to ensure looked after children are receiving health and social care within CSC have been altered to remove health and social care support that is currently support that is currently delays in signing consent. required. required. 7. Recruitment of CSC admin staff has occurred which should aid paperwork transfer. 8. CSC IT system LCS is being updated which will also speed up paperwork completion and transfer. 9. LAC champions within CSC are being sourced to support SW's to complete paperwork/trouble shoot issues. 10. the DN MKCCG has requested that a multi agency action plan is devised with robust governance structures to assist in tracking actions. 11. the DN MKCCG is having monthly 1:1's with the CNWL Children's service manager to maintain oversight and guidance. 12. The Chief Nurse and Children's commissioner are meeting with the Dir of Children's and Families social care in September 2019. 13. The DN MKCCG maintains to discuss and monitor the situation within the Health of Children in Care Forum held monthly, any delays/blocks/issues are raised in relevant 1:1's with the CNWL Children service manager. 14. 10th October 2019 a LAC Health Focussed meeting was held and action plan agreed (attached) to facilitate further oversight and management of the issues.
Monthly meetings with social care, CNWL and MK CCG. Luton CYP Children with Complex Weaknesses I = 4 L = Budget agreed for 19/20 with monthly I = 4 L = Children's CHC Action Plan implementation 9 Needs Inadequate capacity within 4 monitoring. 3 Person Responsible: Lucy Hubber existing Community 16 Full community nursing team in place 12 To be implemented by: 31 Mar 2020 Nursing Team to meet Training available to nursing team when increasing numbers of recruited and as required children with complex Joint working with LBC and Luton disabilities in Luton Inability Community Services on establishment of to provide timely training to integrated health and social care nursing team community team for children with Funding.. Review of expenditure ongoing to identify Consequence any possible savings to be released for Negative outcomes for the investment in community nursing team child and their family Overspend in community care budget because of use of high cost agency care packages in the community Reputational damage to CCG Potentiall.. Luton CYP CAMHS Strategic Weaknesses I = 3 L = Compliance with DH strict performance I = 3 L = CAMHS Transformation Plan Implementation 18 Transformational Plan * New national CAMHS DH 3 monitoring reporting. 2 Person Responsible: Lucy Hubber 5-year funding: 9 LCCG 'ring fence' funds for CAMHS 6 To be implemented by: 31 Mar 2019 Year 1 - funding only Working with HEE and part of LTP to available within year - develop 5- year workforce plan pressure to spend all the allocated funding Lack of existing appropriately qualified staff, all chasing same.. Luton CYP Designated Medical Officer Weaknesses I = 3 L = CQC/Ofsted Local Area Inspection I = 3 L = Recruitment to DCO Role 19 for Children with SEND Due to Maternity Leave of 3 Process for SEND 3 Person Responsible: Lucy Hubber Clinical Director Lead for 9 9 To be implemented by: 31 Mar 2019 Children’s Commissioning, Luton CCG has had a vacancy for the Designated Medical Officer (DMO) for SEND for a significant period of time. There.. Consequence We may be unable to meet our statutory responsibilities regrading medical input into the SEND agenda. We may be unable to meet our statutory responsibilities regarding health oversight and quality.. Luton S/G 5 Quality & Safeguarding Weaknesses I = 3 L = Commissioner visits to service provider to I = 3 L = Person Responsible: To be implemented by: Concerns at Moorland Quality and safeguarding 3 personally assess quality and 3 Gardens concerns regarding care 9 safeguarding risks and require provider 9 provision to patients at Escalation of concerns from any health Moorland Gardens may and/or social care commissioner leading result in LBC taking to escalation of concerns through a provider performance formal process operated by LBC action. Routine meetings with LBC & CQC for Consequence information sharing Embargo on admissions. Plans to expand capacity to support Winter pressures may also be at risk.
Luton S/G 6 Deprivation Of Liberty Weaknesses I = 2 L = Creation of a DoL Register to record all I = 2 L = Person Responsible: To be implemented by: (DoL) in the Community The CCG commission high 3 packages of care that amount to a DoL. 2 care packages which 6 4 involve a number of restrictions that indicate, that the person is deprived of their liberty in their own home. Consequence There are financial costs involved in making lawful applications to the Court of Protection, which will impact on NHS Luton CCG's ability to be in a financial balance at year end. These costs will be.. Luton S/G 7 LeDeR Programme Under Weaknesses I = 3 L = Local Area Coordinator now in place who I = 3 L = Person Responsible: To be implemented by: Resourced Due to Lack of Resources 3 is managing the process locally. 3 i th i l t ti f th 9 9
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BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
in the implementation of the 9 9 LeDeR programme advised to instigate by NHSE, Learning Disability Mortality Reviews are not undertaken in a timely fashion. Consequence This means that learning from the local reviews are not implemented which could result in patients dying unnecessarily and NHS England holding NHS Luton CCG to account.
Luton S/G 8 Replacement for DoLS - Weaknesses I = 3 L = Person Responsible: To be implemented by: Liberty Protection The law is changing , the 4 Safeguards Deprivation of Liberty 12 Safeguards (DoLS) is changing to the Liberty Protection Safeguards which receives royal assent 24th April 2019. This means that NHS Luton CCG will be.. Consequence The change in law to Liberty Protection Safeguards (LPS) will mean that NHS Luton CCG will be required to fund assessments and have oversight of the process for NHS Luton CCG patients. The service.. Luton S/G 9 Failure to achieve stautory Weaknesses I = 3 L = Comprehensive policies, procedures and I = 3 L = Pursue Contractual Performance Measures with duty for safeguarding If the CCG does not ensure 2 protocols in place including induction and 2 existing providers. children & vulnerable adults appropriate systems, 6 full engagement on Local Safeguarding 6 Ensure robust contractual measures and processes and capability Boards with reports to CCG Board specificiation in new contracts. are in place for Governance of safeguarding processes Regular routine monitoring of LAC Health Team safeguarding children & monitored through provider contracts. Action Plan with provider vulnerable adults across Revised quality team structure with Person Responsible: Chris Harvey providers, then these enhanced safeguarding capacity with To be implemented by: 31 Jan 2020 patients may be put at.. designated roles in post. Consequence Safety issues legal cases Luton S/G Children not safeguarded Weaknesses I = 3 L = Monthly reporting from LDH I = 3 L = Evidence of programme of extra sessions being 10 due to low levels of Safeguarding Children 4 2 provided. safeguarding L3 training training level 3 access 12 Plan to deliver extra sessions to capture 6 Monthly reporting on levels of staff (numbers and below KPI (35%) and non- staff who have not accessed level 3. %) to CCG adherence to IC guidance Monthly updates regarding compliance Audit of outcomes of training standards @ LDH. being monitored by designated nurse and 6.9.19: continue to monitor via quarterly reporting Risk of staff not being standing item on des and named to quality team and safeguarding team aware of factors that 21/11/17: Meeting with Training Department indicate abuse and thereby planned to improve accuracy of level 3 cohort, and resulting in.. recording. Consequence Named Doctor to meet with Managers/Matrons. Director of Nursing to drive improvement in compliance. To continue with additional level 3 Refresher Training sessions now weekly (including learning from Serious Case Reviews.) To improve LDUH Staff attendance on Pan Bedfordshire Multi-agency Training Programme through Ward Managers/Clinical Directors. Alternate methods being used for training- drama, video scenarios and reflection. Health Education England resources used to promote visual learning in mandatory training 15.9.17: Overall LDH L3 safeguarding training not improved. Good improvement across paediatric departments.Review of actions with quality team and further remedial process to be agreed 12.09.17: Further discussions to be held with the quality team re penalties 6.10.16 Exceptional reporting to the CCG two weekly from October till end of December to get level 3 to 90% 1.8.18: Action plan to be shared with the CCG and monthly exceptional reporting to follow
Person Responsible: Chris Harvey To be implemented by: 20 Dec 2019
Luton S/G Child sexual abuse service Weaknesses I = 2 L = Service in place I = 2 L = Explore commissioning with NHS England. 11 for Luton Children CCS being 3 3 Mountain Health Ltd stepped in to provide SARC in decommissioned NHS 6 6 July 2015 as G4S pulled out of contract Current England and Bedfordshire service provision only 1 days weekly for Luton police commissioned children Mountain Health care to however advice is available provide CSA service. Further reviews of service provision through quality Service provision for and contract meetings. examinations not available 15.9.17: Mountain health now provide 4 days 24/7. service to Bedfordshire. Concerns still exist on the Advice is available.. level of practitioner competencies. Openness to Consequence inform CCGs on the number of activities carried 1.8.18: NHSE was out to support level of competency contacted to explore the 21/11/17: Improved reporting of activities from MH. concerns raised in regards Will present competency levels of practitioners at to practitioners keeping up next quarterly meeting their competencies. They 1.8.18: NHSE and Mountain Health to inform informed the CCG that Bedfordshire CCGs of practitioners competencies Mountain Healthcare will be in Q1 including additional.. Person Responsible: Chris Harvey To be implemented by: 31 Jan 2020 Luton S/G Neglect assessment tools. Weaknesses I = 2 L = CCS Named nurse to undertake training I = 2 L = Person Responsible: To be implemented by: 12 Staff not using Graded 3 on CGCP2 3 Care profile tool /other tool 6 LSCB have launched Graded care profile 6 to assess impact of neglect May 2015 on child/young person. Training being provided across LSCB This may result in neglect agencies including CCS health visitors not being adequately and hospital staff. CCS currently assessed with potential to providing training on Neglect 21/11/17: lead to child death.. Staff who will be using the tool have been Consequence trained and are using the tool for In June, a brief evaluation t CCG iti t d was presented to the LSCB on the implementation of Corporate (Strategic) GCP2 Th f th
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton ST 81 S1 - Failure of successful Failure of a successful and I = 3 L Development of ICP is a central area of I = 3 L Kenyes H&W Integrated Care productive ICP being = 4 established BLMK One Team = 3 Outcom Partnership (ICP) to be developed and agreed 12 Programme Plan, with specific actions 9 es developed across Milton across Milton Keynes identified.
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CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Keynes partners, there is a risk that Development of Target Operating Model Owner: Richard Alsop progress with achieving for wider cross CCG changes will support Risk Lead: Alison Joyner further service integration determination of the local ICP scope for Last Updated: 04 Jun and/or system discussion with partners. 2020 transformation will cease. Latest Review Date: Partnership working to help establish 04 Jun 2020 parameters of emerging ICP being Latest Review By: provided by external support (Carnell Alison Joyner Farrar) Last Review Comments: Action Updated Milton ST 83 To be Covid-19 As a result of expected I = 4 L Kenyes allocate d Owner: Richard Alsop increasing cases of = 4 Risk Lead: Debra confirmed Covid-19 in 16 Mordecai Britain and subsequently in Last Updated: 26 Feb Milton Keynes there is a 2020 risk that the increase in response support and NHSE/I reporting will stretch CCG resources and provider resources beyond reasonable measures
Milton ST 61 S3 - CHC overspend against Demographics relating to I = 4 L Additional management and PMO I = 3 L Root & Branch Review Consultancy engaged via Jan Wood 30 Jun I = 3 L Kenyes Financi al budget elderly population and = 5 support to project manage efficiencies = 4 closed tender process. Precise outcomes specified 2020 = 3 Sustain Owner: Richard Alsop complexity of cases. 20 and improvements and raise exceptions 12 - concentration on processes, challenges and 9 ability Risk Lead: Jan Wood Requirement to ensure as they arise budget right-sizing Last Updated: 02 Mar timely and appropriate Ensure team capacity and capability in 2020 packages of care are in place to manage reviews and caseloads place which minimise Latest Review Date: delays across the health Strengthen financial reporting and 31 Mar 2020 and social care system scrutiny through regular finance reports Latest Review By: interface and represent and monthly review of efficiency projects, Jan Wood value. and agreement of actions Last Review Comments: Covid-19 work preventing Strengthen governance, care brokerage progress here. Review in and admin support for reviews and case 12/52 management processes
Milton ST 73 S2 - Risk of the impact of Brexit A 'no deal' Brexit may lead I = 4 L MKCCG to appointed a Senior Richard Alsop appointed as I = 3 L Regional NHSE workshop 16th September to be Debra 24 Sep I = 3 L Kenyes Access & on the delivery of services to lack of supply from = 4 Responsible Officer for Brexit and an SRO Debra Mordecai, = 3 attended by CCG Brexit SRO and System Mordecai 2019 = 3 Quality Owner: Richard Alsop Europe for medical 16 Operational Lead Operational Lead Contact 9 Resilience Manager. Self-assessment being 9 Risk Lead: Debra supplies, including drugs, NHSE to provide link to regional Brexit information given to NHSE completed and will be presented at MKCCG Board Mordecai as well as equipment or leads TV and NHSE M&E NHSE on 24th September 2019 Last Updated: 26 Feb maintenance. There could have provided links to 2020 be a sudden increase in regional Brexit Leads Latest Review Date: British Nationals who 09 May 2019 currently receive medical Latest Review By: care abroad returning for NHSE and Local Resilience Forums to Debra Mordeci attending Alison Joyner NHS treatment. Possibility provide workshops/briefings re Brexit TVLRF Brexit Workshop Last Review Comments: of demonstrations/unrest on 11.1.19 Updated 5th April resulting in increased A&E Richard Alsop and Debra attendances. Mordecai to attend Current EU staff may TVLHRP Brexit meeting on return home leaving gaps in 28.1.19 NHS organisations and care providers. NHSE have indicated 'sufficient and Copy of DOHSC NO Deal All above results in seamless supply of medicines in the UK Brexit letter additional pressures on the in the event of 'no deal' Brexit (6 weeks NHS and the local MK supply) health system, in addition, MKUHFT BREXIT group meeting although there will not be a fortnightly lack of fuel there may be a DoHSC issued EU Exit Operational shortage as a result of Readiness Guidance on 21.12.18 with panic buying resulting in a Action Care for Commissioners which delay in petrol station re- has reviewed acted on. fuellng. Currently no specific concerns for MK Brexit date has been have been identified. postponed to October 2019 and currently all Various workshops being attended.
reporting has been suspended. We currently await further guidance from NHSE. No further update received to date 24.6.19. No further update received to date 2.7.19 New Brexit date is 31st October 2019. Guidance was re-sent to all CCG Providers on 23.8.19 with a request that they acknowledge receipt of the Guidance and will act as necessary. Daily Brexit reporting likely to re- commence from 21st October 2019. Regional Brexit work being attended by CCG on 16.9.19 NHSE/I have stood- down Brexit reporting - this will resume again from 6th January 2020, pending the outcome of the General Election in December 2019. Local plans will be reviewed following the election outcome. Teleconference hosted
Page 4 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
by Keith Willett on 9th January 2020: EU exit no- deal preparations to stop Following the vote at second reading of the Withdrawal Agreement Bill on 20 December, the government has stepped down preparations for a no- deal exit from the European Union. The Department of Health and Social Care has informed NHS England and NHS Improvement that for the health and care system this means that no-deal preparations should cease. As a result, staff working on no- deal preparations are being redeployed and other health and care organisations should do the same. The risk rating has, therefore, been reduced, until instruction is received from NHSE/I to stand- up planning - likely to be December 2020. 26 Feb - risk reviewed, no additional info at present. Risk rating remains the same
Milton ST 78 S2 - Removal of financial Due to the GIC there is an I = 3 L Improved Collaboration - Since the I = 3 L Continued close working between MKUHT and the Rachel 30 Jun I = 3 L Kenyes Access & penalties from GIC may initial risk to performance = 3 introduction of the GIC there has been = 3 CCG during the COVID 19 period. Regular virtual Leach 2020 = 2 Quality lead to a deterioration in whilst the CCG and Trust 9 improved joint working through CCG 9 meetings to be arranged between the CCG and 6 Performance standards work together to implement attendance to the PTL meetings, onsite Provider contract manager to maintain flow of Owner: Richard Alsop changes. This may result in presence of CCG staff working at Trust information and updates until regular monitoring Risk Lead: Neve Patel an adverse impact on RTT in the week, and appetite to share can resume. Last Updated: 09 Jun performance resulting in information between both organisations 2020 increased waiting times, including data and project plans. Latest Review Date: further deviation from the 09 Jun 2020 92% standard, a potential Performance Monitoring - Monthly Latest Review By: rise in 52 week waits, lower performance monitoring is carried out Neve Patel patient satisfaction, and through contract meetings. Last Review Comments: reputational impact to both Monthly reporting of both CCG and This risk has been the CCG and Trust. As the MKUHT performance is required and reviewed and updated as GIC and processes fully submitted to NHSE best as possible in light of embed, we expect current covid 109 period associated risks to reduce and associated contract and stabilize. management pause.
Milton ST 52 S2 - Insufficient Health and National, regional and local I = 4 L Transformation teams raising and I = 3 L Quality Committee review regular workforce Jenny 12 Nov I = 3 L Kenyes Access & Social Care Workforce staff shortages in key = 5 monitoring risk in Programme Boards. = 4 reports from providers. This work will link into Brooks 2019 = 2 Quality Capacity and Capability to areas, there are significant 20 12 LWAB for a wider picture, this will then be present 6 deliver transformation plans challenges in recruiting and LWAB local Workforce Action Board Action notes attached to the Quality Committee. (ST28) retaining substantive staff working through leadership & Owner: Linda Chibuzor into new and existing roles organisational sub-groups with providers Health and social workforce risks discussed at Linda 31 Mar Risk Lead: Julie Uglow within the health and social to secure recruitment and retention integration board to identify opportunities for Chibuzor 2020 Last Updated: 19 Feb care workforce to deliver initiatives and development of attractive workforce integration to improve efficiency. This 2020 service transformation. offers and portfolio careers work is ongoing completed in line BLMK and Latest Review Date: Resulting in inability to Integration work. 19 Feb 2020 implement transformation plans impacting on quality Development of staff into new roles in Workforce plan and update Providers working with education institutions to Linda 31 Mar Latest Review By: secondary and primary care attached make training more accessible, improve workforce Chibuzor 2020 Linda Chibuzor of patient care and delivery of new ways of working. supply, develop new roles and grow the medical Last Review Comments: LWAB scoped workforce hotspots across Hotspot scoping attached workforce. Ongoing until the end of the year No change BLMK Monitoring and investigation of P2 update serious incidents in provider services will flag staffing related incidents.
Workforce planning across STP through Local Workforce Advisory Boards.
Milton ST 74 S3 - Lack of provider As a risk of providers not I = 3 L Guaranteed Income Contract with MKFT I = 3 L CCG working with hospital to re-allocate Mark Cox 14 Feb I = 2 L Kenyes Financi al enagement in pathway engaging in transformation = 3 in place for 2019/2020 = 2 Transformation resource to defined schemes to 2020 = 2 Sustain transformation which will result in a loss of 9 New governance process being 6 support timely implementation. 4 ability Owner: Richard Alsop income to their implemented, Transformation Delivery Risk Lead: Mark Cox organisations. meetings to be set up Last Updated: 02 Jan Resulting QIPP delivery not New governance process in place, 2020 being achieved. transformation Delivery meetings started Latest Review Date: (Joint Workplan Leads Meeting). 02 Jan 2020 Joint Workplan Leads ToRs have been Latest Review By: signed off. Mark Cox Last Review Comments: 02/01/20 Risk reviewed. Option to utilise hospital's internal transformation meetings to monitor schemes to be explored. Milton ST 63 S3 - Insufficient capacity & The alignment of the I = 4 L CCGs Transition Team & Transition plan I = 3 L On going monitoring Richard 27 Mar I = 3 L Kenyes Financi al capability as a result of CCGs; the development of = 4 established to manage practical aspects = 4 Alsop 2020 = 3 Sustain increased partnership & the ICS and reduction in 16 of commissioning alignment. 12 9 ability matrix working running costs required by requirements 2020 there is a risk that Owner: Richard Alsop the CCG has insufficient Do, Buy, Share Project underway across Risk Lead: Richard Alsop capacity to deliver its CCGs to review CCG support functions Last Updated: 09 Jan statutory business. to ensure that they are both robust and 2020 aligned and have sufficient capacity for Latest Review Date: the future. 09 Jan 2020 Ensure Director lead for key priorities and Latest Review By: cross organisational workstreams. Joyce Baskerville Last Review Comments: Limited use of interim capacity being Reviewed and updated used to support high priority areas
One Team approached established Nov 19 - additional resources to support this transition
Milton ST 82 S2 - Cessation of the CNWL Extra Care have given I = 3 L Action plan created by CNWL monitored I = 3 L Replacement premises to be found & approved Jan Wood 30 Jun I = 3 L Kenyes Access & TOPAS service if new notice to CNWL to vacate = 4 through contract meetings = 4 2020 = 3 Quality accommodation cannot premises occupied by 12 12 Location of new premises; business case to Jan Wood 01 Jul 9 found TOPAS service which Weekly project meetings support estates changes to be approved: weekly 2020 Owner: Jan Wood could result in no premises project meetings to mainatain momentum: MKC to Risk Lead: Jan Wood for clients leading to excess be kept informed Last Updated: 31 Mar cost & anxiety for patient & 2020 families due to placements Latest Review Date: out of area. 31 Mar 2020 Latest Review By: Jan Wood Last Review Comments: ON progress
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CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton ST 53 S2 - Failure to achieve 18 & 52 As a result of the long waits I = 4 L Attendance at the Patient List Tracking I = 4 L Work with Acute Trusts to perform a Demand and Michael 30 Sep I = 4 L Kenyes Access & week performance. for elective care, there is a = 5 meeting to gain assurance on the Trust's = 4 Capacity review in the context of the Covid 19 Ramsden 2020 = 3 Quality Owner: Richard Alsop risk that health needs will 20 actions on long waiters, especially those 16 pandemic. Outputs will determine the implications 12 Risk Lead: Michael deteriorate resulting in who have waited 40 weeks + to avoid for elective care in the short and medium term. Ramsden poorer outcomes for further 52 week breaches. Last Updated: 05 Jun patients. This risk has 2020 increased due to the Covid- Maximise the use of the NHSE funded Use contractual measures to understand issues Michael 31 Mar Independent Sector to delivery some and apply mitigation. Ramsden 2021 Latest Review Date: 19 pandemic implications elective care. This will create additional This is an ongoing action . 05 Jun 2020 on surgery capacity, reducing the wait list and Latest Review By: treatment timeframes. Michael Ramsden Last Review Comments: Monthly Commissioner, Contracts and Meeting Minutes RIsk reviewed in light of the Performance meetings with provider Covid 19 pandemic. Risk teams increased and will be a RMS referral triage to deflect national issue. Mitigations unnecessary activity away from and actions added secondary care into community services. This will increase treatment times for those not needing consultant led care.
The IMSK service will assess & triage all IMSK related referrals from Primary Care to ensure all alternative clinical pathways are explored and fully utilise conservative treatments where surgical options are expected to deliver poor outcomes.
Trust led review of operating procedures in light of the Covid- 19 pandemic. To only operate when it is safe to do so and supported by national guidelines. Embed virtual clinics which reducing the need for unnecessary face to face appointments moving to a phase of watchful waiting
Milton ST 64 S3 - Lack of alignment between Lack of alignment between I = 4 L BLMK CCG shadow working now in I = 3 L Regular reporting on STP to CCG Board &, Alison 31 Mar I = 2 L Kenyes Financi al existing structures and new accountability and = 3 place = 3 Monthly staff Briefings, Staff Forum. On Joyner 2020 = 2 Sustain system-wide ways of work contracting mechanisms 12 CCG led comms & engagement 9 -going action review 4 ability Owner: Richard Alsop for commissioners and programme in place for staff to Commence operating in 'shadow' form for CCG Richard 01 Apr Risk Lead: Alison Joyner providers across the ICS understand move towards becoming a organisational governance across collaborative. Alsop 2020 Last Updated: 04 Jun may lead to single CCG from April 2021. 2020 transformational delay One CCG Approach in place across Latest Review Date: BLMK CCGs at Exec Level with defined 04 Jun 2020 functions/responsibilities from 1st April Latest Review By: Regular Collaborative level CCG briefings Alison Joyner for staff on One CCG approach to Last Review Comments: change/transformation of functions. Tier Actions & Mitigations 2 & 3 HR processes planned for 2020. Updated
CCG representation and involvement across ICS Workstreams Head of Strategy & Planning providing local leadership within ICS led process for developing the Long Term Plan. Lead SRO arrangements in place across collaborative for key commissioning areas.
Director of S & P in place.
Executive Team established to enable a joined up commissioner view
Single System Operating Plan 2019/20 in place final agreement was 30/4/19
STP DoF Group established
Milton ST 77 S3 - Retained behaviours As a result of staff across I = 4 L Clear Governance has been agreed to I = 4 L CCG working with hospital to re-allocate Mark Cox 14 Feb I = 3 L Kenyes Financi al leading to opportunities in MKCCG and MKUHFT = 4 enable swift escalation of issues/risk to = 2 Transformation resource to defined schemes to 2020 = 2 Sustain GIC not being optimised. retaining old behaviours 16 delivery (incl behaviours). 8 support timely implementation. 6 ability Owner: Richard Alsop appropriate to the previous Risk Lead: Mark Cox contracting form, there is a Honorary contracts for key CCG staff to 2 honorary contract already Last Updated: 29 Oct risk that new opportunities enable truly integrated working in the signed. 2019 won't be optimised and Trust building relationships and privding Will bring more on line in Latest Review Date: joint projects will not be ditstributed leadership to continuously tandem with developing 03 Feb 2020 effectively delivered promote joint working. projects/co-working Latest Review By: resulting in increased cost initiatives. Mark Cox and financial risk to the Last Review Comments: CCG and/or reluctance on 3 Feb 20 the part of the hospital to - Ongoing close work with continue a GIC into 20/21. the recently appointed COO at MKUHFT will help to mitigate his risk.
Milton ST 76 S2 - Cyber security risks As a result of outdated I = 4 L A plan is in place to replace Windows 7 I = 4 L AGEM to install new servers and turn off old Wendy 30 Jun I = 3 L Kenyes Access & Owner: Wendy Rowlands unsupported systems or = 3 with Windows 10 = 3 servers in GP Practices. 8 out of 11 completed. Rowlands 2020 = 2 Quality Risk Lead: Wendy delays in patching 12 Fire wall in place at each GP site New 12 Deadline extended again due to Covid-19. 6 Rowlands systems, there is a risk servers are being installed to replace Last Updated: 31 Jan that the CCG IT Windows 2012 servers HBL to undertake a cyber security risk assessment Wendy 31 Jul 2020 infrastructure is Microsoft have agreed to continue to when they take over services Rowlands 2020 Latest Review Date: unprotected, resulting in support Windows 7 for an additional 12 Complete implementation of W10 in remaining GP Wendy 30 Sep 19 May 2020 the CCG being prone to months. Upgrade will offer additional practices once HBL ICT take over services from Rowlands 2020 Latest Review By: Cyber attacks. This could security therefore the CCG will still push April 2020 Wendy Rowlands impact on other partners forward with the upgrade plan. Last Review Comments: joined to the network. Risk dates updated Windows 10 installation completed in the CCG site. Milton ST 48 S3 - Capacity of CCG to There is a risk of a loss of I = 3 L - Ensure recruitment processes are as I = 2 L Regular & On-going Actions including: Process for Emma 31 Jul I = 2 L Kenyes Financi al operate will be reduced as key personnel due to = 4 streamlined as possible to support swift = 4 Tier 2 & 3 In place and timetable resumed Richards 2020 = 3 Sustain a result of loss of key staff further CCG alignment, MK 12 appointments 8 Communications to staff via AO blog & Webex 6 ability (ST34) system wide changes and - Exit interview process (comms) Owner: Alison Joyner uncertainty about the - Management and peer support to staff - - Pan CCG briefings & regular SLG updates Risk Lead: Emma onward development of the including monitoring of work loads (comms) Richards ICS/STP. - Effective communications and - SLG workshops (comms) Last Updated: 04 Jun organisational priority setting - Local recruitment / leaver process 2020 - Review of recruitment to EMT communications Latest Review Date: Review of recruitment to EMT. Recruitment Update 04 Jun 2020 Latest Review By: Alison Joyner Last Review Comments: Actions Updated Milton ST 55 S2 - Patients have poor cancer Complexity of cases, wait I = 4 L Cancer lead is now assigned to cancer I = 4 L Conduct a Peer review of urology pathways with Maria 29 Feb I = 4 L Kenyes Access & outcomes times (particularly in = 4 transformation along with Programme = 3 NHSE ensuring lessons learnt and to drive Browne 2020 = 1 Quality Owner: Linda Chibuzor Urology) hand off between 16 Support and a an allocated person from 12 improvements 4 Risk Lead: Linda Chibuzor secondary care and tertiary the Cancer Alliance. The Trust are also Continue attendance at meetings and monitor Linda 31 Mar Last Updated: 27 Feb centres, and capacity in out to advert for a project lead. mitigations through CQRMs. Chibuzor 2020 secondary care resulting in 2020 CCG and MKUH colleagues are working delays in accessing cancer Latest Review Date: together and have reviewed the cancer treatment and subsequent 19 Feb 2020 pathways. There is now a Clinical triage risks to patient recovery, Latest Review By: of patients and this process priorities outcomes and mortality Linda Chibuzor those patients who need to be seen rates. Last Review Comments: sooner following blood results etc. To be updated to be include speciality areas i.e.
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CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
urology CCG and MKUH colleagues are working together on the reporting. CCG colleagues attend MKUH the cancer meetings. Collaborative work between MKH, MKCCG and the Cancer Alliance to improve cancer pathways - utilising the available national funding to support transformation. Contract levers in place to manage pdf of contract attached underperformance Increased CCG and provider board focus Board report Board Minutes
Oversight and scrutiny of performance at MKH PTL and Contract meeting.
QSG oversight and escalation to Regional MK CCG report to QSG QSG as required RCA reviews of all 62 day breaches rca review doc
Recruited a Urology Nurse within the Trust to increase capacity and release Consultant work. The provider utilises a cancer PTL tool . Scheduled PTL meetings and speciality meetings re division capacity and demand. Through regular CQRMs, the CCG and MKUH have worked together to provide assurance on cancer pathways, diagnosis and the workforce. The waiting lists for patients has reduced and patients are being diagnosed sooner and this improves the patient's prognosis.
Luton BC 21 BCF and iBCF may not Weaknesses I = 4 L = Allocation of funding is robustly managed. I = 4 L = Project leads to provide monthly Highlight reports meet the defined outputs Difficulty recruiting and 3 New and more detailed Business Cases 2 detailing KPI's, issue and risks. retaining personnel to 12 created to ensure the proposals meet the 8 Person Responsible: Yasmin Martin-Leggett project teams; criteria and are able to clearly evidence To be implemented by: 01 Jul 2020 Some projects do not have Assurance and Governance embeded adequate measures and into the programme controls in place; BCF report, risk register and highlight Difficulties gaining report presented to JSCG engagement from key Monthly Joint Financial Reporting to FSG stakeholders; and JSCG Consequence Individual projects may be Monthly project reporting established to delayed or may stall or may measure outputs and impact of the have to be closed; Unable Programme Manager, FSG and JSCG to assign benefits and have a full understanding of the BCF outcomes to individual Quarterly reports to the Better Care Fund projects so unable to Board as part of the NHS England quantify success; programme governance Luton BC 22 Effectively Manage S75 Weaknesses I = 3 L = 1) Backing data - invoicing, reporting & I = 3 L = Physical Disabilities new clients - to agree Partnership * failure to manage 3 budgetting 1 Person Responsible: Karen Stagg partnership relation 9 2) Open transparent reporting 3 To be implemented by: 03 Apr 2020 – expectations, 3) Shared evidenced activity data and performance, capacity spend for joint planning process for monthly update to LCCG finance of * Health versus Social Care new clients MH & PD - who pays is a grey area Person Responsible: Andrew Bland * lack of statutory backing To be implemented by: 30 Jun 2020 to S75 pooled budget Mental Health LCCG funded clients - to agree Consequence Andrew Bland * disputes weaken S75 Person Responsible: partnership To be implemented by: 30 Jun 2020 * financial loss to one BCF ASC budget - to agree partner Person Responsible: Andrew Bland To be implemented by: 30 Jun 2020
Finance
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton F 19 S3 - CSU provision of services As a result of the Do, I = 3 L 19/20 Financial value agreed including I = 3 L Review other CSU services and decide the Wendy 30 Sep I = 3 L Kenyes Financi al Owner: Richard Alsop Share, Buy Review there is = 4 stranded costs = 3 direction of travel for a One Team approach Rowlands 2020 = 2 Sustain Risk Lead: Wendy a risk that outsourced 12 Board approved decision to inhouse IM&T 9 6 ability Rowlands services could be services into HBL partnership Last Updated: 02 Apr destabilised if changed to 2020 align with BLMK, leading to Extension of remaining services agreed Latest Review Date: a lack of financial control for 20/21 and withdraw from AGEM 19 May 2020 HBL transition plan between the new and services could lead to Latest Review By: old IM&T providers in place and significant additional Wendy Rowlands monitored through weekly conference stranded costs which Last Review Comments: calls. would impact on delivery of Updated actions IG & ECM services has successfully the financial plan . transitioned to Beds CCG
meet regularly with current provider to review their service provision
Milton F 21 S3 - Failure to deliver 20/21 As a result of the carried I = 5 L Financial Plan Developed for 20/21 with I = 5 L Seek support and capacity from NHSE/I East Wendy 30 Jun I = 5 L Kenyes Financi al Financial Plan fwd underlying financial = 4 QIPP schemes identified for 63% of = 4 Region. Rowlands 2020 = 3 Sustain Owner: Wendy Rowlands position of the CCG, and 20 target 20 BLMK CCG QIPP Programme Board to be Paul 30 Jun 15 ability Risk Lead: Wendy the new 20/21 cost Joint Savings Programme in Place with established chaired by Director of Performance. Burridge 2020 Rowlands pressures leading to a Providers with joint review meetings & Put on hold due to Covid-19 Last Updated: 02 Apr consequential significant CCG Lead co- ordinator. CCG Identification of schemes - a workshops took place Paul 30 Jun 2020 QIPP required to deliver Commissioners have honorary contracts on 11th and 12th March 2020 conducted at a Burridge 2020 Latest Review Date: the 20/21 Financial Plan with providers to support joint BLMK level with attendance from Directors and 19 May 2020 target - there is a risk that transformation programmes Assistant/Associate Directors from all 3 CCGs. Latest Review By: the CCG is unable to fully Aim to agree a small number of large financial Monitoring Process in place through Wendy Rowlands identify and deliver the opportunities that can be scoped and built up Finance Committee & Board Last Review Comments: required quickly to mitigate the financial gap. A number of Actions updated QIPP/Transformation areas were identified and action for leads to build savings plan and by opportunities into programmes, with measurable consequence the 20- outcomes and plans, which can then be tracked 21 Financial Plan target. and managed via the PMO. - Put on hold due to Covid-19
Scoping opportunities with BLMK system partners Wendy 30 Jun via CEO/CFO fora. Put on Hold due to Covid-19 Rowlands 2020
Re-assess the position as part of the recovery Wendy 30 Jun workstream actions for Covid-19 Rowlands 2020 Milton F 25 S3 - Covid-19 Impact on As a result of the Covid-19 I = 4 L LA/CCG Finance Cell has been I = 4 L Model impact of interim contract and payment Wendy 29 May I = 4 L Kenyes Financi al delivery of 20-21 Financial incident the NHS is = 4 convened. Reimbursement for hospital = 4 arrangements to assess financial impact outturn Rowlands 2020 = 3 Sustain Plan operating with amended 16 discharge costs expected based upon 16 scenarios. Engagement with Regional NHSE/I 12 ability Owner: Wendy Rowlands contract and payment data submitted by CCGs. Team to set out key financial and contractual risks, Risk Lead: Wendy arrangements - there is a this includes payments under the revised Rowlands risk that the CCG is The CCG has created an incident cell contractual arrangements that are greater than Last Updated: 19 incurring additional and structure which includes finance would otherwise be expected. unfunded costs that could representation. Revenue and capital May 2020 CCGs to review SFIs in light of response. Wendy 30 Jun Latest Review Date: jeopardise the delivery of commitments agreed by the Cell are being captured to support financial Rowlands 2020 Latest Review By: the 20- 21 financial targets. reporting locally and nationally. S75 agreement to be agreed with Local Authorities. Wendy 30 Jun Last Review Comments: Rowlands 2020 Milton F 22 S3 - Failure to Deliver MHIS As a result of financial I = 4 L Acting CFO has written to NHSE/I East I = 4 L Work with NHSE/I to set out financial and Wendy 30 Jun I = 3 L Kenyes Financi al Owner: Wendy Rowlands pressures the CCG is = 3 Region setting out position re: MHIS = 3 consequential implications of recovering cumulative Rowlands 2020 = 3 Sustain Risk Lead: Wendy unable to deliver the 12 delivery in 2019/20 and cumulative under 12 MHIS under performance. 9 bilit i t f th M t l d li l ti t i tt i t
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BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
ability Rowlands requirements of the Mental delivery relating to prior year attainment Ensure that recommendations of the MHIS audit Wendy 30 Jun Last Updated: 02 Apr Health Investment (as pe MHIS audit, yet to be issued). undertaken by GTUK are implemented. Rowlands 2020 2020 Standard (MHIS); including Latest Review Date: cumulative recovery of all appropriate spend is captured 19 May 2020 under delivery against the and reported against the standard Latest Review By: target for the 18/19 Enhanced reporting of delivery against Wendy Rowlands financial year (as identified the MHIS to Finance Committee and Last Review Comments: through the 18/19 MHIS Governing Body. Actions updated audit). MH provider has signed-off 20-21 MHIS plans. Milton F 24 S3 - Delegated Primary Care As a result of the nationally I = 4 L Financial monitoring through Primary I = 4 L Assess opportunities for slippage in plans to Wendy 30 Jun I = 4 L Kenyes Financi al Spend to Exceed 20/21 agreed Primary Care = 4 Care Committee, Finance Committee and = 4 mitigate financial pressure Rowlands 2020 = 3 Sustain Allocation Contract settlement and 16 Board 16 Review calculations of impact of new GP contract Wendy 30 Jun 12 ability Owner: Wendy Rowlands the increase in GP Financial plan developed based on deal and anticipated allocation top up to assess Rowlands 2020 Risk Lead: Wendy practices in MK to meet assessment of new contract deal and potential to offset financial pressure. Reconsider Rowlands population growth there is a practice growth in MK this in light of new budget regime for Covid-19 Last Updated: 02 Apr risk that expenditure on 2020 delegated primary care will Latest Review Date: exceed the allocation 19 May 2020 resulting in failure to deliver Latest Review By: the financial control total Wendy Rowlands Last Review Comments: Actions updated Milton F 26 S3 - Covid-19 impact leading to As a result of the Covid-19 I = 3 L Targeted guidance has been sent staff to I = 3 L Agree with the CFO Counter Fraud specific work Wendy 30 Jun I = 3 L Kenyes Financi al increased risk of fraud incident there is potential = 4 ensure that staff remain astute to fraud = 4 items to be pursued locally. Rowlands 2020 = 3 Sustain Owner: Wendy Rowlands increased risk of fraud, this 12 risks and the changing nature of fraud 12 Regular staff communications to be issued. Wendy 31 Jul 9 ability Risk Lead: Wendy includes: cyber fraud, during the crisis. Rowlands 2020 Rowlands misappropriation, invoice The CCG has a Local Counter Fraud Last Updated: 19 fraud, procurement fraud May 2020 etc… Service (LCFS). Latest Review Date: Latest Review By: Last Review Comments: Milton F 16 S3 - Delivery of 2019/20 There is a risk that we will I = 5 L A CHC recovery plan developed and I = 3 L Provide evidence as required for completion of Wendy 25 Jun I = 3 L Kenyes Financi al Balanced Plan overspend our control total. = 4 under implementation = 2 external audit review of accounts Rowlands 2020 = 1 Sustain Owner: Richard Alsop Delivery of 2019/20 20 An internal recover plan for CHC 6 3 ability Risk Lead: Wendy Balanced Plan to provide a overspend is in place. Including Rowlands full QIPP Plan, resulting in processes to control authorisation of Last Updated: 19 CCG entering into financial expenditure and to delegate budget May 2020 deficit. Failing our statutory responsibility to nurse assessors. Latest Review Date: duties, putting MK CCG at 19 May 2020 risk of entering special Contract negotiation plan underway. Latest Review By: measures. Completed and contracts agreed. Wendy Rowlands Last Review Comments: Developed in year head room plans, to Risk score updated mitigate financial pressures and support delivery of financial balance for the year by slipping investment and use of maximising income.
Draft accounts have been prepared which deliver a balanced position
Monitoring by Finance Committee, CDG and Board Projects have been risk rated and co- ordinator meetings setup QIPP plan finalised and signed off by Board Weekly panel meetings have been implemented to approve CHC expenditure
Milton F 23 S3 - Loss of Financial grip due As a result of the I = 3 L Clear change management programme in I = 3 L Identify key posts required under the new Richard 30 Jun I = 3 L Kenyes Financi al to development of single organisational change = 3 place = 3 structure, advertise and fill as soon as possible. Alsop 2020 = 2 Sustain BLMK CCG process to create a new 9 Policies, standard operating procedures 9 6 ability Owner: Wendy Rowlands single CCG for BLMK from and risk registers to be aligned across New operational structures to be prepared and Emma 30 Jun Risk Lead: Wendy Apr-21, and the the three BLMK CCGs. consulted upon in Spring '20. Richards 2020 Rowlands requirements for all CCGs Last Updated: 02 Apr to reduce Running Costs 2020 by 20%, there is a risk that Latest Review Date: a change in key personnel 19 May 2020 could result in a loss of Latest Review By: corporate knowledge and Wendy Rowlands reduced financial grip at Last Review Comments: MKCCG. No change
Luton BAF 5 The CCG may fail to meet Weaknesses I = 5 L = A number of business functions such as I = 5 L = Assess the success of the Cambridge Community its statutory duty to deliver Possible Acute Sector 4 payroll, financial services, prescriptions 4 Services and the Luton and Dunstable Hospital the agreed end of year Over delivery Insufficient 20 payments and Electronic Staff Records, 20 plan to mitigate emergency demand and agree risk financial position and the head room in the budget Accounts audited externally share for 2019/20 system control total. Challenging control total Person Responsible: Chris Ford Possibility of QIPP Areas of CCG business subject to To be implemented by: 31 Oct 2018 schemes not delivering internal audit in line with annual Capacity of the CCG to Implementation of the Financial Recovery Plan Contract Management with major deliver the QIPP and Person Responsible: Chris Ford providers to control activity manage.. To be implemented by: 31 Mar 2020 Consequence Financial Assurance Meetings held with The CCG will not meet its NHS England's Regional Chief Finance financial target and will be Opportunities and Risk log reviewed on subject to special weekly basis measures Review of financial risks and mitigation take place at weekly Financial Resilience Group Meetings with issues escalated to Luton BAF 6 The QIPP programme may Weaknesses I = 4 L = Financial Resilience Group meets weekly I = 4 L = Person Responsible: To be implemented by: fail to deliver its key Programmes not achieving 3 with a monthly in-depth focus on QIPP 2 objectives and savings desired outcomes 12 PMO Structure and Governance in place 8 leading to an unplanned Poor engagement from through Financial Resilience Group deficit and failure to deliver L&D Pace and scale not ensuring robust accountability and the best outcomes for achieved Acute sector patients. continues to over performance Consequence Poor outcomes for patients Not achieving financial position Won't meet priorities of the STP
Luton LD 1 Transforming Care may not Weaknesses I = 4 L = Highlight report on admissions and I = 4 L = Place-based task and finish group for health deliver improvement in Transforming Care 3 discharges of people with a learning 2 improvement to be set up health care for people with Programme has not 12 disability and/or autism to mental health 8 Person Responsible: Angela Duce learning disabilities and/or delivered the scaled unit of ATU due to behaviour or mental To be implemented by: 31 Mar 2020 autism change in commissioning; Joint commissioning strategy developed Admissions have not been with LBC to ensure that commissioning Implementation of Transforming Care Partnership prevented; Luton does not for learning disabilities focuses on the key Programme Plans have an active learning Transforming Care Partnership Board Person Responsible: Angela Duce disability market; oversight of programme To be implemented by: 31 Mar 2020 Lack of a strategy.. Transforming Care Partnership Board, Consequence reporting to the CCG Patient Safety & People with Learning Quality Committee will oversee the Disabilities will continue to implementation of Transforming Care be admitted to long stay hospitals; People will be placed out of area; Health needs of people with learning disabilities will not be met; People..
Page 8 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Luton LD 2 People placed out of area Weaknesses I = 3 L = Luton Learning Disability strategy in place I = 3 L = Review of out of area placements to prioritise for are not subject to clinical People with complex needs 4 with a focus on market development, 3 review and repatriation if necessary oversight are often placed out of 12 developing small supports and 9 Person Responsible: Angela Duce area; To be implemented by: 31 Mar 2020 Provider market in Luton does not have the diversity of experience; Non-typical forms of autism and sensory processing disorders not widely.. Consequence People are placed out of area; Poor outcomes and increased hospital admissions; People do not get the right support; Families are separated; Development of risky behaviours and mental health.. Luton MH 2 Cost pressures of complex Weaknesses I = 3 L = S75 50:50 funding split for S117 and joint I = 3 L = Establish a risk share arrangement with ELFT to placements CCG does not control the 4 funded packages 3 manage the complex patient cohort number of people who 12 9 Person Responsible: Loraine Rossati require placement. To be implemented by: 01 Jun 2020 There is no local provision, and people are sent out of area. Cost pressure due to CCG managing this cohort of patients. Luton MH 3 Not meeting IAPT Access Weaknesses I = 3 L = Monthly contract review meetings I = 3 L = Person Responsible: To be implemented by: Rate Provider (Turning Point) 5 4 has been unable to recruit 15 12 to full complement of staff. Consequence Provider has been unable to meet IAPT access rate of 19% in year 1 of contract and 22% in year 2, therefore unlikely to achieve 25% national target in year 3 (2020/21).
Luton MH 8 Reimagining Mental Health Weaknesses I = 3 L = CCG manages budgets for programme I = 3 L = Person Responsible: To be implemented by: will not meet programme Reimagining Mental Health 3 2 objectives is a co- production 9 Steering Group meets bi-weekly to 6 programme, which involves develop the Open Access model a wide range of people to Weekly assurance calls with the 'own' the programme - it is Innovation Unit not a CCG controlled programme. Project funding (£100k per year for 3.. Consequence Delays in programme implementation impact on evaluation Delays in programme implementation impact on network partner staffing - may lose staffing Luton MH 9 Open Access service Weaknesses I = 4 L = Data Protection Impact Assessment I = 4 L = Person Responsible: To be implemented by: - unable to share data IG/data sharing agreement 3 being submitted to IG team 3 within network unable to be established 12 12 due to NHS restrictions on data sharing within Open Access Network non-NHS organisations Consequence Open Access service is limited on ability to share information among the network; jeopardises transformational working
Luton PMO Failure to deliver the full Weaknesses I = 4 L = A 0.2 WTE Head of PMO and 1 WTE I = 4 L = Person Responsible: To be implemented by: 20 £12.518m QIPP At M7, the QIPP 4 PMO Analyst that is focused on 4 Requirement in 2019/20 Programme is forecasted 16 managing and controlling the QIPP 16 to deliver £11.822m, which Programme and supporting the is £697k short of the Commissioners with QIPP scheme £12.518m target. In A robust process to managing and addition there is an controlling the QIPP Programme to estimated £1.8m of risk ensure all benefits are cross- reviewed by within the remaining £6.3m Finance/PMO before being included in to be delivered.. Weekly Financial Recovery Group (FRG) Consequence oversight Potential failure to achieve the overarching Financial Control Total. Potential failure to settle historic deficit as a result of potentially not achieving overarching Financial Control..
Luton PMO Failure to deliver the full Weaknesses I = 4 L = A 0.2 WTE Head of PMO and 1 WTE I = 4 L = Person Responsible: To be implemented by: 21 £14m QIPP Requirement in At this early stage LCCG 4 PMO Analyst that is focused on 4 2020/21 has identified less than 16 managing and controlling the QIPP 16 25% of the QIPP Programme and supporting the requirement for 2020/21. Commissioners with QIPP scheme £14m is a challenging A robust process to managing and QIPP requirement based controlling the QIPP Programme to on LCCG track- record of ensure all benefits are cross- reviewed by delivering QIPP Finance/PMO before being included in Programme savings. Weekly Financial Recovery Group (FRG) Consequence oversight Potential failure to achieve the overarching Financial Control Total in 2020/21 Reputational damage with Regional Team Luton PMO Insufficient Capacity in the Weaknesses I = 3 L = Person Responsible: To be implemented by: 22 PMO to provide support to A 0.2 WTE Head of PMO 3 Commissioners to best and 1 WTE PMO Analyst 9 ensure QIPP reaches its can provide management full potential and control of the QIPP Programmes 2019/20 and 2020/21, however it is insufficient capacity to provide individual support to.. Consequence Some QIPP schemes will not fulfil their full potential, including: - unrealistic plans leading to unnecessary negative attention and wasted commissioning time - unrealistic financial/activity..
Page 9 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Luton PMO The PMOs ability to Weaknesses I = 3 L = Person Responsible: To be implemented by: 23 dedicate a majority of its There is already a lack of 3 resource to QIPP will be resources in the PMO 9 challenged even more in across BLMK, and more 2020/21 as wider agendas and more these resources gain momentum, including are being asked to support QIPP / CIP relationships, non-QIPP related work. One Team Programme and Consequence involvement in ICS/ICP/SC QIPP will not receive the development same degree of dedicated support it had in 2019/20, resulting in less control and management, less awareness of issues/risks and subsequent less delivery against plan. Luton PMO Mental Health complex care Weaknesses I = 3 L = Clinical case manager reviewing existing I = 3 L = Person Responsible: To be implemented by: 24 QIPP target may not be QIPP linked to complex 3 complex patient list. Regular reviews of 3 met care risk - CCG is not in 9 i li 9 control of the number of new patients requiring complex care. Consequence QIPP target may not be met due to additional costs for new patients being higher than savings from existing packages.
