governing body meeting (held in public) · 1. integrated quality, safety and performance report...

DATE: 28 January 2016 Title

Integrated Quality, Safety and Performance Report January 2016

This paper is for Information

Recommended action for the Governing Body

That the Governing Body: Note

1. Integrated Quality, Safety and Performance Report January 2016.

Potential areas for Conflicts of interest

None.

Executive summary

Outcome data: Oct-15 • 63 cases of C.Diff reported from Apr-Nov15 (target 37, annual target 56) • 2 CCG assigned MRSA YTD • RTT: 18 weeks not achieved • RTT: 52 weeks (admitted) not achieved (1 breach) • RTT: 52 weeks (incomplete pathway) not achieved (1 breach) (RTT data does not include Kings as a 12 month suspension in reporting for them has been agreed with NHS England and Monitor) • A&E target not achieved • Cancer waits: 2 weeks not achieved • Cancer waits: 62 days not achieved

How does this paper support the CCGs objectives?

Patients: Improve the health and wellbeing of people in Bexley in partnership with our key stakeholders.

People: Empower our staff to make NHS Bexley CCG the most successful CCG in (south) London.

Pounds: Delivering on all of our statutory duties and become an effective, efficient and economical organisation.

Process: Commission safe, sustainable and equitable services in line with the operating framework and which improves outcomes and patient experience.

ENCLOSURE: I (i) Agenda Item: 12/16

Governing Body meeting (held in public)

What are the Organisational implications

Key risks N/A

Equality No Equality and Diversity issues identified.

Financial N/A

Data N/A

Legal issues N/A

NHS constitution

Paper supports the NHS constitution.

Engagement Audit trail Comms plan Author: David Parkins, Ina Herridge, Susan Higgins

Clinical lead: Dr Sonia Khanna-Deshmukh Frognal Locality Representative

Executive sponsor: Simon Evans-Evans Director of Governance and Quality

Date 15 January 2016

Excellent healthcare – locally delivered

Integrated Quality,

Safety and

Performance Report

January 2016

2

Contents Page No.

Patient stories 3

CCG Outcomes Data 4

Outcomes analysis 5

Quality Strategy - priorities for 15/16 8

- audit plan 9

CQUINS 10

Quality Premium 14

Assurance meetings – NHS England 15

Safeguarding Children 16

Safeguarding Adults 18

Serious Incidents 21

Quality Alerts (GP) 22

Lewisham & Greenwich NHS Trust 23

Dartford & Gravesham NHS Trust 26

Kings College NHS Foundation Trust 30

Guy’s & St Thomas’ NHS Foundation Trust 33

Oxleas NHS Foundation Trust 36

Other Contracts - Care Homes, UCC 38

Engagement Activity 42

3

Patient Stories

Source: CCG PE Team

Subject Detail

MSK – hand therapy

(names changed to protect

patient identity)

Jane had a fall and sustained an injury to her hand, following triage she was put in plaster and sent home. The following day she received a call advising that she should return to PRUH as she required an operation/procedure. After the procedure Jane received another call regarding a physiotherapy assessment, which had been booked at Beckenham Beacon. Jane advised that she could not drive and that it was difficult to make the journey to Beckenham from her home in Bexley (which would involve 2 buses). Consequently, Jane asked if she could receive her care/follow up treatment locally at Queen Mary’s Hospital. However, staff advised Jane that they do not provide services on this site. Jane then contacted the CCG to ask why commissioners do not fund local services. Action & outcome: The Patient Experience Team at Bexley CCG contacted the Commissioning and Contracts team who confirmed that Kings College Hospital NHS Foundation Trust (KCH)provide hand therapy services at Queen Mary’s Hospital. A follow up call to the MSK Manager at KCH confirmed that this service was available locally and that staff should have offered choice of a local service to Jane. Finally, Jane contacted the PET again at the end of October to offer her thanks and to confirm that she was now able to see a hand therapist at a local hospital of her choice.

Bexley CCG Outcomes data

Source: SESCU integrated report – Month 7 (includes NHS England top priority targets)

4

Monthly Performance

Target Apr May Jun Jul Aug Sep Oct

C Difficile <5 9 10 7 5 10 7 8

Diagnostic tests waiting time 99.0% 98.3% 99.0% 98.9% 99.0% 99.4% 99.6% 99.4%

A&E waiting times 95.0% 92.8% 94.8% 95.0% 93.2% 93.1% 90.9% 90.7%

Cancer two weeks (monthly) 93.0% 93.0% 96.0% 92.7% 94.2% 97.1% 94.3% 90.4%

Breast symptoms two weeks (monthly) 93.0% 97.7% 96.4% 98.2% 95.7% 97.4% 91.3% 95.9%

Cancer first definitive treatment 31 days (monthly) 96.0% 98.3% 94.9% 100.0% 99.0% 95.4% 93.8% 100.0%

Cancer subsequent treatment 31 days, surgery (monthly) 94.0% 92.3% 94.1% 96.6% 100.0% 94.1% 100.0% 90.5%

Cancer subsequent treatment 31 days, drug (monthly) 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer subsequent treatment 31 days, radiotherapy (monthly) 94.0% 97.2% 100.0% 97.9% 100.0% 100.0% 95.6% 100.0%

Cancer first treatment 62 days, excludes rare cancers, GP

Referral (m) 85.0% 77.3% 84.8% 89.7% 80.0% 66.7% 79.1% 72.7%

Cancer first treatment 62 days, Screening (monthly) 90.0% 93.8% 80.0% 100.0% 100.0% 100.0% -- --

Cancer first treatment 62 days, Consultant upgrade (monthly) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% --

RTT 18 weeks (admitted patients) 90.0% 91.4% 91.9% 92.0% 92.2% 87.2% 84.9%

RTT 18 weeks (non admitted patients) 95.0% 96.0% 97.1% 97.1% 94.3% 94.6% 94.7% 94.7%

RTT 18 weeks (incomplete pathways) 92.0% 92.4% 93.5% 93.2% 93.5% 93.1% 92.4% 92.9%

RTT 52 weeks (admitted patients) 0 0 0 1 0 1 1

RTT 52 weeks (non admitted patients) 0 0 0 0 0 1 0 0

RTT 52 weeks (incomplete pathways) 0 0 0 1 1 0 0 1

IAPT-Patient numbers as % of population with depression etc. 1.1% 1.29% 0.97% 1.29% 1.26% 1.19% 1.26% 1.40%

IAPT - Proportion moving to recovery 50.0% 47.0% 44.0% 44.0% 44.0% 48.0% 47% 45%

Estimated diagnosis rate for people with dementia 66.7% Data not available 64.4%

Health visitors (WTE) At end of October there were 4.22 WTE

vacancies in Health visiting which are being covered by

bank/agency staff. Recruitment to vacant posts is under way

39.59 37.97 37.93 37.15 36.63 36.63 35.84

Winterbourne- Bexley have 3 mental health patients meeting this criteria, all had care and treatment reviews in November with

discharge planning in place for discharge before March 2016

CCG Outcomes Analysis

Source: SESCU integrated report – Month 7 & HCAI DCS

5

Outcome Detail

Healthcare

Associated

Infections (HCAI)

• 63 cases of C.Diff reported from Apr-Nov15 (target 37, annual target 56) across all providers for Bexley patients.

• 21 cases have been attributed to acute trusts with 42 being attributed to the community.

• 2 MRSA cases have been assigned to the CCG since Apr15, 2 further cases reported have been investigated

and assigned to a third party. The Infection control nurse at Bromley LA is supporting Bexley by leading on post

infection reviews of MRSA.

• Bexley LA have commissioned a private company to carry out infection control audits at all Bexley GP practices

over the next 18 months and this process is under way.

• A new Infection Prevention & Control Nurse at the LA is due to take up her post in February 2016.

• The medicines management team are working with GP practices around appropriate antimicrobial prescribing.

18 Weeks RTT

• Bexley CCG achieved the RTT incomplete pathway in October. However at CCG level, performance was not

achieved in the following high volume specialties; Gastroenterology, Plastic Surgery and Urology. At the LGT

CMB in November, there was discussion around actions to address the underperformance in T&O and ENT. The

Trust reported that they would struggle to deliver to required performance levels in T&O as capacity levels were

an issue. The Trust had been funding this work at premium costs and this situation is not sustainable, therefore

commissioners and the Trust will have to consider outsourcing some of this work. An update from commissioners

is expected at December CMB. KCH is aiming to upload data from February 2016 following the agreed

derogation in reporting. In the meantime, the Trust will continue its waiting list validation programme and

continue to reduce the current backlog of over 18 week waiters.

Patients waiting

52+ weeks RTT

• There was 1 patient waiting 52+ weeks in October, which occurred at GSTT in Plastic Surgery. KCH have

confirmed a Trust wide position of 127 patients waiting over 52 weeks in October. The Trust will produce a

recovery plan by 17 December. The expectation is that non-neurosurgery long waiting patients will be cleared by

the end of January 2016, neurosurgery requires further work in the light of PMO activity being significantly less

than planned. An additional assurance process has been put in place for clinical review of the additional long

waiters identified. This will have input from clinical leads from Southwark CCG.

CCG Outcomes Analysis (cont’d)

6

Mixed Sex

Accommodation

• The CCG has 15 breaches in October which occurred at D&G. D&G reported in its M7 Board Report

that the reason for the breaches was lack of capacity. The Trust has agreed a detailed action plan

with commissioners. However, there were no safety concerns and no patient experience issues or

complaints as a result of the breaches.

Cancer waiting

times

• The CCG did not achieve the 2WW with an outcome of 90.4% (45 avoidable and 21 un-avoidable

breaches out of 691 patients) against the target of 93% and 62 day standard with an outcome of

72.70% against the target of 85% (9 avoidable and 3 un-avoidable breaches out of 44 patients) in

October. All patients waiting over 100 days are reviewed on a monthly basis at CQRG. All trusts in

SEL have action plans developed as a result of the IST review to address these issues, which are

monitored through regular performance meetings both on an individual trust basis, and a pan

provider/commissioner basis. Progress continues to be made in implementing the actions; however

this has yet resulted in the required level of improved performance. LGT did not achieve the agreed

trajectory of 85% by the end of Q2 with an outcome of 81.3%. Following CCG assurance meetings

with NHSE, a revised action plan was submitted to NHSE on 30th November 2015. This action plan

was partially assured by CCGs, who are awaiting feedback from NHS E. In addition the Trust is

making their weekly Priority treatment list (PTL) available to commissioners. The PTL includes

Decision to Treat Data and is discussed at a joint weekly PTL call between Commissioners, the Trust

and CSU. This call will also review the action plan on a weekly basis. A GP from each CCG will also

attend the Trust’s cancer weekly PTL clinical review on a rotational basis. The Trust has also raised

an issue regarding a number of patients whose data did not migrate from iCare to Infoflex and have

raised a serious incident. Further details to be provided.

Cancer

Subsequent

treatment 31 days,

Surgery

• The CCG did not achieve this standard in October with an outcome of 90.5% against the target of

94.0%, (3 breaches out of the 21 patients). All of the breaches were avoidable (2x capacity and 1x

Administrative).

Source: SESCU integrated report – Month 7

CCG Outcomes Analysis (cont’d)

A&E Waiting Time

4 hour DTA

• The A&E 4 hour target was missed by D&G in November at 80.4%. Performance was 92.2% for

year to end of November. Key issues impacting the performance were: high occupancy rate,

medical staff sickness and a significant variability in arrival numbers – usually associated with

winter months. The Trust in its M8, Board report states that two additional consultants have been

planned for November and April 2016 and agency crews are regularly commissioned to reduce

delays. The Frail Model has commenced on 5th October and the Ambulatory Care Unit phase 2

will commence in December, building work within the department has been completed. Finally, a

revised and detailed action plan has been agreed with commissioners.

