board - wandsworth ccg...2016/10/12 · c02 finance report (p.90) nm 12:00 10 mins c03 performance...

Board

MEETING12 October 2016 10:00

PUBLISHED7 October 2016

W A N D S W O R T H C C G P A G E 1 O F 2

Board AgendaDate 12/10/2016 Time10:00 Location: Wandsworth CCG

Meeting of the Wandsworth CCG Board

Held at 73-75 Upper Richmond Road, East Putney SW15 2SR,

on Wednesday, 12th October 2016, at 10:00

P A R T A | M E E T I N G O P E N S T A R T D U R A T I O N

A01 Apologies, Declarations, Quorum 10:00 5 mins

A02 Clinical Chair’s Opening Remarks NJ 10:05 5 mins

A03Minutes – 14th September 2016: Approval

and Status of Actions (p.5)NJ 10:10 10 mins

A04 Items for AOB NJ 10:20 00 mins

P A R T B | D E C I S I O N S & D I S C U S S I O N S

B01Clinical and Operational Focus – St

George’s Hospital (p.24)SM/LW 10:20 20 mins

B02Multi-speciality Community Provider (MCP)

procurement (p.49)AM 10:40 20 mins

B03 Talking Therapies procurement (p.57) LW 11:00 20 mins

B04 Battersea Locality Annual Report (p.67) NW/JC 11:20 20 mins

B05 Lay Member Board Roles (p.79) GM 11:40 15 mins

P A R T C | M A N A G E M E N T R E P O R T S

C01 Executive Report (p.86) GM/NJ 11:55 5 mins

C02 Finance Report (p.90) NM 12:00 10 mins

C03 Performance Report (p.122) SM/SI 12:10 10 mins

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]


P A R T D | B O A R D G O V E R N A N C E

D01

Summary Minutes:

Primary Care Committee (p.133)

Finance Resource Committee (p.135)12:20 5 mins

D02 AOB & Other Matters to Note 12:25 5 mins

D03

Open Space: Public’s Questions

Members of the public present are invited to

ask questions of the Board relating to the

business being conducted. Priority will be

given to written questions that have been

received in advance of the meeting

NJ 12:30 10 mins

P A R T E | M E E T I N G C L O S E

E01Clinical Chair’s Closing Remarks:

NJ 12:40 00 mins

E02

To resolve that the public now be excluded

from the meeting because publicity would be

prejudicial to the public interest by reason of

the commercially sensitive or confidential

nature of the business to be conducted in the

second part of the agenda

E03Part II Agenda items:

Next meeting of the Board: 14/12/2016 10:00-12:30 East Putney

Part A: Meeting Open

Page

1. Part A: Meeting Open 4

1.1. A01 Apologies, Declarations, Quorum

1.2. A02 Clinical Chair's Opening Remarks

1.3. A03 Minutes 14th September 2016: Approval and Status of Actions 5

1.4. A04 Items for AOB

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Minutes of a meeting of the Board held on 14th September 2016

Present: Nicola Jones (NJ) CCG Clinical Lead (Chair)Graham Mackenzie (GM) Chief Officer Neil McDowell (NM) Acting Chief Finance OfficerStephen Hickey (SH) Lay Member GovernanceAndrew Neil (AN) Secondary Care DoctorZoe Rose (ZR) West Wandsworth Joint Locality LeadRumant Grewal (RG) West Wandsworth Joint Locality LeadMike Lane (ML) Wandle Joint Locality Lead Seth Rankin (SR) Wandle Joint Locality LeadJonathan Chappell (JC) Battersea Joint Locality LeadSean Morgan (SM) Director of Corporate Affairs, Performance

and QualityLucie Waters (LW) Director of Commissioning and PlanningAndrew McMylor (AM) Director of Primary Care DevelopmentHouda Al-Sharifi (HAS) Wandsworth Director of Public Health

In attendance:Jamie Gillespie (JG) Healthwatch WandsworthSandra Allingham (SA) (Minutes)

16/081 Apologies for AbsenceReceived from Carol Varlaam, Di Caulfeild-Stoker, Nicola Williams, and Cathy Kerr. The meeting was quorate.

NJ acknowledged that this was Seth Rankin’s last Board meeting as Clinical Lead for Wandle. Thanks were recorded to Seth for his service in Wandsworth and contribution to the work of the CCG.

It was noted that Mike Lane would continue as the sole representative of the Wandle Locality, with the support of Wandle GPs. The election process would go forward in June 2017 as previously scheduled.

16/082 Declarations of InterestItem B04 Nine Elms Vauxhall Outline Business Case – JC recorded a conflict of interest as the Thessaly Road practice, which was referenced in the paper, was a branch surgery of the practice at which JC was a partner. It had been agreed that JC would leave the table for this discussion and decision.

16/083 Minutes from the previous meeting held on 20th July 2016The Minutes were agreed as being an accurate record.

16/084 Matters Arising16/071 Operational Focus – Performance – The CQC report for the recent visit to St George’s Hospital (SGH) had not yet been published.

16/073 Stakeholder Survey and action plan – It was noted that no immediate issues of concern had been identified regarding CCG engagement with the Adult Safeguarding Board. The action plan was being implemented.

16/085 Clinical Focus – Mental HealthTom Coffey (TC) and Mark Robertson (MR) attended to present the report. The

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main focus of the report was to inform the Board of the experience and joint work that has been taken forward by the Clinical Reference Group (CRG).

The following key points were noted:

The focus of the CRG was on what can be done through the whole pathway to improve Mental Health (MH) in Wandsworth, to prevent deterioration, early intervention, to prevent relapses and support rehabilitation.

One of the most transformational initiatives originated from patients and carers involved in the CRG and other groups.

Targets – Performance against most of the targets was good.o IAPT (Improving Access to Psychological Therapies) access

performance was above target. o Recovery rate performance was currently below target at 48%. This

was due to Wandsworth including people from both clusters 1-4 and 4-7, which included more unwell patients with, therefore, a slower recovery rate.

o Psychosis target was now 73%, which was above the national target.o Five Year Forward View – There was a large focus on MH to confirm

that Parity of Esteem was being achieved with money being used for appropriate care.

Discharge of patients from CMHTs (Community Mental Health Teams) – A new Primary Care Plus model will be implemented in the Wandle locality initially, and then rolled out in the Battersea and West Wandsworth localities next year. This will provide for practitioners to go into practices to work with practice teams. The practitioners will see all patients that are discharged from the CMHT, all patients on the practice MH register, patients identified as requiring input, and patients discharged into the supported system.

Single Point of Access (SPOA) – There were three CMHTs working in pairs across localities. The single point of access, based on the Sutton model, will work to improve access to those services through a more centralised system. This will enable patients to be seen quicker, with improved patient feedback.

CMHTs have now agreed to take self-referrals from patients and carers. This initiative has not been implemented anywhere else and will transform access for the community in Wandsworth.

Social Services – There had been some changes in how Social Services work, with Social Workers being moved back into the Town Hall. This change has identified a gap, therefore, some money has been invested to provide six more posts, which should help underpin that change.

BME – One priority was to improve work with BME patients with a specific work stream to look at prevention and support in the community.

IAPT procurement – A new specification had been developed through the CRG with input from GPs, patients and carers. It was expected that the contract would be awarded soon.

The CRG was used to test out ideas using the resource in the community to develop and take forward areas of work.

Suicide Prevention – A lot of work has been done with an audit undertaken of suicides over the past few years, which has indicated an increased rate. The number of suicides reported through the Serious Incident process has also increased. Other boroughs were being encouraged to undertake a similar audit.

Comments and questions were invited from members of the Board:

Psychosis Decision Unit (PDU) – This will bring all resources into one place. The most appropriate setting for the unit was to be based in the MH setting,

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rather than in A&E. GPs will make initial assessments and then send patients to the PDU. However, sometimes it will be necessary to ensure there are no physical health elements that need to addressed, so patients may be sent to A&E from where, following assessment, patients would then be sent to the PDU. This will be a 24/7 service but there may be a staged opening initially. There has to be appropriate staffing in the unit with the right level of clinical support.

Perinatal psychosis – National guidance states that patients must be seen in A&E within four hours, with specialist beds funded by NHSE in mother and baby units. Perinatal psychosis is a very specialist group.

Timeline for practice based practitioners in localities – This was due to be implemented in Wandle by November, to then be rolled out in April next year in Battersea and West Wandsworth localities.

Comments from Healthwatch members:o LD Placements Panel – A paper on the work of the Panel will be

brought to the Board. Carol Varlaam, Lay Member Patient and Public Involvement (PPI), has been invited to attend the Panel to advise on how to get PPI into the work of the Panel itself and decision making.

o CRG public information – The CRG Minutes are published on the website, but it was noted that a summary may be useful. This report to the Board was the annual report on the work of the CRG. Patient and carers representatives on the CRG have the responsibility to obtain views on the work of the CRG from a wider audience and to feed back to the CRG.

o Section 75 impact – The Section 75 agreement had been put in place to benefit Social Workers being placed in CMHTs, who had undertaken both social and health work. An improvement has also been seen in the number of Personal Budgets, which can now be signed off by Social Workers if under a certain amount – previously all Personal Budgets for MH were escalated for sign off at senior level. It was noted that the Council should respond to the changes in arrangements and a written response to this question would be requested from them.

Estates Modernisation Programme – The opportunities of the programme were significant, with anything to improve the estate welcomed. There were some risks around the aim to reduce admissions through the Crisis House initiative, and there remained a significant pressure on beds. The Crisis Café initiative was particularly successful. The planned number of beds on the new estate could be insufficient for the present need.

Education – The current provision for schooling was based on the Springfield site, with an outstanding Ofsted report. The plan was to move the school to either Kingston or Tolworth, which could create a risk around recruitment and retention of staff.

IAPT reprocurement – A potential risk has been flagged by NHS England (NHSE) that if a new provider was selected this could impact on clinical continuity of needs to be provided for patients already in the system. The mobilisation period of the key part of the process and discussions have been held with the current provider on how this would be managed. The new service was due to start in April 2017. Some changes have been made to the tender document to invite bidders to provide better plans for the Q4 period and the timeline extended. Work was already in place to mitigate this potential risk.

Scope for diagnosis of MH illness – The SPOA will provide a transformational level of access to CMHTs with an increased level of confidence for practitioners.

A written question had been submitted prior to the meeting:

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Talking Therapies – It is stated that “50% achieve recovery”. Over what period of time were the statistics taken. If this a one year, three year, or five year timescale?

Response - People who enter the service are asked to complete a self-evaluation questionnaire regarding their level of unwellness. The score from the questionnaire is reviewed through the period of treatment. The final score given at the end of the period of treatment indicates the level of recovery. The Wandsworth performance includes the recovery for all patients across clusters 1-4 and 4-7.

Comments and questions were invited from members of the public:

What work was being done to think about the effectiveness of some of the IAPT programmes?

Response – The new specification requested providers to identify what they think is the most intervention based evidence. The work with the psychology practitioners provides some guided self-help, but there is less evidence regarding this type of work. Wandsworth provide a twenty week intervention as this is considered to be more effective than a twelve week intervention period - the main throughput was reducing because patients were being seen for a longer period. Re-referrals are also allowed in Wandsworth. A review was also being done on the interventions available, as well as development of a STEPS programme, which was a long term programme.

The Board noted the work and progress of the CRG over the past year and welcomed the insight from clinicians, patients and carers, and input from Public Health and the commissioning managers. The work of the CRG was exemplary and the Board wished to note their thanks to all those involved.

16/086 West Wandsworth Locality Annual ReportZoe Rose, Rumant Grewal, and Tanya Stacey (TS), Locality Manager, presented the report.


The role of the Locality Clinical Lead was to engage and support Member practices and patient groups. One-to-one meetings had been held with the Clinical Leads and each practice – this approach was welcomed by practices.

A weekly newsletter was circulated to provide information to Members at both Locality levels and Wandsworth-wide.

The structure of Locality meetings had been revised, with information on the processes and structures of the CCG made available, including an awareness of Agendas for key meetings and items for discussions, to ensure feedback to practices.

Patient Engagement – There was an active and lively Patient Consultative Group in the Locality. Discussions have been held on the transformational change that is required in the CCG, and it was important for patient groups to understand the impact this will have. The patient groups have been involved in the understanding and delivery or Locality initiatives that will benefit the population.

Queen Mary’s Hospital (QMH) remains a centre of concern for the Locality and on-going work was in place to review pathways on that site.

Key outcomes of initiatives were noted:

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NHS Health Checks – Support has been put in place to enable practices to exceed targets set by Public Health and provide an improved service to patients.

MH project – Over 290 people over the year, some from the more deprived areas in the Locality, have received minimum health checks and lifestyle advice. The target group for this initiative has been those less likely to visit their GPs.

Putney Wellbeing Friends Initiative – So far this year, ninety clients have been seen, with referrals to a number of community activities and organisations. This initiative will be rolled out to other Libraries in the borough.


MH initiative target group – It had previously been identified that the data reflected that less than half of participants had been men - the issues regarding demography would need to be addressed. There has been a specific initiative implemented with barber shops, where it was hoped to reach some of those groups in a different way.

This was an excellent report with the outcomes enabling discussion.

Health Checks – This was a great approach to get practices back on board.

Immunisation work was good but not yet proven as a successful approach. Other Localities were encouraged to look at the approach if proved successful.

One-to-one practice meetings – These had not identified any unknown issues. Some Members preferred this approach and, for some practices, provided the opportunity to discuss surgery specific concerns. Collaborative working, particularly around Roehampton, was being done to improve services for patients, with work being done together to provide equity of provision.

NJ thanked the Locality team for the smooth transition and for the report outlining the work undertaken over the past year.

16/087 Operational Focus – FinanceThe report comprised two parts – Month 4 position, and the 17/18 plan to reflect the recently issued guidance.

Month 4 position

Financial strategy work was being done with SWL around the Sustainability Transformation Plan (STP), which will underpin the planning and guidance.

The Finance Resource Committee (FRC) regularly reviews the QIPP plan. A Finance Recovery Group had been set up to review the detail.

Surplus was expected to be achieved at this stage.

Emerging risks have been reviewed. Pressures currently on Continuing Health Care (CHC), and acute SLAs. There was an emerging risk around Free Nursing Care (FNC). Currently, it was expected that all risks would be covered from reserves. No additional allocations have been received in Month 4.

Acute contracting reports an over-performance of £3m. It was hoped that some improvement will be seen through the year.

Overall over-performance of £6m was expected to be covered from reserves. It was expected that all reserves would be utilised by the end of the year.

QIPP – There was an approximate slippage on schemes of £1m.

SGH – Issues around data at month 3 indicated an under-performance – performance was now reported as an over-performance.

Pressures being reported for Chelsea and Westminster, Guys and St Thomas’, and UCLH. Some offset was provided from the Elective Orthopaedic Centre due to waiting time issues, and Kingston Hospital.

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SGH – Issues around emergency and short stay admissions. An Activity Query Notice has been issued relating to the substantial increase.

Direct access Pathology from Epsom and St Helier Hospital – Referrals had now been switched to SGH.

Chelsea and Westminster – Critical care and Maternity were the significant drivers of the over-performance, which was subject to clarification from the contracts team.

Non-acute – The biggest area of concern was around CHC. Some progress has been made but the level of over-performance was still significant. It was anticipated that the current trajectory will be addressed with activity slowing in the second half of the year.

FNC – A 40% price increase had been agreed by the Department of Health for nursing home beds. This was expected to create a cost pressure of up to £600k.

Corporate Costs – Cost pressure was driven by expenditure relating to the CHC provider. No further costs were expected.

Primary Care – Limited forecast information was available. The report shows an under-spend and assumes the QIPP will be achieved. A break-even position was currently assumed for primary care overall. No areas of concern had been flagged.

Prescribing – Prescribing was expected to break even due to a change in some national pricing.

Risks and mitigations – There was a bigger potential risk than the CCG currently has mitigations for. Areas that could be used to mitigate the risk of meeting the 0.5% surplus were being reviewed. The current view was that the likely shortfall would be £2m. Any further slippage in acute, CHC, and QIPP will have an adverse impact.

Comments and questions on the Month 4 position were invited from members of the Board:

The FRC had discussed the position in detail the previous week, and noted sufficient concern regarding the position. The Committee proposed some urgent contingency work to be done in the CCG to review options. It was important to be able to recover the position as soon as possible.

This was new territory regarding financial management for the CCG. The Finance Recovery Group had been implemented, and messages have been sent out to the organisation regarding control of the financial position, arrangements regarding discretionary spend, and other pieces of work.

1% non-recurrent uncommitted reserve – Guidance from NHSE states that no assumption should be made that this money will be available to offset our position.

17/18 and 18/19The following key points were noted:

Planning Round – This has been brought forward by three months and would be applied over two years. This was a significant ask for the organisation as this links to the baseline and would also link to the STP. SWL CCGs would be discussing the approach to be used over the next three months.

Guidance on the planning round was not yet firm. Not all of the source data to formulate contracts and the Operating Plan would be available. Work was being done in parallel in SWL regarding principles for working across SWL.

Finance and Activity Working Group – This SWL group has been set up to look at how this would work across all CCGs with delegated authority around contract negotiations.

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Contract Delivery Group – This will feed into the Finance and Activity Working Group. The role of the group is to give assurance, direction and support to unblock challenges.

Milestones - Sign off of contracts in March. Some issues have been identified regarding the national tariff. Consultation on the tariff would be required, therefore, the national tariff would only be in draft format at the time of activity being agreed. This was a risk.

QIPP – Need to ensure QIPP plans are developed quicker both locally and across SWL as well.

It was critical that the 16/17 position is maintained and delivered as this will impact on 17/18 and 18/19. The identified challenges in 16/17 would therefore need to be addressed.

The CCG will still receive minimum growth. There will be some directed allocations from the Department of Health that will need to be spent, eg Parity of Esteem.

QIPP ask will continue to be significant, if not greater.

Business rules – Assumption that the business rules will be the same as for 16/17. A recovery plan has been submitted to NHSE to achieve the 1% surplus in 17/18.

Risk analysis – Risks were identified around growth, the financial distress of the main provider, financial pressure in the SWL economy, and delivery of a balance financial plan, which was contingent on achieving 16/17.


The budget was the only known element for 17/18, everything else was uncertain.

Move from PBR to block contracts – A new approach to contracting was probably required. The new tariff would be on a different basis, which would enable more specialist providers to be compensated appropriately. Contracts have to be balanced against the money available. Recommendations from the Contracting Group will feed into the Finance and Activity Group. It would be important to engage providers early in the planning round.

The issue for options for using block contracts across SWL have been discussed – this would probably need to be done across all providers in SWL, which could provide stability but there was a potential risk that detail could be lost.

A written question had been submitted prior to the meeting:

Based on current figures how much will need to be taken out of reserves for the financial year 2016/17? What is the total amount what Wandsworth CCG has in reserves?

Response – The reserves will be fully utilised by the end of the year. Currently £1m is still available. This position could change if the policy regarding the 1% non-recurrent uncommitted reserve changes. It was expected that some of the reserves will be replenished next year as part of the recovery plan. Representation for that funding to be returned to CCGs is made every month both locally and across SWL.

The Board noted the content of the report with significant risks identified, and the new approach to the planning round for 17/18.

16/088 Nine Elms Vauxhall Outline Business CaseJC left the table.

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A summary of the key points were previously circulated along with the full Outline Business Case, which the Board was asked to approve.


The business case proposed total funding of £25.6m, which will be submitted to Wandsworth and Lambeth Councils in October. The CCG has worked closely with the Council and Public Health teams throughout the process.

The business case was based on 34,700 residents coming into the development area, which would require two additional health facilities.

Two sites have been identified: o Sleaford Street – list size of 20k patients, to be available by 2020.o Nine Elms Square (New Covent Garden) – list size of 10k patients, to

be available in 2023.

The business case also provides for up to £2m for the expansion of three Lambeth border practices to accommodate the increase in population in the interim period.

During the interim period, there may be a requirement to have an additional facility at Thessaly Road, as this was the closest practice to the development area. Extended opening hours may be required at that practice, and this would need to be taken into account over the next four years.

Following this meeting, the CCG will continue to work with the Councils over the next three months. Planning and implementation will commence early in 2017.

A FBC (Full Business Case) will be developed, with on-going review of the modelling.

The identified health need for two practices was based on a population of 34,700, but this still remained fluid.

The new facility on the Sleaford Street site and extensions to the three Lambeth practices will be taken forward. A decision regarding the second site would be made in 2020.

The following financial points were noted:

Five funding issues were identified:o Capital costs – Two elements had now merged together to represent

the capitalised lease and fit out. o Financial implications regarding management costs.o Revenue costs overall from within the allocation and capacity.o Revenue costs for the overall population will have to be found from the

allocation.

There was a potential shortfall from the allocation received and the increased population. There was an assumption that a 1% increased population will be reflected in the allocation. If the CCG was unable to evidence any additional population growth in a particular year, it was unlikely that any additional allocation would be received into the CCG. NHSE has confirmed in writing that they will support an application should an increase in population materialises on that basis, but this would be subject to a national process.


Adjustments to the population base –The five-year allocation from 16/17 to 20/21 assumes a 1% increase year on year. Three year hard allocations have been published, but the last two years could change.

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A number of written questions had been submitted prior to the meeting. A full written response would be provided, but it was noted that there was no detail to respond at this stage. The CCG will continue to work with the Councils around the modelling.

It was noted that the CCG was being asked to define the requirements for health services without knowing any information regarding potential demand. The CCG has a duty to provide sufficient services for all the population in Wandsworth, not just the Nine Elms Vauxhall population. The modelling work on the expected population was based on what is known to have happened elsewhere in London.

The Board approved the overall approach and agreed the Outline Business Case for stages one and two of the development.

16/089 South West London Committees in Common Establishment AgreementIn previous discussions, the Board had agreed the principle for arrangements in SWL for a Committees in Common arrangement. The paper provided more detail of how the arrangement would work. It was proposed to exercise more collaborative work and decision making in common across the six SWL CCGs, in particular regarding the development and implementation of the STP across SWL.

The outline Terms of Reference were similar to other previous arrangements. Three nominations from each CCG were invited to sit on Committees in Common. It was proposed that for Wandsworth, the three members would be GM, NJ and SH.

It was important to note that this would not be a Joint Committee, therefore, decision would have to be unanimous. Meetings would be held in public, with the potential for Part II discussion of confidential items.

The revised Establishment Agreement would be presented to all CCG Boards, who had previously discussed and agreed this in principle as the way forward. The proposal would apply for the rest of 16/17 – a decision would be made whether this would be the right arrangement for next year.

No comments and questions were received from members of the Board.

Comments and questions were invited from members of the public:

Would meeting papers be available on the website?

Response – It was expected that meeting papers of the Committees in Common would be published on the SWL Collaborative Commissioning website.

The Board agreed the revised Establishment Agreement.