Mental Health. Continuing Healthcare & Learning Disabilities
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton MH S1 - CNWL Transformation There is a risk that through I = 4 L CNWL have scheduled their I = 3 L Maintain oversight at the mental health and Loraine 31 Mar I = 3 L Kenyes 18 H&W Owner: Richard Alsop CNWL's transformation, = 2 transformation meetings, and circulated = 2 learning disability programme board Rossati 2020 = 2 Outcom Risk Lead: Louis Sanford partners are not sufficiently 8 invitations throughout the system. 6 6 es Last Updated: 02 engaged or feel as though System oversight through the mental Dec 2019 their input has mattered, Health and learning Disability Programme Latest Review Date: resulting in disengagement board 19 Mar 2020 and loss of partnership Latest Review By: working across the system Louis Sanford Last Review Comments: reviewed
Bedford- CHC 1 Owner: Diana Escalated from the CHC I = 4 1) All complex cases have a CHC 1) LD service review for I = 4 During the covid period there has been escalation Melanie 1 shire 73 Butterworth Risk Register and Mental L = 4 assessor case managing, where risks Central Bedfordshire, L = 4 for some individuals unable to access day services. de la Ford escalate involvement from the local delayed There is increased risk that these individuals will Health Risk Register / Gwen MH Learning Disability Local authority/CCG 2) Close working with LAs 16 not wish to leave the family home once services 32 Lead: Melanie de la Provision 16 2) Intensive Support Team intervention to consider available are restablished and increased risk that behaviours Noube Ford / Gwen Noube As a result of only a small when required to support complex cases options may require police support. amount of local provision within area 3) Escalation to Associate The CHC department have supported by for individuals with more Director and Chief Nurse, purchasing equipment for the home to reduce complex and challenging review of current services behaviours and tried to be adaptive and flexible to needs there is a risk that and level of risk support the individuals and their families however care provision will either 4) Collation of CHC the continued uncertainty relating to the covid breakdown or reduced caseload and identified pandemic continues to cause challenges in quality of care which may risks alongside managing these individuals. result in harm to the LD/Children's/Transition to During lock down it is has proved difficult to find individual and requirement ascertain level of risk and provision for Transition cases or support if for urgent new provision provision required packages of care are breaking down, the out of county 5) Draft Learning Disability precarious situation with the LD/ASD market is Caseload Analysis shared further compromised due to the current situation. with BMLK TCP Stratgey group and LD/MH Commissioners, further meeting to discuss future commissioning arrangements 29/08/19 6) Escalation Log implemented to register all risky cases with actions in place 7) During Covid a number of cases are unable to access day services, they are at home with family supporting however there are reports of escalation of behaviours and an unwillingness for individuals to leave the family home and attend respite provision Milton MH S2 - Primary Care Plus As a result PCP developing I = 3 L Progress monitored through a local I = 3 L To convene a meeting of PCP and ICST within a Louis 28 Feb I = 3 L Kenyes 19 Access & Owner: Richard Alsop in isolation, there is a risk = 3 implementation group, with oversight at = 3 single PCN in order to work through opportunities Sanford 2020 = 2 Quality Risk Lead: Louis Sanford that it fails to take 9 the mental Health and learning Disabilities 9 and procedures for integrated patient care between 6 Last Updated: 21 Aug advantage of the broader programme board these initiatives 2019 benefits of collaborative Latest Review Date: working in Primary Care 19 Mar 2020 resulting in poor Latest Review By: partnership working, Louis Sanford negative reputational Last Review Comments: damage within primary reviewed care, and poorer patient outcomes
Milton MH S2 - IAPT review and As a result of the risk that I = 3 L Continually monitoring of service I = 3 L I = 3 L Kenyes 17 Access & performance the review of the IAPT = 3 performance levels in order to ensure = 2 = 1 Quality Owner: Richard Alsop service review not resulting 9 both the CCG and provider are pro-active 6 3 Risk Lead: Louis Sanford in the required service in resolving any potential issues in order Last Updated: 02 improvements, there is a to achieve the performance requirements Dec 2019 risk that CCG performance and avoid assurance escalation where Latest Review Date: and patient experience will not warranted 19 Mar 2020 be negatively impacted Latest Review By: resulting in an unplanned Louis Sanford financial pressure or Last Review Comments: escalating remedial action Service looks set to with CNWL achieve required performance, Milton MH S3 - Sufficient funding of MH As a result of further I = 4 L Transformation and Savings group I = 3 L Hold under continual review as part of Loraine 31 Mar I = 3 L Kenyes 16 Financi al services planning between CNWL = 3 meeting held bi-weekly and MHIS = 2 Transformation and Savings group meeting and Rossati 2020 = 2 Sustain Owner: Richard Alsop and the CCG, it has 12 investment sessions related to 20-25 6 MHIS investment sessions 6 ability Risk Lead: Louis Sanford become clear there are is contract to drive system efficiencies. Last Updated: 14 Feb financial pressure Additional finance meetings held 2020 associated with the MHIS alongside this relating to achieving a Latest Review Date: and delivering the LTP balanced position for 20/21 delivery 19 Mar 2020 requirement in 20/21. This Latest Review By: may result in CCG under- Louis Sanford performance or reduced Last Review Comments: quality of care delivered reviewed
Page 10 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton MH S1 - ASD and Mental Health As a result of a legacy of I = 3 L Autism Pathway meeting between MKC I = 3 L CNWL have agreed to make clinical and cultural Louis 30 Jun I = 2 L Kenyes 15 H&W Support uncertainty, and limited = 4 and CNWL 8/11/19 to develop joint MOU = 2 changes in order to be more accessible to patients Sanford 2020 = 2 Outcom Owner: Richard Alsop funding relating to ASD 12 relating to clinical care and practice for 6 with ASD. This needs to be formalised 4 es Risk Lead: Louis Sanford support, there is a risk that patients with ASD contractually, and defined adequately within the Last Updated: 14 Feb the new post diagnostic ASD post diagnosis support pathway 2020 service maintains the Latest Review Date: ambiguity relating to where 19 Mar 2020 CNWL MH support should Latest Review By: start or operate in tandem Louis Sanford with other services, Last Review Comments: resulting in continued Progressing positively. tensions between providers Likely to close risk after and a poor patient implementation date experiences of care and support
Milton MH 4 S1 - Significant overspend on LEARNING DISABILITY - I = 3 L - Development of local CHC service I = 3 L I = 3 L Kenyes H&W budget associated with high = 4 - Weekly tracker in place with weekly = 3 = 3 Outcom Learning Disabilities cost of placements in 12 monitoring 9 9 es (MH05) particular when people - Identification of people who are Owner: Richard Alsop transfer from NHSE to potentially changing placements Risk Lead: Louis Sanford CCG responsibility - All known & potential spend taken Last Updated: 30 Jan account of in financial forecasting 2020 - Transforming Care Plan being Latest Review Date: developed 31 Jul 2019 Latest Review By: A CHC Nurse Assessor is now in place Jan Wood working on a part-time basis to review all Last Review Comments: past and new LD cases, ensuring that Impasse was reached with criteria is met and providing challenge the review of the 'LD14' where appropriate. The plan is now for case management of all LD cases to be passed to MKC CTALD team.
Milton MH S3 - Mental Health As a result of an under I = 4 L MKC led mental Health accommodation I = 4 L Redefine the project deliverables in order to Louis 31 Jan I = 4 L Kenyes 21 Financi al Accomodation -developed accommodation = 3 board is in place as the for a to develop a = 3 develop short and medium term actions to resolve Sanford 2020 = 2 Sustain Owner: Richard Alsop offer for adult mental health 12 medium term strategy 12 immediate pressures, and ensure sufficient 8 ability Risk Lead: Louis Sanford recovery and support, planning in place for projected need Last Updated: 21 Aug there is a risk that patients 2019 are not supported in the Latest Review Date: most appropriating setting 19 Mar 2020 to live well, resulting in Latest Review By: blockages in the that Louis Sanford impact in system step- Last Review Comments: down and repatriation reviewed
One BLMK Programme
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton 1FI One No budget created for cost No budget created for cost I = 5 L Create a separate "IMPLICATIONS/OPTIONS" Wendy 17 Jul I = 4 L Kenyes 7 BLMK of staff redundancies of staff redundancies, there = 3 Paper for Rowlands 2020 = 3 CCG Owner: Wendy Rowlands is a risk that This cost 15 Programme Board 12 Risk Lead: Wendy pressure will lead to Discuss possible scenarios and options(re cost Wendy 17 Jul Rowlands Inability of BLMK CCGS to implications) with HR Rowlands 2020 Last Updated: 05 Jun achieve their 2019/20 2020 Control Totals. Resulting in Latest Review Date: NHS E decide not to write Latest Review By: off historic debts and these Last Review Comments: are carried forward into the new structure
Milton 1HO One Virtually delivered As a result of some I = 2 L Thorough walk-through of process, I = 2 L Kenyes 5 BLMK organisational change organisational change = 1 understanding of staff concerns, = 1 CCG activities activities being delivered 2 workshops re relevant technology, regular 2 Owner: Emma Richards virtually post Covid-19 (eg. communications to staff / TUs to explain Risk Lead: Emma interviews), there is a risk process and need for use of virtual Richards that challenges re unfair activities, OD support (eg, interview Last Updated: 08 Jun process could be levied at preparation), robust documentation 2020 the CCGs from staff or Latest Review Date: Trade Unions resulting in Latest Review By: claims and delays to the Last Review Comments: programme leading to uncertainty for staff and the organisation.
Milton 1PC One Access to the central As result of not having I = 2 L Establishing an MOU with NHSE to I = 2 L Meeting with NHSE to agree finalise structure and Alison 31 Mar I = 1 L Kenyes 2 BLMK contract files held by access to the central = 4 clarify seconded team agreements = 4 work programmes for individual Joyner 2021 = 3 CCG NHSE contract files held by NHSE 8 8 Version control 3 Owner: Alison Joyner there is a risk that virtual Risk Lead: Alison Joyner control and previous Last Updated: 05 Jun decision are not reflected 2020 resulting in inequitable and Latest Review Date: poorly made decision Latest Review By: making for the organisation Last Review Comments:
Milton 1DS One CCGs currently using As a result of all the CCGs I = 3 L Utilising email and existing shared I = 3 L Transfer onto single IT system will conclude by 1st Mark Peedle 31 Jul I = 2 L Kenyes 1 BLMK different IT Systems & currently using different IT = 3 platforms = 2 July 2020 = 2 CCG Platforms Systems, there is a risk 9 Use of NHS Futures BLMK Portal 6 Data Sharing agreement between three CCGS 4 Owner: Alison Joyner that that information will be Transition of MKCCG employees to being put in place Risk Lead: Mark Peedle captured differently HBLICT platform underway Last Updated: 05 Jun resulting in inefficiency. 2020 Latest Review Date: 05 Jun 2020 Latest Review By: Alison Joyner Last Review Comments: Updated by Alison Joyner
Milton One 2 One Lack of GP membership As a result of local I = 5 L Comms and Engagement strategy to I = 5 L Comms and Engagement strategy implementation Ruth Adams 31 Jul I = 5 L Kenyes BLMK support for creation of one complexities and lack of = 4 include specific script/bullet points to = 4 with reviews 2020 = 2 CCG CCG clarity around the proposal 20 enable Programme Board Members to 20 10 Owner: Jane Meggitt and what it means for GP effectively manage the appropriate Risk Lead: Ruth Adams members. There is a risk messages to their GP communities Last Updated: 09 Mar that we will not secure the through the core script has been 2020 support of GP Members. produced. Resulting in delay in Latest Review Date: Programme Board attendees involved in delivery of the overall 05 Jun 2020 detailed discussions on developing Programme. Latest Review By: messages and delivery mechanisms to Sandra Vanreyk reassure and support GPs on Last Review Comments: Programme progress, its impacts and Reviewed benefits Milton 1CE One Through the staff As a result of the I = 3 L HR to conduct a review of current home I = 3 L As part of estates paper, include projected Lisa Bedding 17 Jul I = 3 L Kenyes 2 BLMK consultation on the identification of a CCG HQ = 4 to base mileage which will enable us to = 3 potential costs of change to contractual base. 2020 = 3 CCG contractual change of and the staff consultation to 12 work out the potential financial impact of 9 9 base, the staff entitlement change contractual base, a contractual change of base. to excess mileage will there is a risk that the need
Page 11 of 26
BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by g increase running costs for to pay excess mileage will a peiod of 3 years increase running costs, Owner: Lisa Bedding resulting in a negative Risk Lead: Lisa Bedding impact on the ability to Last Updated: 05 Jun achieve 20% running cost 2020 reduction. Latest Review Date: Latest Review By: Last Review Comments:
Milton 1HO One Mis-management of As a result of any potential I = 4 L Engagement of a senior HR Lead with I = 4 L Kenyes 4 BLMK organisational change mis- management of the = 2 significant experience in leading = 2 CCG process organisational change 8 Organisational change programmes, 8 Owner: Emma Richards process, there is a risk to robust and detailed plans, partnership Risk Lead: Emma the CCG of delays to the with TUs, detailed communications and Richards programme, legal claims documentation for staff and Programme Last Updated: 08 Jun from staff and Trade Boards, adherence to the BLMK CCGs 2020 Unions and uncertainty for Organisational change policy and current Latest Review Date: staff leading to slippage on Employment legislation. Latest Review By: the finalisation of the Last Review Comments: structure for the new CCG.
Milton 1HO One Impact of remote learning As a result of OD being I = 4 L Set clear OD objectives for providers to I = 4 L Build on OD objectives from the OD plan on a Lisa Bedding 22 Jun I = 3 L Kenyes 3 BLMK & OD delivered virtually due to = 3 meet within the IT capabilities we have = 2 page, for use when discussing outcomes with new 2020 = 2 CCG Owner: Lisa Bedding post- Covid restrictions, 12 currently have. 8 providers. Develop measures to ensure objectives 6 Risk Lead: Lisa Bedding there is a risk that OD are met Last Updated: 05 Jun activity will not have the 2020 same level of impact as Latest Review Date: face to face delivery. This Latest Review By: could result in a reduction Last Review Comments: in the added value of OD and a potential negative impact on the achievement of OD objectives (development of strategic commissioner).
Milton 1PC One Our member practices As a result of our member I = 3 L Comms and engagement strategy I = 3 L Implement plan Alison 01 Aug I = 1 L Kenyes 5 BLMK voting against the practices voting against the = 3 = 3 Joyner 2020 = 3 CCG alignment of the one alignment of the one CCG 9 9 3 consitution with one single constitution Owner: Alison Joyner could result in Risk Lead: Michael disengagement of our Wuestefeld-Gray member practices Last Updated: 05 Jun 2020 Latest Review Date: Latest Review By: Last Review Comments:
Milton 1CE One Staff may leave as a result As a result of a Programme I = 4 L The continuation of home-working I = 3 L HR to analyse current home to base mileage to Lisa Bedding 17 Jul I = 2 L Kenyes 3 BLMK of HQ decision and a Board recommendation/ = 4 following the Covid outbreak, will be an = 3 understand impact of change of contractual base. 2020 = 3 CCG change of contractual base decision on HQ for the 16 attractive solution for staff who may need 9 Assessment of office-based working needs to 6 Owner: Lisa Bedding single CCG, there is a risk to change contractual base. ascertain the requirements for longer term home- Risk Lead: Lisa Bedding that any increase in travel based working and the HR implications. Last Updated: 05 Jun for affected staff may result The above to be included in estates paper for July. 2020 in them choosing to leave Latest Review Date: the CCGs' employment. Latest Review By: Last Review Comments:
Milton 1CE One Not obtaining a positive As a result of not obtaining I = 5 L Support from key spokespeople eg. Good I = 3 L implementation of communications plan Ruth Adams 17 Jul I = 3 L Kenyes 2 BLMK Consitiution GB vote a positive GB vote, there is = 5 engagement plan. = 3 2020 = 2 CCG Owner: Maria Wogan a risk that CCGs cannot 25 Clarity of benefits and compelling case 9 6 Risk Lead: Ruth Adams demonstrate member for Change Last Updated: 05 Jun support which is a key 2020 criteria. Resulting in delay Latest Review Date: to the process with 05 Jun 2020 additional process steps Latest Review By: Sandra Vanreyk Last Review Comments: Updated
Milton 1PC One Primary Care web tool not As a result of the Primary I = 2 L Discussion with NHSE Paul Fogarty to I = 2 L Creat timeline Alison 31 Mar I = 1 L Kenyes 4 BLMK being operational Care web tool not being = 4 see when this will be operational = 4 Joyner 2021 = 3 CCG Owner: Alison Joyner operational there is a risk 8 8 3 Risk Lead: Alison Joyner that there is a risk that Last Updated: 05 Jun single approach to 2020 benchmarking data Latest Review Date: resulting in will not be Latest Review By: consistent and utilising Last Review Comments: additional resource within the one team
Milton One 9 One Lack of budget for As a result of no budget I = 4 L 19/20 Costs have been accommodated in I = 4 L Continue to seek support funding for the extra Wendy 30 Jun I = 4 L Kenyes BLMK programme, creates cost created for the One Team = 3 CCG financial forecasts = 3 costs Rowlands 2020 = 2 CCG pressure and inability to Programme and no 12 12 8 meet control totals provision made for Non Indicative budget approved by Owner: Maria Wogan Pay costs. programme board and monthly financial Risk Lead: Wendy There is a risk that this monitoring in place Rowlands cost pressure will lead to Out of the approx. £1.2m budget most Last Updated: 09 Jun Inability of BLMK CCGS to are established posts 2020 achieve their 2020/21 1. One Team members to be made Latest Review Date: Control Totals. Resulting in aware of restrictions on Non Pay costs 09 Jun 2020 NHSE/I decide not to write 2. Liaised with Alison Malciw re Latest Review By: off historic debts and these optimising usage of resources already Maria Wogan are carried forward into the budgeted for e.g. Room bookings Last Review Comments: new structure. 3. Budget schedule created and report review of risk score - will be provided monthly to track actual adjustment of catastrophic spend impact score Milton One One Lack of team capacity As a result of a lack of I = 4 L Employment of additional staff. Refocus I = 4 L Monitor staffing resources required and escalate as Maria 30 Jun I = 3 L Kenyes 12 BLMK Owner: Maria Wogan capacity within the team = 4 from day job activities/ other strategic = 4 required in conjunction with Covid pressures Wogan 2020 = 2 CCG Risk Lead: Maria Wogan due to pressure of Covid 16 priorities process completed 16 6 Last Updated: 09 Jun work. There is a risk that 2020 milestones will not be Latest Review Date: delivered as required. 09 Jun 2020 Resulting in impact on Latest Review By: critical path and other Maria Wogan deliverables. Last Review Comments: updated due dates for actions and risk scores
Page 12 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton 1FI One Focus on One Team Focus on One BLMK Team I = 4 L Kenyes 3 BLMK Programme of time and Programme and Covid, = 2 CCG skills there is a risk that lack of 8 Owner: Wendy Rowlands focus on BAU/Recovery, Risk Lead: Wendy resulting in deterioration in Rowlands financial position of CCGs Last Updated: 05 Jun 2020 Latest Review Date: Latest Review By: Last Review Comments:
Milton 1FI One Volume of CCG mergers Volume of CCG mergers I = 3 L Prepare early to engage SBS in I = 3 L Notify providers early to give notice of work Wendy 31 Aug I = 2 L Kenyes 5 BLMK Owner: Wendy Rowlands and impact on suppliers. = 2 programme plan = 2 Rowlands 2020 = 1 CCG Risk Lead: Wendy SBS are unable to support 6 6 2 Rowlands BLMK ledger creation in Last Updated: 05 Jun timelines resulting in 2020 Finance System not Latest Review Date: available for CCG start Latest Review By: Last Review Comments:
Milton 1FI One Phased development of Phased development of I = 3 L Consideration of coding ICP support to Programme Wendy 01 Jun I = 2 L Kenyes 4 BLMK staff structure staff structure, the planned = 4 costs Rowlands 2020 = 2 CCG Owner: Wendy Rowlands budget may not adequately 12 Costings to be calculated at each phase Wendy 01 Jun 4 Risk Lead: Wendy cover the actual costs , Rowlands 2020 Rowlands resulting in unaffordable Funding envelope established and provide advice Wendy 31 Jul structure Last Updated: 05 Jun to the Programme/Audit Committees/Governing Rowlands 2020 2020 Bodies on the financial limits, being mindful that a Latest Review Date: reduction in costs (circa 20%) is the running cost Latest Review By: target Last Review Comments:
Milton 1G O One A proportion GB members As a result of a lack of full I = 3 L We have split roles as fairly and equally 1. Governing Body I = 3 L Kenyes 5 BLMK will not have a place in the and open, detailed = 3 as possible in the new structures, and all Development Sessions in = 2 CCG new structure discussion about new 9 GB members are still on their respective December and February 6 Owner: Maria Wogan structures. There is a risk governing bodies. There are four GB 2. Formal papers to Risk Lead: Michael that current governing body members who do not have a place on the Governing Bodes in Wuestefeld-Gray members do not realise new joint committees, shadow working January 2020 Last Updated: 05 Jun that a significant proportion group (or Programme Board) and they 4. Relaying key messages 2020 of them will not have a have been advised that we are looking at to give assurance about Latest Review Date: place in the new strategic leadership development for all GB roles, skills and 05 Jun 2020 commissioner. members. opportunities Latest Review By: Resulting in (a) a failure to Sandra Vanreyk engage with the work to Last Review Comments: deliver that new system updated and (b) disengagement from the opportunities that will exist as part of the Milton 1G O One A lack of member practice As a result of a lack of I = 5 L Engagement has been built into the I = 5 L Constitution approved by GB members in July Michael 31 Jul I = 5 L Kenyes 7 BLMK engagement member practice = 3 planning stage = 2 Wuestefel d- 2020 = 1 CCG Owner: Maria Wogan engagement. There is a 15 Shadow working implemented with 10 Gray 5 Risk Lead: Michael risk that they will not sign relevant governance Wuestefeld-Gray off the creation of the Last Updated: 05 Jun single 2020 constitution. Resulting in Latest Review Date: an inability to progress the 05 Jun 2020 application. Latest Review By: Sandra Vanreyk Last Review Comments: updated
Milton 1CE One Reduction in estates costs As a result of there not I = 4 L Paper on corporate estates being develop I = 4 L Gather intelligence, develop plan and complete Lisa Bedding 17 Jul I = 3 L Kenyes 1 BLMK may not be achieved to being any break clauses = 4 to incorporate all options. This will include = 3 paper to enable Exec level decisions to be made. 2020 = 3 CCG count towards 20% running and the introduction of 16 a review of current leases, impact of 12 9 cost reduction Government guidance social distancing measures, assessment Owner: Lisa Bedding (social distancing in the of functions requiring attendance at the Risk Lead: Lisa Bedding workplace) brings a risk office, a 4th site option, etc. Last Updated: 05 Jun that we will not achieve 2020 estates cost reduction to Latest Review Date: support the 20%. This Latest Review By: may result in the CCGs not Last Review Comments: meeting the 20% cost reduction and puts additional pressure in other areas to find more savings.
Milton One 6 One Poor definition of benefits As a result of Benefits I = 5 L Benefits realisation plan being developed I = 4 L Regular review of stakeholder position Ruth Adams 30 Jun I = 4 L Kenyes BLMK of the programme leads to Realisation Mapping: The = 4 based on learning from other CCG = 2 2020 = 2 CCG lack of support for the system is not able to 20 mergers 8 Development of final case for change and benefits Alison 31 Jul 8 creation of single CCG clearly articulate the stakeholder management plan in place realisation plan Joyner 2020 Owner: Maria Wogan expected benefits to and under regular review by executive Risk Lead: Maria Wogan system transformation/new Last Updated: 09 Jun one CCG. The risk is that Summary case for change first draft 2020 this will impact upon public, approved Latest Review Date: wider stakeholder and 05 Jun 2020 NHSE acceptance and Latest Review By: approval of the system Sandra Vanreyk transformation proposals. Last Review Comments: There is a risk that there reviewed will be an impact upon public and wider stakeholder and NHSE/I acceptance and approval of the System Transformation proposals. Resulting in severe delay or cancellation of the One BLMK Programme.
Milton 1CE One Loss of staff / reputation There is a risk that staff are I = 4 L Close working with HR for staff I = 4 L implementation of communications plan Ruth Adams 31 Jul I = 4 L Kenyes 3 BLMK due to process of not brought into the = 4 consultation messages = 3 2020 = 2 CCG becoming One BLMK process, which may lead 16 Good Engagement Plan 12 8 Owner: Maria Wogan to a demotivate workforce. Risk Lead: Ruth Adams Resulting in the loss of Good leadership from SLG to provide Last Updated: 05 Jun reputation and staff leaving - reassurance 2020 loss of organisational Latest Review Date: memory and a shortage of 05 Jun 2020 skill sets Latest Review By: Sandra Vanreyk Last Review Comments: updated
Milton 1PC One Reorganisation of NHSE As a result of I = 3 L CCG Team supporting critical work I = 3 L Meeting with NHSE to agree clear work plans for Alison 31 Mar I = 1 L Kenyes 3 BLMK seconded staff reorganisation of NHSE = 4 streams and lack of capacity in NHSE = 3 aligned NHSE staff Joyner 2021 = 2 CCG O Ali J seconded staff there is a 12 Contracting team 9 2
Page 13 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by y CCG Owner: Alison Joyner seconded staff there is a 12 Contracting team 9 2 Risk Lead: Alison Joyner risk of capacity and Review of CCG staff through Tier 2 & Last Updated: 05 Jun capability and previous Tier 3 to ensure appropriate capacity & 2020 history being lost resulting capability going forward. Latest Review Date: in non-delivery of critical Latest Review By: work streams and the CCG Last Review Comments: team being diverted in doing business as usual and the one team approach
Milton 1FI One Limited dedicated resource As a result of Limited I = 3 L Resources requested from Executive I = 3 L Actions to be distributed between team members Wendy 26 Jun I = 3 L Kenyes 1 BLMK Owner: Wendy Rowlands dedicated resource there is = 3 Board (27/5) = 3 Rowlands 2020 = 2 CCG Risk Lead: Wendy a risk that the programme 9 9 Request additional BI resources, awaiting Maria 30 Jun 6 Rowlands actions are not completed. confirmation of agreement Wogan 2020 Last Updated: 05 Jun Resulting in delays in 2020 programme plan which Latest Review Date: may also impact on other Latest Review By: workstreams Last Review Comments:
Milton 1HO One mis-management of As a result of mis- I = 4 L Regular communication, discussion to Finalised and approved I = 4 L Involvement/invite to participate in the development Emma 28 Aug I = 2 L Kenyes 1 BLMK process re Change management of process re = 4 resolve the issue, consideration of Change Management = 2 of a formal partnership agreement for the process Richards 2020 = 1 CCG Manangement Policy Change Manangement 16 feedback, assurance re process and policy 8 with the Trade Unions and monthly TU meetings 2 Owner: Emma Richards Policy. There is a risk that future involvement during the transition process. (Emma Risk Lead: Emma the relationship with a Richards/Karen Rhodes, 28/02/2020) Richards significant Trade Union is Last Updated: 09 Jun less robust resulting in 2020 delays regarding the HR Latest Review Date: workstream and Union 08 Jun 2020 involvement through the Latest Review By: process Emma Richards Last Review Comments: This risk record can be closed. The establishment of a TU partnership forum with regular communication and meetings has mitigated the risk.
Milton 1FI One Providers in several key Providers in several key I = 5 L Give notice to relevant providers and procure new Wendy 12 Jun I = 3 L Kenyes 9 BLMK service areas have different service areas have different = 2 BLMK facing services Rowlands 2020 = 2 CCG Contract end dates Contract end dates. There 10 6 Owner: Wendy Rowlands is a risk that contracts will Risk Lead: Wendy not be aligned in time for Rowlands new CCG go live and some Last Updated: 05 Jun contracts may lapse before 2020 this, resulting in Some Latest Review Date: services not available at go Latest Review By: live Last Review Comments:
Milton 1HO One Mis-management of TUPE As a result of mis- I = 4 L Engage a senior HR Lead with significant I = 4 L Kenyes 6 BLMK process and associated management of the TUPE = 2 experience in organisational change and = 2 CCG deliverables process and its associated 8 TUPE processes. Regular 8 Owner: Emma Richards deliverables there is a risk communications with staff and TUs, Risk Lead: Emma of a failure to transfer staff frequent communication, robust Richards and staff- related services consultation process, robust plans which Last Updated: 08 Jun effectively to the new one are regularly reviewed. Adherence to 2020 CCG by the required date, current Employment law legislation. Early Latest Review Date: leading to displaced / non- identification of associated 3rd parties Latest Review By: employed staff. and relevant contracts. Last Review Comments: Milton 1G O One BLMK organisational As a result of there being I = 3 L The Comms and Engagement Team is The Comms and I = 2 L Further work is needed to engage with local public Michael 30 Apr I = 1 L Kenyes 3 BLMK Committee disruption at least three public health = 3 engaging with local healthwatch Engagement Team is = 3 health organisations. Once greater clarity is Wuestefel d- 2020 = 2 CCG Owner: Maria Wogan and four healthwatch 9 organisations to ensure they understand engaging with local 6 available on place-based and BLMK wide work, Gray 2 Risk Lead: Michael organisations across the the changes that are coming and to work healthwatch organisations both at strategic commissioner and in the wider Wuestefeld-Gray BLMK patch. out where they can best be involved and to ensure they understand ICS, mitigation of this risk will be delivered at Last Updated: 05 Jun There is a risk that fulfil their statutory duties. the changes that are greater pace. 2020 logistical management of coming and to work out Latest Review Date: the Governing Bodies where they can best be Latest Review By: Committees in Common involved and fulfil their Last Review Comments: and other committees that statutory duties. they attend will be a challenge. Resulting in chaotic and unwieldy meetings and a breakdown of relationships.
Milton 1FI One Some financial services to Some financial services to I = 4 L Business Case sent to NHS E for IT I = 4 L IM&T & ECM services to transfer in house Wendy 12 Jun I = 3 L Kenyes 10 BLMK MK CCG are provided by MK CCG are provided by = 3 service transfer = 3 Rowlands 2020 = 3 CCG their CSU their CSU. There is a risk 12 12 Decision to be made on remaining services Wendy 12 Jun 9 Owner: Wendy Rowlands that during a procurement Rowlands 2020 Risk Lead: Wendy their may be a requirement Rowlands for TUPE, there are some Last Updated: 05 Jun conflicts of interest with HR 2020 support. Latest Review Date: Resulting in Service quality Latest Review By: may suffer during this Last Review Comments: period and their may also be stranded costs
Milton One 8 One Lack of clarity re: meaning As a result of combining I = 4 L Proposed Agreement to maintain & I = 4 L Develop policy for distribution of primary care Wendy 30 Jun I = 3 L Kenyes BLMK of 'ring- fenced' future financial allocations into = 3 protect the projected funding allocations = 3 funding allocation across BLMK Rowlands 2020 = 1 CCG primary care spending one single system financial 12 in Primary Care have been approved by 12 engage with primary care on the proposals Ruth Adams 20 Jul 3 leads to lack of support allocation. There is a risk Boards regarding 'ring-fencing' of primary care budgets 2020 from membership that members may WR has conducted initial review of the and develop policy based on feedback to address Owner: Maria Wogan perceive their historical Finance Workstream Plan with Luton and concerns Risk Lead: Wendy allocations to be at risk. Bedfordshire CCGs Finance ADs and Rowlands Resulting in CCG members Programme Lead. Last Updated: 09 Jun may not approve new 2020 organisation until there is a Latest Review Date: clear policy about 'ring 05 Jun 2020 fencing' primary care Latest Review By: funding Sandra Vanreyk Last Review Comments: reviewed
Milton 1CB One Procurement delays for procurement delays there I = 4 L Obtain advice from procurement advisors I = 3 L Draft formal Business Case by July 2020. Alison 31 Jul I = 1 L Kenyes 2 BLMK critical support services is a risk that we are unable = 3 Seek Exec approval for extending current = 3 Joyner 2020 = 1 CCG Owner: Alison Joyner to extend current BI 12 arrangements. 9 1 Risk Lead: Alison Joyner arrangements which are Write Business Case for extension of Last Updated: 05 Jun due to expire in Jul current arrangements until 2021 while 2020 -20 for Luton & Beds business case developed for full Latest Review Date: CCGs in lieu of procurement 05 Jun 2020 procurement for single L t t R i B CCG Resulting in Lack of
Page 14 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target
/context Obj. Effect Score (1st Line) nt Responsi implem Score
Score ble ented by
Latest Review By: CCG. Resulting in Lack of Alison Joyner BI function to Last Review Comments: commissioning, contracting Risk Updated by A Joyner and decision making for the CCGs.
Milton 1FI One Significant movement of Significant movement of I = 4 L Contacted other CCGs would have I = 4 L Under Covid estates planning underway and taking Lisa Bedding 14 Jul I = 4 L Kenyes 11 BLMK staff to other accomodation staff to other = 3 completed the merger processes to = 3 into account agile working . 2020 = 2 CCG Owner: Wendy Rowlands accommodation. 12 identify how they handled this 12 8 Risk Lead: Wendy There is a risk that some Rowlands estate with contracted Last Updated: 05 Jun costs maintained after go 2020 live remains unoccupied. Latest Review Date: Resulting in Stranded Latest Review By: lease costs that have not Last Review Comments: been made provision for
Milton 1G O One Cultural view of an As a result of the I = 5 L A tracker is being kept that can provide Clear comms messages I = 4 L It will be critically important to engage with people Michael 31 Jul I = 2 L Kenyes 4 BLMK operational take over development of cross- = 2 evidence that all CCGs are contributing being delivered to the = 2 at all levels to tell them the truth, and listen to their Wuestefel d- 2020 = 2 CCG Owner: Maria Wogan CCG working and 10 as equally as possible to the creation of appropriate audiences 8 concerns. Ideally there would only be one version Gray 4 Risk Lead: Michael governance arrangements. the strategic commissioner or source of communication activity across BLMK Wuestefeld-Gray There is a risk that there and one central place to collate and respond to Last Updated: 09 Jun will be a perception that People are being pushed to be mindful of Papers and minutes ideas, concerns and expectations 2020 one or more CCGs is the correct use of language and avoid reflecting accurate Latest Review Date: taking over the other talking about mergers or similar activity terminology Latest Review By: CCGs. Resulting in a So far people have generally indicated Last Review Comments: cultural problem negatively affecting the operational they are happy as individuals of the sustainability of the new interim shadow working arrangements systems and where possible we have adjusted out approach to take account expressed preferences. As the interim arrangements are in place for 10 months and we are starting the co-design of the new CCG's governing body people affected are more likely to look forward than back
Milton 1CB One Insufficient expertise to Insufficient expertise to I = 3 L Procurement of third-party expertise to I = 3 L Detailed specification for single BI requirement to Alison 30 Sep I = 2 L Kenyes 3 BLMK specify single CCG BI specify single CCG BI = 3 support specification; engagement with = 3 be developed as part of procurement. Joyner 2020 = 2 CCG requirement. requirement., there is a risk 9 NHSE/I and ICS partners to support 9 Dedicated resources for heading up BI within CCG 4 Owner: Maria Wogan that difficulty in specifying development of specification as part of Tier 2/3 reorganisation. Risk Lead: Alison Joyner required BI solution,. Last Updated: 05 Jun Resulting in poor BI to 2020 support future decision Latest Review Date: making. Poor vfm. 05 Jun 2020 Latest Review By: Alison Joyner Last Review Comments: Updated by A Joyner
Luton BAF 4 The CCG may not be Weaknesses I = 4 L = Communications and Engagement I = 4 L = Implementation of Comms & Engagement Strategy effective in engaging and Lack of public engagement, 3 Strategy in place and monitored through 2 for the BLMK area with place specific actions. involving the public, insufficient co-production 12 the Communications and Engagement 8 Person Responsible: Sarah Frisby clinicians and organisations Difficulties reaching diverse Health and Social Care Reference Group To be implemented by: 01 Jun 2020 in the transformation of the population Provider to support engagement with public. NHS in Luton. engagement Primary Care engagement Voluntary Sector engagement Consequence Communication of CCG's intentions not effective Patients not engaged in Primary Care i i i f i
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton ICS T S2 - IM&T / SystmOne - The IM&T SystmOne I = 4 L Options appraisal went to Board and the I = 4 L Liaise with contracts team to establish if IM&T Carla 31 Jul I = 3 L Kenyes 5 Access & support experts are currently on = 4 decision was approved to move to HBL = 3 contract has been extended to include delivery of Barbato 2020 = 2 Quality Owner: Alexia Stenning time limited contracts and 16 for IM&T from April 2020 12 outstanding work. 6 Risk Lead: Carla Barbato are pivotal to the Schedule work and agree timeline Last Updated: 09 Jun SystmOne solutions that Risk rasied at CCG QUIP meeting. 2020 underpin all of the Wendy Rowlands will liase with Latest Review Date: schemes. there is a risk ArdenGEM and STP funding leads to 08 Jun 2020 that if the contracts come agree arrangements to ensure continuity Latest Review By: to an end before the new from April 2019. Carla Barbato SystmOne functionality is Last Review Comments: embedded in practice. The Work suspended during benefits of all of the initial covid-19 response to interdependent schemes be resumed. will not be delivered.
Bedford- Co- To be Owner: Nick Wadeley Escalated from the Primary I = 4 L = Workforce Development Programme The following intiatives are I = 4, Concerns remain around the stability of some Nicky 1 shire comm allocate Care Commissioning Risk 4 Releasing Time for Care expected to be delivered L = 3 practices though there has been improvement Wadely 57 Lead: Nicky Wadeley Register 16 Estates and Technology Development ongoing through 2019/20: generally. d As a result of the multiple Primary Care Network development 12 Date last reviewed: 9 June factors impacting on GP resilience Programme Workforce Development Continued support from place-based teams. 2020 Central Bedfordshire PMS Reinvestment Scheme Programme general practices, there is a Place-based team - GP International Recruits Initiatives in place to build resilience in the longer risk that practices will MK chambers/support offers from MKGP - Recruitment to GP term continue to deliver. become increasingly more Plus Fellowships vulnerable and less RCGP support - Development post CCT Discussions around support from other providers resilient, which may result ELFT primary care solutions GP development / 1st 5's (e.g. ELFT) are taking place where appropriate. in access issues, referral Digital development network - Next Generation variation, reduced morale, Bedoc support offer - Confident Practice PCNs delivering extended hours, many are reduced workforce, Merger support Manager Programme in advertising for thier reimbursable roles (Clinical restriction of services Pre/post-CQC support place Pharmacist and Social Precribing Link Worker) delivered, an increase in - Workforce modelling currently. acute care access with its project x 2 localities resulting financial impact to Releasing Time for Care Resilience programme is continuing to deliver. the CCG, as well as an - Implementation of High inability to transform in line Impact actions Productive General Practice Quick Start with the ICS vision Estates and Technology programme completed successfully. Development - Estates development programme - Rollout and development of online and video consultations Primary Care Network development - Additional roles being recruited, workforce plan developed - Extended hours and access delivery Investment in and support
Page 15 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Bedford- Co 1 Risk owner: Sally Escalated from the I = 4 L Workforce Development Programme Workforce Development I = 4, L Despite improvement there are still concerns Nicky 4 shire Com Adams Primary Care = 4 Releasing Time for Care Programme 3, = 12 around a number of practices. Wadely 60 Commissioning risk Estates and Technology Development - GP International Recruits register. 16 Primary Care Network development - Recruitment to GP Continued support from place based teams. Risk lead: Nicky As a result of the multiple GP resilience Programme Fellowships Wadely factors impacting on PMS Reinvestment Scheme - Development post CCT Initiatives in place to build resilience in the longer Bedford Borough general Place-based team GP development / 1st 5's term continue to deliver. practices, there is a risk MK chambers/support offers from MKGP network - Next Generation Last Updated: 5 June that practices will become Plus - Confident Practice Discussions around support from other providers 2020 increasingly more RCGP support Manager Programme in (e.g. ELFT) are taking place where appropriate. vulnerable and less ELFT primary care solutions place resilient, which may result Digital development - Workforce modelling PCNs delivering extended hours, many are in access issues, referral Bedoc support offer project x 2 localities advertising for thier reimbursable roles (Clinical variation, reduced morale, Merger support Releasing Time for Care Pharmacist and Social Precribing Link Worker) reduced workforce, an Pre/post-CQC support - Implementation of High currently. increase in acute care Impact actions access with its resulting Estates and Technology Resilience programme is continuing to deliver. financial impact to the Development CCG, as well as an inability - Estates development Productive General Practice programme completed to transform in line with the programme successfully. ICS vision - Rollout and development of online and video consultations Primary Care Network development - Additional roles being recruited, workforce plan developed - Extended hours and access delivery Investment in, and support for, practice mergers Milton Pc 21 S3 - Vulnerable Practices As a result of financial I = 4 L GP Resilience Programme started with Diagnostic tool sent out to I = 3 L Continue to monitor practices through Primary Janine 31 Mar I = 3 L Kenyes Financi al Owner: Alexia Stenning sustainability, CQC = 3 HLB LMC to support highlighted all practices First meeting = 3 Care Committee and Risk Sharing Meetings with Welham 2020 = 3 Sustain Risk Lead: Janine inspections, diminishing 12 practices held with both vulnerable 9 the CQC, no further actions are required and we 9 ability Welham and ageing workforce practices highlighted, 3 are accepting the risk at this level score Last Updated: 06 Aug within primary care there is more practices identified for 2019 risk that practices may support from the LMC Latest Review Date: hand back their contract to the CCG resulting in 20 Feb 2020 LMC working with both practices with Initial meetings held with appointing a caretaker Latest Review By: regard merger with another practice both practices and support provider and increased Janine Welham within MK from the CCG Last Review Comments: costs for the CCG Risk reviewed Working with practices with inadequate Project plans devised and CQC reports to help devise project plans shared learning circulated across Primary Care
Milton Pc 25 S3 - Brooklands New Build Of the new build at I = 3 L Business case has been approved by the FBC Business Case I = 3 L NHSE has contacted the District Valuer to confirm Janine 21 Feb I = 2 L Kenyes Financi al Owner: Alexia Stenning Brooklands Health Centre = 3 PCC and can now be progressed to = 3 rental reimbursements and rent abatement for the Welham 2020 = 2 Sustain Risk Lead: Janine there is a risk that the 9 NHSE PAU 9 scheme along with approval for the heads of terms, 4 ability Welham plans will not be approved Meeting with MKC, NHSE and DV to fortnightly teleconferences this is normal process for all new builds Last Updated: 06 Aug for the ETTF funding by agree rental values, working with NHSE set up with all parties in 2019 NHSE which will then to agree section 2, order to work to a quick Assemble writing the business case to be Janine 27 Mar Latest Review Date: impact on the future resolve submitted to NHSE PAU for approval draft Welham 2020 20 Feb 2020 revenue consequences, submitted, to go to PCC in March for final sign off Latest Review By: which will impact on higher The DV needs to agree the rental and the to NHSE in March Janine Welham rent reimbursements for reimbursement until this has been done Last Review Comments: the CCG and the Business case submitted to PAU Risk Reviewed NHSE can not release the ETTF (£1.4m) this has therefore been moved in to next year funding however this needs to be utilised as early as possible in April 2020
Milton Pc 41 To be Whitehouse Premises As a result of the New I = 3 L Discussion with the new provider of I = 3 L Kenyes allocate d Owner: Alexia Stenning Whitehouse premises built = 4 Whitehouse to delay the contract start = 3 Risk Lead: Janine by MKC and funded by 12 until the 1st September 2020 to allow 9 Welham S106 and ETTF there is a time for the Section 2 and the rental to be Last Updated: 11 Mar risk due to the timelines agreed and for the lease to be signed 2020 from NHSE for signing of prior to occupancy Latest Review Date: the section 2 and the District Valuer agreeing the Fortnightly telephone conferences with Latest Review By: NHSE, MKC, CCG and DV to agree Last Review Comments: rental value that the new provider of the service will section 2, rental value and business case not be able to occupy the for ETTF premises as from the 1st July as per the procurement resulting in a delay to the service Milton Pc 37 S2 - Minor Surgery Hub and As a result of limited I = 3 L • Engagement with practices / I = 3 L Monthly data report being created by Laura Dixon Liz Holland 01 Apr I = 3 L Kenyes Access & Spoke Referral Pathway change to GP behaviour = 3 identification of hub practices and = 2 to enable monitoring of activity across all practices 2020 = 2 Quality Owner: Janine Welham there is a risk that where 9 development of awareness of need to 6 6 Risk Lead: Liz Holland surgeries are not engaging address limited primary care activity Last Updated: 31 Jan with the Minor Surgery • On-going engagement with site / 2020 DES inappropriate referrals monitoring of situation Latest Review Date: will be made to secondary • Sufficient capacity highlighted by 10 Feb 2020 care, impacting negatively identified hub practices Latest Review By: on corresponding spend. In Liz Holland addition, as a result of hub Last Review Comments: practices being unable to Three practices now live, meet demand in activity remainder awaiting quality there is risk that those clearance practices who are not engaging with the Minor Surgery DES to refer to secondary care
Milton Pc 1 S2 - Insufficient Estates As a result of lack of I = 4 L Assemble now working with the CCG on I = 4 L Business case being drafted for Whitehouse by Janine 30 Jun I = 2 L Kenyes Access & expertise/resources internal CCG premises and = 3 identified projects to enable estates = 3 Assemble to deliver ETTF funding for new Welham 2020 = 2 Quality Owner: Wendy Rowlands estate expertise there may 12 expertise, along with Business Case 12 premises. Awaiting financial terms from Council for 4 Risk Lead: Janine be lost opportunity in writing for both Whitehouse and new lease which has been delayed Welham bidding for additional capital Brooklands premises developments Last Updated: 16 and developing a strategic Negotiate lease with MKC for Brooklands Wendy 30 Jun Dec 2019 direction for estates for the bi monthly tripartite meetings booked with - Lease terms agreed by the CCG and DV, now Rowlands 2020 local estates forum ETTF funding bid Latest Review Date: health system of Milton awaiting approval from the GP practice incumbant successful for East and CMK remodelling 19 May 2020 Keynes. There is also a Working closely with MKC on S106 Business case being written by External support Janine 31 Jul Latest Review By: risk that agreements for utilisation Wendy Rowlands new premises are not for options for Red House Surgery to access ETTF Welham 2020 finalised in an appropriate and S106 monies, Last Review Comments: Business Case for Brooklands signed of timeframe. The impact is Put on hold due to Covid-19 Action dates updated by PCC and submitted to Region. Delay that potential opportunities in processing at Region due to Covid-19. will be lost increasing the Identify a permanent lead for estates in Milton Richard 30 Sep expenditure of the CCG Keynes. Process has been postponed for six Alsop 2020 months due to Covid- 19. Edna Muraya will continue to cover this role in the interim. Milton Pc 38 S2 - Impact on practices of As a result of the transition I = 3 L IT services have developed timetable for I = 3 L IT team to improve communications to practices so Wendy 30 Jun I = 2 L Kenyes Access & implementation of the to new HSCN practices will = 3 implementation and communicated to = 2 that they can prepare to put in place business Rowlands 2020 = 2 Quality HSCN lose access to computer 9 practices 6 continuity plans if required. New communications 4 Owner: Alexia Stenning systems which may to lead IT strategy group will monitor the being developed as part of HBL ICT transfer Risk Lead: Janine failures in delivery of implementation of this work and any Welham service if business impacts ti it l t t
Page 16 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Last Updated: 16 continuity plans are not put Dec 2019 in place. Latest Review Date: Resulting impact to patient 20 Feb 2020 care. Latest Review By: Janine Welham Last Review Comments: Risk reviewed
Milton ICS T S2 - ICST inconsistent service As a result of the multiple I = 3 L New CCG lead in post on 12 month I = 3 L Work with Primary Care to identify potential Carla 30 Oct I = 3 L Kenyes 8 Access & delivery providers and varying = 4 secondment = 3 opportunities to expand ICST through role Barbato 2020 = 2 Quality Owner: Alexia Stenning maturity of ICST’s across 12 9 reimbursement scheme 6 Risk Lead: Carla Barbato PCNs pre covid-19, there Establish regular contact with Business Manager Carla 31 Oct Last Updated: 09 Jun is a risk that re- and Clinical Directors to review service delivery, Barbato 2020 2020 mobilisation following re- trouble shoot issues and share good practice Latest Review Date: deployment will lead to Latest Review By: inconsistencies in service Establish regular contract meetings with ICST Carla 31 Oct Last Review Comments: delivery culminating in providers, monitor outcomes of service Barbato 2020 failure to achieve projected specification outcomes including activity, Review staffing and facilitate recruitment where Carla 31 Dec quality and financial gaps exist to ensure sufficient capacity. The covid- Barbato 2020 savings 19 recovery plan will impact timelines
Milton Pc 3 S2 - Insufficient Healthcare As a result of the current I = 4 L Carla Barbato leading on workforce for I = 3 L Promote International GP Recruitment programme Janine 31 Mar I = 3 L Kenyes Access & worker recruitment across workforce pressures, = 3 the CCG - initially looking at the GP = 3 and GP retention programme Welham 2020 = 2 Quality MK training and estates 12 recruit and retain programme for the STP 9 Discussed at each practice visit any workforce Janine 31 Mar 6 Owner: Alexia Stenning capacity in general issues to confirm any current workforce issues and Welham 2020 Risk Lead: Janine practice and the inability to Encouraging practices to register for Two practices Stonedean promote schemes that are available currently Welham recruit to vacancies, sponsorship for Tier 2 Visa and MKVP successful in Last Updated: 03 general practice will application for Tier 2 Room reconfiguration to be done at Soveriegn to Janine 30 Aug Sep 2019 become unsustainable and gain 2 more training rooms so the practice can Welham 2020 Latest Review Date: may lead to practices Increase training capacity with the new become a GP training practice 20 Feb 2020 handing contracts back. builds including West, East and the Latest Review By: Resulting in lack of primary proposed expansion of the Red House Janine Welham care provision and higher Surgery Last Review Comments: financials cost due to Meet with neighbouring CCGs to Risk reviewed caretakers and a longer understand workforce and capacity term impact issues Monthly meetings with vulnerable STP General Practice practices Workforce Plan and funding approved through section 96 to Development Programme assist with financial shortfall Clinical pharmacist rollout Working with the STP on Workforce and overseas recruitment EOI out to practices for overseas recruitment and placement for physician associates trainees International Recruitment scheme to be considered
New practice and portfolio careers pilot to be launched in MK for nurses and GP's to entice more new workforce to the area
STP now part of the extended Lincolnshire pilot for International GP Recruitment. Recruitment process due to start January 2020.
