dudley clinical commissioning group board ......presentation dr d hegarty 1.35pm 1.55pm 8. strategy...

DUDLEY CLINICAL COMMISSIONING GROUP BOARD AGENDA

Thursday 9th January 2014 1.00pm – 4.30pm

The Copthorne Hotel, The Waterfront, Level Street, Brierley Hill, Dudley, DY5 1UR

Time Agenda Item Attachment Presented By 1 pm 1. Apologies

1 pm 2. Declarations of Interest To request members to disclose any interest they have, direct or indirect, in any items to be considered during the course of the meeting and to note that those members declaring an interest would not be allowed to take part in the consideration for discussion or vote on any questions relating to that item.

3. Minutes from 7th November 2013 meeting Enclosed

Dr D Hegarty

4. Matters Outstanding Dr D Hegarty

5. Questions from the Public To respond to questions from members of the public present at the meeting on the provision of health care to the population served by the CCG.

1.05pm

6. Chairman’s & Chief Officer Report 6.1 Report to include Strategic Plan and Planning Guidance

Update

Presentation Mr P Maubach

1.20pm

7. Feet on the Street 7.1 Access to Primary Care

Presentation

Dr D Hegarty

1.35pm 1.55pm

8. Strategy 8.1 Urgent Care Consultation Outcome 8.2 Urgent Care Model

Enclosed Enclosed

Mr R Haynes Dr S Mann

2.15pm 2.25pm

9. Quality & Safety 9.1 Report from Quality and Safety Committee 9.2 Update on Francis Report

Enclosed Enclosed

Miss R Bartholomew Miss R Bartholomew

2.35pm ** BREAK **

2.45pm 2.55pm

10. Commissioning 10.1 Report from Clinical Development Committee 10.2 Health & Wellbeing Board Report – Governance Structure

Enclosed Enclosed

Dr S Mann Dr S Cartwright

3.05pm

11. Communications & Engagement 11.1 Report from Communications & Engagement Committee

Enclosed

Mrs J Jasper

3.15pm 3.25pm

12. Governance 12.1 Report from Audit Committee 12.2 Combined Board Assurance Framework and Risk Register

Enclosed Enclosed

Mrs J Jasper Mrs J Jasper

3.35pm 3.45pm

13. Finance and Performance 13.1 Report from Finance & Performance Committee 13.2 IT and Informatics Strategy

Enclosed Enclosed

Dr J Rathore Dr R Johnson

4.00pm

14. Primary Care 14.1 Report from Primary Care Development Committee

Enclosed

Dr J Rathore

4.10pm

Close

15. For Information 15.1 Glossary

Enclosed

Time and Date of Next Meeting 1pm – 5pm, Boardroom, BHHSCC Thursday, 13 March 2014 Thursday, 3 April 2014 (Extraordinary Board) Thursday, 8 May 2014 Thursday, 10 July 2014 Thursday, 11 September 2014 (AGM) Thursday, 13 November 2014

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD

PUBLIC MINUTES

MINUTES OF THE MEETING HELD IN PUBLIC ON THURSDAY 7th NOVEMBER 2013 AT 1.00 PM, BOARDROOM BRIERLEY HILL HEALTH AND SOCIAL CARE CENTRE

ATTENDEES:

Miss R Bartholomew Chief Quality & Nursing Officer

Dr J Darby GP Board Member (Halesowen & Quarry Bank)

Dr K Dawes GP Board Member (Sedgley, Coseley & Gornal)

Dr R Edwards GP Board Member (Kingswinford, Amblecote and Brierley Hill)

Dr P D Gupta GP Board Member (Dudley & Netherton)

Dr C Handy Lay Member for Quality & Safety

Mr M Hartland Chief Finance Officer

Dr M Heber Secondary Care Clinician

Dr D Hegarty GP Board Member (Chair of CCG)

Mrs J Jasper Lay Member for Patient & Public Engagement

Dr R Johnson GP Board Member (Halesowen & Quarry Bank)

Ms V Little Director of Public Health

Mr P Maubach Chief Accountable Officer

Mr J Polychronakis Chief Executive Officer, Dudley MBC

Dr L Pope Clinical Executive – Quality & Safety

Mr S Wellings Lay Member for Governance

IN ATTENDANCE:

Mr N Bucktin Head of Partnership Commissioning

Ms S Cartwright OD Practitioner

Dr R Gee GP Engagement Lead

Mr R Haynes Head of Communications

Ms S Johnson Deputy Chief Finance Officer

Mrs W Saviour Director of the Local Area Team, NHS England

APOLOGIES FOR ABSENCE:

Dr J Rathore Clinical Executive – Finance & Performance

Dr S Mann Clinical Executive – Acute & Community Commissioning

Dr M Mahfouz GP Board Member (Dudley & Netherton)

Dr T Horsburgh LMC Representative

Mr D King Head of Membership & Primary Care

Ms J Emery Chief Officer - Health Watch MEMBERS OF THE PUBLIC/PRESS: Present for the meeting in public were:

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Lucy Bayliss - Dudley CCG, David Stenson - Patient Representative, Selma Toms - BMS, Dottie Tipton - Sandwell and West Birmingham, Tracey Downton - Deputy Office Manager, Dudley CCG, Colin McIntosh - MSD

CCG68/2013 APOLOGIES

Apologies were noted from Dr Rathore, Dr Mann, Dr Mahfouz, Dr Horsburgh, Mr King and Ms Emery.

CCG69/2013 DECLARATION OF INTEREST

Members were asked to disclose any interest they may have, direct or indirect, in any of the items to be considered during the course of the meeting and to note that those Members declaring an interest would not be allowed to take part in the consideration or discussion or vote on any questions relating to that item. None were declared.

CCG70/2013 MINUTES FROM PREVIOUS MEETING HELD ON 5th SEPTEMBER 2013

The minutes of the meeting held on 5th September 2013 were accepted as an accurate record. No changes were noted.

CCG71/2013 MATTERS OUTSTANDING

ADDITIONAL ITEM: NHS 111 CONTRACT The CCG agreed at the last Board meeting that it would extend the contract for a year, however due to national guidance the CCG may have to extend it for longer. CCG61/2013: NORTH WEST MIDLANDS PATHOLOGY PROCUREMENT Mr Bucktin confirmed that this was being picked up at the next Clinical Development Committee and a further update would be in the next report for Board in January. CCG64/2013: AUDIT COMMITTEE REPORT Dr Hegarty confirmed that each Committee Chair has attended Audit Committee or is scheduled to do so. CCG65/2013: RISK REGISTER Mr Hartland confirmed that the risk involving immunisations had been removed from the risk register.

CCG72/2013 QUESTIONS FROM THE PUBLIC

There were no questions from the public present at the meeting. Mrs Jasper asked if members of the public who were unable to attend the Board could ask in advance of the meeting. Dr Hegarty confirmed that this would be acceptable. It was proposed that a message go out to the public in relation to this. Resolved:

1) The Board agreed that a message be sent out in the press through the Communications Team.

CCG73/2013 CHAIRMAN’S & CHIEF OFFICERS REPORT

Announcements Mr Maubach spoke to this item and welcomed Dr Stephen Cartwright as the CCG’s new Clinical Executive for Integration and Partnerships and reported that Dr Jonathan Darby has taken on the responsibility of critically analysing the CCG’s systems and process in order to maximise the CCG’s effectiveness.

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Mr Maubach also welcomed Mr Richard Haynes from Rockhouse Communications who has been contracted to cover for Laura Broster whilst she is on Maternity. Mrs Broster has recently given birth to a baby boy called Harvey and both are doing well. Dr Hegarty also welcomed Wendy Saviour from NHS England who was in attendance at the Board. Specialised Services Mr Maubach reported that the CCG reached a satisfactory conclusion on the specialised services allocation adjustments and that the Area Team had been thanked for their constructive approach to resolving the issues. Downing Street Visit Mr Maubach reported that Dr Hegarty, together with other representatives from various NHS organisations, had been invited to Downing Street to meet with David Cameron and Jeremy Hunt. Dr Hegarty informed the Board that the key messages were to commend the work that the CCGs are doing and encouraging CCGs to maintain the pressure on sustaining excellence. Urgent Care Consultation The CCG is currently out to consultation on proposed changes to the urgent care system in Dudley. The main areas being consulted on are the walk in centre service; out of hours services; and the way in which NHS 111 works. Mr Maubach highlighted that the preferences, which came from the public and on the recommendations of the Health & Wellbeing Board, are improve access to GP Surgeries. This has led to a proposal of establishing a new Urgent Care Centre at Russell’s Hall Hospital which will triage patients in to A&E and provide primary care at weekends and evenings. This will mean improving the access to GP surgeries during the day and closing the current Walk in Centre. The consultation is due to finish on the 24th December 2013 and so far a range of feedback has been received. Commissioning Intentions The CCG’s commissioning Intentions were published on the 1st October and a recent workshop was held with over 50 provider representatives and contracting staff. As one of the first CCGs to adopt this inclusive approach, the main themes discussed were: the CCGs Primary Care Strategy; plans for integration; the urgent care redesign and the CCG’s approach to planned care. Integration agenda Mr Maubach reported to the Board that the CCG was not shortlisted as a finalist for the national integration pioneers. However the CCG is making significant progress in developing plans through Locality meetings; spending time with Dudley Social Services; establishing objectives and governance arrangements; and also developing a partnership with the Health Services Management Centre at Birmingham University. National Innovation Challenge The CCG has been shortlisted as a finalist in the NHS Innovation Challenge Prize for Dementia and the awards ceremony is on the 26th November. Review of A&E Mr Maubach reported that the majority of the Board, clinical and non-clinical members, spent a week in A&E at Russell’s Hall Hospital observing and triaging patients. He confirmed that some extremely important learning has come out of the time spent in the department and the findings will be published shortly. Dr Hegarty informed the Board that the CCG had not been consulted on the recent changes that Dudley Group Foundation Trust had made to the Physiotherpy services in Dudley. He proposed that, if the Board was in agreement, a clear statement would be published informing the public that the CCG was not involved in the changes to the service.

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NHS England Area Team Assurance Meetings Mr Maubach informed the Board that a very positive assurance meeting was held on the 12th September with the Area Team and he reported that no significant issues arose. The next meeting is scheduled for the 4th December 2013. Resolved:

1) The Board noted the report for assurance.

2) The Board agreed to an announcement being made regarding Physiotherapy Services

CCG74/2013 FEET ON THE STREET

Mrs Jasper introduced the “Feet on the Street” video and informed the Board that recent meeting/events have highlighted that there is scepticism around capacity in Primary Care and a strong lean towards not closing the Walk in Centre (WiC) and especially not moving it to Russell’s Hall Hospital due to the parking problems. Dr Gupta highlighted that consideration needs to be given to the high expectations that patients have when it comes to primary care, some patients feel that being offered an appointment the next day is unacceptable. Dr Heber had recent experience of a WiC and can understand the fear of losing that instant access. Dr Pope reported that if the WiC is to remain open then “systems” will need to be able to talk to each other and records of what happens in the walk in centre will need to be shared with the patients GP. Dr Gee highlighted that if the WiC is closed there will be a split in care as the patients on the border will just attend a WiC in another Borough. Mr Polychronakis suggested that the patient experience is very different depending on who you speak to and varies from practice to practice. Mr Maubach reiterated to the Board that the proposal is not to close the WiC but to relocate it, so the out of hour’s service will still be there. He stressed the importance of understanding what “good access” looks like and suggested to the Board that a piece of work is carried out, with the Local Area Team and patient groups to establish what is “good access”. Dr Hegarty echoed the importance of this work and that although Councillors speak on behalf of their constituents, it is important to utilise the varying opinions through evidence and not just what the Councillors are saying. Resolved:

1) The Board noted the content of the video presentation 2) The Board approved the suggestion of working with the Local Area Team and Patient

Groups to establish what is “good access”.

STRATEGY

CCG75/2013 STRATEGIC PLAN TIMETABLE

Mr Maubach spoke to this timetable and reported that as previously mentioned the Commissioning Intentions have been published and consultation is now taking place in various forms as a precursor to developing the CCG’s Strategic Plan. The plan will be expected to cover the CCG from 2014/15 and 2015/16 in detail and as well as an outline until 2019/20. Key dates are: The CCGs allocations and planning guidance will be issued December 2013

First cut plan to be considered by the Board January 2014

Discussion with the Health & Wellbeing Board and submission to NHS England January 2014

Further submission of plan to the CCG Board March 2014

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The supporting Financial Plan to be submitted to the CCG Board April 2014

The Board was asked to consider and approve the planning timetable outlined and note that engagement will take place through healthcare forums; locality meetings; membership events and other consultation events. Resolved:

1) The Board considered and approved the planning timetable

2) The Board will receive a “first cut plan” at the January 2014 Board

QUALITY & SAFETY

CCG76/2013 REPORT FROM QUALITY & SAFETY COMMITTEE

Dr Pope spoke to this item and informed the Board that the report is based on the Quality & Safety Committee meetings held on the 24th September and the 22nd October 2013. Dr Pope spoke to some headline items, The nine complaints regarding Continuing Healthcare are regarding funding requests that have been declined and so these are around appeals for healthcare. Three complaints for CCG and these relate to Individual Funding Requests that have been declined. Healthcare Acquired infections There is an issue with regards engaging clinicians and therefore Dr Rees, Consultant Microbiologist at DGFT has been appointed. A lot of work is being done and hopefully results with show soon. Dr Pope reported that the Committee were informed that the roll out of the Significant Event Analysis Tool for C-Diff Never Events Dr Pope reported that the table top review of the Never Event that occurred in July took place on the 25th September and the review has resulted in its downgrade to a serious incident. It was an equipment failure and DGFT have changed the way they use this equipment and have shared that learning with other Trusts. Pressure Ulcers It was noted that the report states no pressure ulcers were received in 2013 but that was incorrect and it should have said no grade 3 or 4 pressure uclers have been received in 2013. With regards to process for reporting the pressure ulcers, this is now being taken through contracting so that the report is made when the Trust discovers the pressure ulcer rather than when they have gone through the Root Cause Analysis. Cancer Audit DGFT were noted to be in the bottom 10 of the patient experience as regards the cancer audit. Quite a lot of work has already been done on this in the last 10 months. Keogh Report Further work is being done and concerns have been raised about the inaccuracies in the report. Safeguarding Lead Dr Pope informed the Board that an advert had gone out for a safeguarding GP Lead, 2 sessions per week. OFSTED The CCG is expecting an Ofsted visit at some point soon and a lot of work has already been done in preparation. Pauline Owens, Safeguarding Children’s Lead, is planning to make a presentation on how the GPs need to feedback to social services when there are concerns around child welfare.

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Risk Report The CCG had been informed that another individual is leaving the Quality and Safety Team at the CSU and there is a risk about continuity within the team and the Committee had requested that this be added to the risk register. Due to difficulties with support in getting the old PCT policies rewritten, the Quality and Safety Committee had agreed for the policies then be extended until 31 January 2014. Mr Polychronakis and Ms Little asked why the Black Country Partnership Foundation Trust (BCPFT) is not providing any data in relation to complaints. Miss Bartholomew said discussions are with taking place with BCPFT about how, if the Trust is unable to split the complaints, they need to provide them all and extract the Dudley ones. Mr Polychronakis stated this should be a simple request. The Board agreed to have this information for its next Board meeting and if this does not happen, the matter must be raised higher. Mrs Saviour raised the issue that there were no Primary Care complaints included. Dr Pope reported she is working with the Area Team to get this information. Mrs Saviour said that she would liaise with her colleague to progress this. Dr Edwards asked if there would be a conflict of interest with the CCG receiving complaints regarding Primary Care. The proposal was made that it would be anonymised within the report. Dr Hegarty asked whether the trajectory of C-Diff indicated Dudley Group Foundation Trust will breach its target at year end. This was unclear. It was noted that a number of CCGs are using an avoidable/unavoidable tool through the CSU. The CCG was considering whether to use this tool. Dr Heber fully supported that the Trust has appointed the Consultant Microbiologist. She asked if the Consultant had a seat on the Trust Board, as this is crucial to gaining support. Also how much the role is supported by the Medical Director. Dr Hegarty confirmed that this would be followed up. Dr Hegarty expressed real concern about how as a Board, it can be assured that DGFT are doing everything they can. Dr Pope said that many of the C-Diff cases are in Primary Care and work is being done to address that. In terms of support of Dr Rees this will be discussed and the issue of her being present on the Trust Board will be raised. Resolved:

1) The Board noted the report for assurance

2) The Board stressed the importance of BCPT supplying the information required

3) The Board asked for the Consultant Microbiologist to be on the Acute Trusts Board

4) The Board agreed that the revised policies with be extended until January 2014

COMMISSIONING

CCG77/2013 REPORT FROM CLINICAL DEVELOPMENT COMMITTEE

Mr Bucktin spoke to this item in the absence of Dr Mann and informed the Board that the report was based on the Clinical Development Committee meetings held on the 25th September and the 23rd October 2013. He confirmed that the meeting on the 25th September was inquorate however no items were considered that required any decisions. Mr Bucktin confirmed that in relation to Local Quality Premiums, evidence suggests that sufficient progress is being made in relation to hypertension and dementia targets. However there are concerns around atrial fibrillation but a plan is being drawn up in conjunction with the Office of Public Health. Mr Bucktin drew the Board’s attention to the development of the pathway for adult autism which Dr Mahfouz is leading on. This has been agreed at the committee and this will be launched in early December. Resolved:


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CCG78/2013 INDIVIDUAL FUNDING REQUESTS

Mr Bucktin spoke to this item on behalf of Dr Mann and informed the Board that the Individual Funding Request Policy (IFR) is being used by all CCGs in the Birmingham, Black Country and Solihull Area Team. The process has been checked by Mills and Reeve Legal Advisers and training sessions have been run for participants. The process must be in place to allow consistent, informed decisions to be made including documenting the evidence considered, accompanying discussion and reasons for decisions. This will prevent any legal litigation should a decision be challenged. It was noted that there was a proposed membership for the IFR panel and concern was raised that there was no lay involvement on the panel. A suggestion was made that one of the panel members should be a lay representative. Mrs Jasper observed that the guidance on the panel asks for employees of the CCG yet none of the suggested panel members are employees. The Board agreed that this was the right approach. It was agreed that the members on the IFR panels need to be considered as a sub-committee of the Board and there must be trust in those panel members as they are making decision on behalf of the CCG. Mr Wellings reiterated that from a governance perspective, if you have an appeals panel, it is a collective responsibility of that panel to make the decision and provided the policy is followed and is impartial and fair, then their decision should be final. Mrs Jasper suggested that some shadowing sessions be held for those people who are asked to sit on the panel and Mr Bucktin confirmed that some training is scheduled for January. Mr Polychonakis confirmed that no one should sit on the panel unless they have had the training. Resolved:

1) The Board approved the IFR Policy

CCG79/2013 HEALTH & WELLBEING BOARD REPORT

Mr Bucktin spoke to this item and updated the Board on the matters considered at the Dudley Health & Wellbeing Board which were as follows:

Cllr Stuart Turner has now been appointed as the Chair of the Health & Wellbeing Board for the municipal year 2013/14. Other elected members serving on the Board will be Cllrs David Brandwood, Tim Crumpton and Peter Miller

noted the systems in place to provide assurance in relation to Quality & Safety

considered the action plan developed by Dudley Group Foundation Trust in response to the Keogh Review

noted the progress in relation to the local health and social care economy’s response to events at Winterbourne View

considered the annual reports of the safeguarding boards for adult and children services

approved the CCG’s Primary Care Strategy

approved proposals for the use of £5.589m to be transferred from the NHS to Dudley MBC by NHS England and noted the national announcement in relation to the development of the Integration Transformation Fund

noted the publication of the NHS England “call to action”

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received an update on progress with the development of Healthwatch Dudley

held three “spotlight events” on urgent care, healthy lifestyles and healthy children. Feedback will go back to the Health and Wellbeing Board.

Dr Hegarty highlighted the work that is taking place with the Health & Wellbeing Board with regards the Urgent Care Consultation. Mrs Saviour congratulated the CCG on how well the Primary Care Strategy had progressed, and commented that not many CCGs are at this point. Resolved:

1) The Board noted the report for assurance.

COMMUNICATIONS & ENGAGEMENT

/20COMMISSIONING

CCG80/2013 REPORT FROM COMMUNICATIONS AND ENGAGEMENT COMMITTEE

Mrs Jasper spoke to this item and confirmed that the report was based on the meeting held on the 15th October 2013 which was inquorate. The report included details of the key discussions including the Social Media Policy and guidance; the Patient Experience Strategy; and engagement around the CCGs Urgent Care Consultation. Mrs Jasper confirmed that the summary table detailed progress in key areas around the CCGs Communication and Engagement Strategy. As the Committee was not quorate the Board was asked to approve the following:

1) To agree the Patient Experience Strategy 2) To agree the Committee’s suggestions with regards risks 3) To agree the Social Media Strategy and staff guide

Mrs Jasper also highlighted that there are over 50 urgent care consultation events taking place and clinical involvement is crucial. She asked if as many clinical colleagues as possible could be involved. She assured the Board that a Winter Communications plan is in place. Mrs Jasper confirmed that two development sessions had been held for Patient Participation Group (PPG) members. 12 people attended and found the sessions extremely useful and informative. Mr Maubach raised the risk around patient experience being maintained through the CSU, confidence is increasing but there are still areas of concern. He confirmed that this is on the risk register. Ms Cartwright informed the Board that on the 5th December there is a PPG being held and asked if she could have representative from the Board to support Mrs Jasper at the meeting. Dr Johnson raised a concern about CCGs being charged for systems they helped to develop. He felt this went against sharing good practice. Mrs Saviour acknowledged his concern but sometimes this happened due to Procurement rules. Resolved:

1) The Board noted the report for assurance 2) The Board approved the Patient Experience Strategy 3) The Board approved the Committee’s suggestion with regards risks 4) The Board approved the Social Media Strategy and staff guide

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GOVERNANCE

CCG81/2013 REPORT FROM AUDIT COMMITTEE

Mr Hartland spoke to this item and confirmed that the report was based on the meetings held on the 26th September but also sought approval for three matters discussed and agreed at the Audit Committee on the 31st October 2013. The Board was asked to approve: Changes to the CCG Constitution There were a number of proposed changes that will not have a material impact upon the governance arrangements of the CCG, but are necessary alterations that are required to reflect the CCG operating in practice. Dr Horsburgh from the LMC had been sent the changes for comments. Disposal of Premises/Property Mr Hartland reported that the ownership and management of most properties previously held by Dudley PCT transferred to NHS Property Services Ltd from the 1st April 2013 and they manage the estate on behalf of the NHS. The Board is required to approve the disposal of these premises and it also provides an opportunity for the CCG to express any interest in the premises before they are disposed of. The premises under consideration were:

Wolverton House (lease)

Room in Stepping Stones Medical Practice (lease)

Falcon House (Ground floor and 5th Floor) (lease)

St Johns House (lease)

Kings House (lease)

Ridge Hill Site/Gorstyfields (owned)

Willows Respite Care (owned)

Ms Little expressed her disappointment in the amount of money invested in Wolverton House and in such a deprived area of Dudley for it now to be disposed of. Mr Hartland indicated that NHS Property Services works with the Premises Investment Committee which is run by the Local Area Team and therefore there may be an opportunity for them to look at the list. This will give them the opportunity to consider the lease for Wolverton House. Mrs Saviour confirmed she would check with her team as to whether they have seen the list of premises and consideration would be given to deprived areas. She also confirmed that they have no growth in relation to premises this year Procurement Strategy Mrs Jasper confirmed that the CCG is required to have a Procurement Strategy adopted by the Board. There is an intention to update the Strategy once future advice is received from Mills and Reeve. Chair of the Audit Committee Mr Wellings raised the potential conflict of interest with regards him being Vice Chair of the Board and Chair of the Audit Committee, therefore the Audit Committee Chair is now Mrs Jasper. National guidance indicated that the CCG Governance Lead, a role fulfilled by Mr Wellings, should be the Chair of the Audit Committee which was inconsistent with Mr Wellings role as Vice Chair. Legal advice had been sought and this confirmed that there was no problem with Mr Wellings being the Vice Chair of the Board and Mrs Jasper being the Chair of the Audit Committee. Resolved:

1) The Board noted the report for assurance 2) The Board approved the changes to the Constitution as detailed 3) The Board approved the disposal of premises listed 4) The Board approved the Procurement Strategy in its current form, however a further

iteration may follow.

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CCG82/2013 COMBINED BOARD ASSURANCE FRAMEWORK & RISK REGISTER

Mr Hartland spoke to this item and reported that this paper updated the Board on the recently combined Board Assurance Framework (BAF) and Risk Register. This represented the outcome of the detailed work that had been undertaken between the CCG’s committees, the CSU Governance Team and the CCG Interim Governance Support. Those risks that were developed by the CCG Board as part of the BAF remain unchanged. However, following a thorough review of all of the legacy risks on the Risk Register, many of these have been refreshed and a number have been removed as they were no longer relevant or duplicated. Those risks with an initial or residual score of 16 or higher were presented to the Board. This was based on the BAF as at May 2013 and the Risk Register as at 9 October 2013.

Risks above 16 Comments

9. Risk of poor relationship management with the Area Team through the transition/bedding down resulting in breakdown of relationship with GPs and/or disconnected primary care/medical service priorities

Mitigated by the interface group and so the risk has been reduced

36. Failure to achieve whole of Quality Premium resulting in lost income and reputational damage.

That will be discussed further in the financial report – risk will remain until further assurance is received

39. Lack of a systematic approach to ascertaining the quality of the care in our commissioned nursing homes, potentially resulting in harm to vulnerable adults.

Due to Nursing Homes and Miss Bartholomew is mitigation this through the Quality and Safety Committee. Miss Bartholomew updated that work has commenced in the appropriate homes.

Mr Maubach asked for it to be noted that Risk No 8 had been mitigated now and Mr Hartland confirmed that this would be reflected in the next report to Board. Mr Maubach raised that at the last Board meeting a risk with regards Electronic Prescribing was discussed, however he reported that this was not showing in the latest Risk Register. Mr Hartland agreed to follow this up as this matter had been discussed at the Quality and Safety Committee. Resolved:

1) The Board noted the report for assurance 2) The Board agreed that the risk with regards Electronic Prescribing will be checked.

FINANCE & PERFORMANCE

CCG83/2013 REPORT FROM THE FINANCE AND PERFORMANCE COMMITTEE

The report summarised the key issues discussed at the Finance and Performance Committee at its meetings on 26th September and 24th October 2013. Statutory Financial Duties The Committee noted that the CCG was on target to achieve all statutory financial duties by 31st March 2014. Mr Wellings took the Board through some of the main risks facing the CCGs financial position:-

Non-delivery of 2% non-recurrent spend plans. At the September assurance meeting the Area Team confirmed that the 2% non-recurrent reserve could be committed against CCG non-recurrent spending plans. There is a risk that the spending plans will not be delivered by 31st March 2014 but the plans are being actively managed to ensure they are. Mr Wellings reported that some of this non-recurrent spend will be invested in a Primary Care Incentive Scheme.

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Property Services – CCG Commissioned Space. There still remains a resulting cost pressure following the transfer of buildings and services to NHS Property Services (NHSPS) and Community Health Partnerships (CHP). The charges received for 2013/14 are in excess of the budget allocation by £627,000 due to the apportionment of central costs and overheads. This continued to be challenged with the NHSPS/CHP, but the risk remained.

The extent of slippage against non-delivery of cash releasing savings. The QIPP programme at its current level must be delivered. It may also need to increase dependent on the mitigation of the risks above. At present there are sufficient reserves within the CCG to accommodate this risk should it materialise.

The CCG has entered into a risk sharing agreement to cover the collective West Midlands NHS 111 deficit due to under-activity on the NHS 111 contract and the requirement for non-recurrent re-commissioning of services in 2013/14. The CCG’s proportion is currently £52,000 and there is a risk it could increase, although it is not expected to be significant. Work is underway to identify any financial pressures for 2014/15.

Dr Johnson commented that the current building his practice is located in is relatively new and yet there are refurbishments taking place. Mr Hartland was not aware of these refurbishments but highlighted that this responsibility now rested with NHS Property Services. Dr Pope stated that she was unable to take responsibility for risks referred back to Quality and Safety Committee without a conversation with the Chair of the Finance and Performance Committee. Ms Little suggested clinical input was required around the outpatient activity performance. Mr Maubach confirmed that aspect is considered separately through the Clinical Development Committee. Dr Hegarty confirmed that the correct process had been followed with regards to Specialised Services with the Area Team. Dr Hegarty reminded the Board about conflicts of interest and that issues should be picked up in the appropriate forum. Mr Wellings reported that with regards performance, DGFT failed to meet the nationally required standard on two indicators for the month of August:

• Ambulance Handovers >30 minutes • Ambulance Handovers >60 minutes

To date Dudley CCG has enacted the financial penalties for 60 minute breaches but not 30 minute breaches. Dudley Group conducted an audit in April 2013 in order to compare the hospital timings with the Ambulance Service reports (currently the Ambulance Service report is the data used for performance management). The results showed that between the 30 and 60 minute timeframe, the Ambulance Service reported 23% more breaches than were recorded by the hospital. The methodology for this audit was developed in consultation with the West Midlands Ambulance Service. In response to this audit Dudley CCG will enact 75% of the >30 minute financial penalties on a monthly basis. The supporting logic for this decision is that the audit sample had a confidence interval of 2%, therefore at least 75% of breaches are likely to be genuine and indisputable. Since this report had been produced there were indications that the 4 hours wait in A&E had deteriorated and this was being followed up. Diagnostic Waits (Dudley Group Foundation Trust) DGFT performance in non-obstetric ultrasound diagnostics has deteriorated throughout the year. Despite activity falling in July and August the number of patients with waits exceeding 6 weeks have increased. The requisite financial penalties applicable for this performance breach have been invoiced and the CCG is exploring alternative capacity with other Providers.

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Quality Premium Indicators (CCG Focused Indicators) The Quality Premium Payment is £5 per registered patient. In Dudley CCG this amounts to £1,571,945. Dudley CCG is awaiting information on a number of Quality Premium indicators which makes predicting the year end achievement difficult. However, either moderate or high risk failure to meet target is apparent in some of the indicators at this point in the year, but this is expected to improve in the latter part of the year. Meeting these targets involves multiple Providers and CCG assigned indicators. Action plans are developed in relation to each specific indicator and relevant Provider. Discussion took place around the significance of DGFT not reaching the A&E targets and how the CCG will be heavily performance managed if the targets are not achieved. Dr Gee reported that there are a number of different services and departments impacting on the A&E department and Mr Maubach confirmed this.

Resolved: 1) The Board noted the report for assurance

PRIMARY CARE

CCG84/2013 REPORT FROM THE PRIMARY CARE DEVELOPMENT COMMITTEE

Dr Hegarty declared an interest in this item and stepped down from Chair, however as Mr Wellings the Board Vice Chair was presenting the paper, the role of Chair was passed to Mrs Jasper. Mr Wellings informed the Board that this report summarised the key issues discussed at the Primary Care Development Committee on 27th September 2013 and 25th October 2013. The CCG does not directly commission Primary Care Services, but it is responsible for Quality and Safety in the system and Patient Experience so it has a role in some services in Primary Care. Where there might be a conflict of interest, Mr Wellings, as a non-clinical member, takes the Chair and those GPs around the table do not take any part in the resolution of the committee but are able to comment. Patient Participation Representative The Patient Opportunity Panel (POP) would be electing a representative to sit on the Primary Care Development Implementation Group. It was noted that this election has since taken place and David Stenson has been appointed to the role. Practice Development Plans A development plan has been produced and circulated to all practices for completion in relation to the Primary Care Strategy. Primary Care Foundation (PCF) Survey A survey monkey questionnaire has been developed and circulated to all practices to follow up the learning and actions undertaken by practices in response to the PCF audit.

Locality Leadership Teams Dudley Group Foundation Trust, Dudley Metropolitan Borough Council and Dudley and Walsall Mental Health Partnership Trust have identified Directors that will work directly with locality groups to establish closer and more integrated working between the providers and member practices through the locality meetings. Innovation Fund The Committee noted that the CCG’s innovation fund would be equally divided and devolved to locality groups for innovation ideas and projects to be considered by the CCG.

GPwSI Development 2 of the 5 GPs with Special Interest posts have now been developed and advertised. Following procurement advice from Mills & Reeve Legal Advisers, member practices have been identified to host the employment for these posts, underwritten by the CCG.

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Primary Care Incentive Scheme With regards the Primary Care Incentive Scheme, Dr Hegarty stepped down as Chair for this item. A working group of the Committee has been established to develop an incentive scheme that will utilise non-recurrent resource to support and develop those key areas identified within the Primary Care Development Strategy for improving access and patient experience, and commissioning performance within each practice. The working group was led by a lay member of the CCG Board with involvement from the Local Medical Committee. The final version of the incentive scheme would be presented to the Committee in November. Mr Wellings confirmed that he chaired the group. Mr Maubach confirmed that there is a meeting with the Local Area Team to discuss this further as the CCG requires their oversight on the incentive. IT Strategy The Committee accepted the recommendation that the development and implementation of the IT strategy would be overseen by the Finance & Performance Committee. All aspects of the Strategy in respect of Primary Care would continue to be shared and discussed with the Primary Care Development Committee. Resolved:


Please note the 2014 Board Dates. A refreshed Corporate Diary will be sent out to everyone. Thursday 9 January Thursday 13 March Thursday 3 April (Extraordinary Board) Thursday 8 May Thursday 10 July Thursday 11 September (AGM) Thursday 13 November DATE OF NEXT MEETING Thursday 9th January 2014 1pm – 5pm Boardroom, Conference Centre, Brierley Hill Health & Social Care Centre MINUTES ACCEPTED AS A TRUE AND CORRECT RECORD

Name Title

Signed Date

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MATTERS OUTSTANDING

UP TO THURSDAY, 9th JANUARY 2014 – PUBLIC BOARD MEETING

ITEM NO AGENDA ITEM ACTION TO BE TAKEN ACTION FOR DEADLINE

CCG61/2013 NORTH WEST MIDLANDS PATHOLOGY PROCUREMENT

The Board would require an update at the next Board in January Mr Neill Bucktin Update at January Board

CCG72/2013 QUESTIONS FROM THE PUBLIC

The Board agreed that a message would be sent out confirming that questions could be sent in to the Board meeting on behalf of a member of the public who may not be able to attend

Mr Richard Haynes

Update at January Board

CCG73/2013 CHAIRS REPORT – PHYSIOTHERAPY SERVICES

The Board agreed that a clear statement would be published informing the public that the CCG was not involved in the changes to the Physiotherapy service

Mr Richard Haynes


CCG75/2013 STRATEGIC TIMETABLE The Board will receive a “first cut plan” of the Strategic Timetable at the January 2014 Board

Mr Paul Maubach


CCG82/2013 COMBINED BOARD ASSURANCE FRAMEWORK AND RISK REGISTER

The Board agreed that the risk with regards Electronic Prescribing that does not appear to be on the register will be looked in to further and updated at the next Board.