16/090 Executive ReportThe content was noted.

16/091 Audit Committee Annual ReportThe report provided an overview of the work of the Audit Committee over the past year. No immediate concerns were identified regarding the financial control framework. A number of Internal Audit reviews were undertaken on a range of areas. Although a number of reviews were red rated, all actions have been addressed to the satisfaction of the auditors. The Annual Report and Annual Accounts were completed on time, with an Unqualified Audit Opinion.

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The content of the report was noted.

16/092 Performance ReportThe content of the report was noted.

16/093 Summary MinutesThe content was noted.

16/094 Any Other BusinessNone.

16/095 Open SpaceA formal written response will be provided to each of the questions submitted prior to the meeting.

Publication date of the STP

Response – The CCG was working to a national process and timetable. A summary of the first submission was published on the SWL Collaborative website. The next submission was due at the end of October – it was expected that a summary would be made available on the same website. No firm date was available for consultation of the STP.

Personal Health Budgets

Response – A full presentation was provided to the Board in February 2016, a copy of which was available on the website.

A question was received from the live streaming of the meeting relating to invoicing issues. A written response will be provided.

There being no further business, the meeting closed at 12:16.

Date of next meeting: 12th October 2016

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Summary of discussion from Part II of the Board meeting held on 14th September 2016

Feedback was received from the members of the Board on the Part I meeting.

Sustainability and Transformation Plan – The next submission date was 21st October, the content of which would be sent round to CCGs for comment and sign off. Comments were invited on a draft list of questions to promote awareness across all Boards, to be fed back to the Collaborative team.

South West London Operating Model – An update was provided on discussions around collaborative working across SWL in response to the NHSE requirement for more collaborative working to deliver financial sustainability. Draft proposals had been submitted to NHSE. The Board was asked to support the proposed direction of travel, this was agreed.

CCG Assurance 15/16 – Following on from previous discussions at the Integrated Governance Committee and Board, a letter was sent to NHSE outlining the concerns of the Board regarding the 15/16 assessment. A response was received, which made reference to the RTT performance at SGH and patient safety being used to inform the assessment. The Board discussed potential options on how to take this matter forward, from which it was agreed that a short reply would be sent in order to draw a line under the debate. The response would also register the issues going forward around SGH, noting that a better dialogue regarding expectations of the CCG would be useful.

Remuneration Committee Recommendations – The Board was asked to consider and approve one recommendation from the Remuneration Committee. Following discussion, the recommendation was agreed.

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Declarations of Interest - Board Members 2015

Date Role Status Name Details of Declaration Committee membership Comments8/14/2015 Clinical Chair Board Voting Member Nicola Jones Managing Partner - Brocklebank Group Practice, and St Paul’s Cottage Surgery (both

practices hold PMS contract). Practice is a member of Battersea Healthcare CIC - Dr NJones holds no director post and has no specific responsibilities within that organisationother than those of other member GPs

Wandsworth CCG: Board (Chair); Integrated GovernanceCommittee (Chair); Management Team; CardiovascularDisease CRG (Chair); St George's Hospital ClinicalCommissioning Reference Group; Primary CareImplementation GroupSWL: Joint Committee for Primary Care Co-Commissioning; System Resilience Group' Clinical Leadfor SWL Transforming Primary Care ProgrammeHealth and Wellbeing Board

8/13/2015 Chief Officer Board Voting Member Graham Mackenzie None Wandsworth CCG: Board; Integrated GovernanceCommittee; Management Team (Chair); FinanceResource Committee; Audit Committee; GP ResourcesCommittee; Workforce Committee (Chair)SWL: Joint Committee for Primary Care Co-Commissioning; System Resilience Group; SWLCollaborative Commissioning ProgrammeWandsworth Health and Wellbeing BoardHealthy London Partnership - SRO for Personalisationand Participation

8/13/2015 Chief Finance Officer Board Voting Member Hardev Virdee Trustee - Point of Care Foundation (Charity); Member of CIPFA (accountancy body)Health Panel; Member of CIPFA Council (CIPFA is a Charity as well)

Wandsworth CCG: Board; Integrated GovernanceCommittee; Management Team; Finance ResourceCommittee; Audit Committee; Delivery Group; GPResources Sub CommitteeSWL: SWL Collaborative Commissioning CFO lead andEstates lead

8/24/2015 Lay Member - Governance Board Voting Member Stephen Hickey Chair - St George's Hospital Charity; Community Transport Association UK; Member - StGeorge's University Hospitals Foundation Trust; Chair - Community Transport Association(UK); Shaw Trust - member of Disabled Living Foundation Advisory Board

Wandsworth CCG: Board; Integrated GovernanceCommittee; Audit Committee (Chair); Finance ResourceCommittee (Chair); Remuneration Committee (Chair);GP Resources Committee (Chair); Workforce Committee

SWL: South West London Financial Risk CommitteeWandsworth Health and Wellbeing Board

8/14/2015 Lay Member - Patient and Public Involvement Board Voting Member Carol Varlaam Trustee - St George's Hospital Charity; Trustee - Wandsworth Care Alliance; Member - StGeorge's University Hospital Foundation Trust; family member is resident in a localnursing home receiving NHS Continuing Care funded by Wandsworth CCG

Wandsworth CCG: Board; Integrated GovernanceCommittee; Audit Committee; RemunerationCommittee; GP Resources Committee; PPI ReferenceGroup (Chair); Primary Care CommissioningImplementation Group; Communications andEngagement Working GroupSWL: Joint Committee for Primary Care Co-Commissioning (Chair)

8/18/2015 Secondary Care Clinician; Caldicott Guardian Lead forCommunity Development

Board Voting Member Andrew Neil None Wandsworth CCG: Board; Integrated GovernanceCommittee; Information Governance Steering Group(Chair)

8/14/2015 Registered Nurse Board Voting Member Diana Caulfeild-Stoker Trustee Cavell Nurses Trust; Member - Moorfields NHS Trust Wandsworth CCG: Board; Integrated GovernanceCommittee; Quality Group (Chair); SafeguardingCommittee (Chair)

5/1/2015 Battersea Locality Commissioning Group Joint Lead

Board Voting Member

Jonathan Chappell Practice is a member of Battersea Healthcare CIC - Dr Chappell holds no director postand has no specific responsibilities within that organisation other than those of othermember GPs.

Wandsworth CCG: Board; Integrated GovernanceCommittee; Management Team; Finance ResourceCommittee

1/31/2015 Battersea Locality Commissioning Group Joint Lead Nicola Williams GP Partner Battersea Rise Practice. Practice is a member of Battersea Healthcare CIC -Dr N Williams holds no director post and has no specific responsibilities within thatorganisation other than those of other member GPs

Wandsworth CCG: Board; Management Team; DeliveryGroup

9/3/2015 Wandle Locality Commissioning Group Joint Lead Board Voting Member Michael Lane GP Partner, Grafton Medical Partners; GP Partner - Lambton Road Medical Partnership;Director - Raynes Park Health Ltd (building management company); London MaternityLead, Royal College of General Practitioners; Member - London Clinical Senate Forum;Member - agenda advisory panel, UK Health Informatics Forum; Practice is a member ofBattersea Healthcare CIC- Dr Lane holds no director post and has no specificresponsibilities within that organisation other than those of other member GPs.

Wandsworth CCG: Board; Management Team;Integrated Governance Committee; Communicationsand Engagement Working Group; Wandle LocalityForum (co-Chair); Quality Group; Clinical ScrutinyGroup; Primary Care Transformation GroupSWL: Clinical Advisory Group member; Clinical Lead forMaternity Clinical Working GroupSt George's Clinical Quality Review Group

8/20/2015 Wandle Locality Commissioning Group Joint Lead Board Voting Member Seth Rankin Partner - Wandsworth Medical Centre; Member of Battersea Healthcare CIC, holding nodirector post and no specific responsibilities within that organisation other than those ofother member GPs; Director - London Travel Clinic Ltd providing private travelvaccinations; Director - London Doctors Clinic Ltd providing primate GP services; Director- Medilaser Ltd (trading as Wandsworth Village Skincare) providing cosmetic and medicallaser therapy not available on the NHS; Director - Rankin Press Ltd (dormant) intendingto publish books; Director - Healthy Lifestyle Enterprises (dormant) intended to provideand deliver weight management programmes; Director - Ezimed Ltd intended to sellnetworked panic alarm buttons to GP surgeries; Trustee - Sustainable Medical CharitiesInternational (CIO) providing the resources to deliver healthcare to the people ofDarsilameh Village in the Upper River Region of The Gambia; Consulted by CirclePartnership in Community Services Redesign; Advisor/consultant to the Nuffield Trustabout Virtual Wards in Community Services; Consulted by The Sollis Partnership aboutrisk prediction modelling of patients in primary care

Wandsworth CCG: Board; Management Team; DeliveryGroup; PACT project; CAHS project; Frailty Pathwayproject; CQRG and CCRG;

West Wandsworth Locality Commissioning GroupLead

Board Voting Member Zoe Rose GP Partner Commissioning LeadMember of LCG Management Board and Locality Forum for PutneymeadPractice Manager - Lead in GP Federation

Wandsworth CCG: Board; Management Team Appointed wef 01/04/2016

West Wandsworth Locality Commissioning GroupLead

Rumant Grewal Wandsworth CCG: Board; Management Team Appointed wef 01/04/2016

8/17/2015 Director of Public Health Board Non-Voting Member Houda Al-Sharifi None Wandsworth CCG: Board8/19/2015 Director ofChildren's Services Board Non-Voting Member Dawn Warwick None Wandsworth CCG: Board9/4/2015 Director of Corporate Affairs, Performance and

QualityBoard Non-Voting Member Sandra Iskander None Wandsworth CCG: Board; Management Team;

Integrated Governance Committee; WorkforceCommittee; Delivery Group (Chair)SWL: System Resilience Group

9/11/2015 Director of Primary Care Development Board Non-Voting Member Andrew McMylor None Wandsworth CCG: Board; Management Team;Integrated Governance Committee; Delivery Group; GPResources Committee; Primary Care ImplementationGroup; Primary Care Transformation Group (co-Chair);Estates Steering Group; Business Intelligence Group

SWL: SRO 111/Out of Hours Procurement; SRO SWL Outof Hospital Clinical Delivery Group

9/8/2015 Director of Commissioning and Planning Board Non-Voting Member Lucie Waters None Wandsworth CCG: Board; Management Team;Integrated Governance Committee; Primary CareTransformation Group (co-Chair)SWL: System Resilience Group; CCG Directors ofCommissioning; CCG Directors of Commissioning andChief Finance Officers;

8/19/2015 Director of Corporate Affairs, Performance andQuality (maternity cover)

Board Non-Voting Member Sean Morgan Substantive employer is South East Commissioning Support Unit Wandsworth CCG: Board; Management Team;Integrated Governance Committee; WorkforceCommittee; Delivery Group (Chair)SWL: System Resilience Group

8/13/2015 Wandsworth Healthwatch Board Non-Voting Member James Gillespie Executive member Healthwatch Wandsworth; Family member employed by SLAM;Affiliations - 38 Degrees member, SNP member

Wandsworth CCG: Board

1/21/2015 Associate Lay Member Kimball Bailey Director of Alastor - an independent management consultancy practice that has, over thepast five years, carried out work directly or indirectly for the Department of Health andvarious NHS Trusts and other organisations (including Springfield Hospital). None of thishas had a direct impact on commissioning nor is material to my role as Associate LayMember for Governance; member of Essentia advisory board

Wandsworth CCG: Integrated Governance Committee,Audit Committee, Remuneration Committee, GPResources Committee; Estates Committee (Chair)

1/7/2015 Associate Lay Member Chris Savory Advisor Interserve PLC Ltd; Advisor to Liberata and Capacity Grid; Member of the DorsetNHS Trust

Wandsworth CCG: Integrated Governance Committee,Audit Committee, Finance Resource Committee,Remuneration Committee, GP Resources Committee

8/17/2015 Advisor to the Board Board Non-Voting Member Tom Coffey GP Partner - Brocklebank Group Practice; Medical advisor - EY (Ireland); MICAS Advisor- Battersea Healthcare CIC; Practice is a member of Wandsworth Integrated HealthcareLimited - Dr Coffey holds no director post but is the Clinical Lead for the MSK service.

Wandsworth CCG: Board; Management Team; FinanceResource Committee

Resigned wef 10/09/2015

St George's Clinical Quality Review Group (Chair) 2/20/2015 West Wandsworth Locality Commissioning Group

LeadBoard Voting Member Peter Ilves GP Partner - Danebury Avenue Surgery. Practice is a member of Battersea Healthcare

CIC - Dr Ilves holds no director post and has no specific responsibilities within thatorganisation other than those of other member GPs. Primary Care and commissioningadvisor for Big White Wall Ltd. Occasional tutor and advisor for Connecting with People.

Wandsworth CCG: Board; Management Team; DeliveryGroup

Resigned wef 31/03/2016

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Declarations of Interest - Board Members 2016

Role Status Name Details of Declaration Committee membership CommentsChair Voting Member Dr Nicola Jones Managing Partner Brocklebank Group Practice and St Paul's Cottage

Surgery. Both practices hold PMS contracts.Wandsworth CCG - Governing Body (Chair); IntegratedGovernance Committee (Chair); St George's HospitalClinical Commissioning Reference Group (Chair);Management Team

Practice is a member of Wandsworth IntegratedHealthcare Ltd but Dr Nicola Jones holds no directorpost and has no specific responsibilities within thatorganisation other than those of other member GPs.

SWL - Chair System Resilience Group; Clinical Lead SWL& Surrey Downs Health Care Partnership Clinical Boardand Programme Board; Clinical Lead for SWL & SurreyDowns Health Care Partnership Clinical Board andProgramme Board, and Clinical Lead for SWLTransforming Primary Care Programme; Wandsworth - Health and Wellbeing Board

Chief Officer Voting Member Graham Mackenzie Spouse is employed by Imperial College NHS Trust. Wandsworth CCG - Governing Body; ManagementTeam; Integrated Governance Committee; FinanceResource Committee; Audit Committee;Remuneration Committee; Primary Care Committee;Workforce CommitteeSWL - System Resilience GroupWandsworth - Health and Wellbeing Board

Chief Finance Officer Voting Member Neil McDowell Spouse employed by Guildford and Waverley CCG Wandsworth CCG - Management Team; AuditCommittee; Finance Resouce Committee

Lay Member forGovernance, Vice Chair

Voting Member Stephen Hickey Chair, St George's Hospital Charity; Chair Community TransportAssociation; Member DLF Advisory Board; Member Shaw Trust.

Wandsworth CCG - Governing Body (Vice Chair);Finance Resource Committee (Chair); Audit Committee(Chair); Remuneration Committee (Chair); WorkforceCommittee; Primary Care Committee

Wandsworth - Health and Wellbeing BoardLay Member for Patient andPublic Involvement

Voting Member Carol Varlaam Trustee & Vice Chair, St George's Hospital Charity; Trustee, WandsworthCare Alliance; Member St George's University Hospital FoundationTrust

Wandsworth CCG - Governing Body; PPI referenceGroup (Chair); Primary Care Commissioning Committee(Chair elect); Audit Committee; Integrated GovernanceCommittee; Remuneration Committee;Communications and Engagement Working Group.

Secondary Care Doctor Voting Member Andy Neil None Wandsworth CCG - Governing Body; IntegratedGovernance Committee; Information GovernanceCommittee (Chair)

Registered Nurse Voting Member Diana Caulfield-Stoker Trustee Cavell Nurses Trust; Member Moorfields NHS Trust Wandsworth CCG - Governing Body; IntegratedGovernance Committee (Vice Chair); Quality Group(Chair); Safeguarding Sub-Committee (Chair)

West Wandsworth JointLocality Lead

Voting Member Dr Zoe Rose GP Partner Putneymead Group Medical Practice (Holds PMS contract).Practice is a member of the Wandsworth GP Federation(BatterseaHealthcare CIC). No roles or responsibilities held in GP Federation

Wandsworth CCG - Governing Body; ManagementTeam; West Wandsworth Locality Forum andManagement Team; Primary Care Committee; PrimaryCare CQRG (Chair)

Practice is a member of Battersea Healthcare CIC but DrRose holds no director post and has no specificresponsibilities within that organisation other thanthose of other Member GPs.

West Wandsworth JointLocality Lead

Dr Rumant Grewal GP Principal, Lead for Mental Health, Substance Misuse, Primary CareResearch, Referrals Management; on-going work as named author for aCochrane Review

Wandsworth CCG - Governing Body; Management Team Practice is a member of Battersea Healthcare CIC but DrGrewal holds no director post and has no specificresponsibilities within that organisation other thanthose of other Member GPs.

Wandle Joint Locality Lead Voting Member Dr Michael Lane GP Partner, Grafton Medical Partner; GP Partner, Lambton Road MedicalPartnership; Director, Raynes Park Health Ltd (building managementcompany; London Maternity Lead, Royal College of GeneralPractitioners; Volunteer Doctor, Crisis homeless charity; MemberAgenda advisory panel, UK Health Informatics Forum; Member LondonClinical Senate Forum; Non-voting Member of the Clinical Expert Panelfor Maternity of the CCG Improvement and Assessment Framework(IAF)

Wandsworth CCG - Governing Body; ManagementTeam; Integrated Governance Committee; FinanceResource Committee; Communications andEngagement Group; Quality Group; St George's ClinicalQuality Review Group; Community ServicesWandsworth Clinical Quality Review Group (co-Chair);Clinical Scrutiny Group; Primary Care TransformationGroup; Wandle Locality Forum (co-Chair)

Practice is a member of Battersea Healthcare CIC but DrLane holds no director post and has no specificresponsibilities within that organisation other thanthose of other Member GPs.

South West London - Clinical Advisory Group member;Clinical Lead for Maternity Clinical Design Group

Wandle Joint Locality Lead Voting Member Dr Seth Rankin Partner - Wandsworth Medical Centre; Director - London Travel ClinicLtd providing private travel vaccinations; Director - London DoctorsClinic Ltd providing private GP services; Director - Medilaser Ltd (tradingas Wandsworth Village Skincare) providing cosmetic and medical lasertherapy not available on the NHS; Director - Rankin Press Ltd (dormant)intending to publish books; Director - Healthy Lifestyle Enterprises(dormant) intended to provide and deliver weight managementprogrammes; Director - Ezimed Ltd intended to sell networked panicalarm buttons to GP surgeries; Trustee - Sustainable Medical CharitiesInternational (CIO) providing the resources to deliver healthcare to thepeople of Darsilameh Village in the Upper River Region of The Gambia;Consulted by Circle Partnership in Community Services Redesign;Advisor/consultant to the Nuffield Trust about Virtual Wards inCommunity Services; Consulted by The Sollis Partnership about riskprediction modelling of patients in primary care

Wandsworth CCG - Governing Body; ManagementTeam; CAHS Project

Practice is a member of Battersea Healthcare CIC but DrRankin holds no director post and has no specificresponsibilities within that organisation other thanthose of other Member GPs.

Battersea Joint LocalityLead

Voting Member Dr Nicola Williams Partner Battersea Rise Practice Wandsworth CCG - Governing Body; Delivery Group;Management Team; Primary Care TransformationGroup; Primary Care Quality Group

Practice is a member of Battersea Healthcare CIC but DrWilliams holds no director post and has no specificresponsibilities within that organisation other thanthose of other Member GPs.

Battersea Joint LocalityLead

Dr Jonathan Chappell Battersea Fields Practice Wandsworth CCG - Governing Body; ManagementTeam; Integrated Governance Committee; FinanceResource Committee;

Practice is a member of Battersea Healthcare CIC but DrChappell holds no director post and has no specificresponsibilities within that organisation other thanthose of other Member GPs.

Chief of CommissioningOperations

Non Voting Member Lucie Waters None Wandsworth CCG - Governing Body; ManagementTeam; Integrated Governance Committee; FinanceResource Committee; Audit Committee;Remuneration Committee; Primary Care Committee;Workforce CommitteeSouth West London - System Resilience Group

Director of CorporateAffairs, Performance andQuality

Non Voting Member Sean Morgan Substantive employer is South East CSU Wandsworth CCG - Governing Body; ManagementTeam; Integrated Governance Committee; WorkforceCommittee; Information Governance Group; PrimaryCare Committee

Director of CorporateAffairs, Performance andQuality (Maternity Leave)

Non Voting Member Sandra Iskander None Wandsworth CCG - Governing Body; ManagementTeam; Integrated Governance Committee; WorkforceCommittee; Information Governance Group

Director of Primary CareDevelopment

Non Voting Member Andrew McMylor None Wandsworth CCG: Board; Management Team;Integrated Governance Committee; Delivery Group; GPResources Committee; Primary Care ImplementationGroup; Primary Care Transformation Group (co-Chair);Estates Steering Group; Business Intelligence Group

SWL: SRO SWL Out of Hospital Clinical Delivery GroupDirector, Commissioningand Planning

Non Voting Member Rebecca Wellburn None Wandsworth CCG - Management Team; IntegratedGovernance Committee

Local Authority Director ofPublic Health

Non Voting Member Houda Al Sharifi None Wandsworth CCG - Governing Body

Local Authority Director ofChildren's Services

Non Voting Member Dawn Warwick None Wandsworth CCG - Governing Body

Healthwatch Wandsworth Non Voting Member Jamie Gillespie Executive member Healthwatch Wandsworth; Family memberemployed by SLAM; Affiliations - 38 Degrees member, SNP member

Wandsworth CCG - Governing Body

Last updated 17/08/2016

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LOG OF DECISIONS AND ACTIONS - BOARD

Meetingdate

MinuteNo. Item Lead Decision Action Target

Date Progress DateCompleted Conflicts of Interest Action to manage

ConflictsRequest for Chair's

Action Apologies Quorate

9/14/2016

16/085 Clinical Focus - Mental HealthLW None CV, DCS,

NW, CKYes

16/086West Wandsworth LocalityAnnual Report

ZR/RG

16/087 Operational Focus - Finance NM

16/088Nine Elms Vauxhall OutlineBusiness Case

AM Board approved the overall approach andagreed the Outline Business Case forstages one and two of the development

16/089SWL Committees in CommonEstablishment Agreement

GM The Board agreed the revisedEstablishment Agreement

16/091 Audit Committee Annual Report NM16/092 Performance Report SM

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SUMMARY OF QUESTIONS – Wandsworth CCG Board meeting – September 2016

Question: From: Response from:

1. What is a Personal Health Budget? How does this differ from the current arrangement?

2. When will the STP, promised in the summer by the Board, be published?

3. Mental Health Clinical Focus- Talking Therapies. It is stated that "50% achieve recovery". Over what period of time were the statistics taken. Is this a one year, three year, or five year, timescale?