Milton Pc 9 S3 - Financial Viability Neath Hill Key Medical Service I = 3 L Contract Meeting held with KMS in Monthly meetings with I = 2 L I = 2 L Kenyes Financi al Owner: Alexia Stenning delivering the APMS = 4 October and November to discuss the KMS to review = 2 = 2 Sustain Risk Lead: Janine contract at Neath Hill 12 Enhanced services that the practice had performance, quality and 4 4 ability Welham Health Centre, they have not claimed, KMS to relook at all financial finances. Last Updated: 20 Feb reported back to the CCG elements 2020 that they are making a Latest Review Date: financial deficit and the Meeting to be held with KMS directors to 20 Feb 2020 contract may not be advise if they are in agreement with the 2 year extension to the contract Latest Review By: financially viable resulting in Janine Welham either a caretaker being Monthly meetings with KMS Directors to Last Review Comments: appointed or a list dispersal discuss finances, looking at areas that Risk reviewed for the CCG the practice can income generate also looking at workforce opportunities for an MDT model to decrease expenditure
Milton Pc 35 S2 - Online Consultations: Due to a lack of interest I = 2 L • Engagement events scheduled, with Dr I = 2 L Continue engagement with practices across MK Liz Holland 01 Apr I = 2 L Kenyes Access & Limited Uptake / Increased from practices with regard = 5 Hannan acting as advocate. = 4 Ensure uptake of 75% online consultations across 2020 = 4 Quality Demand and Workload to implementing the 10 • Re-launch attempts to gain interest / 8 BLMK by April 2020 8 Owner: Janine Welham Engage Consult system, practice visits scheduled where emphasis Risk Lead: Liz Holland there is a risk of limited is on benefits of system Last Updated: 01 Oct uptake leading to inability to • Care Navigation Training completed 2019 meet NHS E target of 75% • Comms plan & marketing materials in Latest Review Date: of patients having access place 10 Feb 2020 to online consultations by Latest Review By: March 2020 (noted that Liz Holland target introduced at outset Last Review Comments: of 2019). Funding bid successful for Correspondingly failure to Footfall, strategy to be implement an online decided with a view to consultation solution implementing in MK across all GP practices will practices with Engage result in an inequity of Consult service. At practice level there is the risk that the online consultation solution increases demand / workload through introducing another means of access rather than reducing / streamlining demand
Milton Pc 8 S1 - Unwarranted Variation in Month on month increase I = 4 L Monthly monitoring of GP initiated I = 4 L Standing agenda item on the practice visit Janine 31 Mar I = 4 L Kenyes H&W GP Referral Rates (CP32) in GP generated referrals = 3 referrals & Information to CDG on referral = 2 programme to discuss referrals and patterns Welham 2020 = 2 Outcom Owner: Alexia Stenning across Milton Keynes GP 12 trends by practice Practice Visits 8 8 es Risk Lead: Janine practices. discussions discussion with federation Welham about influencing at practice / cluster Last Updated: 03 level Sep 2019 Latest Review Date: 20 Feb 2020 Latest Review By: Janine Welham Last Review Comments: Risk reviewed
Milton Pc 34 S3 - Potential GMS Contract As a result of the ongoing I = 4 L Dr Manu agreement to go on the GMS as I = 3 L LMC Support ongoing for practice including Janine 31 Mar I = 3 L Kenyes Financi al Hand back issues with the premises = 4 an additional partner = 2 Practice Manager mentorship Welham 2020 = 2 Sustain Owner: Alexia Stenning owners at Hilltops and the 16 LMC working with the practice to obtain 6 6 ability Risk Lead: Janine resignation of the senior Practice Managerial support Welham partner, there may be Last Updated: 20 Feb potential that the GMS Senior Partner and practice manager 2020 contract my be handed attending the LMC Business Latest Review Date: back to the CCG with Fundamentals course 20 F b 2020 increased financial costs
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20 Feb 2020 increased financial costs Working with NHSPS to resolve the lease Latest Review By: for this contract of the building, draft sent over and an Janine Welham agreement from PCC to sign the letter of Last Review Comments: comfort required by NHSPS Risk Reveiwed Working with the practice on finances, previous premises owners and the LMC, along with procurement advice for potential procurement of the 17k list size
Milton Pc 18 S3 - Translation Services: Lack As a result of clinicians' I = 3 L • Benefits of telephone service I = 3 L I = 3 L Kenyes Financi al of Engagement / Change to and high user sites = 3 emphasized, with clear examples = 2 = 2 Sustain Clinicians' Behaviour declining engagement / 9 provided through engagement with 6 6 ability Owner: Janine Welham modification of usage due Fishermead Risk Lead: Liz Holland to their perception of the • Engagment events / meetings Last Updated: 01 Oct limitations of remote scheduled with provider 2019 translation etc. there is a Latest Review Date: risk that there will be no 10 Feb 2020 change to current Latest Review By: behaviour, resulting in no Liz Holland change to current spend Last Review Comments: Reduction in F2F seen with 13k saving YTD, work ongoing with high user practices
Milton Pc 6 To be Population Growth As a result of the housing I = 2 L Development of Brooklands development I = 2 L Building now commenced for the Whitehouse Build Janine 04 May I = 2 L Kenyes allocate d Owner: Alexia Stenning growth within MK and the = 3 utilising national transformation funding = 1 for the western expansion and funding is being Welham 2020 = 1 Risk Lead: increased list sizes at 6 (ETTF) and S106 monies 2 sourced from ETTF 2 Last Updated: 31 practices there may be May 2019 premises capacity Development of CMK remodelling through Latest Review Date: problems until new ETTF funding 31 May 2019 buildings have been extension of MKVP through S106 monies Latest Review By: completed along with GP Alexia Stenning workforce issues Implementation of MKCCG local estates Last Review Comments: strategy - key projects to carry out reviewed and dates altered planning to identify sustainable estates in line with current know solutions timescales
Luton PCC Failure of Luton Practice's Weaknesses I = 4 L = Joint Quality/Primary Care practice visits. I = 4 L = LMC resilience scheme to be launched. Focus on 2 delivering primary medical All practices are 3 Resilience scheme launched. Practice 2 strong practices supporting PCNs and Member care services as per independent contractors, 12 diagnostic assessments and support with 8 Practices to increase resilience, improve quality contractual requirements internal issues would not merger, where agreed. and reduce variation. be highlighted until matters The Primary Medical Care Information Person Responsible: Jennie Russell are at breaking point. Sharing Group has been setup to inform To be implemented by: 01 Jul 2020 Finite budget for delivering and proactively manage practices that are primary medical services. requiring support. This PMCISG includes Consequence Patient care interrupted, will require alternative arrangements. Financial strain on primary medical services budget. Luton PCC Insufficient resource and Weaknesses I = 4 L = Temporary agreement to include details I = 4 L = Review relevant resource within BLMK Primary 3 capacity to deliver Primary NHSE transfer of Full 3 of Primary care Contract Manager in 2 Care Contract team and local Primary Care Care Emergency Delegation has not included 12 action card for EPPR. 8 Development team. Preparedness, Resilience additional resource and Person Responsible: Paul Lindars and Response capacity for delivery. To be implemented by: 01 Jul 2020 Consequence Failure to respond timely and appropriately to an Luton PCC No access to NHSE Legal Weaknesses I = 4 L = On-going negotiations between BLMK I = 4 L = Obtaining written agreement from NHSE regarding 6 Team for Primary Care Access to NHSE legal 3 STP and NHSE to clarify access to legal 3 access to legal advice. Contracting team resource not included 12 advise - LCCG Accountable Officer been 12 Person Responsible: Paul Lindars within full delegation given confirmation from NHSE locality To be implemented by: 01 Jul 2020 transfer. Director to use the NHSE legal team for Lack of transparency and consistent message during transfer process. Consequence CCG will need to acquire Luton PCC Failure to Engage GPs to Weaknesses I = 4 L = BLMK Communications Strategy - I = 4 L = Further role out of video and e-consultations 7 Improve Primary Care GPs reluctance to tackle 4 highlighting services of the Primary Care 3 Person Responsible: Paul Lindars Access access issues raised by 16 Team. (My GP Practice is changing). 12 To be implemented by: 01 Jul 2020 patients Extended Access contract to deliver GPs do not engage with 100% of EA to Luton registered patients. Contract negotiations with extended access provider to offer innovative appointments, improved CCG to enable future Heavy focus on improving access and skill mix utilising digital enablers and improve % urgent and emergency care offering advice and expertise by working age appointment utilisation. strategy (same day with PCN PPGS (patient engagement, Person Responsible: Paul Lindars bookable primary care Implementation of the CCG Urgent and 01 Jul 2020 appointments available via.. Emergency Care Strategy - enabling a To be implemented by: Consequence system wide approach ensuring patients PCN's to develop collaborative arrangements to Poor patient access leads have access to same day bookable manage their access and appointments (including to increased urgent care appointments from their GP or via the same day appointments, telephone consultations reliance e.g. A&E, UGPC Urgent Primary Care Clinical Hub where and appointment triaging). and WIC attendances PCN ownership and delivery of Co- Person Responsible: Paul Lindars Poor patient experience ordinated Extended Hours service To be implemented by: 01 Jul 2020 and increased health PCN'S adopting PCH approach and new Continued workstreams to increase "Time for inequalities core Care" Poor results in National Paul Lindars Patient.. Practice access profiles developed for Person Responsible: identified practices to inform the PMCISG To be implemented by: 01 Jul 2020 Practice access profiles developed for identified practices to inform the Implementation of the CCG Urgent and Emergency PMCISG. This includes location and Care Strategy - enabling a system wide approach patient population (demographics) as well ensuring patients have access to same day as other indicators relating to the practice bookable appointments from their GP or via the access e.g. weighted activity usage for Urgent Treatment Centre where appropriate based Primary Medical Care Information on clinical need. Sharing Group (PMCISG) - a sub group Person Responsible: Paul Lindars of Primary Care Joint Commissioning To be implemented by: 01 Jul 2020 Committee. Quarterly review of all Proof of concept for group consultations. member practices against national Person Responsible: Paul Lindars primary care indicators including GP To be implemented by: 01 Jul 2020 patient survey results relating to GP access. Outlying practices identified with sub-group agreeing next actions, taking a collaborative approach to exploring solutions, sharing ideas and.. Where identified as a priority, visits and support offered to practices identified as outliers - escalating as deemed appropriate by the sub- group e.g. to Luton PCC Insufficient resource and Weaknesses I = 4 L = BLMK SRO identified to give Executive I = 4 L = Review functions to establish resource 8 capacity to deliver NHS Transfer of resources from 3 oversight and ownership 3 requirements for a BLMK wide Primary Care England delegated NHSE insufficient across 12 Joint working across ICS taking place to 12 Contracting Team. Ongoing progress update responsibilities BLMK allow for greater collaboration across reports provided to Executive Team. Lack of senior capability/ Person Responsible: Paul Lindars NHS E consultation and subsequent capacity within the 01 Jul 2020 recruitment to Primary Care contracts To be implemented by: contracting team. role including senior team member. Consequence Direct resource implication on the primary care development team May not meet delegated ibiliti M t
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CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Services (Corporate)
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton CS 10 S3 - CSU limited resource As a result of the CSU I = 3 L - Regular service delivery meetings I = 3 L Continue with monthly meetings and react Emma 30 Sep I = 3 L Kenyes Financi al creating instability in winning increased = 3 - Ensure monthly contract performance = 3 accordingly to situations as they arise Richards 2020 = 1 Sustain service provision business, the AGEM 9 meetings 9 3 ability Owner: Alison Joyner resources are being - Completion of monthly AGEM service Risk Lead: Emma stretched resulting in a scorecard Richards noticeable impact on Discussions underway regarding renewal Last Updated: 05 Jun service delivery/escalation of CSU contract from April 2020 2020 routes for some/varying Latest Review Date: CCG services at differing 05 Jun 2020 times. Latest Review By: Alison Joyner Last Review Comments: Updated by A Joyner
Milton CS 16 S2 - Corporate Governance Under the requirement for I = 3 L - Closse working across 3 CCGs I = 3 L - Clarify and meet with executive lead Emma 30 Jun I = 2 L Kenyes Access & Owner: Alison Joyner greater collaborative = 3 - REgular Governance meetings = 3 - Ensure close working with the new CCG Richards 2020 = 3 Quality Risk Lead: Emma working the 3 CCGs are 9 - Appointment of a Governance BLMK 9 Governance Lead across 3 CCGs 6 Richards reviewing and identifying Lead - Establish regular governance meetings inviting Last Updated: 04 Jun opportunities for aligned - Communications / consultations to appropriate staff as required 2020 governance. There is a risk wider BLMK staff on changes to Latest Review Date: that as work progresses Governance 04 Jun 2020 and becomes more - Communications to wider Executive Latest Review By: complex clarity of vision team re progress of work Alison Joyner and direction could be lost Last Review Comments: leading to a delay in Action updated completion of aligned governance which may impact operations and decision-making.
Milton CS 17 S2 - Ageing telephony system The telephony system I = 3 L - Review options for the CCG I = 3 L Implement system upgrade as specified in order Emma 29 May I = 2 L Kenyes Access & Owner: Wendy Rowlands within the CCG is currently = 3 - Closely monitor the system with the = 3 placed with Intralan. System purchased and Richards 2020 = 1 Quality Risk Lead: Emma 10+ years old and is no 9 support of the CCG telephony providers 9 instore. Implementation delayed due to Covid-19. 2 Richards longer supported by the - Ensure approved contingency plans are Last Updated: 31 provider. BT will also not in place should the system fail Dec 2019 accept requests for new ISDN systems or their Latest Review Date: An order has been placed for a system 09 Jun 2020 parts from 2020. There is upgrade following switch failures in Latest Review By: a risk that the system could fail impacting on the December. The new IM&T provider will Emma Richards support the implementation. Last Review Comments: operability of the CCG. Switches now replaced. Equipment purchased and in storage System is in process of (Deployment delayed due to Covid-19) being upgraded to VOIP. New IT provider is New IT provider is engaged in the supporting the transition. process and is advising on the procurement
Milton CS 18 S2 - AGEM CSU Contract The contract between I = 3 L - Monthly contract meetings I = 3 L I = 3 L Kenyes Access & unsigned AGEM CSU and the CCG = 4 - Regular communication = 3 = 3 Quality Owner: Alison Joyner expired on 31/03./2019. 12 - Assurance that existing terms and 9 9 Risk Lead: Emma The controls will continue until new contract Richards CCG Board approved an signed Last Updated: 04 Jun extension for a period of 12 Consider Do, Share, Buy options 2020 months, however a lack of Latest Review Date: agreement regarding the 04 Jun 2020 overall contracat value Latest Review By: means the contract for Alison Joyner 19/20 has not been Last Review Comments: finalised, placing the CCG Updated Action. Propose at an operational risk. closure of this risk
Milton CS 20 S2 - In housing of IM&T service As a result of decision to I = 3 L Business Case submitted to NHSE for I = 3 L Revised action plan to be agreed for full transition Wendy 30 Jun I = 3 L Kenyes Access & Owner: Wendy Rowlands inhouse IM&T services = 3 approval = 3 of infrastructure to new service by 30 June Rowlands 2020 = 2 Quality Risk Lead: Wendy from April 2020 there is a 9 Project plan in place with weekly 9 6 Rowlands risk that the transition plan teleconference cannot be completed in Last Updated: 16 Service has transitioned to HBL from 1st timescales. Dec 2019 April, although due to Covid-19 Resulting in additional Latest Review Date: underlying infrastructure remains costs for contract 19 May 2020 subcontracted to AGEM CSU. extensions and risk to Latest Review By: HBL have MOU with AGEM so that tasks provision of IM&T services Wendy Rowlands & responsibilities are clearly defined Last Review Comments: No changes
Milton CS 6 S3 - Corporate Services With a challenging I = 3 L - Regular communication in ways of I = 3 L Ensure through Tier 2 & 3 appropriate capacity & Alison 30 Sep I = 3 L Kenyes Financi al Capacity recurrent financial position = 4 working and knowledge of onsite = 3 capability for corporate services is in place. Joyner 2020 = 3 Sustain Owner: Alison Joyner of the CCG, there is a risk 12 operations. 9 9 ability Risk Lead: Emma that any requirement to - Communication. Richards deliver increased corporate - Unified workplan for collaborative work Last Updated: 05 Jun services tasks as a result areas 2020 of the commissioning - Clarity of Corporate Services Latest Review Date: collaborative alignment responsibilities in the 'new world' 05 Jun 2020 cannot be achieved with Latest Review By: the current capacity, thus Alison Joyner creating a gap. Local Last Review Comments: resource is being Updated by A Joyner diminished through wider working.
Milton CS 14 S2 - Risk to implementation of Red Centric BLMK's new I = 3 L Double running of access to ensure a I = 3 L Orders places and rollout to 25 practices Wendy 30 Jun I = 2 L Kenyes Access & the HSCN network provider taking over from = 3 smooth network transition, from one = 3 underway. Programme slowed due to Covid-19. Rowlands 2020 = 2 Quality replacement NHS Digital 9 provider to the next. AGEM reviewing all 9 Just a handful of practices now outstanding from c. 4 Owner: Wendy Rowlands -N3 have identified issues sites to identify which can double run. 30 sites Risk Lead: Wendy which are causing delays Rowlands to the transition timeframe Project manager in AGEM working Last Updated: 19 to the new network, directly with Red Centric with a joint Sep 2019 resulting in a delay in project plan, bi-weekly meetings with the Latest Review Date: benefit of the new CCG to monitor progress. 19 May 2020 faster/safer network and Supplier to test transfer to HSCN at MK Latest Review By: the potential increased Wendy Rowlands costs of implementation. Village Practice site was successful, now rolling out to other practices. 25 more Last Review Comments: practices (28ish sites) Action updated
Milton CS 3 S3 - Retention and development Significant transformational I = 4 L - Regular and transparent I = 3 L AGEM to provide on-going support for Tier 2 & 3 Emma 01 Sep I = 3 L Kenyes Financi al of CCG workforce change and requirements = 3 communications re alignment work = 3 organisational change, including OD package. Richards 2020 = 3 Sustain Owner: Alison Joyner on the CCG to work in a 12 - Identification of skill sets internally 9 9 ability Risk Lead: Emma more aligned way across amongst staff & sharing of training and Richards the Commissioning development opportunities Last Updated: 05 Jun Collaborative may lead to a - Transparency on vacancies. 2020 stalling in work around - Robust recruitment processes Latest Review Date: retention and development 05 J 2020 of the CCG workforce
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05 Jun 2020 of the CCG workforce Latest Review By: leading to workforce Alison Joyner unease Last Review Comments: Risk updated by A Joyner
Milton CS 19 S2 - Primary Care Clinical NHS Digital contracts were I = 4 L Mark Peedle is leading on this I = 4 L Mark Peedle to set up a programme of work to Wendy 30 Jun I = 4 L Kenyes Access & System procurement due to come to an end in = 3 procurement for BLMK CCGs and = 2 procure new GP System as a BLMK procurement. Rowlands 2020 = 1 Quality Owner: Wendy Rowlands December 2019 and CCGs 12 keeping the IM&T Strategy group 8 (Action paused due to Covid-19) 4 Risk Lead: Wendy required to reprocure GP appraised regularly Rowlands clinical systems. However NHS Digital have extended current Last Updated: 25 Oct a one year extension has contracts for a further 12 months 2019 been agreed due to national Latest Review Date: delays in setting up the NHS digital have released a new 19 May 2020 procurement framework framework for procurement Latest Review By: and releasing guidance the Wendy Rowlands CCG may not have Last Review Comments: sufficient time to procure a No change new contract leading to the General Practices being out of contract for their clinical systems which may lead to lack of updates & system support, leading to failure of clinical systems. In addition there is a risk through this procurement that individual practices could chose different suppliers which could lead to a lack of interoperability between systems.
Luton Corp Data Privacy Impact Weaknesses I = 3 L = Communication sent to all staff advising I = 3 L = Person Responsible: To be implemented by: 27 Assessments may not be As a result of staff not 3 of the need to complete a DPIA at the 2 completed completing DPIAs for new 9 beginning of new project or the 6 projects or databases introduction of a database. Consequence Meeting held with PMO advising of PIA there is a risk patient confidential, sensitive and high risk data is not handled appropriately e.g Luton Corp Health and Social Care Act Weaknesses I = 3 L = Staff undertake mandatory annual IG I = 3 L = Person Responsible: To be implemented by: 28 2012 Staff may inadvertently 3 training Staff receive communication from 1 receive, handle and 9 IG regarding how to handle and process 3 process patient confidential patient confidential data. data in breach of the Health and Social Care Act 2012. Consequence Resulting in a fine or Luton Corp Information Assets Weaknesses I = 3 L = IG team to deliver information asset I = 3 L = Person Responsible: To be implemented by: 29 As a result of information 3 training to IAOs/IAAs. Training will outline 2 asset owners not 9 the role of an IAO and how to record 6 identifying, recording and risk assessing their assets appropriately. Consequence Luton Corp DSP toolkit Weaknesses I = 4 L = Person Responsible: To be implemented by: 30 As a result of the new DSP 2 toolkit moving from an 8 information governance focus to a more data and cyber security toolkit there is a risk HBLIT evidence may not be of sufficient standard. Consequence Resulting in the CCG Luton EPRR System Wide Business Weaknesses I = 4 L = BCCG BIAs audited and no substansive I = 4 L = To review structure and capacity of EPRR across 2 Continuity Plans may not There is not currently the 3 risk identified, focus to turn to Luton 2 the STP footprint to increase business continuity be robust capacity in the system to 12 primary care BIAs for review 8 capacity. review and test the Business Continuity Plans requested as Person Responsible: Mark Meekins business continuity plans in part of procurement process. To be implemented by: 31 May 2019 primary care and provider Commissioning Support Unit closely organisations . monitor contractual obligations with This may lead to a failure in Providers in the Luton system. the provision of an.. The need for Business Continuity Plans Consequence highlighted in contracts. Luton EPRR CCG NO deal Brexit Weaknesses I = 3 L = Person Responsible: To be implemented by: 5 Implications Issues with: 3 Medication and 9 consumables entering the UK Three quarters of all medications have a touch point in Europe. Half of all medical devices and consumables have a touch point in.. Consequence higher capacity within the h lth t i Luton EPRR National fuel plan not being Weaknesses I = 4 L = The Chair of the LRF has raised theory I = 4 L = Should there be a fuel shortage, the CCG and the 8 fit for purpose As a result of the national 3 concerns nationally, and have requested 2 LRF would create a workaround, as directed fuel plan not being fit for 12 confirmation with regards to resolution 8 nationally purpose, there is a risk that **ON HOLD** Person Responsible: Mark Meekins there will not be any To be implemented by: 01 Aug 2019 mechanism to activate the local fuel plan, should there be a fuel crisis or shortage Consequence There will not be any mechanism to activate the local fuel plan
Luton EPRR Brexit deadline Weaknesses I = 3 L = Head of EPRR to maintain planning, and I = 3 L = Outputs from workshop to be collated into a post 9 As a result of the Brexit 2 ensure EXEC and Board are copied into 2 exercise report and shared with partners deadline being extended, 6 relevant updates 6 Person Responsible: Mark Meekins there is a risk that internal **ON HOLD** To be implemented by: 01 Aug 2019 momentum might be lost within the organisation Consequence Internal momentum might be lost within the organisation
Luton EPRR Brexit No Deal Scenario Weaknesses I = 3 L = Person Responsible: To be implemented by: 10 (Workforce) As a result of a Brexit "no 4 deal" scenario there is a 12 risk of impact upon current workforce and future workforce. Consequence Risk of leaving, uncertainty of status in the UK, desire to work outside EU, barriers to employment and residency
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CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Luton EPRR Brexit No Deal Scenario Weaknesses I = 3 L = Person Responsible: To be implemented by: 11 (Medication) As a result of a Brexit "no 4 deal" scenario there is a 12 risk of impact upon supply of medication into UK from international pharmaceutical organisations based in the EU Consequence
Luton EPRR Brexit No Deal Scenario Weaknesses I = 3 L = Person Responsible: To be implemented by: 12 (Markets) As a result of a Brexit "no 4 deal" scenario there is a 12 risk of EU markets becoming more attractive to international suppliers than dealing with complexity of UK trade once UK is outside of the EU. Consequence Luton EPRR Brexit No Deal Scenario Weaknesses I = 3 L = Person Responsible: To be implemented by: 13 (Prices) As a result of a Brexit "no 4 deal" scenario there is a 12 risk of the impact on workforce, medicine and general supply of goods resulting in increase of prices to NHS suppliers/providers, leading to.. Consequence
Luton Gov 1 Failure to Manage Conflicts Weaknesses I = 4 L = Conflict of Interest Committee in place to I = 4 L = To increase the level of compliance with conflict of of Interest Manual system to manage 3 review key procurements and any issues 2 interest training. conflicts of interest 12 arising from commissioning processes 8 Person Responsible: Angela Duce High risks due to the Declaration of interests a standing To be implemented by: 31 Mar 2020 nature of commissioning agenda item at every Board and sub Clinicians often have dual The conflict of interest register is roles People do not always regularly updated and published on the recognise their conflicts website on a twelve monthly basis. Consequence Difficult to keep track of whether conflicts are in date Changes may not be notified Risk of reputational damage Luton Gov 2 There is a risk of fraudulent Weaknesses I = 4 L = Conflict of Interest Policy is in place and I = 4 L = Person Responsible: To be implemented by: activity Consequence 3 robustly implemented. 2 Impact on reputation and 12 Effective implementation of procurement 8 financial health of the CCG. policy Local Counter Fraud Specialist regularly reviews the robustness of arrangements Travel expenses policy is in place
Luton ICT ICT10 Risk of Cyber Attack Weaknesses I = 4 L = Industry standard practice - firewalls, I = 4 L = Implementation of action plan as per HBL ICT High 23 causing loss of data Risk of cyber attack 4 intrusion prevention systems, web 3 Risk register. breaching the CCG's 16 filtering, network access control and Anti- 12 Person Responsible: Rose Francis system may lead to loss of Virus/Malware solutions in place as part To be implemented by: 31 Mar 2018 data or the environment. Penetration tests undertaken periodically Consequence to ensure compliance Security Policy, Email and Internet, Mobile Device Policy in place Luton ICT ICT08 Tracking of assets Weaknesses I = 4 L = Current system in place but will be I = 4 L = 14/05 - ITSM Tool & Process to be developed in 24 and physical removal and Reputational 2 replaced with an integrated solution within 2 line with timescales as defined in the project plan disposal Damage/Financial Damage 8 ITSM tool when procured 8 to replace Remedy. Consequence 09/07 - Revised the contractual arrangement with Greenworld for asset disposal. SNOW being used for software asset management. 01/10 Snow continues to be used to report for customers. 10/12 - Asset reports have been produced and are available to be reviewed by LCCG on a regular basis Person Responsible: Simon Carey To be implemented by: 31 Dec 2015
Clarification on whether SNOW will continue to be used as management tool for tracking customer assets and disposals Person Responsible: Rose Francis To be implemented by: 31 May 2017 Luton ICT Risk of ICT failure for Luton Weaknesses I = 5 L = ICT services are outsourced to HBL ICT I = 5 L = Person Responsible: To be implemented by: 27 CCG There is a risk of major ICT 3 who manage the risks through the High 2 failure which may impact 15 10 on the ability of the CCG to carry out its functions. Consequence
Luton IG 1 Staff breach information Weaknesses I = 4 L = All staff are required to undertake IG I = 4 L = Person Responsible: To be implemented by: governance guidelines Staff may leave electronic 3 refresher training on an annual basis. 2 and manual records 12 IG team undertake regular IG spot 8 unattended and unsecured checks within the CCG. i.e. pcs, print outs Robust IG policies are in place and are Consequence available on the staff intranet. Unauthorised access to The CCG completes an annual IG DSP patient/confidential data online Toolkit which is submitted to NHS Reputation damage to the digital for sign off. Trust Financial penalty
Luton VA 5 Exposure of Person Weaknesses I = 2 L = Staff are instructed to double check any I = 2 L = Person Responsible: To be implemented by: Identifiable Data External mailing systems, 2 documentation that contains patient 1 e.g., Royal Mail, post going 4 identifiable data prior to sending outside 2 missing of NHS Luton Manager checks Clerical error paperwork that is presented for external Staff not preparing delivery data/information Staff were instructed to ensure methodically appropriate mandatory training is Staff not paying enough attention to documents that contain person.. Consequence Possible loss of confidence in the NHS NHS Luton may be exposed to negative publicity Data being misplaced/misfiled Information sent to/viewed by person(s) to whom the data is not..
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Luton VA 15 CES - Risks to patient Weaknesses I = 2 L = Bag is kept in a locked filing cabinet; I = 2 L = Person Responsible: To be implemented by: confidentiality Concerns around 3 Each bag has a new seal for every 2 robustness of tamper 6 transport of data; 4 evident bag; Data is transported directly from office to Potential to send to the Millbrook depot; incorrect fax number Office is kept locked at all times when (human error). unoccupied; Consequence Tamper evident bag is put in another bag Release of patient so as not to draw attention to it Established that fax number used is a identifiable information; dedicated safe haven. Reputational damage; Loss of confidence in i I t t f STP / ICS
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Milton 39 S3 - Impact of ICS wide Alignment of local MK I = 3 L Robust ICS Governance processes in Membership of STP I = 3 L I = 2 L Kenyes Financi al strategic priorities on transformational priorities & = 3 place Comprehensive involvement of steering group at highest = 2 = 2 Sustain successful delivery of local delivery of system wide 9 local stakeholders in development of MK level Membership of 6 4 ability schemes (ST101) savings initiatives with the LTP response specific programme boards Owner: Richard Alsop delivery of BLMK ICS new Close alignment between local priorities / (local or STP) Minutes from Risk Lead: Alison Joyner models of care priorities ambition and ICS LTP response which all relevant meetings Single Last Updated: 05 Jun may result in a loss of has now been agreed. Local Place Plan System Operating Plan for 2020 momentum for the delivery developed and now agreed via HWB to STP now approved with Latest Review Date: of existing local schemes. ensure convergence. clear priorities across 05 Jun 2020 Long Term Planning response process BLMK and mapping for Latest Review By: and local involvement underway. local priorities fit with this. Alison Joyner Overseen by Integration Board and Last Review Comments: regular updates giving to CCG Board on Risk updated by A Joyner progress.
Luton BAF 1 There is a risk that there Weaknesses I = 5 L = Bedfordshire, Luton and Milton Keynes I = 5 L = Increase joint working across the three CCGs will be insufficient Recruitment of GPs into 4 Commissioning Collaborative established 2 within the STP Footprint in order to maximise workforce capacity across Luton Recruitment of 20 with Executive Team working across the 10 capability and capacity. the Luton System to deliver Practice Nurses Small Collaborative working though the STP Person Responsible: Patricia Davies the priorities of the both the team within the CCG Priority 2 Transformation Boards to To be implemented by: 31 Dec 2019 Integrated Care System Retention of staff improve capacity across the system and the Integration with Consequence Luton CCG and Luton Borough Council Luton Borough Council Shortage of GPs to deliver co- located and integrated working to the changes Retention of avoid duplication. staff who feel under NEL CSU appointed for the functions of pressure Contract Management, Performance and Unable to deliver at pace Business Intelligence New Medical Director working across three CCGs and Executive Lead for Primary Care Workforce, strengthening links with Health Education England OD plan, staff meetings, PDP's for all staff in place. Training, development, appraisal process in place along with talent mapping matched to the objectives Permanent appointments to the Board, Executive and within teams in the CCG to ensure the required longer term capacity and capability to deliver the CCG business professionally and consistently. Luton BAF 2 There is a risk of Weaknesses I = 4 L = Bespoke clinical leadership for priority I = 4 L = Person Responsible: To be implemented by: insufficient engagement Primary Care and Patients 3 areas and programmes throughout the 2 and ownership in the may not believe in the 12 Executive and Clinical Board Directors 8 system vision leading to vision alignment to PCNs resistence to change which GPs feel overburdened Focused agenda at PLT and Member's may delay or prevent the Acute sector do not own Forum progress of transformation. the issue Luton engagement in the STP to provide Consequence the shared vision Poor outcomes for the population Pace and scale PCN chairs meetings with Clinical not achieved Directors to ensure engagement Acute sector Primary Care Investment Scheme to overperformance - eating support Practice Clusters to drive change into scarce resources and strategy delivery. Commissioning plans not Work with LMC liaison committee to achieved ensure that the CCG is working within the GP l l f k Luton BAF 3 Individuals and Weaknesses I = 4 L = Commissioned Cambridge Community I = 4 L = Person Responsible: To be implemented by: organisations resist Primary, Community and 3 Services to be coordinating provider for 2 integration, continuing to Social Care do not have 12 Luton'A H Primary, Fi ' Community and Social 8 work to internal strategies effective relationships Poor Care Transformation Board to ensure rather than the system- commitment to integration Utilise the agreed outcomes of the ICS wide vision. Acute sector continues to CEO's group and Individual Workstreams work to own strategy Consequence Unnecessary admissions to acute for some patients High number of short stay admissions CCG finances strained due to acute sector over performance Luton BC 24 Risk that stateholders may Weaknesses I = 4 L = Engaging stakeholders during the I = 4 L = Person Responsible: To be implemented by: not engage and understand Poor communication. 4 planning stage of project 2 the transformation Benefits may not be 16 Strong communication plan assigned to 8 adequately explained. the project or scheme Consequence Public buy-in to plans and local confidence will be reduced. Public need will not be fully understood and taken into Urgent & Emergency Care
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by Milton UC 8 S2 - The delivery of safe and Increased admissions of I = 5 L "Warm Up For Winter" scheme focused I = 3 L To support the Trust's Length of Stay, LOS, Board Jan Wood 30 Apr I = 3 L Kenyes Access & effective urgent care in MK patients with complex = 4 on improving flow and "re = 3 to reduce LOS and flow patients through their 2020 = 2 Quality is compromised by an problems or increase in 20 -setting" the hospital commenced 7 Nov 9 acute stay. There is an active Task & Finish 6 inability to 'flow' patients complexity of presenting Continued focus on 4 hour standard Ensure continued agenda concentrating on stranded and through the system and conditions, there s a risk through both Operational Contract contractual focus and that superstranded pateints. It has 12 key workstreams discharge quickly after their that their discharge Meetings and Strategic Contract Review proposed national including TTOs, diagnostic requesting, use of the acute treatment. (UC31): arrangements may be of meetings as part of the regular changes to 4 hour standard PDU etc. Linked Sub risk of T5 sufficiently complex nature "Performance (Service Quality are appropriately reflected. Owner: Richard Alsop to create delays, resulting Performance Report)" agenda item. in reduced flow and increased excess bed day Risk Lead: Jan Wood costs Ensure that the contract with the acute Last Updated: 29 Apr trust includes Discharge and Choice 2019 Policies
Latest Review Date: Getting People Home Programme 02 Mar 2020 includes the Discharge to Assess project. Latest Review By: D2A is early supported discharge as Jan Wood soon as the patient is medically Last Review Comments: manageable in the community. This has No change. Problem is with been rolling out since Oct 2016. intra ward LOS as
Page 22 of 26
BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target
/context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
intra-ward LOS, as Optimise Clinical streaming away from MC attending streaming decompensation occurs ED reducing demand and supporting meetings between MKUCS through increased stay, performance against the 4 hour standard. and MKUHFT. leading to increased On-going liaison with MKUHFT and Ensure focus is maintained demand on community MKUCS to improve the pathway and at A&E Delivery Board services and MKC: increase numbers streamed away. significant demand for Number streamed away from ED are double handed care monitored as part of the monthly A&E resulting in depletion of Delivery Board Dashboard. capacity in the community
The Trust has set up a Length of Overall responsibility Stay, LOS, Board to drive the for Trust Contract reduction of the numbers of stranded and super-stranded patients. It has 12 workstreams focussing on ward and process activities that are causing extended LOS. It meets two weekly and is chaired by the Medical Director. Therapy team within A&E department is in place as business as usual function. This enables a return to home supported by appropriate servcies rather than an admission This also results in fewer care home placements in the longer term, hereby freeing capacity downstream in the system Milton AEU S2 - Consistent leadership / As a result of workforce I = 4 L Skills for health funding in place to Mary Tagon is working with I = 4 L Work has commenced across the STP to develop Paul Hayes 30 Mar I = 4 L Kenyes ccp 2 Access & engagement in the capacity in the care home = 2 support care home leadership MKC and the Care Home = 2 a BLMK strategy for the recruitment and retention 2020 = 2 Quality programme may be a market being stretched, 8 collaborative Managers on this. 8 of care staff over the next decade. 8 challenge consistent leadership / This work is on-going at a system through a series Owner: Jill Wilkinson engagement in the of BLMK workshops and meetings. Work will Risk Lead: Mark Cox programme may be a continue throughout 2019 / 2020. challenge. This could impact on the programmes Last Updated: 04 Jun ability to implement 2020 effective, sustainable Latest Review Date: change. 28 Oct 2019 Latest Review By: Paul Hayes Last Review Comments: Risk reviewed
Milton UC 2 S2 - Failure to achieve 4hr A&E Failure to achieve 4hr A&E I = 3 L 2 new ED consultants have been I = 2 L Since August, some increase in demand for Steve 31 Mar I = 2 L Kenyes Access & wait target wait target due to increased = 4 recruited. Start dates anticipate to be in = 4 MKCCG activity. This is being monitored. Gutteridg e 2020 = 4 Quality Owner: Richard Alsop demand with insufficient 12 Q4 19/20. 8 8 Risk Lead: Mark Cox secondary care capacity 4 hour performance forms part of the Last Updated: 29 Apr monthly A&E Delivery Board dashboard 2019 which is reviewed by senior stakeholders monthly. Latest Review Date: 4 hour performance forms part of the 02 Jan 2020 Performance Dashboard as reviewed at Latest Review By: each monthly Operational Contract Mark Cox Review Meeting (OCRM). Last Review Comments: NB Performance against the 4 hour 02/01/20 Though standard is now monitored via the Joint performance has been Finance Group has replaced the OCRM. challenged, for month Nov 19, MK remain in the top New RN's starting in Q4 19/20. However, quartile nationally. Nurse recruitment ongoing to address current vacancies.
Luton UEC Town Centre Surgery Weaknesses I = 5 L = Escalation of premises issues to Propco 40 Premises The current premises 3 Person Responsible: Caroline Capell provides GP services to 15 To be implemented by: 30 Aug 2019 over 11,500 patients, Urgent Treatment Centre (including walk in and direct bookings 8am-8pm) and Out of Hours service (8pm to Midnight and all weekend).. Consequence The premises provides UTC, Out of Hours and GP Workforce i Sh ld h
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by Luton BAF 7 The CCG may be unable to Weaknesses I = 4 L = BLMK Commissioning Collaborative I = 4 L = Implementation of improved staff/clinician recruit and retain staff and Succession planning 3 provides resilience at individual CCG 2 engagement programme of work clinical leaders with the across the system 12 level, with a shared recruitment review 8 Person Responsible: Sarah Frisby right skills and abilities to Competing with larger Engagement with staff through staff To be implemented by: 15 May 2019 deliver the system- wide CCG's with better benefits meetings and annual staff survey strategy. Integration programme Robust system of performance Implementation of HR/ODL Strategy demanding capacity management and development in place to Person Responsible: Nicky Poulain Small pool of clinicians identify talent and map gaps in knowledge To be implemented by: 30 Sep 2019 Consequence th i ti Staff Involvement Group (SIG) is in place High turnover of staff slows to ensure engagement will staff down progress Small teams so cannot Workforce strategy developed with achieve the pace and scale shared service provider Knowledge management
Luton BAF There is a risk that Weaknesses I = 4 L = Engagement with local Healthwatch I = 4 L = Monthly team meetings in place to review 32 providers’ provision may of Consequence 3 3 combined analysis of service provision and quality poor quality due to 12 Ongoing contract and performance 12 delivery. Escalation from this meeting as workforce, or capacity reviews appropriate to Quality Committee and risk register problems which could lead Anne Murray The review and learning from serious Person Responsible: to poorer outcomes. incidents To be implemented by: 03 Mar 2021 Visits to providers to gain assurance of Local Quality team monthly operational meeting to quality and safety flag and concerns or increase focus on service delivery Person Responsible: Anne Murray To be implemented by: 03 Mar 2021 Luton BC 20 Workforce and Weaknesses I = 4 L = Appraisal & supervsion with Line I = 4 L = Person Responsible: To be implemented by: Management capacity and Difficulty recruiting and 3 Management 2 capability may be retaining staff; Skilled 12 BCF Business Case evidences the 8 insufficient to deliver the people not attracted to organisational capacity to manage & programme Luton as a place to work; HR Recruitment process Additional pressures of working in a system Project Leads provide highlight reports, undergoing transformation; detailing risks & issues against attrition & Uncertainty over future.. recruitment, highlighting any impact on Consequence the delivery of the project. Increased pressure and Project Management Framework is in demands on exisiting place services and workforce;
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BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by services and workforce; Individual projects may be delayed, stall or may have to close; Targets for delivery may not be met at pace; May not retain.. Luton BC 23 Risk that Luton providers Weaknesses I = 4 L = Clear communication plans provided and I = 4 L = Joint Corporate Directors, Accountable officers, and internal work force may Difficulty recruiting and 4 in agreement with service directors and 2 Associate Directors, Finance, Council portfolio not engage with the retaining staff. Skilled 16 project management team. 8 holders attend JSCG & HWB Board, ensuring at required changes people not attracted to Joint Corporate Directors, Accountable place wide engagement. Wider engagement is Luton as a place to work. officers, Associate Directors, Finance, disseminated from the two boards. Project Additional pressures of Council portfolio holders attend JSCG & managers to provide assurance that ensure full working in a system HWB Board, ensuring at place wide stakeholder engagement is core to the plan undergoing transformation. engagement. Wider engagement is Person Responsible: Kate Sutherland Uncertainty over funding. disseminated from the two boards. To be implemented by: 30 Jun 2020 Consequence MonthlyP j t highlight reports t to id the Increased pressures and Programme Manager, highlighting risks demands on existing and issues against the project. services and workforce. Individual projects may be Project Managers use the escalation delayed, stalled or may process if the project is at risk. have to close. Targets for delivery may not be met at pace and may not retain..
Luton Corp ESR Management of staff Weaknesses I = 3 L = Person Responsible: To be implemented by: 26 sick absence As a result of staff not 3 understanding or using the 9 ESR sick absence management module Consequence There is a risk of return to work forms and fitness to work forms containing patient identifiable and sensitive data not being handled and processed correctly. Planned Care, Community and Commissioned Services
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by Luton Derm Telederm project may be Weaknesses I = 3 L = Clinical Director and Project Support I = 3 L = To continue to make contact with the LDH to get 1 unable to get clinical input Relationships not yet 3 Manager working closely. 2 clinical involvement. from LDH in a timely developed with potential 9 6 Person Responsible: Lorraine Kavanagh manner provider. To be implemented by: 29 Jun 2018 Project in early stages. Service Spec not yet in place. Consequence Stall commencement of the Luton Derm Telederm Pilot does not Weaknesses I = 2 L = Build good links with clinicians. Set up I = 2 L = Agree clinical referral criteria 2 realise the required savings Criteria for referrals (to be 3 clear referral criteria. 2 Person Responsible: Lorraine Kavanagh decided) 6 Clear guidance on using system/service 4 To be implemented by: 31 Jul 2018 Consequence provided to GPs. Dermatology referrals continue to increase with a large number of Luton MO Opioids prescribing in long Weaknesses I = 3 L = Pilot in large practice revewing patients I = 3 L = Person Responsible: To be implemented by: 30 term pain We already have an 3 on 120mg morphine. CGL and L&D Pain 3 existing problem within 9 team seeing patients as part of a joint 9 Luton in reference to high review. If successful these clinics will be levels of inappropriate There is information widely available in prescribing of prescription the public domain in reference to: a) lack opioids in chronic (non- of evidence base for opioid prescribing in cancer) pain. This problem long term (non cancer) pain and b) the is not localised to Luton.. risk of patient harm and adverse effects. Consequence This issue has had more awareness Although, the risk of raised though national organisations such adverse effects of those as NICE (listed as a key therapeutic area on long term opioids is well f di i ti i ti ) d f lt f Luton MO Complex Paediatrics - Lack Weaknessesk th i l ik I = 3 L = Medicines Optimisation pharmacist for I = 3 L = Person Responsible: To be implemented by: 31 of integration between The medicines optimisation 4 complex paeds presently focussing in one 3 different healthcare settings complex paediatrics QIPP 12 GP practice with high complex paediatric 9 in respect to medication has identified significant weaknesses in the way medicines are managed in this high risk patient cohort. A number of healthcare services provide.. Consequence Medicines safety is a risk; medicines are not Luton MO Response to Care Homes Weaknessest t d/ t d I = 3 L = Person Responsible: To be implemented by: 33 During Covid 19 Pandemic Timely provision of end of 2 life medicines to care 6 homes. Consequence Patients dying in discomfort, distress for Luton PCD Management of extended Weaknesses I = 2 L = Expert procurement advice and guidance I = 2 L = New Specifications to be added to new contracts 69 primary care contracts Poorly managed contracts 4 from Attain. 2 Person Responsible: Paul Lindars will inevitably lead to a 8 Primary care team to lead on approval 4 To be implemented by: 01 Jul 2020 similar situation we had process including: receiving activity data, with previous LESs in that data validation and payment process. Write to practices to confirm: - Continuation of HMG, Minor Surgery activity and quality data will Reviewed the need for primary care - Continuation , and new providers, for phlebotomy not be utilized to full effect - extended services in line with future and gynaecology with a lack of information.. community and primary care contracts. Consequence Proposal has been agreed by F&P and Person Responsible: Paul Lindars Lack of enhanced services To be implemented by: 01 Jul 2020 would shift activity onto Small Task and Finish Group to be convened for acute services which would March to review current situation and next actions lead to higher costs. Person Responsible: Paul Lindars Practices not remunerated To be implemented by: 01 Jul 2020 in a timely way and may lead to disengagement. To review existing enhanced services and determine next steps contract continuation/extension. Person Responsible: Paul Lindars To be implemented by: 01 Jul 2020 Service Specifications to be updated Person Responsible: Paul Lindars To be implemented by: 01 Jul 2020
Luton PCD Failure to implement GP Weaknesses I = 1 L = Recruited PC Team Manager with focus I = 1 L = Person Responsible: To be implemented by: 71 Forward View requirements Insufficient capacity within 3 on recruitment / training 3 / recommendations PCD Team Lack of 3 Workforce recruitment, training and 3 Practice engagement retention programme in place across Consequence BLMK training hub to support delivery. Current workforce 10 additional nurse who have completed unsustainable within training have all now been employed General Practice with low across BLMK levels of recruitment and retention Luton Plann A lack of capacity in the Weaknesses I = 4 L = All projects and programmes have action I = 4 L = Monitor workload of current staff and ensure staff ed 22 Commissioning Team may Planned care has a small 4 plans in place to control the workload for 2 wellbeing reduce potential for workforce to cover a large 16 individual team members 8 Person Responsible: Amanda Flower
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BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
integrated working. portfolio Deep Dives into Planned Care Schemes To be implemented by: 31 Mar 2018 Lack of shared scheduled for Financial Recovery Group responsibility across the Meetings in line with the business cycle Recruit additional capacity to support work programme and integration with LBC as required. CCG/LBC Highlight reports completed for key CCG has a heavy agenda projects to inform team meetings and Person Responsible: Amanda Flower To be implemented by: 31 Mar 2018 for transforming Number of joint posts across planned, commissioning unplanned team. Matrix working in place. Consequence Team fully recruited to. Commissioning strategy and intentions may not deliver QIPP may be negatively Luton Plann Lack of or limited Weaknesses I = 4 L = Cluster meetings chaired by GP cluster I = 4 L = CCG taking on Delegated Commissioning which ed 23 engagement with/from Not all practices are 4 lead with engagement from clinical 2 will empower the CCG in the engagement of member practices and engaged in delivering CCG 16 directors and Executive members 8 practices stakeholders within work work programmes. Limited Comms and Engagement Team have a Person Responsible: Paul Lindars programmes to enable number of clinical leads. strategy to engagement with member To be implemented by: 01 Apr 2018 delivery. Lack of commissioning Lutonti Transformation Board in place with System development needed to support easy experience in some leads. all stakeholder present access and dissemination of pathway changes Development programme for clinical leads not in.. Members Forum and PLT are Person Responsible: Paul Lindars opportunities to engage with practice 01 Sep 2018 Consequence To be implemented by: Programmes may not Programmes have designated clinical Delivery of the GP Forward View deliver. leadership Person Responsible: Paul Lindars Negative impact on To be implemented by: 31 Dec 2018 population/patients. QIPP ill t d li hi h Luton PSQ Failure to achieve safety, Weaknesses I = 4 L = Process for monitoring performance & I = 4 L = Contract management - robust challenge and 1 quality and outcome Capacity & capability 3 quality through routine reporting to 2 holding to account of providers - Quality team, objectives for patients across CCG, due to 12 PSQC, F&P & Board ensure a continued 8 Commissioning / Contracts / Finance to work in expanding responsibilities Quality Governance processes concert regarding quality and embedded within provider contracts Person Responsible: Chris Harvey safety. Revised Quality Strategy - Quality To be implemented by: 11 Aug 2020 Turnaround & Financial Matters, contract monitoring framework. Recovery could cause Patient experience data review including greater focus on short-term patient surveys and Net Promoter. financial situation than.. Consequence If the CCG does not Luton PSQ Out of Area Placement Weaknesses I = 3 L = Continual monitoring for quality issues I = 3 L = Person Responsible: To be implemented by: 4 Quality Lack of robust existing 2 arising for patients placed out of area by 2 mechanisms for assurance 6 Looked After Children's Team. 6 of safety & quality of Investigation into any safety or quality provision of services to issues associated with patients in out of patient in out of area area placements. placements. Patients, families, providers and other Consequence local parties will use existing complaints Poor patient experience. and safeguarding mechanisms to raise Lower quality patient concerns locally outcome. Reputational risk. Out of area placements for people with learning disabilities are monitored with repatriation when possible and in the best Routine contract & service quality monitoring identifies when levels of service quality are of concern for patients Luton PSQ Community Services Weaknesses I = 4 L = A Contract Query has been raised with I = 4 L = Person Responsible: To be implemented by: 6 Nursing Workforce Our community (adult) 3 CCS regarding staffing capacity issues 2 nursing nursing workforce 12 and will continue to be pursued through 8 continues to have a contractual mechanisms number of vacancies. Routine Quality Schedule & CQUIN Covid 19 pandemic has monitoring with Trust superseded current focus with realignment of teams to meet demand. Consequence If they are not successful in recruiting they will either h it i d / Luton PSQ Cambridge Community Weaknesses I = 4 L = Quarterly quality governance processes I = 4 L = Commissioner (LBC Public Health ) agreed action 7 Services 0-19 Service The current 0-19 services 2 with CCS 2 plan with CCS to improve model, delivery and Quality provided in Luton by CCS 8 8 outcome of 0-19 services. are not achieving the Further review required with commissioners quality and safety Person Responsible: Chris Harvey outcomes required of their To be implemented by: 11 Aug 2020 commissioners (LBC Public Health); therefore, there is a risk that children Luton PSQ No provision for Weaknesses I = 3 L = Person Responsible: To be implemented by: 11 initial/review health 1. Early health concerns 2 assessment for out of area are not addressed promptly 6 looked after children 2. CCG not meeting statutory duty to LAC in meeting their health needs irrespective of their local authority. 3. Absence of a Named doctor to.. Consequence A locum GP trained on the BAAF f h Luton PSQ Quality Impact of LDH and Weaknesses I = 3 L = Contract quality governance I = 3 L = Integration of Quality Governance processes with 15 BHT Merger There is a risk that through 3 2 BCCG the process of merger of 9 Contract quality governance 6 Delayed due to Covid 19 the Luton and Dunstable Person Responsible: Chris Harvey Hospital and Bedford Provider internal governance To be implemented by: 11 Aug 2020 Hospital may cause a Ongoing progress and discussions through negative impact on service Contract Quality Meetings with Trust quality for patients' outcomes and.. Person Responsible: Chris Harvey 11 Aug 2020 Consequence To be implemented by: Luton PSQ Health & Social Care Weaknesses I = 4 L = CCG OD Steering Group I = 4 L = Person Responsible: To be implemented by: 17 Workforce There is a risk that the 4 3 Luton and wider system 16 LWAB (Local Workforce Action Board) - 12 will not be able to deliver BLMK STP Workforce Workstream the required transformation STP Workforce Workstream & Plans programmes to recruit and retain sufficient workforce with the required skill-sets to deliver.. Consequence This could potentially lead to failure to deliver the STP plans resulting in failure to Luton PSQ Pressure Ulcer Incidence Weaknesses I = 2 L = Pressure Ulcer Ambition Group meet I = 2 L = Person Responsible: To be implemented by: 18 Pressure damage acquired 3 quarterly to monitor the occurrence of 3 in patient's usual place of 6 avoidable pressure damage. 6 residence. Reporting provider acquired avoidable General health state of Grade 3 & 4 pressure ulcers as SIs and patient in usual state of thematic analysis and data collection of all residence, leading to other pressure ulcers. Routine monitoring difficulty managing skin of provider quality reports of all pressure integrity when admitted for acute.. Consequence As a result of continued hi h l l f Luton PSQ Luton and Dunstable Weaknesses I = 4 L = In addition to routine quality monitoring I = 4 L = Assurance continues to be gained through routine 19 Hospital Foundation Trust If the L&DFT is unable to 3 through quarterly quality schedule 3 Contract Quality Governance Processes CQC Compliance adequately respond to the 12 reviews, further examination will take 12 Person Responsible: Chris Harvey areas of non- compliance place of the areas highlighted by the To be implemented by: 31 Jan 2020 identified by the CQC they CQC inspection. may be subject to Outside of formal contract monitoring, enforcement action. Covid assurances will be sought directly from Pandemic has limited the the Trust's Director of Nursing from the scope for 'business as.. CCG Director of Quality & Clinical Consequence This could distract attention away from other important
Page 25 of 26 BLMK Corporate Risk Register
CCG Ref CCG Risk Descriptor Risk Cause and Initial Risk Control or Mitigation Control Assurance Curre Action Required Person To be Target /context Obj. Effect Score (1st Line) nt Responsi implem Score Score ble ented by
Luton PSQ There is a risk that there Weaknesses I = 4 L = Person Responsible: To be implemented by: 21 may be an insufficient HUC have a significant 3 workforce capacity within vacancy factor that is 12 HUC to deliver the priorities impacting on their ability to of the Integrated Urgent provide all the required Care Sysytem. services of an IUC. They also are experiencing diffiuclties in recruiting to new or existing.. Consequence The consequence is that a reduced service is provided and that additional Luton PCD Failure to engage PCN's Weaknesses I = 1 L = Luton Provider Alliance supporting new I = 1 L = Utilise BLMK PCN development funds to enable 72 with Primary Care Home Practices lack of 4 models of care across all Luton providers 3 PHM approach to developing new models of care. programme understanding of Primary 4 PCIS resource identified to support rapid 3 Person Responsible: Paul Lindars Care Home implementation across Luton. To be implemented by: 01 May 2020 Competing priorities related Secure additional support from NAPC to work with to General Practice Luton PCN's Forward View and PCN Paul Lindars development. Person Responsible: To be implemented by: 01 May 2020 Consequence Unable to meet STP strategic objectives Failure to develop General Luton PCD Failure to engage Practices Weaknesses I = 4 L = Monthly GP Member's Packs providing I = 4 L = Continue to raise awareness of local clinical advice 73 with demand management Lack of understanding and 1 PCN's and Practice activity breakdown 1 and guidance service. QIPP schemes ownership regarding 4 disseminated for review at PCN meetings 4 Person Responsible: Paul Lindars importance of managing PCIS (Primary Care Incentive Scheme) in To be implemented by: 01 May 2020 demand appropriately place to support delivery of demand Poor utilisation of clinical management initiatives within general Clinical support to lead PCN engagement, advice and guidance including support and guidance at Practice level platforms where required. Consequence Person Responsible: Paul Lindars Increased financial burden To be implemented by: 01 May 2020 to LCCG Longer patient waiting times at Acute
Page 26 of 26 5.2
Governing Bodies in Common in Public
21 July 2020
Governing Body Assurance Frameworks
Author: Michael Wuestefeld-Gray, Interim Programme Manager for BLMK Governancce Contact Information: [email protected] Lead Executive: Geraint Davies, Director of Performance and Governance Which CCGs does this paper apply to?