• ED performance for November at QEH was 83.43% for Type 1 and 89.20% for All types. At Trust

level the outcome for type 1 was 87.47% and 89.85% for All Types. As the A&E target was not

achieved in October as planned a recovery plan was presented to the tripartite panel on

30.11.15. This included a recovery trajectory at site level and trust level. The December trust

board report states that this trajectory is based on 14/15 performance, a baseline improvement

level has been added (3% for QEH and 1.65 for UHL).The trajectory also includes the impact of

improvements week by week by scheme. The aim is for performance to recover by the end of

Q4. Performance in 15/16 year to date has been above performance for same period in 14/15.

The revised plan also includes a focus on the impact of the winter schemes on occupancy and

performance. A plan named Operation Aladdin at SRG level has been developed to cover the

period 14th December 2015 to 17th January 2016. This plan involves a multi-agency approach to

avoid the traditional dip in performance after Christmas.

7

To Note – Measles

& Scarlet Fever

Public Health England have written to all South East London healthcare providers to alert them to a

small but significant increase in suspected measles, with 14 laboratory confirmed and 12 probable

cases across South East London. Over the same time period there have also been an increase in

formal notifications of scarlet fever, with 147 suspected cases compared to 86 in the same period in

2014.

Quality Strategy - priorities for 15/16 8

Priorities for 2015-16 have now been set and are listed below. The progress against these priorities will be

monitored by the Q&SSC. Progress will be provided to Q&SSC & GB through this report.

General

• To embed learning from incidents, complaints and patient

feedback, thereby reducing the potential for incidents.

Assurance provided via embedded

learning events at LGT and Oxleas

• Supporting Quality improvement through greater collaboration

between hospital and community services.

Pressure ulcer panels at Oxleas and

LGT

• A better understanding around the prevention of inequality for

the vulnerable groups and their access to treatment. LD nurse in post at LGT and DVH

• Improvement in the quality of information between secondary,

primary and community care.

Development of dashboard for CQRG

• Safeguarding Children and Vulnerable Adults (see

Safeguarding Strategy).

Qtr2 deep dive with NHSE

Specific

Quality Improvement in:

• Care Homes Care homes forum established with

CQC liaison

• District Nursing Joint strategy in place

• The Quality Premium See separate slide

• C.Diff performance

The local authority have recruited an

infection control nurse – start date

February 2016.

• London Quality Standards LGT undertaking an audit

• The quality of maternity provision for the women of Bexley

• The quality of care at Queen Elizabeth Hospital A&E

• End of Life Care/ linking work through Care Home Forum

• Small Contracts Assurance Process PAMS business case to go to FSC

Delivery • Improving Cancer services (especially 62 day waits at L&G). Plan in place

Quality Strategy (audit plan)

11

The Audit Work Plan for 2015-16 has now been agreed and is listed below. The progress against this audit plan

will be monitored by the Q&SSC and reported here.

1 • Older People discharge into care homes (completion by end of Q3).

2 • District Nursing audit of care plans (completion by end of Q4).

3 • AQP Service Community Gynaecology Services (completion by the end of Q4).

4 • End of Life Care - a hospice specific audit (completion by the end of Q4).

CQUINS (Q1) No CQUIN Overview Value %

indicator

weighting

Qtr..

Q1 weighting (%)

Sub payment rules in place?

Requirement Evidence Final RAG

1

Acute Kidney Injury 15.00% 1 2.25% No Agree Q2/3 targets - to be set as soon as possible after Q1 ends using data from Q1 10% of whole-year AKI CQUIN value awarded if the audit is established and results that can serve as a baseline for improvement

Trust submitted baseline audit which identified sensitivities in the sampling methodology causing patients not suffering with AKI to be included in the sample because of their creatinine test results. Agreement reached with commissioners to further cleanse the sample and meet to establish targets

2a

Sepsis Screening 11.00% 1 2.20% No Establish baseline of patients screened for sepsis using the Trust protocol. Protocol to be shared with Commissioners. Agree Q2/3 targets - to be set as soon as possible after Q1 ends using data from Q1 10% of whole-year sepsis CQUIN value awarded if appropriate local sepsis protocol and screening tool are in use and baseline data collection established.

Trust submitted baseline of patients screened for sepsis using agreed protocol. Protocol shared with Commissioners.

2b

Sepsis Antibiotic Administration

11.00% 1 0.00% No milestone actions this quarter None required

3a

Dementia - Find, Assess, Investigate, Refer & Inform

7.00% 1 1.75% Yes in Q4 Quarterly download of dementia patents identified sent to BGL GPs. Provider achieves 90% or more for each element of the indicator for Quarter 1 of 2014/15, taken as a whole

Trust report 100% at both UHL and QEH for each element of the indicator for Q1. Quarterly CCG downloads sent to CCG Clinical Commissioner leads.

3b Dementia - Staff training 2.00% 1 0.50% No Provider to confirm named Clinician leading on dementia and provide a copy of the 2015/16 staff training programme Confirm numbers and cohorts of staff to be trained

Belinda Mc Call - Lead in Dementia Dementia Training prospectus is online

3c Dementia - Supporting Carers of people with dementia

3.00% 1 0.75% No Trust to agree audit content with commissioners Provider to undertake monthly audit of carers of people with dementia to test whether they feel supported with results reported to the Trust Board

A total of 12 surveys were given to carers for Q1 and 0 were returned completed. The Trust continues to deliver Dementia Carers Drop In and Support Sessions twice monthly (day and evening). The Trust also promoted Dementia awareness week from May 18th to 24th

4 Reducing the proportion of avoidable emergency admissions to hospital.

20.00% 1 4.00% No Trust to establish baseline level of avoidable emergency admissions in 2014/15 Report on baseline submitted including methodology. Agree reduction targets in avoidable admissions for Q2 - Q4

Avoidable admissions UHL - 5794 Avoidable admissions QEH - 4236 Report submitted on methodology for establishing baseline. meeting took place with commissioners to agree basis for establishing reduction targets.

5a Maternity - Development of a maternal obesity service

7.00% 1 1.00% No Develop an evidence-based evaluation process for the Pregnancy Plus service (existing and planned) to include specific agreed outcomes and women’s experience. QE site to conduct a baseline audit of 80 women against agreed outcomes. Milestone actions agreed with Commissioner

Audit conducted on a random sample of 80 women, taking a sample from each of the 12 months. The audit took place over a three week period as the records were supplied in batches from medical records. Audit outcomes reported show a positive impact of women being referred to and attending Pregnancy Plus Clinics. meeting with commissioners to place to confirm further milestone actions

10 Lewisham and Greenwich NHS Trust 2015/16

CQUINS (Q1)

5b Maternity - Joint Vulnerability Assessment

8.00% 1 1.50% No Trust to produce a detailed action plan (informed by the 2014/15 Q4 re-audit) which would include updating current training and every available cascade method so that midwives are clear that if a woman is coded to the intermediate pathway because she has social risk factors then she must be directed to appropriate support. Action plan to have sign off from Commissioner

Joint Vulnerability Improvement Action Plan submitted 1.50%

6 Supporting Integration 7.00% 1 1.00% Yes - 50% split

Trust to report on Feasibility Business Case covering co-location, mobile working for nurses and procurement of an IT solution. Trust to provide implementation plan Trust Estates scoping exercise to establish 4 locations for Neighbourhood Teams and develop specification

Four Neighbourhood Hubs Feasibility Study for Building Costs submitted. Feasibility Business Case awaiting planned schedule for agenda at Integration Board to be discussed and/or approved. Mobile working is integrated within the Trust implementation of OpenRIO which is in progress at present. The mobile element of this will be piloted in October within Community Services. Schedule of accommodation for NCT location submitted

1.00%

7a Improving quality and effectiveness of care for children with complex needs through better identification and coordination

5.00% 1 1.00% No • Identify C&YP with complex needs for functional coding (these may be new or review patients) with new patients forming the sample for audit. • Establish and agree audit criteria with CYP Commissioners • Develop and agree audit tool to be used • Set dates for Q2 audit (to take place by the middle of the quarter)

The Service met with CYP Commissioners to agree actions. Actions agreed and reported for the quarter were submitted in a report. Codes have been harmonised within and across the teams to ensure consistency of recording. All teams are clear regarding the changes and codes now in use. Audit criteria and tool submitted. Audit will be carried out in September

1.00%

7b Clinical Pathway Development – Community Children Nursing

4.00% 1 0.50% No Investigate and analyse the movement of children and young people with complex needs and long term conditions that could be shifted from hospital into the community care through rapid response and early discharge

Report submitted analysing the movement of children along care pathways in the following 6 long term conditions: 1. Sickle Cell 2. Epilepsy 3. Cystic Fibrosis 4. Diabetes 5. Asthma 6. Eczema The Trust has agreed with Commissioners to take forward development of two pathways - Sickle cell and Asthma pathway.

0.50%

Total 100.0% 16.450% 16.450%

11

Headlines • L&G NHS Trust CQUINS for Q1 are shown above and have been achieved. • Dartford & Gravesham NHS Trust are focussed on Q3 and Q4. • Oxleas MH and LD CQUINs have been achieved (data on following slide). • Oxleas community CQUINs are based solely on national targets.

Lewisham and Greenwich NHS Trust 2015/16 (cont’d)

CQUINS (Q1) OXLEAS

12

CQUINS (Q1) OXLEAS

13

Quality Premium

14

2015/16 measures (numbers 1-4 – national data collection - data not yet available).

1 Reducing potential years of lives lost through causes considered amenable to healthcare (10%).

2 Avoidable emergency admissions (30%).

3

Mental health: a) Increase in the proportion of adults in contact with secondary mental health services who

are in paid employment (15%);

b) Improvement in the health related quality of life for people with a long term mental health condition

(15%).

4 Improving antibiotic prescribing in primary and secondary care (10%).

5 (local)

a) Introduction of a safeguarding measure (10%). Agreed: May 2015. 1st step: Evidence of process to

collect data developed: A workshop on 21st July at the Forum Community Centre in Greenwich to discuss

and agree this. Target by end of Q4:80% of service users of Oxleas (Bexley) adult mental health services

are asked whether they live with a child/young person under 18yrs. To date 289 service users have been

identified by Oxleas. AMH Practitioners are aware of the need to identify Client's who have children in

particular those subject to a CP Plan or have CSC involvement – Oxleas are working with AMH Business

Support Lead, RiO transformation Team and Clinicians to ensure capture of this data. Regarding early

help/ young carers assessment - Following on from the Young Carers Questionnaire Anna Chan is

undertaking a piece of work which will seek to improve the identification of young carers and consider

appropriate referral pathways either into Early help or directly to Young Carers. Oxleas will audit recording

in April 2016

Q2

b) Increase in Care Home quality reporting (10%). Agreed: May 2015.

1st step: Design new process and start pilot in a 2-3 care homes who are currently commissioned by Bexley

CCG continuing care. Q2 QA System and IT has been set up for Care Home usage and instructions and

leaflets prepared. 2 Care Homes were set up. Q3 Invitations are being made to another 8 Care Homes to

participate in the online process. Visits in process. Target by end of Q4:10 care homes setup and reporting

on QAMS.

Q2

Assurance meetings – NHS England

Q4 2014/15 In Q4 the CCG was assessed against all six domains using the recognised terminology in the national guidance: assured, assured

with support or not assured.

15

Review of

2014/15

Domain

Q4

Assurance

level

Feedback

Quality Assured

with

Support

The key driver for this was poor performance against the urgent care Constitutional Standards at Lewisham

and Greenwich NHS Trust across the quarter and the financial year overall. No evidence of avoidable harm

due to the poor performance has been found, but the CCG will continue to monitor this closely and escalate

any concerns with NHS England should they arise. The current rating will remain until the CCG consistently

meets the A&E target for a full quarter. NHS England expect the Governing Body to continue to ensure that

the CCG is taking every reasonable action to ensure the quality and safety of services provided to its

patients.