Mr Matthew Hartland


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Date of Report: 9th January 2014 Report: Urgent Care Consultation Outcome

Agenda item No: 8.1

TITLE OF REPORT: Urgent Care Consultation Outcome

PURPOSE OF REPORT:

To provide Board members with an overview of consultation activities undertaken and assure them that the CCG has fulfilled its statutory obligations to properly consult on proposed changes to the urgent care system To provide a summary of feedback received

AUTHOR OF REPORT: Richard Haynes, Interim Head of Communications and Engagement

MANAGEMENT LEAD: Richard Haynes, Interim Head of Communications and Engagement

CLINICAL LEAD: Dr Steve Mann

KEY POINTS:

• The consultation ran from 1 October to 24 December 2013 • It generated a considerable amount of interest and comment • Key themes to emerge are summarised in this report and will be used

to inform the development of future services (see separate report on Urgent Care Reconfiguration)

RECOMMENDATION:

Board members are asked to note the consultation activities set out above by way of assurance that the CCG has fulfilled its statutory obligations to properly consult on proposed changes to the urgent care system

Members are also asked to note the feedback received and take it into account when agreeing next steps in developing an improved urgent care system for the people of Dudley

FINANCIAL IMPLICATIONS: Costs of the consultation exercise were met from the communications and engagement budget

WHAT ENGAGEMENT HAS TAKEN PLACE:

The report covers a wide range of engagement activities, before and during the consultation as well as outlining next steps on communication and engagement to support the delivery of improvements to urgent care in Dudley

ACTION REQUIRED: Decision Approval Assurance

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9 JANUARY 2014 URGENT CARE CONSULTATION OUTCOME INTRODUCTION This report focusses on the formal consultation carried out by NHS Dudley Clinical Commissioning

Group between 1 October and 24 December 2013 on proposed changes to the local urgent care system.

It summarises the background to, and context of, the consultation, the steps taken by the CCG in the

pre-consultation period and the activities carried out during the consultation period. It also sets out some

of the key issues to be raised by individuals and groups who responded to the consultation.

Given the very short time between the end of the consultation period and the production of this report, it

is suggested that further detailed analysis of the consultation feedback be included as part of the

development of any specification or performance criteria for future developments on urgent care in

Dudley.

The purpose of this report is to:

• Provide Board members with an overview of consultation activities undertaken by way of assurance

that that the CCG has fulfilled its statutory obligations to properly consult on proposed changes to the

urgent care system

• Provide Board members with a summary of feedback received from the consultation

REPORT

Background and Context The decision to begin a consultation on urgent care was prompted by the imminent (March 2014) need

to retender the current contracts for the Holly Hall walk-In Centre and Out of Hours GP Service.

Against a background of: Growing pressure on A&E; increasing demand for primary care services;

concerns over the recently launched 111 telephone service and the restructuring of the NHS as a result

of the Health and Social Care Act, a decision was made to use the ending of these contracts as an

opportunity to take a wider look at urgent care services in Dudley.

To allow time for these complex matters to be considered in detail and discussed with the local

population, the contract was extended by a further six months (to the end of September 2014) pending

the outcome of a public consultation and further analysis of service requirements and patient flows.

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The CCG’s Statutory Duties in Regard to Involvement and Consultation

The legal duty to consult The law requires NHS bodies to engage with members of the public before making decisions on

changes to health services. Currently, separate sections of the NHS Act apply to CCGs and to other

organisations.

CCGs are governed by section 14Z2 of the NHS Act 2006, which states:

(1) This section applies in relation to any health services which are, or are to be, provided pursuant

to arrangements made by a clinical commissioning group in the exercise of its functions

(“commissioning arrangements”).

(2) The clinical commissioning group must make arrangements to secure that individuals to whom the

services are being or may be provided are involved (whether by being consulted or provided with

information or in other ways):

(a) in the planning of the commissioning arrangements by the group,

(b) in the development and consideration of proposals by the group for changes in the commissioning

arrangements where the implementation of the proposals would have an impact on the manner in which

the services are delivered to the individuals or the range of health services available to them, and

(c) in decisions of the group affecting the operation of the commissioning arrangements where the

implementation of the decisions would (if made) have such an impact.

There are two other relevant aspects to section 14Z2. Subsection 3 requires all CCGs to include in their

constitution a description of their public engagement arrangements and a statement of the principles that

they will follow in when implementing them. Subsection 4 empowers NHS England to publish guidance

on compliance with this section, which CCGs must have regard to.

The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 deal with the statutory duty to consult a local authority, and the powers of the local

authority to report to the Secretary of State if it is not satisfied with the CCG’s proposals or consultation.

The regulations came into effect on 1 April 2013.

Section 23 in Part 4 of these regulations requires a CCG to consult a local authority when it has under

consideration any proposal:

• for a substantial development of the health service in the area of the local authority; or

• for a substantial variation in the provision of such service.1

1 Substantial variation is not defined, but ultimately the OSC will decide if it cannot reach agreement with the CCG; so early discussion with the OSC should be helpful

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Guidance The most recent guidance on consultations for the NHS was published in September 2013 by NHS

England, and is called Transforming Participation in Health and Care.

The guidance sets out a number of suggested features of public participation. The information provided

should be of good quality, and in a number of different formats to ensure that it reaches the intended

target. There should be a range of opportunities for participation, which could include online surveys and

dedicated local events, as well as work through voluntary and community sector organisations. Patients

and the public should be involved from the initial planning stages of service redesign, and special efforts

should be made to reach out to diverse communities. Pre-Consultation Activity and Other Relevant Work Following its formal establishment in April 2013, the CCG was involved in a number of important pieces

of work to support its vision of working with partner organisations to improve health outcomes and

reduce health inequalities for the people of Dudley.

This work influenced in a number of important ways the consultation on urgent care, and it is for that

reason they are included in this report.

Primary Care Strategy The CCG’s Primary Care Development Strategy (approved by the Board in July 2013) aims to support

local GP practices to further improve the quality of primary care. As a clinically-led membership

organisation, Dudley CCG is uniquely placed to deliver change and improvement in primary care. The

strategy aims to build on this opportunity, whilst acknowledging the freedoms and restrictions of the new

NHS arrangements for the direct commissioning of primary care.

The priorities set out in this strategy are based on:

• What member practices told us about their key concerns and how these should be addressed

• What patients and our local communities told us about their current primary care services

• The CCG’s agreed strategic aims and priorities (and those of Dudley’s Health and Wellbeing Strategy)

• The national ‘must do’s’ and performance management requirements.

The biggest single issue raised by patients and members of the public during the development of the strategy was access to GP appointments – in particular same day appointments – and telephone access to practices. The strategy also recognises the positive impact that improved primary care access can have on reducing pressures on the urgent care system.

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Dudley CCG Healthcare Forum – June 2013 The CCG dedicated this meeting of its regular public forum to discuss views and perspectives on urgent

care in Dudley.

The main feedback that we received at this event was as follows:

• There was a suspicion about the quality of; and lack of confidence in; the NHS 111 system

• Concerns were expressed about needing immediate advice/reassurance for ill children

• There was a perception that if an ambulance takes you to A&E you get seen quicker

• Some people need a point of contact for reassurance which could often be all that is needed to avoid

them feeling the need to dial 999

• There was a desire for improved access to primary care outside of routine work hours

• There was an expressed preference to simplify the number of points of access and the signposting to

services

• To have a system that gave more effective triaging so there is more right care, at the right place, at

right time

• There should be patient education at an early age on how to use the urgent care services and there

should be 24/7 access to health advice

Health and Wellbeing Board ‘Spotlight on Urgent Care’ – June 2013 The Health and Wellbeing Board has produced a Health and Wellbeing Strategy for Dudley Borough with

five strategic priorities:

• Making our services healthy

• Making our lifestyle healthy

• Making our children healthy

• Making our minds healthy

• Making our neighbourhoods healthy.

The Board agreed to hold five ‘spotlight’ sessions, involving Board members and other stakeholders,

throughout 2013/14, to stimulate fresh thinking in these areas, generate ideas and maximise the added

value from integrated approaches and partnership working.

On 18 June 2013, the first spotlight session was held on ‘urgent and emergency care. Feedback from

the Healthcare Forum event mentioned above was incorporated into discussions at the Spotlight Event.

Outcomes from the Spotlight Event included agreement on a set of key principles relating to a good

urgent care system, including:

• A joined up, coordinated and seamless system, fluid- no ‘bottle necks’

• A simple system-no confusion for the public ( or professionals) of what to do, who to call or where

to go

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• Safe, responsive and high quality One of the solutions identified was to work to simplify the urgent care system, reduce duplication and develop a system which responded to patients’ ‘default behaviour.’ Specific proposals included “co-locate the walk in centre, with the emergency department.”

Engagement with Members

One of the key differences between the CCG and the Primary Care Trust (PCT) which preceded it is that

the CCG is a membership organisation, led by the GPs who comprise its membership.

That clinical leadership was reflected by the development of the proposals through discussion at a series

of events for GPs – a round of locality meetings (GPs grouped together by geographical location)

followed by a CCG-wide Members’ meeting in September.

Views expressed at these meetings gave clear guidance to the CCG management team that members

did not feel the current walk-in centre arrangements offered the best service to patients during normal

working hours.

The majority of GPs were in favour of relocating walk-in services and co-locating them with the

emergency department at Russell’s Hall, in line with the proposals from the Health and Wellbeing

Board’s Spotlight Event referred to above. They were also supportive of investment to improve access to

primary care during core working hours, in line with the objectives of the CCG’s Primary Care Strategy.

Reports to Health Scrutiny Committee An initial report was presented to Dudley Borough Council’s Health Scrutiny Committee on 25

September 2013, ahead of the launch of the consultation. CCG Chief Officer Paul Maubach and Dr

Steve Mann, clinical lead for urgent care, were present to answer members’ questions directly.

THE CONSULTATION The consultation was launched on 1 October 2013 with an end date of 24 December.

Consultation document A 12 page full colour consultation document was produced by the CCG’s communications and

engagement team. The consultation form was available in hard copy and electronic versions as well as

an ‘easy read’ version. It included a freepost response form.

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An estimated 5,000 hard copies were sent out by the CCG during the consultation period through a wide

range of distribution channels including: GP Practices; healthcare centres; Dudley HealthCare forum

members; Halesowen Older People Forum; Dudley Youth Council; Dudley and Stourbridge College;

Dudley Age Concern; Dudley Carers Forum and numerous other health and other community groups.

By the closing date of the Consultation (24 December) the CCG had received a total of 1390 completed

forms

Online Survey An online survey, using Survey Monkey software was available through the CCG website throughout the

consultation

By the closing date of the Consultation (24 December) the CCG had received a total of 1388 responses

to this survey.

Meetings Over the course of the consultation GPs and senior managers from the CCG had attended more than 40

meetings of local patient, service user and community groups to talk about the proposals and hear first-

hand what local people think of them.

Total attendance at these meetings was more than 1,000 people

Drop In Sessions As well as actively seeking invitations to local organisations, the CCG also hosted its own series of drop-

in sessions, at GP practices or other community locations, as follows:

• 17 October ,12pm to 2pm – Sedgley Ladies Walk

• 7 November, 12pm to 2pm – Worcester Street Surgery

• 15 November, 12pm to 2pm – Halesowen Library

• 28 November, 12pm to 2pm – Brierley Hill Health and Social Care Centre

• 30 November, 12pm to 4pm – Insight House, Pearson Street, Brierley Hill

• 12 December, 12pm to 2pm – Dudley Council Plus, Dudley

• 12 December, 6.30pm to 8pm – Stourbridge Town Hall

• 17 December, 6.30pm to 8pm – Main Hall, Dudley College, Dudley

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The evening sessions in December were added to the original programme in response to concerns

raised during the consultation (from Health Scrutiny Committee members amongst others) that it would

be better to offer meetings at different times of the day.

Despite publicising these sessions widely (including a series of paid for newspaper adverts), attendance

was not as good as at the other community group meetings, although discussions were generally very

productive and produced useful insights. This is consistent with experience in other consultation

exercises.

Healthcare Forum: Members of the Healthcare Forum were given an update on the urgent care

consultation at their meeting on 3 December. Members present noted that they had previously called for

a more simplified system of urgent care and responded positively to the proposals in the consultation.

Website and Social Media All the consultation materials were made available via a dedicated section of our

website www.dudleyccg.nhs.uk and we also used our social media platforms (Facebook and Twitter) to

broaden the range of opportunities that local people had to take part in the conversation about what they

want from their urgent care services.

In addition, we hosted two live ‘webchats’ – one with urgent care clinical lead Dr Steve Mann and one

with Chief Officer Paul Maubach.

‘Feet on the Street’ Feet on the Street is the name for our regular ‘vox pop’ videos, recorded in local communities by our in-

house engagement team. The team took to the streets twice during the consultation period to produce

two separate short films to capture views on urgent care services and our consultation.

These films were screened at the CCG’s Board meetings in October and December and they were also

used at members meetings and the meetings of the Task and Finish Group.

Media Coverage We issued a series of proactive press releases during the consultation period as well as responding

reactively to a number of media inquiries as well as arranging for coverage in the local talking

newspaper.

There was significant media interest in our plans, with front page coverage in the Express and Star on

the launch of the consultation, and a number of follow-up pieces elsewhere in the local media.

http://www.dudleyccg.nhs.uk/

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We also used paid-for advertising in the local press to raise awareness of the drop-in sessions

Report to Health Scrutiny Committee An update report was presented to the Health Scrutiny Committee meeting on7 November 2013.

CCG Chief Officer Paul Maubach attended the meeting to answer members’ questions directly.

Task and Finish Group A Task and Finish group was established with invited representatives from the CCG, Healthwatch,

Dudley CVS, local Patient Participation Groups (PPGs), Dudley Council and Dudley Group’s public

governors.

The group met twice during the consultation period and identified a number of key issues which have

been fed into the key themes and issues set out below.

Healthwatch Survey Healthwatch Dudley were commissioned to carry out a targeted research exercise talking to service

users at Russell’s Hall A&E and the Walk-In Centre in November.

Over a period of seven days, from 29 November – 5 December, space of a week, Healthwatch

volunteers spoke to more than 900 people about their experiences and their reasons for choosing the

service they were using.

Many of the themes which emerged during these interviews are also reflected in the key themes and

issues set out below, but given the very targeted and specific nature of this piece of work, a copy of their

initial report is also attached as Appendix 1.

The report (p18) identifies a significant number of patients using the Walk-In Centre to fill “a gap in

doctors surgery provision” with the majority of patients surveyed agreeing that a doctors’ surgery could

have helped them with the issue which had brought them to the Walk-In Centre. Given the possible

scenarios we have been modelling, it is also interesting to note that in response to a specific question,

“449 patients said they would be happy to be referred back to a doctors’ surgery for treatment after

assessment…” (p5)

Independent evaluation Shortly after the midpoint of the consultation, we commissioned an independent evaluation of the

consultation activities and materials to provide assurance that the process was robust and inclusive.

The review was carried out by Richard Miles, a highly experienced consultant who has worked on both

NHS consultations and with Scrutiny Committees. His review included 1-1 interviews with key clinicians

and CCG managers as well as an in-depth review of the consultation activities and supporting materials.

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His conclusion supported our view that up to the end of the consultation period we had fulfilled our

statutory obligations on consultation and involvement, while also reflecting both the challenge that we

faced in developing and communicating a detailed vision for the future of urgent care services during the

consultation period, rather than having a clearly defined service model set out at the beginning of the

consultation period; and the challenge that we now face in pursuing a service improvement for the

people of Dudley that addresses concerns expressed during the consultation, and overcomes the

constraints of different funding streams for primary care services.

Petitions We are aware of two separate petitions, both protesting against the ‘closure’ of walk-In Centre services.

A petition against the closure of the walk-in centre has also been launched by Natasha Millward,

Labour's prospective parliamentary candidate for Dudley South. That petition is still live and can be seen

on-line at http://www.natashamillward.org.uk/keep_our_walk_in_petition Ian Austin MP (Labour, Dudley

North), and Pat McFadden MP (Lab, Wolverhampton South-East) have also been promoting this petition.

At the time of writing this report (7 January) the petition had 747 signatures.

On 16 December, Chris Kelly MP (conservative, Dudley South) petitioned the House of Commons, as

follows: “The Petition of residents of Dudley South, Declares that the Petitioners believe that proposed

closure of the Dudley Borough Walk-in Centre at Holly Hall Clinic, 174 Stourbridge Road, Dudley DY1

2ER, by Dudley Clinical Commissioning Group should not go ahead; further that the Petitioners believe

that, with its 08:00 to 20:00 opening hours, seven days a week, the walk-in centre currently provides a

vital out-of-hours service for hardworking people in the Dudley Borough and the wider Black Country,

especially on weekday evenings and at weekends; further that the Petitioners believe that the

accessibility of the walk-in centre service contributes significantly to a reduction in the number of

Accident and Emergency visits which reduces pressure on local A&E services such as those at Russell’s

Hall Hospital.

The Petitioners therefore request that the House of Commons urges the Government to urge Dudley

Clinical Commissioning Group to keep the Dudley Borough Walk-in Centre open.”

This petition will be sent to the Department of Health, which will be required to make observations on it

that will be posted in Hansard.

Next Steps Subject to the outcome of discussions at this Board meeting, we will take an update on the Consultation

to the next meeting of the Health Scrutiny Committee on 23 January.

http://www.natashamillward.org.uk/keep_our_walk_in_petition

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Following that, our proposals for the new service, will go the Health and Wellbeing Board for

endorsement on 28 January.

We will then hold a public feedback event on 13 February to offer everyone who has taken part in the

consultation exercise an opportunity to hear what we are proposing to do as a result of what they have

told us.

The information received during the Consultation will be used to support the development of the

specification and procurement process for any future service. (See also the report to this meeting of the

Board on Urgent Care Reconfiguration)

Key Themes and Issues Raised During Consultation From the thousands of responses to set questions and ‘free text’ submissions received, a number of

themes and issues emerged at a very early stage and were topics of consistent interest and discussion

throughout the consultation. They are summarised below.

How would a perfect Urgent Care service work for you? The survey asked respondents to consider

how a perfect urgent care service would work for them. This was an optional question. It should be

noted that ‘urgent care’ meant different things to different people – but by far the most common issue

raised was people’s desire to be seen, or given advice, quickly when they had an urgent need. This point

was reinforced at many of the drop-in sessions and other meetings

A significant number of people also used this question as an opportunity to question the need for

change, which is consistent with the point below (but should also be read in context with the clear and

strong demand for improved access to GP services) Need for Change: Approximately 45% of respondents expressed the view that there was no need to

change the current urgent care system (against 30% who felt there was a need for change and 25% who

were unsure). In terms of support for our proposals, just over 49% agreed or strongly agreed with them,

while just under 51% disagreed or strongly disagreed.

Proposal to relocate services from Holly Hall: Of those who questioned the need for change, a

significant number of responses praised the quality of services provided at Holly Hall and questioned

whether ‘closing’ the Walk-In Centre would improve healthcare locally. A number of respondents stated

that any replacement service should be at least as good as that which is currently provided.

Respondents also highlighted the convenience and accessibility of Holly Hall.

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Problems with primary care access was another key factor for those who opposed change. Comments

included ‘service is important when it is impossible to get access to own GP’ and ‘waiting times to see a

GP will get worse.’ Many people expressed concerns about GPs’ ability to manage an increased

caseload resulting from the changes.

Proposals for an Urgent Care Centre: Throughout the consultation period we were challenged very

robustly to explain how the ‘Urgent Care Centre’ mentioned in the consultation document would work in

practice. Frequently asked questions included location, opening hours, range of services on offer,

staffing numbers and skill mix and whether or not staff at the new centre would have access to patient’s

medical records.

Proposal to co-locate Urgent Care Centre with Emergency Department at Russell’s Hall: A key

issue here was concerns about increased pressure on parking at Russell’s Hall and the cost of parking

for patients and visitors. A number of people pointed out that parking at Holly Hall is free.

A further concern was the risk of increasing pressure on services at Russell’s Hall, particularly A&E, by

directing more patients to the site.

Improved Access to GPs: Access to primary care was one of the most frequently raised issues in

consultation responses and at meetings. The consultation form posed a specific question (Question 5)

inviting people to select, from a list, three services which they felt would most improve healthcare

services in Dudley and the top four most popular choices all related to GP services, as follows:

• Local GPs to open at weekends (68% of all respondents)

• Local GPs to offer walk-in appointments (58% of all respondents)

• Local GPs to open earlier/later (55% of all respondents)

• More urgent appointments at GP services (34% of all respondents)

Questions were raised at a number of meetings as to whether the CCG actually had the power to

influence GP opening times, as the contracts are held by NHS England following the restructuring of the

NHS in 2013.

Other issues: A number of respondents queried how our proposals would impact on patients who are not registered

with GPs.

A point made in many forums was the need for local people to have somewhere to turn for advice or

reassurance at any time of the day or night, either over the phone or face to face. This issue was a

general concern but expressed particularly strongly by those caring for young children. Many

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respondents were aware of the 111 service but there were mixed views about the effectiveness of the

service in its current form, with some users expressing genuine satisfaction but others voicing

reservations about the quality of the advice provided.

Another concern that was raised regularly was the lack of specific provision in the urgent care system for

patients with mental health issues.

Following discussions with a number of public and patient groups, the CCG was also urged to do more

to raise awareness of what has already been achieved locally in terms of improving access to primary

care.

CONCLUSION This consultation took a considerable amount of time and effort to plan and deliver. The timing of the

consultation, and the way the possible service scenarios developed during the consultation period added

to the challenge. Members of the CCG’s Communications and Engagement team, senior managers and

clinical colleagues have all made a valuable and much appreciated contribution and found themselves in

the midst of some robust exchanges of views.

We would also like to express our thanks to everyone who took the time and trouble to complete a

consultation form, come to an event or share their views with us. (We have sent out this week invitations

to all contributors whose details we have, asking them to come to our feedback event next month.)

RECOMMENDATION Board members are asked to note the consultation activities set out above by way of assurance that the

CCG has fulfilled its statutory obligations to properly consult on proposed changes to the urgent care

system

Members are also asked to note the feedback received and take it into account when agreeing next

steps in developing an improved urgent care system for the people of Dudley

APPENDICES Appendix 1 – Healthwatch Dudley report

Appendix 2 – Summary of responses from partner organisations and other correspondence including

contact from MPs

Richard Haynes Interim Head of Communications and Engagement 8 January 2014

1

Dudley Clinical Commissioning Group Urgent Care Consultations

Questionnaire Survey Dudley Borough Walk-in Centre Russells Hall Hospital Accident and Emergency

First Report

Healthwatch Dudley

January 2014

2

Contents Page

Figures…………………………………………………………………………… 3

Acknowledgements…………………………………………………………….. 4

Summary………………………………………………………………………… 5

Introduction……………………………………………………………………… 5

Descriptive Information………………………………………………………… 6

Doctors Surgery Access Issues……………………………………………….. 8

Patient and surgery information………………………………………………… 10

Getting medical advice………………………………………………………….. 13

Views and experiences………………………………………………………….. 16

Why patients are using a service……………………………………………….. 17

Dudley Borough Walk-in Centre and Patient Concerns……………………… 18

What patients want……………………………………………………………….. 18

Questions for Dudley Clinical Commissioning Group………………………… 20

Conclusions………………………………………………………………………. 20

3

Figures Page

Figure1 Participants at the Walk-in Centre……………………………… 7

Figure 2 Age…………………………………………………………………. 7

Figure 3 Participants at Accident and Emergency………………………. 8

Figure 4 Age…………………………………………………………………. 8

Figure 5 Arrivals at the Walk-in Centre (Friday 29 November)…………. 9

Figure 6 Arrivals at the Walk-in Centre (Saturday 30 November)………. 9

Figure 7 Arrivals at Accident and Emergency (Friday 29 November)…... 10

Figure 8 Arrivals at Accident and Emergency (Saturday 30 November).. 10

Figure 9 Patient doctors surgery (Walk-in Centre)………………………… 11

Figure 10 Patients doctors surgery (Accident and Emergency)…………… 12

Figure 11 Patient home address postcode (Walk-in Centre)………………. 13

Figure 12 Patient home address postcode (Accident and Emergency)….. 13

Figure 13 Patient referrals (Walk-in Centre)………………………………….. 14

Figure 14 Patient referrals (Accident and Emergency)……………………… 14

Figure 15 Contact with a doctors surgery (Walk-in Centre)………………… 15

Figure 16 Contact with a doctors surgery (Accident and Emergency)…… 15

Figure 17 Doctors surgery contact outcomes (Walk-in Centre)…………….. 16

Figure 18 Doctors surgery contact outcomes (Accident and Emergency)… 16

Figure 19 No prior contact with a doctors surgery (Walk-in Centre)…………17

Figure 20 No prior contact with a doctors surgery

(Accident and Emergency)…………………………………………. 17

Figure 21 Could a doctors surgery have helped (Walk-in Centre)………….. 18

Figure 22 Could a doctors surgery have helped

(Accident and Emergency)…………………………………………..19

Figure 23 Satisfaction getting into a doctors surgery (Walk-in Centre)…….. 19

Figure 24 Satisfaction getting into a doctors surgery

(Accident and Emergency)…………………………………………. 20

4

Acknowledgements Healthwatch Dudley would like to thank everyone who helped with the questionnaire survey at Dudley Borough Walk-in Centre and Russells Hall Hospital Accident and Emergency including staff, patients and volunteer helpers.

5

Summary Healthwatch Dudley undertook a questionnaire survey at the Dudley Borough Walk-in Centre and Russells Hall Hospital Accident and Emergency on behalf of the Dudley Clinical Commissioning Group (DCCG) as part of its review of Urgent Care services. In total 943 patients (or their representatives) participated in the questionnaire survey that included 395 male and 417 female patients where there sex was known. In turn, the ethnicity of 829 patients was recorded with the majority, 677 patients, being British. Information was obtained that showed 839 patients indicated that they were registered with a doctors surgery and 546 patients indicated that they travelled straight to the Walk-in Centre or Accident and Emergency without getting any medical advice. Patterns in the numbers of patients coming to the Dudley Borough Walk-in Centre and the Russells Hall Hospital Accident and Emergency from different surgeries are shown for 630 patients. When patients were asked about whether they had tried to contact a doctors surgery before coming to the Walk-in Centre or Accident and Emergency 847 patients gave details and 487 of them said they had not tried to contact a doctors surgery. When patients who had obtained medical advice (320 in number) were asked how they were referred on to the Walk-in Centre or Accident and Emergency 98 said they had been referred by a doctors surgery. Patients were concerned about the proposal to close the Walk-in Centre which is popular and fills a gap in primary care service provision (especially for patients unable to get an appointment at a doctors surgery). Any new facility to replace the Walk-in Centre would need to consider patient issues relating to its location and accessibility, the types of services provided, and car parking issues. It is a mixed picture regarding patient perceptions of whether a doctors surgery could have helped them if they had been able to get an appointment and in terms of patients past experience of getting into a doctors surgery. Nevertheless, 449 patients said they would be happy to be referred back to a doctors surgery for treatment after assessment at the Walk-in Centre or Accident and Emergency. Meanwhile, there is a demand from particular patients groups for seven day opening of doctors’ surgeries, longer opening hours, shorter waiting times for appointments, and more same day appointments. Questions arise about how to get patients who are using the Walk-in Centre and where it is appropriate Accident and Emergency to use doctors surgeries and avoid simply shifting patients around without dealing with underlying problems around access to doctors’ surgeries. Introduction Healthwatch Dudley undertook a questionnaire survey at Russells Hall Hospital Accident and Emergency and the Dudley Borough Walk-in Centre over a period of seven days between Friday 29 November and Thursday 5 December 2013. It was undertaken on behalf of the Dudley Clinical Commissioning Group (DCCG) as part of their review of Urgent Care services and consultations taking place between 17 October and 24 December 2013 on proposals to improve the design of primary and community urgent care services, out-of-hours services and close the Walk-in Centre

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and provide a different service based at the Russells Hall Hospital site. Walk-in Centre opening times are from 8.00am to 8.00pm on Tuesday, Wednesday and Thursday and from 8.00am to 10.00pm on Friday, Saturday, Sunday and Monday. Questionnaire survey sessions were from 8.00am to 8.00pm (with an extension to 10.00pm at Accident and Emergency on Tuesday, Wednesday, and Thursday to assess any impact of changed Walk-in Centre opening times on demand for Accident and Emergency services). There were four Healthwatch Dudley members of staff and fifteen volunteer helpers who had attended an induction event to learn more about the project involved in undertaking the questionnaire survey work. At each questionnaire survey location there was a Healthwatch Dudley member of staff and either one or two volunteers covering four hour questionnaire survey interview sessions. Their role was to approach patients in each of the facilities and ask them for their help to answer some questions (designed to take up no more than five minutes of their time) on why they were using the Walk-in Centre or Accident and Emergency.

In the main computer tablets and Survey Monkey online questionnaire survey software were used to collect patient responses to questions (and sometimes the responses of a representative to questions on a patient’s behalf in instances where, for example, they were an infant or young child). Some paper questionnaire surveys were completed at times when WiFi internet access to the online questionnaire survey was problematic or an interviewer was not comfortable using a computer tablet. No patient medical details were collected and confidentiality was ensured to the extent that only aggregated patient information would be used in any report and patient anonymity would be maintained. All questions were optional to answer (except for the question to get a patient’s consent to continue with the questionnaire survey). There were closed questions (requiring a yes or no response) that sometimes directed the interviewer to another relevant part of the questionnaire survey, questions requiring one or more boxes to be ticked from a list, and questions requiring a response on a scale of 1 to 6 where 1 is strongly disagree and 6 is strongly agree with a particular statement. In addition, there were some questions on patient gender, age, ethnicity, home address post code, and work arrangements. Patients also had the opportunity to make any other comments. Finally, non-response rates were recorded where a patient declined to continue with the questionnaire survey or an interviewer decided that it was not appropriate to continue with a questionnaire survey. The aim was to produce a summary report for the DCCG board meeting scheduled to be held on the 9 January 2014.

Descriptive Information At the Walk-in Centre and Accident and Emergency a total of 1,074 patients (or their representatives) were approached and asked for their help to answer some questions on why they were using the facility. After this initial contact 943 patients (or their representatives) agreed to take part in the questionnaire survey. In terms of non-response there were 131 patients (or their representatives) that declined to participate in the questionnaire survey. A breakdown of the participants at each

7

location shows that at Accident and Emergency there were 459 participants and at the Walk-in Centre there were 440 participants (with 44 participants where there was no interview location recorded).

At the two study locations there were a total of 395 male and 417 female patients, one transgender patient, and 130 patients where their sex was not recorded. The question on age was answered by 819 patients with 280 being aged 15 or under, 113 aged 65 or over (see Figure 1 to 4 below) Figure 1: Participants at the Walk-in Centre

Figure 2: Age

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Figure 3: Participants at Accident and Emergency

Figure 4: Age

In turn, 829 patients ethnicity was recorded with 677 being British and smaller numbers from White and Black Caribbean, Indian, and Pakistani ethnic groups. Information on the working patterns (or not) of 809 patients was recorded. For 480 patients the question was not applicable because they were an infant or young person, not in employment, or retired. For the other patients the majority, 250 of them, said they worked days. There was information on 883 patients on how they travelled to the Walk-in Centre or Accident and Emergency. Of these patients 622 travelled in their own or a family car, 110 got a lift from someone, 47 came by bus, 34 came by taxi, 35 came by ambulance, and 29 came on foot.

Information on seeking medical advice before attending the Walk-in Centre or Accident and Emergency was collected for 859 patients. The figures show that 546 patients travelled straight to the Walk-in Centre or Accident and Emergency without

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first seeking medical advice and 310 patients travelled to the Walk-in Centre or Accident and Emergency after first seeking medical advice.

Doctors Surgery Access Issues Information was obtained on 868 patients regarding registration with a doctors surgery. It shows that 839 patients were registered with a doctors surgery. On arrival times, information was collected on 881 patients across the Walk-in Centre and Accident and Emergency study locations. Sample graphs show that a number of patients are using the facilities even when doctors surgeries are open (see figures 5 to 8 below). Figure 5: Arrivals at the Walk-in Centre (Friday 29 November)

Figure 6: Arrivals at the Walk-in centre (Saturday 30 November)

0 1 2 3 4 5 6 7 8 9

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Figure 7: Arrivals at Accident and Emergency (Friday 29 November)

Figure 8: Arrivals at Accident and Emergency (Saturday 30 November)

Patient and surgery information Patterns in the numbers of patients coming to the Walk-in Centre and Accident and Emergency from different surgeries was collected on 630 people about whom the name of the doctors surgery that they used was known (see Figures 9 and 10 below).

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Figure 9: Patient doctors surgery (Walk-in Centre)

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Figure 10: Patient doctors surgery (Accident and Emergency)

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In turn, it was possible to collect information on 740 patients about their home address postcode (see Figure 11 below). Figure 11: Patient home address postcode (Walk-in Centre)

Figure 12: Patient home address postcode (Accident and Emergency)

Getting medical advice When patients who had obtained medical advice (320 in number) were asked how they were referred on to the Walk-in Centre or Accident and Emergency 98 said they had been referred by a doctors surgery. A total of 117 patients were referred on by a pharmacy, a work, leisure facility or school based first aider, community nurse or health visitor. There were 56 patients who had been referred on by the NHS 111 telephone advice line, and 19 patients who were taken to a facility by the ambulance service (see figures 13 and 14 below).

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Figure 13: Patient referrals (Walk-in Centre)

Figure 14: Patient referrals (Accident and Emergency)

When patients were asked about whether they had tried to contact a doctors surgery before coming to the Walk-in Centre or Accident and Emergency there were details provided for 847 patients. The information collected shows that for 487 patients no attempt had been made to contact a doctors surgery and for 356 patients there had been an attempt to contact a doctor’s surgery (see Figures 15 and 16 below).