Bedfordshire X Luton X Milton Keynes X
Information
Which activity does this paper Assurance of effective strategic level risk mangement at the three relate to? CCGs
How? Each CCG maintains a Governing Body Assurance Framework which focus on key strategic risks that link directly to each CCG’s corporate objectives. What is the Governing Body To receive assurance that there is effective strategic risk being asked to do? management at the three CCGs, and work to develop aligned risk management systems is progressing. What are the financial As set out in the individual risks. implications?
Set out the key risks and risk N/A ratings
Date to which the information 8 July 2020 this paper is based on was accurate
Executive Summary
Each CCG maintains a Governing Body Assurance Framework (GBAF) that is populated with risks to the delivery of each CCG’s strategic aims. As with the corporate risk registers these will be brought together into a single working document, but it is not possible to do so as one of the CCGs, Bedfordshire, takes a very different approach to its GBAF. Therefore the GBAFs are still separate documents but a summary is set out below. Next steps for the GBAFs are similar to those for the corporate risk registers.
Governing Body Assurance Frameworks
The three GBAFs have strategic risks in the following areas: Strategic Area Bedford- Luton Milton shire Keynes Quality, Safety and Access Y Y Y Finance and QIPP Y Y Y Engagement with primary care and other partners Y Y Patient and Public Engagement Y Y Development of Integrated Systems Y Being open and transparent Y
The risks were reviewed and updated in June 2020. Each CCG’s GBAF is attached to this paper. To further align strategic risk management across the three CCGs next steps include: • Rolling out consistent risk management systems across the three CCGs. • Working with the joint committees and committees in common for the three CCGs to define the common strategic risks across the BLMK sytem • Working with risk leads and subject matter experts to define those risks and keep them live.
2
The Governing Body Assurance Framework
Priority Area: Priority Area: Priority Area: Priority Area:
Improved Access & Quality Deliver financial sustainability Improve integration of services Improve governance and inform decisions.
Objective: Objective: Objective: Objective: Objective:
We will commission high We will ensure that there is a We will engage with both local We will support local people and We will govern with transparency, quality, safe and sustainable financially sustainable and affordable councils and also our partners across stakeholders to have an influence on comply with best practice and meet our models of care that deliver healthcare system in Bedfordshire. the wider health economy working on services we commission to ensure our statutory obligations. effective clinical outcomes and plans to strengthen primary care, decisions are informed and shaped by patient experience using This will be achieved through: improve outcomes and integrate local views and insights. This will be achieved through: evidence based decisions and services for the populations we serve. best practice. Ensuring the CCG stays within the set This will be achieved through: Working to the Joint Accountable Officer revenue and capital resource limits set by This will be achieved through: and leadership team, streamlining and This will be achieved through: NHS England. Improving communications and strengthening commissioning leadership Ensuring we deliver on the system-wide engagement with staff, GP members, arrangements to deliver better outcomes Ensuring effective commissioning Supporting the delivery of the partial transformation programmes to improve patients, carers and the public in order that for the people of Bedfordshire. arrangements are in place to drive control total for the overall integrated planned care, complex care, urgent & commissioning meets the needs of local up quality in services; and safety care system. emergency services, and mental health people and local health services are Ensure the GB and its committees has the and performance issues are tailored to those who most need them appropriate balance of skills, experience, identified early Securing the financial control total Developing a strong robust system and independence and knowledge to discharge through improved productivity and strong clinical leadership structure for an Increasing awareness and understanding their duties effectively Improving the quality of care by financial control integrated workforce approach to bring amongst patients and the public about local ensuring our workforce has the together partners and providers across health and care services in Bedfordshire Ensure members of the GB and committee right numbers, skills, values and Adherence to strict financial discipline all sectors to create an environment of are appointed and remunerated behaviours to meet the needs of and sound financial governance. collaboration, monitoring and continuous Promoting and embedding communications appropriately patients. Agree where additional improvement. and engagement standards and best capacity is needed in the light of ensuring that the CCG has in place practice amongst CCG staff, supporting Ensuring decisions are made transparently, robust and reliable financial systems to organisational priorities and Continued implementation of our agreed them to deliver key priorities including honestly and with a duty of candour. resource constraints. support informed decision making by clinical commissioners primary care transformation strategy achieving QIPP targets and implementing recognising primary care as the new models of care. Ensure that people are treated ethically, We will assist providers to develop equitably and legally. This includes taking a culture where learning from foundation of our Integrated Care System Maintaining continuous dialogue with the a zero-tolerance approach towards patient safety incidents and from managing bullying and discrimination. patient experience is embedded in Implementation of the NHS’ national public to ensure that the local population is everyday practice priorities (including the NHS Five Year aware of service developments and how it Forward View and GP Forward View) can influence healthcare. Ensure the CCG strengthens the contribution of member practices to the Promote safe, evidence based and cost-effective prescribing while Further strengthening relationships with CCG supporting prescribers to optimise our main providers, acknowledging our Agree clear accountabilities and reporting patients’ medications. respective pressures and the incentives in the system that can currently mitigate structures with other institutional Ensuring our winter plans meet against a system rather than individual stakeholders. specific priorities as well as organisational approach ensuring preparedness to meet the expected increase in demand on Strengthening plans to transfer the the health and social care system responsibility for the core commissioning over the winter months of GP services from NHS England to the CCG. Improving outcomes for children and adults with mental health needs
KEY I R T Inherent rating Residual rating Target
Obj Risk Description 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Trend since Gaps in control Gaps in Assurance Owner last report (actions outstanding) of controls in 1.1 Risk to quality , patient care and experience I R T Yes No Anne Murray
1.2 Risk of increased patient safety serious incidents I R T Yes No Anne Murray
1.3 Risk that workforce issues prevent us from transforming Yes No Jane Meggitt the delivery of care across the local health and social care I R T system 1.4 No Mike The CCG’s 2018/19 winter resilience plan does not result I R Yes Thompson in the achievement of expected targets
2.1b Failure to fully deliver £35.3m of QIPP savings in Yes Yes Chris Ford R T 2019/20, which could result in failure to achieve our I £11.1m control total 3.1 As a result of multiple factors (i.e. workforce, increasing Mike and aging population, premises constraints) practices do Thompson not have the capacity, capability or resilience for I Yes Yes transformation which will result in reduced access to T R services and increase in secondary care activity
4.1 Breach of statutory duty to consult and engage on CCG Yes No Jane Meggitt priorities and service developments. I R T
5.1 Risk of member practices disengaging with the CCG Yes No Mike I R T Thompson 5.2 The CCG fails to comply with legal and best practice Yes No Chris Ford requirements regarding the information it holds. I R T
5.3 Inability to work effectively with partners to improve Yes Yes Mike service delivery and reconfigure health and social care I R T Thompson services within Bedfordshire 5.4 As Bedfordshire, Luton and Milton Keynes move toward I T Geraint becoming a single strategic commissioner there is a risk Yes Davies R that they may not achieve the milestones necessary to do so by April 2021, resulting in disruption to the wider ICS and threats to achieving financial, clinical and operational objectives and performance.
Objective No 1: We will commission high quality, safe and sustainable models of care that Responsible Director: Anne Murray, Chief Nurse deliver effective clinical outcomes and patient experience using evidence based decisions and best practice. Lead: Maria Laffan, Assistant Director of Nursing & Quality
Principal Goal 1. Ensuring effective commissioning arrangements are in place to drive up quality in services; and safety and performance issues are identified early.
Risk 1.1: Risk to quality , patient care and experience Date last reviewed: 9 June 2020
Cause of risk Effect of risk realising Initial Score Current Score Target Score Poor assurance from providers Patients not receiving safe, effective care and there being an through contract monitoring and ineffective costly service delivery. 3 x 4 = 12 2 x 2 = 4 1 x 1 = 1 not listening to patients in relation to their experiences Brief rationale of current risk rating: It is unlikely that this risk may materialise but it remains possible it may do so. Controls have reduced impact.` Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence that our Level controls, on which we are placing reliance, are effective Quality contractual requirements specified with clear reporting lines and timescales in place. Schedule 4 of NHS standard contract with Provider – 2 (Medium) Reported via Service Quality and Performance report ( SQPR) monthly submission Regular quality contractual meetings held with providers to review data and intelligence Contract meeting minutes held on secure drive by CCG 1 (Low) contracting team New CQUIN data means all data will now be reviewed on final end of year submission. Ongoing Minutes of panel decision on achievement or non- 2 (Medium) discussions with providers on general performance will continue achievement – held by quality team and also contractual letters to providers help by contracts team Triangulation of contractual data and intelligence with information received via public and Patient Updates and feedback triangulated to Quality 2 (Medium) forums including Health watch. Quality teams working specifically with Healthwatch on community Operational Group ( QOG) and escalated accordingly to services quality visits Integrated Commissioning Performance and Quality (ICQC) Clear processes established and in place with partner organisations to report information (e.g. Minutes of meetings from safeguarding boards, 1 (Low) safeguarding boards, Transforming Care Learning Disabilities board) Transforming care Operational group, Transforming Care partnership Board. Safeguarding reporting Secure email addresses and in box function to enable information sharing. Serious untoward incident reporting email reporting. Quality Team are active participants in both Local Authorities Safeguarding boards for Children Exec and designates Nurse attendances. Minutes of 2 (Medium) and Adults meetings for safeguarding boards and sub groups Yellow Inform button (reporting system of safety and quality issues by GPs and providers) in Reports provided upon request to quality and primary 1 (Low) place. Feedback being monitored. care meetings. Reporting on themes identified from Route Cause Analysis undertaken on constitutional breaches Reports( Integrated performance and Quality report ) on 2 (Medium) at pathway and patient level is on place. Performance to ICQC Assurance visits undertaken by all members of the quality team, both announced and Quality visit templates used for all quality visits – held on 1 (Low) unannounced as determined by risk level. Update: quality assurances re visiting clinical areas quality secure drive has paused due to Covid impact. Escalation to face to face senior level meetings in relation to risks identified from Serious Incidents Minutes of meetings held with providers to escalate 1 (Low) and Safeguarding alerts. concerns held by quality team. Copies of minutes of provider quality meetings. Reports to Integrated Commissioning and Quality Committee to provide assurance and enable Minutes of Meetings held by Governance directorate and 1 (Low) Independent challenge from Lay members. quality directorate Escalation to Regional Quality Surveillance Group together with details of quality visits to enable Minutes of quality Surveillance groups held with NHSE. 1 (Low) system wide sharing and intervention as required from NHS England. Email of all escalation of concern Increased clinical involvement and sharing of quality impact assessments in relation to service Minutes of CRG 1 (Low) changes at the newly formed clinical reference group. Ensure robust Quality Impact Assessment of all QIPP programmes are in place before PIDs; PMO reporting/dashboard 1 (Low) programmes go live by developing a programme of work for 18/19 19/20 Internal Audit of CHC processes Reasonable Assurance awarded. 1 urgent, 2 important, 3 3 routine recommendations (implemented) (substantial) Monitoring of learning from complaints to identify key themes and learning points to improve Reports to Integrated Commissioning & Quality 2 (Medium) quality of care, treatment and patient experience Committee Learning from Serious Incidents monitored and work on-going with providers on resulting action Reports to Integrated Commissioning & Quality 2 (Medium) plans Committee Provider/Commissioner deep dives undertaken aligned to contract performance notice process. Reports to Integrated Commissioning & Quality 2 (Medium) Committee Ensure safer staffing measurements are in place across all provision Reports to Integrated Commissioning & Quality 2 (Medium) Committee Remedial action plans agreed & status By when? Brief description of intended outcome
Strong relationship with local Health watch being established On-going Monthly team meetings in place to review combined analysis of service On Going Internal flag on risk to constitutional safe and effective care and provision and quality delivery. escalation from this meeting as appropriate to standards ICQC and risk register Local Quality team monthly operational meeting to flag and concerns or On-going increase focus on service delivery 2019 review of yellow inform and purpose commencing in August Year end Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence that Risk 135 Learning Disability Local Provision .As a result of only a small amount of local provision for individuals with more complex and challenging needs there is a risk that care provision will either breakdown or reduced quality of care which our controls, on which we place reliance, are effective may result in harm to the individual and requirement for urgent new provision out of county Risk 144 SEND Working statement of Action. As a result of failing the SEND inspection, and comments received from recent peer review there is a risk the progress over the past year which may result in not passing at re-inspection Risk 146 A&E 4 hour performance at Bedford Hospital Trust. As a result of a decline in A&E 4 hour performance at BHT, there is a risk that delays to patients being seen, treated and discharged/admitted could result in patient care being negatively affected.
Objective No 1: We will commission high quality, safe and sustainable models of care that Responsible Executive Director: Anne Murray, Chief Nurse deliver effective clinical outcomes and patient experience using evidence based decisions and best practice. Lead: Maria Laffan, Assistant Director of Nursing & Quality
Principal goal 2. We will assist providers to develop a culture where learning from patient safety incidents and from patient experience is embedded in everyday practice
Risk 1.2: Risk of increased patient safety incidents Date last reviewed: 9 June 2020
Cause of risk Effect of risk realising Initial Score Current Score Target Score
Culture in providers where learning from SIs and Increased patient safety incidents with similar 3 x 4 = 12 3 x 3 = 9 1 x 1 = 1 patient safety challenge is not embedded. causes and lack of learning Brief rationale of current risk rating: It remains possible that learning from Sis is not embedded in the culture of some providers. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence that our Level controls, on which we are placing reliance, are effective Monthly Serious Incident panel at CCG to include quality and Commissioner leads. Updates on feedback on STEIS for Provider 2 (Medium) Review of all provider 60 day reports on SIs and associated action plans Updates on feedback on STEIS for Provider and 2 (Medium) quality meeting reviews Extraordinary meetings with providers and clinical leaders of organisations who report higher numbers Minute meetings to walk through action plans 1 (Low) of SI Attendance at National patient safety events to share learning Team meeting minutes 1 (Low) Quality review meetings with all providers Minutes of meetings of all quality meetings 1 (Low) Quality visit reviewing if learning is embedded Visit templates completed and shared with Providers 2 (Medium) Deep dives requested into any themed areas of concern Deep dive analysis shared with quality directorate 2 (Medium) Shared discussion at Herts & South Midlands Quality surveillance Minutes of meeting and influence back to providers 1 (Low) and shared emails regarding concerns Escalation to face to face senior level meetings in relation to risks identified from Serious Incidents and Minutes of meetings and evidence of email 1 (Low) Safeguarding alerts. discussions Escalation to Regional Quality Surveillance Group together with details of quality visits to enable system Minutes of meeting and influence back to providers 1 (Low) wide sharing and intervention such as risk summit as required from NHS England and shared emails regarding concerns Remedial action plans agreed & status By when? Brief description of intended outcome
Monthly SI panels in place for Acute. Mental health, Ambulance, Review process to gather themes and identify if learning is community and other providers. Clinical engagement on all SI embedded in service delivery. panels
Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence No high operational risks populating corporate risk register that our controls, on which we place reliance, are effective Objective No 1: We will commission high quality, safe and sustainable models of care that Director lead: Jane Meggitt, Director of Partnerships, deliver effective clinical outcomes and patient experience using evidence based decisions and communications and Engagement best practice. Lead: Helen Haynes, Senior HR Business Partner Principal Goal: Improving the quality of care by ensuring our workforce has the right numbers, skills, values and behaviours to meet the needs of patients. Agree where additional capacity is needed in the light of organisational priorities and resource constraints Risk 1.3: Risk that workforce issues prevent us from transforming the delivery of care Date last reviewed: 10th October 2019 across the local health and social care system. Cause of risk Effect of risk realising Initial Score Current Score Target Score Unclear approach and absence of strategy; Limited Unstable and demotivated workforce; Lack of 5 x 4 = 20 2 x 4 = 8 2 x 2 = 4 system workforce capacity and capability; ability for succession planning; staff shortages Workforce culture not congruent with required and skill gaps; pressure on financial planning. changes; Poor communication with health and social care partners; Limited BCCG workforce capacity and capability to manage multiple procurements alongside business as usual Brief rationale of current risk rating: It is not expected that this risk will materialise but it is possible it may do so. If the risk did materialise the impact on the CCG would be high. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence Level that our controls, on which we are placing reliance, are effective A new HR&ODL Strategy developed with four strands: Leadership Culture; Workforce Planning, Progress against the HR & ODL Strategy is 2 (medium) Recruitment & Retention; Learning & Development; Policies, Procedures & Systems to be reported quarterly (Q2 and Q4 dashboards reported to Executive and Governing Body). Review of workforce metrics report produced by Arden & Gem workforce team A new Service Level Agreement has been signed by the AOs of HVCCG, BCCG, ENH, LCCG and HR&OD service moved to Arden & Gem on 2 (Medium) West Essex, that sets out the HR&ODL services, which is implemented via the approved HR&ODL 1st June (initial 12 month contract). SLA in Strategy. place for length of contract. Current new ways of working locally, regionally and nationally were identified. Attendance at both local, regional and 1 (Low) National workforce forums.Updates on workforce planning across BLMK given to senior leaders and executive Workforce strategy reviewed HR Service Spec in place since from to 2 (medium) Arden and Gem on 1st June. Quarterly review of work plans to ensure actions met in timely manner. STP work streams have been identified with HR&OD leads. Apprenticeship levies - Workforce CCG Retention Plan 2 (Medium) recruitment and attraction. Apprenticeship levy in place and information session held promote opportunities. Bidders for new pathways are being asked to describe workforce solutions in detail. Review procurement specifications and 1 (Low) tender question documentation to ensure inclusion prior to publication to seek potential bidders. Review throughout bidder process and evaluation to ensure questions the requirements of the contract. Remedial action plans agreed & status By when? Brief description of intended outcome Setting out requirements for workforce plan within submissions for In line with timescales of new Workforce requirements and expectations from the service provider new pathways and re-procurements of existing services working pathway and re-procurement included in the tender documentation. All tender documentation with partners to identify workforce capacity and capability processes reviewed to ensure workforce sections meet the requirements of requirements involved in multiple procurements and flag key risks the CCG to ensure that prospective bidders can demonstrate their to the Executive and Board workforce planning for any contracts and highlight any gaps and potential risks, as part of their submissions. Further discussions at the overarching STP workforce group as to Regular updates from BMLK Workforce planning reviewed by BLMK LWAB to highlight how it will be implemented. Workforce planning team. Alison workforce issues, challenges and consequences and how these Lathwell update EMC on 10/10 are being addressed. with latest information and metrics.
Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence October 2019 No high operational risks populating corporate risk register that our controls, on which we place reliance, are effective
Objective No 1: We will commission high quality, safe and sustainable models of care that Director: Mike Thompson, Chief Operating, Officer, BCCG deliver effective clinical outcomes and patient experience using evidence based decisions and best practice. Lead: Emma Hunt-Smith, Assistant Director - Unplanned Care, BCCG
Principal Goal: Ensuring our winter plans meet specific priorities as well as ensuring preparedness to meet the expected increase in demand on the health and social care system over the winter months.
Risk 1.4: The CCG’s winter resilience plan does not result in the achievement of expected Date last reviewed: 5th March 2020 targets
Cause of risk Effect of risk realising Initial Score Current Score Target Score Activity surges Increasing Length of Stay 4 x 4 = 16 3 x 4 = 12 3 x 3 = 9 High Acuity of patients Deterioration of Medically Optimised (MO) and Delayed Out of hospital capacity Transfers of Care (DToC) performance Workforce shortages in groups Deterioration of A&E performance critical to supporting the urgent Overcrowding in A&E care system. Patients in outlying escalation wards with skeletal staff Funding pressures. coverage Risk to patient safety and experience. Brief rationale of the current risk rating: It is possible that the winter plans may not influence the effect of the risk realising. However, this meets the likelihood appetite of the GB. Impact currently remains higher than appetite. Controls What controls are in place now stopping the risk realising Assurances Where we can gain Level evidence that our controls, on which we are placing reliance, are effective A detailed Demand and Capacity Plan commenced September 2019 which managed through a Demand and Capacity Steering Group 2 (Medium) fortnightly system meeting. An average ‘bed equivalent’ capacity gap of 33 was identified. Partner (reports to A&E Delivery Board) organisations including BCCG committed to the provision of additional capacity through efficiencies, transformation and the purchase of additional winter beds in order to bridge this gap. Executive member representatives across Health and Social Care form the Demand and Capacity Steering Group which initially met throughout winter to ensure progression against key milestones for scheme implementation and to review the progression of each scheme and its impact on reducing bed occupancy in the acute trust to 92%. However, in February 2020 it was agreed these fortnightly meetings will continue indefinitely to oversee and manage demand and capacity issues across the system. Members of the Steering Group scrutinise and challenge progress of identified schemes for deliverability. Milestones and KPIs are monitored to ensure delivery against plan.
A comprehensive winter plan is in place which sets out actions being implemented across the System Resilience Group (SRG) 2 (Medium) Bedfordshire Health and Social Care system to ensure that appropriate arrangements are in place (reports to A&E Delivery Board) to provide high quality and responsive services not just for the 2019/20 winter period but for future years in line with the Long Term Plan. These programmes of work collectively aim to meet the national requirements of:
• delivery of the delayed transfers of care <3.5% expectation • reducing length of stay for patients across the system • increase primary care streaming • implementation of Same Day Emergency Care (SDEC) • delivery of seven day services / weekend discharges
Members of the System Resilience Group review the data against these key deliverables each month, reporting slippage and concerns to the A&E Delivery Board Remedial action plans agreed By when? Intended outcome of the action. It is recognised that whilst there are robust plans in place, there Ongoing To avoid unnecessary hospital attendances and admissions and to ensure is still a risk of demand exceeding capacity during the winter patients flow is not compromised. period, which could cause issues with flow in and out of the acute hospital and community services. To prioritise and robustly manage winter surge in order to provide a safe and effective urgent and emergency care system for patients. Therefore, in addition to the aforementioned whole system commitment, whole system surge planning will be led by BCCG as appropriate in line with OPEL escalation triggers and actions.
Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence that our controls, on which we place reliance, are effective
Objective No 2: Deliver financial sustainability Director: Malcolm Miller
Principal Goal: We will ensure that there is a financially sustainable and affordable Lead: Matt Hollex healthcare system in Bedfordshire.
Risk: 2.1b Failure to fully deliver £35.3m of QIPP savings in 2019/20, which could result in Date last reviewed: 5th March 2020 failure to achieve our £11.1m control total (£35.3m is inclusive of £5m ICS pressure, and £4.1m BHT/ L&D Affordability Gap)
Cause of risk Effect of risk realising Initial Score Current Score Target Score Under-Delivery in the existing 50 Savings will reduce and the unidentified QIPP will grow 4x4 4x4 2x2 QIPP Schemes (£24.4m programme) Insufficient new opportunities to BCCG will be unable to bridge the gap between current fill a £10.9m gap (at M7) forecast and target Target too high based on our BCCG has a track record of achieving circa £20m QIPP current capacity and capabilities programmes for the past 2 years. Expecting to achieve £35.3m with the same levels of capacity and capability is unrealistic Acute Over-Performance Acute providers are over-performing. This over-performance is partly offsetting the impact of QIPP, reducing the overall net financial impact of QIPP Acute CIP Programme Acute providers are successfully delivering CIP Brief rationale of the current risk rating: Currently this risk should be Programmes (BHT has a £6m CIP Programme), which are a significant concern to BCCG. partly made up of income generation schemes, which are Using the same resources (both capacity and capability) as 2018/19, increasing demand into certain specialties. This is offsetting BCCG needs to not lose any momentum within the existing 50 schemes the impact of QIPP. and identify £10.9m (M7) more QIPP. This is a significant challenge. The other factor that is compounding the risk is the acute over-performance and CIP, which continues to offset the impact of QIPP. This risk consumes large amounts of resources in understanding it, understanding QIPPs roles in it, and keeping momentum on joint working with our 2 main providers. Target score reduced to 4 to reflect the Governing Body risk appetite, as per the CRR, Head of PMO considers the target score of 4 as unrealistic achievement in year, noting 12 as a more realistic score.
Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence that our Level controls, on which we are placing reliance, are effective A 30+ WTE Commissioning Team prioritising the delivery of existing QIPP schemes and Feedback from NHSE, RightCare Feedback. Evidence 2 identifying new QIPP schemes in QIPP Delivery A 2 WTE PMO dedicated to managing the QIPP Programme, which includes reporting and NHSE QIPP Review Workbook and feedback. Auditor 2 assurance on the programme to ensure risks and identified and controlled, but also Feedback (GT & TIAA) strengthening the delivery of QIPP schemes and the identification of new QIPP opportunities A 50 scheme programme capable of achieving £24.4m Monthly Highlight Reports 1 Weekly Financial Recovery Board (FRB) Action Log demonstrating progress 1 Monthly Finance & Performance Committee Action Log demonstrating progress 1 Monthly BHT Joint Programme Board New opportunities being identified by the Board 2 Monthly L&D Contract Review Meetings (CRM) New opportunities being identified by the CRM 1 Monthly Joint Financial Resilience Group meetings with LCCG Action Log demonstrating progress, and new 1 opportunities being identified to mitigate common issues Strengthening the Financial Recovery Plan (FRP): - Creating monthly highlight reports detailing FRP and QIPP 2019/20 Milestone Tracker – Weekly 1 key KPIs. reviews taking place. Establishing a FRP decision and action tracker (added to the FRB action log) to ensure all movement and forecasting is demonstrated for reference and guarantees version control. Monitoring of QIPP 2019/20 scheme and programme KPIs and Milestones. Demonstrated in the QIPP 2019/20 Milestone Tracker 1 Weekly reviews taking place with scheme leads to support the timely achievement of said milestones and support mitigation in the risks identified. 30 Minute weekly assurance meetings for QIPP 2019/20 Programme. Attendees include scheme Progress and achievement of monthly forecasting/ 1 leads, SRO, Finance Leads, PMO and Business Intelligence leads, to support the timely deliverables. achievement of milestones and support mitigation in the risks identified. New opportunities being identified to mitigate risks and issues Collaborative working across BLMK CC to identify opportunities at scale and opportunities where New opportunities emerging 1 services are nonaligned, understanding the importance of working collaboratively with providers SROs and each Commissioning Area to complete a in identifying schemes that have a net system benefit. single set of 2020/21 Scheme Briefs by COP on 29/11/2019. Gaining mitigation from the FRP circa valued at latest Net Opportunity at M10 of £16,618 New opportunities emerging. 1 Reduction in value of forecast outside of position – increasing actuals already in position. Risk adjusted position. Monthly review. SLG on 17/07 prioritised Respiratory, CVD and High Intensity Users as areas of BLMK CC wide New opportunities emerging 1 focus. These will be worked up for the next SLG in December/ January 2020 Remedial action plans agreed By when? Intended outcome of the action. A Financial Recovery Plan (FRP) Initial FRP - July 2019 To assure ourselves and NHSE / NHSI that we have a plan to address Ongoing review and less favourable financial position monitoring between July 2019 and March 2020. Identify more opportunities Between now and Mar-20 More opportunities to release savings and ease the financial pressures Any opportunities will now feature on the FRP, not in the pipeline for QIPP Programme Strengthen existing opportunities Between now and Mar-20 Stretching existing schemes like Respiratory and Gastroenterology with the aim of reducing the financial pressures in NEL Reduce the risk in the existing 50 schemes Between now and Mar-20 The 50 existing schemes achieving their £24.4m Reduce Acute over-performance (notably NEL at BHT and L&D) Between now and Mar-20 Driving the cost of BHT, L&D and ENH contracts down to an affordable amount Linked operational risks appearing on Corporate Risk Register: CRR131 As a result of the CCG requiring a £35.3m QIPP Programme for 2019/20, there is a risk that the CCG will not be able to identify, initiate and deliver £35.3m of schemes in 19/20, which may result in failure to achieve our 2019/20 financial control total CRR145 As a result of the CCG's continued adverse financial position (£11 slippage at month 7), the CCG remains at significant risk of not achieving its year-end financial control total. Position is considered to be a combination of - implementation on 19/20 NHSE national contract - contract affordability gaps - activity and cost above planned levels at hospitals -QIPP delivery CRR148 Significant proportion of £26m QIPP plan is with acute sector. As a result of providers not accepting full level of QIPP into 19/20 contracts risks arise that not all savings are supported by acute sector and hence full QIPP programme is not achieved putting financial target at risk. Financial slippage from plan also impinges on the CCG's reputation and thereby remaining in special measures. CRR149 As a result of new national contract, differing views on contract values/expectations and levels of QiPP required in contracts, 2019/20 contracts with BHT and L&D hospitals have been agreed with a total £4m gap putting achievement of CCG £6.1m surplus at risk. CRR151 As a result of NHSE requiring a further £5m saving from BLMK ICS, CCG control total has been increased to £11.1m. Whilst the £5m sits with BCCG, it is seen as a system wide issue. Risk is that ICS partners do not identify £5m savings and that B CCG reports non-achievement of financial control total.
Risk 140 As a result of NHSE requiring a further £5m saving from BLMK ICS, CCG control total has been increased to £11.1m. Whilst the £5m sits with BCCG, it is seen as a system wide issue. Risk is that ICS partners do not identify £5m savings and that B CCG reports non-achievement of financial control total Risk 141 As a result of B CCG potentially not meeting its increased financial control total (see FIN 12), the CCG is at risk of (a) reputational damage (b) remaining in special measures
Objective No 3: We will engage with both local councils and also our partners across the wider Director: Mike Thompson, Chief Operating Officer health economy working on plans to strengthen primary care, improve outcomes and integrate services for the populations we serve. Lead: Nicky Wadely, Assistant Director of Primary Care
Principal Goal: Continued implementation of our agreed primary care transformation strategy, recognising primary care as the foundation of our Integrated Care system (ICS) Risk 3.1: As a result of multiple factors (i.e. workforce, increasing and aging population, Date last reviewed: 8 June 2020 premises constraints) practices do not have the capacity, capability or resilience for transformation which will result in reduced access to services and increase in secondary care activity Cause of risk Effect of risk realising Initial Score Current Score Target Score Difficulties in recruiting to Increased locum cost to providers which is not a sustainable model 4.x 4 = 16 4 x 4 = 16 3 x 3 = 9 practices vacancies/resilience and practices hand back contract issues stemming from staff absences Lack of capacity to expand Practices will close their list to new patients causing pressure and within current premises possible domino effect on other practices Lack of resource to enable Practices will not have the internal capacity to support introduction transformation of new ways of working. It is anticipated that further implementation of Primary Care Networks and associated support will enable development of transformation capacity within primary care. Brief rationale of the current risk rating: Whilst capacity is stretched due to population increases and insufficient primary care workforce the likelihood of risk materialising will not reduce. Resilience issues continue to impact practices.
These issues are not yet mitigated by the formation of PCNs, though it is likely that they will have an impact as they mature. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence that our Level controls, on which we are placing reliance, are effective Workforce development strategy in place and into delivery phase. Strategy to be revised for 2019/20 CEPN minutes 1 (Low) linked to ICS Primary Care Strategy Primary Care Strategy International Recruitment Programme Primary Care Home (PCH) programme and implementation of Primary Care Network (PCN) DES Approved and signed PCN network contracts, 1 (Low) contracts to develop integrated working and improve population health Clinical Directors appointed Completion of PCN Maturity Matrix PCN Development Plan in place Population Health packs Multidisciplinary Team approach developed and implemented at cluster level with community, mental MDT reports for PMS scheme 2 (Medium) health and social care teams in both places Community Service transformation plan Support programme for Time for Care and High Impact Actions Audit of GPFV engagement by practice and cluster 2 (Medium) Productive General Practice Programme engagement and progress plans Extended access to primary care across CCG area Provision/utilisation reports. Contract meeting 1 (Low) minutes. Digital transformation work around Primary Care Home, patient access underway. This includes Information Sharing Phase 1/BLMK Digitisation 1 (Low) increasing the sharing of clinical information across a wider range of professionals. Board
Remedial action plans agreed By when? Intended outcome of the action. Outline Business Cases with designs for Dunstable Hub and April 2020 To develop the outline business cases. Draft designs and draft OBC Gilbert Hitchcock House Hub to be completed developed. Phase one of the GHH opening in Q1 2020/21. Dunstable OBC delayed due to COVID-19 response. GHH OBC delayed due to interdependencies and COVID response. Final drafts of Strategic Outline Cases completed for West Mid September 2019 - Complete To develop the strategic outline cases for new Hubs. Being Beds, Leighton Buzzard and Ivel Valley progressed through BCCG governance processes. Work being commissioned to support development of BLMK wide October 2019 – On track BLMK Estates Strategy developed. Outline strategies developed for Estates Strategy, to complement strategic estates priorities Luton, MK to compliment work already complete across established for Bedfordshire Bedfordshire. BLMK Estates Strategy in process of being drafted. Will need reviewing in light of significant digital transformation in primary care as result of COVID-19. Continued development of Primary Care Network leadership Ongoing through 2020/21 Effective leadership in PCNs across all areas of delivery/function Primary Care Network contracts to be signed with further July 2020 Primary Care Networks established delivering integrated services. developments in collaborative working throughout the year 100% of BCCG population is covered by a PCN. Practice resilience programme Ongoing through 2020/21 Reviewed and developed programme which will be delivered throughout 2020/21 Development of caretaker step in provider framework. Provider September 2020 National procurement framework programme announced, to procurement training to take place. commence 2020/21. Framework to cover: a) APMS b) Caretaker contracts BCCG will link into this process/framework through Attain Transformation funding to be used to help enable transformation Ongoing Increased Place/PCN level collaborative working/integration at PCN/Place level Population health analytics capability development Ongoing Work with BI and Public Health to develop packs/data sets for PCNs expected February. National pilot programme on PHM to begin in each place (start date to be reviewed due to COVID-19). Linked operational risks appearing on Corporate Risk Register:
Objective No 4: We will support local people and stakeholders to have an influence on services Director lead: Jane Meggitt, Director of Partnerships, we commission to ensure our decisions are informed and shaped by local views and insights. Communications & Engagement
Principal Goal: Improving communications and engagement with staff, GP members, patients, carers Lead: Sarah Frisby, Senior Communications & Engagement and the public in order that commissioning meets the needs of local people and local health services Manager are tailored to those who most need them. Risk 4.1 : Breach of statutory duty to consult and engage on CCG priorities and service Date last reviewed: 5th March 2020 developments.
Cause of risk Effect of risk realising Initial Score Current Score Target Score Failure to establish and maintain Adverse impact on CCG’s reputation, and ability to influence the 2 x 4 = 8 2 x 3 = 6 1 x 1 = 1 effective relationships with local and national agenda. internal and external Inappropriate use of services due to lack of information and stakeholders understanding. Brief rationale of current risk rating: The CCG does not expect this risk to materialise but it is possible it may do so. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence Level that our controls, on which we are placing reliance, are effective Regular attendance at Overview & Scrutiny Committees and Health and Wellbeing Boards which Minutes of meetings 2 (Medium) provide established channels to consult the public and involve local politicians to seek scrutiny of service development decisions Statement of principles for implementing arrangements to meet statutory duty on patient involvement Constitution on CCG public website 2 (Medium) reflected in CCG Constitution. Healthwatch in attendance at Governing Body meetings Minutes of GB meetings. 1 (Low) The Communications and Engagement team has refreshed its Induction presentation to reinforce the Positive feedback from Induction attendees 1 (Low) importance of engagement and collaboration with our communities. This will be delivered to all new starters. An internal engagement plan to change culture in the organisation has been developed Approved by SIG. All staff meetings 2 (Medium) A new Leadership and cultural values training course has been developed embedding collaboration and Feedback from each course 1 (Low) engagement. Recruitment campaign to strengthen public member involvement took place in 17/18 PPEC Minutes 1 (Low) The Communications and Engagement team engages with the wider CCG to set standards of conduct Team process Handbook, developed 2017 2 (Medium) to ensure all engagement and consultation is best practice. Robust governance arrangement in place for Patient & Public Engagement Committee. (ToR reviewed Regular review of ToR. Ratified by 2 (Medium) recently, signed off by PPEC members in April and ratified by Governing Body in May) Governing Body Internal Audit of Patient Involvement completed and reasonable assurance given as rating. Self-assessment completed and evidence 3 (Substantial) returned to Internal Audit for assessment. IAF Assessment by NHSE completed at end of March to determine compliance. Results due in June Engagement taken place with ICS and LA to agree approaches to engagement for BLMK/ Worked 1 (Low) closely together when engaging on LTP – developing links that can be used in future engagement opportunities Remedial action plans agreed & status By when? Brief description of intended outcome Update Communications and Engagement Plan for BLMK to reflect June 2020 The NHS Long Term Plan will be used as the basis for the strategy new approaches to engagement. New BLMK Communications and and developed as the new structure for BLMK is agreed. As the Engagement Strategy will be drafted. move towards one single structure comes closer, this will inform the plan for wider engagement. Media training to be provided for Chair of Governing Body, Chief March 2020 Waiting for transition period to media train new intake of senior Operating Officer and other relevant staff around reputational staff. issues.
Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence No high operational risks populating corporate risk register that our controls, on which we place reliance, are effective
Objective No 5: We will govern with transparency, comply with best practice and meet our Director lead: Mike Thompson, Chief Operating Officer statutory obligations. Lead: Michael Wuestefeld-Gray, Interim Associate Director of Principal Goal: Ensure the CCG strengthens the contribution of member practices to the CCG Governance
Risk 5.1: Risk of member practices disengaging with the CCG Date last reviewed: 5 March 2020
Cause of risk Effect of risk realising Initial Score Current Score Target Score Insufficient interest from GPs in Governing Body function not supported, unable to demonstrate to 4 x 4 = 16 3 x 4 = 12 1 x 1 = 1 undertaking leadership roles our public that we are clinically led, and do not deliver the transformational changes in clinical pathways we aim for
Brief rationale of current risk rating: The risk is still possible during transition and if realised would have a major impact on the CCG. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence Level that our controls, on which we are placing reliance, are effective Regular GP Governing Body Member meetings arranged with the Chair. The Chair has attended a regular round of 1 (low) meetings with member practices and these are ongoing. Frequency of Members’ Forums increased on request of membership and key national speakers Agenda and Minutes of meetings 1 (low) attending. Medical Director appointed to JET working closely with allied medical professionals across BLMK, Medical Director 2 (Medium) focusing on primary care at scale, clinical leadership, workforce and delivery across the three CCGs Local primary care leaders undertaking national primary care leadership programme and local 2 (Medium) programme of coaching and mentoring via NAPC has been put in place. New Constitution in place which supports four Practice representatives on Governing Body (3 of which CCG Website 3 (substantial) must be a GP) Constitution and Standing Orders changed to reflect the priorities of the membership for targeted use of clinical leadership resources. GPs engaged with CCG to join recruitment panels for recruitment of GP governing body members One Panel convened. 2 (Medium) Two GPs elected by Members to join CCG Governing Body Election process recorded on governance 2 (Medium) shared drive. Verification of votes carried out by Lay Member. Invite extended to GPs to join workshop to build JD for clinical Chair and recruitment material. The JD was finalised and approved by 1 (low) members at their October forum. Commitment made that new Clinical Chair will be in post Spring 2020. A single transitional Chair has been 3 (substantial) appointed for Bedfordshire, Luton and Milton Keynes CCGs, and will start in post on 1 April 2020. Primary Care Clinical Directors in post and CCG supporting development and network maturity This is being taken forward as part of the 2 (Medium) development of a single CCG Remedial action plans agreed & status By when?/Status Brief description of intended outcome Primary Care Strategy to be developed which will include July 2020 A primary care strategy is a requirement of the application to leadership development objectives establish a single CCG, and therefore this forms part of the work of the One Team Programme as well as ‘business as usual’. They will be presented to the Governing Bodies in Common no later than their July 2020 meeting. Survey carried out with all member practices to gain their views on Completed CCG processes designed to ensure that strategy and priority the CCG’s approach to clinical leadership; clinical leadership skills; setting are shaped and influenced by clinical expertise and effective communication and engagement; relationships between experience; clinical leaders and membership. Action plan being developed Review current involvement and engagement arrangements; following presentation of results at Members’ Forum Continued engagement with Member Practices as we move June 2020 To ensure Members have the confidence in the new strategic towards becoming a single strategic commissioner. commissioners and relationships are not adversely affected. Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence No high operational risks populating corporate risk register that our controls, on which we place reliance, are effective
Objective No 5: We will govern with transparency, comply with best practice and meet our Director lead: Chris Ford, Chief Finance Officer statutory obligations. Lead: Lynda Harris, Head of Information Governance Principal Goal:
Risk 5.2: The CCG fails to comply with legal and best practice requirements regarding the Date last reviewed: 5 June 2020 information it holds.
Cause of risk Effect of risk realising Initial Score Current Score Target Score Weaknesses in the CCG’s Sensitive information, including patient identifiable information, held 4 x 5 = 20 2 x 3 = 6 1 x 1 = 1 information governance controls by the CCG could be shared inappropriately and training, meaning staff are unaware of requirements Reputational and potentially legal implications for the CCG Brief rationale of current risk rating: It remains unlikely to happen. When controlled we do not expect any breaches to occur, however, actions to address gaps are still outstanding. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence Level that our controls, on which we are placing reliance, are effective Annual Mandatory IG Training Training Department monthly reports 2 (medium) Data Security Protection Toolkit completed in March 2019 2 (medium) Annual internal audit to provide assurance on the integrity of the self-assessment against the toolkit Reasonable assurance rating in March 3 (substantive) criteria, the overall effectiveness of information governance processes, and wider risk exposures. 2019. GDPR Data Protection Officer in place DPO acts in an advisory capacity to the 2 (medium) CCG and is a critical friend advising on high IG risks which may impact adversely on the CCG. COVID-19 Data Protection Impact Assessments (DPIAs) in place to assess new projects/processes Risk assessments 2 (Medium) Remedial action plans agreed & status By when? Brief description of intended outcome Information Asset Owners to undertake annual IAO training (audit October 2020 IAOs will understand how to manage and protect their assets in recommendation) accordance with data protection legislation .IG team will have dedicated workplans outlining how they will IG workplan in place July 2020 meet the requirments of DPA/GDPR Regular adhoc IG spot checks undertaken within CCG Directorates Ongoing To ensure staff are handling patient confidential and sensitive data safely and not leaving data lying around unclaimed on printers, tables and windowsills.
Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence No high operational risks populating corporate risk register that our controls, on which we place reliance, are effective
Objective No 5: We will govern with transparency, comply with best practice and meet our Director lead: Mike Thompson, Chief Operating Officer/ Geraint statutory obligations. Davies Director of System Commissioning
Principal Goal: Working to the joint Accountable Officer and leadership team, streamlining and Lead: Geraint Davies Director of System Commissioning strengthening commissioning leadership arrangements to deliver better outcomes for the people of Bedfordshire. Risk 5.3 : Inability to work effectively with partners to improve service delivery and reconfigure Date last reviewed: 6 June 2020 health and social care services within Bedfordshire Cause of risk Effect of risk realising Initial Score Current Score Target Score BCCG having insufficient influence Impact on any existing collaborative arrangements 4 x 4 = 16 3 x 4 = 12 1 x 1 = 1 within the BLMK partnership Failure to deliver single system operating plan and Failure to establish a governance objectives of the Integrated Care System structure that provides clarity around All partners not working together in the same way each part of the system. Different objectives and decision making criteria (elected Differential financial positions between members within Local Authorities; CCGs being membership the collaborative CCGs organisations) Brief rationale of current risk rating: With no established governance structure to underpin system in place as yet and merger now being planned it remains possible this risk could materialise. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence Level that our controls, on which we are placing reliance, are effective STP Memorandum of Understanding in place Held with Governance Team 2 (Medium) System Sustainability & Transformation Boards reporting to Health & Wellbeing Boards x 2 Minutes 1 (low) Joint Accountable Officer now in post holding a responsibility for shaping an integration agenda with Accountable Officer 2 (Medium) partners based on delivery of key commissioning objectives. ‘pan-CCG’ staff briefings taking place. Substantive COO now in place at BCCG and has worked across Bedfordshire organisations Chief Operating Officer 2 (Medium) One single executive team in place working as part of the Governing Bodies across all three CCGs, Joint Executive Team 2 (Medium) helping to strengthen the commissioning voice as it continues to lead on developing plans for BLMK with its system partners. Director of Integration in place - a joint post between Milton Keynes CCG and the Local Authority. Milton Keynes CCG 2 (Medium) Governing Body members from across the three CCGs met. The session was aimed at strengthening Joint Executive Team 2 (Medium) relationships across the patch and an opportunity for commissioning leaders to consider the approach, timeline and process we will undertake, as we move towards operating as a single CCG by April 2021. Early thinking plotted an outline roadmap through to April 2021 around key areas such as the role of strategic commissioner within an ICS, clinical leadership, governance and benefits SROs established within the BLMK Commissioning Collaborative. This will help us create capacity and Joint Executive Team 2 (Medium) focus at strategic and operational level, to keep the show on the road and ensure we deliver against our statutory duties, while making plans for the future that will enable us to operate as a single CCG by April 2021. Core Strategic Commissioner functions approved at Governing Body Meeting 21.11.19 Minutes 1 (Low) Collaborative Commissioning Executive Meeting on behalf of NHS partners in place Long Term Plan ratified and submitted to NHSE Bedfordshire Care Alliance established with long term ambition to work together to deliver more integrated care across Bedfordshire. Some care will be overseen at a bigger scale with Milton Keynes where it is economic to do so.
Remedial action plans agreed & status By when? Brief description of intended outcome Establishment of an ICS wide Partnership Board Complete Appointment of Lay Chair across ICS System Complete Working towards becoming a single strategic commissioner for 30 September 2020 To operate as a mature integrated care system BLMK Support the future development of primary care networks Ongoing Support future development of Integrated Care Partnerships Ongoing Establishment of One Team Programme Board to oversee delivery Complete of establishment of one single CCG. As Strategic Commissioner it is the aim to work with four BLMK These working design assumptions will support the design of the local authorities on JSNA, Heath & Wellbeing strategies, public new CCG health commissioning, Better Care funds and Section 75 commissioning arrangement in the 4 boroughs. Some CCG functions and roles will be transferring to ICPs as they No timeline set as yet CCG can be transparent about the resources dedicated to mature. Work to commence on ways in which these roles and supporting the development of ICPs. functions can be distinguished from strategic commissioning roles. Three Local Care Collaboratives (LCCs) being formed under To reflect ambition in the NHS Long Term Plan to radically improve Bedfordshire Care Alliance to deliver elements of integrated care care. LCCs will retain their autonomy and contribute to decisions locally. made at ICS Level. Linked operational risks appearing on Corporate Risk Register: Any gaps in assurance : Where are we failing to gain evidence No high operational risks populating corporate risk register that our controls, on which we place reliance, are effective
Objective No 5: We will govern with transparency, comply with best practice Director: Geraint Davies, Director of System Commissioning and meet our statutory obligations. Lead: Michael Wuestefeld-Gray Principal Goal: Delivery of strategic commissioner as part of the ICS
Risk 5.4: As Bedfordshire, Luton and Milton Keynes move toward becoming a single Date last reviewed: 6 June 2020 strategic commissioner there is a risk that they may not achieve the milestones necessary to do so by April 2021, resulting in disruption to the wider ICS and threats to achieving financial, clinical and operational objectives and performance.
Cause of risk Effect of risk realising Initial Score Current Score Target Score Size and complexity of the The governing bodies cannot effectively work as 12 12 4 governing bodies coming committees in common progressing CCG together to work in shadow form business effectively A failure to align the terms of There is uncertainty about where work can sit reference and scope of work of and be taken forward, resulting in delays and the CCGs’ various committees inaction. Brief rationale of the current risk rating: because work to address the risk’s causes has only recently started it would be inappropriate to assume the effect it will have, which is why the initial scores have not reduced. Controls What controls are in place now stopping the risk realising Assurances Where we can gain evidence that our controls, on which Level we are placing reliance, are effective The three CCGs are working closely on plans to develop the ICS and the strategic Joint working and collaboration arrangements, as well as an 1 (low) commissioner, and a common strategy to deliver this has been developed. The overarching programme and project architecture, have been developed CCGs are increasingly working together to align plans and move in step to achieve and implemented. progress The CCGs have commissioned support to develop a common working governance An interim AD for Governance has been appointed to Bedfordshire 2 (Medium) process using committees in common, joint committees, working groups and CCG who is working closely with his peers and the governance teams delegation to individuals. Sufficient time has been planned for the development and across all three CCGs, which are already co-operating closely and implementation of a period of shadow joint working as if they were already one aligning their work plans. He is working across all three CCG sites to strategic commissioner so the CCGs can learn and adjust before a formal merger facilitate and drive this. takes place Governing body members across the three CCGs are being engaged with to help There is greater understanding and support for this transition to new 2 (Medium) ensure there is a full and common understanding of what the next steps are to arrangements, and these can be progressed smoothly. This will deliver a common governance structure; ensure that their views and needs are facilitate the evidence of successful joint working needed to assure taken into account to deliver this; and identify areas of improvement to be built into NHS England and also governing body members to be ambassadors new arrangements. for the new system to members and other partner in the local health and social care economy. Remedial action plans agreed By when? Intended outcome of the action. The establishment of shadow working arrangements is on track to Complete By establishing and embedding joint working arrangements the three CCGs can start formally on 1 April 2020, with the first meetings of new joint develop the single CCG’s systems together and successfully develop joint working as committees and committees in common due to be done by the end a single organisation providing assurance to governing bodies, members of the CCG of May 2020. and NHS England. Linked operational risks appearing on Corporate Risk Register:
Standard Risk Register
Report Date 11 Jun 2020
Risk Status Open
Risk Area Board Assurance Framework
Control Status Existing
Action Status Outstanding
Page 1 of 5 Standard Risk Register
Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 1 There is a risk that Weaknesses I = 5 L = 4 Bedfordshire, Luton and Milton Keynes I = 5 L = 2 Increase joint working across the three CCGs there will be Recruitment of GPs into Luton 20 Commissioning Collaborative established with 10 within the STP Footprint in order to maximise insufficient workforce Recruitment of Practice Nurses Executive Team working across the three CCGs. capability and capacity. capacity across the Small team within the CCG Collaborative working though the STP Priority 2 Person Responsible: Patricia Davies Luton System to Retention of staff Transformation Boards to improve capacity across deliver the priorities of To be implemented by: 31 Dec 2019 Consequence the system. the both the Shortage of GPs to deliver the changes Luton CCG and Luton Borough Council co- Integrated Care Retention of staff who feel under located and integrated working to avoid System and the pressure duplication. Integration with Luton Unable to deliver at pace Borough Council NEL CSU appointed for the functions of Contract Management, Performance and Business Intelligence New Medical Director working across three CCGs and Executive Lead for Primary Care Workforce, strengthening links with Health Education England (Local Action Workforce Board (LWAB for BLMK). OD plan, staff meetings, PDP's for all staff in place. Training, development, appraisal process in place along with talent mapping matched to the objectives of the organisation. Permanent appointments to the Board, Executive and within teams in the CCG to ensure the required longer term capacity and capability to deliver the CCG business professionally and consistently.