4. How many Community Health Teams are there in Wandsworth?

5. The year end forecast for Acute Care is a £6m overspend. Last financial year the CCG needed to take £8.5m out of reserves. Based on current figures how much will need to be taken out of reserves for the financial year 2016/17? What is the total amount that Wandsworth CCG has in reserves?

6. Nine Elms Vauxhall ProjectOf the projected 18,276 dwellings how many dwellings have been sold so far? How many dwellings that have been sold are occupied? How many dwellings that have been sold are occupied by UK nationals/or those entitled to NHS treatment?How many of the dwellings so far sold are occupied by those who will require treatment under the NHS?On what evidence is the final figure of 34,707 new inhabitants (1.8 person per dwelling) to the area based?

M Squires 1. A full presentation on Personal Health Budgets was presented to the Board in February 2016 – a copy of the paper is available on the CCG’s website.

2. The CCG was working to a national process and timetable. A summary of the first submission has been published on the SWL Collaborative website. The next submission was due at the end of October, a summary of which will also be made available.

3. People who enter the service are asked to complete a self-evaluation questionnaire regarding their level of un-wellness. The score from the questionnaire is reviewed through the period of treatment. The final score given at the end of the period of treatment indicates the level of recovery achieved over the duration of their therapy; 6-20 weeks. The Wandsworth performance includes the recovery for all patients across clusters 1-4 and 4-7.

4. There are three Community Health Teams in Wandsworth, working in pairs across Localities.

5. The £6m over performance figure is the total value not just acute contracts which is £2.9m. Current projection is that we will fully utilise our reserves this year (£7m) with £4.6m having to remain uncommitted as per national guidance.

6. We are responding based on the data available to us at this time.

Of the projected 18,276 dwellings how many dwellings have been sold so far?

We are not in possession of this information.

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How many dwellings that have been sold are occupied?

We are not in possession of this information. We are using population and occupation predictions generated by the Borough Councils and the Greater London Authority for developing population estimates.

How many dwellings that have been sold are occupied by UK nationals/or those entitled to NHS treatment?

We are not in possession of this information. We are using population and occupation predictions generated by the Borough Councils.

How many of the dwellings so far sold are occupied by those who will require treatment under the NHS?

We are not in possession of this information. We are using population and occupation predictions generated by the Borough Councils.

On what evidence is the final figure of 34,707 new inhabitants (1.8 person per dwelling) to the area based?

The population figures are based on a model developed by the Boroughs of Wandsworth and Lambeth. The model will be revisited on a regular basis and the DIFS Bid business case includes a monitoring process to ensure NHS Commissioners plan and provide sufficient health care capacity to meet the needs of the population.

Monitoring of the actual rates of build and occupancy will enable the Health Care Board to update data on at least a bi-annual basis.

When good care agencies fail to have their invoices settled on time, they are forced to relinquish contracts involving patients who rely on

E Hammond Wandsworth CCG treat all care agencies equally in terms of settlement of invoices. The CCG currently has one invoice

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Wandsworth CCG. Patients are then forced to use agencies that are substandard and quite frankly, dangerous and a risk to the health and safety of the patient. What does the board intend to do about the invoicing issues involving good care agencies like Bluebird?

outstanding with Bluebird and CHS (Care Home Select) are working with the supplier to get the query resolved.

Mental Health – What potential impact would there be on the ending of the Section 75 agreement?

Healthwatch Response provided from the Director of Adult and Community Services - It is completely understandable that there are worries about how patients are impacted by these changes and in our preparation for the ending of the partnership arrangement a lot of time was spent preparing both services to maximise the impact of continued close working arrangements for local people.

To this end the Approved Mental Health (AMHP) service continues to be based at Springfield where the team liaise very closely with MHT partners. There has also been a significant improvement in terms of working arrangements for supporting safe and timely discharges for people from the medical wards. Furthermore, my managers meet with colleagues from the trust on a regular basis and have good communications about patients. This has been supported by provision of access to RIO for a limited number of council staff.

To further support the partnership working Kerry Stevens has arranged a meeting with MH leads from the SWL authorities who are now outside of the section 75 arrangements. This meeting followed the CQC meeting with the Trust and aims to provide a more consistent approach from LAs to the Trust to enable all parties to better support local communities.

However as with all partnership arrangements there can be difficulties and areas for future development and learning. This is especially true with this user group, so if you are alerted to any specific areas of concern we will always be happy to consider and work together to resolve them.

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2.1. B01 Clinical and Operational Focus - St George's Hospital 24

2.2. B02 Multi-speciality Community Provider (MCP) procurement 49

2.3. B03 Talking Therapies procurement 57

2.4. B04 Battersea Locality Annual Report 67

2.5. B05 Lay Member Board Roles 79

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W A N D S W O R T H C C G P A G E 1 O F 2 5

Clinical and Operational Focus – St. George’sAuthor: Lucie Waters Sponsor: Graham Mackenzie Date: 12 October 2016

Executive Summary

Context

This report is a combined clinical and operational focus on our main provider – St.

George’s University Hospitals NHS Foundation Trust - for which Wandsworth CCG is the

lead commissioner on behalf of other CCGs and, the lead for performance and quality only

for NHS England Specialised Commissioning. It updates the Governing Body on

performance against NHS Constitution standards, on the assurance the CCG has on the

quality of care provided and gives the latest position on contractual activity and finance. It

sets out to explain why performance on many issues is below plan and why improvements

have not always been evident in the timeframes we would have expected. The Board is

aware of the changes in the leadership team at the Trust, many senior posts, including the

Chair and Chief Executive are in acting or interim arrangements.

The report describes the background to the current issues and notes the context in terms

of the commissioning and regulatory landscape over the last two years and how that has

impacted on the governance of these issues.

We have a number of ways of influencing what happens at St. George’s, from building

strong working relationships, to using formal contractual levers including contract notices

and financial penalties, working with the Trust’s clinicians and managers to redesign better

pathways and working with the Trust and regulators to bring in external support where

specialist expertise is required. The report notes the range of interventions currently in

effect.

There is an appendix explaining the meaning of acronyms used throughout the report.

Question(s) this paper addresses

What is the current position with respect to the St. George’s contract on performance,

quality, and finance?

What has gone well and what requires continued focus?

What has the CCG’s response been with respect to our commissioning

responsibilities?

What is the plan going forward, with respect to governance, the approach to contract

management and in terms of commissioning intentions?


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Conclusion

1. The paper describes the challenges being faced at St. George’s, there are a number

of issues which will need ongoing focus over the long term

2. Progress has been made on a number of the issues the CCG has prioritised with the

Trust, although some performance concerns have proved more intractable

3. The CCG continues to provide considerable support to work with the Trust to turn

performance around

4. The STP will provide the strategic direction for future services models and the local

programme boards will work on priorities for pathway redesign, and the CCG is

working with the Trust and the regulators to ensure the governance is fit for purpose.

Input Sought

We would welcome the board’s input regarding the intentions for the future relationship

with St. George’s. It is recommended that the Acting Chief Executive be invited to attend a

meeting of the Integrated Governance Committee to discuss these issues. The Board is

asked to consider whether any further action should be taken, beyond what is described in

this report.

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The Report

F U R T H E R C O N T E X T

To give some background to the current situation with respect to performance at St.

George’s this section notes some of the key events of the recent past:

The CQC inspection report published in April 2014 rated the overall quality of care as

‘Good’, with ‘good’ ratings in four of the five domains and ‘good’ for 6 out of 8

service areas with one rated as ‘outstanding’, with just one domain and one service

area rated as ‘requires improvement’.

St. George’s was authorised to become an NHS Foundation Trust by Monitor from 1

February 2015, having been assessed through an intensive due diligence process

as having met the required criteria.

The Trust’s financial position deteriorated markedly through the Winter of 2014/15

(largely due to increased spend on agency staffing), with a year-end deficit of

£16.8m

2015/16 was a very challenging year for the Trust in terms of both the size of its

financial deficit which increased to £55.1m (against a plan of £46.2m) and its

difficulty experienced in meeting the core NHS Constitution standards.

The Trust commissioned PwC to review the reasons for the sudden, sharp financial

deterioration, and their report highlighted a range of governance issues and poor

operational leadership

Through the contractual processes initiated by commissioners the Trust was required

in February 2015 to participate in a Joint Investigation which resulted in a recovery

plan for both ED and RTT performance, which was signed off by all stakeholders in

July 2015.

A substantial element of that action plan related to several additional capacity

initiatives most of which were not implemented in line with the agreed timetable for

various reasons. These delays triggered a performance notice being raised in

December 2015.

The Trust initially made an interim appointment to the Chief Operating Officer role in

October 2015, with two subsequent interim appointments in May and September

2016. The three most senior roles – Chair, Chief Executive and Chief Operating

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Officer – have not been through a formal process to appoint substantive

postholders.

An external diagnostic of ED performance and the wider emergency care system,

One Version of the Truth, was undertaken during October and November 2015, and

a subsequent phase resulted in a Flow Programme being established from

December onwards the outcome of which is discussed below.

The Trust commissioned support on a comprehensive demand and capacity model

from KPMG.

There was a marked decline in the urgent 2-week cancer referral standard from

April 2015, the reasons for which are described below. A recovery plan was signed

off by the local tripartite in January 2016. Some progress has been evident in both

the 2ww standard and 62 day standards, which were achieved in July 2016.

External support on RTT and elective access was provided over the last 18 months

by the Intensive Support Team (IST), culminating in a number of concerns being

raised about data quality and completeness.

A more detailed review of data quality was commissioned from MBI in May 2016 who

identified a number of significant weaknesses with the processes for producing and

collating waiting list data and also with the operational management of waiting lists,

such that the reported figures were highly likely to be inaccurate.

The Trust ceased reporting the national RTT returns from June 2016 whilst these

issues are addressed. The Trust is in the process of developing a plan to ensure

data integrity and to reduce the significant number of patients waiting in excess of

18 weeks for treatment. A clinical harm review panel has been established, chaired

independently by Nicola Payne (Associate Medical Director, NHS England).

The Trust’s month 5 finance report was for a year-to-date deficit of £34.9m (£19.7m

worse than plan) and a forecast outturn of a £55.5m deficit (£38.3m worse than

plan), with a number of supplementary recovery actions being put in place

The CQC undertook a further inspection in June 2016, for which the report is

awaited, initial feedback given to the Trust highlighted concerns about the quality of

the estate (particularly Knightsbridge and Lanesborough wings), governance, timely

access to treatment and data quality

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During September the CCG issued the Trust with 3 contract performance notices,

regarding concerns on RTT data flows, cancer 100+ day breaches and root cause

analysis reviews and RTT waiting list management and also issued a contract

activity query regarding the significant increase in short stay non-elective

admissions

During the current financial year the Trust executive team has undergone significant

changes, and at the time of writing all the current team are all either acting up or

interim.

As a result of these issues there is a programme of support in place, covering:

Finance

Quality

Performance

These programmes are described below.

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A N A L Y S I S

What is the current position with respect to the St. George’s contract on performance,

quality and finance?

Summary of Current Performance (July 2016)

Target Latest Data Performance YTD Performance

Month

Breaches

RTT incomplete 92% July 2016 89.9% Not Reporting

Diagnostics Diagnostics - 6 weeks + 99% July 2016 98.9% 99.2% 50

2 week wait 93% July 2016 89.4% 93.1% 71

Cancer - 62 days 62 day standard 85% July 2016 82.8% 90.2% 7

% within 4 hours 95% July 2016 93.0% 94.4% 829A&E

ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION

TRUST

NHS Constitution

RTT

Cancer - 2 weeks

Previous reports have updated the Board on the challenges at St. George’s with

performance on the core NHS Constitution standards over the last two financial years.

These challenges have also been reported to Board seminars, the Integrated Governance

Committee, the Quality Group and to Management Team.

Emergency Department (ED) 4-hour access standard

The issues with performance on the 4-hour ED access standard have been longstanding

as shown on the first chart, and although the 95% standard is not being achieved it can be

seen that there has been an improvement in waiting times in 2016/17 to date.

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89.7%

93.6% 94.0% 94.4%92.7%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

APRIL

MAY

JUN

EJU

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AU

GU

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SEPTEM

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FEBRUARY

MARCH

78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%

88.8%90.2%

91.5% 91.4%92.8% 93.0% 92.6% 92.6%

91.5%92.6% 92.1% 92.2%

2016/17 Actual 2016/17 Plan Target

A&E Waiting Times - Total Time in the A&E Department

The 4-hour ED maximum wait standard has been challenging across most of the country

for a considerable time. Performance at St. George’s dipped in November 2014, as is

often the case going into the Winter months, but other than for very short periods has not

consistently met the standard since.

The Joint Investigation Action Plan of July 2015 included some actions to improve flow

through the system, including within ED and to expedite timely discharge from inpatient

stays when patients are medically fit. The latter issue was a clear priority as the Trust had

seen the usual increase in medical emergency admission average length of stay (LoS)

during the 2014/15 Winter but unusually the LoS had remained at that level through the

first two quarters of 2015/16 resulting in a significant pressure on bed capacity. To address

the bed capacity issue a substantial element of that action plan related to several

additional capacity initiatives. A number of these initiatives were implemented late or not

at all for various reasons, including logistical issues with the estate and the financial

constraints applied to the Trust.

An external diagnostic of system capability to deliver the ED 4-hour standard, One Version

of the Truth, was undertaken in Q3 of 2015/16 on the recommendation of NHS England.

The contract was extended to design and establish the Flow Programme to deliver the key

recommendations of the report. The Flow Programme has been jointly led by the Trust

and the CCG to reflect the whole system focus of the work. This work included an in depth

assessment of the effectiveness of much of the Trust’s internal processes right across the

whole emergency care pathway; it covered the wider system in terms of prevention of

demand which could be directed elsewhere and the alignment of services to achieve

speedy, safe discharge from both ED itself and from inpatient stays. Workstreams were

established and a programme infrastructure was put in place to implement the agreed

actions and to track progress and outcomes. This work is still very much ongoing.

The CCGs are assured that improvements in the operational running of the ED have been

embedded, for example; senior clinician review on arrival for early initiation of diagnostic

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testing Rapid Assessment and Treatment (RAT) teams, onsite hot lab, deployment of the

SAFER bundle on some wards are other initiatives in train which require comprehensive

roll out.

St. George’s is one of a dozen Trusts participating in the pan-London Action Learning Set

on reducing delays to ambulance handovers. There has been a significant reduction in the

length of time taken to handover patients arriving in ED by ambulance and St George’s is

now a high performer against peers.

Performance in 2016/17 is being assessed against an agreed Sustainability and

Transformation Fund (STF) trajectory. Whilst the 95% standard is not being achieved,

performance from May through August has been above trajectory, and has been

consistently one of the highest in London, and St. George’s is one of the few Trusts in

London to have performed better in 2016/17 to date than in the same period the previous

year. However, performance remains variable and performance against the Flow

Programme workstreams shows the further improvements that need to be made.

The work will be enhanced by the mandated establishment of the Emergency Care

Delivery Board, replacing the system resilience group, and directed to oversee the

implementation of five initiatives which it is believed will support delivery of the standard no

later than March 2017.

While acknowledging that recent changes have improved the flow of patients through the

hospital, commissioners are also seeing a marked increase in emergency short stay

admissions, matching the timing of the improved 4-hour performance. This issue is

subject to a contractual activity query notice and a clinical audit is being undertaken in

October.

The challenge will be to continue the implementation of the Flow Programme in full, to

work through the Emergency Care Delivery Board to address the increased demand in ED

attendances being seen from March and to ensure that the whole system can operate

effectively through the coming Winter, whilst ensuring that patients are not having

avoidable short stay admissions.

Referral to Treatment (RTT)

Following a prolonged period when performance has been below the 92% standard for

incomplete RTT pathways St. George’s ceased reporting national RTT information after

May 2016 due to significant concerns having been highlighted by an external review of

data quality.

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It has been clear over the period from mid-2014 that St. George’s was unable to achieve

the RTT 18-week non-admitted waiting standard consistently. There have been some

specialties where performance has been well below the standard, including ENT and

Gynaecology, partly reflecting a mismatch between demand and capacity but also in part

due to how services have been organised.

There has been a long standing concern from a commissioner perspective that outpatient

services at St. George’s have not been organised efficiently, resulting in delays in access

to first attendance and poor communication with patients about their appointments. Only a

limited proportion of outpatient capacity is allocated in clinic templates at the start of each

year, with a significant proportion left unallocated to be managed in-year, which has

created problems for service managers and clinicians to be able to plan adequately to

reduce their backlogs and deliver sustainable performance on the 18-week standard.

Outpatient services have not been controlled from a central point, with each specialty

managing clinic space in isolation, which has not been conducive to enhancing

productivity to create the capacity required.

The Trust has an old and in many areas inadequate estate, with a considerable legacy of

backlog maintenance, which has led to a significant problem with operating theatre

downtime over the last 12 months, because of urgent maintenance requirements.

It has been clear for some time that a comprehensive demand and capacity review was

required. This was one of the key outcomes of the July 2015 Joint Investigation, which

included a requirement for the Trust to produce and implement an Outpatient

Transformation Plan, which was intended to commence from October 2015. A outpatient

transformation review report was shared with commissioners in May 2016;.while this is

now a key trust priority there is a significant amount of work required to achieve a

balanced demand and capacity outpatient system.

As part of the Joint Investigation action plan the demand and capacity and key clinical

pathways in the most challenged specialties were all reviewed. This has resulted in a

number of actions to improve the quality of referrals and streamline the process for

patients. The Trust commissioned external support to design and build a comprehensive

demand and capacity model, taking account of outpatient clinics, diagnostics, theatres and

beds. Commissioners are expecting the Trust to deliver their Operating Policy in October

which will detail the demand and capacity utilisation plan for 2016/17 and beyond

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W A N D S W O R T H C C G P A G E 1 0 O F 2 5

The issues with RTT data quality highlighted in an external review date back in part to the

implementation of the new PAS in 2010 and the go live of the RTT reporting from the PAS

in 2014. The Trust has been working from separate first outpatient, continuing outpatient

and elective admission waiting lists, and the data quality issues were exacerbated by

having two different IT systems at the St. George’s and Queen Mary’s sites which could

not share information in the way required.

The Trust has acknowledged that owing to these inadequacies in its reporting systems:

Many patients are clearly waiting longer than they should for treatment;

The Trust cannot say with confidence how long some patients have been waiting for treatment;

Some patients requiring follow-up may not have an appointment organised.

The Trust has reported taking the following action:

procuring external expertise to address the technical failures and identify patient

cohorts requiring clinical review. This will quantify the scale of the problem and

initiate auto-validation using specific algorithms

urgent staff training is taking place, together with targeted tracking of data entry

errors to prevent new patients from being entered on the system without a ‘clock

start’, thus minimising the risk of clinical harm

a process for clinical review of patients where auto-validation is inconclusive, or

clock stops aren’t found, has been developed to evaluate the risk of patient harm

and urgently recall for treatment where clinically indicated. There is a potential for a

very large number of patients requiring clinical review, and resources to support

rapid review are being provided

improving leadership and oversight of RTT, including dedicated project resource –

independent of normal operations to ensure validation and clinical review is

undertaken promptly

an executive-led RTT Recovery Programme has been developed, with support from

external stakeholders

waiting time helpline set up for patients and GPs.

With the suspension of national reporting of RTT waiting times there is no one robust data

system in place, although it is certain that the RTT backlog in place continues to need to

be addressed. To progress faster treatment for patients the CCG has been working in

partnership with colleagues at Merton CCG, the South East CSU and the Trust to source

external capacity, from local hospitals such as Kingston and Croydon, and from

independent sector providers. Plans are being developed on a specialty basis..

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The CCG has issued the Trust with contract performance notices regarding these issues

with RTT data flows and RTT waiting list management. The Trust has committed to

producing an overarching recovery plan linking together the actions being taken on

recovering performance across all the core NHS Constitution standards, which is awaited.

Cancer

Performance on the cancer waiting times standards has been inconsistent, with particular

longstanding problems in achieving either the 2-week maximum wait for urgent GP

referrals or the 62-day maximum wait standard from urgent GP referral to treatment.

83.1%75.0%

81.6%90.2%

APRIL

MAY

JUN

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SEPTEM

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OCTO

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FEBRUARY

MARCH

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

83.3% 81.7% 83.8% 85.1% 85.1% 85.7% 85.7% 85.7% 85.3% 85.3% 85.7% 85.7%

2016/17 Actual 2016/17 Plan Target

All Cancer 62-Day Urgent Referral to Treatment Wait

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Decline in 2-week urgent waits performance from April 2015, due to a number of issues

which in summary could be described as a lack of operational focus on performance,.

There were capacity issues in dermatology and gynaecology. Outpatient capacity in many

specialties wasn’t allocated to urgent 2-week referrals, or in some areas insufficient slots

were allocated, and service managers didn’t have the ability to flex capacity to deal with

spikes in demand.

The issues with the 62-day standard were related, but in addition lack of established

processes, poor data quality on the cancer system and a lack of capacity in clinical nurse

specialists and MDT coordinators meant that patients could not be adequately tracked

through their pathway, resulting in an inability to know when certain investigations or

treatments ought to have been escalated.

Work on a comprehensive cancer recovery plan through November and December 2015,

including with significant input from subject matter experts at NHS England, with sign off

on 8 January.

Recent actions include CCGs reinvestment of penalties to provide funding for a system

improvement lead, creation of dashboard for routine monitoring of KPIs, establishment of

weekly meetings to review patient tracking lists, 2ww balancing of demand and capacity,

LCAT training of admin staff, weekly calls with all referring trusts to track patients. Risks to

delivery remain including insufficient staff in the 2ww office and MDT coordinators, and an

over reliance on key individuals in interim post. There are also insufficient cancer nurse

specialists. Performance in July 2016 was markedly improved, with the Trust achieving all

of the standards. It is not yet certain that we can be assured that this level of performance

will be sustained.

Quality of Care

Commissioners are assured on the quality of care at a provider in a number of distinct

ways. There are a wide range of quality metrics, which are included at annex x, and which

are routinely reported to the Integrated Governance Committee. These metrics are also

reported to the South London Quality Surveillance Group (QSG) which is hosted by NHS

England and attended by NHSI and the CQC, and well as all CCGs in south London. The

QSG is an assurance mechanism for regulators and commissioners, outwith the contract

management processes. There is also soft intelligence, and the CCG has a well-

established mechanism for picking up and responding to quality issues, through our Make

a Difference alerts system, which for example picked up concerns from local GPs about a

deterioration in performance on 2-week urgent cancer waits before it showed in the formal

monthly data.

The Clinical Quality Review Group (CQRG) forms part of the formal contract management

arrangements and has oversight of the quality of care being provided by St. George’s.

The CQRG has focused on an extensive range of issues.