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Figure 15: Contact with a doctors surgery (Walk-in Centre)

Figure 16: Contact with a doctors surgery (Accident and Emergency)

A question on the outcome for patients following an attempt to contact a doctors surgery show that for the 362 patients that details were collected there were 222 patients that were not able to get a suitable appointment. Other issues include the doctors surgery being closed (36 patients), and not being able to get through on the telephone (16 patients). There were 10 patients who had been to a doctor’s surgery but wanted another opinion, 6 patients who had had an appointment but wanted to be seen sooner, and 3 patients who were not able to get the help they wanted from a surgery reception (see Figures 17 and 18 below).

Yes No Not disclosed

Yes No Not disclosed

16

Figure 17: Doctors surgery contact outcomes (Walk-in Centre)

Figure 18: Doctors surgery contact outcomes (Accident and Emergency)

Views and experiences [There were] thirty-nine people in the telephone queue … difficult to get an appointment … used Walk-in Centre. Appointments hard to get… Called twice for an emergency appointment but couldn’t get in, baby has a chest infection … if the Walk-in Centre closes where will people go? Came to the Walk-in Centre with the same problem two weeks ago, can only get an appointment with GP three days in advance, prefer to be seen at Walk-in Centre … Can never get an appointment, only one doctor and only works three days each week … Can’t plan illness, no appointments for same day at GP … Child ill … it took one and a half hours to get through on the phone to GP, Walk-in Centre provides excellent service. Couldn’t get an appointment for another week, can’t get appointments for children either so usually go straight to Walk-in Centre … Lots of people will be lost without Walk-in

0 50 100 150 200

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Doctors surgery closed

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Unable to get through on the telephone

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Unable to get help wanted from recepSon

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Centre … Walk-in Centre is convenient … Walk-in Centre is fantastic my kids and grand kids use it regularly … Walk-in Centre is very valuable we have used it, don’t know what people will do without them. Why patients are using services Where no attempt to contact a doctors surgery had occurred prior to attending the Walk-in Centre or Accident and Emergency information collected on 412 patients giving one or more reasons shows that for many it was because it was known that the surgery was closed or there was a feeling that it was a medical emergency situation (see Figures 19 and 20 below). Figure 19: No prior contact with a doctors surgery (Walk in Centre)

Figure 20: No prior contact with a doctors surgery (Accident and Emergency)

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Knew doctors surgery was closed

Felt it was a medical emergency


Not disclosed

Not saSsfied with 111 telephone helpline advice

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Knew doctors surgery was closed

Not disclosed

Not saSsfied with 111 telephone helpline advice

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Dudley Borough Walk-in Centre and Patient Concerns There is a demand for Walk-in Centre services (and opening hours have recently been extended). There is some evidence of people going to Accident and Emergency when the Walk-in Centre reaches capacity and it seems there is some extra burden placed on Accident and Emergency due to the way that some patients are not able to effectively access doctors surgery services.

• Patients are worried by the proposal to close the Walk in Centre • The Walk in Centre is popular and the number of patients using it each year

continues to grow • A gap in doctors surgery service provision is being filled by the Walk in Centre

(when people cannot get into doctors surgeries) • Any new facility to replace the Walk-in Centre would need to consider

location, accessibility, service provision and parking issues.

What patients want Of 822 patients for whom information about the helpfulness of a doctors surgery was obtained (on a scale of 1 to 6 where 1 is strongly disagree and 6 is strongly disagree) 411 patients were at level 5 or 6 towards the strongly disagree end of the scale and 322 patients were at level 1 and 2 towards the strongly agree end of the scale. A breakdown of the data for the two study locations is provided in Figures 21 and 22 below. Figure 21: Could a doctors surgery have helped (Walk-in Centre)

Strongly agree Strongly disagree

19

Figure 22: Could a doctors surgery have helped (Accident and Emergency)

On a question about past experience of getting into a doctors surgery the information collected on 819 patients shows that there were 309 patients at level 5 and 6 strongly agree that past experience of getting into a doctors surgery had been satisfactory and 301 patients on level 1 and 2 strongly disagree that past experience of getting into a doctors surgery had been satisfactory. A breakdown of the information on past experience of getting into a doctors surgery for the two study locations is provided in Figures 23 and 24 below. Figure 23: Satisfaction getting into a doctors surgery (Walk-in Centre)



20

Figure 24: Satisfaction getting into a doctors surgery (Accident and Emergency)

On happiness to go back to a doctors surgery for treatment after assessment at the Walk in Centre or Accident and Emergency there were response for 809 patients. Of these response 449 patients were at levels 5 and 6 strongly agree and 190 were at levels 1 and 2 strongly disagree.

Questions for Dudley Clinical Commissioning Group There are patient access to doctors surgery issues that are widespread and even impact on patients who can get appointments but are not necessarily happy about the length of time it takes to get to see a doctor. Being unable to get a suitable appointment at the doctors’ surgery is a significant issue for many patients. In addition, there are particular issues in getting access to a doctors surgery affecting infants and young people.

• How would any replacement facility for the Walk-in Centre be combined with

plans to reduce the difficulties that some groups of patients experience getting access to a doctors surgery?

• How would any replacement facility for the Walk-in Centre avoid simply shifting patients around without dealing with underlying problems around access to doctors’ surgeries?

• Would any replacement facility for the Walk-in Centre put more pressure on Accident and Emergency if access to doctors’ surgeries did not change?

• Would it be better to retain the Walk-in Centre service and try to make changes in dealing with the patient access doctors’ surgeries issues?

Conclusions The questionnaire survey provides valuable initial insights on the views and concerns of patients using the Dudley Borough Walk-in Centre and Russells Hall


21

Hospital Accident and Emergency. It shows that there is a gap in doctors surgery provision that is being filled by the Walk-in Centre. Information on a representative group of 943 patients was collected and many were keen to talk about their experiences of getting access to a doctors surgery and the future of the Walk-in Centre. A number of patients were fearful about what people would do if the Walk-in Centre was closed and there was much elaboration on peoples difficulties getting access to a doctors surgery and in particular suitable appointments without having to wait days or in a few instances weeks. Patients also had concerns about getting access to primary care services when doctors surgeries were not open in the evenings and at weekends. And some patients said they were unable to easily get time off of work for available doctors surgery appointments, they had infants and young children and found it difficult to get access to a doctors surgery when they needed to, or they were older people that sometimes needed to access a doctors surgery at short notice and this was not always possible. Consideration will need to be given to the question of doctors surgeries opening at weekends and for longer in the evenings as well as making it easier for patients to get access to doctors surgery services, waiting less time to see a doctor and able to more easily get a same day appointment. Any plan for a new medical facility at the Russells Hall Hospital site intended to replace the Walk-in Centre would need to include a clear strategy to deal with these patient access to doctors surgery services to prevent just simply shifting patients around and not getting more back into using doctors surgeries as their first port of call when they need medical help.

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9 JANUARY 2014 URGENT CARE CONSULTATION OUTCOME – APPENDIX 2 INTRODUCTION This appendix summarises responses received to our Urgent Care Consultation from key partner

organisations and other examples of correspondence received. The amount of feedback received was

considerable and although we are not able to list every respondent by name we are grateful to them all

for their contributions, which will continue to inform the development of urgent care services.

Dudley Group NHS Foundation Trust Fully supportive of improvements to health and social care that ensure that the residents of Dudley are

cared for in the right place, at the right time, by the right provider.

Extremely supportive of an increase in capacity in GP availability for patients who currently attend the

Walk in Centre (WIC) or our Emergency Department (ED) as these are provided more locally and the GP

is often the best informed and most aware of current care issues. Would expect that this may lead to a

reduction in demand.

Supportive of better 24 hours a day and 7 days a week support for patients in need of urgent health care

through an easier to navigate urgent care centre.

Would like CCG to ensure that ALL patients are able to consistently access care in their area of Dudley.

A collaborative approach to a co-located, Urgent Care Hub/model will ensure streaming of patients

through to the right service. The streaming process at first point of contact will serve to educate patients

and professionals in how appropriate access to services in the borough can be made. Easier choice will

help to manage demand.

For the urgent care centre to operate effectively it will need collaborative working across ambulance

services. health and social care, 7 day access to GP services.

Dudley Group is committed to solving urgent care issues by providing a communication hub with access

to all health and social care, reduce non-elective admissions by 15%, allowing ED to focus on those

needing urgent care, working collaboratively, providing better community based acute services.

Challenges -providing a hub from the Russells Hall Hospital site for ease of access for Dudley residents

requires considerable capital investment and a long term commitment to such a model would be a pre-

requisite.

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Dudley Health and Wellbeing Board Councillor Stuart Turner, Chair of the Dudley Health and Wellbeing Board, has indicated that he is

unable to offer his support for our proposals because of two concerns.

The first relates to a need for further clarity on the location and opening hours of evening and weekend

primary care services. The second is a concern about a lack of detailed information regarding patient

flows and increased primary care access.

West Midlands Ambulance Service WIC provision - the urgent care centre located alongside the emergency department will make it quicker

and easier for clinicians as there have been historic issues in regards to whether the WIC accepts

certain types of patients transported there. Will allow for appropriate triage but needs a single triage

system so no duplication of handover or two queues for ambulance staff. Co-location of services will

reduce confusion for patients.

GP out of hours service - imperative our WMAS clinical staff have direct line access to a GP on the

telephone to enable quicker agreement of treatment plan for patients to enable quicker release of

ambulance resources and ambulance availability for further patients.

Overall Primary and Community Urgent Care - the redesign of services needs to provide services that

compliment and support patients 24/7. For example, if it is deemed after triage not appropriate for ED or

the urgent care centre but still requires another service, then there needs to be a safety net service that

can capture this group of patients in the out of hours period such as rapid response team. The service

could be expanded to include other groups of patients in addition to the elderly. This will help to ensure

patients are treated in the right place, at the right time.

There is a need to community based services to ensure that they are simplified as to who delivers what,

when and how, then make this available in the directory of services or through the urgent care centre.

IT connectivity - it is vital there is an IT strategy that will allow all the IT systems to link up between the

different Trust’s/healthcare providers in the borough to assist in a seamless approach to patient care.

Correspondence from MPs During the consultation period we received correspondence from Ian Austin MP and Chris Kelly MP,

both raising issues relating to their respective petitions which are mentioned in the report. Margot James

MP also wrote to raise concerns about accessibility of the Russell’s Hall site (an issue which was raised

by other respondents and is reflected in the main themes of the feedback).

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Dudley Local Pharmaceutical Committee The LPC was broadly supportive of our proposals but keen to stress the valuable role that community

pharmacists can play in easing pressure on the urgent care system by, for example: Supporting patients

with long term conditions; Urgent repeat prescription dispensing and wider provision of influenza

vaccination.

The LPC also commented on the 111 service, specifically with regard to a need to improve signposting

to community pharmacy.

Dudley Black Country Neurological Alliance (BCNA)

The BCNA undertook consultations with healthcare professionals, service users and carers through one

to one interviews, emails and a workshop co facilitated by Dudley CCG. Their feedback highlights a

range of issues affecting patients with neurological conditions.

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Date of Report: 9th January 2013 Report: Proposal for the reconfiguration of Urgent Care

Agenda item No: 8.2

TITLE OF REPORT: Proposal for the reconfiguration of Urgent Care

PURPOSE OF REPORT:

The purpose of this report is to define the context and future options now available to Dudley CCG Board in regards to urgent care in Dudley. This paper builds on the comprehensive consultation process undertaken by the CCG, evaluates possible future service models and recommends the most robust and cost effective way forward.

AUTHOR OF REPORT: Jason Evans – Commissioning Manager for Urgent Care

MANAGEMENT LEAD: Paul Maubach – Chief Accountable Officer

CLINICAL LEAD: Dr Steve Mann – Clinical Lead for Urgent Care

KEY POINTS:

• The current contracts for the Walk-in-Centre and Out-of-Hours contacts come to an end in September 2014.

• The commissioning of new contracts provides an opportunity for Dudley CCG to adopt national guidance, fall in line with the CCG Primary Care Strategy and respond to the needs of local patients by re-designing these services into a simpler and more cost effective urgent care pathway.

• The Board are asked to consider the 12 recommendations of this paper.

RECOMMENDATIONS:

Recommendation 1: that Board note the reconfiguration of Dudley urgent care system is in line with nation guidance and best practice; furthermore it falls in line with Dudley CCG Primary Care Strategy and they Dudley Health and Wellbeing Board June recommendations on urgent care. Recommendation 2: that the Board approve the rationale and evidence base to redesign the urgent care pathway for Dudley and as a minimum move to adopting scenario 3; thereby developing an integrated UCC on the Russells Hall NHS Trust site, adjacent to ED Recommendation 3: Our proposal in response to the issues raised by the public about the walk-in services is therefore two-fold:

• Firstly, the ability to walk-in and obtain an assessment; especially at evenings and weekends; should be maintained.

• Secondly, the out-of-hours service should be integrated into the walk-in service as part of the urgent care centre to create a new 24/7 service – thus extending the availability beyond the current arrangements.

Recommendation 4: Our original proposal, in response to the issues raised in the consultation, should be modified to include bookable appointments at the urgent care centre and so reduce the impact to the public on the costs of parking at Russell’s Hall. Recommendation 5: The CCG Board will therefore need to obtain assurance at a future meeting, as part of the procurement process, that the specification enhances the quality of the service to take account of the issues raised about Paediatrics, Mental Health and unregistered patients.

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Recommendation 6: The CCG Board should note that our IT strategy will enable further improvements to the connectivity and access to medical records in the future. Recommendation 7: The Board should report our conclusions to the Health and Wellbeing Board and seek endorsement for our planned way forward. Recommendation 8: Our Board is asked to:

• confirm that it should be part of our strategic plan to develop joint commissioning arrangements [for GP services] with NHS England.

• encourage Dudley Health & Wellbeing Board to invite NHS England, as a partner on the Board with the contractual responsibility for GP Access, to demonstrate how they intend to improve this in Dudley.

• ask Dudley Health & Wellbeing Board to support joint commissioning between the CCG and NHS England as a key opportunity for addressing this issue.

Recommendation 9: Our Board is asked to note:

• that the current development support arrangements that we have put in place for GPs, have made, and continue to make, an important contribution to improving access to GPs but will be insufficient longer-term both; without additional resources and without working with the public to change patterns of behaviour and expectation.

• that the risk of GP access deteriorating would place unmanageable pressures on walk-in services

Recommendation 10: Our Board is asked to approve that we should encourage the development of PPGs with all practices and ensure future plans on improving access require their input Recommendation 11: Our Board is asked to confirm that the newly commissioned urgent care centre is initially designed to accommodate the planning assumptions in scenario 3; but should incorporate the flexibility to move to scenario 5 Recommendation 12: approve that we commence the development of the service specification to produce a detailed proposal at the March Board meeting, at which point we will also have received the feedback from the Health and Wellbeing Board.

FINANCIAL IMPLICATIONS:

This premise of this proposal is that it will be financially neutral. However, there would be capital costs associated with the establishment of the UCC and the ability to provide funding to improve GP access will be dependent on two things: firstly that support is available from NHS England and secondly moving towards scenario 5.


Extensive stakeholder, patient and public engagement has been undertaken – See Urgent Care Consultation Outcomes Report (Agenda item 8.1)

ACTION REQUIRED: Approval Decision Assurance

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 PROPOSAL FOR THE RECONFIGURATION OF URGENT CARE IN THE BOROUGH OF DUDLEY CONTENTS 1. Introduction 1 2. Report 1 3. Current Service Configuration 2 4. Scenario detail and estimated activity levels 3 5. How do these scenarios reflect the public consultation 4 6. Draft service outline for Dudley Urgent Care Centre 15 7. Procurement Implications 18 9. Conclusion 19 10 Recommendations 19 1. INTRODUCTION The purpose of this report is to define the context and future options now available to Dudley CCG Board in regards to urgent care in Dudley. This paper builds on the comprehensive consultation process undertaken by the CCG, evaluates possible future service models and recommends the most robust and cost effective way forward. In line with the vision of the CCG Board, current national recommendations on urgent care and the findings of the recent consultation process, this paper will recommend the procurement of an Urgent Care Centre (UCC) located on the Russells Hall NHS Trust site, adjacent to the Emergency Department (ED). A service outline for the proposed UCC is also included in section 6 of this paper which provides an overview of the key elements of the proposed new service. Twelve recommendations are offered for The Board to consider at the end of the paper. 2. REPORT The principles underpinning the redesign of the unscheduled and urgent care in Dudley is affirmed by many resent national publications and urgent care analysis. The NHS England publication ‘High quality care for all now and for future generations: Transforming Urgent and Emergency Care Services in England (Revised November 2013)’, asserts that “the diverse nature of urgent care services causes confusion amongst patients and healthcare professionals.” It further states that “this confused picture can cause the lack of standardised clinical practice amongst differing services and a lack of clear information given to patients” and that “this variation can cause a delay in access to appropriate treatment, multiple contacts with different clinicians and ultimately a poor experience for the patient.” The Royal College of Physicians publication in June 2013 ‘Urgent and emergency care – a prescription for the future’ also identified ten priorities for action by commissioners. Alongside recommendations for acute trusts the report stated there should be:

• Effective and simplified alternatives to hospital admission across seven days • The promotion of greater collaboration within the hospital and beyond to manage

emergency patients

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• The commissioning and planning emergency care services that focus on ambulatory emergency care, setting out which admissions are avoidable, and what proportion should be more appropriately managed in the community.

Significantly these best practice approaches and principles are reaffirmed in the Keogh review ‘Transforming Urgent Care Services in England (November 2013)’. In summary the review recommended from the extensive public, clinical and commissioner engagement undertaken that there was clear evidence base for:

The co-location of community-based urgent care services in coordinated Urgent Care Centres. These will be locally specified to meet local need, but should consistently use the “Urgent Care Centre” name, to replace the multitude of confusing terms that are available at present. Urgent Care Centres may provide access to walk-in minor illness and minor injury services, and will be part of the wider community primary care service including out-of–hours GP services. Considering all local facilities in this way will mean that networks will need to examine the extent of duplication or gaps in service offered by all of these facilities currently. Urgent Care Centres may also be advantaged by co-location with hospital services, particularly in urban areas.

At a more local level the redesign of urgent care has been a core component of the CCG’s Primary Care Strategy and also a focus of Dudley Health and Wellbeing Board. In June 2013 the first ‘Spotlight Event’ was held with the Health and Wellbeing Board on ‘urgent and emergency care’. Outcomes from the event included agreement on a set of key principles relating to what a future urgent care system might include. The principles were as follows:

• A joined up, coordinated and seamless system, fluid- no ‘bottle necks’ • A simple system-no confusion for the public ( or professionals) of what to do, who to call or

where to go • Safe, responsive and high quality

One of the solutions the event delegates identified was to work to simplify the urgent care system, reduce duplication and develop a system which responded to patients’ ‘default behaviour.’ Specific proposals from the event included “co-locate the walk in centre, with the emergency department.” Furthermore, prior to starting this public consultation, our GPs reviewed the current arrangements and concluded that a co-located and integrated urgent care centre would provide the clinically most appropriate and safest service for patients (both simplifying the service and as a result resolving the existing risk of patients self-presenting to the wrong service). Our GPs also concluded that this new arrangement should be developed in conjunction with improving weekday access to general practice in order to ensure as many patients as possible are able to appropriately attend their local practice as the service best able to meet their needs. 3. CURRENT SERVICE CONFIGERATION As a result of overwhelming national and local support for change the CCG has sought to develop a vision forward. The recent CCG urgent care consultation confirms that for some patients there is a fragmented and confusing model of urgent care in Dudley. The current configuration of unscheduled care in Dudley is as follows:

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Provider Contracted

service Service provided

Location Hours

Primecare Walk in Centre Primary Care Holly Hall Clinic 08:00 to 20:00 Mon – Friday (08:00 to 10:00 seven days a week throughout Winter Pressures

Primecare Out of Hours service

Primary Care Holly Hall Clinic 18:30 to 08:00 and 24 hours on Saturday to Sunday and Bank Holidays

49 Dudley GPs Primary Care Primary Care Locations across the whole borough

Core hours between 8am-6.30pm on weekdays, varies by practice

Dudley Group of Hospitals NHS FT

Accident and Emergency services

Primary Care and Major cases

Russells Hall Hospital 24 hours a day 365 days a year

4. SCENARIO DETAIL AND ESTIMATED ACTIVITY LEVELS The following section offers detail and estimated activity levels for five possible scenarios. These have been developed in response to the consultation and in response to a steer from the chair of the Health and Wellbeing Board in order to help illustrate how the issues raised both before and during the consultation will or will not be resolved in different circumstances. These scenarios are as follows:

Scenario 1 - ‘Do nothing’ and simply re-commission the walk-in-centre and out-of-hours contracts in their existing form at their current sites.

Scenario 2 - re-commission the walk-in-centre and out-of-hours contracts in their existing form but specify in the contract that the service must be provided from the Russells Hall NHS Trust site adjacent to ED.

Scenario 3 - Commission a 24/7 UCC combining out-of-hours provision, provided from the Russells Hall NHS Trust site adjacent to ED. Scenario 4 - Commission a 24/7 UCC combining out-of-hours provision, provided from the Russells Hall NHS Trust site adjacent to ED. Invest in GP in-hours access which would result in some patients (10%) changing their current behaviour to preference GP services – but don’t redirect them to those services. Scenario 5 - Commission a 24/7 UCC combining out-of-hours provision, provided from the Russells Hall NHS Trust site adjacent to ED. Invest in GP in-hours access and include arrangements to redirect all non-urgent cases from the UCC back to their own registered GP practice.

Scenario 5 reflects the vision that was proposed in the urgent care consultation as this incorporates:

• the development of an integrated Urgent Care Centre; • the active triage of patients at the UCC both into the emergency department, into urgent

primary care at the centre, or back to the patients’ practice or other appropriate services; • improving GP access to see more patients during the day on week-days

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The follow tables summarises the current levels of activity and how these levels may change dependant on the five scenarios:

5. HOW THESE SCENARIOS REFLECT THE PUBLIC CONSULTATION The pre-consultation and subsequent consultation identified several issues that need to be considered in redesigning the services.

Scenario 1Urgent Non Urgent Urgent Non Urgent

Walk in Centre 1,626 24,409 1,550 23,259 50,844Out of Hours Service 1,005 19,635 20,640A&E 11,447 28,682 18,427 38,981 97,537Total 13,073 53,091 20,982 81,875 169,021Assumes current service configeration remains (Do nothing and re-commission existing serivces)


Walk in Centre 1,626 24,409 1,550 23,259 50,844Out of Hours Service 1,005 19,635 20,640A&E 11,447 28,682 18,427 38,981 97,537Total 13,073 53,091 20,982 81,875 169,021Assumes current Service configuration remains but is moved to Russells Hall NHS Trust site


Urgent Care Centre 8,629 28,061 14,122 50,409 101,221A&E 4,444 25,030 6,860 31,466 67,800Total 13,073 53,091 20,982 81,875 169,021Assumes all Primary Care A&E cases are managed by the Urgent Care Centre


Urgent Care Centre 7,766 25,255 14,122 50,409 97,552A&E 4,444 25,030 6,860 31,466 67,800Total 12,210 50,285 20,982 81,875 165,352Assumes 10% of in-hours cases previously using the UCC, use GP services


Urgent Care Centre 7,766 842 14,122 1,512 24,242A&E 4,444 25,030 6,860 31,466 67,800Total 12,210 25,872 20,982 32,978 92,042Assumes all non-urgent redirected except for unregistered patients

In Hours / Weekday OOH Total





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5.1 MOVING FROM SCENARIO ONE TO SCENARIO THREE 5.1.1 Proposed co-location and integration of walk-in, out-of-hours and A&E services The first key component of our consultation was to recommend that we close the existing walk-in service and create a new integrated urgent care centre at the Russell’s Hall site. To demonstrate the implications of this change: scenario one assumes no change; scenario two assumes merely locating the services on the same site but without any redesign; and scenario three models the impact of creating an integrated service. There is a clear steer both from national guidance and from our own local assessments that this proposal (ie: scenario three) is the most clinically appropriate thing to do and will provide a better service for our population. In the public consultation very clear concerns were expressed that people do not want to see a deterioration in the accessibility that the walk-in service provides (see next section) however no-one provided any challenge or counter argument to the national guidance or to our own prior assessment that this change would be the most clinically appropriate thing to do. There were three concerns that were raised about the transfer of the service to the Russell’s Hall site. Firstly, a concern that the co-location would create added pressure on the existing A&E services. This concern is however, unfounded. In fact it will reduce the pressure on the emergency department. This is because a significant number of patients who self-present and are currently treated at the A&E merely have a primary care need. Therefore these patients would be triaged by the Urgent Care Service and seen by the primary care service. The model (comparing scenario three to scenario one) shows that an integrated service would therefore significantly reduce the numbers of patients who would need to be seen by the A&E. The change is also supported by Dudley Group FT as significantly improving the way the services would operate. Secondly a few individuals queried whether Russell’s Hall is more accessible than Holly Hall. But in fact the hospital site is much better served by public transport and the two locations are very close – only 7 minutes walk apart. Thirdly a concern that was consistently raised in many meetings, and in individual responses is the cost of parking at Russell’s Hall. So the first issue that we have to consider is whether the concerns about the cost of parking at the site outweigh the clinical benefits, national guidance and local assessment that creating an integrated service would provide. i.e: That scenario three is better than scenario one. For completeness, we have included scenario two, but in fact this provides none of the benefits of scenario three together with the pain of parking costs. Recommendation 1: that Board note the reconfiguration of Dudley urgent care system is in line with nation guidance and best practice; furthermore it falls in line with Dudley CCG Primary Care Strategy and they Dudley Health and Wellbeing Board June recommendations on urgent care. Recommendation 2: that the Board approve the rationale and evidence base to redesign the urgent care pathway for Dudley and as a minimum move to adopting scenario 3; thereby developing an integrated UCC on the Russells Hall NHS Trust site, adjacent to ED

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5.1.2 Accessibility of walk-in services and primary care out-of-hours services These two existing services are contracted for separately; albeit provided by the same organisation. The pre-consultation public survey results for the out-of-hours services indicated that it provides poor levels of patient satisfaction. In contrast the public survey and subsequent feedback from the public consultation for the current walk-in service demonstrates very high levels of patient satisfaction. It is clear that people like the ease of use of the walk-in service and there are lessons to be learnt from this in the provision of the out-of-hours service. However the walk-in service currently only operates from 8am-8pm (extended to 10pm over the winter period). It is important to note that, with the creation of an urgent care centre, there would have to be the provision of a 24/7 service because the centre would have to be able to triage patients between A&E and the urgent Primary Service. Recommendation 3: Our proposal in response to the issues raised by the public is therefore two-fold:



This would then provide a significant enhancement to the way the current services are provided. 5.1.3 Providing telephone advice and booking There has been a clearly expressed preference that people would like to be able to access reliable telephone advice that can provide reassurance and/or direct them to the most appropriate service. In particular, parents with ill children would find this extremely helpful. This endorses the need for NHS 111 and the service that they already provide. NHS 111 is now fully in place but the feedback from the consultation reveals a lack of confidence in the current service. It is unclear whether this is informed through practical experience or whether this is perception or lack of awareness. In our consultation we proposed that people should be able to phone 111 for advice or to make an urgent appointment with their local GP the next day. However, we could modify this concept to enable the 111 service to make appointments for patients at the urgent care centre. The front desk of the urgent care centre would triage all walk-in patients: into providing advice, into the primary care component of the service, or into the emergency department. So the telephone service could triage patients in the same way and either solely provide advice, make direct appointments for patients if needed into the primary care component of the service; or advise on the need to go to the emergency department.

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This aspect of the telephone service with bookable appointments would have three distinct benefits:

• Patients who don’t need either primary care or emergency care would not have to go to the urgent care centre at all;

• Patients who get a booked appointment would then not have to wait in the way they would if they walked-in to the centre; and so would spend considerably less time at the centre;

• Both of these outcomes would either avoid, or significantly reduce the time spent at Russell’s Hall and would therefore substantially mitigate against the cost of parking at the site.

Recommendation 4: Our original proposal, in response to the issues raised in the consultation, should be modified to include bookable appointments at the urgent care centre and so reduce the impact to the public on the costs of parking at Russell’s Hall. 5.1.4 Improving the quality of the walk-in and OOH services There are some important issues which have been identified in this process which will need to be addressed, regardless of where and how the services are provided

• A disproportionately high proportion of cases are paediatrics – so it will be important to ensure that any new service is tailored to meet this need.

• Concerns have been raised about the timeliness and accessibility to mental health services as part of these arrangements

• The service will need to provide urgent care to unregistered patients – but also actively encourage those patients to register with a GP

These are issues which will need to be addressed as part of the development of the specification for a new service. A more detailed analysis of the Healthwatch interviews will also help to inform the specification. Recommendation 5: The CCG Board will therefore need to obtain assurance at a future meeting, as part of the procurement process, that the specification enhances the quality of the service to take account of these issues. 5.1.5 Improving connectivity and access to medical records Another concern expressed by both our GPs and by the public is that current A&E, WIC and OOH services do not have access to full patient records. This is one of the reasons why there is a clear preference for people to access their GP rather than a WIC service because they will be seen by a service that knows them and has their full medical history. An additional consequence is also that the A&E, WIC and OOH services are necessarily less efficient than GP services because the former have to undertake consultations which include taking information from the patient that would otherwise be readily available to the latter on their medical records. Our IT strategies will help to improve this situation over the next few years. It is our preferred intention to migrate all GPs over to using the same system. Once this is achieved it would then be possible to provide integrated access to the GP records to the other urgent care services – and so improve the efficiency and effectiveness of those services.

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Recommendation 6: The CCG Board should note that our IT strategy will enable further improvements to the connectivity and access to medical records in the future. 5.1.6 Overall assessment on creating an integrated Urgent Care Centre It is our view that the establishment of an Urgent Care Centre as a replacement for the existing walk-in and out-of-hours services is an essential requirement to improving the provision of urgent care in Dudley and that this is consistent with Dudley Health and Wellbeing Board’s strategic vision. Recommendation 7: The Board should report our conclusions to the Health and Wellbeing Board and seek endorsement for our planned way forward. 5.2 MOVING FROM SCENARIO THREE TO SCENARIO FIVE 5.2.1 The importance of good GP access The overwhelmingly most significant issue raised both before and during the public consultation was around the public’s preference for improved GP access; tempered with scepticism as to whether this can be achieved. Our consultation included in the vision our belief that the individual’s own GP is the best ‘navigator’ for their health needs and care. They hold the records and have all of the medical history on which to make the safest healthcare decisions. Our model proposed that local GPs should be the first place that they go for urgent care and that they should get all of their basic health care at the local surgery during week days. We also identified that this would need additional GP appointments during week days, at the expense of providing a walk-in service during week days. Our model also proposed that the new urgent care service should be available to provide the walk-in and out-of hours care when the local GP service is closed. Scenario three assumes that either no attempt is made to improve GP access or that the attempt to improve access does not deliver any reduction in demand for the Urgent Care Centre. Scenario four assumes that we improve GP access but that we do not direct people to use those service as a first choice, and so reductions in the use of the UCC are limited to public behavioural change. Scenario five assumes that we improve GP access and that we also direct people to use the most appropriate service so that the maximum benefits in matching need to service are achieved. The importance of good access to GP services cannot be underestimated. The current walk-in-centre represents a tiny proportion (less than 3%) of the total number of primary care appointments that are available across Dudley borough. The vast majority of the service is provided by our GPs and only a very small proportion of patients either choose, or feel they have no choice other than to use, the existing walk-in service.

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We should therefore recognise the current success of GP services and we should perhaps consider that the biggest risk to urgent care delivery is not: can we improve GP access further? But what if current pressures on GP services result in a shift in demand to walk-in services? A 1% reduction in availability of GP services could create a 33% increase in demand for walk-in services. Whereas a 50% reduction in walk-in capacity would create only a 1.5% pressure on GP practices. So there is an obvious risk, that a failure to support improving GP access may actually result in undeliverable pressures on the walk-in service. It is therefore encouraging that the public feedback from the consultation places a much greater importance on the need to support GP access, rather than on the need to rely upon walk-in services; and this therefore supports the need to move away from scenario three towards scenario five. However public feedback from the consultation both supports and challenges our proposals on improving GP access: How does it support our proposals? There is a clear public preference for more same-day appointments in General Practice and for more flexibility on booking when you can see your GP (eg: in two or three days’ time, rather than having to choose between an emergency or weeks in advance). There is also clear evidence from those who use the existing walk-in service that they would be happy to see their own GP if they could.

And there is also clear evidence that people would be happy to be redirected to see their own GP if they could access the service and that people should use services appropriately and not abuse the system – which supports the move from Scenario 4 to Scenario 5. How does it challenge our proposals? There is a clear public preference for more early and late opening for GP services and for weekend opening of GP services. This in effect, therefore asks for us to take our plans well beyond what we are currently proposing. However we do raise these issues as part of the longer-term considerations in our primary care strategy. There is also a clear public scepticism, particularly expressed by local councillors, that we won’t be able to improve GP access because the CCG does not have the contractual responsibility for this – NHS England does. How does this affect the priority for this in our proposals? No-one was saying that the objective to improve GP access was not relevant or that we should not be aiming to try and do something to support it. There was overwhelming agreement that this should be our most important priority out of all the issues identified during the consultation.

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5.2.2 Can we improve GP access? The role of NHS England and the CCG NHS England has the contractual responsibility for GP access. Therefore NHS England will have to consider the outcome of this consultation and consider how it will address the issues that have been raised. It is therefore reasonable for the public to raise concerns about the extent to which Dudley CCG can address the issues of GP access in isolation, without cooperation from NHS England. However, Dudley CCG is working in partnership with NHS England and we have already established some joint arrangements together - both with the establishment of a joint performance review group; with NHS England membership on the CCG’s Primary Care Development Committee; and with shared endorsement of our primary care strategy through the Health and Wellbeing Board. There is nevertheless, as a consequence of the national reforms, a disconnect between the CCG responsibility for funding walk-in services (in-hours) and the NHSE responsibility for funding GP services (in-hours). To some extent, the rising pressure on the former could be considered as consequentially arising from the commissioning failure by the latter – ie: NHSE’s failure to adequately address access results in more people using walk-in services when they would rather see their own GP. This challenge could be better addressed by further improved integration between the CCG and NHS England on how we commission these comparable and interconnected services. In addition, the CCG holds the responsibility for quality improvement in general practice. However whilst our CCG has extensive support arrangements in place for working with our practices; our effectiveness in achieving these aims is inevitably partially hindered by the limitations on how we can invest resources. This limitation could also be better addressed by improved integration between the CCG and NHS England – so we should be seeking to bring our improvement responsibilities for these services, together with NHSE’s contractual responsibilities for these services, into a more formalised joint commissioning arrangement. Current evidence for improving GP access The public are saying that GP access is the single most important quality issue arising from this consultation; and so given our responsibilities, we have already been undertaking work with our practices to support improvements. Dudley CCG has been providing a wide range of development support to practices since its inception. This support is detailed in the Primary Care Strategy and it is our view that this has helped practices to meet the year-on-year rise in demand without the need for additional resources. This is evidenced by the fact that demand for A&E services has not risen over the last few years.