Patient and

Public

Engagement

Assured Bexley CCG’s evidence for Domain 2 of the Q4 Deep Dive was comprehensive, providing some excellent

examples of engagement and activities. The examples given for Cardiology and MSK services highlight a

good level of engagement; evidencing outcomes as well as how services have been improved, as done for

the ‘mystery shopper scheme’ could further demonstrate the mechanisms of how feedback is utilised. When

reporting on PPI work we recommend the CCG demonstrate how the use of the CCG website and Twitter

account support your overall engagement strategy and enable you to engage differently.

The self-management and shared decision-making examples highlight the CCG’s understanding of the

benefits these activities have for patients; in reporting, providing details on the metrics you are monitoring

could further demonstrate this.

Your example of the mechanisms used to hold providers to account as well as providing specific outcomes

of improvements were strong.

Delivering

Outcomes

for Patients

Assured

with

Support

Due to IAPT (recovery 49.3%) and dementia (access) not being met in Q4.

Governance Assured

These assurance levels have been signed off following regional and national moderation. Partnerships Assured

Leadership Assured

Safeguarding Children

Source: CCG Safeguarding Children Lead

16

Subject Detail Action Latest

position

CP medicals

Good practice requires a child protection medical to be completed within

24hrs of a request being received from children’s social care for acute

presentations.

Qtr. 2– 80% delays in remaining cases caused by change of appointments

by children’s social care. Awaiting Q3 data. (Previous quarter 100%).

Completion

of

safeguarding

dashboard

Oxleas have agreed additional KPI’s requested from Bexley,

Greenwich and Bromley CCG’s. Will be introduced Q3 & Q4

L&G provide a good level of data

DVH have agreed additional KPI’s.

KCH do not provide separated data for PRUH – this remains an on-

going issue, however has now been escalated to the contracts team

and the Head of Quality Bromley CCG (lead commissioner for PRUH)

is leading negotiations

Escalated to Clinical

Director and Director of

Nursing Oxleas.

Discussed at August

Oxleas CQARG.

Director of Quality

Bromley CCG for

discussion at KCH

CQRG

Looked after

children

initial health

assessments

This is a health indicator but Oxleas are entirely dependent of children’s

social care providing notification and consent. Delays in receiving

documentation and consent have meant health assessments are delayed

beyond 28 day timescale. Oxleas provide a weekly status report.

Qtr. 2 - 75% completed within 28 day timescale.

This has increased significantly following escalation to Deputy Director

children’s services and LSCB (Oxleas provide assurance of 86% completed

within 28 days once paperwork is received from LA.)

Escalated to Asst.

Director children’s

services LBB and Bexley

Safeguarding children

Board

Safeguarding Children (cont’d)

17

Source: CCG Safeguarding Children Lead


position

Suicides

In Bexley there has been a cluster of suicides:

2014/15 1 young person took his life and 1 near miss

2015/16 2 young people have taken their lives

A cluster of suicides is a rare event. Suicide cluster is defined as a

series of three or more closely grouped deaths. In the absence of

transparent social connectedness, evidence of space and time

linkages are required to define a cluster (Larkin& Beautrais 2012)

Cases will be reviewed

together by Bexley’s Child

Death Overview Panel.

Bexley will also host a Suicide

Summit for Lewisham,

Greenwich, Bexley and

Bromley in January 2016

Both meetings will explore

possible common

links between cases across

boroughs in some detail and

how health and partner

agencies should respond.

.

Safeguarding Adults

Source: CCG Safeguarding Adults Lead

18


position

SA

Training

Compliance from providers: Q2 July to September 2015 (awaiting QTR 3 data)

Lewisham and Green Trust:

Training - level 1 is at 100%, level 2 is 84% PREVENT: 1544 staff trained to date

Adults with learning disabilities

• Liaison with partner agencies is on-going to explore the possibility of sharing the registers of

service users with QEH so that known adults with a learning disability can be proactively

flagged on I-Care.

• The Trust is now signed up to the Mencap Patients Charter.

Quality Audit at QEH

Recent audit at QEH as there has been concerns regarding Mental Capacity Act and Best Interest

Decisions regarding patients who do not have mental capacity are being discharged to care

homes without a BIA in place. Other concerns have also been identified. Full report to follow.

Oxleas NHSFT:

Training:- Level 1 97%, MCA & DoLs training 94%, level 2 and 3 safeguarding adults training is

provided by Local Authority.

• Updated MCA & DoLS e-learning package is available all staff. Face to face workshops for

have also been commissioned and commenced. A reviewing of the uptake of the training will

be undertaken at a later date

• PREVENT:- At present 5 members of staff are accredited to deliver WRAP 3, there are plans to

increase this and Oxleas are in the process of identifying staff for this role. As of Oct-15 there

were 2402 staff who required level 1 training, a factsheet has been developed to cascade to all

staff to help achieve the target. There are 1631 staff who require level 2 training. The

compliance target for this is 85% over a three year period. Progress is being made to recruit a

safeguarding co-ordinator to assist with to organising/delivering these workshops

Safeguarding Adults (cont’d)



position

SA

Training

Darent Valley Hospital:

Training:- MCA & DOLS: All clinical staff are encouraged to attend the sessions. The Trust

has 2 full days training on both MCA & DOLS and hold regular 3 hour training sessions on

DOLS and the Supreme court ruling. The training is not mandatory and therefore is not

reported as a compliance figure. For Qtr.. 2 45 people attended MCA and DOLS training.

Domestic abuse training is currently attended by the maternity department.

Safeguarding adults level 1 is at 94% and level 2 94% which includes MCA/DoLs.

KCH, Kings & PRUH

There has been progress in the last year and compliance continues to improve. In March

overall compliance was at 57% against a Target of 80%. As of Dec-15 this is now 66%.

The Safeguarding Adults team deliver training on both the Denmark Hill and PRUH sites to

optimise attendance. In addition the team will provide training within teams via meetings/audit

days etc. when invited.

MCCH training - Level 1 91% and level 2 100%, MCA & DoLs 100%

DVH has

now

appointed a

full time SA

lead.

Process

indicators DBS compliance for new staff is 100% for LGT, Oxleas and MCCH

MCA/DoLs

LGT compliance with DoLs – there has been 17 DoLs authorisation in the last quarter.

MCCH: 231 MCA assessments done and 59 DoLs application.

Oxleas:- No DoLs, Restraint data: Oxleas are undertaking data validation of this information

to understand the increase in reports, further information to follow.

PRUH - The number of applications continues to rise in 2015/16 33 applications made in Q1

and none where rejected which supports that that the quality and appropriateness is

improving.

To obtain

information

on

DoLs/MCA

from

Oxleas &

DBS

Compliance

for Q2 &

data on

Restraint.

19

Safeguarding Adults (cont’d)


SA

Referrals

The local Authority provides a weekly update of all Adults Safeguarding issues which include all

Bexley Care Homes and hospitals.

Safeguarding Adults activity:-

Oxleas – increase in referrals which may be related to the SA Co-ordinator role being introduced and

allowing closer scrutiny of all incidents.

Referrals substantiated – 4 of the substantiated referrals were as a result of a wider investigation at

a care home in Greenwich.

UHL – 47 alerts received, 20 were referred to the local authority

Queen Elizabeth Hospital - 43 alerts received , 11 were referred to the local authority.

Queen Mary’s Hospital - 1 alert received

Community – 5 alerts received, 3 referred.

Bexley – 19 alerts, 9 referrals

Darent Valley Hospital

Darent Valley Hospital submits safeguarding alerts to Kent Social Services (KCC) and Bexley Social

services. With the majority of referrals made to KCC.

The safeguarding alerts that have been raised during this quarter break down as follows

9 = Neglect 1 = self-neglect

The location of the patient of the above alerts were :

5 occurred in the patients own home 1 in a nursing home 1 in a care home 3 at DVH

Ages of patients – 8 patients aged 80-90yrs old 2 patients aged 50-65yrs old

PRUH, KCH and Guys

The alerts received fall into 3 groups, safeguarding, adult at risk or learning disabilities. In 2014 – 2015

the activity data remained fairly static with an increase in Q4.

All

safeguarding

adults alerts

are dealt

with by LA

with action

plans and

follow up

On-

going

20

Period Safeguarding Adults at Risk Learning Disabilities TOTAL

14-15 Q1 161 286 140 587

14-15 Q2 171 300 119 590

14-15 Q3 292 183 145 620

14-15 Q4 197 360 157 714

15-16 Q1 140 407 148 695

Serious Incidents • There have been 7 Serious Incidents affecting Bexley patients in Oct-Nov 2015, none were ‘never events’.

• The types of incident reported were:-

2 Pressure Ulcer meeting SI criteria

2 Delayed diagnosis meeting SI criteria

1 Treatment delay meeting SI criteria

1 Sub optimal care of deteriorating patient meeting SI criteria

1 Apparent/actual/suspected self-inflicted harm meeting SI criteria

Source: StEIS national reporting system

21

0

1

2

3

4

5

6

within 2days within 7days within40days

No

. of

SIs

No of days taken to report SIs for Bexley by all providers in

Oct-Nov 15

0

1

2

3

4

5

6

7

Oxleas L&GT

No

. of

SIs

No of Bexley SIs by provider Oct-Nov 15

Quality (GP) Alerts

Source: Quality Alert Management System (QAMS)

22

12 alerts

received in

Oct/Nov

The number of alerts continues to

decrease

Organisation

highlighted

Lewisham & Greenwich NHS Trust (6)

Kings College Foundation Trust (1)

Oxleas NHS Foundation Trust (2)

Darent Valley (2)

LAS/ 111 (1)

Themes

(top 3)

Insufficient info/poor discharge / poor

communication

Delay in treatment

Poor Communication

Risk rating

7 Amber

5 Green

Lewisham & Greenwich NHS Trust

Source: SECSU Month 7 Scorecard

23

Monthly Performance






A and E waiting times 95.00% 91.3% 95.7% 93.8% 91.9% 91.4% 90.0% 91.3%




Cancer subsequent treatment 31 days, surgery (monthly) 94.00% 100.0% 75.0% 88.9% 92.9% -- 100.0% 100.0%

Cancer subsequent treatment 31 days, drug (monthly) 98.00% 100.0% 100.0% 100.0% 100.0% -- 100.0% --

Cancer subsequent treatment 31 days, radiotherapy (monthly) 94.00% -- -- -- -- -- -- --

Cancer composite, 62 days first treatment plus rare cancers (m) 85.00% 78.9% 80.9% 80.6% 84.6% 62.5% 81.3% 73.7%

Cancer first treatment 62 days, Screening (monthly) 90.00% 75.0% 100.0% 100.0% 100.0% 100.0% 88.9% 83.3%

Cancer first treatment 62 days, Consultant upgrade (monthly) 100.0% 100.0% 57.1% 75.0% 50.0% -- 100.0%





Source: HCAI database and LGT CQRG reports

24

Clinical Effectiveness

MRSA In this financial year there have been 5 cases of MRSA detected at LGT, 3 cases have been

assigned to the Trust (July, August and November)

C-diff

The Trust has been allocated a target of less than 39 hospital acquired C. Difficile cases in 2015/16.

In

September there were 2 hospital acquired cases which is an improvement. The Infection Prevention

and Control Committee will be reviewing the C. diff action plan this month. There has been

significant improvement in the ED and CDU at QEH taking stool samples on admission for patients

presenting with diarrhoea. This has been supported by the Infection Prevention and Control Nurses

visiting CDU regularly and the engagement of the nursing staff.