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Examples of high performance or innovation

good engagement of senior clinicians from the trust in the CQRG process, working

collaboratively with WCCG, MCCG, NHSE and other commissioners to improve

quality of care for patients

a reduction in the number of SGH acquired Grade 3 and 4 pressure Ulcer SIs

Trust has been presented with two national awards for innovation in the process of

engaging patients with the Friends and Family Tests (FFT)

Quality visits to the hospital by GP clinical leads have highlighted high quality of

inpatient care, with mortality rates better than the national standard.

Concerns and Issues raised by Commissioners prior to the CQC Inspection of June 2016

Commissioners were asked by the CQC to forward any issues or concerns prior to the

inspection, and the following issues were highlighted:

Medical personnel issues in Adult Uro-Gynaecology and the Paediatric Adolescent

Gynaecology (PAG) service resulted in a service transfer (Adult Uro-Gynaecology)

and service disruption and quality issues to the remaining PAG service. The PAG

service has now been reviewed and a new service model is in place, being

monitored through the CQRG. An external review of the new service model has

been undertaken in relation to the impact on safeguarding children. Work will be

taking place to consider what level of secondary care Adult Uro-Gynaecology

service could take place at the trust over the longer term.

a number of themes of concern identified from SIs as follows:

Failure to act on test results/consequent delay in diagnosis.

Never Events – include retained swabs in maternity, wrong site surgery in dermatology and dental related incidents. There has been some focused work on the dermatology SIs and actions resulted in some positive service changes.

Delay in treatment – this is a theme in the last few months so will be a focus in

the next coming year.

Concerns around compliance with NHS England SI Framework in relation to

timeliness of reporting SIs – this resulted in a review of the governance

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arrangements related to the SI reporting processes in the Trust being

undertaken by commissioners in April 2016. The review validated commissioner

concerns and an action plan has been agreed to address areas of concern.

Issues with nurse staffing levels, with particular concerns around the high vacancy and

turnover rates, particularly with community services staffing which has high vacancy

rate, high turnover and high agency usage.

The recent staff survey for the Trust highlighted disappointing results with below

average scores. This was reported to CQRG in March 2016, with recognition from

the Trust Board that change is required. Action is being taken on raising staff

morale and this has been placed on the trust risk register.

Outpatient capacity shortfall, poor booking process, poor communication, waiting

times, patients lost to follow-up

Issues with organisational culture

An apparent lack of robust systems and processes (governance arrangements) to ensure concerns are escalated and managed appropriately with Board oversight when required.

Culture within the organisation of being reactive and a tendency to minimise concerns. Apparent lack of ownership of issues at middle management level and not clear if this is a cultural issue with staff not enabled to take responsibility.

Theme of late submission of information and a difficulty gaining information requested. When information is received it is not always of the quality expected.

The culture and capacity within the organisation to provide assurance in relation to quality concerns, and deliver what is requested, is questioned on a repeated basis.

Cancer services including lack of outpatient capacity, lack of rigorous pathways and

processes, concern about the robustness of the Patient Tracking List (PTL) also

reflects a lack of confidence in ensuring all patients are tracked and treated in a timely

way, inadequate numbers of Clinical Nurse Specialists, delayed diagnoses, issues with

the quality of the RCA reports for each patient waiting over 100 days

Maternity services, including capacity and performance, with particular focus on the

Trust not achieving the 12 week and 6 day booking target.

Interventional radiology and vascular surgery suspension of training posts by Health

Education England in November 2015 due to significant concerns over lack of

collaborative working between the two departments. Progress against the action plan

was monitored through a CQRG Part 2 process, chaired by NHSE.

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Spinal rehabilitation delayed transfers for complex rehabilitation

South West London Pathology shared service, mostly IT-related issues

Infection control issues have been raised at CQRG including; poor hand hygiene compliance, adherence to the uniform policy, staffing levels, leadership and vacancies in the Infection Control Team, Legionella remains an ongoing issue, decontamination of nasendoscopes

Safeguarding Children and Adult Training compliance, lack of assurance regarding timely applications for Deprivation of Liberty Standards (DoLS) referrals and a disproportionate number of DoLS authorisations

Community services staffing: high vacancy rate, high turnover, high agency usage

Initial Feedback from the CQC Inspection of June 2016

The Care Quality Commission (CQC) inspected the Trust in June 2016 and initial feedback

given to the Trust highlighted:

Areas of good practice

Our staff were motivated, engaged and had a good understanding of the issues

within their own areas.

Our staff were caring and spoke with candour of the challenges they, and the

organisation faced.

The CQC were impressed with the clinical outcomes and low caesarean section

rates currently reported by the Trust.

Areas of concern

The condition of the estate within renal services and outpatients and wider estates

risk management, and in particular mitigation of fire risk in Lanesborough wing.

Governance arrangements supporting the investigation of serious incidents.

Oversight and delivery of action plans at a local level.

Compliance with the Duty of Candour.

Compliance with the Fit and Proper Persons Requirement.

End of Life care in community settings – oversight and governance regarding the

relationship with Trinity Hospice, and a lack of service level agreement provision.

The management of patients on Gwynne Holford Ward at Queen Mary’s Hospital in respect of monitoring nutrition and hydration, and oversight of the administration of medicines to day patients receiving rehabilitation treatments.

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Empowerment within Theatres. Staff not prepared to challenge colleagues on dress code which raised a question as to whether staff would be empowered to challenge in the event of a patient safety concern.

Staff were knowledgeable about the Mental Capacity Act and Deprivation of Liberty Safeguards,

Governance processes were considered weak, with a lack of accountability, and overall risk management arrangements need strengthening.

Executive portfolios need reviewing.

Data quality, IT infrastructure and unreliable performance information, combined with insufficient clinical oversight and prioritisation of referrals.

Areas requiring immediate assurance to the CQC

Estates – fire safety standards and overcrowding in Lanesborough wing outpatients department, and water leaks and electrical safety issues in the renal department;

Board Assurance Framework and over-riding governance;

Clinical prioritisation of referrals (Referral to Treatment Time).

The Trust has reported that it has taken immediate action on the estates and governance

concerns, and on RTT as described above.

The final report is expected to be published in October. A Quality Summit will follow at

which the key responses and actions will be agreed. The CQC will formally sign off an

action plan with the Trust including a timetable for all concerns raised to be addressed.

The Trust has implemented a new governance framework and will create a new Quality

Improvement Plan, to be finalised after the CQC report is published and the Quality

Summit has taken place. Commissioners have agreed with NHS Improvement and NHS

England that assurance on delivery against the action plan will be overseen through a

Quality Oversight Group, which would also include the CQC. This will ensure a single

process for monitoring and assurance across commissioners and regulators.

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What has gone well and what requires continued focus?

What is working well?

ED performance better than previous year, and above trajectory

All cancer waits standards achieved in July

Diagnostic waits issues tackled as they have arisen and sustainable access in place

External capacity for RTT backlog sourced by commissioners and Trust working

together

Delayed transfers of care (DToCs) remaining at relatively low levels, Wandsworth

consistently c. 5th lowest in London

Significant reduction in the length of time taken to handover patients arriving in ED by

ambulance

Mortality rates better than the expected level for the Trust’s casemix

Zero attributable MRSA cases over the last 12 months

What hasn’t gone well?

RTT data quality

RTT backlog not reduced, pressure points in ENT, T&O, Gynae etc.

Issues with 2-week urgent cancer appointments not being brought forward to 7-10

days, especially in dermatology and gynaecology which are the two most challenged

specialties

Issues with tracking of cancer patients on 62-day pathways

Quality issues including estates issues resulting in theatre downtime, removal of

training posts by HEE, staffing issues in CAHS

ED attendances over plan.

Part of explanation for recent ED performance improvement due to increase in

avoidable short stay admissions

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What has the CCG’s response been with respect to our commissioning responsibilities?

Board to Board meetings held with the Trust on concerns about Community Adult

Health Services, resulting in action being taken to address most of them

Joint leadership of the Flow Programme

Enhanced CCG Chief Officer oversight through weekly SRG sub-groups on planned

and emergency care respectively

Wandsworth CCG created senior role of Chief of Commissioning Operations to have

greater capacity for coordination of management of the contract and liaison with

regulators to ensure interventions were aligned

Wandsworth and Merton CCGs funded additional performance support from South

East CSU significantly over and above the normal input, enabling an experienced,

Director-level post to input to transformation and system-wide performance

improvement interventions, and in practice to provide support with operational

redesign with the Trust

Series of clinical summits at which provider and commissioner clinicians reviewed

pathways to streamline them to improve RTT access, which has fed through to the

workplan of the new Planned Care Programme Board

Review and redesign of ENT hub and spoke arrangements across SWL, being led by

Wandsworth

Use of contractual levers including contractual performance notices / query notices /

activity query notices which at times resulted in contractual penalties being levied,

with the intention of re-investing resources in performance improvements or

additional capacity either at the Trust or alternative providers

Significant work with regulators, in particular NHS Improvement, on enhanced

governance and agreed plans for improvement at the Trust

SRG re-constituted as a sub-regional Emergency Care Delivery Board

Parallel introduction of a sub-regional Planned Care Programme Board

Appendix 2 details the Chief Officer led work under the governance of the SRG across the

urgent care, cancer and RTT programmes.

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What is the plan going forward, with respect to governance, the approach to contract

management and in terms of commissioning intentions?

The commissioning intentions for South West London are to implement the five year

Sustainability and Transformation Plan (STP) across CCGs and providers in South

West London. One of the possibilities under consideration is a review of specialised

services, which could involve a change in the role of St. George’s (alongside other

tertiary providers in South London) in establishing new networks in South London and

the South East.

Following the publication of the CQC Inspection Report an action plan will be agreed

with the trust to address all deficiencies identified progress against which will be

managed by the Quality Oversight Group.

The work of both the Emergency Care and Elective Care Delivery Programmes to

transform care to accommodate new models of care with enhanced out-of-hospital

capacity and capability and to redesign pathways to improve the patient’s experience

and to enhance productivity.

Leading the 2017-19 contracting round to an accelerated timescale and with new

business rules.

The intention is to introduce a new governance structure around St. George’s, in

partnership with NHSI.

C O N C L U S I O N

The report has described the extensive challenges the CCG faces in working with St.

George’s to address the financial, quality and performance concerns. Some positive

changes have been put into effect which have shown that rapid progress can be made,

e.g. with the triage model and clinical leadership arrangements in ED. It is likely that a

comprehensive turnaround and recovery in many areas will require a much longer

timescale, e.g. to address structural financial issues, to change some of the cultural and

leadership issues and also to tackle the significant estates and IT infrastructure issues.

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We would welcome the board’s input regarding the intentions for the future relationship with St. George’s. It is recommended that the Acting Chief Executive be invited to attend a meeting of the Integrated Governance Committee to discuss these issues.

The Board is asked to consider whether any further action should be taken, beyond what is described in this report.

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Appendix 1

List of Acronyms

ED Emergency Department

ENT Ear, Nose and Throat

CAHS Community Adult Health Services (provided by St. George’s for Wandsworth)

CQC Care Quality Commission

CQRG Clinical Quality Review Group

CSU Commissioning Support Unit

ECIP Emergency Care Improvement Programme

HEE Health Education England

KPIs Key Performance Indicators

LoS Length of Stay

MDT Multi-Disciplinary Team

NHSE NHS England

NHSI NHS Improvement

PAS Patient Administration System

PTL Patient Tracking List

RTT Referral to Treatment (waiting times)

SGH St. George’s University Hospitals NHS Foundation Trust

STF Sustainability and Transformation Fund

STP Sustainability and Transformation Plan

SRG System Resilience Group

SWL South West London

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Appendix 2Wandsworth and Merton SRG support to SGH for the delivery of the national emergency care

standard

Establishment of Wandsworth and Merton Emergency Care Delivery board which

has oversight of delivery of the five nationally mandated improvement initiatives

and has been expanded to include the reduction of LAS turnaround times,

improvements to urgent and emergency care pathways for mental health patients

and winter planning.

Establishment of fortnightly Commissioner (WCCG, MCCG and Specialised

Commissioners) review of Trust performance against 4 hour emergency care

operational standard. (The SRG Planned Care subgroup, chaired by AO WCCG).

Commissioned McKinsey to undertake their emergency care system diagnostic

‘One version of the truth’ (OVoT).

Commissioned McKinsey to support the establishment of the whole system FLOW

Programme to implement the recommendations of OVoT. The FLOW programme

is jointly chaired by the Trust and Commissioners (Dr Andrew Rhodes and Dr Tom

Coffey).

Provision of subject matter expertise to aid the Trust to develop its plan to recover

delivery of the emergency care standard for regional area tripartite sign off.

Funding for an interim emergency care improvement lead post through the

reinvestment of fines.

Worked closely with the national emergency care IST - ECIP – to identify priority

areas for support; LAS turnaround times, leadership and operational management

of the emergency department and implementation of the SAFER bundle.

Support and leadership for the ‘Making a Difference Event (MADE)‘ and the

establishment of Platinum Command to focus on the patients whose discharge is

complex.

Focus on repatriation of patients to referring Trusts; daily oversight and

intervention/escalation where patients are waiting in excess of 5 days.

Task and Finish group focussing on the establishment and effectiveness of the

Acute Psychiatric Liaison (APL) team.

Support for the Trust to better prepare for the weekend, taking account of a

reduction in patients being discharged from hospital and the need to strengthen on

call arrangements.

Focus on waiting times for a psychiatric in-patient bed and the establishment of

improved communication and an enhanced escalation process.

Oversight and delivery of SGH plan to reduce LAS turnaround times.

Assurance of surge plans: winter, holiday periods and junior doctor’s industrial

action.

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Wandsworth and Merton SRG support to SGH for the delivery of the national Cancer Waiting Time

standards

Establishment of fortnightly Commissioner (WCCG, MCCG and Specialised

Commissioners) review of Trust performance against the 2ww and 62 day standards

(The SRG Planned Care subgroup, chaired by AO MCCG).

Provision of subject matter expertise to aid the Trust to develop its plan to recover

delivery of the 2ww and 62day standards for local area tripartite sign off.

Assisted development of KPI dashboard.

Funding for an interim cancer improvement lead post and analytical support through

the reinvestment of fines.

Supported SGH to introduce a weekly performance meeting to provide oversight of the

delivery of the cancer recovery plan.

Supported SGH to introduce weekly review of the cancer PTL for all tumour groups.

Supported by the national cancer IST refresh and sign off of the Cancer Access Policy.

Commissioned training for MDT staff from London Cancer Action Team (LCAT).

Provided advice and guidance on national reporting requirements.

Working with NHSE identified the absence of a 31 day PTL. Provided direction on the

approach to restructure the PTL and undertook assurance visit to ensure requirements

had been met.

Following continuing failure to meet the 2ww standard, led a review of the 2ww

recovery plan identifying and subsequently monitoring corrective actions.

Sue Maughn (LCAT) team commissioned to advise on the application of the ‘choice’

rules and actions to be taken to reduce the number of patients choosing to breach the

2ww standard.

Resent checklist to GPs with reminder of the need to advise patients on a cancer

pathway and to be available for an outpatient appointment within two weeks of referral.

Audit of Head and Neck and Lung tumour group pathways against the LCA timed

pathways.

The redesign of the Head and Neck pathway with referring Trusts in SWL is underway.

Establishment of a Clinical Harm Review process, chaired by Deputy Medical Director

NHSE and including review of all patients waiting in excess of 104 days for diagnosis

and treatment.

Reinforcement of the need for weekly telephone calls with referring Trusts to improve

tracking of patients transferred between trusts.

Established CQUIN for the recruitment of Cancer Nurse Specialists for the lung and

gynaecology tumour pathways to improve tracking /reduce waiting times and improve

patient experience.

On-going Risks to delivery

Data quality – MBI review complete and waiting receipt of report.

Need for greater oversight by SGH Executive Team and Board on the delivery of the

recovery plan.

Over-reliance on key individuals including the interim Service Improvement Lead.

Median waits for 2ww appointment too long at circa 12 days.

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Reduced ability to track patients – insufficient CNS, MDT coordinators and 2ww office

staff.

Wandsworth and Merton SRG support to SGH for the delivery of the national Referral to Treatment (RTT)

Waiting Time standards

Establishment of fortnightly commissioner (WCCG, MCCG and Specialised

Commissioners) review of Trust performance against 18-week referral to treatment

standards (The SRG Planned Care subgroup).

Funding for an interim 18-week interim improvement lead post through the

reinvestment of fines.

Mobilisation of the national RTT IST to undertake a review of the Trusts’ RTT

processes and data quality including a technical review of the PTL structure and PTL

exclusion criteria.

Encouraged the procurement of an additional external review of data quality and

supported the Trust through the procurement process, including the development of

the specification and the appointment of the preferred supplier (MBI).

Refresh of the Trusts Access Policy.

Supported SGH to introduce a weekly internal performance meeting to provide

oversight of the delivery of the 18 week RTT recovery plan.

Supported SGH to introduce weekly review of the 18 week RTT PTLs.

Developed and had oversight of the Trusts data validation plan to ensure the records of

all patients waiting > 6 weeks had been validated and corrected.

Review of all patients identified by the IST as inappropriately excluded from the PTL

(pre MBI review/report).

Review of demand and capacity analysis and plans to reduce the backlog of patients

waiting > 18 weeks and alignment with 2016/17 contracts.

Identified theatre estate as risk to delivery. Request for risk assessment and mitigation

remains outstanding.

Identified external provider’s capacity to support backlog reduction, including The

Portland Hospital and Kingston Hospital Foundation Trust (KHFT). Ensure contract in

place with The Portland to treat circa 200 children with ENT conditions in this fiscal

year.

Ensured that specialties, HRGs, patient volumes and timelines identified to transfer

patients to KHFT. Began process to establish contract variation in place. On hold

pending SGH COO confirmation of internal capacity and need for outsourcing.

GPs advised of long waits and data quality issues at SGH and asked to consider all

options available when referring patients for a first consultant led out patient’s

appointment.

Establishment of Wandsworth and Merton Planned Care Delivery board which has

oversight of actions to mitigate demand to SGH, including implementation of the ECI

policy and CQUIN enabled pathway redesign for MSK, gynaecology and urology

pathways.

Establishment of a Clinical Harm Review process, chaired by Deputy Medical Director

NHSE.

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For ReferenceEdit as appropriate:

The following were considered when preparing this report:

The long-term implications [Yes]

The risks [Yes]

Impact on our reputation [Yes]

Impact on our patients [Yes]

Impact on our providers [Yes]

Impact on our finances [Yes]

Equality impact assessment [Not applicable]

Patient and public involvement [No]

Please explain your answers:

This paper relates to the following corporate objectives:

Commission high quality services which improve outcomes and reduce

inequalities [Yes]

Make the best use of resources, continually improve performance and deliver

statutory responsibilities [Yes]

Continually improve delivery by listening to and collaborating with our patients,

members, stakeholders and communities [Yes]

Transform models of care to improve access, ensuring that the right model of care

is delivered in the right setting [Yes]

Develop the CCG as a continuously improving and effective commissioning

organisation [Yes]


Executive Summaries should not exceed 1 page. [My paper does not comply]

Papers should not ordinarily exceed 10 pages including appendices.

[My paper does not comply]

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Multispecialty Community Provider (MCP) Contract AwardAuthor: Katie Denton Sponsor: Andrew McMylor Date: October 2016

Executive SummaryContextIn June 2015 the CCG Board approved development of a Multispecialty Community Provider (MCP) in Wandsworth by April 2017.

Initially incorporating enhanced Primary Care and Community Adult Health Services (CAHS), alongside elements of Mental Health, Social Care and Voluntary Sector support (that are currently commissioned by the CCG as part of CAHS), the MCP will be the key mechanism through which Wandsworth CCG will realise its ambitions for transforming Out of Hospital Care and Primary Care across the Borough.

In April 2016, following an extensive period of development and modelling for the future service, the CCG Board agreed to undertake a competitive tender process for a Lead Provider of the MCP.

This paper describes the tender process which has been undertaken over the last four months and provides a recommended option for delivery of the Multispecialty Community Provider (MCP) in Wandsworth from April 2017.

Questions addressed in this report1. What was the outcome of each stage of the tender process and what is the

recommended outcome overall?2. What are the next steps?

Conclusion The CCG has conducted an open competitive tender process to identify a Lead

Provider to take responsibility for delivery of the MCP from April 2017. Following evaluation of the tenders, Battersea Healthcare Community Interest

Company (BHCIC) were identified as the most capable, and therefore the preferred provider to deliver this contract.

Prior to contract signature some further assurances are required from BHCIC. A summary of these assurances are set out in Section 4.

Input SoughtThe CCG Board is asked to approve award of the “MCP” contract to BHCIC for a period of seven years (with option to extend for a further three) from April 2017, subject to the assurances set out in Section 4 of this paper.

Input ReceivedThe Board approved the tender process for the MCP in April 2016. The MCP model was developed in conjunction with local providers and key stakeholders, including patients and the public.


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The Report1. Background

The MCP will be the key mechanism through which Wandsworth Clinical Commissioning Group (WCCG) will realise its ambitions for transforming Primary Care and Out of Hospital Care across the Borough, and will specifically form the contractual vehicle through which the CCG will deliver on the 17 specifications set out in the London Strategic Commissioning Framework for Primary Care.

Over the last 18 months, extensive engagement and development work has been undertaken to develop the future MCP service model, which aligns with the following agreed key principles:

There should be a single integrated model of out-of-hospital care

The model should promote collaboration, sharing of resources and multi-

disciplinary team working, with integrated IT systems to support communication

Patients should have a single care plan, centrally updated and accessible to all

relevant professionals

Patients are able to see the right healthcare professional at the right time

according to their needs and know how and where to access care locally when

required

The model should seek to empower patients and health care professionals alike

There should be a culture of shared learning and best practice so that all patients

across the Borough can benefit from innovation

In April 2016, the CCG Board approved the launch of a competitive procurement exercise which would identify a Lead Provider capable of delivering the MCP specification for a seven year period starting in April 2017 (with an option to extend for up to a further three years).

2. Procurement Process

The tender process was designed with input from Capsticks Solicitors and NHS SBS Procurement Advisory team to meet the CCGs requirements in line with the Procurement, Patient Choice and Competition (No.2) Regulations 2013 and the Public Contracts Regulations 2006/2015 and to align with the CCGs obligations to ensure it awards any contracts in a;

Fair and open manner,

Non Discriminatory manner,

Transparent manner,

Manner which treats all potential providers equally,

Proportionate manner.

In addition, extensive consideration was given to mitigating the risks outlined in the NHS England Report on the Uniting Care collapse. These mitigations were described in an options paper presented to the CCG Board in April 2016. A further paper describing the CCGs approach to implementing the recommendations from the report in relation to the MCP procurement, was approved by the CCGs Contract and Procurement Management Group (CPMG) in September 2016.