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In addition, Dudley CCG invited all practices to work with the Primary Care Foundation, funded with non-recurrent resources, to review their current access arrangements and there has been 100% take up from our practices to do this. As a result of this work, practices are already looking at how they can make improvements and are sharing their experiences with each other in our locality meetings. This will be brought together over the next 2 months to set out the opportunities and existing improvements that are already being made. Two case study examples are illustrated below.

These demonstrate the commitment of GPs in Dudley to respond to the challenges on access. They also show; though innovative working; that it is possible to make some improvements with modest investment and without having to expand the number of existing appointments. However, some of these changes will have already been implemented by other practices so it would be incorrect to assume that this is the answer to solving all access issues. Each practice will need to be considered separately; a one-size-fits all approach won’t work; and it would be naïve to assume that the current levels of increasing demand can continue to be met both; without additional resources and without working with the public to change patterns of behaviour and expectation. Reviewing access with each practice. Access to GPs is variable (there are 49 practices) and that variability is determined by both how the practices work and also by what their patients expect from their practice. Each practice supports a different population with different needs and has a different level of funding from NHS England to meet that need.

Practice case study one: An online service for booking appointments and requesting repeat prescriptions In late 2013, the practice set in train a number of improvements that will help reduce the number of calls coming in and free receptionists to pick up the telephone when they do. For a start, patients can now book appointments and request repeat prescriptions online. The online services will help increase the accessibility of the practice, by reducing the number of calls and increasing the capacity to answer them.

Practice case study two: Regular review of the calls coming into the practice and the appointments available means the practice can flex to meet changing demand The focus of the practice is on making sure the practice can respond quickly to changing demand by looking in detail at the appointment requests coming in. The change is not just in the volume of calls to the surgery but also for the type of appointments people need. Sometimes there is a surge in demand for same day appointments; other times more people are looking for regular appointments to discuss an on-going health issue. For example, Mondays and Thursdays have proven to be high demand days for same day appointments so on those days, the practice now allocates more slots to same day appointments. By looking in detail at the demand, the practice can make more of the types of appointments available when people need them. The practice team aims to smooth the peaks and troughs making for a better patient experience and a better working environment.

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We have also heard from the public through the consultation that some people speak very highly of their practice and have no difficulties in accessing services (and the vast majority of people get their services from their GP); other people make a choice to sometimes use their practice and at other times use the walk-in service; some people over-use the service and will repeat attendance at all available services; whilst other people are not happy with their GP service and consequently choose to go to the walk-in centre. So how should we define good access and how should we determine what is required for each practice. Our view is that whilst there are some important themes that will be consistent between practices ‘what does good access look like’ is a question that should be answered between the practice and their patients; and both the CCG and NHS England should be actively supporting this. There is a mutual responsibility that should be shared:

- by the public to not use services inappropriately and so create unnecessary demand; - between the practice and their patients to understand what good access means for them; - between the practices the commissioners and the population to ensure there is sufficient

capacity and capability in total to meet overall need. So a key component to improving access is to include the public in that process. We are addressing this by

- prioritising the development of the practice participation groups (PPGs); - supporting the groups to work with their practices on these issues; - and including representation from those groups to inform our overall planning for the

services

Out of the 49 practices we now have 33 PPGs established, with a further 8 practices wanting to set one up. It would add real strength to the role of these PPGs if it was made a requirement that any future investment in improving access with practices should be developed with PPGs. 5.3 How the modelled scenarios reflect the issues raised by the consultation The table below summarises how the scenarios reflect the issues raised through the consultation.

Issue Scenario 1 Scenario 2 Scenario 3 Scenario 4 Scenario 5

National Policy Issues Is service model consistent with principles set out in NHSE ‘High Quality Care’ document?

No No Yes Yes Yes

Is service model consistent with Keogh proposals in ‘Transforming Urgent Care’?

No No Yes Yes Yes

Is service model consistent with recommendations from Royal College of Physicians

No No Yes Yes Yes

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Local Issues

Is it consistent with proposals to improve and simplify urgent care locally set out by HWBB?

No No (because although co-located, not simplified)

Yes Yes Yes

Is it consistent with views of CCG’s GP membership and clinical leaders about urgent care?

No No Partly (addresses co-location but not improving GP access)

Partly (addresses co-location but limits amount of investment in improved GP access)

Yes

Is it consistent with the aims of the CCG’s Primary Care Strategy?

No No No Yes Yes

Issues Raised During Consultation

Does it meet public requirements for a good quality service?

Dependent on contract specification





Does it provide a service for patients who are not registered with a GP?

Yes Yes Yes Yes Yes

Does it support improvements to GP access during weekday day times?

No No No Yes Yes

Does this reduce the pressure on GP services?

No No No No No

Does this avoid increasing the burden on GPs?

Yes Yes Yes No (unless extra funding available)

No (unless extra funding available)

Does this release savings for reinvestment in GP services?

No No No Partly (subject to agreement from NHS England)

Yes (subject to agreement from NHS England)

Does this reduce pressure on ED?

No No Yes Yes Yes

Does this support an affordable option for longer opening hours for walk-in services?

No No Yes Yes Yes

Is parking free? Yes No No No No Will the site be better serviced by public transport

No Yes Yes Yes Yes

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Will this improve access to patient’s own GP outside normal working hours (i.e. at evenings and weekends)?

No No No No No

Will it support provision of more help and advice by telephone?

Yes - Subject to appropriate use of 111

Yes- Subject to appropriate use of 111



Yes -Subject to appropriate use of 111

Does this support improvements to other services (for example mental health)?






Does this encourage more appropriate use of urgent care services?

No No Partly (simplifies choice)

Partly (simplifies choice)

Yes (simplifies choice and directs patients to most appropriate treatment)

5.4 Conclusions There are actions that we can take to improve access to general practice and therefore enable a movement from scenario three to scenario five. However this is challenging! The public challenge and scepticism on achieving improvements is therefore reasonable. So it would be prudent to ensure that any newly commissioned urgent care centre is initially designed to accommodate the planning assumptions in scenario 3; but should incorporate the flexibility to move to scenario 5 as sufficient improvements in GP access are realised. Recommendation 8: Our Board is asked to:

- confirm that it should be part of our strategic plan to develop joint commissioning arrangements [for GP services] with NHS England. - encourage Dudley Health & Wellbeing Board to invite NHS England, as a partner on the Board with the contractual responsibility for GP Access, to demonstrate how they intend to improve this in Dudley. - ask Dudley Health & Wellbeing Board to support joint commissioning between the CCG and NHS England as a key opportunity for addressing this issue.


- that the current development support arrangements that we have put in place have made, and continue to make, an important contribution to improving access to GPs but will be insufficient longer-term both; without additional resources and without working with the public to change patterns of behaviour and expectation; - that the risk of GP access deteriorating would place unmanageable pressures on walk-in services

Recommendation 10: Our Board is asked to approve that we should encourage the development of PPGs with all practices and ensure future plans on improving access require their input

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Recommendation 11: Our Board is asked to confirm that the newly commissioned urgent care centre is initially designed to accommodate the planning assumptions in scenario 3; but should incorporate the flexibility to move to scenario 5 6. DRAFT SERIVCE OUTLINE FOR DUDLEY UCC Should the Board choose scenario 3, moving to scenario 5 over time, the follow sections offer a useful outline definition and service specification of the proposed Urgent Care Centre (UCC). The purpose of the UCC could usefully be defined as:

To develop a coherent 24/7 urgent care service in the Borough of Dudley that makes sense to patients when they have to make choices about their care. This will provide streaming / triage for the front door of ED, if required urgent medical care with a clinical professional and a seamless relationship with 111.

6.1 UCC Aims Draft service aims for the UCC is offered below and would require the following service requirements:

• An Urgent Care Centre (UCC) providing a primary care triage service through bookable appointments 24 hours a day, 7 days a week.

• The delivery of a seamless interface between 111 (currently provided by WMAS), face-to-face streaming / triage and consultations with a clinical professional during the in-hours and out-of-hour’s period.

6.2 UCC Objectives A provider would be commissioned to deliver the best standards of health care that meets the patients need or perceived need through consistent assessment via a ‘primary care triage’ model of service. Upon entering the triage system a patient will be referred back to their GP, provided with advice, booked into a face-to-face clinical consultation at the UCC or directed to the ED. This service would be available in the UCC 24 hours a day 7 days a week. There would be 3 main routes into the service by patients:

1. They walk into the UCC and if appropriate are offered a booked appointment.

2. They call 111 (In-hours and Out-of-Hours) and if appropriate are offered a bookable

appointment with an Advanced Nurse Practitioner (ANP) or General Practitioner (GP)

at the UCC.

3. They are referred by another local provider such as ED (where blue light patients

have been identified as not being appropriate for ED), WMAS non-urgent ambulance

or a local GP.

6.3 Draft UCC Service Outline The UCC would provide a consistent 24/7 assessment of patients who are booked into an appointment for the service by 111. The majority of these bookable appointments would be outside of GP core hours. Ambulatory patients would also be seen who may have accessed the service by walking into the centre and are very ill but do not require 999 services.

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For ambulatory patients the UCC address patient’s needs or perceived needs by face-to-face initial assessment by the triage ‘reception and registration’ facility. A trained receptionist (this model is in operation in Walsall UCC) gives appropriate response to the patient’s perceived need. Following this initial visual assessment and if the patient is sufficiently ill they are offered an appointment at the UCC with an ANP or GP. At this clinical assessment patients are again triaged and may follow one of the following routes, based on clinical risk:

• Seen, treated and discharged • Booked for diagnostic and imaging services • Held for further observation • Streamed to another Trust service i.e. plastering facility and subsequently to an

outpatient’s clinic e.g. fracture clinic • Streamed to the Emergency Department • Transferred to another Healthcare provider, which could include their own GP • Signposted to Rapid Response Service • Signposted to a local Pharmacy

6.4 Accessibility/acceptability The UCC will act as a single point of access for all self-presenting cases at Russells Hall Hospital ED through a common reception gateway. Appropriate cases may also be diverted to the service by WMAS, ED or community based providers. The inclusion criteria for the UCC could be as follows:

Presentation In Hours Out of Hours

Registered with Local GP

Urgent - UCC see and treat

Urgent - UCC see and treat

Non urgent - Refer back to own GP or Advise on self-treatment

Assessed as Non urgent - Refer back to own GP

Not registered with Local GP (out of area, regionally / nationally)

Urgent - UCC see and treat Urgent - UCC see and treat

Non urgent - Refer back to own GP or Advise on self-treatment

Assessed as Non urgent - Refer back to own GP

Not Registered with any GP

UCC see and treat - Signpost to practice near place of residence if local

UCC see & treat - Signpost to practice near place of residence if local

This description is consistent with scenario 5. The is only one difference in this model between scenario 5 and scenarios 3 and 4; namely: in scenarios 3 and 4 all non-urgent cases requiring a GP would be seen by the UCC rather than redirected back to their own GP. The Out-of-Hours period is defined as 18:30 – 08:00 hours, Monday –Thursday and 18:30hrs Friday – 08:00 Monday at weekends plus bank holidays. The In-hours period is defined as 0801 – 1829 hours Monday- Friday (excluding bank holidays) 6.5 Out of Scope

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Dental Services would be out of the scope of the service unless a patient had protracted dental bleeding, trauma or swelling to the face i.e. rapidly spreading infection; these patients may be seen in the UCC or immediately be streamed to ED. 6.6 Service Delivery There are five service elements to the UCC and Out of Hours provision that would need to be commissioned and coordinated as summarised below:

1) Initial self-presentation of patients in the UCC is met by face-to-face triage by a receptionist. The receptionist undertakes a primary assessment using a visual and question based assessment formulary. The receptionist then streams the patient to an appropriate service i.e. back to their own GP, a booked appointment in the UCC or if sufficiently serious direct referral to ED.

2) Face to face consultation and treatment - In hours and Out-of-Hours patients at the UCC are booked an appointment via 111 or the UCC receptionist for a face-to-face consultation conducted by an ANP or GP. A clinician would offer treatment, including assessment, diagnosis, treatment or treatment plan, onward referral, follow-up, or discharge and prescribing of medicines as required.

3) Initial access to Out-of-Hours services and associated call handling will be provided

by 111. There would need to be a seamless approach between 111 and the UCC. An effective relationship between the two would ensure the 111 system would:

a. Enable filtering out of unnecessary referrals to the UCC according to agreed

prioritisation and referral protocols. b. Continue to provide a real-time local information and advice service to signpost

patients to other services (e.g. local pharmacies etc.) and direct patients to their GP as required.

c. Identify and fast-tracks potentially life-threatening conditions to WMAS via 999.

4) 111 provide the Out-of-hours assessment and advice service via a telephone assessment service through trained health care professionals. On the patients request or if deemed necessary 111 would: • Offer a definite clinical assessment of the patient needs conducted by an

appropriately trained clinician working to an agreed clinical protocol (e.g. if not a GP) and within a defined clinical governance framework agreed by the CCG.

• Offer a course of treatment which may include: o Advice on self-management. o A telephone consultation providing advice on self-care. o A booked invitation to attend the UCC for a face-to-face consultation with a

clinician o A home visit planned for a face to face consultation with a clinician o Advice to patients to contact their own GP during the opening hours of their

GP surgery. o Referral to another service i.e. Rapid response, Social services,

Community Nursing, Mental Health, Dentistry, Local Authority Services etc. o Onward referral to another out-of-hours, urgent or emergency service.

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o Advice to patient to contact their local Walk in Centre (if not patient of Dudley GP practice) where these are available.

5) 111 provide the current out-of-hours home visiting service which receives its workload

from the telephone assessment service. 111 will continue to provide a home (home is considered to be where the patient normally resides and may be a care home) visiting service to all patients whom, in the reasonable opinion of the telephone assessment service, and in the light of the patient’s medical condition and/or significantly difficult social circumstances (being “functionally housebound”), it would not be reasonable to expect to be able to travel to the UCC.

6.7 Premises for Urgent Care Centre and Out-Of-Hours Service The UCC will be located on the Russells Hall NHS Trust site, adjacent to ED. 111 call handling and telephone triage elements of the service are located on a separate site and provided by WMAS.

7. PROCUREMENT IMPLICATIONS A significant amount of work still needs to be undertaken to define the model, produce a detailed service specification and determine the type of service contract to be used if scenarios 3-5 are agreed. The procurement procedure for this tender will be the restricted procedure, an advert will be placed in Supply2Health and a pre-qualification process will be undertaken to devise a shortlist of potential bidders to be taken forward to the final invitation to tender stage. Dudley CCG should consider tendering the new service for a period of not less than three years and preferably for up to five years, as implementation of the new service may require significant capital expenditure to secure suitable premises on the Russells Hall NHS Trust site and clinical and non-clinical equipment. An initial contract term of up to five year will enable the successful provider or Prime Contractor to recoup any capital expenditure invested in the service. A contract term of up to five years will also provide assurance to Dudley Group of Hospitals NHS Trust as landlords of the OOH site of Dudley CCG’s commitment to support a viable site for the UCC. 7.1 Timescales for procurement The procurement of the service (with agreement of the Board) will need to ensure that a contract is awarded by the 1st October 2014 and allowing three months for the mobilisation of the service. This affords very little time for delay in determining the detailed service specification and so this process should begin as soon as possible. The development of the specification will need to include appropriate provider, patient and public representation. This will need to establish key performance standards and use both the issues identified in this report as well as further detailed analysis that can be taken from the Healthwatch questionnaires. Recommendation 12: The Board is asked to approve that we commence the development of the service specification to produce a detailed proposal at the March Board meeting, at which point we will also have received the feedback from the Health and Wellbeing Board.

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9. CONCLUSION The case for the redesign of unscheduled care services remains strong. This paper represents the rational and draft service outline in which to define the vision to redesign urgent care in Dudley into a coherent, viable and safe future service provision. It is acknowledged that the draft service outline will require significant expansion, clinical scrutiny and refinement to enable a full service specification to be finalised in preparation for the procurement process. 10. RECOMMENDATIONS Recommendation 1: that Board note the reconfiguration of Dudley urgent care system is in line with nation guidance and best practice; furthermore it falls in line with Dudley CCG Primary Care Strategy and they Dudley Health and Wellbeing Board June recommendations on urgent care. Recommendation 2: that the Board approve the rationale and evidence base to redesign the urgent care pathway for Dudley and as a minimum move to adopting scenario 3; thereby developing an integrated UCC on the Russells Hall NHS Trust site, adjacent to ED Recommendation 3: Our proposal in response to the issues raised by the public about the walk-in services is therefore two-fold:



Recommendation 4: Our original proposal, in response to the issues raised in the consultation, should be modified to include bookable appointments at the urgent care centre and so reduce the impact to the public on the costs of parking at Russell’s Hall. Recommendation 5: The CCG Board will therefore need to obtain assurance at a future meeting, as part of the procurement process, that the specification enhances the quality of the service to take account of the issues raised about Paediatrics, Mental Health and unregistered patients. Recommendation 6: The CCG Board should note that our IT strategy will enable further improvements to the connectivity and access to medical records in the future. Recommendation 7: The Board should report our conclusions to the Health and Wellbeing Board and seek endorsement for our planned way forward. Recommendation 8: Our Board is asked to:

• confirm that it should be part of our strategic plan to develop joint commissioning arrangements [for GP services] with NHS England.

• encourage Dudley Health & Wellbeing Board to invite NHS England, as a partner on the Board with the contractual responsibility for GP Access, to demonstrate how they intend to improve this in Dudley.

• ask Dudley Health & Wellbeing Board to support joint commissioning between the CCG and NHS England as a key opportunity for addressing this issue.

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• that the current development support arrangements that we have put in place have made, and continue to make, an important contribution to improving access to GPs but will be insufficient longer-term both; without additional resources and without working with the public to change patterns of behaviour and expectation;

• that the risk of GP access deteriorating would place unmanageable pressures on walk-in services

Recommendation 10: Our Board is asked to approve that we should encourage the development of PPGs with all practices and ensure future plans on improving access require their input Recommendation 11: Our Board is asked to confirm that the newly commissioned urgent care centre is initially designed to accommodate the planning assumptions in scenario 3; but should incorporate the flexibility to move to scenario 5 Recommendation 12: approve that we commence the development of the service specification to produce a detailed proposal at the March Board meeting, at which point we will also have received the feedback from the Health and Wellbeing Board.

Jason Evans Commissioning Manager – Urgent Care 8th January 2014

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Date of Report: 9 January 2014 Report: Report from Quality & Safety Committee

Agenda Item No: 9.1

TITLE OF REPORT: Report from Quality and Safety Committee

PURPOSE OF REPORT: To provide an update, assurance and details of the discussions at the Quality and Safety Committee meetings held on 19 November 2013 and 17 December 2013

AUTHOR OF REPORT: Mrs Caroline McIntyre, Interim Nursing and Quality Operational Lead(CSU)

MANAGEMENT LEAD: Miss R Bartholomew, Chief Quality and Nursing Officer

CLINICAL LEAD: Vacant

KEY POINTS:

• The factual inaccuracy noted in the DGFT Patient Experience Strategy identified at the December Quality and Safety Committee has been addressed with the Provider.

• Interim arrangements have been implemented to cover the vacancy of the Clinical Executive for Quality and Safety.

RECOMMENDATION:

The Board is asked to consider the level of quality assurance of the providers and to be aware of the position with Dudley Group Hospital Foundation Trust. The Board is asked to note the request for an extension to the deadline for completion of revision of non-clinical policies. The detailed position will be presented to the next Q&S Committee.

FINANCIAL IMPLICATIONS: N/A

WHAT ENGAGEMENT HAS TAKEN PLACE: N/A

ACTION REQUIRED: Decision (for changes to risk log) Approval Assurance

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 REPORT FROM QUALITY & SAFETY COMMITTEE

1.0 INTRODUCTION This report summarises the key issues discussed at the Quality & Safety Committees on 19th November 2013 and 17th December 2013. 2.0 TRUST LEVEL SUMMARY The following table demonstrates the key issues across the four Trusts. The Quality and Safety Committee remain concerned about the range of indicators at Dudley Group Hospital Foundation Trust (DGFT). The Committee are seeking further assurance through the Clinical Quality Review Meeting (CQRM), Keogh action plan, and an announced visit in the next month. The Board is asked to consider the level of assurance outlined in this report in relation to this Trust. Table 1: Key Issues at a Glance – from the Q&S Committee, 17th December 2013

Issue DGFT D&WMHT BCPFT Ramsay Keogh Action Plan

N/A N/A N/A

CQUINs

N/A

Announced/unannounced visit to be determined

Regulatory monitoring

Never Event

New Incidents reported

N/A N/A N/A

Trends in specific SIs

Quality of RCA reports

N/A N/A N/A

Submission of RCA Reports

N/A N/A N/A

Reporting of Pressure Ulcers (DGFT only)

N/A N/A N/A

Infection prevention – increase in C difficile rates

Mortality

N/A N/A N/A

Patient concerns raised through NHS Choice, Patient Opinion and GP

Complaints data submission

Friends & Family N/A N/A

Patient Experience Story Received

Delay in uploading data

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3.0 KEY INDICATOR SUMMARY The following items are indicators of the current position in relation to the main responsibilities and obligations of the committee as defined by the constitution and terms of reference.

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th January 2014 Report from Quality & Safety Committee Table 2: KEY INDICATOR SUMMARY – from data to Q&S Committee November and December 2013

Priority Detail Quality Improvement Quality target Quality outcome Measure

Complaints (all complaints

received by CCG)

Year to date 2013/14: 53 complaints have been received.

5 complaints were received during November 2013.

For upheld complaints an improvement plan is implemented and monitored

For complaints to result in an

improvement that prevents

reoccurrence

N/A

DGFT presented the quarterly complaints report at November

CQRM; quarterly complaints reports will continue to be received

going forward.

Healthcare Acquired Infections

(CCG)

Year to date 2013/14: 82 cases of C.difficile attributable to Dudley

CCG patients have been received (data correct as of 11/12/13).

Zero cases of MRSA bacteraemia since April 2013.

Aim to reduce the number of HCAIs

DOWN IS GOOD

2013/14 thresholds: 84 cases of C.difficile; zero cases of MRSA bacteraemia – have reached C.difficile

threshold

Mortality (CCG)

The latest DGFT SHMI value reported in November remained within the ‘expected’

range at 1.1126

Working with DGFT to deliver the Keogh Review Action Plan

SHMI =<1 Within SHMI range

Never Events

(CCG) Year to date 2013/14

One Never Event reported Zero instances of Never Events Zero cases Zero

Pressure Ulcers (CCG)

Year to date 2013/14: Grade 4: one pressure ulcer reported

Grade 3: fourteen pressure ulcers reported

Reduction of avoidable Grade 3 and Grade 4 pressure ulcers. CQUIN aimed

at significantly reducing avoidable Grade 3 pressure ulcers and to achieve

zero tolerance for avoidable Grade 4 pressure ulcers

DOWN IS GOOD

2013/14 thresholds: Zero Grade 4;

Reducing number of Grade 3s

(Q1=<18, Q2=<12, Q3=<6, zero Q4)

Serious Incidents

(CCG)

Year to date 2013/14: 89 SIs have been reported by DGFT

Announced visit due in Jan/Feb 2014 will include liaison with the internal

DGFT investigations team

Reduction in Serious Incidents

DOWN IS GOOD

Ideal is high reporting of

low harm incidents to reflect high awareness of

patient safety aspects amongst staff and

openness by the Trust. Arrow indicates direction of outcome.

NOTE: The indicator summary above is predominantly based on data relating to the CCG’s main provider, Dudley Group Foundation Trust. A methodology for capturing and reporting on a Dudley population basis, to reflect the CCG’s commissioning responsibilities, is being developed with the Commissioning Support Unit.

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3.1 COMPLAINTS Dudley CCG The next quarterly CCG complaints report is due at the January 2014 Quality and Safety (Q&S) Committee. The Committee have discussed how themes relating to complaints received by the CCG, and the Provider will be jointly analysed this quarter. The Committee agreed due to the relatively small number of complaints that are received by the CCG (an average of 6-7 per month), compared to complaints that are raised directly with the Provider, analysing both sets of data in tandem would provide a more accurate reflection of current Quality issues. Dudley Group Foundation Trust (DGFT) In the November Clinical Quality Review Meeting (CQRM) Dudley Group Foundation Trust (DGFT) presented their Q2 Complaints and Patient Advice and Liaison (PALS) Report. Each complaint is risk rated based on the National Patient Safety Agency (NPSA) guidance. In the quarter ending 30th September 2013, DGFT received 83 complaints, which were categorised as:

High Risk 5 Moderate Risk 41

Low Risk 37 Of the 70 complaints closed in the period, 49% were either upheld or partially upheld. All lessons learned from complaints are shared where appropriate. DGFT have undertaken a review of their complaints process which will be reviewed by the Quality Team. The Quality and Safety Committee will receive a report which will define how actions following upheld complaints are taken forward. A breakdown of the complaints received by DGFT is detailed below:

Category Qtr 2

ending 30/9/12

Qtr 3 ending

31/12/12

Qtr 4 ending

31/03/13

Year ending

31/03/13

Qtr 1 Ending 30/6/13

Qtr 2 Ending 30/9/13

All aspects of clinical treatment 86 88 74 295 65 40 Attitude of staff 2 2 4 14 2 3 Communication/information to patient 4 8 4 19 10 13 Admission, Discharge & Transfer 1 4 2 8 4 7 Outpatient Department appointment/cancellation 5 3 3 17 11 -

Nursing care - - - 8 - - Delay providing service - - - - - 16 Other - - - - 2 - DGFT are reviewing the categories by which complaints are recorded against to enable more detailed analysis of themes and trends. Dudley & Walsall Mental Health Trust (DWMHT) In November, a report was presented at the DWMHT CQRM regarding complaints received during quarter two. 38 ‘informal’ concerns, and 35 ‘formal’ complaints were received. One ombudsman case was received during quarter two. The Q&S Committee discussed the types of complaints that had been received and have asked for reports to include analysis of complaints over a longer time period. The Quality team will provide further evidence of how DWMHT track the corrective actions and how lessons learnt are disseminated across the Organisation.

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The graphs below show the number of complaints/informal concerns reported by DWMHT in Q2.

Black Country Partnership Foundation Trust (BCPFT) In November, a report was presented at the BCPFT Combined Mental Health & Learning Difficulties CQRM regarding complaints received during quarter two. 2 complaints were received about Dudley Children’s Service in this period. The Q&S Committee discussed the low number of complaints, and asked for further evidence of lessons learned as a result of complaints. BCPFT are producing ‘You said, We did’ posters. The Quality team will review these and evidence of changes implemented as a result of upheld complaints when reviewing the Quarter 3 complaints report. Ramsay Healthcare The November CQRM for Ramsay Healthcare was postponed. No complaints data has been received. 3.2 HEALTHCARE ACQUIRED INFECTIONS Dudley CCG The C.difficile update paper received by the Q&S Committee confirmed that 82 cases (correct on 11/12/2013) of C.difficile reported were attributable to Dudley CCG, against an annual target of 84 cases. It is therefore extremely likely that the CCG will breach trajectory for 2013/14. It is anticipated that learning gained from the introduction of the Primary Care C.difficile investigation process will contribute to a sustained reduction of cases in future. The Committee has reviewed the C.difficile Action Plan, and is ensuring Providers and Community deliver their actions through the Infection Control Team based in Public Health. Dudley Group Foundation Trust (DGFT) 26 cases of C.difficile from April to November 2013, have been reported by DGFT against an annual threshold of 38. This creates the potential for DGFT to breach their annual threshold. 72 hour Trust wide C.difficile meetings took place on the 5th and 21st November 2013. A number of key actions were agreed and progress against these actions is being monitored through the CQRM by the Infection Control Team based in Public Health. The Quality and Safety Committee were assured that there has been much stronger clinical engagement from DGFT and progress is being made.

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3.3 MORTALITY Dudley Group Foundation Trust (DGFT) DGFT Medical Director’s Quarter 2 mortality report was submitted to CQRM in December. It was reported that the Trust-wide external mortality indices remain within the “expected” range. The Summary Hospital level Mortality Index (SHMI) value has remained at 1.1126 and an updated figure is expected to be published in January 2014. January Quality and Safety report will include the top 20 SHMI mortality indicator outliers. 3.4 NEVER EVENTS DGFT reported one Never Event in November 2013 which related to a retained throat swab. This is still being investigated by DGFT as they have 60 working days to submit a full Root Cause Analysis (RCA) to commissioners. Initial assurances have been received via 72 hour brief and an update will be provided to the January Q&S Committee. The other main Providers have reported no Never Events in the year to date. 3.5 PRESSURE ULCERS DGFT – Eleven Grade 3 pressure ulcers were reported in November 2013. No Grade 4 pressure ulcers were reported in this period. The increase in reporting in November related to pressure ulcers that occurred from mid July to October. Action taken: The CCG has written to the DGFT Chief Nurse informing the Trust that all grade 3 and 4 pressure ulcers must be reported as serious incidents. DGFT have agreed to this from 1st December 2013 onwards. DWMHT – There have been no grade three or four pressure ulcers reported in the year to date. BCPFT and Ramsay Healthcare – No pressure ulcers have been reported in the year to date. 3.6 SERIOUS INCIDENTS DGFT – The Committee received a serious incidents report at the November meeting. • October: 15 serious incidents were reported. The top three categories were: Maternity – two intrauterine deaths and three unexpected admissions to NICU Slips/trips/falls Unexpected death

• November: 20 serious incidents were reported. The main categories were: Grade 3 pressure ulcers Slips/trips/falls

DWMHT – At the CQRM in November, DWMHT reported 6 Serious Incidents occurred during October 2013 graded as:

two low risk three moderate risk one high risk BCPFT – There were no serious incidents reported in November for the Learning Difficulties Service or for the Children’s Services.

Ramsay Healthcare – No serious incidents have been reported to date.

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4.0 ITEMS DISCUSSED AT QUALITY & SAFETY COMMITTEES 4.1 PATIENT STORY The Committee heard from the Senior Quality Manager who presented two patient experience stories. The patient story presented at the November Committee concerned a patient who recently attended the Day Surgery Unit at Russells Hall Hospital who felt that she had an adverse patient experience. She attended her appointment alone and was nervous and apprehensive about her treatment. This will be followed up by the CSU Patient Experience Team and reported to the Quality and Safety Committee. The December patient story concerned a 75 year old patient who attended the Opthalmology Department at Russells Hall Hospital in March 2013. An update report will be requested and reviewed in the March Q&S Committee. 4.2 CANCER WAITS The Committee were informed that an audit had been carried out to understand where performance targets were being missed within particular specialities, to inform future commissioning intentions. There were some concerns raised regarding patient handover between Providers. The Providers will be asked to provide evidence of the current communication pathway used when handing over patients on a shared pathway. An update will be provided to the January Q&S Committee. 4.3 KEOGH REPORT ACTION PLAN The latest Keogh action plan was submitted by DGFT to the December CQRM. There was a factual inaccuracy identified in the DGFT Patient Experience Strategy which the CSU will address with the Provider and feedback to the January CQRM. A number of documents used as supporting evidence have been requested from DGFT for further review. The action plan will continue to be reviewed on a monthly basis at CQRM. The Q&S Committee discussed the actions with revised completion dates and agreed that it would be useful for a member of DGFT staff to attend and present the report in more detail. 4.4 ANNOUNCED VISIT TO DGFT A planning meeting was held in December to discuss the announced visit to review the frail elderly pathway at DGFT. Serious Incident themes identified earlier in the year relating to maternity and radiology will be incorporated into the visit to Ward A2 and A&E. In addition the DGFT Clinical Governance Team will be involved to facilitate a wider understanding of internal processes in place. 4.5 SAFEGUARDING The Q&S Committee received updates from the Adult and Children’s Safeguarding Leads. Issues discussed include: • Adult Safeguarding The Committee were informed that admissions will continue to be suspended in the nursing home found to be non-compliant in care and welfare and staffing by the CQC. This will continue until the CQC revisit to review the action plan which is still outstanding. The Dudley CCG Safeguarding Lead will be sighted on monitoring the action plan and will report into the Health Forum. A Quality Assessment Framework (QAF) of care in the CCG’s commissioned nursing homes are being undertaken by the CSU. Plans are in place to complete a baseline assessment and two homes per week will receive visits.

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• Children Safeguarding The Designated Nurse for Safeguarding Children is leaving the organisation at the end of December. The post has been successfully recruited to and it is anticipated that the new post holder will commence in February/March 2014. Adequate interim arrangements have been agreed with partner Organisations. Dudley CCG has an action plan following the last Serious Case Review (SCR) and Significant Incident Learning Process (SILP). A universal flagging system and arrangements for information sharing between Health Visitors and GP’s are under discussion. The Health Safeguarding Forum will meet to monitor the action plan and exceptions will be reported to the January Committee. 4.6 RISK REGISTER The risk register was discussed at the December Q&S Committee and action plans reviewed. As the Committee was not quorate it was agreed that the following risks were to be updated and signed off by the Dudley CCG Board. Risk No. Description of Risk Updated position

21 Failure of the CSU to deliver a service offering that delivers the CCG's requirements (particularly quality framework) which underpin the CCG strategy

Interim leadership arrangements in place within the CSU Nursing and Quality Team.

22 The delivery of efficiency savings could impact the drive for quality in health care

This risk will be reviewed following meetings with the Medical Director and Director of Nursing from BCPFT and DWMH

25 The CCG could fail to share learning from serious incidents (never events and near misses) which in turn results in similar incidents occurring

The CCG is working with the Area Team to identify improvements in shared learning from serious incidents

32

Current reorganisation of Health Visiting Service could result in breakdown in continuity of care to patients and consequent risks to safeguarding children.

There has been a management change within BCPFT and it is anticipated that this will support mitigation of this risk

35 111 service - Concerns regarding capacity and capability for patients both out of hours and in hours indicate a failing service provider.