Page 2 of 5 Standard Risk Register
Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 2 There is a risk of Weaknesses I = 4 L = 3 Bespoke clinical leadership for priority areas and I = 4 L = 2 insufficient Primary Care and Patients may not 12 programmes throughout the CCG 8 Person Responsible: engagement and believe in the vision Executive and Clinical Board Directors alignment To be implemented by: ownership in the GPs feel overburdened to PCNs system vision leading Acute sector do not own the issue to resistence to Focused agenda at PLT and Member's Forum change which may Consequence delay or prevent the Poor outcomes for the population Luton engagement in the STP to provide the progress of Pace and scale not achieved shared vision transformation. Acute sector overperformance - eating PCN chairs meetings with Clinical Directors to into scarce resources ensure engagement Commissioning plans not achieved Primary Care Investment Scheme to support Practice Clusters to drive change and strategy delivery. Work with LMC liaison committee to ensure that the CCG is working within the GP legal framework
BAF 3 Individuals and Weaknesses I = 4 L = 3 Commissioned Cambridge Community Services I = 4 L = 2 organisations resist Primary, Community and Social Care 12 to be coordinating provider for 'At Home First' 8 Person Responsible: integration, continuing do not have effective relationships Luton Primary, Community and Social Care To be implemented by: to work to internal Poor commitment to integration Transformation Board to ensure system working strategies rather than Acute sector continues to work to own the system-wide strategy Utilise the agreed outcomes of the ICS CEO's vision. group and Individual Workstreams Consequence Unnecessary admissions to acute for some patients High number of short stay admissions CCG finances strained due to acute sector over performance Voluntary sector resources not fully utilised
Page 3 of 5 Standard Risk Register
Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 4 The CCG may not be Weaknesses I = 4 L = 3 Communications and Engagement Strategy in I = 4 L = 2 Implementation of Comms & Engagement effective in engaging Lack of public engagement, insufficient 12 place and monitored through the Communications 8 Strategy for the BLMK area with place specific and involving the co-production and Engagement Steering Group actions. public, clinicians and Difficulties reaching diverse population Health and Social Care Reference Group to Person Responsible: Sarah Frisby organisations in the Provider engagement support engagement with public. transformation of the Primary Care engagement To be implemented by: 01 Jun 2020 NHS in Luton. Voluntary Sector engagement Consequence Communication of CCG's intentions not effective Patients not engaged in commissioning of services Behaviours slow to change Providers working in silos
BAF 5 The CCG may fail to Weaknesses I = 5 L = 4 A number of business functions such as payroll, I = 5 L = 4 Assess the success of the Cambridge Community meet its statutory duty Possible Acute Sector Over delivery 20 financial services, prescriptions payments and 20 Services and the Luton and Dunstable Hospital to deliver the agreed Insufficient head room in the budget Electronic Staff Records, are outsourced plan to mitigate emergency demand and agree risk end of year financial Challenging control total share for 2019/20 Accounts audited externally position and the Possibility of QIPP schemes not Person Responsible: Chris Ford system control total. delivering Capacity of the CCG to deliver the Areas of CCG business subject to internal audit in To be implemented by: 31 Oct 2018 QIPP and manage.. line with annual programme. Implementation of the Financial Recovery Plan Consequence Contract Management with major providers to Person Responsible: Chris Ford The CCG will not meet its financial control activity target and will be subject to special To be implemented by: 31 Mar 2020 Financial Assurance Meetings held with NHS measures England's Regional Chief Finance Officer Opportunities and Risk log reviewed on weekly basis Review of financial risks and mitigation take place at weekly Financial Resilience Group Meetings with issues escalated to F&P.
Page 4 of 5 Standard Risk Register
Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 6 The QIPP programme Weaknesses I = 4 L = 3 Financial Resilience Group meets weekly with a I = 4 L = 2 may fail to deliver its Programmes not achieving desired 12 monthly in-depth focus on QIPP performance. 8 Person Responsible: key objectives and outcomes PMO Structure and Governance in place through To be implemented by: savings leading to an Poor engagement from L&D Financial Resilience Group ensuring robust unplanned deficit and Pace and scale not achieved accountability and governance. failure to deliver the Acute sector continues to over best outcomes for performance patients. Consequence Poor outcomes for patients Not achieving financial position Won't meet priorities of the STP
BAF 7 The CCG may be Weaknesses I = 4 L = 3 BLMK Commissioning Collaborative provides I = 4 L = 2 Implementation of improved staff/clinician unable to recruit and Succession planning across the system 12 resilience at individual CCG level, with a shared 8 engagement programme of work retain staff and clinical Competing with larger CCG's with recruitment review process in place. Person Responsible: Sarah Frisby leaders with the right better benefits Engagement with staff through staff meetings and skills and abilities to Integration programme demanding To be implemented by: 15 May 2019 annual staff survey deliver the system- capacity Implementation of HR/ODL Strategy wide strategy. Small pool of clinicians Robust system of performance management and development in place to identify talent and map Person Responsible: Nicky Poulain Consequence gaps in knowledge across the organisation High turnover of staff slows down To be implemented by: 30 Sep 2019 progress Staff Involvement Group (SIG) is in place to Small teams so cannot achieve the ensure engagement will staff pace and scale Workforce strategy developed with shared service Knowledge management provider
BAF 32 There is a risk that Weaknesses I = 4 L = 3 Engagement with local Healthwatch I = 4 L = 3 Monthly team meetings in place to review providers’ provision 12 12 combined analysis of service provision and quality may of poor quality Consequence delivery. Escalation from this meeting as Ongoing contract and performance reviews due to workforce, or appropriate to Quality Committee and risk register capacity problems Person Responsible: Anne Murray which could lead to The review and learning from serious incidents poorer outcomes. To be implemented by: 03 Mar 2021 Visits to providers to gain assurance of quality and Local Quality team monthly operational meeting to safety flag and concerns or increase focus on service delivery Person Responsible: Anne Murray To be implemented by: 03 Mar 2021
Page 5 of 5 BAF
Report Date 18 Jun 2020
Status Open
Risk Area Corporate (Strategic), Finance
Control Status Existing
Action Status Outstanding
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 1 of 11
BAF
S2 - Access & Quality
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
Cessation of the CNWL Extra Care have given notice I = 3 L = 4 I = 3 L = 4 I = 3 L = 3 ST S2 - Action plan created by CNWL Replacement premises to be Jan Wood 30 Jun 2020 TOPAS service if new to CNWL to vacate premises 12 12 9 82 Access monitored through contract found & approved accommodation cannot occupied by TOPAS service & meetings Quality found which could result in no Location of new premises; Jan Wood 01 Jul 2020 premises for clients leading to Weekly project meetings business case to support estates Owner: Jan Wood excess cost & anxiety for changes to be approved: weekly
Risk Lead: Jan Wood patient & families due to project meetings to mainatain
placements out of area. momentum: MKC to be kept Last Updated: 31 Mar informed
Latest Review Date: 31 Mar 2020
Latest Review By: Jan
Wood
Last Review Comments:
ON progress
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 2 of 11
BAF
S2 - Access & Quality
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
Patients have poor cancer Complexity of cases, wait I = 4 L = 4 I = 4 L = 3 I = 4 L = 1 ST S2 - Cancer lead is now assigned Conduct a Peer review of urology Maria Browne 29 Feb 2020 55 Access outcomes times (particularly in Urology) 16 12 4
to cancer transformation pathways with NHSE ensuring hand off between secondary & Owner: Linda Chibuzor along with Programme lessons learnt and to drive
care and tertiary centres, and Quality Support and a an allocated improvements Risk Lead: Linda Chibuzor capacity in secondary care
person from the Cancer resulting in delays in Continue attendance at meetings Linda 31 Mar 2020 Last Updated: 27 Feb Alliance. The Trust are also
accessing cancer treatment and monitor mitigations through Chibuzor out to advert for a project Latest Review Date: 19 and subsequent risks to CQRMs. lead. Feb 2020 patient recovery, outcomes
and mortality rates. CCG and MKUH colleagues Latest Review By: Linda are working together and Chibuzor have reviewed the cancer
Last Review Comments: pathways. There is now a To be updated to be include Clinical triage of patients and this process priorities those speciality areas i.e. urology patients who need to be seen sooner following blood results etc. CCG and MKUH colleagues are working together on the reporting. CCG colleagues attend MKUH the cancer meetings. Collaborative work between MKH, MKCCG and the Cancer Alliance to improve cancer pathways - utilising the available national funding to support transformation. Contract levers in place to manage underperformance Increased CCG and provider board focus Oversight and scrutiny of performance at MKH PTL and Contract meeting.
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 3 of 11
BAF
S2 - Access & Quality
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
QSG oversight and escalation to Regional QSG
RCA reviews of all 62 day breaches Recruited a Urology Nurse within the Trust to increase capacity and release Consultant work. The provider utilises a cancer PTL tool . Scheduled PTL meetings and speciality meetings re division capacity and demand. Through regular CQRMs, the CCG and MKUH have worked together to provide assurance on cancer pathways, diagnosis and the workforce. The waiting lists for patients has reduced and patients are being diagnosed sooner and this improves the patient's prognosis.
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 4 of 11
BAF
S2 - Access & Quality
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score
b ST S2 - Insufficient Health and National, regional and local I = 4 L = 5 I = 3 L = 4 I = 3 L = 2 Transformation teams raising Quality Committee review regular Jenny Brooks 12 Nov 2019 Social Care Workforce staff shortages in key areas, 20 12 6 52 Access and monitoring risk in workforce reports from providers. Capacity and Capability to there are significant challenges & This work will link into LWAB for a deliver transformation in recruiting and retaining Quality wider picture this will then be Linda Chibuzor substantive staff into new and Owner: LWAB local Workforce Action Health and social workforce risks Linda 31 Mar 2020 Julie Uglow existing roles within the health Board working through Risk Lead: discussed at integration board to Chibuzor 11 Jun 2020 and social care workforce to leadership & organisational Last Updated: identify opportunities for workforce Latest Review Date: 19 deliver service transformation. sub-groups with providers to Resulting in inability to integration to improve efficiency. Feb 2020 secure recruitment and This work is ongoing completed in Latest Review By: Linda implement transformation retention initiatives and
plans impacting on quality of Chib or Development of staff into new Providers working with education Linda 31 Mar 2020 Last Review Comments: roles in secondary and institutions to make training more Chibuzor
No change accessible, improve workforce LWAB scoped workforce supply, develop new roles and ht t BLMK th di l kf Monitoring and investigation
of serious incidents in provider services will flag Workforce planning across STP through Local Workforce
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 5 of 11
BAF
S2 - Access & Quality
Cyber security risks As a result of outdated I = 4 L = 3 I = 4 L = 3 I = 3 L = 2 ST S2 - A plan is in place to replace AGEM to install new servers and Wendy 30 Jun 2020
unsupported systems or 12 12 6 76 Access Owner: Wendy Rowlands Windows 7 with Windows 10 turn off old servers in GP Rowlands delays in patching systems, & Practices. 8 out of 11 completed. Quality Risk Lead: Wendy there is a risk that the CCG IT Fire wall in place at each GP Deadline extended again due to Rowlands infrastructure is unprotected, site Covid-19. Last Updated: 31 Jan 2020 resulting in the CCG being New servers are being prone to Cyber attacks. This installed to replace Windows HBL to undertake a cyber Wendy 31 Jul 2020 Latest Review Date: 09 could impact on other partners 2012 servers security risk assessment when Rowlands Jun 2020 joined to the network. they take over services
Microsoft have agreed to Latest Review By: Wendy continue to support Windows Complete implementation of W10 Wendy 30 Sep 2020 Rowlands 7 for an additional 12 in remaining GP practices once Rowlands
Last Review Comments: months. Upgrade will offer HBL ICT take over services from Reviewed & no changes additional security therefore April 2020
made the CCG will still push forward with the upgrade
Windows 10 installation completed in the CCG site.
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 6 of 11
BAF
S3 - Financial Sustainability
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
Delegated Primary Care As a result of the nationally I = 4 L = 4 I = 4 L = 4 I = 4 L = 3 F 24 S3 - Financial monitoring through Review calculations of impact of Wendy 30 Jun 2020 Spend to Exceed 20/21 agreed Primary Care Contract 16 16 12 Financi Primary Care Committee, new GP contract deal and Rowlands al Allocation settlement and the increase in
Finance Committee and anticipated allocation top up to GP practices in MK to meet Sustain Owner: Wendy Rowlands Board assess potential to offset financial
population growth there is a ability pressure. Reconsider this in light Wendy risk that expenditure on Risk Lead: Financial plan developed of new budget regime for Covid- Rowlands delegated primary care will based on assessment of new
19 exceed the allocation resulting contract deal and practice Last Updated: 02 Apr 2020 in failure to deliver the growth in MK Assess opportunities for slippage Wendy 30 Jun 2020 Latest Review Date: 09 financial control total in plans to mitigate financial Rowlands
Jun 2020 pressure
Latest Review By: Wendy Rowlands
Last Review Comments:
no changes
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 7 of 11
BAF
S3 - Financial Sustainability
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
Covid-19 impact leading to As a result of the Covid-19 I = 3 L = 4 I = 3 L = 4 I = 3 L = 3 F 26 S3 - Targeted guidance has been Agree with the CFO Counter Wendy 30 Jun 2020 Financi increased risk of fraud incident there is potential 12 12 9
sent staff to ensure that staff Fraud specific work items to be Rowlands increased risk of fraud, this al Owner: Wendy Rowlands remain astute to fraud risks pursued locally.
includes: cyber fraud, Sustain and the changing nature of Wendy misappropriation, invoice ability Risk Lead: fraud during the crisis. Regular staff communications to Wendy 31 Jul 2020 Rowlands fraud, procurement fraud be issued. Rowlands
etc… The CCG has a Local Last Updated: 19 May Counter Fraud Service 2020 (LCFS).
Latest Review Date: 09 Jun 2020
Latest Review By: Wendy Rowlands
Last Review Comments:
no changes
Failure to Deliver MHIS As a result of financial I = 4 L = 3 I = 4 L = 3 I = 3 L = 3 F 22 S3 - Acting CFO has written to Ensure that recommendations of Wendy 30 Jun 2020 pressures the CCG is unable 12 12 9 Financi Owner: Wendy Rowlands NHSE/I East Region setting the MHIS audit undertaken by Rowlands to deliver the requirements of al out position re: MHIS delivery GTUK are implemented. Sustain the Mental Health Investment in 2019/20 and cumulative Standard (MHIS); including ability under delivery relating to Work with NHSE/I to set out Wendy 30 Jun 2020 cumulative recovery of under Risk Lead: Wendy prior year attainment (as pe financial and consequential Rowlands delivery against the target for Rowlands MHIS audit, yet to be issued). implications of recovering the 18/19 financial year (as cumulative MHIS under Last Updated: 02 Apr 2020 identified through the 18/19 all appropriate spend is performance. Latest Review Date: 09 MHIS audit). captured and reported Jun 2020 against the standard Enhanced reporting of
delivery against the MHIS to Finance Committee and
Latest Review By: Wendy Governing Body. Rowlands
MH provider has signed-off Last Review Comments: 20-21 MHIS plans.
No changes
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 8 of 11
BAF
S3 - Financial Sustainability
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
Covid-19 Impact on delivery As a result of the Covid-19 I = 4 L = 4 I = 4 L = 3 I = 4 L = 2 F 25 S3 - LA/CCG Finance Cell has S75 agreement to be agreed with Wendy 30 Jun 2020 Financi of 20-21 Financial Plan incident the NHS is operating 16 12 8
been convened. Local Authorities. Rowlands with amended contract and al Owner: Wendy Rowlands Reimbursement for hospital
payment arrangements - there Sustain discharge costs expected CCGs to review SFIs in light of Wendy 30 Jun 2020 Wendy is a risk that the CCG is ability Risk Lead: based upon data submitted response. Rowlands Rowlands incurring additional and
by CCGs. unfunded costs that could Develop financial plan beyond Wendy 17 Jul 2020 Last Updated: 09 Jun 2020 July once NHSE guidance Rowlands jeopardise the delivery of the Revised budget plan released Latest Review Date: 09 20-21 financial targets. implemented for Covid-19
Jun 2020 and new NHSE financial
regime to top up additional Latest Review By: Wendy costs each month Rowlands The CCG has created an Last Review Comments: incident cell structure which Controls & actions updated includes finance representation. Revenue and capital commitments agreed by the Cell are being captured to support financial reporting locally and
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 9 of 11
BAF
S3 - Financial Sustainability
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
Failure to deliver 20/21 As a result of the carried fwd I = 5 L = 4 I = 5 L = 4 I = 5 L = 3 F 21 S3 - Financial Plan Developed for Scoping opportunities with BLMK Wendy 30 Jun 2020 Financi Financial Plan underlying financial position of 20 20 15
20/21 with QIPP schemes system partners via CEO/CFO Rowlands the CCG, and the new 20/21 al Owner: Wendy Rowlands identified for 63% of target fora. Put on Hold due to Covid-19
Sustain cost pressures leading to a ability Risk Lead: Wendy consequential significant QIPP Joint Savings Programme in BLMK CCG QIPP Programme Paul Burridge 30 Jun 2020 Rowlands required to deliver the 20/21 Place with Providers with Board to be established chaired Financial Plan target - there is joint review meetings & CCG by Director of Performance. Put Last Updated: 02 Apr 2020 a risk that the CCG is unable Lead co-ordinator. CCG on hold due to Covid-19 Latest Review Date: 09 to fully identify and deliver the Commissioners have Jun 2020 required QIPP/Transformation honorary contracts with Seek support and capacity from Wendy 30 Jun 2020 savings plan and by providers to support joint NHSE/I East Region. Rowlands Latest Review By: Wendy consequence the 20-21 transformation programmes Rowlands Identification of schemes - a Paul Burridge 30 Jun 2020 Financial Plan target. workshops took place on 11th Monitoring Process in place Last Review Comments: and 12th March 2020 conducted through Finance Committee No changes at a BLMK level with attendance & Board from Directors and Assistant/Associate Directors from all 3 CCGs. Aim to agree a small number of large financial opportunities that can be scoped and built up quickly to mitigate the financial gap. A number of areas were identified and action for leads to build opportunities into programmes, with measurable outcomes and plans, which can then be tracked and managed via the PMO. - Put on h ld d t C id 19 Re-assess the position as part of Wendy 30 Jun 2020 the recovery workstream actions Rowlands for Covid-19
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 10 of 11
BAF
S3 - Financial Sustainability
Ref CCG Risk Descriptor Risk Cause and Effect Initial Risk Control or Mitigation Current Action Required Person To be Target Obj. Score Score Responsible implemented Score by
Insufficient capacity & The alignment of the CCGs; I = 4 L = 4 I = 3 L = 4 I = 3 L = 3 ST S3 - CCGs Transition Team & On going monitoring Richard Alsop 27 Mar 2020 capability as a result of the development of the ICS 16 12 9 63 Financi Transition plan established to increased partnership & and reduction in running costs al manage practical aspects of matrix working required by 2020 there is a Sustain commissioning alignment.
requirements risk that the CCG has ability Owner: Richard Alsop insufficient capacity to deliver
its statutory business. Do, Buy, Share Project Risk Lead: Richard Alsop
underway across CCGs to Last Updated: 09 Jan 2020 review CCG support functions to ensure that they Latest Review Date: 09 are both robust and aligned Jan 2020
and have sufficient capacity Latest Review By: Joyce for the future. Baskerville Ensure Director lead for key Last Review Comments: priorities and cross Reviewed and updated organisational workstreams.
Limited use of interim capacity being used to support high priority areas One Team approached established Nov 19 - additional resources to support this transition
CCG Objective Key: S1 - Drive Improvement in Health & Wellbeing Outcomes; S2 - Deliver Improved Access & Quality Standards; S3 - Deliver Financial Sustainability. Risks described as Principle Risks will have linked sub-risks which provide detail on controls and assurance. Page 11 of 11
5.3
Governing Bodies in Common in Public
21 July 2020
Committee Minutes
Author: Various Contact Information: [email protected] Lead Executive: Various Which CCGs does this paper apply to?
Bedfordshire Luton Milton Kenyes
Information
Which activity does this paper To provide an update on the most recent activities of each of the relate to? sub-committees of the Governing Bodies, by presenting final versions of meeting minutes. How? The paper serves to provide assurance that the committees are carrying out their functions effectively.
What is the Committee/ To receive the updates and to be assured. Governing Body being asked to do? What are the financial N/A implications?
Set out the key risks and risk N/A ratings
Date to to which the information The dates on the minutes this paper is based on was accurate
Executive Summary
The most recent approved committee minutes are provided for information for the Governing Body
Audit Committee
Minutes of the Audit Committee Meeting Held on 30th April 2020, -09:00-10:15 The Meeting was held virtually via Microsoft Teams Members Present: Saqhib Ali Lay Member – Audit and Governance (Chair) SA Sally England Lay Member – Finance and Performance SE Dr Chris Longstaff GP Governing Body Member CL
Others in attendance Neil Abbott Director of Audit, TIAA, Internal Auditors NA Chris Ford Chief Finance Officer CF Lisa George Lead Counter Fraud Specialist, TIAA, Internal Auditors LG Paul Grady Key Audit Partner, Grant Thornton PG Maryla Hart Governance and Committee Officer (Minutes and presenting) MH Stephen Makin Acting Chief Finance Officer SM Malcolm Miller Deputy Chief Finance Officer, BCCG MM Mark Peedle Head of Digital MP Parris Williams Manager, Audit, Grant Thornton, External Auditors PW Michael Interim Assistant Director of Governance Risk and Corporate MWG Wuestefeld-Gray Affairs, Programme Manager for Governance BLMK CCGs
Apologies: None
1. & Welcome and Apologies for absence Action 2. The Chair welcomed all members and attendees to the meeting. No apologies had been received.
3. Declarations of Interest There were no declarations of interest in relation to the agenda.
4. Minutes of the Meeting held on 20 February 2020 The Audit Committee approved the draft minutes subject to the following changes being made:
Page 4, Item 6, Internal Audit Progress Report
“SE queried whether the committee was happy with the position of the audit given that the majority of systems gained reasonable assurance and one gained limited assurance” to be added before the sentence “SA advised that this is an improvement from 4 years ago and we should be getting better year on year.”
Page 4, Item 6, Internal Audit Progress Report:
Page 1 of 6
“SE praised the good chunky audit”, to be deleted.
Page 5, Item 6, Internal Audit Progress Report: “…in the country” to be removed from the sentence ”There is a common financial environment across 3 CCGs in the country.”
5. Actions from the Meeting Held on 20 February 2020 The following updates were provided.
ACO37: Primary Care Delegated Commissioning internal audit. Update: MM has fed back to Attain the Audit Committee’s views and is awaiting a response. This has been referred internally for review and further comments. BCCG is expecting a more comprehensive response in due course. Ongoing
ACO39. Recommendations from Annual Audit Letter. Update: This is on the meeting agenda under Item 17. Closed
ACO40: Procurement for BI and Analytics service. This is on the agenda under item 16. Closed
AC405: Internal Audit. To forward the Client Briefing Notes actions to Mark Peedle, Head of IT to action, with an update at the second meeting of 2020. Update: This is in relation to windows 7 and other ICT. The CCG corporate side is 100% compliant on windows 10. The CCG has no windows 7 devices. In general practice around 80% of devices are now on windows 10 and there are a few more to be upgraded. Will be done in time for the deadline. Closed.
ACO48a. Gifts & Hospitality Risk Register. MGW to explore the current arrangements around pharmaceutical sponsorship to see how they can be resolved Update: MGW to double check this has been implemented so the action can be closed. Ongoing
ACO48b. Gifts & Hospitality Risk Register. To review the Gifts & Hospitality Policies of the three CCGs and the application of the process. Update: A COI/GSH report is on the agenda of the April meeting. A single COI reporting process is being developed and a single policy will be created late spring or early summer 2020. Due to lockdown this work has slowed a little. The aim is to start reviewing all the policies by the time of first Governing Body in common in May. Ongoing
ACO50. Internal Audit Progress Report February 2020. This action has been completed. Closed.
ACO50. Internal Audit Progress Report February 2020. Mark Peedle to give an update at the next Audit Committee meeting (regarding GP IT and CBN-2001 (action in Client Briefing Notes). Update: This has been addressed under item AC405 above and is on today’s agenda. Closed
ACO51. Audit Scope and Additional Work. Update: Audit Committee Scheduled for 30/04/2020. Closed
ACO52. Audit Scope and Additional Work. MH to send audit reports as individual documents alongside the next meeting pack as links to do not always
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work when embedded in combined documents. Update: To be carried out as Business as usual going forward. Closed
ACO53. Local Counter Fraud Progress Reports – February. 30/04/2020: This links in with Conflicts of Interest Policy to be reviewed by the Time of Governing Body in Common in May 2020 as discussed under action ACO48b. Ongoing
ACO54: Agreement of final accounts timetable and plans. Update: This action has been completed. Closed
ACO55: Review of CCG Assurance Framework and Risk Register. Update: work to review and update risk registers has accelerated due to the Corona virus response, but initially the focus is on risks that may be affected by the outbreak. Consolidating risk management across the CCGs has started, with plans to move at pace once normal business activity has been restored. This item is on the agenda.
ACO56: Competitive Tender Waivers MH to circulate 5029 waiver documentation to the Audit Committee membership for virtual approval. Update: This was circulated on 28/02/2020 and SA, SE and CL replied that they were happy to approve it. The email audit trail has been saved on the drive. Closed
ACO57: Recommendations from Annual Audit Letter SM to take the recommendations from the Annual Audit Letter back to the executive committee to reiterate the findings that had occurred 2 years running. Update: Ongoing
6. Internal Audit Annual Report Neil Abbott, Director of Audit, TIAA presented the report.
ACTION: SA or NA to circulate the last three audit reports since NA February’s meeting.
ACTION: NA to bring a new paper to each Audit Committee in 2020-21 NA/MH tracking recommendations, progress around their completion and comments from management.
The Audit Committee noted and approved the Internal Audit Annual Report. 7. Internal Audit Recommendations, High, Medium and Risks Neil Abbott, Director of Audit, TIAA, gave a verbal update.
The Audit Committee noted the update. 8. ICT Update Mark Peedle, Head of Digital, gave a verbal update on the role out of Windows 10 at the CCG and in practices, The role out of the HSCM network is still on track to be completed by the end of August this year. One positive of the Covid Legacy will be a superior network.
The Audit Committee noted the update.
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9. Draft 2020/21 Counter Fraud Work Plan Lisa George, Counter Fraud Specialist, TIAA presented the work plan
The Audit Committee noted the report 10. Counter Fraud Annual Report Lisa George, Counter Fraud Specialist, TIAA, presented the report.
ACTION: CF and SA to work together to get the report signed off by the CF/SA Counter Fraud Authority. The deadline has been extended to the end of May.
The Audit Committee noted the Counter Fraud Annual Report. 11. External Audit progress report Parris Williams, Audit Manager, Grant Thornton gave an update.
MM and MP advised that they were happy to link PW up with any relevant staff so PW could obtain the updates.
The Audit Committee noted the report. 12. 12.1 External audit plan for 2019/20 12.2 External Audit Plan Addendum 12.3 Key Issues Bulletin – March 2020
Paul Grady, Key Audit Partner, Grant Thornton presented the reports.
SA advised that the deadline for filing accounts to NHSE has been moved back to 25 June 20 and advised moving the May Audit Committee meeting to June.
The Audit Committee noted the reports. 13. Annual Review of Accounting Policies
Malcolm Miller, Deputy Chief Finance Officer advised that there have been no changes to accounting polices since last year.
The Audit Committee noted the update. 14. Annual Governance Statement
Michael Wuestefeld-Gray, Interim Assistant Director of Governance, Risk and Corporate Affairs presented the Annual Governance Statement.
ACTION: An error in the attendance register was pointed out. “6/6” MWG should say “100%”.
Letter Entitled: NHS Bedfordshire Clinical Commissioning Group Statements for the year end 31 March 2020. Understanding how the Audit Committee gains assurance from management
This letter was circulated to committee members earlier today
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ACTION: MWG to remove the comment “The CCG internal control framework is not as robust as management and the Governing Body MWG would wish to see, but actions are underway to make improvements” from the letter”.
ACTION: Once the letter is complete and approved it is to be shared with PW and the auditors. SA/MM/ MWG The Audit Committee noted the draft letter.
15. Corporate Risk Register (CRR) and Governing Body Assurance Framework (GBAF)
Michael Wuestefeld-Gray, Interim Assistant Director of Governance, Risk and Corporate Affairs presented the CRR and GBAF.
The Audit Committee noted the report. 16. Update on Conflicts of Interest Management Maryla Hart, Governance and Committee Officer, presented the report.
The Audit Committee is approved the draft changes to the following templates as shown in the appendices and outlined in the report: • The Register of Gifts, Hospitality and Sponsorship • Declaration of Gifts and Hospitality Form • Conflicts of Interest Register • Conflict of Interest Form The audit committee supported the proposal for these templates to be taken forward and used for BLMK CC. 17. Report on the Use of the Seal
MM advised that there had been no uses of the seal since last year.
18. Losses and Special Payments Report
MM advised that there had been no losses or special payments made. 19. Competitive Tender Waivers
MM advised that he did not have any waivers to present to the committee today, but he is chasing any Tender Waivers.
The Committee noted the update. 20. Any Other Business
NA raised the effects of Covid-19 and remote working arrangements. MM and NA had a discussion about attempting to complete Quarter 1 (Q1) audits. Continuing Healthcare (CHC) and procurement audits are hard to do when staff are redeployed on Covid related matters. There may be some delay in starting some of these planned audits. MM advised that it would be sensible to push these two audits back. He will be active on the procurement and tender waiver front. It was advised to have a conversation with Kathryn Moody.
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21. Items to raise to the Governing Body
The Chair listed the items to be raised at the next Governing Body in Common: • Internal Audit, including the fact that the CCG received reasonable assurance overall • External audit and the fact that the sign-off date has been moved to June from May • Fraud – there is nothing substantive on fraud to raise • ICT – the CCG has an extra year to migrate over to windows 10 • High speed network issues: some GP surgeries will currently only have one network rather than a second as backup. This should be installed within a month from now. . • Work carried out on the Corporate Risk Register and GBAF.
The Chair advised that this is the last BCCG Audit Committee.
MWG advised that the accounts are likely to be signed off at Audit Committee on 23 June rather than in May.
ACTION: MGW/MH to send out invites for 23 June Audit Committee by 8th May.
A conversation took place about getting the the agendas for the Audit Committee in Common aligned and the fact that Luton and Milton Keynes had not had a final wrap up meeting of their audit committees, although they still could do so. The CCGs must show NHSE that they are aligning their committees. Various options were discussed.
ACTION: The three chairs of the current BLMK CC audit committees to have a discussion about agendas.
22. Date of Next Meeting - Audit Committee in Common, 26th May 2020.
The meeting closed at around 10.15am
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Approved Minutes
Meeting: Luton CCG Audit and Risk Management Committee
Date: Tuesday 21st January 2020
Time: 10:00-12:00
Location: Conference Room, Arndale House, 3rd Floor, the Mall, Luton LU1 2LJ
Present: Mahmood Aziz (MAz) Lay Member, Finance and Procurement David Kempson (DK) Chair, Lay Member, Audit & Governance In Attendance: Luton Clinical Commissioning Group Liz Cox (LC) Deputy Chief Finance Officer Gaynor Flynn (GF) Information Governance Manager, Bedfordshire, Luton and Milton Keynes (BLMK) CCGs Lynda Harris (LH) Head of Information Governance and GDPR Data Protection Officer, Bedfordshire, Luton and Milton Keynes (BLMK) CCGs Michael Wuestefeld-Gray Interim Assistant Director of Governance Risk and (MWG) via Teleconference Corporate Affairs, Bedfordshire, Luton and Milton Keynes (BLMK) CCGs Grant Thornton Parris Williams (PW) Engagement Manager RSM UK Liz Wright (LW) Head of Internal Audit Bradley Vaughan (BV) Counter Fraud Manager Minutes: Elaine Baugh (EB) Governance & Risk Support Officer (minutes) Apologies: Chris Ford (CF) Chief Finance Officer Kathy French (KF) Independent Nurse Member Stephen Makin (SM) Acting Chief Finance Officer
Actions 01/20 1. Welcome, Apologies and Chair’s Comments The Chair welcomed all to the meeting and introductions were made. Apologies received as noted above.
LC advised the Committee that Chris Ford is unfortunately away on extended sickness absence and therefore Stephen Makin is Acting Chief Finance Officer in the interim.
02/20 2. Declarations of Interest & Hospitality in Relation to Agenda Items There were no declarations or hospitality in relation to agenda items.
03/20 3. Minutes of the meeting held on 15th October 2019 The Committee reviewed the minutes of the meeting held on the 15th October 2019 and approved as an accurate record of the meeting.
The Committee approved the minutes of the meeting held on the 15th October 2019. 04/20 4. Matters arising from the meeting held on 15th October 2019 The Committee reviewed the Action Log with the following updates noted: 84/17 – The Committee agreed that this action has been superseded by the proposed establishment of a single BLMK CCG. The Committee agreed to close this action. 84/18b – The Committee agreed that this action has been superseded by the proposed establishment of a single BLMK CCG. The Committee agreed to close this action. 92/18a – It is unclear where Whistleblowing/Freedom to Speak Up sits within the Executive Team. This is a significant action required by the Executive Team. LC to prompt the Executive Team for a response. Staff members have approached the Freedom to Speak up Guardian. The Committee agreed that there needs to be ownership and accountability. Action – The Executive Team to identify an officer responsible for Freedom to PD Speak Up, in time for that officer to report to the March Audit meeting. 26/19a – Action transferred to MWG. 26/19b – Action transferred to MWG. 55/19b – Action transferred to MWG. 62/19c – BV advised that the report was sent to the CCG, however was not followed up. A process is now in place to prevent this happening in the future. This was reported in the Annual Report as a requirement for the NHS Counter fraud Authority Standards. The Finance Team are working to address the findings by March 2020. 62/19d – LC to discuss with Stephen Makin. 69/19 – LC advised that she met with MWG after the October 2019 meeting to bring him up to speed with all the outstanding actions. This is part of MWG’s ongoing workload; see minute reference 08/20 Board Assurance Framework.
71/19a – On agenda under item 8 Board Assurance Framework.
71/19b - Part of MWG’s ongoing workload, see minute reference 08/20
Board Assurance Framework.
76/19b – LC advised that MWG has previous experience and could draft a
case study for Committees to work through. DK emphasised that the
training also needs to include how meetings are administered and
minuted when a conflict of interest is declared. MWG Action - Conflict of Interest Training to be developed.
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Action – To review the RAG ratings on the Action Plan. EB 05/20 5. Information Governance Policies LH presented the following Information Governance (IG) Policies for ratification. The policies have been reviewed and approved by the Governance and Risk Steering Group: a. Data Protection by Design & Data Protection by Default Procedure – LH explained that this policy was developed as a requirement of the General Data Protection Regulations (GDPR) to outline the procedure to follow. b. Confidentiality Policy – The policy presented included tracked changes. The changes to the policy are to reflect GDPR requirements. Internal Auditors have requested to see this policy. c. Safe Haven Policy - The policy presented included tracked changes. LH advised that it is a requirement to phase out the use of fax machines, therefore section 10 (Communication by Fax) has been updated to reflect this. The Committee queried the use of social media in sending confidential information to ensure data is kept safe. d. Information Asset Policy – This is a requirement under the Data Security Protection (DSP) Toolkit. Each year the CCG has to log the information assets and any associated data flows. The IG Team offers training to staff in completing and reviewing the Information Assets and Data Flows spreadsheets. It was noted the Stephen Makin will act as the Senior Information Risk Owner (SIRO) in his role as Acting CFO. The policy presented included tracked changes. e. Information Lifecycle Policy - The policy presented included tracked changes. The policy gives guidance to staff on records management, retention and destruction. f. National Data Opt-Out Policy – This is a new policy, developed as a requirement of GDPR. All organisations have to comply with the National Data Opt-out Policy by March 2020. LH explained the work her team have conducting with GP practices to ensure they are compliant by the deadline. g. Information Governance Policy and Management Framework (IGMF) – LH explained that this policy needs to be reviewed annually as directed by Internal Audit. The Committee queried the process for feeding back on reported breaches. LH explained the process for investigating a breach and feeding back to the Governance and Risk Steering Group; however at present there is no formal feedback to staff. The Committee requested that when the policy is next reviewed to give consideration to the feedback process.
It was noted that when the policies are next reviewed it will be for the single BLMK CCG.
The Committee ratified the following policies: a. Data Protection by Design & Data Protection by Default Procedure b. Confidentiality Policy c. Safe Haven Policy
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d. Information Asset Policy e. Information Lifecycle Policy f. National Data Opt-Out Policy g. Information Governance Policy and Management Framework (IGMF) 06/20 6. Hertfordshire, Bedfordshire and Luton ICT (HBLICT) Policies LH presented the following HBLICT Policies for ratification. The policies have been reviewed and approved by the Governance and Risk Steering Group: a. Acceptable Use Policy – This policy has been reviewed and updated. b. Patch Management Policy – The Internal Auditor has requested to see this policy. They are keen know how the patches are applied and how often in view of the possible cybersecurity breaches. The Committee queried the process for applying emergency patches in the event of a cyber-attack for non-standard patches e.g. Wannacry, which needs to be reflected in the policy. c. Telecoms Policy – This policy has been reviewed and updated. The Committee suggested that when the policy is next reviewed to update the ‘Request Form’ (page 20) as the devices listed are out of date in addition to making reference to 5G.
The Committee suggested speaking to HBLICT regarding acquiring Bluetooth speakers to enhance conference calls made via mobile telephones.
Action – To speak to Rose Francis, Business Relationship Manager, HBLICT, LC regarding Bluetooth speakers for the meeting rooms.
The Committee ratified the following policies subject to the recommendations noted above: a. Acceptable Use Policy b. Patch Management Policy c. Telecoms Policy 07/20 7. Freedom to Speak Up Report The Committee agreed to defer this item to the March 2020 meeting while clarity is sought on whom within the Executive Team is responsible for Whistleblowing / Freedom to Speak Up.
08/20 8. Board Assurance Framework [MWG joined the meeting at 10:32 via teleconference]
MWG presented the Board Assurance Framework. MWG has reviewed the actions. The Committee wants to ensure moving forward the BAF risk register reflects the current risks, actions and risk owners.
MWG proposes to contact each risk owner to work through the outstanding actions in order to update the BAF. MWG is keen to ensure that the active work of risk management is taking place and 4Risk is kept up to date.
The Committee agreed that the BAF needs to be reviewed from scratch to give a
4 | P a g e clear and accurate picture as the CCG moves to become a single CCG with Bedfordshire and Milton Keynes CCGs. There needs to be new objectives and the associated risks to the new objectives assessed. The CCG also needs to map the CCG risks against Internal Audit’s map of assurance and review the risks linked to the controls i.e. looking at risks from different angles. The Committee also noted that the CCG is in a changing environment, which needs to be taken into account. The Committee also noted that the seven BAF risks do not include a risk relating to performance, which is a fundamental weakness in how the CCG is looking at risks. MWG suggested that the risks needs to be linked to the Corporate objectives, reference needs to be made on the BAF that there is no corporate level risk for this area and other areas which should be on the BAF.
The Committee acknowledge that this is a huge piece of work to complete, MWG advised that the three CCGs are working together to become one single CCG and that this piece of work will need to take priority in order to bring Luton CCG up to speed with the other CCGs.
Action – To advise the Committee on the realistic timescale for completing this MWG piece of work.
The Committee noted the current Board Assurance Framework and note the additional work required by MWG in order to get the BAF to the required standard. 09/20 9. Corporate Risk Register MWG presented the Corporate Risk Register. The Committee noted that the Corporate Risk Register requires updating in relation to risk owners, outstanding actions etc. MWG acknowledge that the same actions required for the BAF are also needed for the Corporate Risk Register, which will require the support of the Committee to address the issues to get the risk register to a satisfactory position and to escalate if necessary. The Committee were happy to give their support to this.
The Corporate Risk Register is drawn from 4Risk, raising concerns as to whether the system is being correctly used and managed.
Action – To investigate how 4Risk is used and managed within the CCG. MWG
LW suggested the first approach would be to conduct a cleansing exercise. LC added that the Governance and Risk Steering Group does review the individual risk register with the Associate Director for each risk area, however this had proved challenging in terms of attendance at meetings and reviews.
10/20 10. Committees in Common MWG presented an updated on the proposed Committee in Common; this will be discussed in greater detail at the Board Meeting being held later in the day.
The proposed BLMK CCG will operate in ‘shadow’ form from April 2020. As the
5 | P a g e three CCGs will remain single entities until April 2021, the plan is for an Audit Committee in Common (CiC) as these are statutory committees which cannot be merged. The plan is for the CiC to have aligned agendas, common reports etc., although separate minutes will be taken and each CCG is free to take different decisions.
LW advised how this could work in practice, with a single agenda or separate agenda items for place based issues. The CCGs will still have to fulfil their individual statutory responsibilities. LW advised that from her experience issues can occur if there is an imbalance in representation from each CCG i.e. one CCG is not quorate and how decisions are made and recorded in the minutes. LW suggested a workshop to work through the practical issues and behaviours.
MGW advised that the agenda items would run in parallel, with common papers, presentations and discussion. The Governing Bodies (GB) and Committees are free to make their own decisions and there is no requirement for a common decision. Each GB and Committee will have its own minutes to reflect this.
The Committee expressed concerns around the pace of change in relation to the disestablishment of the three CCGs and the establishment of a single BLMK CCG.
[LH and GF left meeting at 10:58] 11/20 11. Governance and Risk Steering Group minutes LC presented the following Governance and Risk Steering Group minutes for information only: a. 10th September 2019 b. 5th November 2019 c. 11th December 2019
The Committee noted the Governance and Risk Steering Group minutes. 12/20 12. Losses and Special Payments ‘Nil’ return 13/20 13. Tender Waivers LC explained that there will be one Tender Waiver coming to the Committee to note. The Tender Waiver relates to the extension of an interim contract while the CCG transitions to a single CCG; however the length of extension is still being finalised.
14/20 14. Going Concern LC presented the Going Concern paper. The Committee was asked to note and approve the preparation of the 2019/20 Annual Accounts on a Going Concern basis, and recommend this to the Board.
The Committee found the Healthcare Financial Management Association (HFMA) Going Concern Assessment and reporting requirements in difficult times briefing paper very useful.
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For 2020/21 Luton CCG will still be a statutory body, the statutory functions will transfer to the single CCG for 2021/22.
PW advised that the disclosure needs to be noted. The Chair advised: The CCG has a deficit The amount of the deficit has been significantly reduced The CCG is still forecasting a surplus with associated significant risks The NHS England Regional Lead has promised that if the CCG achieves the required surplus, the accumulated deficit will be frozen. The CCG needs to review the financial position against the budget The Finance Report will be presented at the Board meeting later in the day. The Chair noted the level of Quality, Innovation, Productivity and Prevention (QIPP) which has yet to be realised.
LC added that the CCG remains in financial turnaround; the Financial Recovery Plan has been updated and will be presented to the Financial Recovery Group next week for review. LC also advised that Cash Flow is managed very closely.
PW advised that the governance arrangement i.e. management preparing the assessment and having it reviewed and approved by the Audit Committee was evidence of best practiceand not always done elsewhere, adding that it is beneficial to undertake the assessment ahead of completion of the Annual Accounts.
The Committee noted and approve the preparation of the Annual Accounts on a Going Concern basis and recommend to the Board. 15/20 15. Standing Financial Instructions (SFIs) LC presented the Bedfordshire, Luton and Milton Keynes CCG Detailed Financial Policies.
The three Deputy Financial Officers were charged with reviewing the policies across the three CCGs as they are most aligned to the NHSE best practice guidelines for CCGs. A version was seen by the Board as part of the revised LCCG Constitution in October 2019. The limits are significantly higher than those currently in place at Luton CCG. The updated Operational Scheme of Delegation will be updated and presented to the March 2020 meeting.
The Committee were assured by the approval process explained by LC.
Action – To remove contact names and numbers from the body of the policies and to place in a separate appendix. LC
The Committee approved the Detailed Financial Policies and to recommend to the Board. 16/20 16. Internal Audit Progress Report
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LW presented the Internal Audit Progress Report; there were no specific issues to bring to the attention of the Committee.
Appendix A details the overall progress of work against the internal audit plan.
The Committee noted the Internal Audit Progress Report. 17/20 17. Internal Audit Reports LW presented the following Internal Audit Reports: a. Better Care Fund – Substantial Assurance b. Primary Care Commissioning - Reasonable Assurance c. Financial Controls – Planning and Forecasting - Reasonable Assurance d. Commissioning and Contract Management - Substantial Assurance e. Operational Resilience - Do, Buy, Share Project - Substantial Assurance f. Conflicts of Interest – Award of Caretaker Contract – conducted at the special request of the CCG
The Committee was very pleased with the outcomes of the reports. RSM are conducting follow up work at present to ensure the recommendations and actions are completed.
The Draft Head of Internal Audit Opinion and the Internal Audit Plan 2020/21 will be presented at the March 2020 meeting.
The Committee noted the Internal Audit Reports. 18/20 18. External Audit Progress Report PW gave a verbal update on the External Audit Progress Report.
External Audit has completed the risk assessment work and no issues were found. They are in the process of drafting the Audit Plan; nothing is expected to change this year. In view of the proposed creation of a single BLMK CCG the Value for Money work may be extended.
The dates have been agreed with the CCG for early testing. Invitations have been distributed for the annual Chief Accountants Workshops and the CCG will be attending.
Progress is being made with the disclosure required to explain the impact of the new Accounting Standard for Leases on the CCG.
19/20 19. Report on the Mental Health Investment Standard Compliance Statement PW presented the Report on the Mental Health Investment Standard Compliance Statement. External Audit was able to complete this piece of work before the revised deadline at the end of October 2019. PW explained that the report is not allowed to be published. PW thanked the staff members who supported the completion of this complex and challenging piece of work. Luton CCG is reporting that they meet Mental Health Investment Standard.
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The main issue found was with Continuing Healthcare (CHC), management were unable to identify how much spend related to mental health and non-mental health. LC explained that they are not able to identify due to the system used by CHC. There is an action to investigate whether the detailed piece of work required is feasible, as other CCGs are reporting this expenditure. LC also explained that the CCG is changing IT supplier which may impact on this piece of work. A general discussion took place on the merits of this exercise.
The Committee noted their concern that the CCG is not able to identify the mental health expenditure for CHC patients and asked for this to be reviewed in the future.
Action – To identify a way to report on the mental health expenditure for CHC LC patients.
LC advised that the CCG submits monthly reports to NHSE as part of the financial return.
The Committee noted the Report on the Mental Health Investment Standard Compliance Statement. 20/20 20. Committee minutes Committee minutes – for information only: a. Clinical Commissioning Committee – 26th September 2019 b. Finance and Performance Committee – 29th August 2019 and 26th September 2019 c. Patient Safety and Quality Committee – 25th July 2019 and 26th September 2019 d. Primary Care Commissioning Committee – 9th July 2019
The Committee noted the Committee minutes. 21/20 21. Any other Business Local Counter Fraud Service (LCFS) Update BV advised that the Staff Survey results will be issued today; the LCFS Team will ensure that communications around this are circulated.
Action – To ensure the outcomes of the LCFS Staff Survey are circulated. BV
There is no formal guidance at present on the Counter Fraud Champions role the NHS Counter Fraud Authority is introducing. It is possible that this will fall into the role of the Deputy Chief Finance Officer.
The Engagement visits by the NHS Counter Fraud Authority, which the CCG maybe subjected to, are now done at any time during the year. If this happens they will need to speak to DK and LC.
With no further business the meeting ended at 11:27
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Dates and Times of Scheduled Meetings Future meeting dates: Arndale House, 3rd Floor, The Mall, Luton, LU1 2LJ 17th March 2020, 10:00-12:00, Meeting Room 1
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Meeting: Luton CCG Audit and Risk Management Committee
Date: Tuesday 17th March 2020
Time: 10:00-12:00
Location: Meeting Room 1, Arndale House, 3rd Floor, The Mall, Luton LU1 2LJ
Present: Mahmood Aziz (MA) Lay Member, Finance and Procurement via teleconference Kathy French (KF) Independent Nurse Member via teleconference David Kempson (DK) Chair, Lay Member, Audit & Governance via teleconference In Attendance: Luton Clinical Commissioning Group Liz Cox (LC) Deputy Chief Finance Officer Stephen Makin (SM) Acting Chief Finance Officer Michael Wuestefeld-Gray (MWG) Interim Assistant Director of Governance Risk and Corporate Affairs, Bedfordshire, Luton and Milton Keynes (BLMK) CCGs Grant Thornton Paul Grady (PG) Engagement Lead via teleconference Parris Williams (PW) Engagement Manager via teleconference RSM UK Liz Wright (LW) Head of Internal Audit via teleconference Bradley Vaughan (BV) Counter Fraud Manager via teleconference Minutes: Elaine Baugh (EB) Governance & Risk Support Officer (minutes) Apologies: Chris Ford (CF) Chief Finance Officer
Actions 22/20 1. Welcome, Apologies and Chair’s Comments The Chair welcomed all to the meeting. It was agreed to hold the meeting via teleconference due to the developing Coronavirus (Covid-19) incident. Apologies received as noted above.
23/20 2. Declarations of Interest & Hospitality in Relation to Agenda Items There were no declarations or hospitality in relation to agenda items.
24/20 3. Minutes of the meeting held on 21st January 2020
The committee reviewed the minutes of the meeting held on the 21st January 2020 and approved as an accurate record of the meeting.
The Committee approved the minutes of the meeting held on the 21st January 2020. 25/20 4. Matters arising from the meeting held on 21st January 2020 The Committee reviewed the Action Log with the following updates noted: • 27/17 – This piece of work has not been conducted by the Governance and Risk Steering Group. The action has since transferred to MWG. The action is to identify the controls map separately from the risks and looking at both in relation to each other. • 75/17b – This risk has also transferred to MWG and linked to the action above. The actions will need to be looked at within the context of the new single CCG where the aim is to develop a single risk management framework. MWG suggested closing the two actions and replace with a forward looking action on how are we going to be assured that we have appropriate risk management going forward. Action – To develop a new risk management process for the single CCG to MWG include the mapping of the controls, to give assurance to the Committee. • 26/19a and 26/19b – Actions transferred to MWG. • 55/19b – The Data Quality Policy is on the agenda for ratification. • 62/19d – For discussion under the Counter Fraud and Security section of the agenda. • 69/19 – See comments under 27/17 and 75/17b above. • 71/19b – For discussion under agenda item 8. Board Assurance Framework. • 76/19b – This will be incorporated into the work around the development of Committees in Common and Joint Committees. • 04/20a – The Freedom To Speak-Up report is on agenda under item. 6 • 08/20 – Part of the ongoing work around the development of a new risk management framework for the new single CCG. • 09/20 - Part of the ongoing work around the development of a new risk management framework for the new single CCG. • 21/20 – There has been a poor uptake to complete the staff survey. BV to liaise with the Communication and Engagement Team to promote the survey to ensure the results are meaningful.
[LC joined the meeting at 10:16] 26/20 5. Committee Effectiveness Report The Committee reviewed and completed the Annual Review of Effectiveness.
Action – To forward the completed report to the Chair for sign off. MWG
27/20 6. Freedom to Speak-Up Report MWG presented the Freedom to Speak Up Guardian Annual Report. No formal whistleblowing concerns have been raised.
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The Committee raised concerns whether staff are aware of who is the Freedom to Speak Up (FTSU) Guardian within the CCG. Rev Lloyd Denny, Board Lay Member is the FTSU Guardian. It was acknowledged that concerns should initially be raised with line managers or HR before being escalated to the FTSU Guardian.
Other mechanisms within the CCG for staff to raise concerns are the Staff Involvement Group (SIG), the Employee Assistance Programme (EAP) and the trained Mental Health First Aiders.
Action – To raise awareness of the role of the Freedom to Speak Up Guardian LC within the CCG and how to access.
The Chair advised that it was best practice to have an Executive Lead for FTSU, by having an Executive Lead demonstrates that the organisation takes this matter seriously.
Action – To raise the concerns of the Committee to the Executive Team to MWG appoint an Executive Lead for Freedom To Speak Up.