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In undertaking the procurement process, an expert evaluation panel was employed to assess submissions from potential suppliers. The panel included the following individuals:

Andrew McMylor: Director of Primary Care Development

Katie Denton: Deputy Director of Primary Care Development

Rebecca Wellburn: Director of Commissioning and Planning

Eileen Bryant: Deputy Director for Quality and Lead Nurse

Kimball Bailey: Associate Lay Member

Dr Andy Neil: Secondary Care Representative

Carol Varlaam: Lay Member for Patient and Public Involvement

Peter Ifold: Finance Expertise

Majid Saber: I.T Expertise

Claire Edgeworth I.G Expertise

Two non-scoring ‘advisors’ to the panel were also appointed to provide external expertise:

Rob Persey / Sandra Storey: Representing Wandsworth Local Authority

Jamie Gillespie: Representing Healthwatch Wandsworth

The following table summarises the three stages of the tender process along with the outcome at each stage.

Stage in Process Date Outcome

Stage 1 – Documentation published on OJEU and EU Supply

27th June N/A

Bidders Day 5th July Slides and FAQs from event

published on OJEU and EU Supply

Stage 1 – Deadline for Expressions of Interest and Pre-Qualification Questionnaire

15th July Three bids received from potential

providers

Stage 1 – Panel review of responses

21st July All three bids scored above the

minimum criteria for progression to Stage 2 (ITT Phase)

Stage 2 – Clarification of provider queries and ITT documentation issued

1st August ITT Questionnaire issued to all three

bidders

Stage 2 – Deadline for ITT Questionnaire

1st September

One ITT Questionnaire response received.

Notification from two bidders of withdrawal from the process.

Stage 2 – Panel review of responses

20th September

Remaining bidder scored above 2 (acceptable) for each of the ITT questions, therefore meeting the criteria for progression to Stage 3.

Panel agreed to progress remaining bidder to Stage 3.

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Stage 3 – Issue of Stage 3 documentation

23rd September Presentation topic and set questions

issued to remaining bidder.

Stage 3 – Final provider interview and presentation with Evaluation Panel.

5th October

Remaining bidder scored above 2 (acceptable) for each of the ITT questions, therefore meeting the minimum criteria for contract award.

Panel agreed to recommend award of the MCP contract to remaining bidder (Battersea Healthcare Community Interest Company (BHCIC)), pending further assurance across a number of key areas (see Section 4)

3. Preferred Bidder – Battersea Healthcare Community Interest Company

Battersea Healthcare Community Interest Company (BHCIC) is a non-profit making organisation comprising membership of 39 of the 42 practices in Wandsworth.

They currently hold contracts with WCCG for the delivery of ‘Planning all Care Together’ (PACT), ‘Improvement of Quality across Local General Practices’, Diagnostics, Community Dermatology and MSK Triage services. Most recently they have been awarded a contract for delivery of the Enhanced Care Pathway, which provides an integrated package of support for 500 of the most vulnerable patients in Wandsworth. In addition, BHCIC has obtained a grant from Health Education South London to become a Community Education Provider Network (CEPN), responsible for workforce development across Primary Care in Wandsworth.

During the procurement, BHCIC scored above the ‘acceptable’ threshold for contract award in each stage and were identified as the most capable, and therefore the preferred provider to deliver the MCP contract.

Throughout the process, BHCIC clearly demonstrated their previous experience of working with Primary Care; their understanding of the risks and challenges associated with this contract; and also their ability to draw on their existing systems and structures for delivery.

4. Assurance and Due Diligence

Overall, the panel were satisfied that BHCIC has the capability to deliver the MCP contract however during Stages 2 and 3 of the process, they identified a number of areas where further assurances are required of BHCIC prior to contract signature, these are summarised as follows:

Assurance on the BHCICs financial governance structures

Provision of a revised mobilisation plan, reflecting key milestones and acceleration of the launch of the CAHS procurement in line with CCG recommendations

Provision of a clear plan for delivery of the Learning Disability Primary Care Case Management service within the budget available

Agreement on the model of support required by BHCIC in relation to procurement expertise and how they will work collaboratively with the CCG to develop this

Further understanding of BHCICs approach to managing Information Governance, specifically, the role of the Caldicott Guardian and the management of information from non-NHS organisations.

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In order to gain the required assurance in these areas, the CCG anticipates conducting a series of assurance meetings with BHCIC and relevant experts from the CCG team over the next two weeks, following approval of the contract award. These meetings will take place in parallel to a number of other formal due diligence checks which are carried out as standard during any contract negotiation process.

5. Mobilisation

The contract start date will be 1st April 2017, however the mobilisation process for the service is expected to start as soon as contracts have been signed. Being able to commence the mobilisation process rapidly over the next month will be crucial in enabling the Provider to deliver on a number of KPIs in the first year of the contract.

Formal agreement between the CCG and BHCIC on a mobilisation plan which is robust and takes into account the CCGs learning from previous mobilisation processes will form part of the assurance process described in Section 4. The agreed mobilisation plan will be included in the contract documentation so that the Provider can be held to account prior to the contract start date.

The service specification for the MCP will be reviewed by Wandsworth CCG on at least a six monthly basis to inform on-going commissioning decision making,

5. Finance

The financial envelope for delivering the MCP is fixed and ultimately covers delivery of a range of existing clinical services.

The annual recurrent budget available to the Lead Provider for delivery of these services is £20,564,000 (assuming 100% delivery against KPIs). It is stipulated that 100% of this funding must be utilised for clinical service delivery at agreed tariffs, and employment of clinical staff as detailed in the MCP Service Specification.

It should be noted that services will be included in the MCP through a phased approach and therefore the full budget will not be available to the Lead Provider until such time that a particular service is introduced to the model.

An additional budget envelope of up to £400,000 is available to the Lead Provider for management costs in each year of the contract. As part of the procurement process, potential providers were required to submit a detailed breakdown of how they propose to utilise the budget envelope for management

It has been stipulated in the MCP contract that if the financial envelope for the MCP is exceeded, the CCG will not be held liable for any additional costs. The CCG has also reserved the right to be refunded on any underspend or savings delivered, although it is anticipated that in the event of this, negotiations may take place as to how the provider may utilise underspend in an alternative way to deliver the services.

6. Governance

A formal governance structure for the MCP is currently under development, however it is anticipated that this will need to take two forms:

1.Mobilisation oversight (prior to contract start date)

A steering group will be set up to oversee the mobilisation of the MCP. The group will meet on a monthly basis and will include representatives from the CCG and BHCIC plus other key stakeholders.

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It is expected that a number of task and finish style groups may also be required, these will meet on a more regular basis to ensure rapid delivery against key milestones within the mobilisation plan.

2.Ongoing monitoring and development (post contract start date)

Following the contract start date, it is anticipated that formal contract meetings will be held on a monthly basis and a clinical quality review group will be set up to maintain oversight of the quality of service delivery.

Furthermore, it is proposed that an integrated governance structure should be developed involving both the CCG and BHCIC. This could take the form of a joint programme board, which would act as a key operational forum for delivery and development of the MCP. Membership of this programme board would include key stakeholders and potentially material subcontractors to the MCP.

Both the Provider and WCCG will provide a named contact who will act as primary contact for the contract.

7. Evaluation

Key Performance Indicators (KPIs) for the MCP have been drafted and were shared with bidders as part of the procurement process. These will be finalised and agreed in dialogue with the provider prior to contract signature.

The Provider will provide reports on a monthly basis which will indicate on-going progress of delivery against the agreed KPIs.

There will be provision within the contract for WCCG to review all elements of the framework and service specification if required and request changes to the service. This will allow for improvements to the services based on feedback from patients and GPs, amendments to local and national guidance and changes to WCCG strategies and priorities.

8. Next Steps

Subject to approval of the recommendation in this paper, a 10 day standstill period will commence prior to contract negotiation/signature.

Assuming that no challenges are raised during this standstill period, the CCG will look to move rapidly to contract signature so that the mobilisation process can commence, as described in Section 5. This will be subject to provision of satisfactory assurance on the areas set out in Section 4.

The CCG is also aware that NHS England, NHS Improvement and the Care Quality Commission are in the process of developing an MCP assurance process which is expected to be finalised in October 2016. It is understood that this will take the form of a single process to test both the case for change in relation to the proposed care model and the capability of the successful MCP bidder to hold the contract. This process will also include an assessment of how conflicts of interest will be managed and these arrangements will be reviewed as part of the assessment.

Whilst it is anticipated that this assurance process will not be enforced until after the MCP contract in Wandsworth has been awarded, significant consideration has been given to these areas during the development of the service model, the procurement process and the contractual documentation and as such, the CCG is confident that it will be able to fully meet the requirements of the framework retrospectively if needed.

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9. Recommendation

In light of the robust tender process carried out, the CCG Board are asked to approve the award of the MCP Lead Provider contract to Battersea Healthcare Community Interest Company (BHCIC) for seven years from 1st April 2017 (with option to extend for a further three years), subject to the assurances set out in Section 4 of this paper.

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For Reference

1. The following were considered when preparing this report:


The risks [Yes]





Equality impact assessment [Yes]

Patient and public involvement [Yes]

The MCP is the key mechanism through which the CCG will deliver on its long term strategy for transforming out of hospital care across the Borough. Patients, the public, providers and other key stakeholders have been engaged and involved via a number of mechanisms throughout the development of the MCP model. An EIA has also been undertaken as part of the development process for this paper.

2. This paper relates to the following corporate objectives:

Commission high quality services which improve outcomes and reduce inequalities [Yes]

Make the best use of resources, continually improve performance and deliver statutory responsibilities [Yes]

Continually improve delivery by listening to and collaborating with our patients, members, stakeholders and communities [Yes]

Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting [Yes]

Develop the CCG as a continuously improving and effective commissioning organisation [Yes]

A primary aim of the MCP will be to transform models of care to improve access, ensuring that the right model of care is delivered in the right setting. As such the MCP will support us in delivering on a number of our statutory responsibilities including making the best use of resources and improving outcomes for patients. An engagement programme for the MCP is ongoing via a number of mechanisms and user feedback on existing services has been used extensively to inform development.

3. Executive Summaries should not exceed 1 page. [My paper does comply]

4. Papers should not ordinarily exceed 10 pages including appendices.

[My paper does comply]

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Procurement Outcomes Report for Integrated Wandsworth Talking Therapies Services

Author: Lola Triumph, Interim Head of Strategic Projects Sponsor Lucie Waters, Chief of Commissioning

Operations Clinical Lead: Dr Tom Coffey, Clinical Lead Date: [12/10/16]

Executive Summary

Context

High quality talking therapies (known previously as Improving Access to Psychological Therapies - IAPT) are a key component of the comprehensive mental health service offer in Wandsworth, acting as the first line of referral for many people facing challenging times in their lives. Achieving the targets is also one of the assessment criteria for Wandsworth CCG assurance.

On 8th July 2015, Wandsworth Clinical Commissioning Group Board authorised the procurement of Talking Therapies Services. An intensive period of development saw service users, carers, community groups and clinicians involved in the finalisation of a new talking therapies specification that integrated traditional face to face (individual and group) services with new digital options. The specification placed a new focus on reaching more people with the talking therapies service, with emphasis placed on those groups who have traditionally been harder to reach including:

New mothers (perinatal care)

Black, Asian & Minority Ethnic communities (BAME)

Isolated single men

Carers

Those seeking employment

Long term conditions (diabetes, cardiovascular disease, Chronic Obstructive Pulmonary Disease - COPD, sickle cell and stable psychosis

Lesbian, Gay, Bisexual and Transgender communities (LGBT)

Dual Diagnosis (substance misuse)

English as a second language

Older people

People with learning disability and/or sensory impairment

Adults who may have experienced domestic abuse.

The specification also requires the future provider to meet all the key access and recovery targets outlined in national guidance.

This report outlines the final stage of the procurement process for the Integrated Wandsworth Talking Therapies Service and makes the recommendation of the Procurement Evaluation Panel that Bidder 2 be confirmed as the Recommended Bidder, subject to delivery of pre conditions to contract signature.


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The recommendation was supported by Wandsworth CCG Management Team on the 5th October 2016.

Questions addressed in this report

1. Who was involved in the tender evaluation? 2. What was the bid evaluation process?3. What are the financial implications?4. What do we need to do next to progress?

Conclusion

1. The Tender Evaluation Panel was chaired by the Lucie Waters, CCG Chief of Commissioning Operations and included Dr Tom Coffey, GP and Clinical Lead for mental health and key stakeholders such as Wandsworth Borough Council Public Health, service users, carers, community providers and CCG commissioners.

2. The tender advertisement generated 19 expressions of interest from a wide range of potential bidders. Submitted bids were evaluated against seven evaluation criteria which are described in detail in point 2.2.1.

3. The submitted bid price was within the financial threshold set by the CCG.

4. A ten day ‘standstill period’ and implementation of the pre-conditions to contract signature will commence following approval by Wandsworth CCG Board.

Input Sought

Wandsworth CCG Board is asked to approve Bidder 2, as the Recommended Bidder subject to delivery of the pre-conditions to contract signature.

Input Received

Service users and stakeholder engagement from October 2015 to September 2016.

Market Engagement in April 2016

Management Team in May 2016 and October 2016

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The ReportPurpose

This report has been compiled on behalf of the Procurement Evaluation Panel for the provision of Talking Therapy Services. The report has been compiled following the completion of the evaluation of bids received in response to the advert placed through the Official Journal of the European Union (OJEU) and Contracts Finder published on Friday 5th August 2016.

The purpose of this report is to present a recommendation for consideration and approval of the NHS Wandsworth Clinical Commissioning Group (CCG) Board. The recommendation is based on the results of the evaluation carried out by the representatives appointed by the CCG to form the Procurement Evaluation Panel to evaluate bids received in response to the Invitation to Tender.

1. Who was involved in the tender evaluation?

1.1. Procurement Evaluation Panel

The members of the Procurement Evaluation Panel having been involved throughout this

procurement are included in the table below.

IndividualDesignation/ Organisation

Response to Confidentiality

Letter received?

Response to Conflict of

Interest statement received?

Any potential conflicts

declared?

Lucie Waters

Chief of Commissioning Operations, Wandsworth CCG

No

Dr. Tom Coffey

Wandsworth GP, Clinical Lead for Mental Health Services

No

Peter IfoldInterim Deputy Finance Officer, Wandsworth CCG

No

Agnieszka Lizska

Management

Accountant - NHS

Wandsworth CCG

No

Antonia Lancaster

Service User Representative

No

Carlis DouglasWandsworth BME Forum

No

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Representative

Christine LewisFamily and Carer representative

No

Graeme Markwell

Public Health Mental Health and Learning Disability Lead, Wandsworth Borough Council

No

Iain RickardPerformance Manager, Wandsworth CCG

No

John Morrill

Service User Involvement Co-ordinator, Voicing Views

No

Lola TriumphInterim Head of Strategic Projects, Wandsworth CCG

No

Mark Robertson

Head of Mental Health Commissioning, Wandsworth CCG

No

Martin HaddonHealthwatch Wandsworth

No

Shenade Windebank

Carer and Development Manager, Wandsworth Carers’ Centre

No

Panel members were each required to complete a Statement of Confidentiality and make a

declaration in regard to potential Conflicts of Interest. No Conflicts of Interest were

identified as raising any concern in regard to this procurement.

NHS Shared Business Services (NHS SBS) provided the external procurement support

and advice to the final evaluation stages.

2. What was the final stage of the procurement process?

2.1. Bid Evaluation Process

2.1.1. The procurement process was managed by NHS Shared Business Services on behalf of the CCG using the NHS SBS EU-Supply electronic procurement system to administrate all communications with bidders and receipt of completed tenders

2.1.2. Following the completion of a market engagement exercise, in response to the likely level of interest in the opportunity, a bespoke single stage procurement process comprising of a written Bid Responses followed by Bidder interviews was designed in

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compliance with procurement regulations and advertised through the Official Journal of the European Union (OJEU) and Contracts Finder.

2.1.3. The procurement timetable followed is as set out below:

Market Engagement phase March - April 2016

Issue advert and Invitation to Tender (ITT) documentation

5th August 2016

Deadline for the receipt of clarification questions from bidders

9th September 2016

ITT submission deadline 15th September 2016

ITT bid evaluation stage 15th – 28th September 2016

Bidder Interviews/Presentations 28th September 2016

2.1.4. The advertisement generated 19 expressions of interest from a range of potential bidders.

2.1.5. During the Invitation to Tender (ITT) stage all potential bidders that expressed an interest were able to request clarifications on the ITT documentation.

2.1.6. Tender receipt, opening and preliminary compliance checks were carried out by NHS SBS on 15th September 2016.

2.1.7. As part of their submission, Bidders were required to submit a completed qualification questionnaire (QQ). All QQ submissions were evaluated to be compliant, meeting the minimum acceptable threshold.

2.1.8. Bid Responses were evaluated in accordance with the evaluation process developed specifically for this procurement and published to bidders within the ITT Documentation designed to select the most economically advantageous tender, i.e. that which offers the optimum combination of service capability, quality and bid price, within affordability parameters. As mandated by regulatory requirements, the evaluation also considered whether the bid prices appeared to be abnormally low.

2.1.9. Tender clarification queries were directed back to the bidders where appropriate.

2.1.10. The evaluation was undertaken between 15th and 28th September, involving scoring by individual evaluation panel members, subsequently moderated to agree a consensus score for each element of each bid on behalf of the CCG.

2.1.11. Compliance with the Contracting Authority’s published maximum and minimum affordability thresholds was checked for each overall bid price submitted. The affordability thresholds having been set in light of market forces and the intentions of the CCG to deliver best value. The scoring methodology published to potential

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bidders encouraged the submission of competitive prices. All bidders met the affordability threshold as set out in the ITT.

2.1.12. None of the bids were considered to be abnormally low, having been in excess of the CCG’s published minimum affordability threshold.

2.1.13. Bidder interviews were held on 28th September 2016.

2.1.14. Moderation of qualitative evaluation scoring took place on 23rd and 28th September, resulting in agreed consensus scores for each Service Delivery and Quality question for each of the bids.

2.2. Bid Evaluation Results

2.2.1. The marks available in the evaluation process were as follows:

Service model 20

Community Engagement 10

Marketing and service location 10

Data Monitoring and Performance 5

Service Mobilisation 20

Overall cost of proposal (Finance) 20

Bidder Interviews 15

Total 100

2.2.2. Bids were evaluated by 14 evaluators.

2.2.3. The overall, high-level results of evaluation, including the moderated scores for Service Delivery and Quality, are:

Bidder 1 Bidder 2 Bidder 3

Service model 10.00 15.00 10.00

Community Engagement 2.50 7.50 7.50

Marketing and service location 3.75 7.50 6.25

Data Monitoring and Performance 3.75 3.75 3.13

Service Mobilisation 10.00 15.00 10

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Overall cost of proposal (Finance) 8.54 11.42 10.76

Bidder Interviews N/A 11.25 11.25

Total 38.54 71.42 58.89

2.2.4. Bidder 1, demonstrated an acceptable level of capability through their proposed service model, their approach to data monitoring and performance and their strategy for mobilising the service. However, their responses in relation to community engagement, marketing and service location did not provide the evaluation panel with confidence in their approach. Bidder 1 failed to achieve the minimum acceptable level of quality (50%) in relation to the non-financial element of their written submission. This being the case, Bidder 1 was informed following the evaluation of written Bids, that their bid had been unsuccessful and they were not invited to the Bidder interview stage.

2.2.5. Bidder 2, demonstrated a service proposal that was consistently considered comprehensive by the evaluation panel, offering a high level of confidence in their ability to deliver. They scored comprehensive against all questions in all non-financial areas of the evaluation, setting out a new service capable of delivering against increasing activity levels.

2.2.6. Bidder 3, demonstrated a comprehensive approach to community engagement, the marketing of the service, data monitoring and delivered a high standard through their performance at the Bidder interview. However, their overall service proposal and service mobilisation strategy, whilst acceptable, lacked local context and supportive evidence.

3. What are the financial implications?

3.1. The Bid Price submitted by Bidder 2 for the delivery of baseline activity across the full potential five year contract term was within maximum and minimum affordability thresholds that was set by the CCG. This represents an overall decrease in expenditure compared with the estimated current cost of £15,675,000. The actual expenditure will be dependent upon activity outturn.

3.2. There are no transition or exit costs expected to be associated with the award of this contract.

4. What do we need to do next to progress?

4.1. Recommendation

4.1.1. The recommendation of the Procurement Evaluation Panel is that Bidder 2, be confirmed as the Recommended Bidder and that engagement commences with

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them to progress toward contract signature, subject to any challenges during the allotted standstill period to enable service commencement by 1st April 2017

4.1.2. Subject to approval, the panel recommends that a standard award letter covering the standstill period be issued to the Recommended Bidder and an unsuccessful letter covering standstill period be issued to the unsuccessful bidder.

4.1.3. The invitation to be extended to the Recommended Bidder to enter into a contract with the CCG will be subject to the usual pre-contractual due diligence and the evidencing of associated assurances and in light of specific issues identified during the evaluation process, the following requirements will also be sought as pre-conditions to contract signature:

Evidence of robust crisis planning systems to manage crisis for individuals on the service caseload

Arrangements for providing talking therapies to individuals who are Hard of Hearing and/or with sensory impairment

Evidence that the service has established processes for suicide prevention

4.1.4. The unsuccessful bidders will be provided with detailed written feedback including comparative marks awarded to the Recommended Bidder. The Recommended Bidder will also be provided with detailed feedback to assist understanding and learning from the bid evaluation process.

4.2. Next Steps

4.2.1. The next steps in the procurement of the Wandsworth Talking Therapies Service are:

Approval by Wandsworth CCG Board (Part 1)

Period when Bids will be approved by the Contracting Authority

12th October 2016

Notification to Bidder regarding Contract Award decision

The expected dates when Bidders will be notified of the outcome of the evaluation and observance of the recommended Standstill Period

14th October 2016

Standstill Period (10 working days)

Period between Contract Award notification and Contract Signature.Acceptance of pre-condition

17th to 28th October 2016

Contract signatureThe expected date for the signing of the Contract between the Contracting Authority and the Recommended Bidder.

31th October 2016

Service mobilisation period

Period when the Recommended Bidder plans and delivers mobilisation activities to prepare for service commencement.

Establishment of Wandsworth CCG Mobilisation and Transition Project Board for the Talking Therapies

1 November 2016 through 31 March 2017

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Service

Service commencementDate when commencement of the new Services is expected

1st April 2017

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The risks [Yes]









inequalities [Yes ]


statutory responsibilities [Yes ]




is delivered in the right setting [Yes ]


organisation [Yes ]

6. Executive Summaries should not exceed 1 page. [My paper does not comply]



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Battersea Locality UpdateAuthor: Emma Gillgrass Sponsor: Andrew McMylor; Dr Nicky Williams; Dr Jonathan Chappell Date: October 2016

Executive Summary

Context

The Battersea Locality covers six wards within Wandsworth and the twelve practices located

there. This report provides an overview of the locality, its priorities and achievements as well

as ongoing projects and future plans to deliver on key targets and improve the care, quality

of services and health of the population.