The 111 service has been re-procured and the Ambulance Trust is now undertaking the service for 18 months

39

Lack of a systematic approach to ascertaining the quality of the care in our commissioned nursing homes, potentially resulting in harm to vulnerable adults

Quality reviews in nursing homes has commenced - risk score to be reduced

4.7 POLICY REVIEW UPDATE Work is underway to organise and review non-clinical policies with the CSU. A paper will be presented by CSU to the January Q&S Committee to update on actions and confirm timescales to complete the work. This will include an assessment of the list of proposed policies across the organisation. 5.0 DECISIONS TAKEN BY THE COMMITTEE The December Q&S Committee was not quorate. The Board is therefore requested to accept the recommendations made to update the actions on the risk register. 6.0 RECOMMENDATION The Board is asked to consider the level of quality assurance of the providers, and to be aware of the position with Dudley Group Hospital Foundation Trust. The Board is asked to note the request for an extension to the deadline for completion of revision of non-clinical policies. The detailed position will be presented to the next Q&S Committee.

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Date of Report: 9th January 2014 Report: Francis Report – Position statement

Agenda item No: 9.2

TITLE OF REPORT: Francis Report – Position statement

PURPOSE OF REPORT: That the Board receive a current position statement on the implementation of the Francis Report Recommendations

AUTHOR OF REPORT: Miss R Bartholomew, Chief Quality & Nursing Officer

MANAGEMENT LEAD: Miss R Bartholomew, Chief Quality & Nursing Officer

CLINICAL LEAD: Clinical Executive – Quality & Safety

KEY POINTS:

• Provider NHS Trusts are expected to respond to the Francis Report, with action plans, by January 2014

• Their action plans will be reviewed by Dudley CCG via the Clinical Quality review meetings which will report to the Quality and Safety Committee

RECOMMENDATION: That the Board are informed of the current progress

FINANCIAL IMPLICATIONS: None

WHAT ENGAGEMENT HAS TAKEN PLACE: Shared with Committees and Localities


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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 FRANCIS REPORT – POSITION STATEMENT

1.0 INTRODUCTION

The report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, Chaired by Robert Francis QC, was made public in February 2013. Dudley CCG Board received the report pertaining to the corporate responsibilities at the September board meeting. 2.0 THE FRANCIS REPORT – UPDATE

Provider NHS Trusts are expected to respond to the Francis Report, with action plans, by January 2014. Their action plans will be reviewed by Dudley CCG via the Clinical Quality review meetings which will report to the Quality and Safety committee. An appraisal of the current cycle of Clinical Quality review meetings (CQRM) is taking place to ensure that the flow of Quality information is the most recently available.

Each of the provider organisations will have the opportunity to present its action plan to their board internally.

Once this has taken place it will then be requested at the next CQRM for assurance. This will provide the opportunity to work with our providers to ensure our cycles of assurance tessellate. Where it is possible to gain assurance through information this will be sought via the contracting process.

The Dudley CCG Board will receive updates at the March and May board meetings.

3.0 CONCLUSION

The purpose of the document is to update Dudley CCG Board. 4.0 RECOMMENDATION

That the Board are assured that the expected cycle of assurance from our commissioned providers is being sought.

Miss R Bartholomew Chief Quality & Nursing Officer 23 December 2013

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Date of Report: 9th January 2014 Report: Clinical Development Committee Report

Agenda item No: 10.1

TITLE OF REPORT: Clinical Development Committee Report

PURPOSE OF REPORT: To advise the Board of matters considered by the Clinical Development Committee on 20th November 2013 and 18th December 2013

AUTHOR OF REPORT: Mr N. Bucktin, Head of Commissioning

MANAGEMENT LEAD: Mr N. Bucktin, Head of Commissioning

CLINICAL LEAD: Dr S Mann, Clinical Executive

KEY POINTS:

• Quality premium indicators were reviewed to assess risk of non-delivery.

• QIPP performance at risk of underperforming and actions to rectify were agreed.

• Position in relation to the development of personal health budgets for NHS continuing healthcare noted.

• Position in relation to the development of the Integration Transformation Fund noted.

• Revised arrangements for implementing NICE Quality Standards agreed.

• Palliative Care Gold Standard Framework (GSF) – service specification for care in the community agreed.

• Business cases agreed and recommended for approval to the Board for community based palliative care consultant and social prescribing scheme for older people.

RECOMMENDATION:

1. That matters considered by the Clinical Development Committee be noted.

2. That proposals in relation to the community based palliative care consultant and the social prescribing scheme for older people be approved.


Financial risks are associated with the non-delivery of QIPP targets and Quality Premium targets. These are reported to the Finance and Performance Committee. The financial implications of the community based palliative care consultant and the social prescribing scheme for older people are identified below


Engagement has taken place in relation to individual proposals considered by the committee as necessary


DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 REPORT OF THE CLINICAL DEVELOPMENT COMMITTEE 1.0 INTRODUCTION The Clinical Development Committee met on 20th November and 18th December 2013. Two items requiring the approval of the Board are set out below. 2.0 KEY INDICATOR SUMMARY 2.1 Local quality premiums The committee have been advised that sufficient progress is being made in relation to the hypertension and dementia targets. Concerns remain in relation to atrial fibrillation. The practice based pharmacists are currently carrying out a review at practice level on performance in relation to this target and a further update will be provided to the meeting if available 2.2 National indicators The committee have noted that risks remain in relation to the targets for :-

• 4 hour A and E wait. • 62 day urgent referral to first definitive treatment for cancer. • 8 minute ambulance response time.

Detailed performance is set out in the report of the Finance and Performance Committee. 3.0 QIPP PROJECT PROGRESS On the following page is a summary of all QIPP projects underpinning each priority for 2013/14. These projects together are designed to deliver £5.4million savings. Projects have been rated in three ways.

• Progress: Where a plan is on track, it is rated green; if there are delays in the plan but there are actions in place to mitigate, it is rated amber; if the plan is at significant risk of non delivery it is rated red.

• Finance: Plans are rated on progress against the monthly financial target. Where an immediate saving has been made due to a lower block contract value being agreed the plan is green. Amber indicates that savings are being realised but have not yet hit target levels. If a plan is focused on quality and efficiency and has no financial implications it is black.

• Outcome: The outcomes are defined for each project. If the project has reached delivery stage and

these are being achieved there is a green rating. If a project has not yet reached the delivery stage it is rated red. A number of outcomes are still amber due to only April and May data being available.

3.2 Risk of underperformance of some projects The committee have noted delays in agreeing the necessary operational changes with providers to redesign outpatient services. Providers have been asked to address delays in specific projects. Commissioners have identified new QIPP schemes to address the potential financial shortfall. Additional resource is being committed to drive projects forward.

3.3. Urgent Care QIPP Proposals in relation to urgent care are the subject of a separate report on this agenda. Work on other elements of the QIPP urgent care programme are progressing. The readmission audit has delivered a reduction in the contract value. The reduction in emergency admissions is being addressed through a number of initiatives including ambulatory conditions, respiratory high volume service users and the nursing home LES. Each initiative is being monitored and the frequency of monitoring will be increased shortly.

Priority QIPP Schemes Quality Improvement Project progress

Financial target

Outcomes being

achieved

Improving outcomes for children and young people

Improving access, early intervention, commissioning new pathways

Increase in numbers of children being seen in community settings more promptly

Improving Primary care mental health

Mental Health Service Transformation Programme

Decrease waiting times and use of bed based services

Improving access to Alcohol support services

Enhanced psychological input to the care pathway

Increase patients accessing support for tackling alcohol problems

Improving care for older people

reducing falls, increasing support for dementia patients, not admitting older people to hospital

Decrease emergency admissions, falls, length of stay

Community nursing services

Integrating community services to support patients and prevent admissions to hospital

Decrease emergency admissions

Improving diabetes services

new diabetes service model, increasing identification of diabetes

Increase in primary care support, increase in numbers diagnosed

Improving access to cardiology

Cardiology Outpatient Redesign

Increase in care plans to primary care/patients seen by right specialist quicker

Ophthalmology Glaucoma Decrease first consultant outpatient appointments

Improving Stroke Care

improving stroke prevention, rapid access to treatment and improved rehab

Decrease in stroke mortality

Better use of resources

Range of measures to increase productivity, procure more effectively and reduce activity

Decrease in costs

Improving urgent care Urgent care model

Decrease in A&E attendance, reducing emergency admissions, reducing ambulance use

5.0 MATTERS CONSIDERED REQUIRING APPROVAL BY THE BOARD 5.1 Palliative Care Consultant in the Community The committee considered this joint initiative involving both Dudley Group NHS FT and the Mary Stevens Hospice based around a bid to Macmillan Cancer Care for funding to support a 1.5 whole time equivalent palliative care consultant and associated support in the community. The committee considered this proposal to be in line with the CCG’s strategy in relation to the development of integrated locality based services as an alternative to hospital admission. In particular, the scheme would:- Facilitate end of life in the preferred place of care Provide a single point of access and appropriate linkages to other community based services Provide early intervention at times of crisis Provide earlier referral to services to prevent unplanned hospital admissions The scheme requires the commitment of £105,000 by the CCG in years 1 and 2. It is anticipated that if 42 admissions are avoided, the scheme will become self-funding by year 3. 5.2 Social Care Prescribing Scheme for Older People The committee considered this proposal, developed in conjunction with Dudley Age UK, to pilot a scheme whereby GPs and other primary/community care based staff will be able to refer older people to Age Concern Dudley in order to access appropriate community based support as part of an integrated locality based response. It is anticipated that such a scheme will prevent social isolation and loneliness and the loss of independence that can result. The service will be particularly appropriate for people:-

• with mild to moderate depression • with multiple long term conditions • who are frequent, inappropriate service users • report feelings of social isolation • have suffered a recent bereavement

The cost of the scheme is c £63,000 per annum for two years. The committee have approved the scheme in principle, subject to final agreement of the costs with Dudley Age UK. 4.0 OTHER MATTERS DISCUSSED BY THE COMMITTEE 4.1 Personal Health Budgets The committee has received a report on progress with the development of personal health budgets for patients who meet the criteria for NHS continuing healthcare. It was noted that there was a statutory requirement that would enable patients to be able to request a budget by 1st April 2014. 20 patients had been identified who might request a budget and work was taking place in relation to these.

In order to have a suitable mechanism in place prospectively for new patients which would involve determining a suitable budget setting methodology and establishing a process to agree the proposed use of a personal health budget. This will be considered further by the committee in January 2014 and a final report made to the Board in March 2014. 4.2 Integration Transformation Fund The committee have considered a report on the implications of establishing this fund. This matter will be considered by the Health & Wellbeing Board on the 28th January 2014 and a final submission will be made to NHS England as part of the strategic planning process. 4.3 NICE Quality Standards The committee have agreed to establish working groups to oversee the implementation of NICE Quality Standards. 4.4 Palliative Care Gold Standards Framework The committee have approved a proposed service specification for the delivery of palliative care in general practice with the support of appropriate community services. Further consideration will be given to the mechanism of remunerating practices for participating in this. 5.0 RECOMMENDATION 5.1 That matters considered by the Clinical Development Committee be noted.

5.2 That approval be given to proposals in relation to:-

• the community based palliative care consultant; • the social prescribing scheme for older people.

Dr S Mann – Clinical Executive Mr N Bucktin – Head of Commissioning December 2013

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Date of Report: 9th January 2014

Report: Dudley Health and Wellbeing Board Agenda item No: 10.2

TITLE OF REPORT: Report of the Dudley Health and Wellbeing Board

PURPOSE OF REPORT: To advise the Board of matters due to be considered by the Dudley Health and Wellbeing Board

AUTHOR OF REPORT: Neill Bucktin, Head of Commissioning

MANAGEMENT LEAD: Neill Bucktin, Head of Commissioning

CLINICAL LEAD: Dr. Steve Cartwright, Clinical Executive – Partnerships and Integration

KEY POINTS: 1. The Health and Wellbeing Board is scheduled to meet on 28th January 2014.

2. Key items scheduled for consideration at this meeting include:-

• CCG Strategic Plan • Urgent Care Consultation • Integration Transformation/Better Care Fund • Francis Report – Implementation of Recommendations • Joint Health and Wellbeing Strategy – Implementation and

Performance

RECOMMENDATION: That matters due to be considered by the Health and Wellbeing Board be noted.

FINANCIAL IMPLICATIONS: None arising directly from this report.


1. Specific engagement has taken place in relation to the spotlight

events. 2. Engagement has also taken place in relation to the development of the

CCG’s Strategic Plan and the CCG’s proposals in relation to urgent care.

ACTION REQUIRED:

Decision Approval Assurance

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DUDLEY CLINICAL COMMISSIONING GROUP – 9th JANUARY 2014 REPORT OF THE HEALTH AND WELLBEING BOARD

1.0 INTRODUCTION

The Health and Wellbeing Board is scheduled to meet on 28th January 2014.

This report sets out those issues due to be considered by the Board. 2.0 CCG STRATEGIC PLAN AND URGENT CARE CONSULTATION

Both these items are the subject of separate reports on this agenda. In accordance with the requirements of the NHS and Social Care Act 2012, the Health and Wellbeing Board will be asked to confirm that the CCG’s Strategic Plan takes proper account of the Joint Health and Wellbeing Strategy. In addition, the Board will be asked to approve the CCG’s proposals for the development of the urgent care system, which have been informed by the Joint Health and Wellbeing Strategy, the outcome of the Board’s spotlight event on “healthy services” and are in keeping with the CCG’s primary care strategy which has already been endorsed by the Board. 3.0 INTEGRATION TRANSFORMATION FUND The Board has already noted the implications of the Integration Transformation Fund (now renamed the Better Care Fund). Colleagues form Dudley MBC, the CCG and Dudley Group NHS Foundation Trust are meeting to develop proposals which will reduce both admissions to secondary care and to residential/nursing home care through the development of integrated health and social care services at locality level. The Health and Wellbeing Board will be required to agree proposals for the utilisation of the fund.

4.0 FRANCIS REPORT – IMPLEMENTATION OF RECOMMENDATIONS

The Chief Quality and Safety Officer’s report on this matter, which is the subject of a separate report on this agenda, will be considered by the Board in order to provide assurance that the recommendations are being implemented. 5.0 JOINT HEALTH AND WELLBEING STRATEGY – IMPLEMENTATION AND PERFORMANCE The Board will receive an update in relation to the implementation of this strategy, the key priorities of which are:-

• Making our services healthy – with a focus on urgent care • Making our lifestyles healthy • Making our children healthy • Making our minds healthy • Making our neighbourhoods healthy

A further spotlight event on “making our minds healthy” has now taken place and the outcome will be reported to the meeting. A final event on “making our neighbourhoods healthy” will take place in February 2014. 6.0 COMMUNITY ENGAGEMENT PRINCIPLES/HEALTHWATCH The Board will be asked to agree a set of principles for community engagement and will receive an update on the work of Healthwatch.

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7.0 RECOMMENDATION That the report of the Health and Wellbeing Board be noted. Neill Bucktin, Head of Commissioning December 2013

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Date of Report: 9th January 2014 Report: Communications & Engagement Committee Report


TITLE OF REPORT: Communications & Engagement Committee Report

PURPOSE OF REPORT:

To update the Board on the activity of the Communications & Engagement Committee. To provide the Board with assurance that the committee is responding to its delegated duties as set out in the Scheme of Delegation

AUTHOR OF REPORT: Richard Haynes- Interim Head of Communications and Engagement

MANAGEMENT LEAD: Richard Haynes- Interim Head of Communications and Engagement

CLINICAL LEAD: Dr David Hegarty

KEY POINTS:

• The committee held its most recent bi monthly meeting on Tuesday 10 December 2013.

• This report includes details of key discussions at the meeting • The summary table details progress in key area around the CCG

Communication & Engagement Strategy

RECOMMENDATION:

• That the Board is assured that the committee is now fully functioning and that statutory duties are being met with regard to engagement with the public & patients.

• That the Board is assured that the Communications & Engagement Strategy is being progressed well.


• The CCG has a statutory duty to involve. Failure to do so could result in costly judicial proceedings.

• All activity reported is covered by the existing communications & engagement activity unless it states otherwise.

• AVE is a method of estimating the value of editorial media coverage, which is widely used throughout the PR industry.


• The committee is responsible for ensuring that appropriate mechanisms are in place for Engagement to take place. Progress on this is included in the report.


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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 COMMUNICATIONS & ENGAGEMENT COMMITTEE REPORT

1.0 INTRODUCTION

This is a report to the CCG Governing Body (Board) from the Communications & Engagement Committee. The Committee had its latest meeting on 10th December 2013.

2.0 KEY INDICATOR SUMMARY (Produced 18th December 2013)

Communications and Engagement Strategy Summary Report

Number of Patient Participation Groups (PPGs)

31

Number of Prospective PPGs 9

Date and agenda of next Patient Opportunity Panel (POPs)

13th January 10.30 – 12.30

Date and agenda of next Healthcare Forum (HCF)

13th February (tbc)

• Urgent Care Consultation Feedback

Twitter Followers 1,370 (up by 133 since last Board)

Facebook Likes 93

Advertising Value Equivalent (AVE)

1/10/13 – 30/11/13:

Total £36,894.85

• On message £12,597.31 • Neutral £15,619.94 • Off message £8,677.60 (mainly critical comment on Urgent Care

Consultation)

Media Coverage Topics

• The death of Dr Liz Pope • Urgent Care Consultation • Healthcare Forum • Patient Participation Groups

Collaborative Work • Building Health Partnerships (including development of

information directory) • Community Engagement Network Event: Organised, run and

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facilitated in partnership with DCVS and the council. The most recent one was held on 20 November and focussed on social media. Around 40 people took part.

Key Projects • Urgent Care Consultation

• PPG Development

Next Membership Meeting Wednesday 5 February 2014

3.0 ITEMS DISCUSSED

3.1 Freedom of Information (FOI) Update

The Freedom of Information (FOI) Update was presented to the committee. The purpose of this report is to provide the Communication and Engagement Committee with an overview of the CCG activity in relation to Freedom of Information requests received and to provide assurance that this key function is being managed well by the team and the contract with CSU is delivering to agreed KPIs.

• Dudley CCG has received a total of 47 FOI requests between 1 October and 30 November 2013 • No trend in terms of request topics • Proportionally more requests from the public than other sources • The average days it takes to complete a Freedom of Information request is 6.62, well within the

statutory 20 working day limit.

3.2 Meetings reporting to Committee

The committee received an update on a number of key meetings which had taken place, including:

• Patient Participation Group (PPG) development session held 13th September 2013 • Practice staff for PPG development session held 8th October 2013 & 27th November 2013 • Patient Opportunity Panel (POPs) met 14th November 2013

The committee noted the positive work that was being done to develop our Patient Participation Groups (PPGs) and strengthen patient voice in the organisation’s decision making process.

3.3 Feet on the Street

The team presented to the committee the ‘Feet on the Street’ footage which focussed on primary care access.

3.4 Urgent Care Consultation

The committee was updated on the extensive amount of work being undertaken to support the consultation on Urgent Care and advised that a separate report on the consultation exercise would be submitted to the January board.

4.0 DECISIONS TAKEN BY COMMITTEE UNDER DELEGATED POWERS FROM BOARD

None

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5.0 DECISIONS REFERRED TO THE BOARD

None

6.0 RECOMMENDATION

• That the Board is assured that the committee is now fully functioning and that statutory duties are being met with regard to Engagement with the Public & patients.

• That the Board is assured that the Communications & Engagement Strategy is being progressed well.

7.0 OTHER ITEMS OF BOARD INTEREST 7.1 Healthcare Forum 3 December The theme of the event was ‘Prevention is Better than Cure.’ More than 80 people took part. Feedback was extremely positive. 7.2 Board Development Session 5 December

This session was dedicated to exploring how to develop the relationship between the Board and our growing network of Patient Participation Groups. Again, the event generated a great deal of positive feedback and a number of actions are being taken as a result – including the production and distribution of a summary of the January CCG Board meeting for circulation to PPGs and other stakeholders. Richard Haynes Interim Head of Communications & Engagment December 2013

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Date of Report: 9th January 2014 Report: Audit Committee Report


TITLE OF REPORT: Audit Committee Report

PURPOSE OF REPORT: To advise the Board of the key issues discussed and agreed at the Audit Committees on 31st October 2013 and 12th December 2013

AUTHOR OF REPORT: Mr M Hartland, Chief Finance Officer

MANAGEMENT LEAD: Mr M Hartland, Chief Finance Officer

CLINICAL LEAD: Dr J Rathore, Clinical Lead for Finance and Performance

KEY POINTS:

• Combined BAF & Risk Register reviewed; updates from Primary Care Development and Finance & Performance Committees received.

• Francis Report-update on recommendations assigned to Audit Committee.

• Updates from Information Governance; Auditors & Local Counter Fraud Services received.

• Prime Financial Policies-No compliance issues. • Other matters considered – Procurement Strategy; Constitution

Changes; Premises Disposals; Annual Accounts Planning; Consultation on CCG Audit Committees

RECOMMENDATION: The Board is asked to note the issues discussed at the Audit Committees on 31st October and 12th December 2013 for assurance and to note that it had previously approved three matters arising from the 31st October Audit Committee at its meeting on the 7th November 2013


WHAT ENGAGEMENT HAS TAKEN PLACE: None


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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 AUDIT COMMITTEE REPORT

1. INTRODUCTION The report summarises the key issues discussed at the Audit Committees on 31st October and 12th December 2013. Some items were approved on the 7th November Board as included in the addendum to November Board paper but are included here to show a true record of the 31st October Audit Committee.

2. KEY INDICATOR SUMMARY The following items are indicators of the current position in relation to the main responsibilities and obligations of the Committee as defined in the CCG Constitution and Terms of Reference.

Indicator Position RAG 1. Regulation & Control Good progress - CCG Governance Arrangements – Constitution Changes approved by

NHS England

- Scheme of Delegation Changes implemented - Compliance with Prime Financial Policies No issues 2. Annual Report & Accounts – CCG 13/14 Committee updated 3. Operational & Risk Management Good Progress - Counter Fraud & Security Good Progress - Risk Management Arrangements – Combined BAF & Risk

Register in place; Chairs/Management Leads of committees attending & updating Audit Committee

Good Progress

- Report newly commissioned services Procurement Strategy approved by CCG Board November 2013

- External Audit No issues - Internal Audit 13/14 Audits

progressing.

- Other Policies – 6 of total of 7 received and approved Good progress - Other Policies – Business Continuity Policy Under development 4. Information Governance Good progress - Information Governance Group established Not met yet* - Information Governance Breaches – Provider Regular updates - Compliance with Information Governance toolkit Action plan agreed &

progressing

- Information Asset Management structure to be established with IAOs and IAAs identified from CCG staff

IAOs identified, IAAs identified by IAOs. CCG staff briefed

- IG Policies – 16 of total of 17 received and approved Good progress - IG Policies – Password Management Expected December

* Responsibilities falling under this being discussed and agreed by Audit Committee

3. ITEMS DISCUSSED-MEETING 31st OCTOBER 2013

3.1 Procurement Strategy The Audit Committee received the draft Procurement Strategy and recommended its approval as it stood to the CCG Board. It was noted that some of the assumptions within the strategy might change following further legal advice. The strategy was approved by the Board at its meeting on the 7th November.

3.2 Board Assurance Framework and Risk Register The Committee received the Combined Board Assurance Framework (BAF) and Risk Register as at 9th October.

The Clinical Lead for the Primary Care Development Committee and the Finance & Performance Committee attended the meeting to explain the process for managing risks within these committees and to provide an update on the risks the committees were responsible for managing. Dr Rathore

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explained that the risks are considered at each committee meeting and robustly challenged as well as being actively managed between meetings.

It was noted that the risk relating to the CCG not being sighted on significant performance issues identified by the Area Team had been downgraded to amber at the last Primary Care Development Committee. Dr Rathore responded that the evidence for this was the establishment of a Primary Care Interface Group, which included representation from the CCG, the Area Team and the Local Medical Committee. Significant performance issues identified by the Interface Group are escalated to the Primary Care Development Committee, Quality and Safety Committee and to the Area Team. The risk would remain as amber as the relationship with the Area Team was still in its infancy.

On the basis of the discussion the Audit Committee felt assured that the risks assigned to the Primary Care Development and Finance and Performance Committees were being actively managed.

3.3 Proposed Changes to the CCG Constitution The Committee considered proposed changes to the CCG Constitution. The changes did not materially impact upon the CCG’s governing arrangements but were required to properly reflect the way in which the organisation was operating in practice. The Committee agreed to recommend adoption of these to the Governing Body. The changes were approved by the Board at its meeting on the 7th November for submission to NHS England for formal sign-off which was received on the 16th December.

3.4 Internal Audit The Committee received a verbal progress report against the 2013/14 internal audit plan. It was noted that six audits were in progress – in year budgetary control and financial reporting; contract assurance; collaborative outsourced arrangements (draft report stage); continuing health care; commissioning, including joint commissioning arrangements and former Section 75; and business intelligence and performance reporting. Internal Audit expected that the majority of the reports would be available for the next meeting.

Another five areas of work, one of which was around financial systems, would be completed in quarter 3 and the rest in quarter 4.

Of the six outstanding audit recommendations, only one was due for completion and this had been addressed with the production of a draft procurement strategy.

3.5 External Audit The Committee received guidance issued by the Audit Commission in respect of the value for money conclusion on the annual accounts. The review would address some of the key risks facing CCGs, categorised as leadership; commissioning; financial planning and management; data quality and external relationships.

3.6 Disposal of Premises/Property The Committee was advised that the ownership and management of most properties previously held by Dudley PCT transferred to NHS Property Services Ltd from 1st April 2013 and they manage the estate on behalf of the NHS. As the CCG is responsible for premises costs associated with the commissioning space it occupies and utilises, NHS Property Services Ltd was seeking formal approval from the CCG Board for several planned premises disposals, most of which were already in progress when they transferred to them. This was also an opportunity for the CCG to express any interest in the premises/properties before they are disposed of.

The premises involved are:

− Wolverton House (LH) − Room in Stepping Stones Medical Practice (LH) − Falcon House, Dudley (Ground Floor and 5th Floor) (LH) − St Johns House Dudley (LH) − Kings House (LH) − Ridge Hill Site/Gorstyfields (FH) − Willows Respite Care (FH) (LH) Leasehold; (F) Freehold The Committee recommended the disposals to the CCG Board which approved them at its meeting on 7th November.

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3.7 Other Issues The Audit Committee considered and received assurance in respect of:

− Information Governance matters – CCG request to be a Safe Haven; GP IG Toolkit − Board to Board meetings − Francis Report recommendations assigned to the Audit Committee − Development of the CCG Business Continuity Plan − IT Major Incident Report – FMC Air Conditioning Failure − Compliance with Prime Financial Policies

• Scheme of Delegation • No Orders

4. ITEMS DISCUSSED-MEETING 12th DECEMBER 2013

4.1 Information Governance Report The Audit Committee received a report from the Information Governance Manager from the CSU. This covered the following key areas:

− Information Governance Toolkit – the IG Toolkit Action Plan was showing a current score of 61%, which is a positive outcome for an organisation of the CCG’s age. The CSU IG team are currently reviewing the evidence available compared to what is required.

− Information Asset Register & Data Flow Mapping – these form a vital part of the IG Toolkit. The information asset register is currently being developed within the CCG supported by the CSU IG team. The data flow mapping will be the next step to evidence that data is received and sent in a controlled manner and that measures are in place to strengthen controls.

− Information Governance Incidents – None since the last report. − Freedom of Information (FOI) requests – 47 had been received between 1st October and 30th

November. The KPI of 95% completed within 20 days was met.

4.2 Local Counter Fraud Specialist Update The Local Counter Fraud Specialist reported on progress against the agreed plan; summarised counter fraud activity, including giving details of any findings and conclusions arising from his work; provided details of ongoing fraud investigations and summarised any which have been closed since the previous Audit Committee update; updated the Committee on the progress made in implementing previously agreed counter fraud related recommendations.

4.3 Board Assurance Framework and Risk Register The Committee received the Combined Board Assurance Framework (BAF) and Risk Register as at 7th November.

Progress was noted in its development. It was agreed that the Deputy Chief Finance Officer and Interim Governance Manager would attend the January Clinical Development and Quality & Safety Committees and meet with the relevant management leads in advance of the meetings to further support the development of the Combined BAF and Risk Register.

4.4 Francis Report Update The Audit Committee received an update on the Francis recommendations that it considered fell under its responsibility. Current status was noted as follows:

93 - Robust Risk Management – the CCG has developed a combined BAF & Risk Register. This is reviewed and updated by the relevant committees on a monthly basis and reviewed by the Audit Committee and CCG Board at each meeting. Whilst further development and embedding is required, the Audit Committee has been assured by the improvement in this document and through the attendance of Committee Clinical and/or Management Leads at the Audit Committee. 126 – Preserving Corporate Knowledge in Organisational Transitions – The PCT then CCG Audit Committees received regular assurance during that transition. For any future organisational changes (commissioner or provider) it would expect there to be a transition board in place from which it received assurance. 209 – Registration of Healthcare Support Workers - Other than mention of Gifts & Hospitality Register under actions in place, it is unclear what role the Audit Committee has in respect of this. Clarification being sort.

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216 – Emphasis on Patient Safety - Patients & Patient Safety to be reviewed on each committee’s agenda. Progress on this to be followed up.

4.5 Internal Audit The Committee received a progress report against the 2013/14 internal audit plan and also a report on the internal auditor’s Compliance with Public Sector Internal Audit Standards. It also received the results of two audits that had been undertaken:

Audit Report-Collaborative and Outsourced Arrangements. There were two recommendations, one of which had already been implemented. The overall opinion was significant assurance.

Audit Report-Business Intelligence and Performance Reporting. There were five recommendations, two of which had already been implemented. The overall opinion was significant assurance but it was noted that this had been achieved through the work that was undertaken locally by the CCG to fill gaps in reports provided by the CSU.

4.6 External Audit The Committee considered the report from Grant Thornton on the auditor’s conclusion on arrangements to secure value for money in 2013/14. This outlined the approach the CCG’s external auditors would be taking to consider the key issues highlighted by the Audit Commission (Leadership; Commissioning; Financial Planning and management; Data Quality) along with any other relevant local issues.

4.7 Other Issues The Audit Committee considered and received assurance in respect of:

− Annual Accounts Update – feedback from NHS England sessions and details of key dates − Department of Health Consultation on the Constitution of Audit Committees – the Audit Committee

considered and agreed its response to this consultation. − Compliance with Prime Financial Policies

• Waivers • Scheme of Delegation • Aged Receivable & Payables

5. DECISIONS TAKEN BY COMMITTEE UNDER DELEGATED POWERS FROM BOARD None

6. DECISIONS REFERRED TO THE BOARD The following matters discussed at the Audit Committee on 31st October were referred to the Board for approval at its meeting on 7th November:

1. Procurement Strategy 2. Changes to the CCG Constitution 3. Disposal of Premises/Property

These have now been discharged.

7. RECOMMENDATION The Board is asked to note the issues discussed at the Audit Committees on 31st October and 12th December 2013 for assurance and to note that it had previously approved three matters arising from the 31st October Audit Committee at its meeting on the 7th November 2013

M Hartland Chief Finance Officer December 2013

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Report: Combined Board Assurance Framework and Risk Register Agenda item No:

TITLE OF REPORT: Combined Board Assurance Framework and Risk Register

PURPOSE OF REPORT: To update the Board on the combined Board Assurance Framework (BAF) and Risk Register and present it as at December 2013.



CLINICAL LEAD: Dr D Hegarty, Chair

KEY POINTS: • Update on combined BAF & Risk Register • Summary of risks as at 6th December 2013 presented

RECOMMENDATION: • The Board is asked to note the report for assurance • The Board is asked to approve the closure of risk 9 in respect of

specialised services and risk 42 in respect of the accounting treatment of provisions

FINANCIAL IMPLICATIONS: None direct. Potential consequence if risks materialise.



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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 COMBINED BOARD ASSURANCE FRAMEWORK (BAF) AND RISK REGISTER 1.0 INTRODUCTION

In accordance with the CCG’s Risk Management Strategy, the combined BAF and Risk Register for those risks scored 16 and over (which comprise the Board Assurance Framework) is presented to the CCG Board. This is based on the position as at 6th December 2013. The Audit Committee reviewed the overall combined BAF and Risk Register at its meetings on 31st October and 12th December. The clinical lead for the Primary Care Development and Finance & Performance Committees plus the management lead for the Finance & Performance Committee attended the October meeting to explain the process for managing risks within those committees and to provide an update on the risks they were responsible for managing. The Audit Committee requested that the Clinical & Management leads for the Clinical Development Committee attend the next Audit Committee to update it on progress in reducing the level of risk.

2.0 COMBINED BOARD ASSURANCE FRAMEWORK (BAF) & RISK REGISTER Those risks with an initial or residual score (after actions having been taken and controls implemented) of 16 or higher are presented to the Board in detail at Appendix 1. These risks are also summarised in the table below. Risk

Initial Risk

Residual Risk

Accountable Committee

1. Failure to resolve potential mortality issues at Dudley Group results in avoidable deaths

25 15 Quality & Safety

6. Failure of a main provider due to financial pressures will result in inadequate care for the local population (note: this accounts for legacy risk brought forward from Cluster regarding failure to manage demand, creating financial pressures within the local health system)

20 12 Finance & Performance

8. Risk that specialised service allocations are not properly resolved resulting in significant financial pressures for the Group – CLOSURE PROPOSED


9. Risk of poor relationship management with the Area Team through the transition/bedding down resulting in breakdown of relationship with GPs and/or disconnected primary care/medical service priorities

16 9 Down

from 16

Primary Care Development

10. Failure of the health economy to work together to implement service changes which will adversely impact commissioning and delivery of health services (note: this addresses the legacy risk from the Cluster regarding failure to agree robust delivery plan with providers).

16 12 Clinical Development Committee

14. Failure to engage with Public Health, Health and Well Being Board and the Local Authority will limit the effectiveness of health care commissioning.


16. Providers may be reluctant to develop and implement alternative approaches to service delivery


17. Tensions between innovation, quality and financial pressures could limit the innovation shown by the CCG


19. Failure to ensure meaningful public engagement will prevent effective commissioning and patient centred services

16 12 Communications & Engagement

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Risk

Initial Risk

Residual Risk

Accountable Committee

20. Failure of a main provider due to quality failures will result in inadequate care for the local population


21. Failure of the CSU to deliver a service offering that delivers the CCG's requirements (particularly quality framework) which underpin the CCG strategy


26. Risks to women and neonates as a result of increased volume of patients which has led to inadequate staffing levels at certain times with particular issues around specialist medical staffing and capacity issues in triage area.


32. Current reorganisation of Health Visiting Service could result in breakdown in continuity of care to patients and consequent risks to safeguarding children.


34. Being unsighted on significant performance issues identified by the Area Team in relation to primary medical services that could result in removal of GP member from the Performers' List.