The Committee noted the Freedom to Speak Up Guardian Annual Report. 28/20 7. Information Governance Policies for Ratification SM presented the Information Governance policies for ratification. The policies have been updated to reflect current legislation. The policies have been reviewed and approved by the Governance and Risk Steering Group. The following policies presented included tracked changes: a. Information Governance and Cyber Security Incidents requiring investigation b. Controlled Environment for Finance (CEfF) Policy c. Data Quality Policy d. Subject Access Request Policy and Procedure e. Social Media Policy – The Committee queried the wording in the Introduction and within the Business Use section. The Committee queried whether the policy covered all types of communication platforms i.e. WhatsApp and suggested referencing existing IT policies. The Committee also queried the sharing of confidential information on personal devices. The Committee also noted that during a major incident social media platforms maybe used differently. From the 1st April 2020 responsibility for Information Governance will transfer to the Director of Governance and Performance, MWG suggested that the comprehensive review of this policy should be part of the overall governance workstream to align all policies across BLMK. The Committee agreed to approve the policy subject to a comprehensive review of the comments noted above.
The Committee approved the following Information Governance policies:
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a. Information Governance and Cyber Security Incidents requiring investigation b. Controlled Environment for Finance (CEfF) Policy c. Data Quality Policy d. Subject Access Request Policy and Procedure e. Social Media Policy – subject to a comprehensive review to reflect current practice. 29/20 8. Board Assurance Framework MWG presented the reviewed and updated Board Assurance Framework (BAF) including the new risk BAF 32 relating to Quality.
The Committee queried whether there needs to be a risk around Covid-19 or pandemics in general. A paper regarding Covid-19 and the response is due to be presented at the Board meeting to be held later in the day. Any risks to the delivery of the CCG’s strategy will be identified and added to the Corporate Risk Registers and the BAF.
The 4Risk system will be adopted across the three the CCGs, with identified risk owners and a fresh approach to risk management in the future.
The Committee noted the new BAF, including new risk BAF 32. 30/20 9. Committees in Common MWG gave a verbal updated on the progress of the Committees in Common and Joint Committees with Bedfordshire CCG (BCCG) and Milton Keynes CCG (MKCCG). There will be shadow working arrangements in place from the 1st April 2020.
The Committees in Common will meet at the same time in the same place, although they will be three separate meetings. The membership and functions of the Audit Committee will remain unchanged. The meeting cycle will follow in due course, however it was noted that the Covid-19 pandemic is causing issues with the delivery of the plans.
31/20 10. Governance and Risk Steering Group Minutes The following Governance and Risk Steering Group minutes were presented for information only: a. 14th January 2020 b. 11th February 2020
The Committee noted the Governance and Risk Steering Group minutes. 32/20 11. Losses and Special Payments ‘Nil’ return.
33/20 12. Tender Waivers SM presented the Tender Waiver to extend the contract of the interim Commissioning Project Manager until the 30th September 2020.
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The role is to support the Unplanned Care Team and is working on key priorities for the CCG including Non-emergency Patient Transport Specification procurement across Bedfordshire and Luton. The role will also provide additional capacity following the resignation of the Associate Director of Unplanned Care.
The Committee approved the Tender Waiver. 34/20 13. Annual Accounts and Annual Report 2019/20 including HFMA Briefing February 2020 SM presented the Annual Accounts and Annual Report 2019/20 including the Healthcare Financial Management Association (HFMA) Briefing February 2020, 2019/20 year-end reminder for non-executive directors and lay members.
The paper is presented to update the Committee on the changes to accounting policies and to highlight key issues in preparing the Annual Accounts and Annual Report: • IFRS16 – from 1st April 2020 all leases will be accounted for ‘on-balance sheets’. • Employer’s contribution to the NHS pension scheme - During 2019/20, NHS employers have been paying an employer contribution of 14.38% to the NHS pension scheme. However, from 1 April 2019, the employers’ pension contribution is 20.68%. The difference of 6.3% has been funded and paid to the NHS Business Services Authority centrally by NHS England. The CCG received an allocation in month 10 to cover the additional costs. • Year End Timetable 2019/20 – detailing the critical dates and leads.
The Committee thanked Finance Team for sharing the HFMA Briefing paper.
With the agreement of the Committee the meeting moved to External Audit. The Committee noted the Annual Accounts and Annual Report 2019/20. 35/20 14. Internal Audit Progress Report LW presented the Internal Audit Progress Report. Appendix A details the opinions issued on the audits completed to date.
There are two audits in draft: • General Data Protection Regulations (GDPR) – no significant issues identified. • Risk managements and Assurance Framework – which is likely to receive partial assurance.
The Committee noted the Internal Audit Progress Report. 36/20 15. Draft Head of internal Audit Opinion LW presented the Draft Head of Internal Audit Opinion for 2019/20. Appendix A outlines the options available. The CCG has been assignment the following draft option:
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Head of internal audit opinion 2019/20
The finalised opinion will be issued as part of the Annual Report process.
The Committee noted the Drat Head of Internal Audit Opinion. 37/20 16. Draft Internal Audit Plan 2020/21 LW presented the Internal Audit Plan for 2020/21. The plan has been developed in conjunction with the Audit Plan for MKCCG to minimise disruption and cost.
The areas for review during 2020/21 are: • Communication and Engagement – BAF 2 • Financial planning and forecasting including QIPP – BAF 5 • Governance – Operational Change • Safeguarding – joint audit with MKCCG • Risk Management and Assurance Framework – core requirement • Delegated Commissioning – Core requirement • DSPT – core requirement • Conflicts of Interest – core requirement
Appendix A outlines the Internal Audit service and fees.
[KF left the meeting at 11:28] The Committee approved Internal Audit Plan for 2020/21. 38/20 17. External Audit Progress Report This item followed the item 13.
PG advised that staff are working remotely due to the Covid-19 outbreak. However they will continue to work to the current timescales unless there are changes to the national guidelines. The External Audit Team will continue to liaise with the Finance Team during this time.
Action – To investigate how the CCG can keep up to date with changes to SM national guidelines and still fulfil its statutory requirements.
PW presented the External Audit Progress Report and Sector Update. No issues have been identified and work is progressing.
The Committee noted the External Audit Progress Report and Sector Update.
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39/20 18. External Audit Plan PG presented the External Audit Plan. The plan details the key areas of focus which are of significant risk and is similar to previous years. Page 4 outlines the key matters impacting on the audit, but does not include Covid-19 as this is a newly emerging risk which could impact on the delivery of the audit.
The significant risks identified are: • Management over-ride of controls • The revenue cycle includes fraudulent transactions (rebutted) • Secondary healthcare expenditure – contract variations (completeness and accuracy assertions)
Action – To consider the provider risk following the merger of Luton & Dunstable Hospital and Bedford Hospital as a risk for the BAF. MWG
Value for Money arrangements will include ‘Working with partners’ as the CCG merges with BCCG and MKCCG.
The Committee were reassured by the Audit Plan and the fact the Audit Team remains the same adds consistency to the audit.
The Committee thanked the Finance Team for the excellent standard of work.
The meeting moved to Internal Audit. The Committee noted the External Audit Plan. 40/20 19. Counter Fraud and Security Progress Report This item followed agenda item 16.
BV presented the Local Counter Fraud Specialist (LCFS) Progress Report. The NHS Counter Fraud Authority (CFA) has brought forward the requirement of the CCG to nominate a Fraud Champion. Whoever is assigned this role will have to complete online training and act as the go-between for the LCFS Team and the CCG.
Counter Fraud has been part of Induction Training; the plan going forward is to have round table discussions for greater staff engagement.
The annual counter fraud survey only received two responses. BV suggested a statement from the Audit Committee Chair or the Audit Committee is a way to prompt staff to complete the survey. The Chair is happy to issue a statement if required. Concerns were raised regarding how the survey was promoted within the organisation.
Action – To look into how the LCFS survey was promoted by the Communications and Engagement Team and to liaise with Becci Goodchild. LC
The Committee noted the LCFS Progress Report.
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41/20 20. Local Counter Fraud Service Workplan 2020/21 BV presented the Local Counter Fraud Specialist (LCFS) Work Plan 2020/21.
The four key fraud related areas are: • Strategic governance • Inform and involve • Prevent and deter • Hold to account
Personal Health Budgets is an emerging risk area.
The Committee was informed that in approving the counter fraud work plan, it should consider the questions. • Are the areas selected for coverage in the work plan appropriate? • Is the Audit Committee satisfied with the current level of counter fraud resources and that it remains suitable? The Committee therefore began by considering the four areas. It took the view that Strategic Governance was particularly appropriate in a year when the governance of the CCG was changing, as joint governing bodies, joint committees and committees in common replaced previous arrangements. It determined that informing and involving staff and others continued to be fundamental in fraud prevention, and strongly aligned to prevent and deter. The prevention has to be considered in the commissioning context created by the new arrangements also, as some contracts may need to be extended and many more will be dealt with jointly. Also the commissioning experts employed may be subject to change, and the whole commissioning area has to be a focus for prevention and deterrence. Holding to account is also fundamental as the decision-makers may change with the changing arrangements. Therefore the Committee considered the areas selected to be appropriate. The Committee considered the current resource level in light of the current level of cases, and the level of engagement, and considered that it remains suitable, but will need ongoing review as if the amalgamation of the 3 CCGs is successful, the operating basis will change.
The submission date for the Self-review Tool (SRT) is the 30th April 2020; this may be subject to change in view of the current situation.
The Committee approved the Local Counter Fraud Specialist (LCFS) Work Plan 2020/21. 42/20 21. Committee Minutes The following Committee minutes were presented for information only: a. Clinical Commissioning Committee – 31st October 2019 b. Finance and Performance Committee – 1st November 2019 c. Patient Safety and Quality Committee – 31st October 2019 d. Primary Care Commissioning Committee – 24th September 2019
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The Committee noted the Committee Minutes. 43/20 Any other business With no further business the main meeting ended at 11:43
44/20 22. Private Discussion with Internal Audit Private discussions took place between the Audit and Risk Management Committee members and Internal Audit. Dates and Times of Scheduled Meetings Proposed Committee in Common dates: Venue TBC • 21st July 2020 • 22nd September 2020 • 17th November 2020 • 21st January 2021 • 23rd March 2021
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AUDIT COMMITTEE Held on Thursday 5th March 2020 at 10:30 Sherwood Boardroom 1
Notes
Present Roland Ginn (Chair) RG Lay Board Member, MK CCG Darren Smith DS Lay Board Member, MK CCG
In Attendance Wendy Rowlands WR Deputy Chief Finance Officer, MKCCG Stephen Makin SM Director – System Finance Parris Williams PW Engagement Lead, Grant Thornton Paul Grady PG Engagement Lead, Grant Thornton Liz Wright LW Director, RSM Becci Goodchild BG Local Counter Fraud Specialist, RSM UK Richard Alsop RA Chief Operating Officer, MKCCG Lorraine Belam LB Team Administrator, MKCCG (Minute Taker)
Apologies Chris Ford CF Chief Financial Officer Steven da Nobrega SdN Head of Financial Reporting, MKCCG
1. Welcome & Introductions
RG welcomed all to the meeting. Apologies were noted above.
2. Conflicts of Interest
No conflicts of interest were declared at the outset of the meeting.
3. Minutes of the last meeting on 9th January 2020 – Enclosure No 20/21
Noted: typing error on Page 2 – PSPT toolkit should read DSPT toolkit.
The minutes were otherwise agreed as an accurate record of the meeting.
4. Matters Arising and Action Log – Enclosure No 20/22
The Action Log is updated and attached to the minutes.
5. Internal Auditors (RSM)
Progress Report – Enclosure 20/23 LW presented:
• Two Final reports have been issued since last Committee meeting:
Audit Committee Minutes 5th March 2020 Page 1 of 7 Roland Ginn Final NHS Classified
Better Care Fund which achieved a substantial opinion, with one medium management action being agreed regarding lack of clarity and progress on actions and expected completion dates. RSM noted that planning guidance for 19/20 was not issued until July 2019 resulting in delay in completing the plan and budget. Commissioning and Contract Management (GIC contract with MKUHFT) Achieved a reasonable assurance opinion with two medium actions agreed with management. DS/RG advised that monitoring of the contract performance is key and questioned if we were assured that our challenges were strong enough. WR commented that the Finance and Performance group was robust and met monthly to discuss and receive reports and the Joint Executive group meet to monitor actions. RA advised that management of general performance was discussed regularly at CDG and that there was an increased level of transparency with the Trust that was not in place under the old PBR agreement.
5.1 Draft Head of Internal Audit Opinion – Enclosure 20/24 LW summarised:
• This draft Opinion is in line with last year: that there is an adequate and effective framework for risk management, governance and internal control with further enhancements identified to the framework of risk management, governance and internal control to ensure it remains adequate and effective. • There were 6 substantial assurances provided during the year (Financial Controls, Primary Care Commissioning, Medicines Management, Operational Resilience, Risk Management and Assurance Framework, Better Care Fund) with two reasonable assurances (Conflict of Interest and Commissioning and Contracts Management). • Two audits remain to be completed and reported in final, DSPT (under Management Review) and Follow Up (in progress). • Final assurance will be declared in April, currently not anticipating any changes to the draft Opinion. • LW/WR confirmed to RG that with respect to service audits both Ardengem and SBS provide own Audit reports. These are not normally communicated to the CCG in advance. WR advised RG that there were small transactional issues with SBS last year re payroll, LW confirmed that payroll was not considered a material issue.
5.2 Internal Audit Plan – Enclosure 20/25 LW presented the Internal Audit Plan for 2020/21:
WR confirmed that discussions have been held with RSM around the plan and agreement reached on the key areas of focus. Where possible this has been matched to the Luton Audit Plan. This plan has been shared with the Executive Team.
RG questioned if we are doing enough with GPs around IG and boundaries of accountability. Action: WR to ask IG lead for an update on current status in Primary Care.
Audit Committee Minutes 5th March 2020 Page 2 of 7 Roland Ginn Final NHS Classified
The Audit Committee:
• Noted the Progress Report, Draft Head of Internal opinion and Internal Audit Plan for 20/21.
The Chair thanked LW for her update. 6. External Auditors (Grant Thornton)
6.1 Audit Scope and Additional Work – Enclosure 20/26 PG presented this update regarding an anticipated increase in audit fee levels post this contract (i.e. from 20/21 audit).
• The FRC (Financial Reporting Council) legislation has set out expectations of improved financial auditing. Increasing the level of challenge and depth of work to be undertaken as standard. • A target has been set for all audits (including local audits) to achieve a minimum Score of 2a (where previously a score of 2b would be acceptable). Managerial oversight will be increased to manage this risk and the CCG should expect the audit team to exercise greater challenge of management in areas that are complex, significant or highly judgmental. DS asked what the implications were for the CCG if this score was not reached? PG confirmed that there would be no penalties for the CCG as this was a standard for the Auditors to reach. • The National Audit Office has consulted on proposed changes to the scope of audit work in the Public Sector – most significant changes in relation to the Value for Money arrangements. Until this consultation has been finalized it is difficult to assess the impact on increased costs. PG assured the CCG that further thoughts on the potential impact on future audit and associated costs would be shared once details are known.
6.2 Progress Report & Sector Update – Enclosure 20/27 PW summarised:
• Interim Audit visits were conducted in February to carry out early testing on key account balances and transactions in order to reduce the amount of work required at final accounts in May. • Several elements were uncompleted due to working papers not being available from the CCG in advance. • PW confirmed to RG that there appeared to be no underlying issues just a delay on the timing of receiving the relevant papers. • Meeting held with Deputy Director of Finance to discuss impact and action plan agreed: Additional resource from Grant Thornton in Feb/March to complete work on two of the sample areas. CCG management have agreed to defer other incomplete activities until May and provided assurance that working papers will be provided by CCG on time for the May audit visit.
• Sector Update has been circulated internally to CCG’s Senior Leadership
Team for their information.
Audit Committee Minutes 5th March 2020 Page 3 of 7 Roland Ginn Final NHS Classified
6.3
Audit Plan – Enclosure 20/28 PG summarised key aspects of the Audit plan for 19/20 reports. Two key risks had been identified for consideration during the audit
• Management override of controls • Completeness of secondary healthcare expenditure
The materiality levels for the audit remained similar to the prior year and there was just a small uplift in fee to £35,500.
PG also outlined the focus for review of the Value for Money Arrangements, which would be based on the following assessed risks: Financial position and sustainability Financial and non-financial delivery of QIPP Working with partners – Shared executive team and the arrangements to facilitate the merger Delivery of constitutional targets and healthcare performance outcomes The Chair thanked PG and PS for their updates. 7. Counter Fraud (LCFS)
Work Plan for 20/21 – Enclosure 20/29 BG advised: • The workplan is balanced to ensure a risk based document. • Resource available remains as last year at 30 days, split between the following areas: Strategic Governance, Inform and Involve, Prevent and Deter), Hold to Account ,Other Area Input. • NHSE has introduced a requirement for a ‘Fraud Champion’. The CCG needs to nominate someone for this role (not a finance position an someone in a senior position – one level below Director). WR reported that Geraint Davies had been asked if this could be taken on by the Associate Director responsible for risk management within his team within the new risk structure for BLMK. • Cyber risk – new service partner HBLICT will feed into this when they come on board from April. • DS asked how much fraud was seen in general in the NHS. LW and BG confirmed that it was in the billions, predominantly in areas of staff fraud (staff being off sick but working elsewhere), cyber crime and procurement type fraud, prescription fraud. RG questioned fraud within GP’s area. BG confirmed that if patient attempted fraud NHSE have own counter fraud team which would investigate.
The Audit Committee noted the Counter Fraud Work Plan for 20/21.
The chair thanked BG for her presentation.
8. Governance 8.1 Internal Audit Actions – Enclosure No 20/30 Audit Committee Minutes 5th March 2020 Page 4 of 7 Roland Ginn Final NHS Classified
WR presented this report which provided a progress update on 19/20 internal audit plan and delivery of agreed actions from all finalised audit reports.
• Since last audit committee, 3 further actions have been added to the 2 actions brought forward, 1 action has now been closed leaving 4 actions outstanding. • DS questioned process of moving audit completion dates and whether management had oversight of this. WR advised that there has been an improvement in actions being completed more promptly but confirmed that management did have scrutiny over these and challenged individuals where appropriate. • VFM audit actions update provided as at Appendix C as evidence to External Auditors of progress against these actions.
The Audit Committee: • Noted the progress against the 2019/20 Audit Plan. • Noted the additional external VFM audit actions and progress to date. 8.2 MKCCG Risk Register/Board Assurance Framework – Enclosure 20/31 WR presented and highlighted:
• Not a great deal of movement from last report in January. • 2 risks have been removed from the BAF due to reduction in scores. (ST73 Risk of impact of Brexit on the delivery of services reduced score from 16 to 9) and (F17 New Acute Contract Financial Risk Share mechanism reduced score from 12 to 9) • One risk added. ST82 – Cessation of the CNWL TOPAS service (mental health elderly inpatient service) if new accommodation cannot be found. CNWL are working on a plan with preferred option to relocate to another inpatient unit on the hospital site but this option entails a lot of capital funds. • Other new risks had been assessed by CDG as not suitable for addition on to BAF. • RA reported that Coronavirus would be added. Business Continuity Plan being developed looking at resilience across 3 CCG areas. Complicated by MK response to the Thames Valley resilience forum as we are in a different response area. Could impact on all areas; RTT, Cancer, Workforce and this will be tracked. • RG asked how costs will be recovered regarding CCGs support for recent quarantine at MK Conference Centre. WR confirmed that mechanisms are being set up centrally to reimburse costs.
The Audit Committee noted the Risk Register update.
8.3 Health and Safety Minutes (for information) – Enclosure 20/32
The Audit Committee Noted the Health and Safety Minutes
8.4 Information Governance End of Year Report – Enclosure 20/33 WR updated:
• A lot of work has been undertaken in preparation for submission of DSP
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Toolkit. • RSM conducted an audit in January to assess the control framework in place to meet this toolkit submission. Four medium and two low risks actions were identified – all these actions have now been implemented and closed off. • The Toolkit submission deadline is 31st March 2020. • RG noted that there was only 1 incident recorded in Quarter 4 which was logged onto the toolkit but didn’t meet the criteria for reporting to the ICO. Action: to provide RG with details of the incident. • MK CCG and Bedfordshire IG team have reviewed the evidence and request permission to submit the MK DSP Toolkit. The CCG has completed 105 out of 106 assertions and achieved 98% training compliance.
The Audit Committee noted the report and approved the submission of the DSP toolkit.
8.5 Annual Governance Statement Checklist – Enclosure 20/34 WR summarised:
• This Checklist is presented to Audit Committee for information and has been submitted to NHSE. Currently awaiting feedback. • The Checklist submission should highlight control issues which are significant enough to be reflected in the end of year Annual Governance Statement. • The main risk areas have been identified from the Board Assurance Framework and these have been reviewed by DCFO and COO.
The Audit Committee: • Agreed the Control Issues highlighted in the report are sufficiently significant to be reflected in the Annual Report on the basis that the issues are included on the CCG strategic board assurance framework. • Noted the mitigations and controls associated with each individual control issue and that the BAF and the mitigations are presented to the Board on a regular basis. • Noted the Month 9 AGS checklist document.
9. Finance 9.1 Report on any waivers of Standing Orders – Enclosure No 20/35
• WR reported that there was just one waiver in the period from the Quality Team at a value of £25k. • The waiver was approved by the DCFO on 31st January 2020. • DS observed from another Committee meeting that there was an inconsistency in the format of the Waivers of Standing Orders being presented and they do not always list what needs to be considered. Action: Managers to be reminded of key information required to be included in waiver submission
The Audit Committee: Noted the report on the waivers of Standing Orders.
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9.2 Audit Committee Going Concern Paper – Enclosure 20/36 WR presented:
• Going concern is a key concept in the preparation of the financial statements for the CCG, referring to the basis of measurement of an organisation’s assets and liabilities in its accounts. • Management should assess, as part of the Annual Accounts preparation process, the CCGs ability to continue as a going concern. • The statement attached indicates that the CCG can ordinarily be viewed as continuing in business for the foreseeable future and does not intend to apply to NHS England for the dissolution of the CCG.
The Audit Committee approved the report and recommend to the Board that the 2019/20 Annual Accounts be prepared on a Going Concern basis.
10. Any Other Business
There being no other business the Chair thanked all attendees and the meeting was concluded at 11:20am.
11. Date and Time of Next Meeting
19th May 2020 at Sherwood House, Boardroom 1 from 10:30 to 12:00. (Note: date subject to revised BLMK governance arrangements).
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BEDFORDSHIRE AND LUTON JOINT PRESCRIBING COMMITTEE Notes of the meeting on Wednesday 26th February 2020 Room 130, Enterprise House, Wrest Park, Silsoe, Bedfordshire, MK45 4HR.
Attendees: Dr J Fsadni (JF) GP (Retired) Committee Chairman Jacqueline Clayton (JC) Secretary/Pharmaceutical Adviser, Bedfordshire CCG (BCCG), working on behalf of BCCG & LCCG Dona Wingfield (DW) Pharmacist Representative, BCCG Fiona Garnett (FG) Assistant Director and Head of Medicines Optimisation, BCCG. Sandra McGroarty (SMcG) Pharmaceutical Advisor, BCCG (working JPC work streams) Dr Kwapong Medical Representative, Bedford Hospital Dr L MacKenzie (LMacK) Executive Team Representative, BCCG. Dr Kate Randall (KR) GP Representative, BCCG Dr Jenny Wilson (JW) GP Representative, BCCG Dr M Sarkar (MS) GP Representative, LCCG Dr Joy Muttika (JM) Medical Representative, Keech Hospice Victoria White Representative, St John’s Hospice Anne Graeff (AG) Pharmacist Representative, LCCG Dr M Nisar (MN) Medical Representative, the Luton and Dunstable University Hospital NHS Foundation Trust (LDUH) Gemma McGuigan (GMcG) Pharmacist Representative, Bedford Hospital NHS Trust (BHT) Julie Phillips (JP) Pharmacist Representative, the Luton and Dunstable University Hospital NHS Foundation Trust (LDUH) Russell Foulsham (RS) Pharmacist Representative, Cambridgeshire Community Services NHS Trust (CCS) Adrian Spurrell (AS) Lay Representative Dr Samantha Chepkin (SC) Consultant in Public Health Medicine Chinedu Ogbuefi (CO) Pharmacist Representative (Bedfordshire and Luton, ELFT {Mental Health} Lead) Rachel Neve (RN) Formulary and Medication Safety Pharmacist, BCCG.
In attendance: - Full meeting (Observer) - Koseen Fiaz, DSN, the Luton & Dunstable Hospital; Mary Ann Canares, DISN, the Luton & Dunstable Hospital; Raye Summers (RSu) (PA/Administrator, Medicines Optimisation Team, BCCG).
For Agenda item 5.1 (tbc) - Hüseyin Hüseyin BSc (Hons) RN, Clinical Operational Lead – Neurology, Luton & Dunstable University Hospital 1 Bedfordshire CCG Luton CCG
For Agenda item 5.2 – Naomi Currie, Locality Lead Pharmacist, BCCG For Agenda item 5.7 – Bernadette Sebastian, Locality Lead Pharmacist, BCCG
Agenda item Action 1 Welcome and Apologies The chair welcomed everyone to the meeting and new venue, in particular, Raye Summers (PA Administrator to the BCCG Medicines Optimisation Team), Koseen Fiaz, DSN, the Luton & Dunstable Hospital, Mary Ann Canares, DISN, the Luton & Dunstable Hospital, and Hüseyin Hüseyin BSc (Hons) RN, Clinical Operational Lead – Neurology, Luton & Dunstable Luton & Dunstable University Hospital
It was noted that Raye had replaced Amy Flynn and the chair thanked Amy on behalf of the Committee for her service to it.
Apologies for absence received from: Janice Jones, Dr Muffazal Rawala, Dr Sarah Whiteman, Gerald Zeidman, and Sandra James.
2 Conflicts of interest declaration ALL No conflicts of interest relating to the current meeting agenda were declared by Committee members.
Committee members were reminded that some 6 monthly written conflict of interest declarations were due. The relevant Committee members had been reminded several times and were asked to complete these as soon as possible and return them to the Secretary or RSu. 3 Minutes of the last meeting (4th December 2019) The minutes of the meeting were approved for accuracy. 4 Matters Arising
4.1 Feedback on miscellaneous actions not included on the agenda. 4.1.1 Antimicrobial Guidelines Update Close A section on WHO ACCESS WATCH and RESERVE list action has been added to the introduction pages of the guidelines and going forward, as part of the JPC antimicrobial update work stream it was agreed that the JPC works with the microbiology teams at both Bedford and Luton & Dunstable Hospitals to create a localised list and include this as an appendix to the guidelines. This task will be investigated outside of the JPC (via the Bedfordshire and Luton Antimicrobial Pharmacists Group) and brought back to a future JPC meeting when an update was available. 2 Bedfordshire CCG Luton CCG
4.1.2 Antibiotic Prophylaxis to prevent exacerbations for AG Non-Cystic Fibrosis Bronchiectasis – Focus on the use of Inhaled/Nebulised Tobramycin and Inhaled/Nebulised Colistimethate sodium At the April 2019 meeting, the committee agreed to support use in line with criteria to be developed in conjunction with the Specialists and there would be no funding until the criteria were agreed and proformas set up. It was agreed that the proformas and pathways would be developed as a result of the commissioning policy approval. LCCG Medicines Optimisation Team is working on the above actions and has asked for consideration at the April 2020 JPC meeting. These were therefore ongoing actions. 4.1.3 Apomorphine Shared Care Guideline ELFT The ELFT Community Services Pharmacist had agreed to Community take forward an action to investigate the use of Homecare, Services working with the CCGs as necessary. Pharmacist At the December 2019 meeting the following feedback was received:- Homecare had been scoped and the team were waiting on:- A quote from the homecare service provider Go ahead from ELFT Governance Team.
Update - 10/02/20 Meetings are underway with Specialist Nurses, company who manufacturer Dacepton Apomorphine, and Pharmaxo (homecare). SLA to be prepared, and pathway reviewed. This is therefore an ongoing action. 4.1.4 Alemtuzumab SCG Update by Cambridgeshire Joint Prescribing Committee Following an MHRA alert in May 2019, the JPC requested information on an update to the SCG produced by Cambridgeshire Joint Prescribing Group. An updated version of the guideline was going to the Cambridgeshire University Hospital Trust Joint Prescribing Group in January 2020. This had been followed up and an outcome awaited. The latest MHRA Drug Safety Update (February 2020) has again flagged safety issues relating to Alemtuzumab (see agenda item 8.0).
CUFT had responded to advise that review of this SCG was a trigger for Cambridgeshire and Peterborough CCG to review their processes around SCGs where prescribing sits with the Trust to ensure that patients are not lost to follow-up. However, due to the new alert, they are restarting the review process. The JPC Secretary asked for timescales on completion of this work and assurances that GPs are being asked (by CUFT Neurology Department) to monitor in accordance with the MHRA recommendations 3 Bedfordshire CCG Luton CCG
rather than the current 2018 SCG. The response was as follows:-
‘We will be updating the SCG as per MHRA as soon as possible and I have notified our neurology leads to disseminate the information to the department. I think due to half-term a few relevant leads are off so we can pick this up next week again.’
The JPC discussed the response above and agreed that in SMcG/JC the interim, pending the update to the CUFT SCG, the front sheet of the SCG should be updated to advise that the SCG was under revision due to the MHRA updates and links to these updates included. It was further agreed that this information would be highlighted in the JPC Newsletter. 4.1.5 Choice of Melatonin Preparation JC A decision was deferred from the September 2019 meeting pending a legal and commissioning position. The All Wales Medicines Committee and the Scottish Medicines Committee has agreed that Slenyto® is not cost-effective. EoEPAC has agreed to produce a position statement based on this information and this will come to a future meeting. This is therefore an ongoing action awaiting the EoEPAC position statement. 4.1.6 NICE Guidance – Fluocinolone acetonide intravitreal Close implant for recurrent non-infectious uveitis – TA590. action To be added to the Ophthalmology Pathway. See agenda item 5.4. This agenda item could be closed as the updated ophthalmology pathway was approved by the Committee. 4.1.7 ICS Protocol (within COPD Guidance) Update The Committee was asked to note that DW had made very minor amendments to the ICS protocol. More (not new) information from the COPD Guideline was added relating to the LABA + LAMA combination. 4.1.8 Primary Care Management of Adult Female Urinary In continence and Prolapse - Pharmacological Management. The Priorities Forum chair advised that the pathway that we had received from the Priorities Form was an East and North Herts treatment pathway, not a Priorities Forum Statement. Post meeting - it was discovered that the Priorities Forum Statement on Urinary Continence was still available and had not been revised. The Priorities Forum chair agreed to investigate further and the JPC Secretary agreed that publication of the updated Pharmacological Pathway would be held until this further information had been received to minimise confusion, as the new and old Pharmacological Pathways were different.
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The Priorities Forum Chair had confirmed that in Hertfordshire, they have four separate sets of female urinary incontinence guidance (Priorities Forum, HMMC guidance, clinical pathways x2). They're similar but with some conflicts e.g. around drug therapy. The HMMC guidance from 2017 (due for review this month) looks much more similar in terms of drugs to the draft Beds and Luton guidance reviewed at the December 2019 JPC meeting. The latest pathway that was added to the clinical pathway website and shared with the JPC by the previous PF chair refers to local medicines optimisation team guidance and the PF chair feels that this is the most appropriate direction of travel. The current PF chair has started discussions about removing some of the duplicates, including the priorities forum guidance, to avoid having outdated info and conflicting guidance. BCCG CRG has considered the E and NHerts Pathway but could not approve it due to a lack of similar commissioned services in Bedfordshire. The development of a new pathway was required, but was low priority. The author of the JPC Pharmacological Guidance had therefore been asked to slightly amend the document so that it could be issued as a 'standalone' document. The Committee confirmed that this document could be published pending a clinical pathway being developed. It was agreed that a note would be added to the document cross-referencing it to the PF guidance on the CSU website (BCCG) and LCCG website (https://www.lutonccg.nhs.uk/page/?id=4135) but stating that JPC ratified Pharmacological pathway BS/SMcG should be used in preference. SC advised that when the PF guidance was updated, it would not contain any pharmacological management. 4.1.9 Luton and Bedfordshire Continence Appliance JC Prescribing Guidelines It has been discovered that Bedford Hospital continence service nurses (in addition to those at the Luton & Dunstable Hospital) supplied free starter packs. The LCCG and BCCG Quality teams had raised this issue with the Trusts and a response was awaited. This was therefore an ongoing action. 4.1.10 Other outstanding actions for Committee to note:- SMcG The following papers had not yet been finalised and added to GPref due to work load issues. However, these would be completed shortly: Amiodarone SCG (awaiting contact details) Palmdoc (addition to BGTS bulletin) IBD SCGs Apomorphine SCG 5 Bedfordshire CCG Luton CCG
5 Items for consideration 5.1 Medicinal Cannabis with a focus on the provision of Sativex® (Cannabis extract) for the treatment of spasticity
The Committee discussed the paper and the following key points were raised:- Current JPC position on the use of Sativex® is -‘The use of Sativex® to treat spasticity and neuropathic pain associated with MS is not supported. No GP Prescribing.’ This JPC position was a ratification of the East of England Priorities Advisory Committee (EoEPAC) Bulletin on Sativex® issued in April 2015. EoEPAC is withdrawing its position following the publication of NICE Guideline 144 and therefore a local position statement is required. NICE Guideline 144 recommends Sativex® as a clinically and cost-effective medicine for the treatment of spasticity in MS patients who have failed to respond to other treatments. The ICER was £19,512 per QALY gained. Based on the NICE resource impact report, it is estimated that 6.34 patients per 100,000 population would be eligible for treatment at an approximate cost of £20,576 per 100,000. Annual cost per patient was £3,200. NICE is not recommending use in chronic pain indications, including neuropathic pain associated with MS
There is a Multiple Sclerosis (MS) centre based at
the Luton and Dunstable hospital with estimated
patient numbers of 20.
Bedford Hospital does not have an MS centre but Dr
Manford has indicated that he is likely to see about
20 patients in his clinic and that supply will create a
demand.
Milton Keynes MS Clinic estimate about 15 patients with about 10 out of 15 responding. MKPAG has approved the use of Sativex® (Cannabis extract) for hospital prescribing only, subject to a 6 month audit of patients. It was proposed that Sativex® (Cannabis extract) – support an Integrated Care System (ICS) Position i.e. hospital only prescribing (criteria for use - in accordance with NICE Guideline 144) subject to a 6 month audit of patients. (MK to share audit information). NB – Sativex® is included in the National Tariff which would mean that funding of 6 Bedfordshire CCG Luton CCG
treatment, during the 6 month trial period, would come from Trusts. After the audit is complete and presented to the JPC, the Committee would review its position on prescribing responsibility. This could mean that the ‘status quo’ is retained i.e. hospital only prescribing or a recommendation that shared care is now considered appropriate. The Luton & Dunstable Hospital Trust is not able to fund a 6 month trial of Sativex® without additional funding from the CCGs. The Luton & Dunstable Hospital DTC has advised that as shared care is an option included in NICE Guideline 144, this would be their preferred method of providing Sativex®. This view was supported by the neurology department prior to the JPC meeting. Concerns were raised around GP prescribing and ‘prescribing creep’ for other patients or indications. HH advised that if funded, the neurology department at the Luton & Dunstable would be willing to undertake all prescribing and that this would be in line with the NICE Guideline. GMcG advised that although she had not received any feedback on the proposals from her neurologists, she anticipated that it was unlikely that Bedford Hospital neurology department would have the capacity to undertake all prescribing. There was a possibility that this position could change with the Trust merger but this was the current position. HH advised that it was likely that patient numbers would be lower than estimated and he thought that the Bedford Hospital numbers could be an overestimate. JC advised that part of the reason for the proposal that the hospital undertake the proposed trial was have greater clarity on patient numbers which could in turn inform a business case for funding. The JPC agreed to support the use of Sativex® in accordance with NICE Clinical Guideline 144, and that GP prescribing was not recommended at the current time.
The Committee noted that in the absence of an
agreement to fund by the Trusts, any prescribing
would need to await production of a business case
to each CCG for funding. This business case would
need to investigate the comparative costs of
providing the drug directly from the hospital or via JC/GMcG/A Homecare and include any costs that could be offset G/HH e.g. use of baclofen pump. JC agreed to produce the business case in consultation with GMcG, AG
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and HH. In the interim, if the Trust decided to prescribe Sativex® for patients, this would be ‘at risk’.
In addition to recommendations on the use of Sativex®, NICE Guideline 144, made recommendations on the use of nabilone for the treatment of chemotherapy –induced intractable nausea and vomiting. As this would be prescribed short term by specialists as part of chemotherapy support it was proposed and supported by the Committee that nabilone would be hospital only prescribing.
NICE supported Cannabidiol with clobazam as an option for treating seizures associated with Dravet syndrome (NICE TA 614) and Lennox-Gastaut syndrome(LGS) (NICE TA 615) in people aged 2 years and older. It was proposed and agreed by the Committee that there should be no GP prescribing. Rationale:- these technologies are commissioned by NHS England and providers are NHS hospitals. (In addition, NHS England Specialised commissioning has confirmed that the care of patients with Dravet and LGS who are on Cannabidiol (Epidiolex®) with clobazam will stay with NHSE on reaching adulthood, assuming the treatment doesn’t change). Although shared care is technically possible for these indications, the PAS price is not available in primary care and this is a highly specialised area of therapeutics.
The Committee agreed to support the final recommendation: - GP Prescribing of Medicinal Cannabis (licensed or unlicensed) for any other indication is not supported.
It was noted that some patients were asking GPs to prescribe Cannabis oil and that GPs should advise patients to purchase it.
Equality and Diversity Impact Assessment – A positive impact as these treatments have not been recommended previously. E and D Lead Comment -This one has the potential to impact on a protected group if the decision to add this to the provision is not made. This is because the condition support MS is a disability under EA 2010. As there are other options I think is sufficient to note this. 5.2 Antimicrobial Guideline Update
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Bedfordshire and Luton Community Antimicrobial Guidelines No. 12 (2020) and the BCCG Acne dermatology pathway have been updated in line with proposed Antimicrobial guideline changes from NICE. In particular NICE had published new guidelines relating to antimicrobial prescribing in Community Acquired Pneumonia and Cellulitis since the last update of the antimicrobial guidelines.
The major proposed changes, discussion points and JPC decision were:- Page 18 – Lower respiratory tract infection section removed and replaced with acute cough (already approved by JPC) – some discussion around duration of therapy agreed by JPC (for what is often a viral illness) which exceeded the 5 days advised by NICE. GP representatives, while acknowledging the reasons behind the NICE recommendations (evidence for 7 days therapy was no better than for 5 day course, therefore 5 days recommended to assist in the reduction of antimicrobial resistance), felt that 5-7 course provided GPs with more flexibility. Page 21 - Antibiotic choices for community acquired pneumonia updated in line with NICE guidelines (CG 191 and NG 138). – Again there was discussion around duration of therapy (as above for acute cough). It was agreed that this could be a severe infection and that the guideline should be amended to allow treatment for 5-7 days, rather than 5 days as advised by NICE. The Committee was also asked for its opinion regarding providing a treatment option for CRB65 score of 3 or 4. At this stage patients are normally referred to hospital but oral treatment options are available. The Committee agreed to remove the options as best practice, at this stage in treatment would be referral to hospital. Page 26 - Section on Pertussis updated in line with most up to date PHE guidance, treatment options removed to ensure PHE guidance is used – Agreed by the Committee. Page 53 - Acne vulgaris section revised in line with NICE CKS and Primary Care Dermatology (PCDS) advice, the BCCG dermatology acne pathway has been updated to reflect these proposed changes – there was some debate over the NICE recommendations on treatment duration of antibiotics – the previous guidance had recommended 6 months therapy, while the new guidance recommended 3 months with the 9 Bedfordshire CCG Luton CCG
emphasis that topical retinoids were started at the same time and continued after the antibiotic course was discontinued. GP representatives felt that in practice it took up to 2 months for antibiotics to take effect and there was a risk that patients could be reviewed earlier and started on a second ‘different’ antibiotic if the duration of treatment was shortened (clinician assuming that the first treatment hadn’t worked), which in turn could result in more (and earlier) referrals to secondary care. After some debate it was agreed that the NICE Guidance reflected best practice and should be the information included in the antimicrobial guidelines. The only amendment suggested (and approved) was removal of the word ‘future’ from the statement ‘courses could be repeated in the future’. Page 53 - A new section on Rosacea acne included in line with NICE CKS and PCDS advice – approved by the Committee. Page 54 – Section on cellulitis and erysipelas re- written in line with NICE guidelines (NG 141) – approved by the Committee. Page 61 – Treatment options for H. pylori infection removed. This information is changing regularly and is available in the BNF – it is therefore recommended for removal from the community antimicrobial guidelines to avoid outdated advice being used – Approved by the Committee. Page 61 - Travellers diarrhoea section updated in line with PHE advice – Approved by the Committee. Page 63 - Management of acute diverticulitis antibiotic choices updated in line with NICE guidelines (NG 147). The option of ciprofloxacin plus metronidazole listed in NICE guidelines is not included due to the safety concerns with quinolones. There remains 3 treatment options – Approved by the Committee.
Additional points raised:- The local antibiotic sensitivities data was last updated in 2015. Both Acute Trusts have been approached regarding updating this information but have advised that this is difficult to obtain. It was therefore proposed (and agreed) that this table be removed, pending the availability of more up to date information. The Guidelines state that food poisoning was a notifiable disease. SC advised that the same was
10 Bedfordshire CCG Luton CCG
true of ‘bloody diarrhoea’. It was agreed that this information would be added to the guideline. It was confirmed that warnings about use of tetracyclines in patients under 12 years were included in the Acne section. LMacK advised that she had seen a recent alert which suggested that macrolides were not as safe in pregnancy as has been previously advised. NC agreed to follow this up and report back to the Committee. It was noted that if this was the case, then treatment options for a pregnant patient who was penicillin allergic would be very limited. NC
With the amendments outlined above, the Committee approved the revision to the Antimicrobial Guideline and thanked NC for her work. NC The Bedfordshire Acne Pathway had been updated to include the new antibiotic information as outlined above. With the changes outlined above (under the Acne point), the revised Bedfordshire Acne Pathway was approved by the Committee.
Equality and Diversity Impact Assessment – No impact anticipated. The guidelines are in line with NICE antimicrobial prescribing guidelines which have been widely consulted on nationally. There is no reduction in the formulary choices of antibiotics available. BCCG E and D Lead Comment -This is not going to stop people accessing medicines since it is down to clinical appropriateness. It is in line with NICE. 5.3 Growth Hormone – Information Sheet for GPs Growth Hormone is a CCG commissioned drug which is excluded from the national tariff. There are different models of prescribing and supply in use within the county, which is in part due to historical commissioning arrangements. In some parts of the county, supply is via Homecare and GPs do not prescribe. In other parts of the county, GPs may prescribe after stabilisation of the patient but monitoring of the patient remains with the Specialist Centre. The information sheet aimed to provide advice to GPs on prescribing Growth Hormone in primary care to further support the established pathway. The Committee reviewed the Information Sheet and the following key points were raised:- LCCG Prescribing Committee was supportive of the document.
11 Bedfordshire CCG Luton CCG
Amend (Under funding approval process section) Add ‘As per The East Of England Priority Advisory Committee ‘PAC’ guidance statement, for any paediatric patient who chooses to use Norditropin SimpleXx or Nordiflex the growth hormone prescriptions will be provided via secondary care.’ Document to be checked and the spelling of ‘paediatric’ to be made consistent throughout. RN With the above amendments, the information sheet was approved.
The Committee also noted the following information with respect to Growth Hormone:- The JPC support the EoE PAC Recommendations on the use of growth hormone devices in children (updated 2018) which states: Prescribing of Norditropin SimpleXx and Nordiflex pre-filled pen devices is to remain in secondary care o Current prescribing data indicates that GPs are prescribing these items o Further investigation is into this existing cohort of patients to formalise as to whether they are retained in primary care or move back to the specialists. (Noted that it was likely that patients would receive the supply via Homecare if this was the case). It is anticipated that going forward the PAC recommendation will apply to new patients with the current cohort continue with the current prescribing model The products are not restricted in adults, this is an established pathway and there are no plans to JC change this. (It was noted that the information to be included in the JPC Newsletter would make it clear that the pathway and information sheet referred to paediatric patients only). DW/AG The Commissioning team will be updating the proforma and removing the reference to formal shared care agreement in the High Cost Drug Document.
Equality and Diversity Impact Assessment – There will be no impact on the availability to their treatment to specific groups however the route in which supply is obtained in paediatrics is different however the choice is not restricted. To mitigate the potential impact it is likely that existing
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cohorts will not be affected by this and the change will apply to new patients going forward. E and D Lead Comment - The main risk here is in changing meds due to side effects / patient concern. As this isn’t happening the issue would be more about communication. If existing patients aren’t to be kept on the current approach then there needs to be sufficient appropriate communication of the change. 5.4 Ophthalmology Intravitreal Pathway Update The pathway has been updated to reflect the inclusion of NICE TA 590 Fluocinolone for the treatment of recurrent non-infectious uveitis.
The pathway was discussed and the following key points raised:-
Fluocinolone acetonide intravitreal implant is recommended as an option for preventing relapse in recurrent non-infectious uveitis affecting the posterior segment of the eye (NICE TA 590)
Fluocinolone acetonide intravitreal implant contains 0.19 mg of fluocinolone acetonide and releases fluocinolone acetonide for up to 36 months.
Benefits are reduced hospital visits, one dose for up to 36 months in comparison to dexamethasone every 6 months, reducing treatment burden.
Due to its potency, the risk of the need for cataract operation, cataract formation and increased intraocular pressure is higher and more commonly associated in comparison to alternative treatments like dexamethasone.
Local clinician consultation highlighted that in general, the use of adalimumab or dexamethasone is preferred over fluocinolone. This is due to its potency and increased risk of side effects. The majority of patients who have uveitis frequently have systemic disease which would result in direct referral to the tertiary centre and specialist teams for full review and adalimumab treatment (NHSE funded).
During NICE’s consultation process, patient experts reported the effects of the dexamethasone implant had lasted for much less than the 6 months they had been expecting and that the clinical experts
13 Bedfordshire CCG Luton CCG
highlighted that biologic treatments are not effective in 20% to 30% of people with recurrent non- infectious uveitis so there is a need for alternative treatment options.
NICE agreed it was likely that the fluocinolone acetonide implant would be used after corticosteroids, as an alternative to the dexamethasone implant.
The marketing authorisation for the fluocinolone acetonide implant is for recurrent disease, so the clinical experts explained that they would most likely offer it to people who had already had corticosteroids. They explained that if the disease responded well to a dexamethasone implant, they would consider using a fluocinolone acetonide implant instead of another dexamethasone implant.
In relation to the pathway, DW stated that any requests for additional treatments with fluocinolone would be outside routine commissioning pathways and an IFR would need to be submitted for consideration.
The revised pathway was approved.
In addition to the update of the pathway (addition of NICE TA 590), LCCG and BCCG reviewed current antiVEGF for horizon scanning purposes and produced a combined paper. There was a price drop in ranibizumab in December 2019 and it was agreed following consultation and review of treatment regimens for both aflibercept and ranibizumab that this would have minimal impact on the current management of ocular conditions requiring anti-VEGF treatment.
It is anticipated that consultation will be underway with the ophthalmologists in the future, with two new products in development and expected to be licensed for wet AMD in 2020 (brolucizumab and abicipar pegol). Both products can be given every 12 weeks compared to 4 or 8-weekly dosing for current options (dosing frequencies without “extend and treat”). There are also existing product patent expiries and biosimilar development in the pipeline – bevacizumab patent expiry due this year and Ranibizumab patent expiry due January 2022. If these developments have any impact on the pathway and this will be brought 14 Bedfordshire CCG Luton CCG
back to a future meeting. AG advised that with the introduction of new products with shorter treatment intervals (bevacizumab, if ophthalmological license approved for the biosimilar product(s)), there were likely to be capacity issues for the providers.
Equality and Diversity Impact Assessment - This decision has been reviewed with regard to Equality, Inclusion and Human Rights and no restrictions have been identified, this is an additional treatment option which will have a positive impact on patient choice and outcomes. E and D Lead Comment - As a limited update to include new approach and maintain NICE compliance there might be a minor positive impact but nothing significant. Not following the update however would be more of an issue. 5.5 Mucosamin® Rectal Gel (Formulary application) The Committee was asked to consider whether Mucosamin® Rectal Gel should be added to the Bedfordshire and Luton Joint Formulary to be prescribed for the treatment of proctitis. This product is a medical device used in the therapeutic management of actinic proctitis caused by radiation treatment of the pelvic region, and proctitis caused during chemotherapy, or a combination of both treatments (chemotherapy and radiotherapy).
This request has originated from the Colorectal Specialists at Bedford Hospital.
The bulletin was reviewed by the Committee and the following key points were raised:- Radiation/chemotherapy induced proctitis (anal mucositis) and diversion proctitis are currently managed through the use of mesalazine suppositories. An evidence review found no definitive national clinical guideline for the management of proctitis. Mucosamin® rectal gel is a licensed medical device, for use in the therapeutic management of proctitis (anal mucositis) cause by radiotherapy, chemotherapy or both. Mucosamin® rectal gel is composed of hyaluronic acid (the primary component of connective tissue) and 4 amino acids that promote collagen formation. There is a limited body of evidence that supports the use of hyaluronic acid, with or without amino acids, in the management of oral mucositis. Studies report a statistically significant improvement in a range of outcomes measures including symptom severity, pain experience and duration of symptoms.
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The evidence review carried out found no studies which considered the effectiveness of hyaluronic acid, with or without amino acids, or Mucosamin® rectal gel specifically in the management of proctitis. It is not possible from the available evidence to determine whether the apparent benefits of the active ingredients in treating oral mucositis would necessarily be replicated in the treatment of proctitis Bedford Hospital Trust estimates 10 patients per year. Annual cost of treatment per patient is estimated at £1650 compared to £355.44 for Salofalk (Mesalazine) 500mg suppositories. There is very limited evidence to support use but the Colorectal Service at BHT felt that there were no other no other treatment options if mesalazine fails and this was a very distressing condition. One patient (with diversional proctitis) was being treated by the hospital with improvement shown after 4 weeks. The device was not on the CUFT Formulary nor listed on the Oxford Cancer Centre website. The L &D Colorectal Service had been contacted and were not aware of the product. JP advised that the L & D used sucralfate (4 week course supplied from the hospital) following failure of mesalazine in the group of patients who had proctitis due to chemotherapy and radiotherapy. There was some evidence to support the use of sucralfate (JP agreed to share with GMcG) at a cost of £41 per patient.
GMcG advised that many of the patients had proctitis
due to diversion rather than chemotherapy and and/or
radiotherapy. It was unclear whether the L & D
clinicians had used sucralfate for this indication, but the JP/GMcG Committee noted that this information should be
sought.
Mucosamin® oral gel was available in the Drug Tariff
but the rectal gel was not (at the current time), which
meant that GPs could not prescribe the product. This
meant that it would be a hospital DTC decision on GMcG whether the product should be supported for addition to Joint Formulary with the hospital being responsible for prescribing and funding. The JPC view was that due to a lack of clinical evidence to support the use of the product and the potential availability of an alternative treatment (sucralfate) which was potentially more clinically and cost-effective, Mucosamin® rectal gel should not be added to the Joint Formulary.
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Equality and Diversity Impact Assessment - The application will be reviewed together with the clinical evidence, cost-effectiveness and safety information. E & D Lead Comment - I wasn’t clear how many alternatives there were if this wasn’t approved. I am assuming there are other suitable options. 5.6 Lithium SCG Update The current Lithium shared care guideline was originally produced in 2013 by the Secondary Care Mental health pharmacist (SEPT). The guideline was later reviewed and endorsed by ELFT (last updated in 2016). As part of the JPC 3 yearly review of documents process, the shared care guideline was due a review. SMcG had produced the draft update to the shared care guideline in conjunction with the ELFT Mental Health Specialist Pharmacist. In summary, the shared care guideline has been reviewed and updated (effectively rewritten in parts) to incorporate wording from the ELFT document entitled ‘Protocol for the Safe Use of Lithium, March 2016. The previous drug fact sheet has been replaced with the appendix 1 &2 from the ELFT Protocol for safe use of lithium document.
The reference to the Lithium monitoring APP has been removed from the guideline as this APP is currently no longer in use. It is proposed that reference to the APP can be added at a later date if / when it becomes available again.