Patient Experience

Complaints No formal complaints received by the CCG during Oct/ Nov

Mystery Shopper

• 60 feedback forms received regarding L&GT services

• 90% positive / 10% negative

• Positives = Phlebotomy at QMH (customer care), Midwifery (customer care)

• Negatives = Surgery (waiting time & quality of care), T&O (appointment delay)

NHS Choices

headlines

QEH

• Positive - Obstetrics & Fracture clinic

• Negative - Phlebotomy (attitude of staff) and A&E (quality of care)

Lewisham Hospital

• Positive - Physiotherapy (excellent customer care)

• Negative - A&E (quality of care), Oncology (administration), haematology (appointment waiting

time)

Lewisham & Greenwich NHS Trust (cont’d)

Source: LGT CQRG Papers (Nov-15)

25

Patient Safety

Learning from

recent Never

Events

A guide wire was inadvertently retained following insertion of an internal jugular line in Critical Care.

Several lessons were learnt through the root cause analysis leading to changes in practice firstly it is now a

requirement to have 2 practitioners scrubbed in throughout invasive procedures carried out in the

department; and secondly the implementation of an electronic audit system for all invasive procedures within

the Critical Care units on both hospital sites. This has to be completed by the clinician who undertakes any

invasive procedure in the department. It includes a requirement for the practitioner to confirm that any guide

wire has been removed, thus acting as a reminder.

A patient was fed through a misplaced nasogastric feeding tube. As a result of this incident the

interpretation of radiological images to confirm correct placement of NG feeding tubes was restricted to

consultant radiologists only on both hospital sites, until a robust training programme with competency

assessment could be put in place to retrain / assess all other staff who need to undertake this task. This is

underway.

Wrong site surgery. A patient had skin lesions on both legs; one was diagnosed as malignant and a

referral made from dermatology to general surgery for removal under local anaesthetic. Following surgery it

was discovered that the wrong lesion had been removed. The Trust is actively participating in the

implementation of the NatSSIPs (National Safety Standards for Invasive Procedures) under which Local

Safety Standards will be developed for each invasive procedure including many ‘minor’ procedures. Progress

will be monitored by the Quality and Safety (Q&S) Committee. Gap analysis is currently underway and due to

be reported to Q&S in December 2015 by all clinical Divisions.

Dartford & Gravesham NHS Trust

Source: SECSU DGT Scorecard Month 7

26

Indicator Monthly Performance






A and E waiting times 95.0% 95.4% 95.9% 97.0% 94.2% 94.5% 91.3% 89.2%




Cancer subsequent treatment 31 days, surgery (monthly) 94.0% 100.0% 100.0% 94.4% 100.0% 100.0% 100.0% 100.0%

Cancer subsequent treatment 31 days, drug (monthly) 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer subsequent treatment 31 days, radiotherapy (monthly)

94.0% -- -- -- -- -- 100.0% --

Cancer composite, 62 days first treatment plus rare cancers (m)

85.0% 95.8% 91.0% 90.7% 84.6% 89.0% 87.5% 85.1%

Cancer first treatment 62 days, Screening (monthly) 90.0% 77.8% 100.0% 85.7% 96.7% 100.0% -- --

Cancer first treatment 62 days, Consultant upgrade (monthly)

100.0% -- -- -- -- -- --





Source: SECSU Month 7 Integrated report


27

Analysis / Commentary

A&E targets

The A&E 4 hour target was missed in October at 89.2%, YTD A&E target is 94.0%. The Trust remains

focused on addressing back end issues and is still struggling with social services and access to

community beds whilst demand management plan implemented by commissioners has taken patients

away. A revised and detailed action plan will be agreed with commissioners; however occupancy remains

the key issue affecting A&E performance.

Handover targets

Ambulance handover delays remain high, increasing from 183 in September to 258 in October and

inpatient occupancy remains the key issue causing delays. Implementation of the HAS 2 Portal to capture

real time ambulance offload information is fully operational.

Cancer performance

targets

The 14 and 31 day cancer performance targets were met. The 62 day GP cancer performance target was

met in September at 87.5%.

Length of Stay

Overall average non-elective length of stay has increased (surgical by 5.9% and medical by 4.5%).

Further analysis of surgical length of stay by speciality is being undertaken with increasing pressures in

ITU and Laurel ward resulting in an increased number of MET calls. Access to community beds and

social services remains difficult with low community bed turnover preventing patients accessing step down

care with occupancy remaining high in July at 99. Complex discharge meetings each week and proactive

management of LOS through the Integrated Discharge Team with daily escalation on individual cases

through Patient Safety meetings held three times a day.

Training

Overall mandatory training rate remains unchanged in October. Trust has been requested to share

detailed plan to meet the trajectory position particularly with safeguarding level 2 <70%. The Trust

appraisal rate remains steady but below target in October at 81% against a target of 85% and a plans to

achieve 85% compliance by September is a focus of directorate Q2 performance meetings.

Mixed sex

accommodation

New revised guidance and monitoring system agreed with the CCG is now in place. 93 reportable

breaches in October which include previously excluded units such as ICU, MSU. Concise RCAs will be

completed and sent to the DoN for review including Trust documentary evidence which shows that

patients are aware of the MSA protocol.

Dartford & Gravesham NHS Trust (cont’d)


Maternity

Midwife to Birth Ratio: The Midwife to Birth ratio target met in October at 1:34 against the target of 1:34.

The current delivery rate is 2% higher than the same period last year. 11 midwives have been appointed

and in the recruitment process – due in post from September. 9 midwives are on maternity leave (6.03

wte) with further recruitment planned. Monthly central control and monitoring in place for all maternity

staffing.

C-section (maternity): The elective C-Section rate remains above target at 12% in October.


Healthcare

Associated

Infections (HCAI)

MRSA – 1 MRSA bacteraemia case was reported in September and 0 case reported for October (the

reported case in June has been validated and allocated to the Trust)

CDiff – 1 cases of C Diff reported in October (13 reported cases YTD across six clinical areas - all non-

related. 9 of these cases have been reviewed with the CCG – 8 were deemed not due to lapse of care.

Any reportable HCAI cases are fully investigated and are reviewed at the weekly Infection and Prevention

Control meeting.

Patient Safety

Serious Incidents

and Never Events 2 Open serious incidents in October. There were no never events in October.

Falls

There were no fall resulting in fractures in October. RCAs have been completed for all nine reported

cases; eight have been reviewed with one scheduled for review in November. Trust assured that the falls

rate and preventive measures are progressing and monitored through the falls group with a robust review

of the Falls Policy completed including new care plans and a comprehensive falls training Programme to

commence in September.

Pressure Ulcers Hospital Acquired reported pressure sores have increased to 24 from 15 in September, with no grade 4, 2

grade 3 ulcers and 1 deep tissue injuries and 3 unstageable (attributed 1 patient).

28

Dartford & Gravesham NHS Trust (cont’d)

Source: CCG PE team

29

Patient Experience

Complaints No formal complaints received during Oct/ Nov

Mystery Shopper

28 feedback forms received

75% positive / 25% negative

Positives : X-ray (QMH),

Negatives: A&E (treatment)

NHS Choices

headlines

Positive

Maple ward, Obstetrics, A&E, Rowan Ward (all excellent customer care)

Negative

General Surgery (waiting time), A&E (quality of care), discharge process (waiting time)

Patient Story

Doris explained that her husband had been referred to Dartford and Gravesham as he has

prostate cancer. Consequently, he will need to attend Maidstone hospital on a daily basis for

several weeks for treatment. Doris went on to say that they do not drive so needed to ask their

children for support, which puts a lot of pressure not only on patient but also the family.

After contacting the Patient Experience Team enquiries were undertaken with the patients’ GP –

who agreed that the 1½ hour journey each way would be stressful. Consequently, the GP

contacted the transport department at Maidstone Hospital who confirmed that the patient could

have transport to and from the hospital.

Outcome:

Transport arranged and implemented to support patient treatment/ attending healthcare

appointments out of borough.

King’s College NHS Foundation Trust

*please see text on page 31

Source: SECSU KCH Scorecards Month 7

30

Monthly Performance


RTT 18 weeks (admitted patients) * 90%

RTT 18 weeks (non admitted patients) * 95%

RTT 18 weeks (incomplete pathways) * 92%

Diagnostic tests waiting time 99% 96.8% 96.8% 98.4% 98.7% 98.8% 98.4% 98.6%

A and E waiting times 95% 87.8% 89.0% 92.9% 92.4% 93.1% 89.9% 91.7%

Cancer two weeks (monthly) 93% 97.7% 95.5% 97.7% 97.5% 97.3% 97.7% 95.2%

Breast symptoms two weeks (monthly) 93% 100.0% 98.9% 98.6% 99.0% 100.0% 98.9% 100.0%

Cancer first definitive treatment 31 days (monthly) 96% 97.9% 97.4% 99.6% 99.6% 99.5% 99.0% 100.0%

Cancer subsequent treatment 31 days, surgery (monthly) 94% 98.3% 100.0% 98.2% 98.1% 94.1% 97.0% 100.0%

Cancer subsequent treatment 31 days, drug (monthly) 98% 100.0% 100.0% 98.7% 100.0% 100.0% 100.0% 100.0%

Cancer subsequent treatment 31 days, radiotherapy (monthly) 94% -- -- -- -- -- -- --

Cancer first treatment 62 days, excludes rare cancers, GP Referral (m) 85% 86.7% 88.0% 78.9% 86.8% 91.5% 82.5% 91.0%

Cancer first treatment 62 days, Screening (monthly) 90% 95.3% 95.2% 97.3% 95.6% 90.7% 91.4% 93.9%

Cancer first treatment 62 days, Consultant upgrade (monthly) 87.5% 100.0% 95.2% 92.9% 95.0% 100.0% 100.0%

RTT 52 weeks (admitted patients) * 0

RTT 52 weeks (non admitted patients) * 0

RTT 52 weeks (incomplete pathways) * 0

Kings College NHS Foundation Trust


Patient Safety

A&E targets The A&E 4hr target for September was not met at 91.7% (target 95%) however the figures have

improved on previous month’s performance

Winter Bed Plan

Previous demand and capacity modelling has highlighted a 3% increase in emergency bed

occupancy compared to winter last year with bed occupancy running at 95%. This modelling

indicates a potential shortfall of 40-60 beds over the 5 months for November 2015 to March

2016. There are a number of initiatives have been introduced to close the bed gap.

Pressure Ulcers

There were 25 pressure sores reported on the DH site, of which 23 were grade 2 and two were

grade 3 cases - on Surgical critical care and Lister wards. The 7 cases reported at PRUH were all

grade 2 cases.

* RTT Reporting

Suspension update

Earlier in the year, the Trust agreed a 6-month RTT reporting suspension period for April –

September 2015 with NHS England, Monitor and our commissioners. The Trust’s Board has agreed

with approval from its commissioners, NHS England and Monitor for a further 6-month extension of

its reporting suspension period based on the data validation progress to-date and feedback from a

review of the governance and validation methods implemented within the Trust by the Head of

Planned Care at the Intensive Support Team. However, the Trust intends to return to national RTT

reporting of January 2016 performance in February next year.

Healthcare

Associated

Infections (HCAI)

There were 5 new c-difficile cases reported in October on the DH site only. 52 c-difficile cases have

therefore been reported to the end of October which is above the quota of 42 cases. There have

been 34 cases reported at the DH site which is above the quota of 31 cases, and 18 cases at the

PRUH which is above the quota of 11 cases. Only surgical wards have taken part in the planned

ward deep cleaning programme at PRUH due to continued pressures on beds.