16 9 Down

from 12

Primary Care Development

36. Failure to achieve whole of Quality Premium resulting in lost income and reputational damage.


39. Lack of a systematic approach to ascertaining the quality of the care in our commissioned nursing homes, potentially resulting in harm to vulnerable adults.


41. Lack of capacity in the right place for patient access to phlebotomy services.


42. Continued uncertainty over the treatment of legacy provisions such as Continuing Healthcare in 2013/14 causes a risk to the delivery of the 13/14 financial control total. NEW RISK / CLOSURE PROPOSED


43. Failure to deliver significant QIPP targets in 14/15 and 15/16 puts the future financial stability of the CCG at risk. NEW RISK


3.0 RECENT AMENDMENTS TO THE BAF AND RISK REGISTER

Following consideration of the BAF and Risk Register at Committee meetings and the Audit Committee, the following amendments to risks 16 and over have been made since the last Board meeting:

New Risks – Two new risks have been added by the Finance & Performance Committee. The first (42) relates to uncertainty around the accounting treatment of legacy provisions, particularly those for continuing healthcare, and the potential impact this might have on the CCG’s control total. The second (43) is the risk in delivering significant QIPP targets in 2014/15 and 2015/16 to secure financial stability.

Changes to the Risks – Two risks that fall under the Primary Care Development Committee (9 & 34) have been downgraded mainly due to the establishment of the Primary Care Strategy Implementation Group and the CCG and NHS England Area Team Interface Group both of which help mitigate the risks.

Following recommendations from the Committees and approval by CCG Audit Committee members, the risks listed below are being recommended for closure by the CCG Board:

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8. Specialised Services – This was a time-limited risk and recent allocations and contract adjustments cover the majority of the cost pressure recurrently. 42. Accounting Treatment of Provisions - Recently issued NHS England guidance for 13/14 accounting means this will no longer have a financial impact in the current financial year.

4.0 RECOMMENDATIONS The Board is asked to note the report for assurance.

The Board is asked to approve the closure of risk 9 in respect of specialised services and risk 42 in respect of the accounting treatment of provisions.

5.0 APPENDICES

Appendix 1 – Combined BAF & Risk Register as at 6th December 2013 (risks 16 and over) M Hartland Chief Finance Officer December 2013

Dudley CCG Combined Board Assurance Framework and Corporate Risk Register 2013/1406 Dec 13

NOTE: TREND IN RESIDUAL RISK AGAINST PREVIOUS MONTH IS SHOWN //=

ID Original Date

Last Update

LIN

K T

O C

OR

POR

ATE

O

BJE

CTI

VE (S

EE K

EY

AB

OVE

)

Risk Description Accountable Committee

Accountability Sponsor & Owner

Management Lead

P I Initial Risk Score (PxI)

Score before any

controls are in place.

Key ControlsWhat controls/systems are in place to assist in securing delivery of ourobjective. Such as strategies, policies and procedures

Gaps in ControlWhere are we failing to put controls/ systems in place. / Where are we failing in making them effective. For example lack of training or no regular review of performance

Gaps in Assurance Where are we failing to gain evidence that our controls/ systems, on which we place reliance, are effective. Such as no assurance a strategy or policy is effective

P I Residual Risk Score

(PxI)Score

following controls put

in place

Risk Trend Internal AssurancesBoard Reports, Minutes of meetings

External AssurancesInternal and External Audit Reports, CQC Reports

ActionsTo improve control, ensure delivery ofprincipal objectives, gain assurance

TimescalesDate action will be completed

COMMENTS

1 01/05/2013 01/10/2013 1 Failure to resolve potential mortality issues at Dudley Group results in avoidable deaths

Q&S Rebecca Bartholomew

5 5 25 Robust contract management via contract review meetings and clinical quality review meetings, stringent adherence to contract mechanisms, performance management, joint strategic planning. Monitoring via the defined quality indicators

No system in place to consistently report and monitor upon mortality rates

Need to establish reporting to Q&S Committee and governing body

3 5 15 = None Keogh Review, Monitor and CQC reporting

Establish mortality reporting to Q&S and governing body

Jul-13 The Committee agreed that the gaps in control are in place and it is established but members would like it broken down further by directorate and the residual risk score reviewed.

6 01/05/2013 03/12/2013 2 Failure of a main provider due to financial pressures will result in inadequate care for the local population (note: this accounts for legacy risk brought forward from Cluster regarding failure to manage demand, creating financial pressures within the local health system)

F&P Jas Rathore Matt Hartland 4 5 20 Robust contract management via contract review meetings, performance management, joint strategic planning. Financial Plan and contracts agreed with providers. Financial Assurance KPIs reported to Board. Joint monthly payment reconciliation process including validation of activity.

Review of methods to mitigate financial risk to provider and CCG.

3 4 12 = Reports to F&P & Q&S, Board reports - minutes of CRM and QRM meetings. Performance report across a range of KPIs

AT review, Monitor financial rating, Internal Audit review.

Implement new methods to mitigate financial risk (e.g. reinvesting penalties).

Dec-13

8 01/05/2013 03/12/2013 2 Risk that specialised service and other allocations are not properly resolved resulting in significant financial pressures for the Group

F&P Jas Rathore Matt Hartland 4 5 20 Finance Plan, Annual Budget, and QIPP, risk sharing agreement with Area Team, Contract clauses within main provider contract to protect against loss of specialised services allocation. Recurrent allocation and contract adjustements actioned.

2 5 10 = Finance Report to Board Internal and external audit reviews

Confirm outcome of High Cost drugs consultation. Recommend closure of risk to next Governing Body meeting.

Jan-14

9 01/05/2013 01/11/2013 2 Risk of poor relationship management with the Area Team through the transition/bedding down resulting in breakdown of relationship with GPs and/or disconnected primary care/medical service priorities

PCD Jas Rathore Daniel King 4 4 16 Develop primary care strategy with the Area Team. Agree roles and responsibilities with Area Team in relation to developing/implementing primary care strategy

Develop reporting to Primary Care Development Committee

3 3 9 = Ongoing report to Board on progress developing primary care strategy

Primary Care Strategy Implementation Group established. CCG and NHS England Area Team Interface Group established.

Jul-13

10 01/05/2013 03/10/2013 2 Failure of the health economy to work together to implement service changes which will adversely impact commissioning and delivery of health services (note: this addresses the legacy risk from the Cluster regarding failure to agree robust delivery plan with providers ).

CDC Steve Mann Neill Bucktin 4 4 16 QIPP plan and implementation. Joint approach to QIPP development with Dudley Group. Service Improvement Delivery Plans in place with providers

Need to develop joined up approach across the whole health economy (egg mental health services)

4 3 12 = QIPP reporting to CDC and governing body

Internal and external audit reviews

1.Develop and implement service improvement development plans with all our providers. 2.Implement Aspyre reporting

Nov-13 Completion of Aspyre information has started. System is being refined to deliver relevant reporting template in November 2013.

14 01/05/2013 16/07/2013 2 Failure to engage with Public Health, Health and Well Being Board and the Local Authority will limit the effectiveness of health care commissioning.

CDC Vacancy Neill Bucktin 4 4 16Memorandum of Understanding with Public Health, membership of H&W Board, contribution to JSNA

Vacancy for Clinical Executive - Partnerships

None 2 3 6 = Board report on H&W Board activity

Complete review of clinical leadership structure

Jun-13

16 01/05/2013 03/10/2013 2 Providers may be reluctant to develop and implement alternative approaches to service delivery

CDC Richard Johnson Neill Bucktin 4 4 16 Commissioning intentions, Change Meetings with providers

Reporting process not yet in place for all providers

Reporting to CDC 3 4 12 = None Internal audit review Commissioning intentions lay out case for change. Contracting round for 14-15 will require providers to sigh up to explicit change programme

Dec-13

17 01/05/2013 03/10/2013 2 Tensions between innovation, quality and financial pressures could limit the innovation shown by the CCG

CDC Richard Johnson / Jas Rathore

Neill Bucktin 4 4 16 £200k to be invested in innovation pilots for 2013-14. Innovation bid process to be handled through localities

4 3 12 = reports to CDC Programme to be agreed.

Nov-13

19 01/05/2013 04/09/2013 2 Failure to ensure meaningful public engagement will prevent effective commissioning and patient centred services

C&E Vacancy Neill Bucktin/Richard Haynes (Rockhouse Communications)

4 4 16 Communications & Engagement StrategyHealth Care ForumIndividual Service User Groups, Business case process, Compact with local community, Relationship with Overview & Scrutiny Committee

Business cases / service change proposals need to identify that appropriate engagement has taken place

Reporting on proper engagement through the business case process

3 4 12 = Report to Commissioning Development Committee through business cases, assurance that engagement is taking place to Comms & Engagement Committee.

Health Watch, Overview & Scrutiny Committee

Establish revised business case process. Ensure clear exposition of engagement process is followed before recommendations to Board through the revised business case process

Jun-13

20 01/05/2013 01/10/2013 3 Failure of a main provider due to quality failures will result in inadequate care for the local population

Q&S Steve Mann Neill Bucktin/Rebecca Bartholomew

4 5 20 Robust contract management via contract review meetings and clinical quality review meetings, stringent adherence to contract mechanisms, performance management, joint strategic planning. Monitoring via the defined quality indicators

Need risk profiling system for each provider

None 2 5 10 = Reports to Q&S, Board reports - minutes of CRM and QRM meetings. Performance report across a range of Quality KPIs

CQC reports when appropriate. Monitor for 2 providers, Healthwatch, Keogh review at DGOH

Develop risk profiling system for each provider

Jul-13 The Committee will be receiving all the RAG rates on a quarterly basis within the Quality and Safety Report and the amber and red will be received by the Board. A clear criteria is being developed and brought back to Quality and Safety Committee in October.

21 01/05/2013 01/10/2013 3 Failure of the CSU to deliver a service offering that delivers the CCG's requirements (particularly quality framework) which underpin the CCG strategy


4 5 20 Regular meetings with CSU. Reporting to Q&S and other committees established

Performance resolution process not fully in place

Quality and safety reporting still not developed and delivered by CSU. Reporting template agreed as first stage.

3 4 12 = Q&S committee reports to Board

Clinical Surveillance Meeting at Area Team, Internal Audit review

1.Delivery of quality assurance framework 2. Develop robust performance resolution process

Aug-13 Issues remain with regard to MiCS and dashboard CSU offer agreed. Systems being tested. This is an ongoing risk.

26 26/09/2011 03/10/2013 2 Risks to women and neonates as a result of increased volume of patients which has led to inadequate staffing levels at certain times with particular issues around specialist medical staffing and capacity issues in triage area.

CDC Mark Curran Neill Bucktin 4 4 16 Any GP practice located within a 16 minute travel time from City Hospital is not able to book patients at Russell Hall Hospital. New cap agreed for 13/14 through contracting round which allows for sufficient staffing for demand.

Outcome of maternity services review across the Black Country by Sandwell & West Birmingham CCG.

None 1 4 4 = Monitoring via Clinical Quality Review Meetings (DPCT/DGFT). Monitoring of SIs (DPCT/DGFT). Maternity ratios within acceptable range

None Specific request made to DGFT to assure that sufficient staff are in place to undertake triage

Oct-13 Cap in place however concerns raised re quality of triage service which are currently being investigated. Therefore risk is being kept on until response received.

CORPORATE OBJECTIVES

1. Reducing health inequalities2. Delivering best possible outcomes3. Improving quality and safety

ID Original Date

Last Update

LIN

K T

O C

OR

POR

ATE

O

BJE

CTI

VE (S

EE K

EY

AB

OVE

)

Risk Description Accountable Committee

Accountability Sponsor & Owner

Management Lead

P I Initial Risk Score (PxI)

Score before any

controls are in place.

Key ControlsWhat controls/systems are in place to assist in securing delivery of ourobjective. Such as strategies, policies and procedures

Gaps in ControlWhere are we failing to put controls/ systems in place. / Where are we failing in making them effective. For example lack of training or no regular review of performance

Gaps in Assurance Where are we failing to gain evidence that our controls/ systems, on which we place reliance, are effective. Such as no assurance a strategy or policy is effective

P I Residual Risk Score

(PxI)Score

following controls put

in place

Risk Trend Internal AssurancesBoard Reports, Minutes of meetings

External AssurancesInternal and External Audit Reports, CQC Reports

ActionsTo improve control, ensure delivery ofprincipal objectives, gain assurance

TimescalesDate action will be completed

COMMENTS

32 12/04/2013 01/10/2013 2 Current reorganisation of Health Visiting Service could result in breakdown in continuity of care to patients and consequent risks to safeguarding children.

Q&S Neill Bucktin/Paul Maubach

Neill Bucktin 4 4 16 Monthly performance review meeting with Trust, GPs escalating concerns through locality meetings and GP Lead

None None 3 4 12 = Reporting to Q&S Committee

None This remains a risk.

34 22/04/2013 01/11/2013 2 Being unsighted on significant performance issues identified by the Area Team in relation to primary medical services that could result in removal of GP member from the Performers' List

PCD Dan King Dan King 4 4 16 CCG and Area Team interface group. Support mechanisms for under-performing GPs/practices

Need to establish reporting from interface group

3 3 9 = NHS England and CCG Interface Group established and reporting into Committee

Aug-13

36 16/05/2013 03/10/2013 3 Failure to achieve whole of Quality Premium resulting in lost income and reputational damage.

CDC Neill Bucktin Neill Bucktin 4 4 16 Plans for local targets mostly in place and on track, but still significant risk of not achieving national domains 1 and 5 (PYLL and HCAI)

Successful plans for domain 1 and 5 need to be put in place

None 4 4 16 = Quality Premia achievement reporting to CDC and governing body

None Public Health requested to prepare report for CDC on recommended interventions to reduce PYLL

Nov-13 Plan for Domain 5 in place and approved by Q&S committee

39 16/07/2013 16/07/2013 3 Lack of a systematic approach to ascertaining the quality of the care in our commissioned nursing homes, potentially resulting in harm to vulnerable adults


4 4 16 (some) nursing home provision is provided under suitable commissioning contracts. Self-assessment reporting by nursing homes

No systematic approach to monitor and act upon poor quality. No consistent on-site review process. Some providers don't have suitable contracts in place

Reporting on quality 4 4 16 = None Rolling CQC inspection programme

(1) Desktop RAG rating of all nursing homes (2) Systematic on-site reviews introduced (3) Ensure NHS contracts in place with all nursing homes

(1) Aug-13 (2) Sept-13 (3) Apr-14

41 03/10/2013 03/10/2013 2 Lack of capacity in the right place for patient access to phlebotomy services.

CDC Steve Mann Neill Bucktin 4 4 16 Performance management of phlebotomy service through contracts.

Service specification does not have sufficient performance standards.

Phlebotomy service not on priority list for CCG.

3 2 6 = CDC sighted on complaints and concerns raised by practices.

Review of service brought to CDC in November 13 with new service standards.

Nov-13

42 05/12/2013 05/12/2013 2 Continued uncertainty over the treatment of legacy provisions such as Continuing Healthcare in 2103/14 causes a risk to the delivery of the 13/14 financial control total.

F&P Jas Rathore Matt Hartland 4 4 16 Regular contact with NHSE nationally and locally to seek final decision.

None Assurance around treatment required from NHSE.

4 4 16 NEW Reports to F&P Committee; regular review by finance staff.

None at this stage. Continue to seek assurance locally and nationally from NHSE. Develop contingency plans to deal with final decision on treatment.

Dec-13

43 05/12/2013 05/12/2013 2 Failure to deliver significant QIPP targets in 14/15 and 15/16 puts the future financial stability of the CCG at risk.

F&P Jas Rathore Matt Hartland 5 5 25 The current QIPP challenge process is robust and the CCG has a history of delivery. However, the scale of the QIPP target in 14/15 and 15/16 requires key controls to be enhanced.

Not determined at this stage. Awaiting final allocations and plans for achievement.

QIPP assurance process is in place but this may need to be enhanced given the scale of the overall QIPP.

4 5 20 NEW QIPP challenge process; F&P Committee oversight; internal audit reviews.

Reports to NHS England. QIPP plans to be developed as position becomes clearer.

Mar-14 QIPP target for 15/16 has increased by £12m due to the planned transfer to the local authority.

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Date of Report: 9th January 2014 Report: Finance and Performance Committee Report


TITLE OF REPORT: Finance and Performance Committee Report

PURPOSE OF REPORT: To advise the Board of key issues discussed at the Finance and Performance Committee on 21st November and 19th December 2013.



CLINICAL LEAD: Dr J Rathore, Clinical Executive for Finance and Performance

KEY POINTS:

• Statutory financial duties to be achieved. • Risks reducing. • Key performance issues discussed and actions agreed. • QIPP target for 2013/14 forecast to over-achieve. • QIPP plans being reviewed to achieve 2014/15 target. • 2014/15 planning guidance/allocations released. The impact

will be modelled, but financial pressure on the CCG for next two years is expected to increase.

• IT and Informatics Strategy presented for approval

RECOMMENDATION: The Committee is asked to approve the report.

FINANCIAL IMPLICATIONS: Agreed Area Team control total of £5.4m is forecast to be achieved.



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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 FINANCE AND PERFORMANCE COMMITTEE REPORT 1.0 INTRODUCTION

The report summarises the key issues discussed at the Finance and Performance Committee at its meetings on 21st November 2013 and 19th December 2013. The following items are indicators of the current position in relation to the main responsibilities and obligations of the Committee as defined by the CCG Constitution and Terms of Reference. The finance indicators summarise the CCG’s key financial indicators and performance against its statutory financial duties for the eight months of the financial year ending 30th November 2013 as reported to Committee on 19th December 2013.

2.0 KEY INDICATOR SUMMARY The table below identifies key financial indicators as at 30th November 2013.

Performance ItemPlan

£000's

Year To Date

£000's

Forecast Variance

£000'sRAG

Statutory Financial DutiesAchieve Revenue Resource Limit Control Tota l (5,400) (3,639) (5,400)

Capita l Resource Limit 0 0 0

Running Costs 7,710 (307) (0)

Cash Limit 0 597 0

Better Payment Practice Code - NHS 95% 97.28% 96%

Better Payment Practice Code - Non NHS 95% 96.32% 96%

LAT Assurance IndicatorsUnderlying Recurrent Surplus (7,206) (4,804) (7,508)

Programme Surplus - Year to date performance (3,311) (3,332)

Running Cost Surplus - Year to date performance (291) (307)

Programme Surplus - Ful l year forecast (5,400) (5,400)

Running Cost Surplus - Ful l year forecast 0 (0)Management of 2% Non Recurrent funds within agreed processes

Yes YES YES

QIPP - Year to date del ivery (3,715) (3,959)

QIPP - Ful l year forecast (5,339) (5,478)

Activi ty trends - Year to date (IP/ OP / A&E) 386 390

Activi ty trends - Ful l year forecast (IP/ OP/ A&E) 579 585Clear identi fication of ri sks aga inst financia l del ivery and mitigations

Met in ful l Met Met

Internal & External Audit Opinions and an assessment of the timel iness and qual i ty of returnsBalance Sheet indicators including cash management and BPCCLocal IndicatorsRevenue Resource Limit

Planned Care 170,536 184 272

Urgent Care 76,445 1,742 2,835

Preventative Care 37,305 (254) (381)

Reablement 24,841 (993) (1,094)

Corporate 7,710 (307) (0)

Non Recurrent 7,206 (49) 0

Reserves including Surplus 15,076 (3,602) (6,637)

Other 40,510 (360) (396)

Tota l 379,628 (3,639) (5,400)

There were no exceptions to report this month

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The Committee noted that the CCG is on target to achieve all statutory financial duties by 31st March 2014 and is currently achieving all its LAT assurance indicators.

3.0 EXCEPTION REPORTING 3.1 Local Indicators

The majority of the local indicators are being achieved with the exception of the following.

3.1.1 Revenue Resource Limit Whilst we are achieving our revenue resource limit statutory duty, urgent care remains as an amber RAG rating and is due in the main to over-performance in emergency activity for maternity and vascular surgery

3.1.2 Localities Kingswinford, Amblecote and Brierley Hill Locality is rated as ‘amber’ as it is reporting a forecast over-performance of 1.98%. The main areas of over-performance are a 5% variance against both the outpatients and non-electives budget.

3.1.3 Activity Outpatient activity is reporting a rating of amber for both year to date and forecast activity levels against the plan being over the 101% of plan tolerance threshold. The over-performance on activity is due to the increase in outpatient activity at Dudley Group Foundation Trust (DGFT) and West Midlands Hospital. Actions proposed to rectify current over-performance issues were noted.

4.0 ITEMS DISCUSSED – FINANCE

4.1 Revenue Resource Limit The CCG has an annual budget at November 2013 of £379,628,166, which reflects the notified allocation from NHS England and agreed anticipated allocations. The CCG is currently reporting a year to date underspend of £3,639,000 and is forecast to achieve a surplus of £5,400,000 at year end, meeting its control total agreed with the Area Team.

4.2 Capital Resource Limit The CCG submitted capital plans of £200,000 but is no longer planning on receiving a capital allocation. The CCG is reviewing its capitalisation policy for IT expenditure and is currently funding the migration of GP systems to a preferred provider through revenue plans.

Performance ItemPlan

£000's

Year To Date

£000's

Forecast Variance

£000'sRAG

Localities

Dudley & Netherton 53,382 (362) (414)

Sedgley,Coseley & Gornal 52,487 (538) (673)

Halesowen & Quarry Bank 49,701 (150) (109)

Stourbridge, Wol lescote & Lye 61,868 (90) (2)

Kingswinford, Amblecote & Brierley Hi l l 81,203 944 1,609

Centra l i sed Budgets/Unregis tered Population 44,487

Tota l 343,128 577 1,580

Activity

Emergency Activi ty 34 1 1

Elective Activi ty 39 (1) (1)

A&E Activi ty 84 (3) (4)

Outpatient Activi ty 422 7 10

Tota l Activi ty 579 4 6

Memorandum ItemsTota l Revenue Resource Limit 379,628Movement in Revenue Resource Limit s ince las t month

1,548

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4.3 Running Costs The CCG is forecasting a breakeven position against its running cost allowance in 2013/14. The expectation is that the year to date underspend, due to slippages in recruiting to vacant posts within the CCG structure, will be used to further support the organisation in the form of strategy development and implementation.

4.4 Cash Limit The CCG is required to meet two targets in relation to cash management - to remain within the allocated cash limit and to ensure that monthly cash balances are within 5% of the cash requested from NHS England. The CCG is expected to achieve its cash target for the year and achieved the cash limit for November with a balance of £597,000 remaining from the cash drawn down from NHS England. Cash plans are continuing to be monitored closely by the CCG and CSU to ensure the target continues to be met.

4.5 Better Payment Practice Code – NHS The CCG is required to pay 95% of NHS creditors within 30 days. As at November the CCGs cumulative performance was meeting the target at 97.28%.

4.6 Better Payment Practice Code – Non-NHS

The CCG is required to pay 95% of trade creditors within 30 days. As at November the CCG’s cumulative performance was meeting the target at 96.32%.

4.7 QIPP 2013/14

The Financial Plan for 2013/14 contains a QIPP target of £5.339m. Project performance reports for November have confirmed that the target is forecast to over-achieve by £0.139m at £5.478m.

4.8 Activity Month 7 initial data has been received from all providers, but there are data quality issues with

particular providers. For the basis of the report to the Committee month 6 data was used. Overall, activity was over-performing by 1.05%, mainly due to an increase in outpatient activity at DGFT and West Midlands Hospital. The over-performance at DGFT relates to outpatient attendances for nephrology and rheumatology. At West Midlands Hospital the over-performance related to trauma and orthopaedics and gastroenterology.

4.9 Statement of Financial Position The Committee noted the statement of the financial position of the CCG. There were no areas of concern reported.

4.10 Workforce An establishment register has been constructed for which employees and contracted staff will be reported against such established values. Workforce issues pertinent to provider organisations are managed by the Quality and Safety Committee.

4.11 Localities

Individual practice budgets have now been presented to locality meetings. All data is available at practice level within the MiCS system with the exception of the plan for Robert Jones and Agnes Hunt, which has been raised as an issue with the Commissioning Support Unit. At month 7 localities were rated Green as they were less than 1% over their delegated budgets. The reasons for the over-performance within the Kingswinford, Amblecote and Brierley Hill locality are being reviewed and corrective action taken. The forecast over-performance for Halesowen and Stourbridge, Wollescote and Lye has deteriorated slightly since the previous month, while the position for the remaining localities has improved slightly.

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4.12 Area Team Assurance The CCG is performing well against Area Team financial indicators. Previously QIPP delivery to

date had showed an amber rating. However, since month 7 the CCG has shown a green rating as the year to date target is now being met.

5.0 COMBINED BOARD ASSURANCE FRAMEWORK AND RISK REGISTER

The risks assigned to the Committee were reviewed. It considered that three of the risks under its remit could be closed, two of which require CCG Board approval as the initial risk score was 16 or over and these are detailed in the table below. The Board is asked to approve the closure of risks 8 and 42. The two Lay Members present at the Finance and Performance Committee are also members of the Audit Committee. They confirmed their agreement to this action.

No

Risk Description

Basis for Recommending Closure

Approval Required by (based on initial risk score):

8 Risk that specialised service and other allocations are not properly resolved resulting in significant financial pressures for the Group

Recurrent allocations and contract adjustments cover most of the cost pressure recurrently.

CCG Board

37 Operational pressures in the 111 service may result in additional costs being incurred.

Cost pressure in 13/14 minimal and interim contract with WMAS for 14/15 is cost neutral

Audit Committee

42 Continued uncertainty over the treatment of legacy provisions such as Continuing Healthcare in 2013/14 causes a risk to the delivery of the 13/14 financial control total.

Recently issued NHS England guidance for 13/14 accounting means this will have no financial impact in the current financial year.

CCG Board

6.0 QIPP

The Committee received a report summarising the CCG’s current and forecast achievement against the QIPP target for 2013/14 and progress to date on the development of plans for 2014/15. The position for 2013/14 is described in 4.7 above. The latest financial plan produced in August included a QIPP target of £5,622,000 for 2014/15. This represented an additional target of £1,498,000 compared to the current QIPP plan. This target is likely to increase further to about £7m when the impact of the 2014/15 planning guidance has been modelled. A review of current plans has been undertaken and identified a shortfall against the revised draft QIPP target for next financial year. A revised QIPP plan to be constructed in agreement with commissioners and clinical leads is to be presented to Committee in January.

7.0 2014/15 PLANNING GUIDANCE/ALLOCATIONS

The Committee was updated on the potential financial consequences of the planning guidance for 2014/15 released that morning. Detailed financial modelling is to be undertaken, but it is expected to increase the financial pressure on the CCG for the next two years. The impact of the modelling will be incorporated into the CCG strategic and financial plan to be submitted in February and presented to Committee in January.

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8.0 KEY INDICATOR SUMMARY – PERFORMANCE The table below identifies key performance indicators as at 30th October 2013, the last period for

which validated data has been received.

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9.0 EXCEPTION REPORTING

9.1 National Quality Requirements (Dudley Group Foundation Trust) DGFT failed to meet the nationally required standard on three indicators for the month of September: • C.Difficile • Ambulance Handovers >30 minutes • Ambulance Handovers >60 minutes

9.2 C.Difficile

If the provisional data is confirmed DGFT will have had 34 cases of C.Difficile to the mid- December point (incidence limit is 38 for the year set nationally). Therefore if DGFT have more than 4 cases of C.Difficile in the last three and a half months remaining in the contractual year they will have failed the incidence control target.

This analysis suggests that the most likely year end position for C.Difficile incidence will be 44 cases which is 6 cases above the DGFT specific limit which was set nationally. This would incur a financial penalty of approximately £310,000.

9.3 Ambulance Handover In October there was a marked increase in both 30 minute and 60 minute breaches to levels previously noted only in April.

Fines for this performance breach have been applied at 75% for 30 minute breaches (agreement for this percentage reported in the October). The full financial penalty has been applied for 60 minute breaches.

9.4 National Operational Standards DGFT failed one National Operational Standard (A&E 4 hour waits). In October performance was 91.5% and in November 94.1% against the target of 95%.

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9.5 A&E 4 hour waits DGFT have failed the monthly target for October and November and can now only achieve the quarter target if: (a) A&E attendances increase by 26.4% in December and (b) there are no more than three 4 hour wait breaches per day through to the end of December.

The scenario described above appears highly unlikely and therefore the assumption is that DGFT will fail the Q3 target. The financial penalty associated with a 4hour breach for quarter 3 will be applied once the breach has been confirmed.

9.6 18 Weeks Referral to Treatment (RTT) Performance (DGFT) The October Provider RTT figures were not published in time for inclusion within this report. However, the CCG figures for Dudley CCG suggest that DGFT will have achieved the aggregate RTT target but failed the ENT and Urology targets at specialty level. This can only be confirmed once the Provider view is published.

The requisite financial penalties for the above breaches have been served and Dudley CCG has requested a recovery trajectory from DGFT to be submitted at the January Contract Review Meeting.

9.7 Mortality Indicator (DGFT) The Standardised Hospital Mortality Index scores are published quarterly. The October publication (relating to 2012/13 data) showed that DGFT had a higher than expected mortality value. However, this value was within the normal variance range.

9.8 Ambulance Response Times (West Midlands Ambulance Service) West Midlands Ambulance Service failed to meet the Category A (Red 2 response) target. The Category A Red 2 responses are those with presenting conditions which may be life threatening (requiring a defibrillator), but less time critical than Red 1 and should receive an emergency response within 8 minutes, irrespective of location in 75% of cases.

Financial penalties relating to this breach apply and the performance management and rectification plan is managed via the Contracting Collaborative forum.

9.9 Improving Access to Psychological Therapies (IAPT) (Dudley and Walsall Mental Health Trust) With the Black Country Partnership and Big White Wall figures added to the Dudley and Walsall Mental Health Partnership figures, IAPT for the CCG is exceeding the target trajectory (year to date target for October is 3031 with performance at 3199).

9.10 Friends and Family Test (DGFT) Dudley Group exceeded the Family and Friends Test response rate for the first time this Contractual year in October. Both In-Patient and A&E response rates were above the required 15%. However the test scores for DGFT appear to have plateaued in the high 60s.

9.11 Quality Premium Indicators (CCG Focused Indicators) The Quality Premium Payment is £5 per registered patient. In Dudley CCG this amounts to £1,571,945. The Potential Years of Life Lost indicators are awaiting refresh analysis conducted by Public Health. Improving quality of life domains are currently all performing below the target, although the baseline has not yet been confirmed. Friends and Family scores are currently lower than the baseline. The greatest risk of target failure for the HCAI indicators is C.Difficile incidence. Local Quality Premiums for Hypertension and Dementia are on or close to target and practice based pharmacists are collecting data for Atrial Fibrillation.

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10.0 SCORECARD REPORT The CCG Scorecard Report was presented to the Committee. Extracts at a summary level are shown below.

10.1 Community Indicators Almost all of the aggregated Practice scores for locality demonstrated performance at the Platinum or Gold levels. However, it is worth noting that many of the percentage achievements at Practice level were derived from very low levels of activity. This is less of an issue with the aggregated locality view, but is important when comparing individual practices. The ENT, Gynaecology and Vasectomy indicators have very low levels of activity in many Practices. The bar chart below illustrates the degree of change in performance from the previous month by locality. Generally COPD and Gynaecology performance improved. Other variances are either marginal or due to very low volume activity.

10.2 Secondary Care Indicators

There was one indicator which demonstrated a Red category performance classification • Emergency Admissions

For the first time this year the A&E attendances per 1,000 registered population indicator performed at the Silver level of achievement at the CCG level; previously this indicator has performed at the Red level of performance.

10.3 Primary Care Indicators

All localities performed between the Silver and Platinum standard for primary care indicators.

44.54%

84.22% 90.58% 73.95%

36.46%

88.75%

0%20%40%60%80%

100%

Community - Dudley CCG

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The Balanced Scorecard performance exceptions are reported at the Finance and Performance Committee and addressed in the Practice Performance reviews.

11. REPORTS FROM GROUPS ACCOUNTABLE TO THE COMMITTEE 11.1 CCG IT Strategy Group

The Committee received an update from the issues discussed at the IT Strategy Group on 4th December 2013.

11.2 Draft IT and Informatics Strategy The Committee reviewed the draft Strategy and approved its submission to the Board, subject to minor amendments.

11.3 Estates Strategy Group

The Committee received a verbal update on the Estates Strategy Group which had met for the first time the previous day. The update focuses on the role of the group and how the CCG is part of the overall framework for Estates issues in the Local Area Team and the action plan for the production of the CCG Estates Strategy.

12.0 CONCLUSION The CCG is on target to achieve all statutory duties for the 2013/14 financial year, but there are in-year pressures that could require corrective action and is currently achieving all its LAT assurance indicators. There are risks to the delivery of performance targets, but this Committee and respective Committees as appropriate, are working with providers to improve the position.

Matthew Hartland Chief Finance Officer December 2013

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Report: Draft IT and Informatics Strategy 2013-2016 Agenda item No: 13.2

TITLE OF REPORT: IT and Informatics Strategy 2013-2016

PURPOSE OF REPORT: To present to the Board the IT and Informatics Strategy for the CCG.

AUTHOR OF REPORT: Mr Matthew Hartland, Chief Finance Officer

MANAGEMENT LEAD: Mr Matthew Hartland, Chief Finance Officer

CLINICAL LEAD: Dr Richard Johnson, Clinical Lead for IT

KEY POINTS:

• IT is a key enabler to meet strategic objectives of the CCG. • IT is also key to ensuring our membership provides high quality

care to our population. • This strategy describes how we will invest in IT and informatics

to deliver both aims.

RECOMMENDATION: The Board is asked to approve the Strategy.

FINANCIAL IMPLICATIONS: To be determined within the financial plan.