The revised SCG was reviewed by the Committee and the following key points raised:- The SCG includes a statement around’ Transfer of clinical responsibility to primary care’. This was included in the SCG template but had caused confusion. Did this mean that the patient was discharged into the care of the GP (formal referral {urgent or routine} being required or transferred to the GP with an easy route back into secondary care? It was noted that the former was probably the case, but that as the language was ambiguous it needed to be defined more clearly in the document. It was noted that arrangements for referral back for patients being treated under the shared care and those patients who had been stable for many years and were solely under the care of the GP needed to be clarified and relevant contact details included in the document. CO agreed to raise at the next ELFT CO MMC. GPs advised that in the main they were able to get urgent advice/referral for lithium patients when needed. 17 Bedfordshire CCG Luton CCG
It was noted that the SCG may be of most use when patients were first started on lithium. A question was raised about the actions that GPs needed to take in patients who had Lithium levels of – 1-1.5 mmol/L. GP representatives advised that they would follow the instructions but would probably still contact the Specialist Centre (or the CCG mental Health Lead GP) for advice. This needed to be added to the SCG. SMcG requested advice on the wording on P7 of the SCG in relation to patients not complying with the necessary monitoring arrangements. It was agreed that the wording should be amended to state that ‘If a patient does not comply with the necessary monitoring requirements, the GP should contact the Secondary Care Mental Health Services and withdraw Lithium treatment.’ It was noted that GPs would do both these actions at the same time and it was important to note that Lithium should not be stopped suddenly. Information on how to withdraw Lithium therapy safely was included on P11 of the SCG and this should be cross-referenced. It was agreed to add in a sentence re liquid vs tab. ‘Lithium carbonate is available as standard release and modified release tablets and Lithium citrate is available as liquid’ when the fact that they are not interchangeable is mentioned and in addition to add brand names of Lithium products Typo error under “Monitoring Requirements” on Page 12. “Weight or BM I annually” should read “Weight or BMI annually”. The use of the purple book was discussed. It was noted that while the Specialist centre issued these books when patients were commenced on Lithium, it was clear that GPs were not using them. Noted that when the NPSA alerts had been issued many years ago, everyone was working on a paper-based system but this was now not the case with most prescriptions going electronically and patients not attending the surgery. Unfortunately, the NPSA alerts had not been withdrawn and the SCG expressed ‘best practice’ advocating the use of the ‘purple book’. Concerns were raised that if an incident occurred and the purple book was not in use, in accordance with the SCG, this could be a problem. It was noted that technology was needed to solve the practicalities on transmission of the relevant information between healthcare professionals.
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Indeed, this was the reason that the Lithium App (produced by and for the NHS) had originally been produced. While it was noted ELFT do not have access to blood test results and neither do Community Pharmacists, ELFT clinicians would just get a blood test done before prescribing if they needed to and Community Pharmacists could/should check with Prescribers before dispensing (although in practice, GPs representatives advised that this did not seem to happen). It was noted that ICS Medication Safety Group was looking into issues around safe monitoring and prescribing of Lithium. It was agreed that the SCGs would be amended as outlined above and following discussions with ELFT and the Medication Safety Group, re-written as SMcG required. It was noted that if the purple book is not in use, the SCG may just have to specify that prescribers (in primary and secondary care) needed to satisfy themselves that the necessary blood tests had been undertaken and the blood test results had been reviewed, prior to prescribing.
Equality and Diversity Impact Assessment – No impact anticipated. This decision has been reviewed with regard to Equality, Inclusion and Human Rights and no issues have been identified. This is an update to existing Shared Care Guidelines which are used to support the safe prescribing of Lithium. E & D Lead Comment - The change is not significant in terms of patient’s experiences. 5.7 LMWH Prescribing responsibilities paper This an update to the original document which was produced in 2015 with the addition of the section on choice of LMWH. The Prescribing Responsibilities were largely unchanged from the previous version of the document but the following updates had been made:-
Both hospitals now used tinzaparin as the LMWH of choice – the document was updated accordingly. Reference section updated. Addition of the L& D Hospital dose banding for bariatric patients. Addition of information on the use of NOACs for VTEs in oncology patients. It was noted that evidence for use was limited. The information included in the document came from the Specialist
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Pharmacy Service. It was noted that the L & D hospital did not use but that BHT had done so in small cohort of patients (needle phobic, compliance issues).
The Committee was asked for views on where prescribing responsibility for prescribing LMWH for oncology patients lies. During the course of the discussion RF advised that CCS had just been commissioned to prescribe and supply LMWH for these patients. This was a new service (started in December 2019) and should remove the need for LCCG GPs to prescribe for this patient group. RF/AG/BS It was agreed that the remit of this service would be confirmed and the document updated to reflect this information.
It was agreed, that with respect to BCCG patients:- Oncology patients on active cancer treatment – hospital should retain all prescribing. Oncology patients being managed in primary care – LMWH prescribed should be retained in primary care.
Post meeting note:- RF confirmed that CCS does not provide a service relating to the prescribing and supply of LMWH to cancer patients. Therefore the statements outlined above relating to BCCG oncology patients also apply to LCCG patients. With the above amendments the revised document was approved by the Committee.
The Joint Formulary group had been asked to review the choice of LMWH used in primary and secondary care. Tinzaparin is currently the most cost effective product for hospital prescribing however in primary care Arovi® which is a biosimilar of enoxaparin is more cost effective. The JPC was being asked to consider whether it would be appropriate to recommend a switch to Arovi® for those patients whose prescribing will be continued in primary care. FG asked about repatriation of patients on LMWH given that the hospital contract prices were so much lower than those in the Community. It would be a better use of NHS resources. JC advised that she had explored this several years ago, but the project did not go ahead due to extreme resistance from the acute Trusts. This could be revisited if required.
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The Committee raised concerns re risks associated with switching patients on LMWH in the Community, particularly as many GPs were not comfortable with prescribing LMWH. In addition, the potential savings were at the higher doses of LMWH of which there was a lower level of prescribing. There was no precedence for switching LMWH.
The Committee agreed that, overall the risks outweighed the potential benefits of switching LMWH in primary care.
Equality and Diversity Impact Assessment – No impact anticipated. This is an update to an existing document and no major changes on prescribing responsibilities. There is a possibility of a change to choice of LMWH. However, no change to patient cohort. E & D Lead Comment - This is an update not bringing significant change. 6 NICE Guidance 6.1 NICE Guidance Summary – Published Guidance – from 21st November 2019 to 19th February 2020 (inclusive)
The following NICE Technology Appraisal Guidance (CCG Commissioned) have been published:-
Lusutrombopag for treating thrombocytopenia in people with chronic liver disease needing a planned invasive procedure Technology appraisal guidance [TA617] Published date: 08 January 2020 https://www.nice.org.uk/guidance/ta617 NICE does not expect this guidance to have a significant impact on resources; that is, the resource impact of implementing the recommendations will be less than £5 million per year in England (or £9,000 per 100,000 population). The technology is a further treatment option and due to this the overall incremental cost of treatment is not deemed to be significant. JPC Action – added to Joint Formulary (new drug created and NICE link added). Specialist only prescribing.
Dapagliflozin with insulin for treating type 1 diabetes Technology appraisal guidance [TA597] Published date: 28 August 2019 Last updated: 12 February 2020. https://www.nice.org.uk/guidance/ta597 This is an update to guidance previously discussed by the Committee. 21 Bedfordshire CCG Luton CCG
In February 2020, NICE changed the measures of assessing haemoglobin A1c (HbA1c) in the recommendations to reflect those commonly used in the NHS. Other minor changes have been made to the recommendations to align them with dapagliflozin’s expected clinical use. JPC action – none
Sotagliflozin with insulin for treating type 1 diabetes, Technology appraisal guidance [TA622] Published date: 12 February 2020, https://www.nice.org.uk/guidance/ta622 Sotagliflozin is not yet available in the NHS, but the company anticipates that it will be available to the NHS in England and Wales within 12 months of guidance publication. Therefore the period of time the NHS has to comply with these recommendations has been extended (see the section on implementation). The guidance will have similar financial impact to the Dapagliflozin with insulin guidance (TA587) with which it will compete. Implementation issues will be as for TA587 and agreed at the December 2019 JPC meeting (relevant extract from notes outlined below):- ‘It was agreed that it would be helpful if GPs could receive the initiation checklist (produced by the manufacturer) alongside the clinic letter advising that patients had been commenced on this combination therapy but that it may need to be modified locally to include patient’s name and who had initiated the therapy if this was not made clear in the clinic letter. The GP representatives advised that with this information, they would be happy to continue prescribing without a formal shared care guideline. It was therefore agreed, initiation (and continued supervision) of prescribing by Consultant Diabetologist (as per NICE TA) with GP continuation.’ JPC Action - To add to formulary and confirm any JC additional implementation actions when the product is launched.
Patiromer for treating hyperkalaemia, Technology appraisal guidance [TA623] Published date: 13 February 2020, https://www.nice.org.uk/guidance/ta623
Using NICE assumptions, the Drug Tariff Price for Calcium Resonium and Patiromer and the PAS price for Sodium zirconium cyclosilicate (with which it will compete), the estimated cost of implementing the guidance will be £68,000 for BCCG and £31,500 for LCCG over a 5 year period. These figures are approximate as they depend on 22 Bedfordshire CCG Luton CCG
usage of zirconium cyclosilicate and in which sector ongoing prescribing of patients with persistent hyperkalaemia are treated.
JPC Action – add to Formulary – Proposed amber, Specialist Initiation with GP to continue (for patients with persistent hyperkalemia) and red (hospital only) for emergency treatment of hyperkalaemia. This was agreed by Committee but that GPs would need specific information on required monitoring of patients. GMcG and JP to feed this information back to relevant clinicians within GMcG/JP their respective Trusts and GMcG to feedback on BHT GMcG clinicians’ views. JP advised that her cardiologists had not expressed a particular desire to use the drug but that renal clinicians were more interested. Concerns had been raised by the cardiologists that it was not particularly effective in the emergency situation (did not reduce levels by much and took too long to work).
NICE CCG Commissioned Appraisal withdrawn (Monday 10th February 2020):-
Collagenase clostridium histolyticum (CCH) for treating Dupuytren's contracture (TA459) https://www.nice.org.uk/guidance/ta459/chapter/1- Recommendations
In order for patients to have met NICE criteria for CCG funding they would have needed to be a part of the clinical trial (as documented in the TA), there has been an ongoing supply issue with collagenase recently as well which may have impacted on uptake/ use. Numbers are relatively low (BCCG), 9 patients in 2018, 6 patients in 2019 and 1 patient in 2020.
The following NICE Guidelines (NG) (Medicine related and CCG Commissioned) have been published / updated by NICE:
Diverticular disease: diagnosis and management, NICE guideline [NG147] Published date: November 2019, https://www.nice.org.uk/guidance/ng147 This guideline covers the diagnosis and management of diverticular disease in people aged 18 years and over. It aims to improve diagnosis and care and help people get
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timely information and advice, including advice about symptoms and when to seek help.
Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer Clinical guideline [CG164] Published date: June 2013 Last updated: November 2019, https://www.nice.org.uk/guidance/cg164 In November 2019, we updated the recommendation on topics that should be discussed with a person before making a decision on whether to have annual mammographic surveillance and added a link to patient decision aids.
Menopause: diagnosis and management, NICE guideline [NG23] Published date: November 2015 Last updated: December 2019. https://www.nice.org.uk/guidance/ng23 In December 2019, in response to an MHRA safety alert on hormone replacement therapy (HRT) and the risk of breast cancer, we replaced the table in the recommendation on breast cancer risk with a link to the MHRA's advice on HRT risks and benefits. We will also update this recommendation as part of the planned update to the guideline.
Acute kidney injury: prevention, detection and management, NICE guideline [NG148] Published date: December 2019, https://www.nice.org.uk/guidance/ng148 This guideline covers preventing, detecting and managing acute kidney injury in children, young people and adults. It aims to improve assessment and detection by non- specialists, and specifies when people should be referred to specialist services. This will improve early recognition and treatment, and reduce the risk of complications in people with acute kidney injury.
Colorectal cancer, NICE guideline [NG151] Published date: January 2020, https://www.nice.org.uk/guidance/ng151 This guideline covers managing colorectal (bowel) cancer in people aged 18 and over. It aims to improve quality of life and survival for adults with colorectal cancer through management of local disease and management of secondary tumours (metastatic disease).
Leg ulcer infection: antimicrobial prescribing, NICE guideline [NG152] Published date: February 2020, https://www.nice.org.uk/guidance/ng152
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This guideline sets out an antimicrobial prescribing strategy for adults with leg ulcer infection. It aims to optimise antibiotic use and reduce antibiotic resistance. See a 2- page visual summary of the recommendations, including tables to support prescribing decisions – JPC Action – FG/NC Update Community Antimicrobial Guidance (at next update). Refer to Wound Care Group and Antimicrobial Group for implementation.
Bipolar disorder: assessment and management, Clinical guideline [CG185] Published date: September 2014 Last updated: February 2020, https://www.nice.org.uk/guidance/cg185 This guideline covers recognising, assessing and treating bipolar disorder (formerly known as manic depression) in children, young people and adults. The recommendations apply to bipolar I, bipolar II, mixed affective and rapid cycling disorders. It aims to improve access to treatment and quality of life in people with bipolar disorder. MHRA advice on valproate: In February 2020, we amended recommendations in line with the MHRA guidance on valproate use by women and girls. The MHRA states that valproate must not be used in women and girls of childbearing potential (including young girls who are likely to need treatment into their childbearing years), unless other options are unsuitable and the pregnancy prevention programme is in place. This is because of the risk of malformations and developmental abnormalities in the baby. See update information for details.
Epilepsies: diagnosis and management, Clinical guideline [CG137] Published date: January 2012 Last updated: February 2020, https://www.nice.org.uk/guidance/cg137 The guideline covers diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care. It offers best practice advice on managing epilepsy to improve health outcomes so that people with epilepsy can fully participate in daily life. MHRA advice on valproate: In February 2020, we amended recommendations in line with the MHRA guidance on valproate use by women and girls. The MHRA states that valproate must not be used in women and girls of childbearing potential (including young girls who are likely to need treatment into their childbearing years), unless other options are unsuitable and the pregnancy prevention programme is in place. This is because of the risk of malformations and developmental abnormalities in the baby. See update information for details.
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Antenatal and postnatal mental health: clinical management and service guidance, Clinical guideline [CG192] Published date: December 2014 Last updated: February 2020, https://www.nice.org.uk/guidance/cg192 This guideline covers recognising, assessing and treating mental health problems in women who are planning to have a baby, are pregnant, or have had a baby or been pregnant in the past year. It covers depression, anxiety disorders, eating disorders, drug- and alcohol-use disorders and severe mental illness (such as psychosis, bipolar disorder and schizophrenia). It promotes early detection and good management of mental health problems to improve women’s quality of life during pregnancy and in the year after giving birth. MHRA advice on valproate: In February 2020, we amended recommendations on anticonvulsants for mental health problems in line with the MHRA guidance on valproate use by women and girls. The MHRA states that valproate must not be used in women and girls of childbearing potential (including young girls who are likely to need treatment into their childbearing years), unless other options are unsuitable and the pregnancy prevention programme is in place. This is because of the risk of malformations and developmental abnormalities in the baby. See update information for details.
Asthma: diagnosis, monitoring and chronic asthma management, NICE guideline [NG80] Published date: November 2017 Last updated: February 2020. https://www.nice.org.uk/guidance/ng80 This guideline covers diagnosing, monitoring and managing asthma in adults, young people and children. It aims to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks. It does not cover managing severe asthma or acute asthma attacks. In February 2020, we reviewed the evidence for increasing the dose of inhaled corticosteroids within a self- management programme in children and young people with asthma. We updated the advice on self-management for children and young people with deteriorating asthma control. JPC Action - Review Paediatric Asthma Guidelines.
The following NICE TA’s are the commissioning responsibility of NHSE and are listed for information only. Cerliponase alfa for treating neuronal ceroid lipofuscinosis type 2, -Highly specialised technologies guidance [HST12] Published date: 27 November 2019. 26 Bedfordshire CCG Luton CCG
https://www.nice.org.uk/guidance/hst12 - JPC Action - none – not added to Joint Formulary as unlikely to be used locally.
Cannabidiol with clobazam for treating seizures associated with Dravet syndrome, Technology appraisal guidance [TA614] Published date: 18 December 2019. https://www.nice.org.uk/guidance/ta614 - JPC Action – added to Joint Formulary (created and link added) – Hospital Only Prescribing.
Cannabidiol with clobazam for treating seizures associated with Lennox–Gastaut syndrome, Technology appraisal guidance [TA615] Published date: 18 December 2019, https://www.nice.org.uk/guidance/ta615 - JPC Action – added to Joint Formulary (created and link added) – Hospital Only Prescribing.
Cladribine for treating relapsing–remitting multiple sclerosis, Technology appraisal guidance [TA616] Published date: 19 December 2019 https://www.nice.org.uk/guidance/ta616 - JPC Action - link added to Joint Formulary - Hospital Only Prescribing.
Atezolizumab with carboplatin and nab-paclitaxel for untreated advanced non-squamous non-small-cell lung cancer (terminated appraisal) Technology appraisal [TA618] Published date: 15 January 2020. https://www.nice.org.uk/guidance/ta618 - JPC Action – None as terminated Appraisal
Palbociclib with fulvestrant for treating hormone receptor- positive, HER2-negative, advanced breast cancer Technology appraisal guidance [TA619] Published date: 15 January 2020. https://www.nice.org.uk/guidance/ta619 - JPC Action – Link added to Joint Formulary and TA information amended.
Olaparib for maintenance treatment of relapsed platinum- sensitive ovarian, fallopian tube or peritoneal cancer Technology appraisal guidance [TA620] Published date: 15 January 2020. https://www.nice.org.uk/guidance/ta620 - JPC Action – Link added to Joint Formulary and TA information amended.
Osimertinib for untreated EGFR mutation-positive non- small-cell lung cancer, Technology appraisal guidance [TA621] Published date: 22 January 2020.
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https://www.nice.org.uk/guidance/ta621 - not recommended - JPC Action – none
Peginterferon beta-1a for treating relapsing–remitting multiple sclerosis, Technology appraisal guidance [TA624] Published date: 19 February 2020, https://www.nice.org.uk/guidance/ta624 - recommended - JPC Action – link added to Joint Formulary
6.2 NICE Guidance Summary – Anticipated Guidance – February – April 2020 The summary was noted for information by the Committee 7 Virtual Recommendations/Documents – for discussion/ratification:- None 8 Drug Safety Updates – December 2019, January 2020 and February 2020
The following Drug Safety Updates came to the Committee for information (any actions taken are noted beneath the relevant alert):- MHRA Drug Safety Update December 2019 Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents.No longer licenced in children under 12 or under 35kg. Actions BCCG- Scriptswitch message updated to reflect license change. Epact dashboard identified practices who have prescribed to children, practices contacted directly to advise of contraindications and need to review patients. BHT - removed as stock from paediatric and neonatal ward. Any request will be made on a patient specific basis considering the MHRA alert although continued prescribing is not expected. LCCG – ePACT search run to identify practices who have prescribed for children. Practices contacted directly to advise of contraindications and need to review patients.
MHRA Drug Safety Update January 2020 E-cigarette use or vaping: reporting suspected adverse reactions, including lung injury. Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy. Mecasermin (Increlex▼): risk of benign and malignant neoplasia.
MHRA Drug Safety Update February 2020 Ingenol mebutate gel (Picato▼): suspension of the licence due to risk of skin malignancy
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Actions Joint formulary website updated to show that marketing authorisation is suspended.
Lemtrada▼ (alemtuzumab): updated restrictions and strengthened monitoring requirements following review of serious cardiovascular and immune- mediated reactions. Action See agenda item 4.1.4 Valproate (Epilim▼, Depakote▼) pregnancy prevention programme: updated educational materials. Nexplanon (etonogestrel) contraceptive implants: new insertion site to reduce rare risk of neurovascular injury and implant migration. Action BCCG added message to Scriptswitch Support Yellow Card: report suspected reactions in patients taking multiple medicines.
9 Formulary Update – These items come for information and ratification DTC decisions noted for information
BHT No additions Vitamin B compound removed from alcohol withdrawal pathway in response to RMOC position. LDH Humalog Junior Quickpen – added to formulary as an option for children who require a device which measures in 0.5 units. Vitamin B Compound in alcoholism – Adoption of the RMOC position, prescribing restricted to a 10 day course for patients at risk of re-feeding syndrome. BCCG Prescribing Committee – no meeting prior to JPC LCCG prescribing committee – none
Items agreed by the Formulary Group
Midodrine to be added to formulary Riluzole entry updated to show no longer HCD and amend to Amber shared care Riluzole liquid added to formulary as per SCG Spiriva handihaler – no longer listed as ‘first choice’ as per COPD guideline Diprosalic scalp application – Added to formulary
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Ketamine amber SCG – palliative hospice
Fidaxomicin - Change net formulary entry to reflect community antimicrobial guideline, only to be prescribed by GPs on the advice of a microbiologist Fluticasone nasal spray – added Colomycin nebulised for non CF patients - Added 2MU strength.
Other items RMOC Position Statement Vitamin Compound Supplementation in alcoholism
RMOC-position-sta tement-oral-vitamin-B-supplementation-in-alcoholism-v1.0-1.pdf AG
BCCG will adopt the RMOC position as per LDH, BHT, and ELFT confirmed with Path 2 Recovery. Post meeting note - LCCG has confirmed that it will also adopt the RMOC position.
Equality and Diversity Impact Assessment – Not assessed. 10 East of England Priorities Advisory Committee (PAC) – items for noting. (JC) 10.1 EoEPAC Minutes – November 2019 (Draft) - noted for information by the Committee. 10.2 Novel Nicotine containing Devices This is an update to and replaces the current EoEPAC Guidance statement entitled “Electronic cigarettes” which was previously ratified by the JPC as bulletin 236. The bulletin has been updated to reflect the fact that the ‘Voke’ device has now been launched. The EoEPAC (and JPC) recommendations remain unchanged.
The Committee ratified the EoEPAC recommendations and bulletin.
Equality and Diversity Impact Assessment – This is just an update to a current bulletin which reflects the fact that the ‘Voke’ device has now been launched in the UK. The EoEPAC (and JPC) recommendations remain unchanged, therefore, not assessed. E & D Lead Comment - This wouldn’t stop prescribing anything, simply adding the Voke option.
11 Bedfordshire Local Prescribing Committee Minutes for information
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11.1 Minutes from the Luton and Dunstable Hospital DTC meeting – December 2019 11.2 Minutes of the Bedford Hospital DTC meeting – October 2019 11.3 ELFT Medicines Management Committee Minutes (Mental Health) – November 2019 11.4 Minutes of Circle/MSK MMC Meeting – December 2019 11.5 Minutes of the Bedfordshire and Luton Wound Management Formulary Steering Group – January 2020 11.6 Minutes of the Cambridgeshire Community Services Medication Safety and Governance Group – December 2019 12 Additional Documents for information/approval
12.1 RMOC Update The JPC is asked to note for information (and action), the following documents that have been issued by RMOCs since the papers for the December 2019 JPC meeting were circulated:-
Free of Charge (FOC) Medicines Schemes: Updated Advice for adoption as local policy at https://www.sps.nhs.uk/articles/free-of-charge-foc- medicines-schemes-rmoc-advice-for-adoption-as- local-policy/
Comment – this should be read alongside the BCCG Commissioning Policy on Risk Sharing/Patient Access Schemes for Drugs.
Sequential Use of Biologic Medicines at https://www.sps.nhs.uk/articles/rmoc-advisory- statement-sequential-use-of-biologic-medicines/
Comment – The JPC already applies the principles contained within this document. MN asked about limit on number of biological therapies that could be used. Agreed that this would be discussed between MN, AG and DW at a DW/AG/MN forthcoming meeting and reported back as necessary.
RMOC: Standard Principles for Medicines Prior Approval Forms at https://www.sps.nhs.uk/articles/rmoc-standard- principles-for-medicines-prior-approval-forms/
Comment – the commissioning team have reviewed the RMOC guidance and agree that it is primarily aimed at Trusts and CCGs that are yet to implement blueteq system
31 Bedfordshire CCG Luton CCG
for CCG commissioned high cost drugs. The guidance has prompted the commissioning team to review their current process against the guidance and it was noted that the guidance advises that the final draft of the proforma should be sent back to the area prescribing committee for sign off. The Secretary proposes that we continue with the system that has been in operation locally over 10 years:- – Blueteq forms are used as standard practice for a consistent approach to ensuring financial control and assurance for all high cost drugs (tariff excluded), with the JPC advised of any exceptions. – The NICE update document presented to the area prescribing committee indicates the CCG commissioned high cost drugs issued via NICE TAs; the commissioning team routinely produce proformas as an action from the recommendations. – The proforma workplan and respective meetings ensure that the proforma implementation date is consistently met – this can be a 30 day or 90 day turnaround time for NICE TAs and shorter time period for other local/national guidance– there is a standard process in place for proforma production, consultation and sign off. – Continuation forms are used to enable commissioners and clinicians to fully comply with outcomes as defined by NICE TA/ local guidance. The commissioning team have taken measures to make the process seamless - the use of auto approval, if all outcome parameters met. – The JPC will not routinely discuss the forms unless there is any clinical clarification/input required. Clinicians, specifically the consultant lead for the speciality of the high cost drug indication, will continue to be consulted if there is any clinical clarification/input required.
The Committee supported the continued ‘status quo’ as outlined above. 12.2 Horizon Scanning The JPC was asked to note for information that Horizon Scanning (Medicines – 2020/21) has been completed and passed to relevant budget holders within the CCGs and Acute Trusts. The document will also be used to set future JPC/DTC work plans and further information on this will be brought to a future JPC meeting.
13 Any other Business – The chair asked Committee members to raise any major issues/comments on the papers for consideration in advance of the meeting.
32 Bedfordshire CCG Luton CCG
14 Dates of future 2020 meetings - all at Enterprise House (NOTE VENUE CHANGE) (Room 130), Wrest Park, Silsoe, Bedfordshire, MK45 4HS.
Wednesday 29th April 2020 Wednesday 1st July 2020 Wednesday 23rd September 2020 Wednesday 2nd December 2020
N:\Medicines Management\JPC\JPC FILE - IN USE FROM SEPT 2015\2020 JPC MEETINGS\February 2020\Draft Notes\JPC February 2020 Final Draft Notes v2.docx
33 Bedfordshire CCG Luton CCG Patient and Public Engagement Committee Minutes of meeting held on 6 February 2020 at Great Denham Community Hall,
Present: Alison Borrett AB Chair and Lay Member for Patient and Public Engagement – and Chair for meeting Steve Black SB Patient and Public Representative Cheryl Green CG Patient and Public Representative Lisa Wright LW Youth Support Services, Central Bedfordshire Council Catherine Jackson CJ Locality Integrated System Manager, Adult Services, Central Beds Anona Hoyle AH Senior Communications and Engagement Officer (BCCG) Jackie Bowry JB Communications and Engagement Manager (BCCG) Balraj Singh Rai BSR Deputy Business Manager, Central Bedfordshire Localities (BCCG)
1 Welcome and Introduction Alison Borrett (AB) welcomed everyone to the Patient and Public Engagement Committee and invited members to introduce themselves.
AH confirmed that the meeting was quorate.
2 Apologies The following apologies were received:
Bob King BK Patient and Public Representative David Simpson DS Patient and Public Representative Faiza Al-Abri FA Healthwatch Bedford Borough Diana Blackmun DB Healthwatch Central Bedfordshire Martin Trinder MT CEO, Community Voluntary Service (CVS) Simon White SW Adult Services, Bedford Borough Council Sarah Frisby SF Senior Communications and Engagement Manager (BCCG) Adele Slaney AS Primary Care Development Manager, Bedford Place (BCCG) Hayley Mills HM Youth Engagement, Bedford Borough Council
Jane Meggitt JM Director of Partnership Engagements and Communications 3 Declarations of interest No declarations of interest were made by members present.
4 Minutes of meeting held on 15 October 2019 The minutes were reviewed and agreed as an accurate reflection of the meeting.
5 Action Tracker The action tracker was reviewed. All actions had been either partially completed, completed, or covered by items on the agenda.
6 Chairs update
AB advised that the CCG was working with colleagues from Luton and Milton Keynes CCGs, regarding governance arrangements and developing a Committee in Common (CiC).
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AB reflected that she was both delighted and impressed with the way the committee had developed over the past 12 months, delivering on its remit as a formal subcommittee of the Governing Body with valuable contributions made by its members. AB added that the excellent work of the committee had been recognised by NHS England and that NHS England had awarded an outstanding score for governance in the CCG’s 2018/2019 Improvement Assessment Framework (IAF) submission for Patient and Public Involvement. Adding that she considered that the committee had continued to improve and develop during 2019/2020 with the recruitment of the new committee members. The PPEC model would be used as a Blue-print when establishing the new Joint Patient and Public Involvement Committee for Bedfordshire, Luton and Milton Keynes (BLMK) CCGs. 7 One Team Overview and Governance Arrangements Lead by Jackie Bowry – Communications and Engagement Manager
JB delivered a PowerPoint presentation explaining that the NHS was going through a cycle of change. She explained that the Long Term Plan (published in January 2019) set out that every ICS would need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This meant that in Bedfordshire, Luton and Milton Keynes (BLMK), there would be a single CCG.
In BLMK the CCGs have been working towards this since 2018, when one executive team was established to work across the three CCGs (replacing the three executive teams). The proposal to have one CCG by April 2021 was shared with the three CCG chairs Heather Moulder (BCCG), Nina Pearson (LCCG) and Nicola Smith (MKCCG) in November 2019 who agreed with the proposal. The rationale was shared with the three Governing Bodies in January 2020 who all supported the proposal.
A programme team has been established to oversee the work. The team has developed an engagement plan where CCG representatives will be talking to members, partners and other stakeholders about the proposals before the proposal is submitted to NHSE in September 2020. The proposal needs to evidence that it will work, and therefore the CCG’s need to ensure that there are systems in place by April 2020 (when the CCGs will operate in shadow form).
During 2020/2021 NHS Bedfordshire, Luton and Milton Keynes CCG will operate in shadow form and during this first year there will be both joint committees and committees in common, this will remove the need to have versions of each committee. The new Governing Body will hold its first meeting in May 2020.
In April 2021 the committee structure will change – a new ‘NHS Bedfordshire, Luton and Milton Keynes Governing Body’ will be established, single committees will become standard with one ‘NHS Bedfordshire, Luton and Milton Keynes Patient Engagement Committee’.
JB went on to explain that the purpose of the ‘NHS Bedfordshire, Luton and Milton Keynes Patient Engagement Committee’ will be to provide assurance to the new Governing Body that the new CCG is meeting its legal duty to engage and consult. Currently each CCG has a patient involvement group – in Bedfordshire the Patient and Public Engagement Group (PPEC), in Luton the Health and Social Care Engagement Group (HSCEG) and in Milton Keynes the Public Involvement and Advancing Equality Reference Group (PIAERG). All of these groups are chaired by the CCG’s lay member for patient and public involvement.
The groups operate very differently – the PPEC is the only group that has patient representatives, scrutinises plans and provides assurance to the Governing Body that the CCG is meeting its legal duty to involve and engage.
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JB explained that the three lay members, Alison Borrett (Chair of the PPEC), Lloyd Denny (Chair of the HSCEG) and Mike Rowlands (Chair of the PIAERG) have agreed that Alison Borrett would Chair the new NHS Bedfordshire, Luton and Milton Keynes Patient Engagement Committee.
JB advised that AH would be sending out an invitation shortly to members of the PPEC to attend a co-production workshop with representatives from the other two groups to co-design what the new group should like it, its membership, Terms of Reference etc. The meeting would take place on Wednesday 26 February 2020, 10:00-12:00 at Flitwick Football Club.
Members were encouraged to attend so they could participate in the discussions and share their ideas and experience of being a member of the PPEC.
A discussion was held following the presentation, during which the following points were raised / clarified:
i. Committee should be a manageable size and include young people and a mental health representative
ii. Training should be provided for the new committee which explains clearly the purpose of the committee and what is expected of both the new committee and its members
iii. Role descriptions should be developed for all committee members
iv. There should be a robust process to recruit individuals to the committee
In addition to comments about the new committee, there was a discussion about patient and public engagement.
v. Whether there would be opportunities for Patient Participation Groups (PPGs) to participate/influence at Primary Care Network (PCN) level?
vi. PCNs have been established in order for local practices to work more closely together with other providers in order to provide proactive, coordinated and more integrated health and social care. They are collaborations and not legal entities.
vii. There are 11 Primary Care Networks across Bedfordshire. Details of these and their constituent practices and a short animation about PCNs can be found on the CCG website.
viii. Patients can understand the reasons for the structure and management changes for the CCG, however engagement still needs to be conducted at a local level.
ix. Need to ensure that the links with the community and PPGs are not lost within the new BLMK structure.
Following the presentation and discussion the members of the PPEC agreed with the proposal to disband the PPEC as the new BLMK Patient and Public Involvement Committee will perform the scrutiny and assurance role that PPEC has been performing.
Action required: I. AH to send email to all PPEC members to inform them of the disbandment of the PPEC.
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8 Long Term Conditions Engagement Workshops
The three reports that had been produced following the engagement activities for Epilepsy, Multiple Sclerosis (MS) and Heart and Lung conditions had been shared with members of the committee prior to the meeting.
The committee commented that they had approved the proposed engagement approach that had been presented to them at the previous meeting on 15 October 2019, but in order to be able to assure the work had requested a detailed plan. The committee were therefore disappointed that they had not received a detailed plan for this work and that the engagement activities had proceeded without the plans being assured by the committee. Adding, that at the previous meeting in October, they had suggested promoting the workshops via a multi-pronged approach and made a number of suggestions of who to involve.
They advised:
i. It was unclear from the engagement report and with no sight of the engagement plan they did not know whether any of their suggestions had been implemented.
ii. the engagement reports should have included more detail to enable them to understand the level of take-up, the reports should have included: the number of patients with the condition(s) number of patients contacted by their GP practice inviting them to workshop / to participate in questionnaire iii. patients may not realise that the posters were for different conditions due to the same design being used for all 4 different workshops
AH advised that she had not invited a member of the commissioning team to the meeting to present the engagement reports, which in retrospect it would have been helpful as they may have been able to respond to the questions raised. AH added, that it would be beneficial in the future for the Communications and Engagement team to develop a suite of reporting templates for teams to use depending on the level of engagement/involvement i.e. formal consultation, engagement activity.
AH stressed that the Long Term Condition workshops were held to gather feedback on existing services rather than feedback on proposed service changes.
AH advised that the commissioners had provided an update following the epilepsy and MS workshops, advising that:
• East London Foundation Trust (ELFT) have recruited an MS nurse who should start on 6 April 2020, service users were not part of the interview panels • The ELFT Patient Participation lead has made contact with the MS and Epilepsy service users and recruited them to join the ELFT patient voice groups • ELFT have re-advertised the Epilepsy Nurse positions as they failed to recruit to the positions • Commissioners had met with some service users with learning disabilities (LD) at the Child Development Centre on 13 January and received feedback about children’s epilepsy services and the parents worries regarding transitioning to adult services and also about the issues around the adult service at Bedford Hospital • Arrangement had been made to attend the Speech and Language Therapy (SALT) Service Users Forum on 26 February to carry out more LD engagement
CJ advised that the Preparing for Adulthood (Pfa) team and Adults with Learning Disabilities team (ALDT) team might be able to offer some ideas / opportunities for engaging with adults with learning disabilities.
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AB concluded that it was disappointing that the process for assurance had not been followed on this occasion.
Actions required:
I. CJ to forward contact details for the Preparing for Adulthood (Pfa) team and Adults with Learning Disabilities team (ALDT) team
II. AH to work with the new BLMK Patient Involvement Group (a new committee which is part of governance arrangements) to develop suite of templates which will support them to fulfil their role of assuring the Governing Body.
9 Patient and Public Involvement Report Lead by Anona Hoyle – Senior Communications and Engagement Officer
The Patient and Public Involvement Report for the period January to December 2019 had been shared with members of the committee prior to the meeting.
AH advised that the report provided a summary of the involvement and engagement activities that the CCG had conducted over the past year, the report was available to view on the CCG website.
Members of the committee fed back that they considered it to be a very comprehensive report, saying it contained a broad selection of examples and outcomes, particularly liking the ‘You said we did’ section.
Members suggested that the CCG should be more pro-active in promoting its good news stories and that a summary section should be added to the report.
10 Update on Bedford Hospital MSK Hydrotherapy Services Lead by Jackie Bowry, Communications and Engagement Manager
JB provided a brief recap on Hydrotherapy Services, advising
- The draft engagement and approach had been approved by PPEC in July 2019 - In August 2019 the PPEC were informed that engagement had gone live - In October 2019 PPEC were presented with a report detailing the findings of engagement activity. PPEC provided assurance to the Governing Body that that they were satisfied with the involvement and engagement that had been conducted. - The engagement report fed into the full report and was considered by Bedford Hospital Trust Board and Bedfordshire CCGs Governing Body. The Boards approved the recommendation to provide Hydrotherapy Services at facilities in the Community. JB then updated the committee advising that a report had been taken to the Bedford Borough Overview and Scrutiny Committee (OSC) in January informing them of the outcome (decision) made by the Governing Body and Hospital Board. The OSC advised that they were dissatisfied with the decision made by the Boards and would write formally to both the CCG and Hospital Board regarding the decision made
AOB
I. JB advised that the ‘Your GP is Changing’ campaign had been rolled across BLMK.
Members commented that they thought patients appeared to be more comfortable seeing other health care professionals at their practice.
5 | Page II. SB and CG advised that they had attended the Bedfordshire Luton and Milton Keynes (BLMK) workshop as patient/public representatives to help define a BLMK plan for population health management.
The workshops were attended by a range of partners from across BLMK. They found the workshops most informative and interesting how partners were thinking about public health, they did feel however that the workshop was pitched at analysts and not the workshop attendees.
C Next meeting: No further meetings following decision to disband committee.
Signed Dated
Alison Borrett Lay Member for Patient and Public Engagement
6 | Page Luton Health and Social Care Engagement Group (LHSCEG) Minutes of meeting held on 28 January 2020 at Dallow Road Community Centre, Luton
Present: Andy Assan AA Healthwatch Luton, Woodlands Avenue PPG Rev Lloyd Denny LD Chair LHSCEG and Lay member for Patient and Public Engagement, LCCG Keith Dobbs KD Gardenia Surgery PPG Anona Hoyle AH Communications Team for Bedfordshire, Luton and Milton Keynes CCGs Maureen Matthews MM Healthwatch Luton and PPG representative Amanda Murrell AM Communications Team for Bedfordshire, Luton and Milton Keynes CCGs David Palmer DP Leagrave Surgery PPG Jamu Patel JP Bell House Surgery, ELFT Governor Nicky Poulain NPo Luton CCG and BLMK Commissioning Collaborative Derek Smith DS The Biscuit Group Phil Turner PT Healthwatch Luton and Barton Hills Medical Practice Claire McKennie CM East London Foundation Trust (ELFT) Vannett Wilson VW Nyabingi Nina Pearson NPe Luton CCG , GP at Lea Vale Medical Group Michelle Summers MS Communications Team for Bedfordshire, Luton and Milton Keynes CCGs
1 Welcome and introductions
LD welcomed everyone to the meeting and invited all attendees to introduce themselves.
2 Apologies
The following apologies were noted:
Helen Owen Keith Williams Michelle Bradley Lucy Hubber 3 Declarations of interest
No conflicts of interest were raised.
4 Minutes of previous meeting
The minutes from the meeting held on 26 November 2019 were reviewed and agreed as an accurate reflection of the meeting subject to one amendment: - Derek Smith representative from Biscuit Group 4 Action tracker
The action tracker was reviewed, the actions were either updated on the tracker or covered by items on the agenda.
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Item 26 The Medina Road options paper is still at discussion stage and options are evolving. It is expected that the options will be available in March. The diabetes service which was previously operating from the Kingsway site has moved in the process. They had been operating at the site without any formal agreement.
PT commented that he had heard that Medina PPG had dissolved.
5 Update from Luton Place and Question and Answer Session & Led by Nicky Poulain and Lloyd Denny 6 1. JP commented that at a recent meeting, someone had advised that paper prescriptions were going to stop being issued.
NPe and NPo responded that they were not aware of this, adding that hand-written prescriptions are quite rare (usually issued by dentists) and that most pharmacies and GPs prescribe electronically.
Action: NPo to find out, liaise with teams and provide clarification.
2. AA commented that there had been delays /issues with communication between the Out Patients Team at the hospital and GP surgeries. There had been a number of cases where a patient had been seen at the hospital, but the results and/or information about treatment had not been forwarded to the practice.
Action: NPo to forward feedback to L&D forum
3. In response to a question raised about NHS111, NPo advised that if a person rings NHS111 the person is clinically assessed to see which service is most appropriate to meet their need. Therefore if the person is assessed as requiring a GP appointment they should be allocated one, this could be a same day, out of hours or extended access appointment.
AH advised that no questions had been received prior to the meeting. LD reminded the group that if they had a technical question they would like to ask at a meeting, to submit it in writing prior to the meeting, to enable officers’ time to collate a response.
7 One Team Led by Michelle Summers, Head of Communications and Engagement for Bedfordshire, Luton and Milton Keynes CCGs
I. Overview of One Team MS explained that the NHS was going through a cycle of change. The Long Term Plan (published in January 2019) set out that every Integrated Care System (ICS) would need streamlined commissioning arrangements to enable and deliver a single set of commissioning decisions at system level. This means that in Bedfordshire, Luton and Milton Keynes (BLMK), there would be a single Clinical Commissioning Group (CCG).
In BLMK the CCGs have been working towards this since 2018, when one executive team was established to work across the three CCGs (replacing the three executive teams).
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The proposal to have one CCG by April 2021 was shared with the three CCG Chairs Nina Pearson (LCCG), Heather Moulder (BCCG) and Nicola Smith (MKCCG) in November 2019, who agreed with the proposal. The rationale was shared with the three Governing Bodies in January 2019 who supported the proposal.
A programme team has been established to oversee the work. The team have developed an engagement plan where CCG representatives will be talking to members, partners and other stakeholders about the proposals before the formal proposal is submitted to NHS England (NHSE) in September 2020. The proposal needs to evidence that one CCG will work, and therefore the CCGs need to ensure that there are systems in place by April 2020 (when the CCGs will operate in shadow form).
II. Governance Arrangements
During 2020/2021 NHS Bedfordshire, Luton and Milton Keynes CCG will operate in shadow form. There will be joint committees and committees in common, therefore removing the need to have three types of each committee meeting (for example three audit committees, three quality meetings, three finance meetings).
Then in April 2021 the committee structure will change, single committees will become standard and one new ‘NHS Bedfordshire, Luton and Milton Keynes Governing Body’ will be established. One of the sub committees will be the ‘NHS Bedfordshire, Luton and Milton Keynes Patient Engagement Committee’.
The purpose of the ‘NHS Bedfordshire, Luton and Milton Keynes Patient Engagement Committee’ will be to provide assurance to the new Governing Body that the new CCG is meeting its legal duty to engage and consult.
Currently each CCG currently has a patient involvement group. Bedfordshire has the Patient and Public Engagement Committee (PPEC), Luton has the Health and Social Care Engagement Group (HSCEG) and Milton Keynes the Public Involvement and Advancing Equality Reference Group (PIAERG). The committees and groups are chaired by the lay member for patient and public involvement and operate very differently.
The three chairs, Alison Borrett (Bedfordshire), Lloyd Denny (Luton) and Mike Rowlands (Milton Keynes) have agreed that Alison Borrett would chair the new NHS Bedfordshire, Luton and Milton Keynes Patient Engagement Committee’.
MS advised that the CCG was hosting a co-production workshop and inviting representatives from each of the groups to a meeting to look at what the new group should like it, its membership, Terms of Reference etc. on Wednesday 26 February 2020, 10:00-12:00 at Flitwick Football Club.
Following the presentation, the group held a discussion during which the following points were made:
• The new ‘NHS Bedfordshire, Luton and Milton Keynes Patient Engagement Committee’ will be to provide assurance to the new Governing Body that the new CCG is meeting its legal duty to engage and consult. • The HSCEG focuses more on patient experience • The CCG would provide training for the new committee to facilitate them to perform their roles • The CCG would be engaging with stakeholders over the coming months. Part of the public engagement would be the introduction of ‘Listening Posts’ in May 2020, where members of the public can talk and ask questions to CCG representatives before Governing Body meetings
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• The new organisation NHS Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group will be a legal entity • The new joined up CCG will enable services to be commissioned on a larger scale, reduce health and services inequalities between areas and provide the opportunity to commission specialist services which the individual CCGs cannot afford • The new Patient and Public Engagement Joint Committee should have local authority representation, to support the joint working between health and social care • Bedfordshire, Luton and Milton Keynes have different demographics and different health and social care needs – this should reflected in the plans and the engagement and involvement activities • The CCG and Council have good connections with local businesses and communities, these connections should continue to thrive • The GP practices previously belonged to clusters, the clusters have now morphed into Primary Care Networks (PCNs)
Following the discussion, members of the group advised that they wanted the HSCEG to continue to meet. DP, AA, EA, PT and JP volunteered to attend the co-production workshop on 26 February.
Action:
MS agreed to share the Communications and Engagement Plan which would include the milestones for the programme.
8 Luton and Dunstable Hospital and Bedford Hospital merger
The slides from the Luton and Dunstable Hospital’s public meetings were circulated to members prior to the meeting.
AH advised that she had received an update from the Head of Communications at the L&D which advised:
• Good progress being made and the hospitals were on track to become a single Foundation Trust on April 1. Their Shadow Board had been confirmed, so there was clarity about leadership.
• The Full Business Case has been submitted to NHS England/Improvement and the hospitals are working closely with them to ensure they are satisfied with the progress proposed future structure.
• There will be some changes to the way that they manage and operate across the two sites with opportunity to realign both clinical and corporate services (as well as our corporate ones). Patients should notice very little difference in the early days
• Pathology services will be merging on April 1 due to the ending of the private contract at Bedford.
• They have run public engagement sessions in Bedford, L&D and in Central Beds – which they were pleased with, reporting there was improved positivity and understanding/appreciation from the public that there is a firm commitment to keep core services (like A&E, maternity) at both sites, and that in most cases, patients’ pathways will be unaffected, so they are not anticipating patients travelling further or having to go to different sites
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Action: AH to find out more about the pathology merger and ensure GPs are sighted on the change
9 Agenda items for next meeting Suggestions included • One Team • Focus areas for the PCNs – complex children and older people • Proof of concept • Recruitment and retention in primary care • Flu plan.
Action: AH to schedule for future meeting
10 A.O.B.
AM advised that ‘Your GP is Changing’ packs of information will be rolled out early February and the campaign launched
AM advised that the CCG’s constitution had been revised so it aligned with Bedfordshire and Milton Keynes’ constitutions.
11 Next meeting: Tuesday 31 March 2020 from 6:00pm – 8:00pm The Dallow Centre
Signed Dated
Lloyd Denny Lay Member for Patient and Public Engagement
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Minutes of the Primary Care Commissioning Committee – PART 1 (in PUBLIC)
Wednesday, 12th February 2020 from 13.00 – 14.00 pm
The Davis Suite, Rufus Centre, Steppingley Road, FLITWICK Present:
Alison Borrett (Chair) AB Lay Member of Public and Patient Engagement Sally England (Vice Chair) SE Lay Member Finance and Performance Dr Sarah Whiteman SW BLMK – Medical Director Nicky Poulain NP BLMK – Director of Primary Care (from 01.04.20.) Nicky Wadely (representing COO) NW BCCG - AD Primary Care and Transformation, BCCG Tony Medwell TM BCCG - Head of Primary Care Contracting and Commissioning Dr Roshan Jayalath RJ Bedford Place GP Chair Nicky Williams NW LMC – Medical Director and Herts GP Roger Hammond RH BCCG – Deputy Chief Finance Officer Maria Laffan (part) ML BCCG – Associate Director of Nursing & Quality Richard Noble RN BCCG - GPFV Transformation Manager, BCCG Nikki Barnes part NB BCCG - Head of Infrastructure & Integration, BCCG Maryla Hart MH BCCG – Governance & Committee Officer Lynn Turner – Note-taker LT BCCG - Office Manager, Primary Care Contracts and Commissioning
Apologies: Mike Thompson, Patricia Coker, Heather Moulder, Laurie Hurn-Healthwatch, BBC
Agenda Item Action 1 Welcome and Introductions
AB welcomed everyone to the meeting and introductions were made AB around the table. A noted there were apologies from Mike Thompson, Patricia Coker, CBC, Heather Moulder, Laurie Hurn-Healthwatch, BBC
Nicky WADELY was representing Mike Thompson, COO 2 Declarations of Interest Dr RJ declared an expression of interest regarding King Street/Cater AB Street practices. Agenda Item Action STRATEGY & GPFV 3 Minutes and matters arising from October meeting The Minutes of the October meeting were agreed as an accurate AB reflection of the meeting and signed off by the Chair. 4 Action Tracker – October meeting PCC 8 Communication moving forward with TVMC not part of a PCN. In NW agreement with De Parys for TVMC to join North Bedford PCN. Extended hours and approval on the workforce re clinical Pharmacy and Social Prescriber for review in March to formalise TVMC being part of the PCN rather than an Associate. Bring
back in April.
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PCC17 TVMC procurement. New Provider and recommendations from TM the audit which have been implemented but mobilisation not completed. Bring back Audit report from Cauldwell once completed.
PCC18
ToRs have been updated. BLMK to bring into one Governance NW structure. The proposal is there is a Committee in Common which will meet in May 2020. CLOSE. PCC 24 - Action in Public Agenda ITEM 5. NW Presentation. CLOSE. NW PCC 25 – Action in Public Flu update - TM reported this as 2.5% lower than the previous TM year due to supply issues with Sanofi and the nasal spray for children. However, higher than the national average. CLOSE 5 Primary Care Development updates Presentation showing the development and support of PCN’s and NW/RN Maturity matrix.
NW led the presentation stating that financially with support from NHSE ITEM 5 PCCC circa £730,000 had been allocated through the development funds of Development updates PCN across BLMK to be used to develop PCN’s along the maturity matrix. It was agreed there would be an additional amount available for Bedfordshire PCN’s to use in organisational development work and engagement. Needs identified as far as development support required was guidance around Clinical Director and succession planning support for individuals and the wider team. Looking at a dynamic Procurement Framework set up by NHSE for various providers with one called Primary Care Commissioning Programme, a national organisation who have composed 3 separate support offers for delivering wider leadership for developing projects and support for newly appointed clinical directors within the NHS and their understanding of the national picture. Also recognising the difference between a Practice Manager and a Strategic Manager within a PCN. There is an element that is Fair shares which is £21,000 per PCN used for supporting population health needs. SE asked RH what was the current financial position regarding these monies as this appears to be happening in the future and only 6 weeks away from year end whereby this money should be spent and not thinking about spending it as would assume it will be lost if not spent? RH responded that the money had come into the system in July 2019 but was held by MK. Only last week MK released an amount of £233,000 to use for PCN Development. It is unknown if there will be any 20/21 PCN development money centrally therefore discussion with the Auditors of how the money can be carried forward. NW stated that NHSE gave a timeline in August re Maturity Matrix being clear with PCN’s about going through that process with the completion of the exercise being end of November beginning of December 2019. NHSE have committed that if we have identified the resource and the way in which we are going to use it in the form of a plan they are satisfied. SE to urgently consider the COMMS and the messaging with having to use next year’s money as PCN’s need to be actively spending this in Q4 and not lose it. NW assured there was a 2
development plan for each of the PCN’s and have received support from LMC Law as well as identifying the bursaries and the back fill. Clinical directors have put through some work re population health management and the resource has already been given to PCN’s. AB asked if some of the work has been started what does the £21,000 per PCN really look like and to understand what the total figure is, left from the £50,000? RH responded £21,000 is still there (total figure of what is left from £50,000 which has already been committed). NW confirmed this was subject to discussion at this Committee today and how the funds have been utilised against the Maturity Matrix 19/20 money. Not all 11 PCN’s wanted to have access to NAPC as they wanted some alternative options. NP stated that PCCC need to support the PCN’s by stating how they think the money should be used and demonstrate how the funds can be utilised. NWi reiterated that the language must be clear with a proper process for supporting PCN’s in how CCG thinks the funds should be spent. RH suggests this paper should be re-presented at the April meeting as this will give the Committee assurance this is moving on and secondly, RH’s input into that paper together with a plan should provide assurance to the Auditors if questions are raised. AB asked: 1) What is the manpower support that the CCG has in ensuring that working together with the PCN’s that this can happen? NW responded that the teams are equipped to support with already doing that work through the maturity matrix and has no concerns. 2) Will any PCN not make the deadline of receiving those funds and is there a risk of them not being able to have those funds? NW responded that with CCG support the PCN’s will meet that deadline.