Question(s) this paper addresses

1. How does the Locality engage with its key stakeholders?

2. What outcomes have been achieved through the Locality investment budget?

3. What are the future plans for Locality Investment?

4. How is the Locality working towards improving quality in primary care?

Conclusion

1. The Locality engages with its Members Practices, Patients and other stakeholders in a range of ways including meetings, newsletters and visits

2. Outcomes include: 8 Mindfulness courses with 190 attendees; 7 Parenting courses with 30 new mothers; 512 Children weighed and measured at their pre-school booster, 170 Patients referred to the Patient Welfare Advice Service

3. The Locality plans to review its current projects to ensure they are addressing the needs of the locality and delivering value for money. New projects will also be considered to address priority areas

4. Improving quality in primary care is through practice engagement with the Members Quality and Engagement Scheme, use of the Local Quality Tracker and participating in Practice Support Team visits

Input Sought

The Board is asked to accept and approve this report.


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The Report

F U R T H E R C O N T E X T

The Battersea Locality has twelve GP practices and covers the wards of Queenstown,

Shaftsbury, St Mary’s Park, Latchmere, Northcote, and parts of Balham. It has a growing

population with an April 2016 registered population of 95,750, approximately a quarter of

the Wandsworth population. The population is expected to increase by over 26,000

residents within the next fifteen years, mainly due to the Nine Elms Vauxhall major

redevelopment. Battersea has pockets of high deprivation, including the most deprived ward

in Wandsworth, as well as some of the least deprived areas. While sharing many of the

same health priorities as the rest of Wandsworth, public health analysis shows that

Battersea has its own specific issues.

The locality has two Joint Clinical Leads and a Management Lead who work closely to ensure the smooth running of the locality, provide support to practices and deliver on locality priority areas. Figure 1 below shows the structure of the Locality.

Member Practices (list size April 2016)

Balham Hill Medical Practice (1494) Battersea Fields Practice (10114) Battersea Rise Group Practice (7435)

Bolingbroke Medical Centre (5341) Bridge Lane Group Practice (14034) Clapham Junction Medical Practice (3231)

Falcon Road Medical Practice (9110) Lavender Hill Group Practice (12727) Queenstown Road Surgery (7999)

St Johns Hill (Begg) Practice (4360) The Junction Medical Centre (7355) Thurleigh Road Practice (12550)

Members Forum

Practice Commissioning Leads Public Health CCG Prescribing Advisor

Locality Management Lead Localtiy Patient RepsCommunity Pharmacist

Managment Team

Locality Clinical Leads Locality GPs x3 Locality Management Lead

Public Health CCG Prescribing Advisor Locality Patient Rep

Patient Consultative Group Practice Managers Forum Practice Nurse Forum

Figure 1

A N A L Y S I S

1) How does the Locality engage with its key stakeholders?

1.1) Member Practices

Members Forums: Monthly Members Forums are held, attended by representatives of each of the locality practices, Public Health, prescribing, the Locality Management Lead and representatives from the Locality Patient Group. The meeting is chaired by the independent Locality Patient Group Chair.

Practice Managers: The Practice Managers Forum gives practice mangers the opportunity to discuss issues specific to them and provide a support network for each other on a monthly basis.

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Practice Nurses: A new Lead Nurse for Battersea was appointed in 2015 and the regular Practice Nurse Forums have restarted, providing an opportunity for support, networking and learning.

Weekly Updates: A weekly email is sent to Practice Managers, GPs and nurses, providing information both locality specific and Wandsworth wide. This communication is well received by the practices.

Joint Localities Members Forum: Twice a year a Joint Localities Members Forum (JLMF) is held, to bring together the three localities and discuss CCG wide issues. In the last 12 months JLMFs were held in November 2015, focusing on delegated commissioning and the development of the Multispecialty Community Provider (MCP) model, and May 2016 focusing on Primary Care quality. These were attended by representatives from eleven and seven of the Battersea locality practices respectively.

1.2) Locality Patient Consultative GroupBattersea has an active Locality Patient Consultative Group, currently formed of members from nine practice patient groups. The group has engaged with a range of topics over the year, providing their feedback and input into strategy, plans and consultations, as well as being informed about various schemes that they were then able to take back and promote within their practices (figure 2).

Topics discussed with Battersea Patient Group

Transforming Primary Care

Delegated Commissioning

South West London Collaborative Commissioning Issues

Community Adult Health Services

Nine Elms Vauxhall update

Public Health locality overview

Friends and Family Test results

Quality in Primary Care

Improving Practice Patient Groups

PPI Annual Report

GP Patient Survey results

Locality projects

Figure 2

The Patient Group is also involved in discussions about Locality priorities and projects, and fed directly into the development of the pre and post course surveys for the Parenting and Mindfulness courses. They have been closely involved in the development of the Patient Advice and Welfare Service and also in the rebranding of the parenting course to the Mum and Baby club.

1.3) Seldom Heard and Community GroupsOver the last three years GPs have been encouraged to visit Seldom Heard and community groups, to create links and further understand the role of these groups and how they may be beneficial to their patients. A wide variety of groups have been visited by the locality GPs as shown below (figure 3):

2015-16 Groups visited

STORM; Wandsworth Food Bank; The Dragon Café at Morley CollegeFemale Genital Mutilation (FGM) Champions; Generate UKWandsworth Community Learning Disability Health TeamThe Poklington Trust; Katherine Low Settlement; Mercy Foundation Centre

Figure 3

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1.4) Clinical Reference Groups (CRGs)A number of locality GPs are engaging, on behalf of Battersea, with CRGs including, mental health, children’s services, cardiovascular disease, substance misuse and cancer.

1.5) Acute Providers A significant proportion of patients from the Battersea Locality are referred to Chelsea and Westminster NHS Foundation Trust for their healthcare. In order ensure the Locality and CCG views are represented at the Trust, Battersea GPs sit on the Clinical Quality Review Group and the Council of Governors. The Locality has also built close relationships with Guy’s and St Thomas NHS Foundation Trust. Both Trusts are discussed at Members Forums and representatives have attended these meetings to further improve relationships and patient experience.

1.6) Nine Elms and Vauxhall DevelopmentNine Elms Vauxhall (NEV) contains an existing deprived population, with Queenstown Ward in Battersea being one of the most deprived areas in Wandsworth. Meeting the new NEV population’s healthcare needs will require 19 new GPs across Wandsworth and Lambeth by 2030, including an increase in capacity for other health services by about 6% over the next 15 years. Two new health centres are planned to be built within Wandsworth, whilst three existing practices in Lambeth will be developed to increase capacity

Battersea Locality are liaising directly with the NEV Health Project team and attend the Project Group and Board meetings, ensuring a close engagement with local residents, Wandsworth Council, including Public Health and NHS England

2) What outcomes have been achieved through the Locality investment budget?

Each locality has an investment budget to focus on projects specific to the needs of the locality. The budget for Battersea is £72,000. The priority areas have been identified through reviewing public health data about the needs of the area, and potential projects are assessed against criteria which included need, equality, benefits and feasibility.

2.1) Mental Health: Mindfulness Course (2014-15, 2015-16, 2016-17)Battersea has high levels of mild mental health illness, including an incidence of depression higher than the Wandsworth average. Mindfulness and stress reduction courses have been shown to be beneficial to both psychological and physical well-being, reducing anxiety and low mood. The courses were initially started by Thurleigh Road practice for their patients and were then rolled out and made available to all the Battersea practices.In January 2016 – October 2016 8 courses have run with 190 attendees. Further courses are planned for the rest of the year (to March 2017). Pre and post course surveys are carried out to measure the impact of the courses.

Following the course 80% of participants reported that they were confident in their ability to deal with stress, compared to 41% prior to the course. Positive comments were also received from patients who had completed the course. (Figure 4)

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This course has much to offer for all types of people in all sorts of circumstances. I am pleased I was offered the course

I found this to be a wonderful opportunity to pick up some great skills

I cannot recommend this course highly enough - it is a really brilliant offer from the NHS to encourage and support us in taking responsibility for our own well-being

I would recommend this course to anyone

Figure 4

Patients are also asked to rate how often they experience a range of issues, both before they start the course and after completion (figure 5) The majority reported improvements by the end of the course.

Figure 5

2.2) Parenting Courses (2014-15, 2015-16, 2016-17)In 2014-15 the parenting course that had been developed by Thurleigh Road practice was rolled out to be available to all new parents in Battersea. The courses are being delivered from four community localities across Battersea: St John’s Therapy Centre, Thurleigh Road Practice, Katherine Low Settlement and STORM. Each course runs for five weeks and is aimed at new parents in the first year after birth.In January 2016 - October 2016 seven course have been run with 30 new mothers. Following discussion with the course providers, GPs and the Battersea Patient Group the parenting classes were re-branded as Mum and Baby Club. It was felt that this would sound more supportive and be more likely to attract new parents.

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The courses provide support and post-natal education to parents and promote parenting skills. The pre and post course questionnaires show an improvement in the health and wellbeing of participants, along with increased confidence in their own parenting skills.

Prior to the courses 20% of participants reported they ‘strongly agreed’ that they were confident in their approach to parenting, rising to 45% after the course, with a further 27% reporting they ‘slightly agreed’. Infant first aid was one of the most popular session with 96% of participants prior to the course reporting that they needed to learn. After the course 91% of participants reporting being confident in dealing with infant first aid. Overall 91% of participants agreed they would recommend the course to other new parents.

Figure 6

There has been positive feedback from the participants:

All courses were very useful and the trainers very qualified, motivated and very nice. I would recommend the course any time! Thank you for everything

It really was a fabulous set of workshops

Overall it is such a good idea and I felt the workshop forged a bridge between parents and medical help on offer

2.3) Childhood Immunisations: Birthday Card Pilot (2015-16)As part of the Members Development Programme for 2015-16 Battersea focused on improving child immunisation uptake through engaging with Public Health to pilot a “Celebrate and Protect” birthday card scheme, targeting three, four and five year olds, and reminding their parents/guardians about upcoming or outstanding immunisations.Public Health designed and had printed a series of birthday cards for practices to send to specified cohorts of patients, targeting those with birthdays in October 2015 – December 2015. Initial results are already demonstrating an increase in uptake for immunisations.

Nine practices took part in the pilot with 701 birthday cards sent out across the three months. The highest proportion of cards was sent to those children turning three, who would become

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eligible for their pre-school booster and second MMR immunisation. The cards sent to four and five years olds were for those children who had missed out on previous immunisations.

Comparing the 3 months of the project to the same three months in 2014-15 (figure 7), across five immunisations used as the standard for measuring practice uptake, there was an increase in four of the five immunisations measured. The biggest increase was in the uptake of the pre-school booster (DTaP/IPV/Hib) from 66.4 % in 2014-15 to 96.6% in 2015-16. This was followed by the increase in uptake of the second MMR immunisation (at the same age) from 80.3% to 84.8%.

Figure 7

2.4) Childhood Obesity (2015-16, 2016-17)Through the National Child Measurement Programme (NCMP) children are measured at school in Reception and Year 6. Battersea has the top two wards for levels of overweight and obese reception year pupils (Latchmere 28.3%; Queenstown 28.8%) and the top three wards at Year 6 (Latchmere 41.5%; Queenstown 41%; St Mary’s Park 41.1%) (Public Health Intelligence September 2015).

In order to identify and address issues at an earlier age, and gather further information about the levels of pre-school obesity in the locality, Battersea practices took part in a pilot (October 2015 - June 1026) to weigh and measure children when they attended the practice for their pre-school booster. Practice Nurses and Healthcare Assistants were trained on the technicalities of measuring Body Mass Index (BMI) in children and how to discuss the issue of child obesity in an effective, compassionate and motivating way. Practices are able to refer patients on to the Mini Boost service, an educational healthy lifestyle programme for children aged 2-5 and their parents. The data from this has now been collated. Initial evaluation shows that over 500 children were weighed and measured across seven Battersea Practices over the nine-month period. Based on the BMI Centiles of the children 79% registered as a health weight, 11% as

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overweight or obese and 10% as low weight/underweight. Further evaluation will be undertaken to inform future projects to target obesity in Battersea.

2.5) Patient Welfare Advice Service (2015-16, 2016-17)Battersea are piloting a Patient Welfare Advice Service that delivers non-medical advice and support to patients. This is delivered by Citizens Advice Wandsworth (CAW), Family Action and DASCAS, working closely together, ensuring an efficient and effective service for Battersea patients in need of social welfare support. Since its launch in January 2016 170 patients from nine Battersea Practices have been referred to the service. Of these, 12 have been referred on to Family Action and 28 to DASCAS. Citizens Advice WandsworthOf particular note is the fact that 74% of patients referred to the project have not previously used Citizens Advice Wandsworth services. The project is therefore reaching local residents in need, and the referral from a trusted GP is a proven way to removing barriers to accessing support.Housing has been the most common issue clients want advice on, (39%), followed by benefits (35%) (figure 8). This is different to clients acceding the core CAW services where benefits are usually the number one advice issue, followed by debt and then housing.

Figure 8

A survey of GPs who have referred patient to the service is currently being undertaken to help with evaluation of the project. Feedback received so far includes the following comments:

EA (a patient) has just spent a long time telling me how helpful the advisor has been. Another thank you!

We have really needed this type of service for our patients and am very glad to have access to it again.

The service saves my time explaining and writing letter

It has reduced my need to research options for patients or see them so frequently about social issues that I may not even be able to help with! So has reduced workload but not hospital admissions for me

It makes it much easier for patients to access the 3rd sector services they need

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Clients are also asked to complete an evaluation form to report on their experience of the services. 60% reported receiving the services had enhanced their quality of life, and 95% that the service fully or mostly met their needs. Levels of stress and worry also decreased after accessing the service.

Client comments I love the service; I hope they keep on doing it because there are so many people like me

who need help. Because of their help I can now look for a job and be a good mother to my children

It’s good to know that they are there. They all know what they are talking about

I am getting adaptations in the property and my benefits have increased

Family ActionFamily Action are specialists in mental health recovery. They use trained counsellors,

typically providing 6 sessions. They support patients through supportive listening and

assistance with practical tasks including dealing with benefits, housing and debt issues.

Twelve patients have been referred on to Family Action under this project. Seven cases have been managed and closed, five are still open. Referral reasons include anxiety and depression. Additional issues include money management, housing, emotional support, isolation, mental health support.

Patients have referred on to services including Wandsworth Young Carers, Wandsworth & Westminster Mind Active Wellbeing (1-1 personal training sessions), One Support Housing, as well as being signposted to a variety of other services.

DASCASDASCAS specifically provides information, advice and casework for people with disabilities,

to empower disabled people living in Wandsworth and their families and carers, to improve

the quality of their lives through access to benefits and services.

Twenty-eight patients have been referred to DASCAS under this project. Many of the clients

referred have had severe disabilities; two clients self-reported as having terminal illnesses;

seven required home visits and ten had mental-health issues alongside other health

conditions. Waiting time have been kept to a minimum and attendance rates are high (out

of 65 advisory events only six were cancellations or ‘no shows’). The majority of clients also

required several interventions to address their needs and have been empowered to support

their own claims in the future.

Issues address include Personal Independent Payments; Employment Support Allowance,

Disability Living Allowance, housing, aids and adaptations in the home.

3) What are the future plans for Locality Investment?

3.1) MindfulnessDiscussions are underway with the IAPT service as to how the Battersea Mindfulness courses could be incorporated with the courses offered by IAPT, whilst continuing to

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ensure ease of referral and convenient times and locations of the courses. This would provide patients with a wider range of times and venues for courses as well as ensuring equal provision across Wandsworth.

3.2) Parenting / Immunisations / Childhood ObesityThese three projects all target a similar population and so the Locality is looking at how these can be drawn together and further developed to improve health and wellbeing for parents and their children within Battersea.The content and promotion of the parenting courses is being reviewed to ensure it meets the needs of the population. Options for course content include focus on exercise and nutrition, immunisations, psychological wellbeing and physiotherapy. Promotion of the course is being discussed with Health Visitors and Practice Nurses and it is proposed to use stickers on the front of the Red books and flyers in new baby packs.The data gathered through the obesity project is being evaluated in conjunction with Public Health to identify the areas of Battersea with the most need and what interventions may be appropriate to implement.

3.3) Patient Welfare Advice ServiceThis service is running as a pilot until the end of January 2017. Evaluation has already started in order to make a decision as to whether this will be continued, and how it may be linked to other services to provide the best outcomes for patients.

3.4) Other Priority AreasOther priority areas that are being considered within Battersea, identified through review of Public Health and other data available, include COPD and smoking, mental health and sexual health.As part of its priority around sexual health Battersea will be reviewing cervical screening in the locality and how this can be improved, following data showing that Wandsworth is not meeting targets in this area.Also highlighted as an issue for Wandsworth is care for those with Learning disabilities. Battersea will be looking to see how the locality is performing and what can be done locally to support patients and practices.

4) How is the Locality working towards improving quality in primary care?

4.1) Members Development Programme 2015-16The Members Development Programme (MDP) allowed protected time for practices to focus on developing and improving quality. For 2015-16 all twelve practices in Battersea signed up to the MDP, focusing on areas such as governance, patient experience, safeguarding children and adults, staffing and improving back office processes. Practices submitted regular action logs of activities they had undertaken and the outcomes achieved.

4.2) Members Quality and Engagement Scheme 2016-17The Members Quality and Engagement Scheme is new for 2016-17 and builds on previous schemes undertaken by practices. The scheme includes continued engagement of practices as members of the CCG and commissioners. The main focus of the scheme is the development of Quality Coordinators within each practice, to support delivery of the CCG Quality agenda and engage with the Provider of the Quality Contract, to delivery specific outcomes as agreed. All twelve practices in Battersea have signed up to the scheme and

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are participating in the events and tasks required. The outcomes will be monitored through monthly returns from practices to provide evidence of working towards improved quality in Primary Care and continued engagement.

4.4) Local Quality Tracker and Practice Support TeamThe Local Quality Tracker was developed to provide an overview of quality in primary care, using a range of data sources including Quality and Outcome Framework (QoF) data, General Practice Outcomes Framework data and NHS England data.

The Practice Support Team (PST) is a multidisciplinary team who facilitate discussions within practices to identify areas of good practice and also areas where improvements could be made. The team then support the practice to identify and implement actions for improvement, and also share good practice identified with other practices.The Practice Support Team has so far visited eight Battersea practices and some of the areas identified within the visits, following a review of data provided, are shown in figure 9. Further visits are planned for the rest of the year to the remaining practices.

Good Practice Areas to Focus on

Identifying Cancer

Childhood ImmunisationsFlu VaccinationCytology uptake

Patient Experience; Satisfaction – AccessSignificant events and complaints

Constructive prescribing; Effective anti-inflammatory prescribing

Psychologist works in the practiceRecording smoking status; advice givenChild A&E attendances

Dementia Diagnosis RateDepression diagnosis rateDiagnosis of COPD and Asthma

Flu vaccinationsImmunisations; MMR uptake

Patient Experience

Recording of smoking status; advice givenSMI Physical Health Checks uptakeCervical screening uptake

Figure 9

At the Practice Support Team visits the practice data and areas of good practice and areas to focus on were discussed with the practice to identify learning that could be shared and actions that could be taken forward to improve on particular areas. The visits, along with follow up and review of actions identified is coordinated by the Federation.

C O N C L U S I O N

Battersea will continue to engage with member practices, patients and the public and other relevant stakeholders. On-going development and delivery of priority areas and investment schemes outlined above will take place and the locality will work closely with all stakeholders to build on and develop the work undertaken so far.

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The risks [Yes]







All of the above areas are considered during the on work of the locality. The impact of locality

investment initiatives on the above areas are monitored and assessed, stakeholders, patients and the

PPI team are engaged with to considering the impact on patients.



inequalities [Yes]






is delivered in the right setting [Not applicable]


organisation [Yes]

The Battersea locality utilises the opportunity to develop locality initiative investment projects, in

conjunction with key stakeholders, to work towards reducing inequalities, improving performance in

primary care and to continually develop the CCG at a local level.




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Review of Lay Member rolesAuthor: Graham Mackenzie Sponsor: Graham Mackenzie Clinical lead: Dr Nicola Jones Date: October 2016

Executive Summary

Context

Following a period of national consultation, NHS England published revised statutory

guidance on the management of conflicts of interest by CCGs in June 2016. The revised

guidance indicates a number of actions required by CCGs in the areas of policy, practice,

training and governance surrounding the management of conflicts of interest.

This paper considers the specific requirement for CCGs to operate with a minimum of

three Lay Members appointed to the CCG Board, one of whom should be designated as

the conflicts of interest ‘champion’ for the organisation.


1. What is the CCG required to do according to the revised statutory guidance with

regard to Lay Member appointments?

2. What is our proposed approach?

3. What actions are required and within what timescales to make progress?

Conclusion

1. The CCG is required to operate with a minimum of three Lay Members appointed to

the Board. Currently the CCG has two Lay Members on the Board, supported by two

Associate Lay Members.

2. It is proposed that the CCG recruits a third Lay Member to be appointed to the Board.

The specific roles and areas of responsibility for the three Lay Members would be

structured around the respective areas of Governance, PPI and Finance. No

immediate changes to the existing roles and responsibilities of the Associate Lay

Members are proposed.

3. Subject to formal approval by the CCG membership and Board, work will be taken

forward to launch an open recruitment process for the three Lay Member roles, with

priority being given to the appointment of the third Lay Member by January 2017.

W A N D S W O R T H C C G P A G E 1 O F [ X ]

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Input Sought

The Board is asked to consider and approve

the proposal to recruit a third Lay Member

and, if agreed, to launch an open

recruitment process for the three Lay

Member roles.

Input Received

NHSE statutory guidance on COI; informal

discussions with CCG Board members.

The Integrated Governance Committee has

previously considered and approved

the proposal.

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The ReportWhat is the need or opportunity and why now?

In June 2016, NHS England published revised statutory guidance on the management of

conflicts of interest (COI) by CCGs. Alongside a broad range of actions required, the

guidance includes a specific requirement to operate with a minimum of three Lay Members

appointed to the CCG Board and Associated corporate committees. An internal audit of

COI arrangements, measured against the revised guidance, is expected to be undertaken

by the end of the 2016/17 financial year. The CCG therefore needs to make rapid progress

to ensure compliance with the statutory guidance.

At the present time the CCG has two Lay Members appointed to the Board, covering the

respective areas of Governance and Patients & Public Involvement (PPI). These

appointments were in accordance with the prevailing guidance at the time of the

establishment of the CCG in 2013. The periods of appointment for the current Lay

Members are due to end on 31st March 2017 (Governance) and 31st August 2017 (PPI)

respectively.