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Contents

1.0 Foreword .........................................................................................................................................4

2.0 Introduction ....................................................................................................................................5

3.0 Strategic Drivers and Context ...........................................................................................................6

3.1 Policy Environment ....................................................................................................................... 6

3.2 Connecting for Health ................................................................................................................... 7

3.3 GP Systems of Choice (GPSoC) ...................................................................................................... 7

3.4 Local Drivers and Strategies .......................................................................................................... 8

4.0 Our Strategy .................................................................................................................................. 10

4.1 Vision........................................................................................................................................... 10

4.2 Values .......................................................................................................................................... 10

4.3 Minimum Standards ................................................................................................................... 11

4.4 Education and Training ............................................................................................................... 11

4.5 Information Governance (IG) ...................................................................................................... 11

5.0 Delivery of the CCG Strategic Commissioning Plan .......................................................................... 12

5.1 Planned Care ............................................................................................................................... 12

5.1.1 Efficient services ........................................................................................................................... 12

5.1.2 Value ............................................................................................................................................. 13

5.1.3 Effective Outcomes ....................................................................................................................... 13

5.1.4 Patient Experience ........................................................................................................................ 13

5.2 Urgent Care ................................................................................................................................. 14

5.2.1 Access to Primary Care Information from ED, Urgent Care and OOH Settings ............................ 14

5.2.2 Urgent Care Dashboard ................................................................................................................ 14

5.3 Reablement ................................................................................................................................. 15

5.3.1 Delayed discharges ....................................................................................................................... 15

5.4 Preventative Care/Integration .................................................................................................... 15

5.4.1 Risk Stratification .......................................................................................................................... 16

5.4.2 Improved Data Quality .................................................................................................................. 17

5.4.3 Summary Care Record .................................................................................................................. 17

5.4.4 Electronic Shared/Single Care Record .......................................................................................... 18

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5.4.5 Tracking Patients through the System .......................................................................................... 18

5.4.6 Telehealth/Telecare ...................................................................................................................... 18

5.4.7 Membership Database .................................................................................................................. 18

6.0 Health Economy Interoperability/Strategies ................................................................................... 21

7.0 General Practice IT ......................................................................................................................... 23

7.1 GP Architecture ........................................................................................................................... 23

7.2 GP Clinical Systems ..................................................................................................................... 24

7.3 Electronic Document Management (EDM): ................................................................................ 24

7.4 Text Messaging to Patients ......................................................................................................... 24

7.5 Patient Self-Check in Screens ...................................................................................................... 24

7.6 GP2GP Messaging ....................................................................................................................... 25

7.7 Electronic Prescription Service ................................................................................................... 25

7.8 Patient Access to Electronic Records .......................................................................................... 25

7.9 Mobile devices ............................................................................................................................ 26

7.10 Non-GMS Applications ................................................................................................................ 26

7.11 GP Imaging .................................................................................................................................. 26

7.12 Intranet ....................................................................................................................................... 26

7.12 Interactive Screens ..................................................................................................................... 26

8.0 Corporate Services ......................................................................................................................... 29

8.1 Organisational Intelligence ......................................................................................................... 29

8.2 Financial/Corporate Systems ...................................................................................................... 29

8.3 Mobile Devices ............................................................................................................................ 29

8.4 Remote Working ......................................................................................................................... 30

8.5 Smart Phone Applications ........................................................................................................... 30

8.6 Networking/hosted servers ........................................................................................................ 30

8.7 Email ........................................................................................................................................... 30

8.8 Contractual Clauses: Healthcare and Commissioning Support Providers .................................. 30

9.0 Delivery Arrangements .................................................................................................................. 33

10.0 Funding and Finance ...................................................................................................................... 34

11.0 Risks .............................................................................................................................................. 35

12.0 Implementation Plan and timescales .............................................................................................. 36

13.0 Conclusion ..................................................................................................................................... 38

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1.0 Foreword I have been working in general practice for over 25 years, and now, more than ever before, do I believe that IT and Information is fundamental to shaping and improving healthcare services for the future. Healthcare workers cannot function effectively without appropriate IT support. And IT without robust, upto date information, is not appropriate. This strategy sets a three-year vision for information and IT across Dudley CCG and reflects local requirements driven by improvements in the quality of care, patient health and care outcomes, the reduction of inequalities and increasing productivity and efficiency. The ambition is bold, but the aim is to deliver the whole of this strategy within 3 years in times of reducing resources in the NHS. However, information and information technology is a critical tool which successful CCGs will use to deliver the necessary improvements within such diminished resources. The success of this strategy depends as much on a culture shift – in the way patients and professionals think, work and interact – as it does on data or IT systems. It depends on making the shift to give patients more control of their health and care and on recognising that professionals collecting and sharing good information is pivotal. I believe this is vital for success for both the CCG, our member practices, our partner organisations and more importantly our population.

Dr Richard Johnson Clinical Lead – IT December 2013

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2.0 Introduction

Information, and the infrastructure upon which it is built and applied, is one of the CCG’s key assets. The CCG requires accurate, timely and relevant information to enable it to both commission and deliver the highest quality health care and to operate effectively as a modern and efficient public sector organisation responsible for health and social care of individuals requiring support. Having accurate relevant information available at the time and place where it is needed, is critical in all areas of the CCG’s business and plays a key part in corporate and clinical governance, strategic risk, service planning, commissioning and performance management. We are also aware that our members, practices within our CCG and the patients they care for, require 21st century infrastructure to enable them to provide the best possible care. This Strategy describes the CCG’s vision and strategic direction for information management and technology developments for the period 2013 – 2016.

It describes the strategic drivers and context within which it must operate, considers the impact of national initiatives and strategies, the data required, the information systems needed to deliver the data and the technical infrastructure, governance arrangements and the delivery model required. The document describes how the CCG will utilise IT and information to best deliver in four areas:-

1. Delivery of the CCG’s Strategic Plan. 2. Ensuring the ‘business’ of the CCG operates effectively. 3. Working with partner organisations. 4. Supporting our members in having effective IT provision in primary care

The Strategy will be updated annually to reflect changes in priorities.

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3.0 Strategic Drivers and Context

3.1 Policy Environment The most recent reforms in the NHS commenced with the publication of a Government white paper Equity and Excellence: Liberating the NHS, published in June 2010. This recommended changes to the NHS encompassing the following domains: • Putting patients and public first • Improving healthcare outcomes • Autonomy, accountability and democratic legitimacy • Cutting bureaucracy and improving efficiency The Health and Social Care Bill was developed in response to this and was initially published in January 2011 and following further revision was finally published in March 2012. The Health and Social Care Act details the current commissioning model whereby Clinical Commissioning Groups have the responsibility for commissioning the healthcare services listed on page one. In addition to core changes in commissioning arrangements the Act placed an emphasis on a number of other areas including huge improvements in efficiency and the way in which the NHS both manages and uses information. It is anticipated that increasingly patients will have a far greater say in making informed decisions about their care. The Department of Health sought to add further clarity around Information Management and published The Power of Information. In June 2013 the Department of Health has published the information strategy, The Power of Information, which set a ten year framework for transforming information for the NHS, public health and social care. Unlike previous information strategies, The Power of Information does not reinvent large scale information systems or set down detailed mechanisms for delivery. Rather, it provides a framework and a route map to lead a transformation in the way information is collected and used. It takes the needs of patients, carers, users of care services and citizens as the key driver for change. It provides the infrastructure to support the things that need to be done system wide, but recognising that information technology is always advancing, it promotes flexibility and local innovation. The Strategy focuses on information in its broadest sense, including the support people need to navigate and understand the information available. This is about ensuring that information reduces, not increases, inequalities and benefits all.

The Power of Information strategy’s main ambitions:-

• Information used to drive integrated care across the entire health and social care sector, both within and between organisations

• Information regarded as a health and care service in its own right for us all – with appropriate support in using information available for those who need it, so that information benefits everyone and helps reduce inequalities

• Change in culture and mind set, in which our health and care professionals, organisations and systems recognise that information in our own care records is fundamentally about us – so that it becomes normal for us to access our own records easily

• Information recorded once, at our first contact with professional staff, and shared securely between those providing our care – supported by consistent use of information standards that enable data to flow (interoperability) between systems whilst keeping our confidential information safe and secure

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• Our electronic care records progressively become the source for core information used to improve our care, improve services and to inform research, etc. reducing bureaucratic data collections and enabling us to measure quality

• A culture of transparency, where access to high quality, evidence based information about services and the quality of care held by Government and health and care services is openly and easily available to us all

• An information led culture where all health and care professionals and local bodies whose policies influence our health, such as local councils, take responsibility for recording, sharing and using information to improve our care

• The widespread use of modern technology to make health and care services more convenient, accessible and efficient

• An information system built on innovative and integrated solutions and local decision making, within a framework of national standards that ensure information can move freely, safely, and securely around the system

The intention is for clinical staff to access, contribute to and choose to share health and care records, supporting a culture of ‘no decision about me without me’ for the patient. Better use of information and innovative technology can help professional teams to prioritise more face-to-face support where that is needed, and can also enable local areas to design integrated health and care services, and improvement strategies that reflect local need. The Power of Information states an expectation for all general practices within England to offer Patient Online by 2015. This has also been mandated by NHS England. Patient Online includes transactional services such as booking and cancelling appointments, requesting online prescriptions, online access to the medical record and secure online communication. Implicit within these service enhancements is an aspiration to ensure communications between the NHS and its patients is “Digital by default”. The success of The Power of Information depends as much on a culture shift – in the way patients, users of services and professionals think, work and interact – as it does on data or IT systems. It depends on making the shift to give patients more control of our health and care and on recognising that collecting and sharing of good information is pivotal to improving the quality, safety and effectiveness of patient care, as well as patient experiences of care. 3.2 Connecting for Health In March 2013 Connecting for Health was disbanded and the majority of its former functions amalgamated within the Health and Social Care Information Centre (HSCIC). This included the transfer of responsibility for the contract management of nationally defined contracts including those formerly commissioned to support GP Primary Care under GP Systems of Choice (GPSoC). In addition, NHS England has set out new national arrangements for the management, support and commissioning of GP IT services. In “Securing excellence in GP IT Services – Operating Model” NHS England has established the commissioning and accountability processes encompassing information technology for general practices. The model sets out a number of core or mandatory services (which must be funded and provided to GP practices) together with a number of additional or discretionary funded items which are subject to local strategic direction and choice. 3.3 GP Systems of Choice (GPSoC) The GPSoC framework still exists; however as of September 2013 the GPSoC framework governing procurement of GP clinical systems is being both redesigned and re-negotiated with a range of national

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suppliers. The revised arrangements for the framework will include a number of tiers, some setting out centrally funded components and others where items have been tested and certified with a centrally negotiated approach to procurement. The outcome of these negotiations and the introduction of the new arrangements is some months away from being understood in detail nevertheless a revised approach, implementing a number of changes is being developed which will bring about:

• An improved alignment between primary care IT and the national strategy for primary care • Improved levels of engagement between all parties in designing and continually improving the

procurement framework • Incentives for use of systems as opposed to remuneration linked to deployment targets • Commoditisation, e.g. national procure certain line items – at least one provider for national

infrastructure • Achievement of equity (whilst ensuring that people operate within governance standards and meet

minimum specifications) • Delivering value for money • Determining a “maturity index” to help identify areas of greatest need • Ensuring the GMS contract obligations are fulfilled • Local CCG level responsibility for the management of GP primary care IT budgets through a yet to be

determined process of delegation from NHS England It is widely recognised there are some significant national challenges with the current arrangements for supporting GMS IT in general practices. These include an inequitable distribution of budgets, a separation between budget holders and service commissioners which causes confusion, a lack of clarity on responsibility for some items, capacity and capability issues at a locality level, confusion around complimentary items and legal ownership of assets and depreciation. These issues all currently affect Dudley CCG and its general practices to a greater or lesser extent. The new GPSoC framework will provide a tiered procurement solution. Core (mandatory) services will be included in a tier one offering. Two subsequent tiers will include system enhancements from GP clinical system suppliers and other suppliers which will be subject to accreditation and testing arrangements. Locally Dudley CCG will need to develop and adopt a policy in respect of GPSoC to ensure a fair and consistent approach to the implementation of these systems is enabled. It is understood future arrangements for funding could mean a re-baselining of local GP IT budgets. The effect of this combined with a suggested real terms increase on overall funding for GP IT is unknown, but given the increased expectations around Primary Care IT and particularly the delivery of Patient Online will inevitably mean the pressures around managing Primary Care IT budgets will not subside. 3.4 Local Drivers and Strategies At the time of writing this Strategy the CCG has been in operation for six months and during this time there have been a number of strategic documents approved by the CCG Board which will be dependent on the utilisation or implementation of robust IT and informatics systems. These include the CCG’s:

• Strategic Plan – describes the overarching aims and objectives of the organisation, including the commissioning and service change priorities

• Primary Care Strategy– defines how the CCG will develop our membership and improve the quality of primary Care provision in Dudley

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• Quality and Safety Strategy – defines the CCG’s approach to measuring and improving the quality and safety of commissioned services from our providers

• Communications and Engagement Strategy – describes how the CCG will engage with our members, patients and public, and our communication systems

• Social Media Strategy – defines the intent of the CCG to embrace social media as a form of communication with the public

• Financial Plan – describes the financial context of the CCG for the next 3 years The IT and informatics requirements of each are described in this Strategy.

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4.0 Our Strategy This strategy provides a strategic framework for IT and informatics developments within the CCG. This strategy is compatible with the recently announced NHS information strategy “The Power of Information: putting us in control of the health and care information we need”.

The Strategy aims to link IT developments into the CCG’s overall objectives and details the governance arrangements underpinning further investment in IT. The Strategy argues that the implementation of the IT systems it describes is a critical factor in improving efficiency and patient safety and underpins the overall strategy of the CCG.

4.1 Vision IT is a key strategic enabler to delivering what we as a CCG have been established to deliver. It is fundamental to the effective and efficient delivery of health services, both in a hospital setting, but increasingly community and primary care services. As a membership organisation we aim to ensure that services provided by and commissioned by our members are of the highest quality and a progressive IT strategic platform is key to achieving this.

Dudley CCG wishes to increase the use of digital technology in the delivery of healthcare services to patients in order to bring about improvements in the quality, safety and the efficiency of the NHS services it commissions on behalf of the population we serve.

More specifically we will ensure that:

• high quality clinical information is accessible in an integrated, shared clinical record, in real time, at the point of care;

• IM&T programmes are fully aligned to enable the clinical business needs of Clinical Commissioning Group;

• the CCG is able to fully implement Patient Online and the unnecessary duplication of the capture and dissemination of patient information for the management and care of patients is kept of a minimum.

4.2 Values We have identified a number of core values against which we have assessed priorities for investment in Information technology solutions. In no order of importance or priority they are:

• We will commission effective, safe and efficient healthcare • We will provide of high quality timely information • We will record information once and sharing it through the interoperability of systems • A patient’s medical data is to be shared with clinicians in other settings on an individual basis where a

legitimate relationship exists, at the point of care, with the consent of the patient • Information will be used for secondary purposes such as establishing the health needs of a population

and shared with all relevant parties • We will ensure appropriate disclosure of information to fellow professionals and patients • Clinicians and carers to predict which patients will need enhanced or tailored care • We will enable the CCG to better understand the diversity of our patient population. By gaining a

deeper and more accurate understanding of the diversity of our patients we can ensure equity of access to healthcare and its provision

• We will predict how needs will change at a population level to be able to plan for the future needs of our population we need to understand how the demographics and health profile

• We will share knowledge about best practice

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• We will support evidence based decision making

4.3 Minimum Standards As a CCG we strive to achieve and deliver to the highest standards possible. Therefore, in order to ensure proper arrangements are in place to support project implementations and ‘business as usual’ support activities the following standards will apply:-

• Project Management activities will adhere to Prince II project management methodology • Where necessary relevant ITIL standards will be required to be adhered support all activities relating

to changes of the IT infrastructure owned or maintained by the CCG • Information systems integration will be based upon the good practices and standards laid down by the

NHS IT toolkit • All proposals will be compliant with the IOC standards with regard to information governance.

4.4 Education and Training Dudley CCG recognises the need to ensure users of IT systems are appropriately trained in order to ensure the systems can be used safely and appropriately and that the CCG is able to extract the maximum return for its investment for the benefit of patients. This strategy requires the introduction of new systems and processes covering a range of areas from Summary Care Records to Electronic Prescribing, from Patient Online to changes in GP clinical information systems. For the introduction of new systems to be a success it is imperative that our users are appropriately skilled and trained in their usage. As the project to develop and implement each new system commences an appropriate training needs analysis will be undertaken to ensure the necessary resources to support the training required are available. 4.5 Information Governance (IG) IG provides a framework to bring together all the legal rules, guidance and best practice that apply to the handling of information. Due to the range and complexity of the standards and legal rules, the Department of Health has developed sets of information governance requirements which enable NHS and partner organisations to measure their compliance. In order for the CCG and our member practices within Dudley to comply, with NHS IG requirements the CCG will provide training and support in the following areas:

• General awareness training • Information sharing management protocols • Caldicott requirements guidance • End to end data protection compliance • Freedom of Information Act compliance • IG audits and Toolkit completion support • Development of yearly IG improvement plans • Incident management support

All developments proposed within this strategy will meet IG standards and be implemented to ensure maximum IG Toolkit ratings. However, we are currently restricted in the delivery of key objectives by the inability to access Patient Identifiable Data (PID) as a consequence of the implementation of the Health and Social Care Act 2012. This is not acceptable to us as an organisation and we will work with the Health and Social Care Information Centre to identify and source alternative networks to access such data where appropriate.

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5.0 Delivery of the CCG Strategic Commissioning Plan The strategic plan of the CCG has been constructed to describe the 4 main commissioning priorities of the organisation, namely Planned/Elective Care, Urgent Care, Reablement and Preventative/Integrated Care. Each has differing IT and Informatics requirements, as described below: 5.1 Planned Care Planned care services relate to the delivery of short term, reliable, value added interventions at a time and place of the patient’s choice. Planned care services are our largest area of spend. However there is also a significant variation both between services and between providers in the number of steps that a person may go through during the course of their treatment. As a commissioner we have very little direct input to the delivery of these services, but we will expect our providers to be able to articulate and publish the value of their services to patients and carers. We will develop a publicly available provider dashboard which will set out how we evaluate and benchmark the quality of services from every one of our providers with whom we hold a contact based upon these measures and the feedback from patients.

We intend to deliver our priorities on Planned Care by focussing on the efficiency of services; value of services; effective outcomes and Patient experience.

5.1.1 Efficient services Planned care services are our largest area of spend. However there is also a significant variation both between services and between providers in the number of steps that a person may go through during the course of their treatment.

Therefore, we will commission by working with providers to determine how they will improve the efficiency of the services that they provide. In April 2015 we will use this information to publish an ‘efficiency index’ for all planned care services and will use this with our GP members as one criterion when advising on managing referrals and on setting commissioning priorities.

Methods to achieve this will include:-

5.1.1.1 Patient Pathways Patient care pathways are structured multi-disciplinary care plans which detail essential steps in the care of patients with a specific clinical problem. They have been proposed as a way of encouraging the translation of national and local guidelines into local protocols and their subsequent application to clinical practice. They are also a means of improving systematic collection and abstraction of clinical data for audit and of promoting change in practice. We will review care pathways as a contributing means to defining efficient providers.

5.1.1.2 Map of Medicine/Referral Management System Map of Medicine is a methodology for creating care maps and keeping them up to date with emerging evidence, informed by practice-based knowledge, and, where appropriate, cognisant of healthcare policy. It enables GPs to offer comprehensive, evidence-based local guidance and clinical decision support at the point of care and aids CCGs in achieving their quality and productivity targets.

The system includes:

• GP system integration • Locally relevant information • Standardised referral forms

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• The ability to monitor local performance • Pre-populated referral forms

It is the intention of Dudley CCG to implement Map of Medicine to improve the efficiency and effectiveness of its referral management of patients for further support and packages of care.

5.1.2 Value It is important for us as a commissioner that we can establish with our providers a shared understanding of how our services deliver value. We will work with our providers to identify how to evaluate and monitor, both individually and collectively, levels of dependency, patient improvement and the social value of services.

5.1.3 Effective Outcomes Planned care services are value added treatment services, i.e. their purpose is to enhance a patient’s health and wellness. The basic premise for the intervention of planned care is to undertake it knowing what is required to return the patient to their home following the maximised potential resolution of their condition through the correct intervention.

Providers will be expected to demonstrate the effectiveness of the services that they provide. We will work with providers to define expectations, but we expect them to offer solutions on how to measure outcomes that matter to patients. It is important that we develop a shared understanding of the value that these services offer, their effectiveness, and their rates of success. Services which demonstrate effective outcomes will be positively promoted and ultimately any service where the outcome value cannot be demonstrated will ultimately be decommissioned.

5.1.4 Patient Experience A key test of the effectiveness of services is whether or not patients report a good experience on the care they’ve received. The experience of the service is therefore the fourth key measure of care alongside the effectiveness, efficiency and value. We will work with our commissioning support providers, covering IT, patient experience and health intelligence to develop a system to record, monitor and evaluate patient experiences.

We will then work with providers to develop a smart dashboard for planned care which illustrates the performance of services against each of these four measures and so inform patient choice and GP referrals; and in addition inform future CCG prioritisation decisions. Where possible we will collate existing publicly available information to populate this dashboard but we anticipate that providers will need to consider how they will promote their own information that demonstrates the value of the services that they provide.

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Benefit analysis:

Description Benefit Type Beneficiary

Efficiency index - Financial Savings Patient, CCG, GP Practice

Demonstration of value - Added value of service demonstrated

- Assurance Value for money is being delivered

CCG Patient

Patient experience - Efficient delivery of services - Better adherence to treatment

plans - Reduction in complaints

Patient, NHS Trust, CCG, GP Practice

Planned case dashboard - Financial Savings - Efficient delivery of services - Better adherence to treatment

plans - Reduction in complaints

Patient, CCG

5.2 Urgent Care Urgent care services are designed to deliver value added interventions in a crisis, where the capacity available is appropriate to the presenting need and each part of the system has a clear, distinct and exclusive role. For the urgent care system to operate effectively, there are some fundamental IT/information requirements as described below:

5.2.1 Access to Primary Care Information from ED, Urgent Care and OOH Settings It has been demonstrated that the efficiency of patient flows and effective clinical decision making would be increased if clinicians in the A&E Department had access to, and utilised, primary care systems. It will be a pre-requisite of providers in the new urgent care model in Dudley that the preferred system for primary care is used at the front-desk of the Urgent Care Centre, the A&E Department and by Out of Hours providers.

5.2.2 Urgent Care Dashboard A key determinant of a provider’s, and CCG’s, success is the performance of the urgent care system. A robust, real-time performance management and tracking system will be developed to ensure all partners, including Dudley Group Foundation Trust (DGFT), West Midlands Ambulance Service, Dudley and Walsall Mental Health Partnership Trust (DWMHPT) and Dudley Social Services have access to valid information to enable better management of the system.

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Benefit analysis: Description Type Beneficiary

Primary Care system in A&E - Complete medical history when patient attends urgent care centre

- Reduction in medical tests carried out - Reduction in duplication of medications

prescribed - Reduction in administration time for

medicines reconciliation requests - Avoidance of emergency admissions - Quicker discharge from hospital

Patient, NHS Provider Trust, CCG, GP Practice

Urgent Care Dashboard - Reduction in capacity issues - Quicker identification of system bottlenecks - Improved throughput of patients - Quicker discharge from hospital - More joined up delivery of healthcare

services - Improved patient experience


5.3 Reablement Reablement services are designed to deliver an integrated system, where people regain independence in the least restrictive setting possible. They are intended to reduce dependence.

To facilitate this, the following developments are proposed:

5.3.1 Delayed discharges Effective patient flows from hospital into residential and nursing homes are key to the effectiveness of DGFT. We will work with Dudley MBC and DGFT to construct an effective system to aid such flows this reducing the number of delayed discharges


Delayed discharges - Quicker identification of system bottlenecks - Improved throughput of patients - Quicker discharge from hospital - More joined up delivery of healthcare services - Improved patient experience


5.4 Preventative Care/Integration Our key strategic priority is to support and invest in services deliver what the CCG terms preventative care. Privileging these services is not just about prioritising these services, it is about making these services the preferred, default activity in the way health and social care is delivered.

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This includes both services which empower people to take as much care of themselves as possible (i.e. be autonomous), in partnership with appropriate professionals, so that their overall health and wellbeing is enhanced and their level of clinical risk is reduced. This also includes those services which are designed to reduce people’s levels of dependency or support people with long-term care and often includes the voluntary sector as well as NHS services. Our strategy is for all primary and community based services to integrate in order to deliver better co-ordinated and seamless care, through a single point of contact, in each of our five localities, thus developing five community hubs across the borough. The diagram on the right illustrates our locality model which is being developed together with Dudley MBC Social Services. We therefore expect all such providers which operate across a catchment area to organise their services in one of three ways:-

Services will be expected to deliver on a 7 day basis to ensure that patients needing prompt treatment are treated in a timely manner with no delays due to services not being available just because it is the weekend. We therefore intend to develop a model of delivery which provides a better response. We will redesign and invest in community and social care to provide rapid response service, 7 days a week, into people’s homes (and care homes) either to provide home treatment or, if necessary, arrange an urgent planned transfer directly into the right service in the hospital (not via the A&E department). To enable the above to ambition to be realised, it is important that we progress on the following enablers: 5.4.1 Risk Stratification We will be developing our risk stratification tools as one means of evaluating and monitoring clinical risk. Dudley CCG has been selected as one of three pilot sites to test potential new risk stratification tools to be provided by the CSU. This piece of collaborative project work will involve experts from within the CSU working closely with both clinicians and commissioners from the CCG to understand their needs and test the use of risk stratification reports. The intention is to enable Dudley CCG to gain a granular understanding of the characteristics of their population at an individual patient level. This will in turn support locality based commissioning based on the characteristics of defined cohorts of patients within a local geography. Furthermore, when it comes to direct clinical care of patients, GPs, practice staff and other members of the community team who are providing direct clinical care will have direct access to the patients risk score and past health care resource utilisation across primary and secondary care. Initially the risk

• Aligned to individual GP practices • Operating on a locality basis, aligned to one

or more of our five localities; • Operating across the whole of Dudley, but

with links to each locality.

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stratification reports are being targeted for use by case managers and GPs working in the context of a virtual ward. However the aim is to rapidly develop reports collaboratively with commissioners to support commissioning of services by locality teams.

There is an ongoing feedback and evaluation programme in place designed to support the effective roll-out of the risk stratification tool across the CSU pilot sites.

5.4.2 Improved Data Quality We will develop a data quality programme for general practice to ensure Primis Data Quality principles are correctly applied and that general practices in Dudley are compliant with appropriate legal and NHS governance requirements. Dudley CCG GP Practices will work to Primis CARAT (Clear, Accurate, Relevant, Accessible and Timely) principles. The CCG will also provide a continual reminder to GP practices of the 8 principles of the data protection act:-

1. Fairly and lawfully processed 2. Processed for limited purposes 3. Adequate, relevant and not excessive 4. Accurate and up to date 5. Not kept longer than necessary 6. Processed in accordance with individual’s rights 7. Secure 8. Not transferred to countries without adequate protection

Whilst all General Practices use their clinical systems for the capturing of contemporaneous notes on patient consultations this Strategy will not only reinforce the importance of this work, but further enhance it. New developments including protocols to support the consistent recording and management of disease registers, templates for data capture, receipt of electronic clinical correspondence, guidance on clinical coding and developments to enhance the current scope of current clinical messaging arrangements will all help improve the depth and quality of the clinical record held in General Practices. The CCG will support its member practices by undertaking a baseline audit in each surgery and agree a number of actions which will form part of an overall development plan to be reviewed annually.

5.4.3 Summary Care Record The Summary Care Record (SCR) (GP extract of current medications, adverse reactions and allergies), continues to be deployed and utilised across the NHS in England. The Public Information Programme, informing patients of the service and giving them the opportunity to opt-out, has completed, and over half the population of registered patients have an SCR that can be viewed nationally by clinical staff in other settings when providing patient care. In addition, SCRs can be created for new patients and updated for existing patients at over half of GP practices in England. Demand for the service, in general practice (temporary and migratory residents, university students), secondary and community care settings, remains high and utilisation (record access and viewing) continues to increase as more records become available.

The rollout of the SCR service is supported by NHS England and remains endorsed by leading healthcare, policy and governing bodies such as the British Medical Association, Royal College of General Practitioners and the General Medical Council. The future of improved healthcare provision has the safe and secure sharing of key patient information, combined with an increased interoperability of systems, as a key contributor to the NHS Outcomes Framework, which the creation and utilisation of patient summary care records supports.

The purpose of the SCR is to provide safe and secure access to key elements of a patient’s GP record within any appropriate healthcare setting, nationally, and without a dependence of any specific GP system. It is

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recognised that local data sharing solutions exist that utilise richer functionality of provider systems and make more data available to clinical staff providing care.

With regard to patient consent, as a patient’s medical data follows them through the local health system, general practice need to be sure that access to this data is controlled and that the appropriate laws and regulations are respected. Patients should have ultimate control over how their data is disclosed and to whom.

We will ensure adequate protocols are followed with Dudley patients and conform to implement SCR.

5.4.4 Electronic Shared/Single Care Record Numerous organisations play key roles in the delivery of care and so effective communication between GP and provider is extremely important; as is the sharing of data and records so that we can support better and seamless delivery of care. We will therefore expect all providers to contribute to the development of a shared/single care record in Dudley. This will build on the nationally mandated summary care record, and will be a locally defined patient record with the ability to combine primary care, secondary care, community care and social care information. Better communication is at the heart of improving the care for our patients. A centralised electronic shared care record will help create a safer and more joined up NHS in Dudley helping make vital information more accessible at the time of need. 5.4.5 Tracking Patients through the System A key element of this priority to deliver integrated care is the ability to track patients through the system. The CCG needs to identify each intervention in a patient’s journey through the health system and the associated cost. We will work with providers and commissioning support to ensure this is possible. To aid this, we will expect every organisation to use the NHS number and GP code as patient identifiers in all contract datasets and information requirements. The use of a common identifier will improve communication and data integration between services and practices. Any activity associated with data supplied without the NHS number will not be paid for.

5.4.6 Telehealth/Telecare Planning guidance for 2013 describes the requirement for the utilisation of telehealth and telecare to deliver improved care for patients. We have previously piloted teleheath for respiratory and heart failure patients and will develop a programme, in conjunction with DGFT, our main provider, to increase utilisation across Dudley. Initial discussions have targeted surgical specialities, to review how monitoring devices could be used to discharge patients into their homes with support from Community services.

5.4.7 Membership Database A unique feature of the NHS is that the public register with their GP. It is the GP who is at the central point in the NHS system that supports their patients throughout their life as the central co-ordinator of their care. The CCG is a membership organisation. This could be interpreted as the CCG’s members being constituent practices, but we take the view that our members are also members of the public registered to our practices. We need to understand our registered members and their use of the health system so we intend to develop a membership database to record such information.

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Description Type Beneficiary

Risk stratification - Greater understanding of dependency of individual patients

- Reduced admissions - Reduced cost

Patient, NHS Provider, CCG, GP Practice

Improved Data Quality to enable data sharing for safety, quality and integrated care

- Legal compliance - Enables streamlining and

simplification of routine reporting - Easier identification of areas for

improvement - Reduced administrative overheads

Patient, NHS Provider Trust, CCG Commissioner, GP Practice

Summary Care Record - Avoid harmful prescribing and treatment

- Avoid duplicate or ineffective interventions

- Reduce delays in diagnosis & treatment

- Greater ownership by patients through access to their own SCR

- Reduced administrative burden (repeated data entry)

- Reduced errors of recorded information

- Greater adherence to pathways and care plans


Dudley Electronic Shared/Single Care Record

- Avoid harmful prescribing and treatment

- Avoid duplicate or ineffective interventions


- Greater ownership by patients through access to their own SCR

- Reduced administrative burden (repeated data entry)

- Reduced errors of recorded information

- Greater adherence to pathways and care plans, eg end of life preference.


NHS Number/Patient Identifiers - Ability to identify patients’ usage of health system.

- Enables streamlining and simplification of routine reporting

- Easier identification of areas for improvement

- Reduced administrative overheads due to automation of record sharing

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Telehealth/Telecare - Improved patient experience - Reduction in emergency

admissions - Reduced cost of unscheduled care

services

Patient, CCG

Membership database - Access to registered membership - Cost per patient in whole system

Patient, CCG, GP Practice

Tracking patients through the system - More effective use of scarce resources

- Adherence to NHS England targets - Improvements in care ownership

Patient, NHS Trust, CCG, GP Practice

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6.0 Health Economy Interoperability/Strategies

The vision for the CCG is that the health economy as a whole will have arrangements for ensuring Interoperability of each of its core systems.

Dudley CCG commissions a number of parties to provide NHS care and treatment to the population it serves. Increasingly with developments in technology and increasingly complex needs of the patient population the packages of care will require delivery from a number of providers. In order to ensure a seamless package of care can be delivered to those in need it will be necessary to ensure all providers can share relevant information about those for whom they are providing services to other care providers with the GP Commissioner at the heart of the process.

The diagram below outlines this:

Within each provider there are various systems at different levels of operational performance and we intend to ensure that systems deployed meet the requirements to deliver the CCG’s strategic plan.

We aim to ensure that provider IT strategies are aligned to the CCG’s IT and Informatics Strategy and will do this by co-production and implementation where appropriate. We support the model described by DGFT as identified below, and will support its delivery alongside ensuring it is appropriate for the needs of our member practices and CCG commissioning objectives.

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REAL TIME BUSINESS INTELLIGENCE

CUSTOMER RELATIONSHIP MANAGEMENT

MESSAGING HUB

FINANCE & PATIENT LEVEL COSTING

BIG DATA

HR & ROSTERING

TELE-CARE

TELE-HEALTH

PATIENT OPINION

PATIENT PORTAL

SOCIAL CARE VIEW

AMBULANCE SERVICE

VIEW

PRIMARY CARE VIEW

CLIN

ICA

L PO

RTA

L

MOBILITY

ENTERPRISE SCHEDULING

ORDER COMMS

DECISION SUPPORT

E-PRESCRIBING

PATHOLOGY/PACS

CARDIOLOGY

EDM

CLINICAL NOTING

EPR/THEATRES

PAS

SELF CARE ACUTE & COMMUNITY SOCIAL & PRIMARY CARE

AmbulanceService

Social Care

PrimaryCare

PATIENT CARE

PLANNING

Extract: DGFT IT Strategy

We will adopt the same approach for other providers, including DWMPHT, Black Country Partnership Trust, West Midlands Ambulance Service, Dudley MBC and private/voluntary sector.

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7.0 General Practice IT Responsibility for the management of primary care IT services is delegated to the CCG from NHS England. Funding to support this has also been delegated, currently at 2012/13 levels. It is unclear at the time of writing this Strategy exactly how primary care IT will be commissioned and funded from 2014/15 onwards as national policy is awaited. The approach to be taken by the CCG is that we will invest in primary care IT if we foresee a demonstrable improvement in either the quality of service provided or commissioning outcomes.