31

Kings College NHS FT (cont’d)

Source: CCG PE Team

32

Patient Experience

Complaints No formal complaints received during Oct/ Nov

Mystery Shopper

134 feedback forms received regarding Kings services

83% positive / 17% negative

Positives = MSK services, (42) Ophthalmology, (49) & Dental/Maxillo Facial (10) – quality

of care

Negatives = Ophthalmology (communication & appointment delay) & Rheumatology

(MSK) delay in clinic

NHS Choices

headlines

Positive

• MSK, Ophthalmology, dermatology, ward (medical 2)

Negative

• A&E (quality of care & attitude staff), Obstetrics (appointment cancelled),

ward surgical 5 (quality of care)

Guy’s & St Thomas’ NHSFT

Source: SECSU KCH Scorecard Month 5

33

Monthly Performance

Target Apr May Jun Jul Aug

RTT 18 weeks (admitted patients) 90% 87.6% 88.1% 86.8% 85.5% 85.6%

RTT 18 weeks (non admitted patients) 95% 94.1% 94.5% 94.3% 93.8% 93.2%

RTT 18 weeks (incomplete pathways) 92% 92.8% 93.4% 93.1% 92.7% 92.2%

Diagnostic tests waiting time 99% 98.2% 98.4% 98.6% 98.7% 98.7%

A and E waiting times 95% 95.0% 95.1% 95.7% 95.6% 92.3%

Cancer two weeks (monthly) 93% 93.7% 93.1% 93.0% 94.8% 95.5%

Breast symptoms two weeks (monthly) 93% 97.7% 97.1% 95.8% 99.1% 92.3%

Cancer first definitive treatment 31 days (monthly) 96% 93.4% 94.6% 95.8% 96.1% 94.5%

Cancer subsequent treatment 31 days, surgery (monthly) 94% 89.0% 94.2% 92.0% 89.3% 93.9%

Cancer subsequent treatment 31 days, drug (monthly) 98% 100.0% 98.2% 99.4% 99.4% 99.4%

Cancer subsequent treatment 31 days, radiotherapy (monthly) 94% 96.6% 95.5% 98.4% 96.3% 95.6%

Cancer first treatment 62 days, excludes rare cancers, GP Referral (m) 85% 71.7% 67.3% 70.3% 66.8% 66.3%

Cancer first treatment 62 days, Screening (monthly) 90% 80.0% 100.0% 87.5% 100.0% 100.0%

Cancer first treatment 62 days, Consultant upgrade (monthly) 72.70% 94.7% 69.6% 75.0% 61.9%

RTT 52 weeks (admitted patients) 0 1 0 0 1 1

RTT 52 weeks (non admitted patients) 0 1 3 4 2 4

RTT 52 weeks (incomplete pathways) 0 1 1 1 2 2

Guy’s & St Thomas’ NHSFT (cont’d)


34

Patient Safety

Serious Incidents &

Never Events

10 Serious incident were reported on STEIS in Oct-Nov of those reported 4 were never events (misplaced

naso-gastric tube, retained foreign object post-procedure, wrong site surgery, wrong route administration of

medication)

There are a number of overdue SI reports and a number on extension. Action is required to finalise root cause

analysis (RCA) on these SIs. The Trust acknowledged this issue is serious and the RCA list will be cleared as

soon as possible. An ad hoc discussion outside of CQRG analysing 3 reports in detail will be carried out jointly

between CCG and Trust reps to understand why reports have not been completed. This will be fed back to a

future CQRG meeting.

Pressure ulcers

Acute incidence of Pressure Ulcers has remained below 1% for the last 5 years which is a very positive

achievement. Likewise, the performance in the community has remained stable. There is a lot of work taking

place across the Hospital to embed into practice lessons learnt, including supporting clinical teams to make

changes rapidly and ensuring the Tissue Viability Service (TVS) team has a visual presence on ward rounds.

Further work to improve staff training is underway with an online app in use to allow staff to complete training

via their smart phones. Regarding the reduction of pressure ulcers acquired outside hospital there is a major

focus on outreach, particularly using the national Zero Pressure Campaign. A remarkable achievement is the

work of the team done in Nursing Homes which includes 3 Homes which have gone pressure ulcer-free for

over 630 days, 6 for over 365 days and 4 for over 200 days.

Healthcare

Associated

Infections (HCAI)

7 cases of C.diff were reported in September and 3 in October. The Trust has not had any cases of MRSA from

Jul-Oct 15.

Maternity

C-section rates continue to increase and are outside of <27% target in M7, at 35.4%. The numbers of births per

midwife have increased from 28.94 in September to 29.31 in October. There are on-going discussion about C-

section rates at the Lambeth and Southwark Joint Maternity working group (Lambeth and Southwark CCGs,

KCHFT and GSTFT reps).

Guy’s & St Thomas’ NHSFT (cont’d)


Patient Safety

Falls

The incidence of Falls has reduced. 1500 falls have been reported Trust wide over the last year,

which is about 125 falls per month on average. The majority of falls happen in Acute Medicine

with the lowest number reported in Evelina London (25 falls per year) and on the midwifery wards

(10-15 falls). The Trust reported that a significant amount of work is taking place on the Elderly

Care unit to reduce falls that result in moderate harm or above. The next step is to prevent people

over 65yrs old who are not on the Elderly Care Unit from falling, this is taking a focus at the Trust

Falls group. Assisted technology is in use across the Trust where appropriate and there is a ‘Call

don’t fall’ approach to complement the use of technology. Local areas are being encouraged to

map and take ownership of falls management and prevention. This will take time to embed but is

seen as a positive development.

Patient Experience

Complaints 1 formal complaint has been received by the CCG regarding community cardiology services, issues relate

to delay in communication and receiving treatment

FFT

The Trust continues to meet the internal target for response rate to the in-patient FFT. There has been an

increase from 29.6% in September to 31.4% in October.

The response rate for A&E has fallen from 17.8% in September to 15.3% in October. 96% of patients would

recommend GSTT for in-patient care in M7, which is slightly higher when compared to the previous month

(95%) and this is still below internal target. There is a slight improvement in the percentage recommended

for the Trust A&E services in October (85%) compared to 84% in previous month.

The Trust is performing very well in meeting the Safeguarding targets in M7. Children Level 2 and L3

Safeguarding figures are both above 80% and Adults Safeguarding L2 training exceeds 90%.

Mystery

Shopper

3 feedback forms received regarding GSTT services

2 negative (cancer services & physio waiting time)

1 positive (cancer services – location of service)

35

Oxleas NHS Foundation Trust

Source: CCG PE Team

36

Patient Experience

Patient Story

The Patient Experience Team received a number of comments from visitors to the Queen Mary’s

site regarding availability of wheelchairs. Specifically, a number of chairs was de-commissioned

for repair, which was having an impact on patients/visitors. Staff members also reported

difficulty and how this had on occasion caused a delay to patients getting to their appointment on

time.

Action & outcome

Patient Experience team highlighted concerns at Queen Mary’s Site Services Focus Group.

Consequently, assurance given that a number of chairs had been replaced and repaired.

Subsequent visits to the site confirmed that a good supply of wheelchairs is now available for

patient/visitors to use.

Complaints/

feedback

• No formal complaints received during Oct/ Nov

• 19 Mystery shopper feedback forms received

• Positives: Meadowview ward, Diabetes and Cardiology clinic (all customer care)

• Negatives: community nursing, mental health rehab (waiting time)

• A number of additional negative comments have been received regarding the condition of

the QMH building, availability of wheelchairs and parking bays

• NHS Choices highlighted negative feedback regarding attitude of staff in children’s

audiology and attitude of staff and poor administration in mental health services (particularly

Stepping Stones)

Oxleas NHS Foundation Trust (cont’d)

37

Patient Safety

DXS Electronic

referrals from GP’s

to Oxleas

• The pilot has gone well, 23 GP surgeries/group practices attended training, which was co-

ordinated and hosted by the CCG. For the 3 GP’s surgeries/group practices who to date

have not participated in the system, contact will be made to encourage full participation. It

is planned for the system to roll out into go live at the beginning of Nov-15. Further to

clinical input an integrated meeting was held to discuss hot clinics within the context of

winter resilience planning.

Pressure ulcers

• No avoidable grade 4 pressure ulcers acquired in Oxleas care in Q2.

• Increase in reported pressure ulcers for Aug-15 compare to same time last year.

• Bromley Borough appear not be submitting pressure ulcers via Datix.

• Increase in the number of grade 2 & 3 pressure ulcers since Q1.

• There has been a slight increase in the total number of deteriorations in 15/16 compared

to 14/15 but this could be due to the way we are now asking staff to report.


Neuro Rehab

• Oxleas have appointed an MS nurse due to start this month (Nov-15). Oxleas have been

asked to provide a work plan to address waiting lists as this post has been vacant for

several months with activity data dropping to its lowest in Aug-15 to 5 patients.

Flu vaccinations • FLU Jabs are in the process of being administered by Oxleas Nursing team as per the

lists provided by GP’s for housebound patients.

Other Contracts - Care Homes


38

Subject Detail

Maples Care Home

• The operational and business manager has now been replaced, the Maples Manager and the newly

appointed clinical lead have left end of October.

• With respect to incontinence pads, Nursing Homes within Bexley are on a 12-week delivery cycle. The

issue of incontinence pads was raised by LBB on previous occasions as a topic and the CCG has

already spoken to the service provider. Nursing Homes are required to carry out their own

assessments and send through their requirements to the service provider in time for delivery. To-date,

nursing staff at Maples have not attended any assessment/service training (which is required as part of

the switch to a new product). Therefore, begs the question of how assessments are being conducted

and how orders are being processed. The service provider has also received no complaints or

feedback for their service. LBB were asked to forward a list of the homes that had a poor experience

with the service to the CCG/Service provider for follow-up and investigation. This is still outstanding.

• Both LBB and the CCG are doing unannounced visits at the Maples. So far all the quality visits have

been positive and feedback sent to CQC.

Sidcup Nursing and

Residential Care Home

• Communication much improved with the GP, have monthly clinical meeting with Dr Martin- this is

working very well to identify any clinical issues and problems in an attempt to reduce unplanned

hospital admissions. The Barnard medical group sent a letter to Bupa HQ in November to appraise the

care home for their improvement in quality of care and communication.

• When somebody has had a fall, the doctor is called first to assess whether the person requires further

treatment or can be treated at the home, but this depends on the injury.

• There has been 17 residents admitted to hospital in the last quarter, 10 of which are from Nursing due

to various clinical presentation and 7 from residential. In December there has been less people being

admitted to hospital. But usually they returned back.

• The home recently as they have successfully recruited 6 non-qualified staff and one RGN for night

duty. 3 non-qualified staff are yet to start and the RGN will start end of November.

• Recent audit in December to look at quality and care planning. No major issues found.

Other Contracts - Care Homes (cont’d)


Subject Detail

Northbourne Court

Care Home:

• Safeguarding lead has been providing support and visibility in the home and to review admissions

activity. The has been a reduction in LAS call outs and hospital admissions

• Manager has been asked to attend the QCS themes meetings monthly to discuss issues at

Northbourne court.

• Quality alerts in terms of medicine management have dropped quite considerably and

Northbourne court is getting significantly better.

Riverdale

• A few quality alerts have been made by their own team leaders. A new team leader has been

recruited and 2 to 3 of staff on duty were agency. A couple of senior staff have moved from Park

View to Riverdale so there is currently a bit of a gap.

Care plus Partnership

• Recent meeting was held in November for organisational abuse. Teleconference held on the 15th

December and follow up action plan on the 18th December at NHSE. CCG lead to conduct

another audit in January at Oakwood house.

QAMS: Quality Alerts

Monitoring System

• The following Care Homes have agreed to participate in QAMS namely Abbotsleigh,

Northbourne Court, St Aubyns, Sunrise, Marlborough, Baugh House. Bexley

Safeguarding lead has been involved in the approaches and the AD of Quality is visiting each

Care Home.