In addition, the CCG identified the need for greater capacity amongst the Lay Member

community supporting the corporate governance of the CCG and appointed two Associate

Lay Members. Whilst the Associate Lay Members support all committees of the CCG,

neither is formally appointed as a member of the CCG Board and therefore are not

recognised against the new requirement for there to be three Lay Members appointed to

the Board.

What do we propose to do and why?

It is proposed that the CCG recruits to one additional Lay Member role at Board level to

ensure that we comply with the requirement to progress from two to three Lay Members.

In moving to three Lay Members, it will be important that each has a clearly defined role

and specific areas of responsibility. In addition to holding broad corporate oversight

responsibilities, it is proposed that the three roles are structured around the following

specific areas of responsibility:

Lay Member for Governance (to include oversight of all corporate governance, Chair

of the Audit Committee, COI Champion)

Lay Member for PPI (duties and responsibilities as at present)*

Lay Member for Finance (to hold a recognised professional finance qualification and

provide oversight of financial and resources management including QIPP, Chair of

the Finance & Resources Committee).

(* The PPI Lay Member currently serves as the Chair of the Primary Care Committee. In

the future this role could be held by either the PPI or Finance Lay Members, but not the

Lay Member for Governance/Audit Committee Chair).

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Given the relatively urgent need to appoint a third Lay Member, and the forthcoming end

of the period of appointment for the two current Lay Members in 2017, it is proposed to

recruit to all three posts together through an open process. Formal appointments would be

staggered to reflect the urgent need to appoint a third Lay Member whilst respecting the

scheduled end date of current appointments, where relevant. Current Lay Members are

eligible to reapply for a further period of appointment.

It is proposed that in future the appointment for each Lay Member will be for a period of

four years. Staggered start dates should ensure we mitigate the risk of turnover in all Lay

Member appointments happening at the same time. Subject to satisfactory performance

(as appraised by the CCG Chair and approved by the Board), a Lay Member may be

directly reappointed for a second term. After a maximum of two terms, all Lay Member

roles must be subject to an open recruitment process and the most recent post holder may

reapply.

No change to the present role, responsibilities or periods of appointment (31st March and

30th November 2017 respectively) of the Associate Lay Members is currently suggested.

The CCG will review the ongoing requirement for Associate Lay Member roles towards the

end of each period of appointment in the context of overall Lay Member capacity and

wider organisational changes.

In considering the addition of a third Lay Member to the CCG Board, we have taken

account of potential impacts to the balance of the voting membership of the Board and the

commitment to retain a clear clinical majority in decision making. Adding a third Lay

Member will increase the voting membership of the Board to twelve, comprising seven

clinical (five GPs, secondary care consultant and nurse), three Lay Members and two

executive members (Chief Officer and Chief Finance Officer). Following discussions

amongst members of the Board it is felt that this represents an acceptable balance at the

present time. If there is any significant turnover in individual appointments to the Board

that may result in a change to the operating culture, this position may be further reviewed.

A voting membership of twelve will require an amendment to the terms of reference for the

Board to enable the Chair to holding a casting vote in the event of tied decision.

The costs Associated with this proposal are for one additional Lay Member i.e.

£12,120/£13,267 per annum (pro-rata in 2016/17) for an appointment of three days per

month.

What do we need to do next to progress?

Subject to Board agreement, a number of actions will be required to implement the

changes proposed, these include:

An amendment to the CCG Constitution will be required, to be discussed and agreed

with the CCG membership (through locality meetings) prior to formal adoption by

the CCG Board (October 2016);

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Preparation of job descriptions for the three Lay Member roles (October 2016) and

open recruitment process, post CCG Board approval (November/December 2016);

Appointment of third Lay Member (January 2017) as priority; further appointments

into 2017;

Amendment to Board and committees terms of reference (October 2016);

Internal audit of COI (January – March 2017)

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The risks [Yes]



Impact on our providers [Not applicable]





An EIA has not been completed for this proposal as the requirement to appoint a third

Lay Member is a matter of statutory guidance. The potential to address equality and

diversity considerations in future appointments to the Board is recognised.



inequalities [Yes]




members, stakeholders and communities [Yes /]


is delivered in the right setting [Yes]


organisation [Yes]




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Part C: Management Reports

Page

3. Part C: Management Reports 85

3.1. C01 Executive Report 86

3.2. C02 Finance Report 90

3.3. C03 Performance Report 122

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Executive ReportAuthor: Sandra Allingham Sponsor: Nicola Jones / Graham Mackenzie 12/10/2016

0

Executive Summary

Context

The report provides information on the following items for information:

Management Team Summary

Personal Health Budget Steering Group

Mental Health and Learning Disability Placements

IAPT (Improving Access to Psychological Therapies) Procurement

Annual General Meeting

Input Sought

The Board is asked to note the content of the report.


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The Report

Management Team SummaryA summary of the main issues discussed by the Management Team in the period following the previous Board meeting is outlined below:

Performance

Serious Incidents and ‘Make A Difference’ Alerts

St George’s University Hospital Foundation Trust

Updates on services/contracting

Quality and safety issues

Financial position

Clinical Reference Groups

GP Out of Hours Base Locations

Mental Health and Learning Disability Placements Panel

Personal Health Budgets

Patient and Public Involvement

Personal Health Budget Steering GroupThe Personal Health Budget (PHB) Steering Group has been established to provide assurance to Wandsworth CCG Board and ensure that the governance framework for the implementation of personal health budgets for both adults and children are in line with statutory requirements. The Panel is jointly chaired by the CCG Chief of Commissioning Operations and Clinical Lead for Personalisation. The Panel is overseeing the development of the Wandsworth CCG PHB Resource Allocation System (RAS) which will calculate personal health budgets in a fair, accurate, consistent and sustainable way from November 2016 onwards. Existing and new PHBs will be assessed against the new RAS. There is a focus on developing new mental health and learning disability PHB pilots in the coming months.

Mental Health and Learning Disability placementsThe CCG has a budget of £6.2M for Mental Health and LD placements. These placements are in the main rehabilitation placements which are out of the area, where local provision is not able to meet the specific and complex needs of the individuals placed. The CCG contracts with all these placements using the NHS Standard contract, undertakes regular review meeting and quality assurance visits. In order to strengthen the governance of these placements, including managing the process of new referrals, the CCG has introduced a Placement Panel in 2015. The Panel is led by the Chief of Commissioning Operations and has clinical input from a GP and the Mental Health Provider. The Panel is working well to ensure good governance practice for new placements and providing increasing challenge to the quality and ongoing length of stay for patients in placements. Annual General MeetingThe Wandsworth CCG AGM was held on Wednesday, 21st September, at which the annual report and accounts were presented as well as a review of our plans for the current year. The meeting was well attended and a number of questions were received from members of the public. The event was also live streamed with fifteen viewers recorded.

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A market stall event was held both before and after the formal meeting, with information on a wide range of projects in Wandsworth including Self-Management, Enhanced Care Pathway, Personal Health Budgets, Public Engagement and more.

Use of the Seal

Since the previous report the corporate seal was applied as follows:

22/09/2016 Deed of Variation relating to the Better Care Fund Partnership

Agreement

Conclusion

The Board is asked to note the information on the items above.

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The long-term implications [Not applicable]

The risks [Not applicable]

Impact on our reputation [Not applicable]

Impact on our patients [Not applicable]

Impact on our providers [Not applicable]

Impact on our finances [Not applicable]

Equality impact assessment [Not applicable]

Patient and public involvement [Not applicable]


The content included in the report relates to items for information only.



inequalities [Not applicable]


statutory responsibilities [Not applicable]


members, stakeholders and communities [Not applicable]


is delivered in the right setting [Not applicable]


organisation [Not applicable]


The content included in the report relates to items for information only.




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Month 5 Finance Report Author: Peter Ifold, Deputy CFO Sponsor: Neil McDowell, Acting CFO Date: 09/2016

Executive Summary

Context

The Finance Team is responsible for reporting the financial position for the CCG each

month. This paper provides information on the month 5 financial position, highlighting key

issues and the forecast outturn. In addition, this paper updates the Board on the 2017-19

planning round and highlights key information from the recently published operating plan

guidance.


1. What is the CCG’s year to date financial performance against the approved budget?

2. Is the CCG on target to meet the planned 0.5% financial surplus at year end?

3. Implications around financial governance, strategy, performance and risk.

4. Can we keep running costs within the target set?

Conclusion

1. The CCG is on course to meet its target surplus of £2.08m.

2. We expect to meet the running cost target.

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [

Input Sought

The decision we would like from the

Board is:

To note the contents of the report

Input Received

The Finance and Resources Committee

did not meet in September due to a later

meeting held in August 2016. This report

has been circulated top members of the

FRC for information and comment.

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The Report

Looking Back

W H A T H A S G O N E W E L L ?

The CCG is on course to achieve a balanced Financial Position and achieve the

planned 0.5% financial surplus at year end.

We are on course to meet the running cost target.

W H A T H A S N O T G O N E W E L L ?

Continuing care remains a cost pressure in the early part of the year.

It is hoped that the CHC provider will be on top of the issues to slow the run rate

seen over the first half of the year.

The Primary Care co-commissioning budget detail received from NHSE indicates a

£172k shortfall in addition to a £233k

This shortfall will be funded from the over performance reserve

QIPP is not delivering on some of the schemes with a total forecast of £1.6m under

target.

Looking Ahead

O P P O R T U N I T I E S ?

Investment in non-acute services that started in 2015/16

By investing in out of hospital services this should help manage demand and

costs around acute and other high cost services.

R I S K S O R C O N C E R N S ?

Managing acute performance

If we don’t manage performance, then this will limit our ability to manage within

the resource limit in 16/17 and meet the business rules set.

Managing the financial impact if Continuing Healthcare growth continues.

If we don’t manage the financial impact of growth in Continuing Healthcare this

will limit our ability to manage within the resource limit in 16/17 and meet the

business rules set.

Non delivery QIPP

This is essential for the future financial health of the CCG

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In ConclusionC O N F I D E N C E ? I M P L I C A T I O N S ?

I am confident that the financial position

outlined in this paper is accurate based on

available information and reflects the risks

moving forward.

The CCG is on course to achieve a

balanced Financial Position and achieve

the planned 0.5% financial surplus at year

end as well as hit its running cost target.

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Data DashboardSee following PowerPoint slide pack.

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The long-term implications Yes

Ensuring that we understand cost drivers that will impact on future years

The risks Yes

Mitigations against a number of risks have been considered and implemented

where appropriate

Impact on our reputation Yes

By not achieving the targets set would have an adverse impact on our

Organisational reputation.

Impact on our patients Yes

Insufficient funding or poor planning would impact on our ability to commission

services in an efficient way.

Impact on our providers Yes

Prompt payment, accurate reflection of activity and finance

Impact on our finances Yes

Throughout the report

Equality impact assessment Not applicable

Patient and public involvement Not applicable




inequalities Yes


statutory responsibilities Yes


members, stakeholders and communities Not applicable


is delivered in the right setting Yes


organisation Yes

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Wandsworth Clinical Commissioning Group

Finance Report up to the end of August

2016

Presented by Finance –

October 2016

07 October 2016

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Contents1. Month 5 Financial Position

2. Balance Sheet

3. 2017-19 Planning

4. Recommendations

Board October 20162 07 October 2016

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Finance Scorecard up to August 2016

Board October 2016

Financial Strategy Financial Performance• SWL Collaborative Commissioning programme

work is ongoing to deliver system transformation plan.

• Allocations have been published for the next 5 years with the first 3 years confirmed (hard) and the following 2 years indicative (soft)

• 1% non recurrent reserve cannot be committed at 1 April 2016

• Expectation for a 2 year contract plan agreed by December for which planning guidance is expected towards the end of September.

• Plan to achieve the target surplus of £2.08m (0.5%)• Contract values agreed with all main providers• Plan for QIPP has been agreed and expect to meet

running cost target• Action is being taken to manage Continuing Health

Care costs following concerns raised• Overall there is no variance from plan at month 5 but

note the risks to this position.

Financial Governance Financial Risk• Annual internal audit plan is in place.• Board Assurance Framework has been updated in

July 2016.• Financial control environment assessment has

been submitted with action plan in place• Finance Recovery Group set up in September

2016 to oversee the QIPP programme and report into the Finance & Resources Committee

• Financial ledger system has limited capability to do detailed analysis.

• Emerging issues around acute contracting and continuing care may impact on our ability to achieve the target surplus. Further mitigations are being developed to ensure that flexibility is built into the position.

• 2016/17 QIPP delivery represents a significant risk due to size of the programme and the level of reserves held to mitigate against performance.

3 07 October 2016

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Month 5 – WCCG Key Messages

Board October 20164

• We still plan to achieve the target surplus set (£2.08m)

• The overspend on Continuing Healthcare has increased to £1.9m (year to date) and £2.6m (full year). As the database becomes more robust the true level of spend is being identified, although there is still more work to be done on this and it is envisaged that the outturn may worsen prior to the positive impact of savings plans.

• The full year forecast for the Acute SLAs has worsened by £693k. The biggest adverse movements are on St George’s and Chelsea & Westminster.

• We are now forecasting a full year underspend of £770k on Prescribing due in part to a reduction in national pricing.

• Reserves are being used to support the £6.2m forecast overspend on operational expenditure.

• We expect to meet running costs.

• To ensure the target surplus is achieved the CCG is identifying a list of mitigating actions with a view to implementing savings that will generate upwards of £4m in 16/17 to ensure financial targets are met.

07 October 2016

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Month 5 – Revenue Resource Limit

Board October 2016

• The Resource Limit reflects the amount of money the CCG has available to commission services (programme) and to run the CCG (admin). At Month 5, the CCG received £29k to fund Named Safeguarding GPs and £34k for the GP Development Programme

5 07 October 2016

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Month 5 Financial Position


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Month 5 Acute Analysis


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Month 5 – Acute Commentary• Overall we are reporting an adverse forecast outturn variance of £3.8m, compared to a £2.9m overspend

at month 4. The major movements are on St George’s and Chelsea & Westminster.

• The main areas of forecast overspend are focussed on St George’s (£1,530k), Chelsea & Westminster (£1,060k), Guy’s & St Thomas (£801k) and UCLH (£368k) offset by Kingston Hospital (£500k) and Elective Orthopaedic Centre (£602k).

• St Georges over performance is against Emergency, Out patient attendances and Direct Access partially offset by underspends on elective and maternity. Within the SLA there is a significant QIPP (£1.6m), which has not impacted on the year to date position and is phased to impact in the second half of the year.

• Chelsea & Westminster are showing over spends on critical care, elective, emergency, and maternity with an underspend on out patients.

• The Guy’s & St Thomas overspend is focussed on Elective and Drugs & Devices whilst the UCLH overspend is widely distributed with the main focus on Elective.

• Elective Orthopaedic Centre are the most significant under performer on elective and Kingston Hospital the most significant underperformer on emergency. Imperial Hospitals are showing an over performance on critical care.

• The London Ambulance Service budget has now been amended to reflect the agreement of the CQC investment and a breakeven position is now reported.

• In addition to the SLA’s we are reporting a £400k forecast overspend against NCA’s resulting from a £500k reduction in the budget for QIPP which is not achieving and the forecast overspend on Other Acute QIPP not attributed to SLA’s remains £1,275k reflecting an acknowledgement that the full KPI QIPP (£1.8m) is very unlikely to be achieved.


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Primary Care Month 5

Board October 20169

• There is a YTD overspend of £108k on the delegated element of Primary Medical Care. This is explained by an overspend on discretionary payments and under-achievement of QIPP, offset by a small underspend on core services. NHSE have not provided a forecast outturn – we will continue to pursue this issue. We have assumed for now that the delegated budget will break even at year end, e.g. because refunds relating to prior year business rates are expected to contribute towards the QIPP target. However, there is clearly a risk of an overall overspend on the delegated budget.

• Reflecting the recent Prescribing information, the Primary Care budgets are now forecasting an underspend of £0.51m being the Prescribing underspend (£0.77m mentioned above) offset by other small overspends elsewhere – APMS: Walk In Element and cost pressures on OOH, GP In hours, and SPA111.

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Month 5 – Other Commentary• Non-Acute Services are reflecting an overspend of £1m year to date and £2.95m full year,

so there has been an adverse movement from Month 4 of £0.19m YTD and £0.23m in the full year.

• The main reason for the movement in this area is an increased forecast overspend on Continuing Healthcare (£2.6m) offset by one or two areas of underspend (circa £0.2m) where it has been identified that spend is unlikely to be incurred. The Continuing Healthcare overspend has continued to increase as the new contractor (CHS) has more reliable and robust processes than its predecessor and continues to identify the full financial value. There is, however, still some more work to be done which may result in further cost pressures though the current understanding is that in parallel with this cost efficiencies will be identified which should contain the over spend to the current level. Together with the forecast overspend on Free Nursing Care (£450k) reflecting the new rates these two areas account for the full forecast outturn.

• Spend on the South London & Maudsley SLA and the s117 agreement with the Council has increased. These increases are offset by a reduction on the Mental Health Placements line. Overall mental health expenditure is meeting the value to achieve parity of esteem.

• Running Costs are reflecting a year to date overspend of £86k, but we are expecting breakeven at year end. On Corporate Programme Costs, there is YTD overspend of £15k, but again we are forecasting breakeven for the full year. We have increased some budgets to more realistic levels: in particular, the management budget for the Continuing Healthcare service now reflects the additional investment required to get this service up to business as usual.


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Running Costs at Month 5

Board October 201611

The forecast spend is within the CCG’s Running Cost resource allocation of £7,481k

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CCG Risks and Mitigations


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2. Balance Sheet

3. 2017-19 Planning

4. Recommendations


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Statement of Financial Position at Month 5


• This balance sheet snapshot reflects payments to be made on 1st September (in month 6). Therefore cash position above is not correct. Real cash position is a surplus of £133k as per Cash Drawdown slide

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Cash flow Statement at Month 5


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Cash Drawdown to Month 5


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Better Payment Practice Code


• We are achieving the target, which is 95%

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2. Balance Sheet

3. 2017-19 Planning

4. Recommendations


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Approach to 17/18 PlanningOverview

• The publication of the “Strengthening Financial performance and Accountability 2016-17” document recently has given added impetus to setting clear commissioning intentions early and moving the business cycle forward, to get contracts signed by the end of December 2016 that cover a two year period.

• All CCG’s are expected to have signed all NHS contracts by the end of December, and the tariff and business rules guidance will be brought forward to facilitate this. Formal guidance is yet to be issued but it is expected that contracts will be based on activity assumption with financial values based on the draft 17/18 tariff.

• NHSE have signalled a much more structural approach to linking STPs with and contracts. Tariffs will be set for two years and local systems will be incentivised to work together more collaboratively. It is clear there will need to be a radical change in the behavioural dynamic of planning/contracting towards a more collaborative process

Approach

• A contracting and financial framework is in the process of being agreed, which will outline the agreed core principles at an STP level with clear lines of accountability and delegation between CCGs at a sub-regional level and the parameters each sub region can negotiate within. Each sub regional lead CCG DoC will establish negotiation teams and negotiating mandates such that all contracts are set within the parameters defined by the CCGs. The CCG lead will negotiate and deliver specified contracts for 2017/18 18/19, on behalf of their own CCG, SWL CCGs and London CCGs.

• Formation of a SWL Contract Delivery Group formed of directors from each of the 6 SWL CCGs as well as senior representatives of the CSU.

• The role of this group is to provide assurance, direction and support to unblock challenges as required of the overall contracting round


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Planning Guidance - Headlines2 year contracts signed by 23 December 2016

CCG’s need to break even in year

1% non recurrent reserve

0.5% uncommitted

0.5% invested in STP transformation

CQUIN – 1.5% for national initiatives, 0.5% to providers for achievements, 0.5% to a risk reserve

Control totals to be issued to all organisations

Sustainability and transformation funding available for 2 years to providers (subject to hitting agreed performance targets)

Commissioner allocations maybe refreshed for impact of tariff changes and NHS England specialised commissioning transfers.

07 October 2016 Board October 201620

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Business RulesTaken from the 2017-19 Planning Guidance:

• In year break even.

• 0.5% contingency reserve.

• 1% non recurrent reserve but note the use as per previous slide

• 2.09% growth in our allocation.

• 0.1% net national tariff uplift.

• Separate growth assumptions to be planned for Prescribing and continuing health care.

• Mental health parity of esteem continues (links to allocation growth)

• No investments planned.

• Expectation that individual CCG and provider organisations as well as local systems overall need to deliver within a financial control total


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Timetable


Item Date

Provider Control Totals & STF Allocations published 30/09/16

Commissioner allocations published 21/10/16

Submission of STPs 21/10/16

National tariff section 118 consultation published 31/10/16

Final CCG & specialised service CQUIN scheme guidance published 31/10/16

Submission of summary level 17/18 and 18/19 operational financial plans 01/11/16

Issue initial contract offers to providers 04/11/16

Providers to respond to initial contract offers 11/11/16

Submission of full draft 17/18 to 18/19 operational plans 24/11/16

Submission of progress on contract negotiations (weekly from…) 21/11/16

Contract mediation advised and entered into. 05/12/16

Publish national tariff 20/12/16

National Deadline for Signing contracts 23/12/16

Submission of final 17/18 and 18/19 operational plans aligned to contracts 23/12/16

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Looking Forward - Issues• Issues from 16/17 moving forward:

• Growth in continuing care has continued through 16/17 so will be a pressure moving forward together with the new rates for Free Nursing Care.

• Prescribing cost pressures will need to be assessed particularly around those areas beyond our control (national pricing etc.)

• Acute contracts continue to over perform & given 2 year planning cycle will be critical that these exit at as close to plan as possible.

• Making good the non achievement of 16/17 QIPP

• Making good the non recurrent benefit from surplus accrual resource.

• Into 17/18

• Another challenging year with a potentially complex contracting round for the acute sector

• Minimal growth has been given to the CCG so will be key to understand those areas where we will be mandated to fund.

• QIPP ask is significant again for this year (upwards of £12.5m or in excess of 2.5% of allocation). This also includes where recurrent pressures in 16/17 were covered from non recurrent resources.


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Risk AnalysisRisk BAF Ref

(likely x impact)

Detail / Mitigating Actions

Allocation is less than expected

Risk:16(5x4)

Current draft plans assume low growth. However any non discretionary allocations will further eat into the growth available. Specialist commissioning transfers are not fully funded.

Financial pressure in SWL economy

Risk:75(4x4)Risk: 7(4x4)

Providers and commissioners are working on delivering a sustainable health economy with improved quality health outcomes.

Financial distress of main provider

Risk: 89(4x4)

CCG continues to work closely with St George’s and regulators on a recovery plan. This may impact the way some of the services are currently commissioned.

Deliver a balanced financial plan

Risk: 9(4x4)

Large QIPP challenge planned for 17/18 will put pressure on the plan to deliver a 1% surplus. Plans are currently being drawn with mitigating actions to manage the riskOther factors to note include the late issuing of the final tariff after contracts have been agreed.