The level of investment in GPIT by the predecessor PCT was below regional average. A programme of investment in hardware has occurred over the last 12 months; however there are further steps that need to be taken to ensure that our members are provided with robust and effective infrastructure to deliver the high quality service to patients and support to improve the efficiency of internal working practices, such as back-office functions. The following initiatives are proposed over the next 3 years:

7.1 GP Architecture Dudley CCG is responsible for the delivery of GP Systems and the technical architecture that underpins them. There are a number of significant risks and issues associated with these including but not limited to:

• Clinical systems software provider support is now end of life • Windows 2003 and XP currently used by some practices • There is limited resilience, recovery and maintenance arrangements in place • Limited consistent security and user policies • Limited integration with other services • Challenges around the monitoring and management of backups

There is a current GP Practice network that is nearing the end of its life and has some technical limitations around Wi-Fi, IP addressing and web filtering. Support for the current infrastructure will become increasingly costly. There is an urgent need to redesign the infrastructure and present GP practices with a virtual desktop environment. In addition, virtual domain controllers and file servers for each practice will help with more efficient security, user’s authentication and file management arrangements. This will enable many of the current risks and issues to be mitigated for and the overall environment to be managed and maintained in a more cost effective way going forward. The key benefits will be:

• Consistent arrangements for user authentication with improved security • Password self-service for users reducing support overhead • Ease of implementation of new technologies • Centralised monitoring and management of backups • Enhanced capability to provide support and remote software deployment enabling a more cost

effective and streamlined service to be provided to users The deployment of such a virtual environment will require both significant testing and piloting together with investment. It is recommended that a solution be developed and piloted prior to rolling out more widely across all General Practices in Dudley.

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7.2 GP Clinical Systems Over the past ten years there has been a national reduction in the number of both GP clinical system suppliers and numbers of systems. This has often meant a consolidation of systems, suppliers and functionality. The first version of the GPSoC framework under Connecting for Health set out a tiered approach to systems functionality and suppliers were encouraged to bring to the market Cloud or remotely hosted solutions which had a number of significant benefits for general practices. The decision of iSOFT to withdraw from the UK GP computing market has left Dudley CCG managing two suppliers (Emis and InPractice Systems) who currently supply five separate systems (Emis LV, Emis PCS, Emis Web, In Practice Vision 3 Hosted, In Practice Vision 3 Practice server based). The two hosted cloud solutions are EMIS Web and In Practice Vision 3 hosted. The majority of Emis users remain on locally hosted or practice based systems that are no longer being developed therefore, as a matter of priority each are being offered a fully funded migration to the replacement Emis Web product. Dudley CCG will continue to promote a choice of GP Clinical Systems but its preferred product is Emis Web, and we wish to see all practices migrate to this during 2013/14. We wish to see one system for a variety of reasons but including:

• The ability to have one clinical system to support all of general practice in Dudley, our Urgent Care centre (incorporating A&E triage), our Out of Hours provider and community services will be a significant step towards the delivery of a seamless, efficient, service to patients

• The CCG’s Primary Care Strategy describes how the CCG will support member practices to work together to deliver primary care over the next 10 years. All practices on the same IT platform significantly improve interoperability and the sharing of data, thus increasing our potential to support practices to work in this manner.

• The streamlining and simplification of technical support. We believe it is in the interest of the patient to utilise scarce resources to develop and fund new technologies rather than fund technical and maintenance support to various system providers

• One clinical system in Dudley will drive, and simplify, innovation. We will fully fund, and provide operational support, to practices choosing to migrate to Emis Web. We will also prioritise the development of new products with practices using EMIS.

7.3 Electronic Document Management (EDM): EMD, incorporating Docman, enables GP practices to quickly process electronic documents and provides instant access to information. This enhancement of access for general practices to clinical information generated in DGFT and other providers is a high priority for the development of local system interoperability. This will improve the efficiency of GP practices and the quality of discharge letters from hospitals. We have implemented Docman to each of our practices and continue to ensure its operational effectiveness. We are working with DGFT on the introduction of the ‘hub’ and the benefits improved two-way communication will bring to the health economy.

7.4 Text Messaging to Patients Automatically sending electronic appointment reminders to patient’s mobile phones is known to reduce non-attendance in General Practice. We will explore the options available to Dudley practices.

7.5 Patient Self-Check in Screens Not all GP practices in Dudley use patient self-check in screens. We will perform an options appraisal of the most effective product and develop a plan for implementation.

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7.6 GP2GP Messaging GP2GP enables patients' electronic health records to be transferred directly and securely between GP practices. It improves patient care as GPs will usually have full and detailed medical records available to them for a new patient's first consultation. Within Dudley CCG each of the current GP clinical information systems are GP2GP compliant and we will instigate its implementation. 7.7 Electronic Prescription Service This enables prescriptions to be sent electronically to a dispenser of the patient's choice, making the prescribing and dispensing process safer and more convenient for patients and staff. We will perform an options appraisal of the most effective product and develop a plan for implementation. 7.8 Patient Access to Electronic Records The NHS and care services are undergoing rapid transformation of business and communication opportunities enabled by digital technology. In England, General Practice remains at the forefront of opportunity, with a widespread deployment of electronic record systems, paper-lite practices and a history of adopting and adapting new technology for direct clinical and business benefit. The ‘Power of Information’ and NHS Mandate specify the policy requirements to deliver electronic booking/cancellation of appointments, repeat prescription ordering, secure electronic communication and record viewing. Multi-professional, patient and supplier input into the RCGP led patient online road map provides an evidence based template on which to incentivise the delivery of these policy aims, focusing on benefits for patients, supporting clinicians and practices and the wider care services. The ambition for general practice is to enable new, efficient, convenient ways of working through technology to support patients to safely and independently manage and take more responsibility for their own health issues and choices. There are many ways of delivering this including the wider spectrum of Digital Primary Care. It is expected that the delivery of new technology will enable and encourage clinician and patients to interact in different ways that enhance the patient experience and begin to relieve the pressure on clinicians from the traditional service models. Underpinning the ambition for ‘digital options’ to become universally available in the General Practice environment, is a need to sustain the momentum for introduction of technology. Evidence based implementation of innovative new pathways will drive professional and public support for convenient, safe and effective new options as replacements for face-to-face contact. There is clear evidence that online services have potential to increase capacity and efficiency, but part of the implementation challenge is persuading practices of the value of these potential benefits versus the effort and cost required to realise them. Mindful of variation in appetite and capacity between practices, as well as competing priorities, there will be a national support and training offer, that will be developed in partnership with the profession and taking account of the of the recommendations in the RCGP Roadmap. Dudley CCG will work with EMIS Web to progress practices to switch on:

• Online patient booking of GP Appointments • Online repeat prescriptions • Online access to a patient’s own medical record

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7.9 Mobile devices The CCG recognises the benefit of GPs having access to clinical records whilst doing home visits and when not in practice. We will therefore procure and implement appropriate mobile devices for all GP members. This will access GP clinical system data, and will facilitate the use of the single/shared record drawing information from partner organisations. We will also require community staff to utilise mobile devices when delivering care to patients following the implementation of the integration model. This will dramatically improve the operating efficiency of such staff, whilst improving accessibility to relevant information thus improving care. 7.10 Non-GMS Applications Dudley CCG readily recognises that General Practices may, from time to time wish to install additional software applications on to Personal Computers or Servers within the practice. The CCG is in effect held to account by NHS England for the IT support provided to General Practices and as such must seek to mitigate risk for unplanned outage as par as it practicably can.

The CCG will work with general practices to agree a ‘white list’ of applications which it recognises as acceptable for use within Dudley’s General Practices. Ad-hoc requests will be assessed and not always approved.

7.11 GP Imaging Dudley general practices all currently enjoy the benefits of electronic pathology results messaging. Currently arrangements exclude the use of Edifact pathology messaging capabilities for the transmission of radiology reports. A project will be established to build on the current radiology viewing capability provided by DGFT to enable the electronic transmission of radiology reports that can be received and stored in the patient’s primary care record.

7.12 Intranet The CCG intranet will incorporate a section for GP practices. It is intended that this is the repository for posting commissioning policies, information updates, referral criteria/forms and other relevant information.

7.12 Interactive Screens The use of posters and leaflets in GP waiting areas is an inefficient and increasingly ineffective way of sharing information with patients. We will review the benefits of implementing interactive screens in waiting areas and if appropriate roll out to all member practices.

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Benefit analysis:

Description Type Beneficiary

GP Architecture - Legal compliance - Reduced burden of support - Reduced downtime - Increased productivity


GP Clinical Systems - Legal compliance - Enables streamlining and

simplification of routine record keeping

- Easier identification of areas for improvement

- Electronic messaging with other care providers

- Improved patient experience


Electronic Document Management (EDM - Increased productivity of administrative staff in GP Practices

- More rapid receipt of information from secondary care providers to Primary Care


Text Messaging to patients - Reduced administrative overheads due to automation of record sharing

- Reduction in DNA appointments

Patient, GP Practice

Patient Self Check in screens

- Enables streamlining and simplification of patient check in

- Improved capturing of changes of patients PID information

Patient, GP Practice

GP2GP Messaging - Enables streamlining and simplification of patient record transfers

- Safer and more cost effective treatment of newly registered patients


Patient, GP Practice, CCG

Electronic Prescription Service - Enables streamlining and simplification of patient prescription issuing

- Reduced costs - Improved service for the

patient - Avoid harmful prescribing and

treatment


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Patient Access to Electronic Records - Enables consistent approach to patient record access

- Reduced administrative burden of patient record access



Mobile devices - Reduced administrative burden of patient record access

- Improved GP productivity - Improved patient experience - Safer treatment of patients

away from the GP Surgery


Non-GMS Applications - Legal compliance - Enables streamlining and

simplification of routine record keeping for both patient data and GP Practice business data

- Easier identification of areas for improvement and impact of management changes

GP Practice

GP Imaging - Safer treatment of patients in the GP Surgery


- Improved patient experience - Reduced administrative burden

of patient record access - Reduced costs associated with

scanning, location of records, etc

- Improved GP productivity

Patient, CCG, GP Practice, Patient

Intranet - Complete repository of current documentation

GP Practice, CCG, provider

Interactive Screens - Focussed message delivery - Constantly up to date - Aesthetically pleasing

Patient, GP Practice, CCG

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8.0 Corporate Services The CCG exists to deliver better quality services to patients. The previous chapters have described the proposed IT and informatics developments that will impact on direct patient care to patients, but the CCG also has corporate enabling functions to facilitate such improvements. Described below is the CCG's strategy for such enabling functions. 8.1 Organisational Intelligence The CCG is currently data rich but information poor. The ability for clinicians and commissioners to access accurate information is imperative for a successful CCG. The following developments are planned:

• Develop a weekly dashboard for CCG Executive, including real time performance information for the CCG and main providers.

• Utilise technology within the headquarters to publicise performance information • Develop a performance assurance tool that identifies progress against key metrics and indicators • Publish the performance tool on the website for external review and utilisation • Developing the CCG external website and intranet, including the Publication Scheme • Strategic corporate reporting to Committees and Board • Develop tools to identify; record and utilise non-contractual performance information. a knowledge

portal 8.2 Financial/Corporate Systems There are a number of corporate systems used by the CCG to deliver its business objectives.

We will seek to continually improve the operational effectiveness of these systems and utilise new applications as appropriate.

Projected developments include:

• In conjunction with partner organisations develop business reporting systems. Develop analytical and reporting tools for commissioned activity (MiCS)

• Enhance the use of MiCS and business reporting tools in general practice and throughout the CCG • Enhance finance reporting to supplement the current SBS offer • Roll out Electronic Staff Record

8.3 Mobile Devices Changes in technology over the past five years have brought about two significant changes to mobile computing solutions; a huge improvement in capacity and availability of mobile networks and a significant reduction in the cost of devices and more flexible contract terms making solutions far more affordable and cost effective. In addition to devices for GPs, the CCG will carry out a review of its current mobile working solutions in order to identify the most appropriate for CCG staff to have access to core corporate systems whilst working away from the office at alternative locations

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8.4 Remote Working The CCG’s Remote Working policy provides the ability for CCG staff to work off site as required. To facilitate this, the ability to work effectively off-site is required. We will ensure that an appropriate solution, that is robust and cost effective, is developed and implemented. 8.5 Smart Phone Applications We intend to assess the potential for the development and utilisation of smartphone technology to support both general practice and corporate functions within the CCG.

8.6 Networking/hosted servers Each GP practice in the Dudley borough has its own local active directory domain. This is a legacy configuration from the clinical system providers and has proved problematic and inefficient to manage.

The majority of GP sites have now migrated to cloud based clinical systems, the only local dependencies on the legacy domains is GP file data and logon accounts. These will all be moved to the new Dudley CCG “connect environment” where practice and corporate servers will be removed and the service hosted off site. This will improve security, system integration, efficiency for practice and IT support provider and increase resilience and business continuity.

8.7 Email The CCG currently uses local NHS mail (@dudleyccg.nhs.uk) for email services. Some individuals also have NHS.net mail accounts established from the implementation of SBS. A review of both email options will be undertaken to identify the best option in terms of security and cost effectiveness. 8.8 Contractual Clauses: Healthcare and Commissioning Support Providers Contracts with providers will stipulate minimum information requirements for the delivery of this strategy.

The CCG will not accept providers not meeting this objective and will not pay for any activity where minimum information requirements are not provided.

Contracts with commissioning support partners will also stipulate development and reporting requirements. The CCG will not pay where a provider does not fulfil its obligations in developing data sets, information systems and robust reporting mechanisms.

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Organisational intelligence - Better informed organisation - More informed decision

making - Improved efficiency (reduce

duplication).

CCG, GP Practice

Financial/Corporate Systems - Better value for money - Improved operational

effectiveness.

CCG Staff

Mobile Devices / Remote working - Reduced administrative burden associated with remote access to core CCG IT systems

- Improved staff productivity - Improved staff/ user

experience - Increased availability of

information whilst staff work off site enabling better decisions/more joined up working

CCG, GP Practice

Networking/hosted servers The Immediate benefits - Improved security: All users

are logging in with named accounts and not generic or administration accounts. This improves your IG toolkit rating. Windows updates can be applied under a schedule

- Accountability: Accounts can be audited to track usage. File data can also be audited to track file creations, deletions, amendments etc.

- Integration: Seamless access to data centre applications (email, Intranet, Citrix)

- Enhanced Support: Dudley IT can deploy security and configuration policies at an organisational level or per practice

- Remote deployment: Software can be deployed to each

CCG, GP Practice

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machine without any user interaction.

- DHCP: IP addresses will be sent to the workstations from the data centre, simplifying network support.

Email - Local control CCG

Information Schedules/Contract clauses - Legal compliance CCG, Patient

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9.0 Delivery Arrangements Responsibility for the construction and delivery of this Strategy sits with the CCG’s Chief Finance Officer, alongside the Clinical Lead for IT. The CCG has procured IT support functions from the following commissioning support providers in 2013/14:

• Strategic IT is procured from Central Midlands Commissioning Support Unit (CSU). • Operational IT delivery is procured from Dudley IT services, a trading arm of DGFT. • Project management support for GP IT is procured from Central Midlands CSU.

The CCG will continually assess the performance and operating success of each of the above contracts and will amend the delivery model as required.

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10.0 Funding and Finance

There are two funding sources for the proposals described in this strategy. Requirements to support the commissioning and corporate functions of the CCG are funded from within the CCG’s recurrent allocation. The CCG, along with the NHS as a whole, is under financial pressure from increasing demand, a more educated patient population and the cost of new technologies. There is a requirement therefore to ensure that the organisation operates as efficiently and effectively as possible. We will therefore prioritise our investment to ensure that these aims are achieved, but will do so in a manner that achieves the best value for money. Responsibility for the management of primary care IT services is delegated to the CCG from NHS England. Funding to support this has also been delegated, currently at 2012/13 levels. It is unclear how primary care IT will be commissioned and funded from 2014/15 onwards as national policy is awaited. The approach to be taken by the CCG is that we will invest in primary care IT if we foresee a demonstrable improvement in either the quality of service provided or commissioning outcomes. The implementation plan for this strategy has been costed and included in the draft financial plan for 2013-2016.

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11.0 Risks Risks to the delivery of this strategy can be defined as:

Risk Description Mitigation

1. Insufficient buy in from GP Practitioners or staff either in GP Practice or the CCG

- Involvement of all staff and clinical groups in project governance arrangements where appropriate

2. Insufficient buy in from patients - Involvement of patient representatives in project governance arrangements where appropriate

3. Insufficient financial resources to deliver key projects

- Alignment to CCG financial planning - Robust project planning arrangements - Identification of possible alternative sources of

funding - Robust benefits management cases/

arrangements for realisation

4. Technology failure/lack of suitability - Proper testing and end user sign off - Piloting solutions where appropriate - Payment schedules designed to transfer

financial risk to suppliers - Robust requirements

5. Insufficient staff capacity/capability to deliver key projects

- Identify alternative options for obtaining staff resourcing through contractor, agency and secondment arrangements

6. Staff/clinicians resistance to change - Robust benefits management cases/ arrangements for realisation

- Proper testing and end user sign off - Involvement of all staff and clinical groups in

project governance arrangements where appropriate

7. Change in responsibility for GPIT from CCG to NHS England or alternative

- Keep Area Team informed

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12.0 Implementation Plan and timescales The strategy covers the period to April 2016, when all objectives are expected to have been implemented. A draft implementation plan has been constructed and is shown below:

Description Completion date Financial Year

Planned Care

Efficiency Index April 2015 2015/16

Demonstration of Value April 2015 2015/16

Patient Experience October 2014 2014/15

Planned Care Dashboard April 2015 2015/16

Urgent Care

Primary Care System in A&E December 2014 2014/15

Urgent Care Dashboard September 2014 2014/15

Reablement

Delayed Discharges September 2014 2014/15

Preventative Care/Integration

Risk Stratification September 2014 2014/15

Improved data quality to enable data sharing for safety, quality and integrated care

September 2014 2014/15

Summary Care Record April 2015 2015/16

Dudley Electronic Shared /Singe Care Record April 2015 2015/16

NHS Number/Patient Identifiers April 2014 2014/15

Telehealth/Telecare March 2015 2014/15

Membership Database September 2014 2014/15

Tracking patients through the system April 2014 2014/15

General Practice IT

GP Architecture April 2014 2014/15

GP Clinical Systems June 2014 2014/15

Electronic Document Management March 2014 2013/14

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Text Messaging September 2014 2014/15

Patient Self Check in Screens April 2014 2014/15

GP2GP Messaging March 2014 2014/15

Electronic Prescription Service October 2014 2014/15

Patient Access to Electronic Records October 2014 2014/15

Mobile Devices April 2014 2014/15

Non-GMS Applications June 2014 2014/15

GP Imaging To be confirmed

Intranet June 2014 2014/15

Corporate Services

Organisational Intelligence April 2014 2014/15

Financial/Corporate Systems September 2014 2014/15

Mobile Devices/Remote Working April 2014 2014/15

Networking/Hosted Servers April 2014 2014/15

Email March 2014 2013/14

Information Schedules/Contract Clauses April 2014 2014/15

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13.0 Conclusion The IT and Informatics Strategy as described above is designed to enable the CCG to do two things:

• Exceed its constitutional and statutory requirements to commission high quality services for the population of Dudley

• Support its member practices to ensure they are utilising the most effective and appropriate IT and

information systems to provide excellent services to patients whilst delivering improved efficiency. It will be challenging to deliver, but once achieved it will ensure that Dudley is an innovative, progressive health economy utilising IT as a conduit to improving the health of our registered members, our patients.

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Date of Report: 9th January 2014 Report: Primary Care Development Committee Report


TITLE OF REPORT: Primary Care Development Committee Report

PURPOSE OF REPORT: To advise the Board on key issues discussed at the Primary Care Development Committee on 20th December

AUTHOR OF REPORT: Mr D King, Head of Membership

MANAGEMENT LEAD: Mr D King, Head of Membership

CLINICAL LEAD: Dr J Rathore, Clinical Executive for Finance and Performance

KEY POINTS:

• Primary Care Incentive Scheme developed and awaiting response from NHS England

• Executive Management Team have met with Directors from NHS England Area Team to share learning from Dudley on development and implementation of Primary Care Strategy

• CCG will be working with NHS England Area Team to determine greater commissioning responsibility for Primary Care.

• Patient Opportunity Panel has elected David Stenson to sit on Primary Care Implementation Group

• 43/49 practices have completed Practice Development Plans • Primary Care Foundation working with CCG to review access to

Primary Care • Practice Nurse Education event established

RECOMMENDATION: The Board is asked to note, for assurance, the issues discussed at the Primary Care Development Committee and approve the recommendations to the Board.




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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 9th JANUARY 2014 PRIMARY CARE DEVELOPMENT COMMITTEE REPORT 1.0 INTRODUCTION

This report summarises the key issues discussed at the Primary Care Development Committee on 20th December 2013.

2.0 ITEMS DISCUSSED

2.1 Primary Care Strategy Development Update The Committee received updates from the Primary Care Implementation Group in respect of the following Primary Care Incentive Scheme The final version of the incentive scheme was approved by the Committee and submitted to NHS England for approval. The incentive scheme had been discussed with all locality groups, and the membership event in November 2013. Despite an indication from NHS England Area Team that they were supportive of the scheme and its objectives, they have since raised a number of issues with the CCG. In particular, they are concerned that incentivising ’50 hour’ opening could be seen as duplication of the requirements of the GP contract which NHS England commission from GPs. This was not a view shared by the Committee or the CCG. The CCG Executive Team has met with Director’s from NHS England Area Team and has formally asked for NHS England to re-consider their response. Executive Management Team Meeting with NHS England Area Team The Committee received an update on a meeting that took place on 8th December 2013 with the NHS England Area Team with the CCG Executive Management Team that was organised at the request of the NHS England Area Team specifically to discuss the development of Primary Care Strategy for NHS England. The purpose of the session was to learn about the CCG challenges and areas of focus, to discuss the way forward in the development of primary care, and to learn about the CCG approach to developing the quality of services and undertaking patient engagement. The information from the meeting will be used to inform the NHS England Area Team Primary Care Strategic Framework. The feedback from NHS England was very positive in that the Area Team acknowledged that the CCG is advanced in its thinking, strategy, and implementation and must find a way of working and supporting the CCG with greater autonomy and delegated responsibilities for the commissioning of Primary Care. It was agreed that the CCG would formally respond with ideas and suggestions as to how this could be achieved.

Patient Participation Representative The Patient Opportunity Panel (POP) has elected David Stenson to sit on the Primary Care Development Implementation Group.

Productive General Practice A study day has been organised on 21st January 2014 for the 6 practices participating in the programme.

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Practice Development Plans 43/49 practices have completed and returned the development plans that will be summarised and discussed at the Primary Care Implementation Group in January.

Primary Care Foundation The Primary Care Foundation audited all member practices in Dudley during April 2013, producing a report and a set of recommendations for each practice for how improvements could be made to access. Six months on from this piece of work, the Primary Care Foundation will be following up on the audit to determine what improvements have been made. The Primary Care Foundation have been meeting with locality groups to assess and report on the improvements that have, or are being made in access to Primary Care access within the CCG. The Primary Care Foundation will also be gathering the views of patients via the Patient Participation Groups on their experiences of improved access. The Primary Care Foundation will produce a written document and a video of patient experiences to the different approaches that practices have been adopting that will be shared with the Committee in February 2014. The final report will set out the different needs and expectations of patient groups wishing to access General Practice, the issues that patients face, the different ways that practices are meeting these needs, including case studies from our member practices. The final report will be shared with member practices through locality meetings and membership event, and with the Patient Participation Groups through the Patient Opportunity Panel. The purpose of which will be share and enable the CCG to facilitate good practice. The Committee noted that issues that had been raised as a result of the recent online survey and the actions being undertaken by the Primary Care Implementation group as a result. Practice Nurse Education Event The Committee noted that a programme had now been established. It was agreed that the meetings would be organised over a lunch time, and that the next event would host Lisa Hatch, Care Quality Commission for Primary Care, West Midlands. Innovation Fund The Committee noted and supported the proposals put forward by locality groups.

GPwSI Development The Committee noted that the interview had taken place on 19th December 2013 for the Commissioning and Engagement GPwSI and that the post had been offered to a GP currently working in Birmingham.

NHS England and CCG Interface Group The Committee noted the update from the Interface Group.

2.3 Risk Register

The committee made the following recommendations to the Audit Committee

• To close risk number 9, 33 and 34 (number 9 in relation to relationship management with the NHS England Area Team, number 33 in relation to premises as the process is now known and understood, and number 34 in relation to being unsighted on significant

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performance issues) as Interface Group is now established and the Area Team has established their governance structures

• To add two additional risks in relation to the uncertainty of funding for premises development within NHS England, and the process be followed by NHS England for terminating the contracts for CCG member practices.

3.0 DECISIONS TAKEN BY THE COMMITTEE UNDER DELEGATED POWERS FROM BOARD

None

4.0 DECISIONS REFERRED TO BOARD

None. 5.0 RECOMMENDATION The Board is asked to note the issues discussed at the Primary Care Development Committee on

20th December 2013 and approve the recommendations to the Board. Dr J Rathore Clinical Executive, Finance and Performance December 2013

1

GLOSSARY ABBREVIATIONS

Abbreviation Meaning

#NOF Fractured Neck of Femur

£K £1,000 equivalent

A&E Accident and Emergency

ABC / ABCD Above and Beyond the Call of Duty (Local surveys which include praise for

nominated staff members as well as assessment of services)

ACRA Advisory Committee on Resource Allocation

ACS Acute Coronary Syndrome

AD Assistant Director

AfC Agenda for Change

AHSN Academic Health Science Networks

ALE Auditors Local Evaluation

ALOS Average Length of Stay (in hospital)

AMI Acute Myocardial Infarction

AMMC Area Medicines Management Committee

AMPDS

Anti-D An antibody occurring in pregnancy

Anti-TNF Drugs used in the treatment of rheumatoid arthritis and Crohn’s disease

ARIF Aggressive Research Intelligence Facility

ASAP As soon as possible

AVE Advertising Value equivalent

BACs Bank Automated Credit

BCC Black Country Cluster

BCG Bacillus Calmette-Guerin

BCUCG Black Country Urgent Care Group

BFT Behavioural Family Therapy

BLCCB Black Country Local Collaborative Commissioning Board

2

BME Black Minority Ethnic

BMJ British Medical Journal

BPAS British Pregnancy Advisory Board

BSCCP British Society of Colposcopy and Cervical Pathology

CAB Citizens Advise Bureau

CABG Coronary Artery Bypass Graft

CAMHS Children and Adolescent Mental Health Service

CASH Contraception and Sexual Health

CAT Change Agent Team

CBSA Commissioning Business Support Agency

CCBT (CBT) Computerised Cognitive Behavioural Therapy

CCF Capable Care Forum

CCG Clinical Commissioning Group

CCRN Comprehensive Clinical Research Networks

CQI Continuous Quality Improvement

CEO Chief Executive Officer

CHADD The Churches Housing Association of Dudley & District Ltd

CHD Coronary Heart Disease

CIS Community Investment Strategy

CMO Chief Medical Officer

CMS

CNST Clinical Negligence Scheme for Trusts

CNT Community Nursing Team

CONNECT Mental Health information website for staff

COSHH Control of Substances Hazardous to Health Regulations 2002

CPA Care Programme Approach

CPN Community Psychiatric Nurse

CRL Capital Resource Limit

CSSD Central Sterile Services Department

CT scan Computer Topography

CQUIN Commissioning for Quality and Innovation

CQRM

CVD Cardio Vascular Disease

CWAS Coventry and Warwickshire Audit Services

3

DACHS Directorate of Adult Children and Housing Services

DCS Dudley Community Services

DCVS Dudley Community Voluntary Service

DES Directed Enhanced Service

DfES Department for Education and Skills

DGoH Dudley Group of Hospitals

DNA Did not attend

DoH Department of Health

DoS Directory of Service

DTC Diagnostic and Treatment Centre

DXA Dual X-ray Absorptiometry (measures bone density).

E&D Equality and Diversity

EAU Emergency Assessment Unit

EBME Electro Bio-Mechanical Engineer

ECA Extra Care Area

ECM Every Child Matters

ECT Electroconvulsive Therapy

ED Emergency Department

EI Early Implementer

EI Early Intervention

EMI Older People with Mental Illness (Elderly Mentally Ill)

EPP Expert Patients Programme

EPR Electronic Patient Record

ERMA Emergency Response & Management Arrangements

ERT Enzyme Replacement Therapy

ESR Electronic Staff Record

FCEs Finished Consultant Episodes

FED Forum for Education and Development

FHS Family Health Services

FIP Computerised data collection facility used by community health teams.

FMC Facility Management Centre

FOI Freedom of Information

FYE Full Year Effect

GMS General Medical Services

4

GOWM Government Office for the West Midlands

GP General Practitioner

GPAQ General Practice Assessment of Quality

GPwSI GPs with Special Interest

GU Genito-urinary

GUM Genito-urinary Medicine

HCAI Health Care Acquired infection

HENIG Health Economy NICE Implementation Group

HF Heart Failure

HIC Health Improvement Centre

HIV Human Immunodeficiency Virus

HPA Health Protection Agency

HPS/S Health Promoting Schools / Service

HPU Health Protection Unit

HR Human Resources

HSC Health and Safety Commission

HSCQC Health and Social Care Quality Centre

HSE Health and Safety Executive

HSMR

HT Home Treatment

HV Health Visitor

IAPT Improved Access to Psychological Therapies

IC Infection Control

ICAS Independent Complaints Advocacy Service

ICNA Infection Control Nurses Association

ICP Integrated Care Pathway

ICSM Interim Customer Services Manager

IFR Individual Funding Request

IG Information Governance

IOSH Institute of Occupational Safety and Health

IT Information Technology

IUCD Intrauterine Contraceptive Device

JCAB Joint Clinical Advisory Board

JCC Joint Consultative Committee

5

JD Job Description

JE Job Evaluators

JM Job Matching

KLOE Key lines of enquiry

KSF Knowledge and Skills Framework

LAA Local Area Agreement

LAC Looked After Children

LBC Liquid Based Cytology

LD Learning Disability

LDP Local Delivery Plan

LEA Local Education Authority

LIFT Local Improvement Finance Trust

LIG Local Implementation Group

LIT Local Implementation Team

LMC Local Medical Committee

LNG Local Negotiating Committee

LPS Local Pharmaceutical Scheme

LRF Local Resilience Forum

LTC Long Term Conditions

LVD Left Ventricular Dysfunction

LVSD Left Ventricular Systolic Dysfunction

MAPA Management of Actual and Potential Aggression

MAU Medical Assessment Unit

MBC Metropolitan Borough Council

MDT Multi Disciplinary Team

MIMT Major Incident Management Team

MIRE Major Incident Response Executive

MLSOs Medical Laboratory Scientific Officers

MRSA Methicillin Resistant Staphylococcus Aureus

MSS Medium Secure Service

NCA Non contract activity

NCB National Commissioning Board

NCRS National Care Record System

NELHI National Electronic Library for Health Information

6

NICE National Institute for Clinical Excellence

NGMS New General Medical Services

NHS National Health Service

NHSCPT NHS Community Practice Teacher

NHSCSP NHS Cancer Screening Programme

NHSLA NHS Litigation Authority

NHSP National Healthy Schools Programme

NICE National Institute for Clinical Excellence

NOF New Opportunities Fund

NPfIT National Programme for IT

NPSA National Patient Safety Agency

NRF Neighbourhood Renewal Fund

NRLS National Reporting and Learning System

NRT Nicotine Replacement Products

NSF National Service Framework

OAT Out of Area Treatment

OBD Occupied Bed Day

OD Organisational Development

ODM Oesophageal Doppler Monitoring

OOH Out of Hours

OSC Overview and Scrutiny Committee

OT Occupational Therapist

PALS Patient Advice and Liaison Service

PAF Positive Assurance Framework

PAS Patient Administration System

PAU Paediatric Assessment Unit

PbR Payment by Results

PC Personal Computer

PCDB Primary Care Delivery Board

PCDC Primary Care Development Committee

PCT Primary Care Trust

PDF Portable Document Format

PDP Personal Development Plan

PDS Personal Dental Services

7

PDSA Plan, Do, Study, Act

PDU Professional Development Unit

PE Pulmonary Embolism

PEAK Database holding the main registered details of patients and associated referral,

contact, caseload, outpatient, inpatient, MH Act and clinic information.

PEAT Patient Environment Action Team

PEC Professional Executive Committee

PEPP Pooled Budget External Placement Panel

PFI Private Finance Initiative

PICU Psychiatric Intensive Care Unit

PID Project Initiation Document

PIN Personal Identification Number

PMLD Profound and Multiple Learning Difficulties

PMS Primary Medical Services

PPA Prescription Pricing Authority

PPIF Patient and Public Involvement Forum

PSA Public Service Agreement

PSHE Personal and Social Health Education

PTCA Percutaneous Transluminary Coronary Angioplasty

Q&A Questions and Answers

QA Quality Assurance

QIPP Quality, Innovation, Productivity and Prevention

QMAS Quality Management and Analysis System

QOF Quality and Outcome Framework

QPDT Quality and Practice Development Teams

RACPC Rapid Access Chest Pain Clinic

RAS Respiratory Assessment Service

RCA Root Cause Analysis

RES Race Equality Scheme

RHH Russells Hall Hospital

RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

RMO Responsible Medical Officer

RRL Revenue Resource Limit

RSL Register Social Landlords

8

RTT Referral to Treatment Target

SAP Single Assessment Process

SEPIA Mental health computer system

SFBH Standards for Better Health

SFI Standing Financial Instructions

SHA / StHA Strategic Health Authority

SHMI

SIC Statement of Internal Control

SLA Service Level Agreement

SRE Sex and Relationship Education

SSD Social Services Department

SSDP Strategic Services Development Plan

STI Sexually Transmitted Disease

STRW Support, Time & Recovery Worker

TB Tuberculosis

THUNDERBURDS The High User Number Delivering Early Referrals By Urgent Right Direction System

TIA Transient Ischaemic Attack

TP Teenage Pregnancy

TPT Teenage Pregnancy Team

UHBT University Hospital Birmingham Trust

Vaccs & Imms Vaccinations and Immunisations

WAN Wide Area Network

WCC World Class Commissioning

WIC Walk in Centre

WMAS West Midlands Ambulance Service

WMHTAC West Midlands Health Technology Advisory Committee

WMSCG West Midlands Strategic Commissioning Group

WMSSA West Midlands Specialised Services Agency

WTE Whole Time Equivalent

dudley clinical commissioning group board ......presentation dr d hegarty 1.35pm 1.55pm 8. strategy...

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