ML joined the meeting at 1.30 pm NW reported that CCG are not aware of the quantum of funds allocated to PCN’s but there is likely to be further funding available. There is an updated guidance agreement with the GP contract linked to PCN’s stating that from 1st April 2020 roles such as Clinical Pharmacists, Physiotherapists and Social Prescribers will be paid out of this funding. NW asked if the Committee would like a more detailed Presentation regarding what is included in the contract going forward and will circulate today’s presentation to members. On-going recruitment with Clinical Pharmacists and CCG fortunate that a high proportion did transfer over from the NHSE scheme into PCN scheme as well as Pharmacy Technicians. New GP International recruits will be joining CCG practices within the next few months in particular, two at Putnoe and all Care homes are now aligned to their practice within their PCN. From 1st April CCG will be managing a change of provider at Cauldwell Medical Practice entering into a PCN.
SE requested an urgent action to tighten up issues regarding the money imminently to be utilised in 19/20 and not lost to PCN’s. AB asked for the support of the funding of the PCN’s from the Committee which was agreed. AB asked RH with going forward to BLMK will CCG be notified of where that money is allocated of how to plan ahead moving into the new financial year. RH affirmed there will be central PCN money available 3
but given that we are not under a single CCG legally, next year assumed it will be held in the books of one CCG with similar Governance arrangements. The following year 21/22 will come into one CCG. SE reaffirmed that this money is to be spent within the BLMK system with solid plans to disperse as the money should be spent by PCN’s before the end of March 2020. ACTION: NW to progress the funding of the PCN’s imminently FINANCE & CONTRACTS 6 Finance MO10 report RH RH reported the last Committee meeting would have presented Month 7 and his comments will cover from Month 7 to present month. Year to date an under-spend of just over £500,000, with forecast underspend of £700,000 which is £140,000 up from Month 7 totalling 1% of the entire budget. Breakdown of that with the biggest element being the Core funding in terms of GMS and APMS with a small pressure arising from patient list sizes increasing and the savings from the Clapham Road dispersal costs from last year are not flowing through as expected. The forecast there for Q4 regarding patient list size is reported as fairly solid. Enhanced services there is still some slowness on claims and along the Premises lines as well but DP/BC are chasing this with practices as there are 13 practices with outstanding rates to be claimed. Some practices were unaware of claiming for CQC fees and 1 practice has just sent in a backdated claim over 3 years with 2 years going to NHSE. The largest element of Enhanced Services is Minor Surgery which is claimed quarterly and showing as under spent. Primary Care Other with small pressures and CQC registration fees higher than budgeted for which CCG reimburse practices. Premises One – small pressures at the higher end of the table usually rent reviews that have been back-dated and not necessarily budgeted for. The big number, 252 under Other is a Section 96 overspend that has been given but does not anticipate any more over the next 7 weeks. Prescribing/Dispensing fluctuates monthly and is showing an underspend. QoF – with an issue on Achievement which is unknown until after year end. PCN’s - Additional Roles which have been slow in the early months but picking up now with the monthly budget being £65,000 a month with January claims totalling £42,000 continuing with an underspend of £20,000. PMS Reinvestment – Some slippage during the first two quarters with Walk-in Centre higher activity and lower income. Reserves are assessed monthly with a minimal risk and have released Reserves with the exception of £100,000 which will be assessed at year end.
RH concluded that pressures within the budget are manageable, there will be an underspend at year end despite endeavours to spend where necessary.
SE queried the numbers in Minor Surgery – Is there any clinical evidence why numbers are going down, are they being moved to Acute? Response from ML was there was an increase in dermatology. Dr RJ added that you can claim for certain types of minor surgery but 4
the criteria had changed hence reporting of lower numbers. NW stated regarding some of the suspected cancers, there is a requirement for a different skill base whereby individuals need to reaccredit and able to manage those. ML added there is a clinical format for Minor Surgery within Primary Care. TM stated there is a real capacity issue within Primary Care at present. NB arrived at 13.47 pm The Chair commented how do we engage with our members moving forward as in shadow form this year so that they are claiming on time for what rightly is their’s, making this more transparent as if there is money to spend they should be spending it which RH responded it was happening more now there is a delegated budget. Finance team issue to the Place base teams regularly which practices are not claiming and this is pursued. This impacts on their cash flow and their business so is their job to chase and for Practice Managers within GP surgeries to cascade information of not re-couping the re-imbursement available from BCCG as they are not claiming. AB further commented how do we engage with our PCN Directors in a very transparent way to claim for what they need. NW spoke about the use of Arden’s templates to enable the practices have more consistent pro-actively claiming which can be communicated through Practice Managers Forums. ACTION: NW to reiterate this to Practice Manager’s forums. ML observed invoicing claims as a back-office function and difficult for PM’s to take on everything and who would take on that function. AB stated there was further money to spend on development. NW assured that discussions were happening within PCN’s and business fundamentals that LMC run in conjunction with BCCG for developing a new Practice Manager. NWi stated that Bedfordshire are the first area running the Practice Manager modules and has not heard of any issues from other PCC’s which must be reflective of the resilience and pressures within BCCG Primary Care. The financial flows coming into the Practice are hard to identify and are much more complex than shown on a spreadsheet and would necessitate a full-time job to manage. NP stated that this has been experienced in Luton when using PSU and the learning following this was to get some systematic processes in place within practices and keep it simple. 7 Risk Register Review The Risk Register was projected onto a TV screen for members to view RN and RN reported both Reds as still being general risks around resilience within practices within BBC and CBC which will be discussed further in Part 2 of the meeting. RN stated at the December meeting that one of the risks would be closed around PCN’s with the practice that was not part of a PCN namely TVMC who have Associate status with De Parys but have now formed North Bedford PCN. Therefore this risk is now CLOSED. The last two risks shown on the Risk Register are new namely: Risk 83 – Out of date since papers circulated to Committee due to revised guidance received Thursday, 5th February. Draft Specifications for PCN’s published in December 2019 received a mixed response nationally to the Consultation which this paper does not reflect but this risk will now be downgraded shortly. 5
There is an added risk around Disengagement. Risk 84 – Reimbursable roles which PCN’s are entitled to – progressing against what PCN’s can claim, still not fully in place. The revised guidance informs that from April 2020 PCN’s are able to claim for far wider type of roles i.e., Pharmacy Technicians, Podiatrists. This guidance has been published as a result of a national workforce shortage. SE queried Risk 84 stating that since the Presentation at a previous meeting this felt like a positive story regarding successful recruitment of the various roles into PCN’s namely Social Prescribers and Clinical Pharmacists and has now been added to the Risk Register as a moderate risk. NB added they have managed to find some creative solutions in bringing the Social Prescribing Link workers through the sub-contract arrangement of BRCC and the Clinical Pharmacists TUPE arrangements through NHSE but have not resolved the risks for PCN’s around recruitment for a range of different roles. NP stated CCGs should be supporting PCNs to recruit staff and we must have a BLMK wide offer to mitigate the risk of not utilising the additional reimbursement monies. NWi stated that the risk should be reflected on the register and for this year was employing 2 people per PCN and that the Specification states an average size PCN will employ 21 people in 4 year’s time? Workforce is the biggest risk and how you employ people. NW concluded that this is a fast moving and changing picture and will continue to review the risks as to have all these new roles they have to have somewhere to potentially sit and currently PCN have capacity issues. The meeting finished at 2 pm. The Chair noted the Premises Highlight Report was for information only which received no comments from the Committee. Documents attached to note: BCCG Premises Highlight Report – January 2020 (for information only)
This concludes PART 1 of the meeting. Minutes of the confidential PART 2 meeting are recorded within a separate document.
Date of next Primary Care Commissioning Committee meeting:
Approval of Minutes:
Interim Chair:
Signed: ______
Date: ______
6
PCC20/20
PRIMARY CARE COMMITTEE Wednesday 12 February 2020 2pm – 4pm Sherwood Board Room 1
Minutes
Present Richard Alsop RA Chief Operating Officer, MK CCG Carla Barbato CB Delivery Manager Planned and Primary Care, MK CCG Dr Nessan Carson NC GP Board Member, MK CCG Edna Muraya EM Senior Finance Manager, MK CCG Kayley O’Sullivan KO’S Primary Care Support Officer, MK CCG (Minutes) Wendy Rowlands WR Deputy Chief Finance Officer Darren Smith DS Lay Board Member, MK CCG Alexia Stenning AS Deputy Director of Programme Delivery and Head of Primary Care, MK CCG Janine Welham JWe Primary Care Manager, MK CCG
Apologies: Dr Matt Mayer MMa CEO – Berkshire, Buckinghamshire & Oxfordshire LMC Linda Chibuzor LC Deputy Director of Nursing and Quality, MK CCG Andrew Harrington AH Chief Executive Officer, MKGP Federation (MKGP Ltd & MKGP Plus Ltd) Mike Rowlands MR Lay Board Member, MK CCG Nicola Smith NS GP Chair, MK CCG Dr Krishna Patel KP GP Board Member, MK CCG Dr Edward Sivills ES GP Board Member, MK CCG Maxine Taffetani MT Chief Executive Officer, Healthwatch MK Dr Sarah SW Medical Director Bedfordshire, Luton & Milton Keynes Commissioning Whiteman Collaborative
In Attendance
Action 1. Welcome and Apologies As above 2. Declaration of Interest Dr Nessan Carson – GP at Central Milton Keynes Medical Centre 3. Minutes of the previous meeting held on 15 January 2020 The minutes were agreed as accurate. 4. Matters Arising Actions update: Action 57 – Closed. Action 62 – Closed. Action 63 – There are workforce concerns across the ICS but the focus is still place based and still average compared to the across the country. Another version to be released at the end of February. JWe to check how the rankings are calculated and review for the next meeting. JWe Operational
Primary Care Committee Minutes 12 February 2020 Page 1 of 2
PCC20/20
5. Primary Care Budget – 19/20 – Edna Muraya The committee noted the contents of the paper. 6. Windows 10 Upgrade in Practices No further update due to the transfer over to the new IT provider on the 1 April 2020, HBL ICT. It was agreed with the current provider that they would continue with the update when the computers are reimaged however the windows 10 update has been completed by January 2021. Some members of ArdenGEM staff have been TUPE over so there will be some continuity of staff for the practices.
Wendy Rowlands is currently working with HBL ICT to provide communication to the practices regarding the changes and dates. Contact numbers will also be provided ready for the change. Frequent messages will be circulated so practices are aware.
Action 64 – Update agenda item to transition to HBL ICT. KO’S
Meeting closed at 2.20pm. 7. For Information None Any Other Business None Date of next meeting Wednesday 18 March 2pm – 4pm - Sherwood Board Room 1
Primary Care Committee Minutes 12 February 2020 Page 2 of 2
ITEM 4.0 Integrated Commissioning and Quality Committee meeting MINUTES
Minutes of the meeting held on Thursday 23 January, 10.30am to 12.00pm Training Room, Endeavour House, Wrest Park, Silsoe, Beds MK45 4HR
Members Present
Heather Moulder Registered Nurse, Lay Member (Chair) HM Maria Laffan Associate Director of Nursing and Quality ML Linus Onah GP - Governing Body LO Roshan Jayalath Locality Chair, Bedford RJ
Others in attendance Bernie Harrison Senior Quality Manager - Community, Mental Health & MSK BH Carol Davies Head of Performance Reporting and Analysis CD Sue Jolly - minutes Interim Personal Assistance to Maria Laffan SJ
Apologies for absence Ann Murray Chief Nurse AM Mike Thompson Chief Operation Officer MT Alyson Franklin Infection Prevention and Control Nurse AF Sarah Frisby Senior Communications and Engagement Manager SF Sarah Whiteman Medical Director, BLMK Commissioning Collaborative SW
No Item 1.0 & Welcome and Apologies 2.0 Apologies for absence were noted as recorded above.
The meeting was quorate.
3.0 Declarations of Interest
There were no declarations in relation to items on the agenda, or noted over and above those on the Conflicts of Interest register.
4.0 Minutes
4.1 The minutes of the meeting held on 31 October 2019 were discussed. An amended copy would be circulated outside of the meeting.
Action: HM and ML to finalise the minutes from the 31 October 2019 and circulate outside of the meeting
Page 1 of 9
5.0 Action Log
The actions were discussed and logged with the relevant updates added to the action tracker.
All closed actions will be archived for future reference.
HM thought it necessary to reinstate the Forward Planner so that key priorities/themes would be carried forward.. ML suggested liaising with Michael Wuestefeld-Gray in relation to the setting up of the new BLMK Quality Committee.
Action: ML to catch up with Michael Wuestefeld-Gray re: Forward Planner
6.0 Integrated Quality and Performance Report – CD
Cancer
November was the latest position for cancer performance standards - 4 out of 8 achieved.
6.1 The biggest risk was histopathology at BHT. The provider - Backlog - had a contract to deliver within 7 days, but results had taken up to 6 weeks. BHT were now more robustly managing the situation. Backlog planned to embed two members of staff at BHT from February 2020 which should result in an improvement.
6.2 HM said the BHT Cancer Action Plan, which had arisen from the Cancer Board, provided a longer-term solution for histopathology. CCG working with the Cancer Alliance in relation to initiating a BLMK Cancer ‘deep dive’
6.3 CD reported that records demonstrated the 62-day standard had not been met since 2018.
6.4 HM stressed the high level of support that was being given, including from BCCG, The Cancer Alliance, and NHSE.
6.5 CD set out in the report the situation regarding patients who had waited over 104 days on the 62-day pathway. Clinical harm figures had been obtained from all providers. In November, there had been 9 instances at BHT and 2 at East & North Herts. Many of the reasons for Breach were healthcare provider initiated delays to diagnostics.
6.6 LO asked for clarification around the term 'patient choice' when given as a reason for delay. CD explained that was where patients themselves delayed parts of their pathway. CD was assessing the clinical harm review to look at different elements of the pathway and to identify what effect a patient choice delay of two weeks would have on a total waiting time of 104+ days.
6.7 LO asked if there was any risk of tissue degradation as a result of delays in pathology. CD said this was being looked at. CD had all of the clinical harms for BHT. East & North Herts results would take longer to obtain. She explained that clinical harm cases had been reviewed by the clinical team to establish whether they were avoidable, unavoidable or multi-factor.
6.8 ML commented on the importance of monitoring cancer pathways. Assurance of correct procedures was necessary. HM said that Anne Murray and Geraint Davis were the CCG SROs regarding clinical and contracting aspects respectively and were actively involved in improving the work of the Cancer Board. .
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Action: HM to talk with the relevant SROs in terms of formal reporting by of BLMK Cancer Board into the new joint BLMK Quality Committee
Waiting List
6.9 CD reported that numbers of breaches of the 18 week standard had risen and the 92% aggregated standard had not been met since before April 2018. December figures showed trauma and orthopaedics waits extending and getting closer to 52 weeks. The number of patients at 39+ weeks was 90. The number on the waiting list had been increasing month on month, as was the figure waiting at the critical end of the pathway. There were 837 patients breaching 18 weeks, and, of them, 90 were at 39+ weeks.
6.9 ML suggested it was Circle's responsibility that these figures were showing up as BHT patients. Patient's choice had potentially led to these levels. CD said a formal contract notice had been issued to BHT requesting a delivery plan to reduce the waiting list.
6.10 In April for the CCG there were 29,089 patients on the waiting list - now 31,380. Extra CCG funding had been put into operational costs rather than activity. ML was not confident that BCCG was managing the Circle contract in the correct way - if 50% of patients arrived on the waiting list through the MSK route, there was a responsibility on Circle. BH said Circle referrals should show up on their PTL.
Action: ML to liaise with Contract team re Circle PTL to identify whether any concerns
6.11 HM pointed out that patients waiting long-term would cause extra pressure on GPs. ML said Circle had reported the continuation of safety checks on long-waiting patients and that they had been offered a second-choice alternative. RJ was aware of patients who had been on the waiting list, missed an appointment and had been referred back to the GP.
Action: CD to check the revised access policy for D&A criteria
6.12 CD outlined the process whereby BCCG had written to the provider regarding each patient in the high-risk position in order to mitigate a 52-week breach.
Neurology
Concern raised by GP that neurology patients at BHT being cancelled at short notice and not being rebooked. Tara (Planned Care Lead) working with the Trust
Action HM to write to BHT to raise associated clinical risk concerns
Dermatology
6.13 ML highlighted the number of breaches caused by delays around dermatology. She had asked the Planned Care Team to look at how many of those breaches were paediatrics or over-18s and to identify how many were paediatric dermatology patients.
6.14 ML reported that there had been instances of patients choosing to be treated privately and this may have been connected to a particular area of children's services.
Action: Item on next agenda - Dermatology update
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Diagnostics
6.15 December's data showed paediatric audiology breaches (CCS) had increased from 16 to 52. BH said they had tried to make the vacant Audiologist position more attractive by sharing a senior role with BHT. Union Street facilities were no longer suitable and most appointments took place at Houghton Regis or Redgrave Gardens. Bedford and Central Bedfordshire had differing commissioning arrangements - CCS had been asked to look at the issue.
Urgent and Emergency Care
6.16. The new dashboard was set out in the report, covering the whole of BLMK and split down into Bedfordshire, Luton and Milton Keynes.
6.16.1 OHH services ML said there appeared to be a momentum of change and improvement which was not reflected in the figures. At a GP recruitment event in December the mood was more positive towards HUC as an employer.
Four- Hour Wait
6.17 HM reported that November data rated BHT the 14th best Trust in the country. On a quality visit in December, ML said the response from A&E patients was that they were satisfied with the service they had received.
CPA - 7 day follow up
6.18 There were 15 breaches in Q2 and 24 in Q3. All of them were ELFT. 8 of the 21 cases were CPA breaches, and 5 of these were deemed avoidable by the Trust.
Action: Clinical catch-up (ML, BH, RJ, HM) on CPA prior to meeting with ELFT
Early Intervention Psychosis
6.19 ELFT had been reporting 50%. Updated data showed that of the five patients treated, only one was a breach - the other two reported cases were data errors.
6.20 BCCG is challenging levels reported against SQPR.
Action: Ongoing - The committee to be aware of data quality issues around monitoring the contract
Learning Disability Healthchecks
6.21 CD reported that data had recently been signed off and published. 310 healthchecks had been completed against the CCG plan of 710.
6.22 Anticipating Q3 data to be better owing to the ways GPs process their work
Action: Mental Health Lead targeting those Practices with poor results
SMIs
Page 4 of 9
6.23 Q3 data collected from System One showed a worsening position. RJ said measures which had been expected from ELFT had not improved figures. A PMS incentive would be in place from March to incentivise GPs, at which point ELFT's input would cease. ML felt information was not being escalated to BCCG from GPs. RJ confirmed that the planned centralised sharing of information was intended to improve the flow of data.
Action: Given the difficulties around ELFT performance in this area, discussions would be ongoing to have the work delivered by PMS funding
6.24 RJ pointed out the performance disparity between GPs - some did not carry out all of the six checks. There might be a two month gap before PMS began - targets would not be met because of this. BH said ELFT did have access to System One through their GP primary care link workers.
Action: Item on next agenda - Further assurance needed regarding the solution to increasing SMI checks
Action: Item on next agenda - ICE update - Lead: Mark Peedle or Mark Thomas
6.24 Dementia Diagnosis
December figure was 63.8% - short of the 66.7% target. RJ reported that the incentive scheme had ended in December, dementia nurse funding ended and the care home project ended. PMS had agreed to a £30 incentive for diagnosis. GPs had decided that District Nurse diagnoses could not be included where no further treatment was needed - RJ would be disputing this decision. ELFT had offered GPs telephone guidance on diagnosis.
Action: Ongoing work to outturn the target - including ELFT offering advice, and making GPs aware they could diagnose patients when no further treatment was required
6.25 BH pointed out that, upon diagnosis, dementia patients were entitled a 25% discount on their Council Tax, and Council Tax was free for single occupancy.
Mixed Sex Accommodation
6.26 ML said mixed gender accommodation existed at BHT. Reported data suggested the cause to be a shortage of available beds in the system.
Action: ML to have a further conversation with BHT's Director of Nursing around mixed gender accommodation
Infection Control
6.27 ML drew attention to the increased YTD figure for C-diff.
6.28 ML said the Committee should be aware of the current heightened awareness of the Corona Virus. Early guidance was available from Public Health.
7.0 End of Life and Mortality Data – ML
7.1 SMHI data within normal limits The Mortality Board had reporting that people had died in an inappropriate place of care. HM spoke about the Governing Body having recently signed off the End of Life Strategy, which included the identification of who would monitor the implementation Page 5 of 9
plan. Clinicians' response was that acute staff did not understand how to deliver specialist end- of-life care.
Action: ML to link with managerial and clinical leads for End Of Life care in relation to anecdotal evidence from Mortality Board that care could be better managed in a more appropriate location
8.0 SEND Update – BH
8.1 BH reported that the Bedford re-visit would take place 3 - 5 February 2020 to assess progress against the written statement of five actions. Evidence had been submitted by BCCG. A key marker would be whether the local population considered that actions taken had resulted in sufficient progress. Public forums and focus groups would be asked for their opinions. GPs would be encouraged to put forward examples of positive outcomes.
8.2 ML suggested circulating to GPs a summary of improvements.
Action: BH to send out information sheet re: SEND
8.3 CBC Inspection
Took place in November. Formal results yet to be published.
8.4 ML said there had been a specific focus around BHT's management of children with complex needs. Concerns were raised by parents around level of care and staff skills within the acute paediatric setting for children with complex needs . ML to continue to work on identifying the level of assurance needed and believed there to be room for some quality improvement work.
Action: ML to continue to work with BHT for assurance regarding the management of children with complex needs
9.0 Primary Care Quality Update – ML
Headlines
9.1 Cater Street received a CQC rating of Inadequate. CQC findings included concerns about safety. BCCG to meet to discuss mitigation measures.
9.2 Village Medical Centre - CQC would revisit in January/early February. A formal BCCG quality visit was planned.
9.3 Kirby Road – CCG visit took place which identified increasing concerns about the resilience of the practice in relation to senior leadership
Action Medical Director to revisit practice
9.4 Cauldwell - Working through new contract mobilisation
9.5 West Street - Positive feedback feeding through after a difficult 6 months. The GMC work done with them had been helpful.
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SI Report
9.8 There was an increase in the numbers for BHT in October. Some concerns existed around the volume of Maternity SI's and there was a loose association with gynaecology and Women and Children's Directorate. ML met with them to identify themes. Escalation is a concern - obstetrics and gynaecology in particular. Weekend Registrar cover was an issue. BHT has been told that if there is concern around their planned level of risk, that needs to be heard back at BCCG from a systems escalation perspective.
Action: ML to take the issue around the reporting into BLMK LMS
9.9 Safety Improvement Boards now saw all SI's and there was a different system of grading in place, resulting in higher volumes of SI's at BHT. L&D were not reporting in the same way.
Action ML to establish the reasons behind differing methods of reporting and feed results into LMS.
9.10 Because cases had to be referred to HSIP and due to the high volume, reports took significant time to come back. In the meantime, BHT had been conducting their own rapid learning reviews. ML was pushing to get sight of those reviews.
9.11 There had been key incidents around failure to escalate within Adults and Paediatrics. ML felt that BHT were still in the early stages of measures around Paediatric escalation.
9.12 ELFT work had not changed. Decreased number of unexpected deaths. There was media interest in an ELFT/BHT case of suicide from July 2019.
9.13 Whilst regional QSG recognises ELFT’s CCG rating as an outstanding provider it has concerns re quality issues and is considering a risk review. QSG has requested BCCG and other CCGs to gather information in order that an assessment can be made whether a QSG risk review is required
Action: ML to pull together intelligence around performance in ELFT and quality concerns arising from SIs
9.14 One SI existed around the suicide of an ambulance member of staff.
10.0 Communications and Corporate Affairs
11.0 Complaints and FOI Reports – GH
GH gave overview of Q3 reports. Reports were noted. 11.1
11.2 In Q3 there was only one formal complaint, regarding the IFR process. Patients do not hav understanding of the appeals process. Discussion took place around the contents of the decis
Page 7 of 9
BH explained that the letter was addressed to the clinician, and it was then the clinician's responsibility pass on the contents to the patient.
RJ said that the decision letter contained an explanation of the grounds for refusal, on which grounds a appeal could be based. The Appeal is put forward by the clinician. LO explained his procedure include an explanation to the patient of the process and the likely outcome, and that if the outcome was n favourable an Appeal could be launched. LO would then offer a consultation to discuss the patien options.
GH said that some Practice Managers were telling patients to contact the CCG if they were unhappy w the decision.
HM said an audit had found that the exclusion policy was very clear about why the patient might not me the exceptionality criteria, and suggested that the GP might have difficulty discussing this with the patien GH said it might be helpful if the GPs gave out a leaflet when speaking with patients but it needs updatin BH said the policy had recently been updated and she would review the information leaflet to ensure was brought in line.
Action: BH to review the IFR leaflet to ensure it is in line with the new IFR policy, BH will upda GH re the leaflet
11.3 Herts Urgent Care (HUC) had been quiet in Q2 but there had been an increase in concerns in Q3. M said an element of systems failure over the Christmas period might have affected reported data.
Primary Care – some Practice Managers do not have a good understanding of the complaints proce and are wrongly signposting patients to BCCG instead of the Ombudsman following local resolution. B pointed out that some providers had also historically misdirected patients to BCCG, causing unnecessar antagonism to patients.
FOIs - BCCG would be dealing with FOIs across BLMK from 1 March 2020.
12.0 Any Other Business
12.1 The date of the next meeting will be co-ordinated to tie in with the One Committee approach.
13.0 Items to be raised to the Governing Body
Histopathology impact on cancer treatment times 13.1 Neurology consultant vacancies BHT
14.0 Date of Next Meeting To be advised. Page 8 of 9
Signed (As a true record) Dated
Heather Moulder – Chair, Integrated Commissioning and Quality Committee
Page 9 of 9
Luton CCG Board Patient Safety and Quality Committee Minutes 27th February 2020 13:00-15:00 Meeting Room 1, Level 3 Arndale House, The Mall, Luton, LU1 2LJ
PSQC Members Name Role (LCCG unless otherwise stated) Initials Present Apols Kathy French Independent Nurse Board Member (Chair) KF Nicky Poulain LCCG Chief Operating Officer NPo Gerry Taylor Corporate Director Public Health, Commissioning & GT Procurement Dr Anitha Prabhu GP & Clinical Lead for Cancer APB Bolanthur Lloyd Denny Lay Board Member – Patient, Public & Stakeholder LD Engagement (Deputy Chair) Jennie Russell Deputy Director of Nursing and Quality JR Chris Harvey Head of Quality CH Anne Murray Chief Nurse (BLMK Commissioning Collaborative) AM
Advisors on circulation list attending as required Name Role (LCCG unless otherwise stated) Initials Present Alison Franklin Infection Prevention and Control Nurse AF Richard Jones Head of Medicines Optimisation RJ Tess Dawoud Assistant Head of Medicines Optimisation TD Angela Duce Assistant Director – Governance AD TBC CDOP Manager Dr Chirag Bakhai Clinical Director CB Gill Humberstone Complaints and FOI Manager GH Michelle Powell NELCSU Head of Delivery MP Lynda Harris Head of Information Governance LH Paul Lindars Head of Primary Care PL Clare Flower Quality Manager – Patient Safety CF Apologies Sheelagh Coe Quality Manager- Patient Experience SC From 13:20 Teresa McDonald Head of Safeguarding Children and Designated Nurse TM Julie Hall Head of Safeguarding Adults and Designated Nurse JH Others in attendance Name Role (LCCG unless otherwise stated) Initials Present Kath Gerrard Quality Support Manager – Patient Safety (Minutes) KG
1
Item Comment Action 1 Apologies and introductions Apologies were received as shown above.
2 Declarations of Conflict of Interest No further conflicts of interest were declared.
3 Minutes and Matters Arising not within Action Log The previous minutes from 30th January were reviewed and with the addition of the Chair’s report, were agreed as an accurate record.
4 Action Log Review The action log was reviewed and updated.
5 Governance and Strategy 5.1 ICS and Integration Update Restructuring to merge the three CCGs to form one BLMK CCG has started. A GP members vote is still required to formally agree the merger. Staff restructure: Tier 1 (the Executive Team) is now complete. Tier 2 (direct reports) – a 30 day consultation started on 20th February, with confirmation of posts expected in April. Tier 3 (all other staff) – consultation is expected to start in June.
Nicola Smith, Chair of MKCCG, is the new Chair of BLMK. Nina Pearson will no longer be Chair for Luton CCG.
Nicky Poulain is Primary Care Director and also responsible for Luton place.
The governance structures will also change.
The staff will be impacted and will need support. The Committee was concerned that adverse impact on staff be avoided. In particular that Luton is not left behind, the Luton voice not be lost, and the service to the local community not be affected.
KF attends One Team meetings and will raise these concerns there, and bring updates back to the Committee.
5.2 IQPR The committee received and noted this report for November 2019 (M8)
RTT performance is deteriorating- in January it is reported down to
88%. This is partly due to the anticipated effect of the NHS pensions
issue, plus increased workload from winter pressures. Uncertainty over coronavirus mean this is unlikely to improve. No harms have been recorded.
2
MMR improvement in uptake noted. Data is now being received monthly. Public Health have provided an update in response to action log item 525.
CCS – still working on improving the report.
5.3 QIPP/FRG Nothing to report.
5.4 Review of Committee Effectiveness The Committee reviewed the template report and the comments already submitted. The final version was agreed for KF to submit. KF
6 Provider Quality 6.1 Provider Quality Exception Report The committee received and noted this report.
CH reported on key issues: An unannounced site quality visit to the ELFT Inpatient wards was carried out in response to concerns raised by Healthwatch about Mental Health Inpatient care. The visit found positive results. A subsequent Quality Meeting with ELFT was also positive, although responsiveness to queries is still a bit slow. Issues regarding restraint are still to be fully assured.
Care homes- Serious concerns have been raised for Capwell Grange, particularly regarding how management changes impact the quality of service. Fedora unit has an embargo applied. The improvement plan applies to the whole home.
LDH reported a failure of the lift in the maternity unit which lasted 5 days. The CCG were assured that business as usual continued. Some patients were transferred to other sites.
HUC – The UGPC reports a significant increase in activity due to winter pressures. Performance is still good. The HUC vacancy factor has improved, with no vacancies currently. Coronavirus is having an impact – some 111 call centres have had their efforts re-directed to exclusively respond to coronavirus queries.
Cancer – three 62 day breaches recorded.
Kingsway HC – The lift has been out of order for some months. The Committee expressed concern regarding access for patients to the GP practice on the upper levels.
6.2 ELFT Q2 Quality Report The committee received and noted this report.
FFT scores need to be increased- dedicated staff are being allocated to focus on this.
Memory assessment process reviewed.
3
MDT discussions needed for discharge to include housing and closer work with social care.
ELFT are involved in suicide prevention; and in reimagining Mental Health, planning how investment is being used. The plan is to move to an outcome focussed model.
KF asked about the 15 incidents of serious harm or unexpected death reported and how many resulted in suicide. SC confirmed that increased incidents reports reflect an improved reporting culture. The Committee asked for further details on absconsions and an analysis of the circumstances- were the cases detained under section? What leave conditions applied at the time? What level of SC harm and/or criminal damage was associated with each instance?
ELFT are reviewing the leave policies in line with legal requirements
CAMHS – CHUMS and Tokko working for earlier access to talking therapies and having a good impact with reduced A&E attendances. Funding released for 1 year, with a further extension of funding being sought.
6.3 CCS Q2 Quality Report The committee received and noted this report.
Staffing levels for Health Visitors are an issue. An action plan is in place to meet needs based on risk and to direct staff accordingly. Safeguarding is creating additional pressures.
LBC received a recent Ofsted report which rated them as inadequate. It highlighted that the system is flawed and caseloads very high leading to increased pressures for staff.
Pressure Ulcer reporting has increased- as expected in line with the new guidance
6.4 Quality in Primary Care Report The committee received and noted the report.
The report presents a positive overall picture. The key risks listed on page 2 indicate the position is improving.
Castle medical practice has now returned to their premises after flood repairs.
A new section about site visits gives insight into the actions taken is very informative.
The programme of visits is ongoing and is being synchronised to minimise disruption to practices.
6.5 Items for Escalation to QSG Nothing to escalate.
4
7 Patient Safety 7.1 SI and Never Event Q3 Quarterly Report The committee received and noted the report.
HSIB reports on maternity incidents are slow to be finalised, in part because the process involves both Trust and family. A draft report shared recently with the CCG by the Trust is clear and easy to read.
Two SIs relate to surgery and are being explored further for any themes and learning
An SI reported by an ultrasound service provider has been complex and required substantial input from the team.
The format of the report and the context of the SIs was discussed in depth. The SI report needs to be reviewed to include themes, and any increases in numbers. Is there a spike, what are lessons CF learned. Keep a track on specific cases to avoid deaths from avoidable causes.
ELFT SI involving death from pulmonary embolism was this a preventable death? Risk assessments for venous thromboembolism (VTE) on immobile patients were discussed. Only snapshot information given of early reports – need to wait for the final report before making any judgments.
7.2 Infection and Prevention Quarterly Report The committee received and noted this report.
The committee also discussed the impact of COVID-19 and the emerging impact on healthcare
8 Patient Experience 8.1 Provider Complaints Q2 Quarterly Report The committee received and noted this report.
No emerging concerns or key risks to report.
9 Clinical Effectiveness 9.1 CQUIN Q3 Report The committee received and noted this report.
CH highlighted that the process is more complex this year, with no quarterly reporting required.
10 Documents received Documents Received / of Interest The committee received and noted this report.
11 AOB Nothing further was raised
The meeting closed at 15:10
5
PSQC - Chairs report 27th February 2020
• Care homes- Serious concerns have been raised for Capwell Grange, particularly regarding how management changes impact the quality of service. Fedora unit has an embargo applied. The improvement plan applies to the whole home which LCCG Quality Team are supporting
• LDH reported a failure of the lift in the maternity unit which lasted 5 days. The CCG were assured that business as usual continued. Some patients were transferred to other sites. This has now been resolved
• Cambridge Community Service -Staffing levels for Health Visitors are an issue. An action plan is in place to meet needs based on risk and to direct staff accordingly. Safeguarding is creating additional pressures. The Trust is working on recruitment to essential roles
• Infection Control Q2 report - C Diff -LCCG has had 12.58 cases per 100,000 population which is the 2nd lowest in the East of England and is significantly below the England total of 18.18 cases per 100,000 population at the end of December 2019. Primary Care: 8 infection prevention and control practice reviews have been carried out since April 2019, and full reports have been written giving advice regarding expected infection prevention standards. Useful resources were discussed and shared with each practice and electronic copies included with each report. IPC training for primary care has been carried out over the year with a total of 54 attendees so far this year and 24 booked for March training. Next year’s dates have been organised and have been circulated. The committee also discussed the impact of COVID-19 and the emerging impact on healthcare.
Next Meeting: Thursday 26th March 2020, 15:15-17:15, Conference Room, Level 3, Arndale House
6
NHS MKCCG QUALITY COMMITTEE Tuesday 10th March 2020 2.00 pm – 4.30 pm Sherwood Drive, Boardroom 2 Part 1
Minutes
Present: Mike Rowlands (Chair) MR Board Lay Member – Public and Patient Engagement, MKCCG Dr Edward Sivills ES GP Board Member, MKCCG Amanda Derbyshire AD Adult Safeguarding Lead, MKCCG Dr Amit Goyal AG GP Board Member, MKCCG Andrea Bushell AB Commissioning Manager, MKCCG/MKC Dr Nessan Carson NC GP Board Member, MKCCG Lorraine Belam LB Team Administrator (Minute Taker) MKCCG
In attendance: Neve Patel NP Head of Performance (for agenda item 4.1 Quality Performance Report) Paul Burridge PB Head of PMO (for agenda item 4.4 Review of Quality Risks) Clinical Quality & Effectiveness Facilitator (for agenda item 4.5 S117 Julie Uglow JU Aftercare Policy)
Apologies received: Darren Smith DS Board Lay Member, MKCCG Alexia Stenning AS Deputy Director Programme Delivery & Head of Primary Care (MKCC) Dr Krishna Patel KP GP Board Member, MKCCG Jenny Brooks JB Quality Improvement Manager, MKCCG Linda Chibuzor LC Director of Nursing, Quality and Safeguarding, MKCCG Dr Nicola Smith NS Chair, GP Board Member, MKCCG Claira Ferreira CF Patient Experience Lead, MKCCG (Items 7) Richard Alsop RA Chief Operating Officer, MKCCG Michelle Millard MM Patient Safety Coordinator, MKCCG, (Item 6.2) Anne Murray AM Chief Nurse Mandy Park MP Designated Nurse: Safeguarding Children and Looked After Children
No. Item/Discussion Actions
1. Welcome & Apologies The Chair welcomed the members to the meeting and introductions around the table were made.
Apologies were noted as above.
Conflicts of Interest
There were no conflicts of interest declared at the start of the meeting. 2. Notes of last meeting – 14th January 2020 (Ref: 20/10)
The minutes were agreed and approved as an accurate record of the meeting.
Quality Committee Minutes – part 1 - 10th March 2020 Page 1 of 4 Linda Chubizor NHS Classified
3. Action Log and Matters Arising (Ref: 20/11)
Action Log (attached) updated.
Chair confirmed with attendees that there were no other matters arising.
4. Governance and Strategy
4.1 Quality Performance Report (Ref: 20/12) NP highlighted the following areas of this report which provides data for.M9 (December 2019)
• RTT performance continues to decline to 80.4% in December. Waiting list has increased from 14,600 in December to 18,242 in January. The reason for the increase in numbers is due to numbers on a secondary list had not been reported along with the main waiting list. These two lists are now amalgamated. The Committee discussed and expressed the wish that these would be reported going forward as an amalgamated list and not revert back to two separate lists. • NC questioned at what point does the CCG say that the list is too big? NP replied that that this is taken up via the contractual route. • 52 week waits – 3 reported in December (ENT, General Medicine and Gastroenterology) 2 of these patients have been treated with 3rd under review. For January 1 x 52week wait reported – in General Medicine but no further details reported yet. • Diagnostics – declining performance achievement with 80 breaches in December across 7 providers. 28 cystoscopy breaches from MKUHFT for which data quality issues are being cited as the cause of the breaches. The CCG are continuing to monitor this. • NHSE Improvement Assessment Framework (IAF) has been superseded by a revised framework called the NHS Oversight Framework – the dashboard for which will be presented at the next iteration of this report. • The recent performance at December for Dementia diagnosis was 70.8% (above the Prime Ministers challenge of at least 66.7%). • Rates for Mental Health IAPT access and recovery rates is under target, CCG holding weekly assurance calls re recovery rate and aim to reach target rates by end of March.
The Chair thanked NP for her report.
4.2 Reviewing ‘high impact’ rated Quality and Equality Impact Assessments.
Nil to report. 4.3 Review and Ratification of related Quality and Safeguarding Policy according to policy review dates.
Nil to report. 4.4 Review of Quality Risks on the Risk Register (Ref: 20/13) PB summarised movement on risks:
• 15 risks currently (reduction of 1 as two risks have been merged as they have similar outcomes – PC26 (underperformance in national cancer wait times) and ST55 (poor cancer outcomes). • The highest risk area for Quality is within CYP&M.
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• Immunisation had a score of 15 now reduced to 10 (ambition for this score to be reduced to 2). Draft business case for an immunisation service will be presented to CDG in March with an aim to have service in place by July this year. • ES noted that all the implementation dates either have expired or will expire before the next Quality Committee Meeting. NC commented that there needs to be a review of the implementation dates with the report. PB agreed but stated that at a granular level these risks and their implementation dates were being reviewed regularly. • The Committee asked if this risk register would be impacted by the merger of the CCGs. PB confirmed that this would be a single process in the future, the ‘One Team’ are currently developing risks relating to the changes. • PB also noted that in the new structure portfolio there will be greater emphasis on performance delivery and constitutional targets, there should be a more holistic approach to risks. • NC asked if Coronovirus will be on the BAF? AB advised that there will be impacts on current workforce due to the Coronavirus situation. PB confirmed that this risk has been identified as a strategic risk and will go to CDG for approval to go on the BAF risks in early April. (Risk Description: As a result of expected increased cases of confirmed Covid 19 in Britain and subsequently in Milton Keynes there is a risk that the increase in response support and NHSE/I reporting will stretch CCG resources and provider resources beyond reasonable measures).
The Quality Committee Noted the Risk Register and Assurance Report.
4.5 S117 Aftercare Policy (Ref: 20/14) JU summarised this final draft policy which was brought to the Quality Committee for approval.
• This is a Joint policy drafted by CCG, Council and CNWL and following a complaint from a mum to the ombudsman that no after care service was arranged for her child after discharge. The complaint was upheld, an apology given and compensation paid to the family and the need to develop a robust policy was highlighted. • There is a need for a Section 117 Register which is being worked on. There have been a few patients who have not been looked after after discharge and have re- offended. • After care services is not defined in the Mental Health Act but is clarified by MHCoP within the policy. • The policy has been approved by the Council and is going to Central CNWL HQ for their approval.
The Quality Committee noted and approved the policy.
5. Patient Experience 5.1 MiDOS/Community Sector Listings (Ref 20/15) SM outlined the project:
• The project aims to provide a MK wide directory of services capturing health, social care and third sector services to enable searches to be undertaken for both health and social care practitioners and the public. • MiDOS is a digital tool which enables different ‘front ends’ to be built for a variety of users, including health care professionals, social care professionals and the public. MK council have agreed to share their adult social care directory so that this can be accessed (by professionals) via MiDOS.
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• MK are keen to utilise this functionality to promote offerings within the voluntary and community sector (VCS) to support the development of social prescribing services and to allow local population to take steps to support their own health and wellbeing. • There have been concerns raised around the ability to validate all the VCS listings and the use of disclaimers to non-commissioned listings has been discussed. • SM seeking approval to move forward with soft launch of this offering to include certified providers only initially.
The Quality Committee discussed the implications of this signposting service, raised the question as to who has control of this list and ownership of information, what providers are on there, is list automatically updated if e.g. the Council update their list? The Committee agreed that they were unable to approve this to go forward without seeing the actual link. Action: SM to provide link and further information, to be circulated to QC for virtual approval.
6. Clinical Effectiveness 6.1 Mortality SHIMI Annual Report Presented by George Akomfrah & Grace Norman (Population Health Intelligence)
Summary: • The data reported is from a national level and is routinely collected in a standardised way. Comparisons are made against similar authorities. • Number of death per year in MK is increasing as expected from a population that is growing and ageing. • Life expectancy for males at 65 remains significantly lower than England. • The neonatal and infant mortality rate in MK has returned to being statistically higher than similar local authorities having been similar for the past two years. • Lower respiratory infections, tracheal, bronchus and lung cancer accounted for a significantly higher proportion of deaths compared to England. Higher mortality rates in MK from lung cancer and chronic obstructive pulmonary disease. • Report Recommendations: System support in sharing and implementation of CDOP recommendations. Ongoing LTP workstreams around respiratory, cancer and cardiovascular to incorporate monitoring of relevant mortality outcomes and inequalities in mortality to assess long term impact.
The Committee discussed the report data and questioned whether the cancer data could be broken down further, i.e. by type of cancer. Action: GA/GN to double check. ES questioned if the difference in life expectancy at birth between the most and least deprived deciles presented for MK could be compared to similar population areas – are we better than the national average? Action: GA/GN to check.
The Chair thanked GA/GN for their presentation.
7. Any Other Business Piarg Minutes (dated 25.11.19 & 29.1.20) – For noting
The Quality Committee noted the above minutes.
There being no other business the Chair thanked the attendees.
8. Date of next meeting Tuesday 12th May 2020 at 14:00 to 16:30 in Boardroom 1, Sherwood Place
Quality Committee Minutes – part 1 - 10th March 2020 Page 4 of 4 Linda Chubizor NHS Classified
CONFIDENTIAL
Quality and Performance Joint Committee
Minutes of the Quality and Performance Joint Committee Held on 09 June 2020, 10:0011:00am The Meeting was held virtually via Microsoft Teams Members Present: Richard Alsop Director of Commissioning and Contracting BLMK RA Mahmood Aziz Lay Member Luton MA Alison Borrett Lay Member Bedfordshire AB Geraint Davies Director of Performance and Governance BLMK GD Sally England Lay Member Bedfordshire SE Kathy French Chair of Q&PJC / Independent Nurse Luton KF Jane Meggitt Director of Communications and BLMK JM Engagement Anne Murray Chief Nurse BLMK AM Linus Onah GP Member Bedfordshire LO Uzma Sarwar GP Member Luton US Ed Sivills GP Member Milton Keynes ES
Others in attendance Linda Chibuzor Deputy Director of Nursing Milton Keynes LC David Foord Programme Director Nursing & Quality BLMK DF Maryla Hart Governance and Committee Officer Bedfordshire MH (Minutes) Aneet Judge Medicines Optimisation Pharmacist Luton AJ Maria Laffan Deputy Chief Nurse Bedfordshire ML Jennie Russell Deputy Director of Quality and Clinical Luton JR Governance Kirti Singh GP Member Luton KS Michael Wuestefeld- Associate Director of Governance BLMK MWG Gray
Apologies:
Carol Davies Head of Performance Bedfordshire CD
1.1 Welcome, Introductions and Apologies Action The Chair welcomed all members and attendees to the meeting. Apologies were noted as above.
Page 1 of 6
1.2 Declarations of Interest JR advised that her partner is a GP in Luton.
1.4 Draft of previous meetings: BCCG: • 23 January 2020 ICQC LCCG: • 27 February 2020 PSQC MKCCG: • 10 March Quality Committee in Public • 10 March Quality Committee in Private
The Quality and Performance Committee approved all of the minutes listed above. 1.5 Action Trackers: BCCG All Actions were agreed to be closed.
The following actions were closed as a result of updates acquired prior to the meeting and printed in the meeting pack:
ICQC151 ICQC 159 The following updates were given at the meeting:
ICQC 145 - Work with the hospital on death and end of life data and present the results at ICQC. Update: Anne Murray advised that there is still some work to be done with the acute trust. This is not of significant concern at this time. This action can be closed and Anne Murray to pick up under normal review work. ICQC 149 - Arrange a clinical meeting with Paul Calaminus and AM. Update: Closed. ICQC 150 - HM to follow up the Board to Board meeting with Mike Thompson (with the Provider Board) - Update: Closed. ICQC158: Discuss forward tracker. Update: The work plan for Quality and Performance Joint Committee is being worked on and will be brought back to the next meeting. Closed
LCCG All Actions were agreed to be closed.
The following actions were closed as a result of updates acquired prior to the meeting and printed in the meeting pack: 525
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538 539 546 549 552 554
The following updates were given at the meeting: 551 - Complete and submit the Review of Committee Effectiveness. Update: Close 553 - Kathy French to raise Committees concerns regarding the impact of the BLMK CCG changes on staff and the Luton place at Board and the One Team meetings and bring updates back to the Committee. Update: Closed
MKCCG All actions were agreed to be closed as a result of updates acquired prior to the meeting and printed in the meeting pack. MWG joined the meeting 1.3 Matters Arising
Virgin MSK Patient Group Directions(PGD) Policies for Luton CCG AJ introduced the item. The policies had been circulated in advance of the meeting. The documents had been produced by Virgin MSK who are responsible for the content of the PGDs.
The committee ratified the following PGD policies for use in Luton: 1. Lidocaine Hydrochloride 1% Injection 2. Methylprednisolone acetate 40mg with lidocaine 10mg/ml 3. Triamcinolone acetonide 40mg/1ml.
AJ left the meeting 2 Terms of Reference (TOR) and Working toward a single BLMK Quality and Performance Focus
MWG and the Chair presented this item for discussion. The Quality and Performance Joint Committee was asked to consider the Terms of Reference with a view to developing the governance structures of the single CCG.
The following points were raised and questions asked:
• MWG recommended sending committee minutes to Governing Body rather than a Chair’s Report 3 | Page
• Will the committee receive annual reports such as Safeguarding, and Infection Prevention Control? This could be done and added to the TOR. MWG advised he was happy to include this in the TOR and work plan • Looking at quality elements of performance specifically within the TOR.
Action: The committee to decide who the Deputy Chair will be. KF / AM / MWG The following changes were requested /suggested to the wording of the TOR:
The typo at the top of page 3 ‘Finance and Performance’ to be corrected.
3.1 - xiv. “Approve all CCG policies”...Should “…ensure compliance with these policies” be added? .
Section 4 – The attendance does not allow Sally England and Mahmood Aziz to attend as currently defined. This should be amended and the TOR should be clearer about membership. Some generic references to be added to allow others to attend in future including deputies.
LO pointed out that Section 3.1 should list as a function: to look at the effect of changes on healthcare inequalities and not allow these changes to affect people with different disabilities from having the ability to access services.
Section 3.1 xiv. “Approve all CCG policies relating to quality, clinical effectiveness and safety.” This sentence is compulsory due to the Schemes of Reservation and Delegation. But the words could be separated out somewhat.
Action: AM and LO to pick up about primary care reporting into the AM/LO CCG on reports relating to serious incidents, never events and other
patient safety or safeguarding incidents, as outlined in section 3.1vii of the TOR.
ACTION: KF, AM and MWG to pick up on the kinds of reports to be KF/AM/ received by the Committee. MWG
ACTION: To change the lead director for the Committee from GD to GD/ AM. MWG
ACTION: MWG to amend the TOR following the discussion as MWG noted in the minutes.
ACTION: MH to circulate the minutes for agreement to members of MH the Quality and Performance Committee.
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3. Annual Workplan and Quality and Performance Priorities and planning (current position and for the rest of 2020/21)
The Chair gave a verbal update.
ACTION: It was agreed that AM would bring a draft workplan to the AM next Quality and Performance meeting.
4 4a. Performance and Quality Report
AM is to ensure that the Quality Team is working with commissioners and have up to date mitigation. GD is to look at the report from a
constitutional point of view.
ACTION: GD to work with AM on enriching the dashboard with GD/AM primary care data.
ACTION: There was concern around Improved Access to
Psychological Therapies (IAPT) in treatment pathway waits. This
may be taken offline with Carol Davies by RA. RA advised that in RA Milton Keynes this was the subject of a recovery plan before Covid. It needs to be reset and reflected on with a new baseline. To include timescales on trajectories and narrative on trends that are moving in the wrong direction.
ACTION: AM to come back to KF with details about the Beds CCG AM CDIF rates. The data in the report is incorrect on this.
ACTION: AB asked that the recovery and treatment backlog is looked into and once the plan is ready, this is shared with the GD / AB Patient and Public Engagement Joint Committee (PPEJC).
It was raised that Quality needs to be front and centre versus outcomes as the report is being brought together.
4b. Learning Disability Update – Assurance
DF presented the report and advised he was happy to share his full action plan.
The Committee noted the report. 5 Review of Core Risks (Corporate Risk Register)
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MWG gave a verbal update and advised that he was working with risk leads to review core risks and collate them into a single BLMK risk register for next committee.
The committee noted the update. 6. 6a Response to Corona Virus – Returning to Business as usual. Anne Murray gave a verbal update and acknowledged Maria Laffan who led the project with care homes and did a phenomenal job.
The Committee noted the report
6b. COVID-19 Infection Prevention and Control Training to Care Homes. The Committee noted the report 7. Any Other Business There was none.
8. Date of next meeting. 7 July 2020
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