39

Other Contracts - Care Homes (cont’d)


Subject Detail

Training to Care

Homes

• A Training Plan was partially scoped out, and an interim document has been circulated to all involved.

However, all on-going work has been suspended as this has been superceded by the Care Homes

Strategy Assessment which will incorporate training. The Assessment is being led by Lindsey Couer-

Belle and Zoe Hicks-John, and is currently in draft format awaiting comments/input.

• LBB Update – There is still no response. However, this section is also incorporated into the wider

Strategy Assessment mentioned above.

Providers Managers

Forum

• Working jointly with the LA, Bexley CCG have agreed dates for a Care Homes Managers Forum, which

will be driven and facilitated by LA and CCG members. A forum was held on the 9th September 2015 at

Gallions View which was poorly attended. A Dietician attended as per the request of the LA, but care

homes did not take advantage of their expertise. Next forum is due to be held on 20th January 2016.

Joint Care Home

Meetings

• Working jointly with LA and Bexley CCG to ensure that we minimise and prevent duplication to achieve

the strategic objectives to support care homes within the borough of Bexley. Dates are already in diaries

for the year

• The QCS meetings are weekly and have themes, dom care and Residential/supported living.

40

Other Contracts

Source: CCG PE Team

41

Patient Experience

Hurley Group

• In Oct/Nov the CCG received 1 formal complaint regarding services received in UCC (Quality

of care and treatment)

• 26 mystery shopper feedback forms have been received, 81% positive all regarding

experiences within UCC at QMH site.

• Negative feedback relates to OOH services (quality of care) and EDH (quality of care)

• NHS Choices feedback highlights positive experiences at UCC (speed of service and care).

However, negative comments have been noted regarding manner and attitude of Doctor at

EDH site and poor quality of care.

Engagement Activity

Source: CCG PE Team

42

Patient Council

• The Patient Council held a meeting on the 17th November 2016

• Agenda items included ‘Our Healthier South East London’, Winter campaigns, update on developments at

the Queen Mary’s Hospital site

• Several members of the Patient Council and PPG members attended a ‘Patient and Public Voice’

workshop, provided by the CCG. The purpose of this was to strengthen understanding of NHS and

structures for involvement, sharing views in relation to service development.

• Three members of the Patient Council are now represented on the QMH site services development group

and the Chair/ PPI Lay Member is a member of the Primary Care Development Group

CCG activity

• Two formal complaints have been received regarding CCG services in relation to CHC retrospective

reviews (Continuing healthcare funding)

• The Head of Patient Experience has been working closely with the commissioning and contract team and

is supporting engagement activities with several redevelopment projects (pulmonary rehab,

anticoagulation).

• Patient representatives have also been recruited and are supported in attending contract monitoring

meetings, including MSK, Cardiology, Ophthalmology services and Physical Disability re-procurement

Engagement

• Bexley Older People’s day – 120 residents in attendance

• Commissioning Intentions event – 50+ local residents and stakeholders in attendance

• Engagement/mystery shopper stand at QMH

• Healthbus in Broadway (supported by CCG Chair). Promoting national and local campaigns

• Youth Health Ambassador (inaugural meeting of 25 young people including reps from local schools,

colleagues and Youth Council)

• Erith Town Forum

• PPG meetings (held within local GP practices)

In addition to the above the PET attended service provider AGMs, including AGE UK Bexley and Mencap.

We also interviewed services users at Mencap to capture feedback on their experiences of local health

services.

This report provides a summary of quality, safety and performance. Further information can be obtained from the Quality and Patient Experience teams.


Month 8 Finance Report

This paper is for Discussion


That the Governing Body:

1. DISCUSS & NOTE that the Month 8 (November) and forecast outturn financial position are in line with the plan submitted to NHS England;

2. NOTE the details of the 2015/16 allocations (programme and running costs) received and expenditure to date;

3. NOTE the returns made to NHS England reporting the Month 8 financial position, QIPP delivery, use of 1% transformation fund, underlying position, mental health spend, information on penalties and Continuing Healthcare Retrospective claim cases and the CCG’s risks and mitigations (Appendix 1);

4. DISCUSS & NOTE the key risks, non-recurrent support and cost pressures identified to achieving the breakeven position in 2015/16 and the management actions being taken to address and mitigate the risks where possible;

5. NOTE the potential underlying position for 2016/17; 6. NOTE the financial position for month 8 (November) for primary

medical services as provided by NHS England; 7. NOTE the month 8 actual performance against the key national

finance targets.


None.

Executive summary

A surplus of £101k was reported at month 8, which is in line with the 2015/16 plan position submitted to NHS England. The in-month position necessitated the use of some available reserves to achieve this.

ENCLOSURE: I (ii) Agenda Item: 12/16


The CCG is forecasting an outturn position of £151k surplus in line with the original plan and in agreement with NHS England, as it is accepted that the CCG is still unable to meet 1% surplus. In order to meet the planned surplus, the CCG is using nearly all of its available reserves.

Whilst the financial position is safer in 2015/16, than in recent years, it remains at risk. This risk is mitigated by the agreement of block contracts with the Guy’s and St Thomas’ and King’s and a cap and collar contract (excluding maternity) with Lewisham; leaving just Dartford & Gravesham (D&G), of the CCG’s main contracts, as a true PbR contract. In month 8, the D&G contract improved again but is still over-performing. The CCG is calling on reserves to cover some of the reported outturn position this month.

The risks identified in month 3 relating to Continuing Healthcare remain, which are in part due to the requirement for expensive care packages to meet the needs of some clients, and also due to the potential for paying for costs not previously incurred relating to Free Nursing Care Contributions at a nursing home in Greenwich. The costs relating to the Free Nursing Care element of this cost pressure are being challenged, but despite letters to Greenwich CCG a resolution is still being sought and a meeting is being arranged to discuss this issue. The other main risk is the prescribing budget. The indications on forecast outturn from the Prescription Pricing Authority (PPA) is that there will be an overspend of circa £500k at year end, which is around the same as predicted last month. Further risks are now included regarding several requests for additional funding from Lewisham & Greenwich NHS Trust.

There is a significant risk to the CCG’s 2016/17 financial position relating to the underlying position of the acute contracts where the main concerns are around King’s which requires further clarity and shows c£800k over-performance, before any adjustments for MSK drugs, which the CCG believe should be adjusted for, and Lewisham which is currently showing c£6.1m over-performance after adjustments for AQP activity, but before adjustments for challenges and penalties. Should these positions prove accurate following validation, the CCG will need to budget for these costs next year which could result in reporting a deficit position. This will be clearer following validation and after receipt of the 2016/17 planning guidance and allocations. Running costs remain within the budget which has been set £232k lower than the allocation. In month 8, the running costs are showing an underspend of £74k year to date, due partly to vacancies but also to the fact that the IT department have been successful in securing additional income. Currently, a forecast outturn position of breakeven is being predicted as finance are now predicting an underspend of £50k which

together with the IT underspend are offset by the Commissioning department’s FOT overspend of £120k.

At month 8, forecast outturn QIPP delivery has been assessed at £5.32m (87%) of the RAG rated QIPP. The overall forecast position is a net under-achievement of £(0.80)m, which results in the CCG being RAG rated Amber by NHS England for QIPP delivery. The deterioration from plan is primarily as a result of the slippage on the Children’s Services scheme and underperformance on the Prescribing, AQP and GP referral scheme, partially offset by QIPP reserves and reductions in investment.

Performance against the Better Practice Payment Code (BPPC) is continuing to perform well. This month all targets, both in month and cumulatively, were met as had been the case earlier in the year. The CCG finance team, in conjunction with CSU colleagues, are continuing to remind budget holders of the importance of correctly processing invoices via SBS in a timely manner to ensure that all targets continue to be met in future months.

Primary Medical Services results for eight months to 30th November are showing a slight overspend of £135k (0.8%) of which £248k is attributable to under-delivered QIPP offset by a slight underspend on core services and non-recurrent benefit from 2014/15 accruals. Other causes of the overspend are cost pressures emanating from QOF and discretionary payments such as locum GP cost for maternity cover. This is an improvement on the position reported last month. The forecast year end outturn variance based on month 8 is an overspend of £185k (0.7%), comprising £296k QIPP under-achievement offset by a non-recurrent 2014/15 accrual of £166k. Bexley’s weighted population has increased by 1.6% year on year from April 2014 to April 2015. There has been a growth of 0.2% (470 weighted population) year to 1st October 2015 (quarter 3). As per last month, in the Non ISFE return to NHS England, the CCG was required to complete additional pages in respect of the underlying position, actual and forecast mental health spend and information on penalties and fines. The Continuing Healthcare information on retrospective claims has also been incorporated into this return. No underlying position for acute has yet been included, as agreed with NHS England, due to the current uncertainties with that position. However, this will need to be included for month 9.


Patients: N/A People: N/A

Pounds: The CCG continues to meet all of its statutory duties in this month and is forecasting achievement for year end.

Process: The CCG has processes in place to ensure that it commissions high quality services for the residents in Bexley.


Key risks

As detailed in the report, there are a number of risks which may affect the ability to achieve breakeven. These are primarily the acute over-performance, CHC costs and prescribing overspend. However, there are mitigations in place for these items and generally the financial position is safer than in previous years. However, if the position worsens the CCG does not currently have any more reserves to cover the position as they have been utilised this month in covering the acute over performance. There is a significant risk, in respect of the underlying position, that the CCG will not achieve breakeven in 2016/17.

Equality N/A

Financial

At this point in the year, the CCG is predicting achievement of the planned surplus of £151k. However, there are a number of risks identified to achieving this position as above. In order to qualify for any quality premium the CCG will be expected to achieve its financial plan.

Data N/A

Legal issues N/A

NHS constitution N/A

Engagement N/A

Audit trail This paper has been to the Finance Sub Committee for discussion and sent to Governing Body members for information.

Comms plan None Author: Julie Witherall AD Financial Management

Clinical lead: Dr S Deshmukh GP Finance lead

Executive sponsor: Theresa Osborne Chief Financial Officer

Date 15 December 2015

1

Financial Performance Update as at Month 8 (November) 2015/16

1. FINANCIAL KEY INDICATORS 2015/2016

Table 1 below sets out the CCG’s statutory targets, and progress to date, on which it reports to NHS England; and will include in its Annual Accounts and Annual report. Table 1: Key Indicators 2015/16

Target Forecast

Outturn Var

% Var

M8 % Var

M7 Indicator M8

CCG Statutory Targets:

Achieve control total (Programme)

£151k £151k £0k 0% 0% =

Achieve Financial Balance – Revenue (Programme)

£0k £0k £0k 0% 0% =

Remain within Running costs allocation

£5,121k £4,889k £(232)k (4.53)% (5.90)%

Better Payments Practice Code (BPPC) Compliance – by count (number)

95% 97.08% 2.08% 2.05%

Better Payments Practice Code (BPPC) Compliance – by value

95% 99.71% 4.71% 4.70%

KEY: Significantly Below Target (over 3%)

Marginally Below Target (Between 1% and 3%)

On or above target or less than 1% below target

Reduction in Performance from last period

Same performance as last period = Improvement from last period

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2. HIGHLIGHTS

• A surplus of £101k was reported at month 8, which is in line with the 2015/16 plan position submitted to NHS England. The in-month position necessitated the use of some available reserves to achieve this.

• The CCG is forecasting an outturn position of £151k surplus in line with the original plan and in agreement with NHS England, as it is accepted that the CCG is still unable to meet 1% surplus. In order to meet the planned surplus, the CCG is using nearly all of its available reserves.

