NHS Waltham Forest Clinical Commissioning Group Annual Report 2017/18 1 2 Contents FOREWORD .............................................................................................................. 7 PERFORMANCE REPORT ....................................................................................... 9 Performance Overview ............................................................................................. 11 Performance analysis ............................................................................................... 13 The performance management framework ......................................... 13 CCG Improvement and Assessment Framework................................ 14 Urgent and emergency care (UEC) .................................................... 18 Discharge efficiency ............................................................................ 20 Mental Health services ....................................................................... 21 Maternity Services .............................................................................. 23 Children and Young People Services ................................................. 27 Learning Disability .............................................................................. 29 Cancer services .................................................................................. 31 Long Term Conditions (LTCs) ............................................................ 32 Medicines Optimisation – Prescribing ................................................. 34 End of life care .................................................................................... 36 Personal Health Budgets (PHBs) ........................................................ 38 Continuing Health Care (CHC) ........................................................... 39 Planned care....................................................................................... 40 Primary Care....................................................................................... 41 Sustainable Development ........................................................................................ 44 Improve quality ......................................................................................................... 48 Friends and Family Test (FFT) – Whipps Cross Hospital A&E ........... 49 Pressure ulcers at Whipps Cross Hospital (Grade 3 and 4) A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence and range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle. ............................................................................................... 50 Emergency preparedness, response and resilience (EPRR) .............. 51 3 Patient Experience .............................................................. 51 Friends and Family Test (FFT) – Whipps Cross Hospital ................... 51 Quality incentives CQUIN ................................................................... 52 Care Quality Commission (CQC) Inspections ..................................... 54 GP Alert System ................................................................................. 57 Infection Prevention and Control......................................................... 57 Safeguarding ...................................................................................... 57 Child Protection Information Sharing Project ...................................... 58 PREVENT ........................................................................................... 58 Learning Disabilities Mortality Review (LeDeR) Programme .............. 59 Engaging people and communities .......................................................................... 60 CCG Communications and Patient and Public Participation Team .... 62 Patient Reference Group .................................................................... 63 Development of PPG local standard ................................................... 68 Patient and Public Participation (PPP) quarterly newsletter ............... 70 Patient and Public Participation quarterly events ................................ 70 Development of Waltham Forest Children and Young People’s participation toolkit .............................................................................. 72 Increasing the uptake of cervical screening Waltham Forest .............. 73 Participation in developing Mental Health Services ............................ 75 Engaging on prescribed medication .................................................... 76 Stay Well This Winter ......................................................................... 77 GP out-of-hours home visiting service review ..................................... 78 NHS 111 procurement ........................................................................ 78 Patient and public engagement in Maternity Services ........................ 79 Patient and public engagement during the mobilisation of a new Community and Domiciliary Phlebotomy Service for Waltham Forest 81 Reducing health inequality ....................................................................................... 83 Health and wellbeing strategy .................................................................................. 86 ACCOUNTABILITY REPORT .................................................................................. 88 Corporate Governance Report ................................................................................. 90 Members report ........................................................................................................ 94 Member practices ............................................................................... 94 Audit Committee ............................................................................... 100 4 CCG Patient Reference Group ......................................... 102 Medicines Optimisation Committee .................................................. 103 IT committee ..................................................................................... 105 Locality Commissioning Committees ................................................ 107 Planning and Innovation Committee ................................................. 109 Finance and Quality, Innovation, Productivity and Prevention (QIPP) committee ......................................................................................... 111 Performance and Quality committee ................................................. 112 Remuneration and staffing committee .............................................. 114 Primary Care Commissioning Committee ......................................... 116 Statement of Accountable Officer’s Responsibilities .............................................. 120 Governance Statement .......................................................................................... 122 Head of Internal Audit Opinion ............................................................................... 142 Review of the effectiveness of governance, risk management and internal control 147 Remuneration and Staff Report .............................................................................. 149 Remuneration report .............................................................................................. 149 Staff Report ............................................................................................................ 157 Parliamentary Accountability and Audit Report ...................................................... 165 ANNUAL ACCOUNTS ............................................................................................ 168 Independent Auditor’s Report to the Members of the Governing Body of NHS Waltham Forest Clinical Commissioning Group ..................................................... 170 Accounts ................................................................................................................ 175 5 6 FOREWORD Welcome to the NHS Waltham Forest Clinical Commissioning Group (CCG) annual report 2017/18. As you may agree as you read through the following pages, it’s been quite a year for the borough as a whole in terms of health and care. Waltham Forest’s Managed Network of Care and Support was cited as a good example, of organisations working together to reduce hospital admissions and length of stay in hospital, in Health and Social Care Secretary Jeremy Hunt’s speech We Need To Do Better On Social Care. Baroness Julia Cumberlege, Chair of the National Maternity Better Births Review, praised the work of the team delivering the CCG’s continuity of care pilot, which forms part of Waltham Forest’s Maternity Choice and Personalisation Pioneer work with neighbouring Newham and Tower Hamlets CCGs, and the wider East London Local Maternity Services Transformation Programme. In cancer services there was national recognition for the CCG’s focus on increasing the uptake of cervical screening, with the charity Jo’s Trust awarding the CCG the highest possible rating for undertaking comprehensive work. Mental health service transformation over 2017/18 has seen the introduction of a single point of access for all mental health services in the borough, with the CCG's Associate Director for Strategic Commissioning leading an integrated approach to commissioning mental health services. We have also introduced health care tools to empower people to manage their own conditions better.