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2. Balance Sheet

3. 2017-19 Planning

4. Recommendations


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Recommendations• The Board are asked to note the month 5

position and the risks contained within it• The Board are also asked to note that the 2017-

19 planning section has been updated to reflect the recently published operating plan guidance


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Performance ReportAuthor: Iain Rickard Sponsor: Sean Morgan Date: 12 October 2016

Executive Summary

Context

This paper details the current and year-to-date performance against all NHS Constitution and Improvement and Assessment Framework (IAF) indicators (subject to available data). Extraordinarily, this report also includes a summary of the current Board Assurance Framework.

NHS England have not yet published a methodology for determining overall CCG performance for the ED 4-hour target, therefore this report focuses slightly more on the performance of our local providers and, in particular, St. George’s progress against its Sustainability and Transformation Plan trajectories.

As of 8th July 2016, St. George’s have suspended formal national reporting against the 18 week RTT target until further notice, although St. George’s will continue to informally report some data locally. The CCG is working with the Trust, other commissioners and the regulators to ensure that the improvement plans will result in recovery of both data quality and performance delivery as soon as practically possible, although this is expected to take many months.

Clinical Priority Area: Cancer

NHS England has published assessments of the cancer clinical priority area under the Improvement

and Assessment Framework for all CCGs. This is one of six clinical priority areas, data for three of

which was published in September and reported to the previous Board meeting. The CCG has been

rated as “Needs Improvement”, which is driven by our performance against the 62-day waiting time

target.

NHS Wandsworth CCG

Overall

Rating Indicator Ratings

49.9% 83.3% 70.5% 87.8%

Needs

Improvement

New of cases of cancer diagnosed

at stage 1 and 2 as a

proportion of all new cases of

cancer diagnosed

Of people with an

urgent GP referral

having first

definitive treatment

for cancer within 62

days of referral

of adults

diagnosed

with any type of cancer in a yearwho are still alive

one year after

diagnosis.

Of responses ,which were positive to the

question "Overall, how

would you rate your

care?"


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Looking Back

W H A T H A S G O N E W E L L ?

C. Difficile & MRSA Infection Rates

No cases MRSA reported in July. 5 C. Difficile cases reported in July, equalling 10 in the

year to date, although this is well within the expected upper limit of 17 cases.

6-Week Diagnostics Waiting Time

Diagnostic 6-week wait performance has improved to 99.3% in August.

Cancer Waiting Times

Data for July shows that the CCG has achieved all but one of the cancer waiting time

targets. The 31-day wait target for subsequent radiotherapy treatment was not achieved.

St. George’s also achieved all the cancer waiting time targets. August data is awaited at

the time of writing.

IAPT Waiting Times

6 and 18 week waiting time targets for IAPT continue to be met and were consistently

achieved during 2015/16.

Early Intervention in Psychosis 2-week Wait Target

This target is being met, although performance is sensitive to small numbers of patients.

Ambulance Response Times

London Ambulance Service has met response time targets for Wandsworth patients.

W H A T H A S N O T G O N E W E L L ?

ED 4 Hour Waiting Time

ED waiting time performance has been improving steadily at St. George’s since April 2016.

Performance is still below the 95% target, although the Trust reports that it achieved the

STP trajectory in Q2.

18-Week Referral to Treatment Waiting Time (Incomplete Pathways)

With St. George’s temporarily not reporting national data Chelsea and Westminster is now

the biggest driver of the CCG’s 18-week performance. It has been achieving the 92% target

since May. Guy’s & St. Thomas’ has missed the target by 0.5% in July and King’s has only

achieved 82%.

52-Week Waiters

There was one 52-week waiter in at Imperial reported for August, in T&O. The cause and

outcome is currently being investigated.

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Looking Ahead

O P P O R T U N I T I E S ?

We continue to see the following positive trends:

Zero MRSA infections

Increase in percentage of cancer patients seen within 2 weeks

Maintenance of IAPT waiting times

Continued high levels of dementia diagnosis rates.

Improvements in ambulance response times.

Clinical Priority Area: Cancer

In addition to working with St. George’s on the recovery plan for the 62-day

standard we need to work through the CRG to ensure actions are being identified

and taken forward on each of the metrics, including to improve early diagnosis

and improve survival at one year.

R I S K S O R C O N C E R N S ?

18-Week Waits at St. George’s

Due to the data quality issues, we cannot know with certainty the length of time patients are

waiting for outpatient appointments and for operations at St. George’s. The Trust is supplying

regular updates on waiting list size and activity, but due to the data quality issues identified

that information is not necessarily a reliable indicator of actual performance.

ED Performance at St. George’s

Much of the recent improvement in performance has been supported by bed availability.

Looking ahead to the winter period and based on historical experience, there is unlikely to

be excess bed capacity to support initiatives that have improved ED performance.

IAPT Access and Recovery

Performance against these indicators has improved significantly. However, there is a small

risk that performance may be affected if there is a transfer to a new provider as a result of

the current procurement process. We are working with the current provider to plan any

potential transition very carefully to ensure that the quality of service and performance is not

affected.

In ConclusionC O N F I D E N C E ? I M P L I C A T I O N S ?

We have seen improvements in a number of

the NHS Constitution indicators in recent

months, although we need to work to ensure

these are sustained as winter approaches. The

greatest risk is around the uncertainty around

There are a small number of indicators which

are not supported by work programmes or

which have determinants that are difficult for a

CCG to influence, certainly in the short term.

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18-week RTT performance at St. George’s. It will be difficult for us to assure ourselves on

performance and progress towards resolving

18-week RTT data quality issues without robust

data.

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Board Assurance FrameworkThe dashboard below summarises the Corporate Objectives and lists the relevant principal risks.

Corporate Objective Potential Principal Risk Initial

Score

Current

Score

Tolerance

Score

Movement

from previous

review

Date of

last

Review

Risk 16 – Failure to receive the appropriate level of

funding allocation. 20

(5x4)

16

(4x4)

9

(3x3)

↔ 04/10/16

Risk 33 – Failure to have sufficient plans to cater for

surges in activity and growth in population caused

by local community developments.

9

(3x3)

9

(3x3)

6

(3x2)

↔ 04/10/16

Risk 47 – Failure to have a shared understanding

with providers of what safe high quality care looks

like and how to recognise failure of care in light of

the Francis, Keogh and Berwick reviews.

16

(4x4)

8

(4x2)

8

(4x2)

↔ 04/10/16

Risk 50 – Failure to commission services in a way

that delivers integrated and sustainable models of

care.

16

(4x4)

2

(2x1)

8

(4x2)↓

(3x2)

04/10/16

Objective 1:

Commission high quality services

which improve outcomes and

reduce inequalities

Risk 99 – Challenges facing main provider20

(5x4)

20

(5x4)New 04/10/16

Risk 7 – Financial pressures across the health and

social care economy.16

(4x4)

16

(4x4)

9

(3x3)↔ 04/10/16

Risk 9 – Failure to plan expenditure to reflect

budget and maximise use of resources.16

(4x4)

16

(4x4)

6

(3x2)↔ 04/10/16

Objective 2:

Make the best use of resources,

continually improve performance

and deliver statutory

responsibilities

Risk 68 – Failure to achieve performance ambitions

set out in the 2015/16 Assurance Framework and

the 2015/16 Operating Plan.

16

(4x4)

16

(4x4)

8

(4x2)↔ 04/10/16

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Risk 75 – Sustainable health economy16

(4x4)

12

(4x3)

9

(3x3)↔ 04/10/16

Risk 95 – 1% non-recurrent uncommitted reserve

16

(4x4)

12

(3x4)↔

Risk 97 – Primary Care Commissioning

20

(5x4)

12

(4x3)

6

(3x2)↔ 04/10/16

Objective 3:

Continually improve delivery by

listening to and collaborating with

our patients, members,

stakeholders and communities

No corporate risks currently highlighted

Objective 4:

Transform models of care to

improve access, ensuring that the

right model of care is delivered in

the right setting

Risk 29 – Failure to reshape the local out of hospital

and urgent care services to respond to local

system.

20

(5x4)

16

(4x4)

6

(2x3)

↔ 04/10/16

Objective 5:

Develop the CCG as a

continuously improving and

effective commissioning

organisation

Risk 65 – Failure to develop and improve the CCG

as an organisation. 9

(3x3)

4

(2x2)

1

(1x1)

↔ 04/10/16

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NHS Constitution Scorecard

Health Outcomes Framework / Every one Counts Target Performance

YTD

Performance

Month

Breaches Latest Data May-16 Jun-16 Jul-16 12M Trend

MRSA - Incidence of HCAI YTD 0 0 0 0 (YTD) Jul-16 0 0 0 ▼C. difficile - Incidence of HCAI YTD 17 10 5 0 (YTD) Jul-16 2 0 5 ►

NHS Constitution

RTT admitted (Provisional) 90% 78.5% 81.2% 107 Aug-16 78.5% 79.0% 78.1% ►RTT non-admitted (Provisional) 95% 92.9% 93.5% 227 Aug-16 92.7% 94.0% 93.5% ▲RTT incomplete (Provisional) 92% 91.5% 91.0% 876 Aug-16 92.0% 91.2% 91.5% ▼RTT 52+ week waiters (Provisional) 0 14 1 1 Aug-16 4 3 3 ►RTT Admitted Backlog (Provisional) 251 251 Aug-16 755 236 250 ▼

Diagnostics (Provisional) Diagnostics - 6 weeks + (Provisional) 99% 98.9% 99.3% 28 Aug-16 99.1% 99.3% 99.1% ►2 week wait 93% 89.6% 93.7% 49 Jul-16 87.6% 90.7% 93.7% ▲Breast symptoms 2 week wait 93% 92.2% 93.8% 9 Jul-16 95.5% 85.8% 93.8% ►31 day first definitive treatment 96% 97.6% 97.6% 2 Jul-16 97.4% 98.7% 97.6% ►31 day subsequent treatment surgery 94% 97.9% 100.0% 0 Jul-16 90.9% 100.0% 100.0% ►31 day subsequent treatment drug 98% 99.2% 100.0% 0 Jul-16 97.7% 100.0% 100.0% ►31 day subsequent treatment radiotherapy 94% 96.1% 93.8% 2 Jul-16 96.9% 100.0% 93.8% ►62 day standard 85% 85.8% 93.0% 3 Jul-16 78.8% 80.0% 93.0% ►62 day screening 90% 91.9% 100.0% 0 Jul-16 81.8% 100.0% 100.0% ►62 day upgrade 90% 100.0% 100.0% 0 Jul-16 100.0% 100.0% 100.0% ▲Mixed-sex accommodation breaches 0 2 2 2 Aug-16 0 0 0 ►Total number of Delayed Transfers of Care 0 393 87 87 Jul-16 105 112 87 ▲CPA follow up within 7 days 95% 95.7% 95.7% 7 Jun-16 95.7% ►IAPT 6 week target 75% 94.9% 95.6% 25 Jun-16 95.1% 95.6% ▲IAPT 18 week target 95% 99.2% 99.1% 5 Jun-16 99.2% 99.1% ▲IAPT in recovery 50% 45.4% 45.9% 165 Jun-16 45.1% 45.9% ▲Early Intervention Psychosis 2 week target 50% 69.2% 66.7% 3 Jul-16 75.0% 70.0% 66.7% ►Dementia 67% 73.2% 73.7% 492 Aug-16 73.1% 72.9% 73.7% ▲

A&E 4 Hour Waits

% within 4 hours ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 95% 93.0% 94.4% 829 Jul-16 93.6% 94.0% 94.4% ▼% within 4 hours CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 95% 95.2% 95.0% 1206 Jul-16 95.8% 95.7% 95.0% ►% within 4 hours KINGSTON HOSPITAL NHS FOUNDATION TRUST 95% 93.2% 93.8% 614 Jul-16 92.1% 91.9% 93.8% ►% within 4 hours KINGS COLLEGE HOSPITAL NHS FOUNDATION TRUST 95% 84.0% 83.5% 4121 Jul-16 85.1% 83.8% 83.5% ▼% within 4 hours GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 95% 90.5% 90.8% 1517 Jul-16 89.4% 89.8% 90.8% ▼% within 4 hours

Trolley Waits >12Hrs ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 0 1 0 0 Jul-16 0 1 0 ►Trolley Waits >12Hrs CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 0 0 0 0 Jul-16 0 0 0 ▼Trolley Waits >12Hrs KINGSTON HOSPITAL NHS FOUNDATION TRUST 0 0 0 0 Jul-16 0 0 0 ►Trolley Waits >12Hrs KINGS COLLEGE HOSPITAL NHS FOUNDATION TRUST 0 17 6 6 Jul-16 1 5 6 ►Trolley Waits >12Hrs GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 0 0 0 0 Jul-16 0 0 0 ►Trolley Waits >12Hrs 0

Ambulance

Red 1 75% 75.8% 80.0% 7 Aug-16 72.2% 67.5% 82.1% ►Red 2 75% 73.1% 75.9% 275 Aug-16 71.8% 73.8% 72.1% ▲Cat A19 95% 97.5% 97.3% 32 Aug-16 97.4% 97.3% 97.7% ▲

Latest Month data shows an increase over previous 12 months (using 6 sigma methodology), which is an Improvement in performance ▲Latest Month data shows an increase over previous 12 months (using 6 sigma methodology), which is a Deterioration in performance ▲

Latest Month data shows an Decrease over previous 12 months (using 6 sigma methodology), which is an Improvement in performance ▼Latest Month data shows an decrease over previous 12 months (using 6 sigma methodology), which is a Deterioration in performance ▼

Latest Month data is within normal variation of previous months data and is neither showing a statistical increase or decrease ►Achieving Target

Failing Target

Safe environment and protecting from

avoidable harm

A&E

Mental Health

RTT (Provisional)

Cancer - 2 weeks

Cancer - 31 days

Cancer - 62 days

LAS

Trust Measures

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Improvement & Assessment Framework Scorecard

Please Note: If indicator is highlighted in GREY, this

indicator will be available at a later date

KEY

H = Higher

L = Lower

<> = N/A

Improvement and Assessment IndicatorsLatest

PeriodCCG England Trend Better is… Range

Better Health

Maternal smoking at delivery 15-16 Q3 2.5% 10.6% L

% children aged 10-11 classified as overweight or obese 2014-15 33.3% 33.2% L

Diabetes patients that have achieved all three of the NICE-recommended treatment targets 2014-15 41.5% 39.8% H

People with diabetes diagnosed less than a year who attend a structured education course 2014-15 6.7% 5.7% H

Injuries from falls in people aged 65 and over per 100,000 population Nov-15 2,724 2,027 L

People offered choice of provider and team when referred for a 1st elective appointment Feb-16 0.26 0.5 H

Personal health budgets per 100,000 population (absolute number in brackets) 15-16 Q4 1.58 14.45 H

% deaths which take place in hospital 15-16 Q3 51.4% 46.9% L

People with a long-term condition feeling supported to manage their condition 2015 61.0% 64.4% H

Inequality in avoidable emergency admissions 15-16 Q2 1,068 #N/A L

Inequality in emergency admissions for urgent care sensitive conditions 15-16 Q2 1,856 #N/A L

Anti-microbial resistance: Appropriate prescribing of antibiotics in primary care 15-16 Q4 0.9 (1.2) #N/A L

Anti-microbial resistance: Appropriate prescribing of broad spectrum antibiotics in primary care 15-16 Q4 12.6 (12.6) #N/A L

Quality of life of carers - health status score (EQ5D) 2015 0.80 #N/A H

Better Care

Cancers diagnosed at early stage 2014 49.9% #N/A H

People with urgent GP referral having 1st definitive treatment for cancer within 62 days of referral 15-16 Q4 83.3% 81.9% H

One-year survival from all cancers 2013 70.5% 70.2% H

Cancer patient experience 2014 87.8% 89.0% H

Improving Access to Psychological Therapies recovery rate Feb-16 47.9% 47.6% H

People with 1st episode of psychosis starting treatment with a NICE-recommended package of care treated within 2 weeks of referral Mar-16 74.2% 62.9% H

People with a learning disability and/or autism receiving specialist inpatient care per million population Mar-16 46 58 L

Proportion of people with a learning disability on the GP register receiving an annual health check 2014-15 47.0% 47.0% H

Neonatal mortality and stillbirths per 1,000 births 2014-15 4.69 7.10 L

Women’s experience of maternity services 2015 74.79 #N/A H

Choices in maternity services 2015 0.65 #N/A H

Estimated diagnosis rate for people with dementia Apr-16 72.3% 66.4% H

Emergency admissions for urgent care sensitive conditions per 100,000 population 15-16 Q2 2,725 #N/A L

% patients admitted, transferred or discharged from A&E within 4 hours Apr-16 91.8% 89.0% H

Delayed transfers of care attributable to the NHS and Social Care per 100,000 population Apr-16 5.05 13.04 L

Emergency bed days per 1,000 population 15-16 Q2 0.73 #N/A L

Emergency admissions for chronic ambulatory care sensitive conditions per 100,000 population 2014-15 869.30 811.80 L

Patient experience of GP services Jan-16 86.4% 84.9% H

Primary care workforce - GPs and practice nurses per 1,000 population 2015 0.96 #N/A H

Patients waiting 18 weeks or less from referral to hospital treatment Apr-16 91.5% 91.7% H

People eligible for standard NHS Continuing Healthcare per 50,000 population 15-16 Q3 36 48 H

Sustainability

Financial plan 2016 Red #N/A H

Digital interactions between primary and secondary care 15-16 Q4 57.8% #N/A H

Local strategic estates plan (SEP) in place 2016-17 Yes #N/A H

Well Led

Staff engagement index 2015 3.8 3.8 H

Progress against Workforce Race Equality Standard Jul-05 0.2 0.2 H

Effectiveness of working relationships in the local system 2015-16 78.60 #N/A H

Quality of CCG leadership 2016-17 Amber #N/A H

If indicator is highlighted in BLUE, this

value is in the lowest performance

quartile nationally.

KEY

Nat Average Org Value

25th 75th

Worst Best

Percentile

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Sustainability & Transformation Programme Trajectories

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The long-term implications

The risks

Impact on our reputation

Impact on our patients

Impact on our providers

The performance report provides a view of current performance and, based on this and

wider intelligence, likely future trends. If future performance is expected to be below targets

or expected levels, then this is highlighted as a risk. Our performance relates to the work

of our providers in many areas and is a reflection of our reputation and the quality of care

our patients are receiving.



inequalities


statutory responsibilities


organisation

Our overall performance and performance in specific areas reflects how successfully we

are meeting these objectives.

3. Executive Summaries should not exceed 1 page. [My paper does not comply]



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Part D: Board Governance

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4. Part D: Board Governance 132

4.1. D01 Summary Minutes: 133

4.1.1. Primary Care Committee 133

4.1.2. Finance Resource Committee 135

4.2. D02 AOB and Other Matters to Note

4.3. D03 Open Space

4.3.1. Members of the public present are invited to ask questions of the Boardrelating to the business being conducted. Priority will be given to writtenquestions that have been received in advance of the meeting.

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COMMITTEE FEEDBACK FORM

Committee: Primary Care Committee

Meeting date: 5th July 2016

Main items discussed: Terms of Reference

Primary Care Transformation

Primary Care Commissioning

Primary Care Quality

Estates and Technology Transformation Bid Update

Finance Report

Decisions: Terms of Reference – The Terms of Reference had previously been discussed and amended. It was noted that the new Conflicts of Interest guidance had been published, against which the Terms of Reference for this and other Committees would need to be checked to ensure compliancy. Any further changes would be reported back to the Committee. The Terms of Reference were agreed, to be reviewed again in September.

Particular points to note:

Primary Care Transformation – A paper was presented to the Committee, providing a high level summary on the approach to primary care transformation, the Five Year Forward View, and GP Forward View. The CCG would be working with general practice to deliver the standards over the next three years. The MCP (Multi-speciality Community Provider) is the contractual vehicle the CCG will use to deliver primary care transformation. The Committee noted the content of the paper.

Primary Care Commissioning – This standard report outlined the key activities that had been undertaken. An outline of the process undertaken to resolve the legacy issue relating to the Trinity Branch closure was noted. An update was provided on the work undertaken by the Primary Care Operational Group since the previous report, including weekly meetings with the NHSE team. The content of the report was noted.

Primary Care Quality – The Committee received a report on the work to promote and improve primary care quality. There were a number of schemes currently in place. A Primary Care Clinical Quality Review Group had been set up with the aim to oversee all of the work around quality in primary care. A process would be developed to capture soft intelligence from other organisations and stakeholders, which will be used with existing data to identify any issues and good practice. The content of the report was noted.

Estates and Technology Transformation Bid Update – The paper provided an update on the work that has been taken forward to develop the infrastructure to deliver models of care going forward, linking in with the primary care strategy. The paper included information on schemes

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currently in place and the preferred position in the next five years. Sixteen bids had been submitted for Wandsworth. There was no guarantee that funding would be achieved. The content of the report was noted.

Finance Report – The report highlighted the current position on budgets, and financial risks. The content of the report was noted.

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COMMITTEE FEEDBACK FORM

Committee: Finance Resource Committee

Meeting date: 6th September 2016

Main items discussed: Financial position and next steps

Month 3 QIPP

St George’s Hospital position

Decisions: No decisions required.

Particular points to note:

Financial position and next steps / Month 3 QIPP – The items were discussed under one banner as the information was closely interlinked. A supplementary finance paper and risk schedule was also discussed.

QIPP – There had been some further movement in the position since the report had been produced. A new reporting cycle had been agreed with the addition of a Finance Recovery Group, alongside the Delivery and Business Intelligence Group. It was noted that performance at Month 3 was under-achieving by £1.6m. Performance on some schemes could slip into amber next month. Some schemes to address emergency activity were not expected to deliver until the second half of the year.

Financial position – The current position was noted. Over-performance in acute activity was noted. Issues have been identified around the shift of activity from the acute setting, and a 40% increase in the rate for Free Nursing Care, which would result in a cost pressure. Continuing Health Care remains an area of concern – an over-performance level of £2m was identified at month 4, but this could increase to £3m. Savings may not be identified until next year.

The Committee expressed grave concern at the overall in-year financial position, and the serious risk that the financial targets for 2016/17 might not be achieved. The potential risk appears to be in the range of £2m-£4m. Identifying options as a matter of urgency to recover the position was therefore essential. It was agreed that a list of potential areas of saving would be generated for discussion by the Management Team.

St George’s Hospital – The current position was noted. The Trust was now reporting a £53m deficit against the original £17m deficit plan.

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Part E: Meeting Close

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5.1. E01 Clinical Chair's Closing Remarks

5.2. E02 To resolve that the public now be excluded from the meeting becausepublicity would be prejudicial to the public interest by reason of thecommercially sensitive or confidential nature of the business to be conducted inthe second part of the agenda.

5.3. E03 Part II Agenda items:

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