• Whilst the financial position is safer in 2015/16, than in recent years, it remains at risk. This risk is mitigated by the agreement of block contracts with the Guy’s and St Thomas’ and King’s and a cap and collar contract (excluding maternity) with Lewisham; leaving just Dartford & Gravesham (D&G), of the CCG’s main contracts, as a true PbR contract. In month 8, the D&G contract improved again but is still over-performing. The CCG is calling on reserves to cover some of the reported outturn position this month.

• The risks identified in month 3 relating to Continuing Healthcare remain, which are in part due to the requirement for expensive care packages to meet the needs of some clients, and also due to the potential for paying for costs not previously incurred relating to Free Nursing Care Contributions at a nursing home in Greenwich. The costs relating to the Free Nursing Care element of this cost pressure are being challenged, but despite letters to Greenwich CCG a resolution is still being sought and a meeting is being arranged to discuss this issue. The other main risk is the prescribing budget. The indications on forecast outturn from the Prescription Pricing Authority (PPA) is that there will be an overspend of circa £500k at year end, which is around the same as predicted last month. Further risks are now included regarding several requests for additional funding from Lewisham & Greenwich NHS Trust.

• There is a significant risk to the CCG’s 2016/17 financial position relating to the underlying position of the acute contracts where the main concerns are around King’s which requires further clarity and shows c£800k over-performance, before any adjustments for MSK drugs, which the CCG believe should be adjusted for, and Lewisham which is currently showing c£6.1m over-performance after adjustments for AQP activity, but before adjustments for challenges and penalties. Should these positions prove accurate following validation, the CCG will need to budget for these costs next year which could result in reporting a deficit position. This will be clearer following validation and after receipt of the 2016/17 planning guidance and allocations.

• Running costs remain within the budget which has been set £232k lower than the allocation. In month 8, the running costs are showing an underspend of £74k year to date, due partly to vacancies but also to the fact that the IT department have been successful in securing additional income. Currently, a forecast outturn position of breakeven is being predicted as finance are now predicting an underspend of £50k

3

which together with the IT underspend are offset by the Commissioning department’s FOT overspend of £120k.

• At month 8, forecast outturn QIPP delivery has been assessed at £5.32m (87%) of the RAG rated QIPP. The overall forecast position is a net under-achievement of £(0.80)m, which results in the CCG being RAG rated Amber by NHS England for QIPP delivery. The deterioration from plan is primarily as a result of the slippage on the Children’s Services scheme and underperformance on the Prescribing, AQP and GP referral scheme, partially offset by QIPP reserves and reductions in investment.

• Performance against the Better Practice Payment Code (BPPC) is continuing to perform well. This month all targets, both in month and cumulatively, were met as had been the case earlier in the year. The CCG finance team, in conjunction with CSU colleagues, are continuing to remind budget holders of the importance of correctly processing invoices via SBS in a timely manner to ensure that all targets continue to be met in future months.

• Primary Medical Services results for eight months to 30th November are showing a slight overspend of £135k (0.8%) of which £248k is attributable to under-delivered QIPP offset by a slight underspend on core services and non-recurrent benefit from 2014/15 accruals. Other causes of the overspend are cost pressures emanating from QOF and discretionary payments such as locum GP cost for maternity cover. This is an improvement on the position reported last month. The forecast year end outturn variance based on month 8 is an overspend of £185k (0.7%), comprising £296k QIPP under-achievement offset by a non-recurrent 2014/15 accrual of £166k. Bexley’s weighted population has increased by 1.6% year on year from April 2014 to April 2015. There has been a growth of 0.2% (470 weighted population) year to 1st October 2015 (quarter 3).

• As per last month, in the Non ISFE return to NHS England, the CCG was required to

complete additional pages in respect of the underlying position, actual and forecast mental health spend and information on penalties and fines. The Continuing Healthcare information on retrospective claims has also been incorporated into this return. No underlying position for acute has yet been included, as agreed with NHS England, due to the current uncertainties with that position. However, this will need to be included for month 9.

4

3. BUDGETS A summary of the 2015/16 budgets showing the approved opening budgets and any movements between the month 7 reported position and the month 8 position are shown in table 2 below. The month 8 budgets, shown, equal the expected allocation shown further on in the report, except for a small rounding error of £207. The resources shown are net of miscellaneous income that the CCG receives for the goods/services it provides to other organisations. The total allocations reflect the resource limit that the CCG receives from NHS England. During the month, the main adjustments have been to adjust for mental health investments in line with the 5 year forward view, identify some QIPP in Learning Disability Services which can be reinvested, adjust the Hospice contract for additional beds and to further increase winter pressure funding from reserves in order to re-open Foxbury Ward at Queen Mary’s Hospital. Table 2: 2015/16 Budget Summary

Note: Budget changes are only shown where there is a change between directorates.

5

4. CCG ALLOCATIONS / REVENUE RESOURCE LIMIT (RRL)

In month 8, the CCG was not notified of any changes to its 2015/16 allocation and none were expected. The guidance states that allocations should not be anticipated and so no anticipated items are shown in the table below. The final allocation / RRL is the figure that the CCG’s net spend will be measured against when reviewing its achievement of financial balance for the year. The current allocations are shown in table 3 below. Table 3: Month 8 (November) CCG Allocation

Month Description AllocationInitial Initial Allocations (259,166,030)Initial 15/16 growth (12,975,970)Initial Running Cost Allowance (5,121,000)Initial Better Care Fund (4,255,000)

Initial Allocations (281,518,000)Month 1 Brought forward surplus (151,000)Month 1 2014/15 recurrent transfers post allocation setting (879,000)

Month 1 Allocation (282,548,000)Month 2 ETO/DTR Funding (590,901)

Month 2 Allocation (283,138,901)Month 3 GP IT (595,000)

Drugs Expenditure for DVH (529,000)Sickle Cell (76,000)Specialist Childrens Services - clinical systems (372,000)MFF adjustment - SE London agreement (2,500,000)London Transformation Fund 0.15% 408,000Month 3 allocation (286,802,901)

Month 4 IAPT waiting list validation (8,000)Month 4 allocation (286,810,901)

Month 5Initial allocation of funding for eating disorders and planning in 2015/16 (126,000)Month 5 allocation (286,936,901)

Month 6 Month 6 allocation (286,936,901)Month 7 Tier 3 Neurology Commissioning Responsibility transfer (120,000)

Liaison Psychiatry (50,000)111 Pharmacy Hub 8,000SRG Winter Monies 319,000Month 7 allocation (286,779,901)

Month 8 Month 8 allocation (286,779,901) The final programme allocation cannot be used to fund any overspend on running costs. However, any underspend on the running cost allowance may be used to fund the programme costs of the CCG.

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5. CAPITAL RESOURCE LIMIT (CRL)

Within the 2015/16 financial planning return, a capital plan was submitted as replicated in table 4. Table 4: Planned Capital Expenditure NHS Bexley CCG 07N Contents

Planned Capital Expenditure (Please describe the Scheme)

BLANK1 Business Case Submitted

(Y/N)

2015/16

Value £'000s

Capital Grants IT hardware replacement - primary care Y 250 P/care pooled Ipads for improved access Y 15 IT hardware replacement – CCG Y 75 Mobile devices replacement programme – CCG Y 26 TOTAL 366

The CCG submitted Project Initiation Documents (PIDs) to NHS England in support of the bids in the table above some months ago. Further to this submission, in May 2015, the CCG was asked to re-submit primary care bids for lower values. The CCG has now been informed that these lower Primary Care bids have been taken through the appropriate processes within NHS England and have been approved. The CCG has now gone ahead and ordered primary care capital to the value of £192k and will be recharging these costs to NHS England per their instructions. Unfortunately this amount will be insufficient to carry out the entire programme. Despite trying to obtain a supplementary amount, it now appears that this will not be forthcoming. In respect of the CCG capital bids, the CCG has been advised that these requests have been successful and a capital allocation of £101k has been received. The IT team have now ordered the required equipment and are deploying the equipment within the CCG.

7

6. 2015/16 MONTH 8 (NOVEMBER) FINANCIAL POSITION Table 5 summarises the financial position, at category of care level, for the CCG at Month 8 (November). The financial position is then also reported at a cost centre level for information. The national ISFE / SBS system has an extremely limited coding hierarchy and the CCG has to work within the nationally set parameters. Additional levels of information can be provided off line if required. Table 5.1: Summary financial position by category of care – November 2015

Table 5.2: Summary financial position by cost centre – November 2015

10

At the end of month 8, the CCG is reporting a surplus of £101k YTD which is in line with the financial plan submitted to NHS England. The CCG remains on target to achieve the forecast surplus of £151k by year end. It was agreed with NHS England, as part of the planning process, that the CCG will not be required to make the expected 1% surplus in 2015/16.

To meet the planned surplus position, it has been necessary to draw down on reserves. Programme projects’ costs of £2,524k have been incurred to date, which is £439k more than the month 8 plan. This includes the cost of project managers and additional staff supporting the delivery of the QIPP schemes and SE London PMO, which is funded by the use of the 1% transformation fund and therefore not formally budgeted. Monitoring and reporting on QIPP schemes for 2015/16 continues to ensure that targets are achieved to support the overall financial position. QIPP scheme delivery is currently running below target as detailed in the QIPP report.

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7. SUMMARY OF MAIN VARIANCES Mental Health YTD Variance £50k, FOT £227k The South London & Maudsley (SLAM) SLA continues to overspend at month 8 with a predicted year end position of £167k overspend, which is due to a high demand for specialist out-patient mental health services. Work continues to try and bring the contract back in balance before the year end. Learning Disabilities continues to underspend at month 8 by £(95)k, and is due to the commercial sector placements; it is expected to breakeven at year end. The overspend on the Aspergers budget in Mental Health Other has decreased slightly in month 8 to £39k. The overspend is due to higher than anticipated activity. Work continues by the budget holder to negotiate the costs whilst maintaining the services. Acute YTD Variance £1,119k, FOT £1,663k The table below shows the reported variances against acute contracts, based on contract type and activity. An additional column is included to show the current reported underlying financial position, being the actual cost of activity with the contractual financial parameters and challenges removed (where known). Table 1: Acute contracts and unplanned care expenditure variances Trust YTD

variance (£k)

FOT variance

(£k)

Comments Underlying position

(£k)


(890) (1,335) The FOT variance recognises that the cap value of £980k is likely to be required to be paid at the year end, in addition to non-capped maternity overperformance. Work continues on validating the current year’s and underlying position.

(6,091)

Kings College Hospital NHS Foundation Trust

0 0 King’s is paid under a block contract arrangement so there are no variances to report. The underlying position has shown a significant swing in the CCG’s favour this month overall but with noticeable variances on elective (+£704k), emergency (-£626k), other (+£550k) and outpatients (-£337k).

(21)

12


(21) (170) A low level of reported activity in month 7 has meant that Dartford & Gravesham are showing a favourable reduction of £337k in the FOT variance this month to £(170)k. Within this, POD variances to note are emergency (+£1,342k), other (-£957k), A&E (+£305k), elective (-£291k) and outpatients (-£478k).

(170)

Guys and St Thomas’s NHS Foundation Trust

0 0 This is a block contract and so there are no variances to report in actuals and FOT.

The most significant variances in the underlying position are reported in elective (+£422k), emergency (+£167k), outpatients (-£164k), drugs and devices (-£229k), critical care (-£173k), and other (+£389k).

227

Non local acute trusts

(58) (43) Providers who are anticipating variances in value on FOT in excess of £100k are Barts (+£174k), Moorfields (-£217k). In terms of percentage variance, London NW Hospitals is reporting a FOT that is 35% over budget, Imperial +33%, and BMI and St George’s 29% lower than budget, although the values of these variances is less significant.

(43)

NCAs (252) (319) FOT on NCAs is showing a 13% increase on budget; there are no specific concerns at present in this area.

(319)

TOTAL (1,221) (1,867) (6,417)

The FOT position of £1,335k for Lewisham and Greenwich recognises that the Trust has advised that they will require to be funded to the upper limit of their cap and collar agreement. It also recognises that there is overperformance in the maternity pathway which is outside of

13

the cap and collar agreement. Further work is being carried out on the LGT position to firstly confirm the cause of the maternity increase, given that the CCG has not seen a corresponding reduction in maternity services from other Trusts, and to obtain assurance around Cerner activity reporting and how patients that are transferred from the Emergency Department to the CDU are recorded. Work also continues on challenges and claims. Given the low level of activity reported by Dartford & Gravesham in month 7, assurance is being sought that all data has been recorded and there will be no adverse movement in month 8 and beyond. Discussions are also underway with King’s to confirm that the position does not include any AQP work, and that MSK drugs costs are excluded from their SLAM data. Other acute contracts are reporting a YTD position which is within 1% of budget so there are no major concerns in this area. Prime contractor activity for the MSK and cardiology services is also included in Acute; these services are charged under a block contract arrangement and therefore in line with budget expectations. The issue reported in month 7 around an invoice received from King’s for ophthalmology work is ongoing as the budget and costs remain within the current block contract. Overall, planned care is reporting an overspend of £51k, principally relating to the increased costs of Mildmay Hospital, which is under investigation, as this is also a block contract in 2015/16. Maternity costs are also included under acute, reporting a small variance of £(38)k YTD, which has also been reflected in the FOT. The remaining differences are on GUM income. Additional information on the performance of the acute providers can be found in the Integrated Contracts Report presented by the Commissioning team. Primary Care YTD Variance £380k - FOT £825k Prescribing spend is informed from data provided by the Prescription Pricing Authority (PPA). The data provided is two months in arrears, due to the time required for its processing, therefore an extrapolation of trend is used to ensure an indication of YTD costs is reflected in the month end position. In addition, the percentage of any reimbursement due to a locality who achieves an underspend against budget is booked, as well as an amount for primary care investment. This is currently due to one of the CCG’s three localities. Consequently, YTD actuals are reporting an adverse variance of £463k, with FOT showing a £825k overspend against budget. South East London 111 service costs are £(71)k under budget YTD; this has been informed by service provider data forwarded from NHS Bromley as the lead commissioner. Costs include CSU charges for provision of a 111 service clinical lead. Current service provider data suggests a benefit of about £120k against budget may be achievable this year. However to date we have consistently recognised no FOT change given the variable nature of activity for this service. This will be reviewed in month 9. Continuing Healthcare (CHC) YTD Variance £719k - FOT £1,400k The Adult placements continue to overspend at month 8 by £411k, with a predicted year end position of £800k overspend. The position is based on the detailed activity database provided

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by the Continuing Healthcare (CHC) Team. The CHC Learning Disability cost centre is showing an underspend of £(165)k due to lower than anticipated activity, but this is expected to breakeven at year end. Funded Nursing Care (FNC) is £469k overspent with a year-end FOT overspend variance of £600k predicted as an extrapolation of the current variance. The Continuing Healthcare nurses continue to review patients during their stays within CHC in line with the strict eligibility criteria, but the demand for CHC generally remains high and the CCG must remain reactive to the activity as it arises. Retrospective Review claims are continuing to be assessed and paid where eligibility is proven. NHSE requires completion of 5 reviews per month and the CHC team are using in-house and external resources to meet this target. A risk pool is being maintained by NHSE to settle future claims. The CCG’s contribution in 2015/6 has been set by NHSE at £1,727k with the full impact of this being reflected in the YTD financial results. NHSE has recently completed an analysis which indicates that the risk pool will underspend in the current year. However it is intending to use this underspend to support the financial challenge across the NHS rather than return the relevant proportions to contributing organisations. The CCG will however benefit from making a reduced contribution in 2016/17, which will be reflected in our planning. Community Health YTD Variance £(86)k - FOT £(70)k Community services is underspent at month 8 by £(139)k which is due to income from Oxleas in respect of the Joint Equipment Stores. This offsets the overspend on anti-coagulation services. Intermediate care continues to overspend by £23k due to Plaster of Paris cases. The £30k overspend on wheelchair services reflects the issue that has been reported throughout the year around non-accrual of a prior year invoice which will have to be managed within the current year. Other YTD Variance £(2,108)k - FOT £(4,045)k The planned month 8 position has been achieved through a draw down on reserves, utilising the maximum available from the non-recurrent reserve budget, with the remainder booked against the commissioning reserve. Furthermore, a significant proportion of available reserves have been used to achieve the FOT position of £151k surplus. Programme projects’ costs, which are covered by the 1% transformation fund, is currently £439k overspent. It includes costs for GP incentive schemes, contractor services in support of the South East London PMO, ongoing service redesign work, and local primary care innovation and federated working projects. The CCG contribution of £6m towards the Better Care Fund, jointly managed with the London Borough of Bexley (LBB), is currently showing a £148k underspend as the performance payment for quarter 4 of 2014/15 has been agreed by all parties as non payable and therefore this underspend is required to offset overspends in the acute budget. Due to information issues with Lewisham and Greenwich NHS Trust, the data for quarters 1 and 2 of 2015/16 are just being validated for the quarter 2 return and must be agreed with LBB prior to submission, which was after the month end. However, the initial view is that the performance payment for these quarters will also not be payable resulting in an increased FOT of £567k underspend.

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Corporate YTD Variance £(74)k - FOT £0k Corporate departments overall are reporting an underspend at month 8 of £(74)k. The main contributors to this variance are above target income generation by the IT team together with lower than forecast depreciation charges and staff vacancies in Finance, offset by additional agency costs within Commissioning. FOT has been adjusted for these three items, which overall nets to zero. Continuing Care Unassessed Periods of Care Claims In the books of Bexley Care Trust, a provision was made for c£7m for the impact of the c300 claims in respect of continuing healthcare. It remains important for the CCG to monitor progress against these, as CCGs now need to pay for these from current allocations. For 2015/16 Bexley CCG has been required to contribute £1,727k to a risk pool to cover the outstanding claims. This is being funded from the 1% non-recurrent transformation reserve. The calculation of the 2015/16 contribution was based on the value of provisions as at 31st March 2014, rather than March 2015, where numbers had been revised significantly downwards. This methodology was challenged with NHS England, but no changes were made to the value of the contribution. Returns to support the revised numbers are provided on a monthly basis to NHS England. A recent letter has been received from NHSE stating that no refund will now be received in 2015/16 against the pooled contribution. Instead the predicted underspend will be carried forward to reduce CCG contributions in 2016/17. The full letter was attached to the finance report last month. Updates are provided on a regular basis by the CHC team and the best, worst and most likely cases for the various categories of care are calculated. As knowledge becomes better on the remaining cases, the CCG can more accurately predict the provision. Claims are now being approved for settlement, with £827k approved for payment as at 30/11/2015. Any expenditure incurred by the CCG in 2015/16 will be repaid by NHS England from the national risk pool. Latest calculations based on the information available as at 30/11/2015 shows that the most likely impact of the claims received is now £2,155k, which is very slightly lower than the provision advised to NHSE at the end of the year and in the reported position at the end of month 7. From last month the CHC return has been incorporated into the non ISFE return which requires the approval of the Director of Commissioning and is appended to this report (Appendix 1). Excluded from this value is the £827k of settled claims; others are awaiting payment or calculation at this time. The worst case position remains substantially higher than the provision. In order to arrive at the potential liability figures, percentages have been assigned to the likelihood of the claims coming to fruition. This includes provision for a percentage of the claims going to the ombudsman in case a decision is made against the organisation. The other variable in the calculation is the number of weeks that it is expected would be paid. For many cases this is not known; an average of the number of weeks, where this is known, has therefore been used in these cases.

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Guidance received prohibits the cost of administration to settle the claims being paid from the provision. For cases which were received for subsequent periods i.e. for periods of care from 1st April 2012, the CCG included the values as either a provision or contingent liability in the 2014/15 year end Accounts. The CCG will assess any further claims received on an individual basis and include in the accounts as appropriate. An updated position will be reported at month 9 in the draft accounts, which will be submitted to NHS England. It is not thought that the value of these items will be material.

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8. RUNNING COSTS (CORPORATE) Within the ledger, there are a number of cost centres which are mapped as administration, where running costs must be coded. The running costs allocation for 2015/16 is £5,121k, with a forecast outturn of £4,819k, giving rise to a £232k underspend. The ledger shows an underspend of £74k, against the budgeted figure, in this area for month 8. There has been a small movement in the predicted FOT from the reported month 7 position, with Finance predicting an underspend of £50k at the year end, IT maintaining its £70k underspend and Commissioning expecting a FOT of £120k overspend, giving breakeven overall. In order to arrive at the 2015/16 budget and expenditure figures the CCG has ensured the following steps have been taken:

• The application of the running cost guidance which has been formulated by London CFOs; and agreed with the NHS England London Director of Finance. This guidance gives standard definitions for running costs expenditure to be applied across London. This has resulted in some staff being split coded between running costs and programme costs in consideration of the roles undertaken.

• The expenditure on running costs is under constant review and monitoring to ensure that it is kept to a minimum.

• An analysis of rental costs has been undertaken to ensure appropriate allocation

between programme costs and running costs.

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9. RISKS

Table 7: Risks as at month 8

Table 7 shows the risks to the CCG at month 8. It shows the likely position, which matches the actual reported position, the best case and worst case (based on the information available if all of the potential risks come to fruition); and how the risks can be mitigated within the current resources available to the CCG. At the time of preparation, the range of forecast outturn was between a £(2.3)m deficit, should all risks occur, and £2.4m surplus, if

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the position improves. The largest risk to the CCG’s financial position during the year will be the acute activity, although much of the risk has already been mitigated by the fact that there is a cap and collar agreement in place with LGT and block contracts with King’s and GSTT, leaving just Dartford and Gravesham and the externals as true PbR contracts. The acute risk shown in the table above assumes that the LGT cap value is required to be paid and there is maternity overperformance which is outside of the agreement. It also assumes that the external and Dartford & Gravesham contracts continue to over-perform, although there has been some improvement again this month. The AQP issue at Dartford has been resolved and the Trust has invoiced the CCG separately for that work. The LGT reconciliation for quarter 1 has not yet been finalised but there is ongoing dialogue to ensure this is completed as soon as possible. The worst case risk has been increased in month 8 as a result of a number of additional funding requests from LGT for a number of items including RTT and winter resilience. Another risk identified is that despite changing the budget setting methodology in 2015/16, to issue a more realistic budget, and also the implementation of delegated prescribing by localities, the prescribing budget will see an overspend in year. Since last month, there has been little movement in the forecast information from the Prescription Pricing Authority (PPA) but there remains a predicted overspend of circa £500k. In addition, one of the localities is recording an underspend position and therefore, as agreed in the delegated prescribing agreement, payment would need to be made to those practices. The cost of QIPP implementation (SE London PMO and agency staff within the CCG) is being met from the 1% transformation fund in 2015/16. Costs must be contained within this envelope otherwise there will be a cost pressure for the organisation. The risk identified in month 3 relating to Continuing Healthcare still remains unresolved and letters has now been sent to the Commissioning Department as well as the Chief Financial Officer at Greenwich CCG. The issue relates to an invoice for circa £980k in respect of Free Nursing Care Contributions for two nursing homes, one of which the CCG has never been invoiced for previously. A meeting will now be held to try and resolve the issues. The other pressure on the CHC budget is an increase in the number of patients having to be found expensive care packages in order to meet their needs. These risks will be continually reviewed and adjusted, and the impact on the financial position monitored as they crystallise or circumstances become clearer. The most likely case is as shown in the reported forecast outturn income & expenditure position. The non ISFE risk return for month 8 (Appendix 1) has been populated based on the difference between the likely case and the worst case scenarios, with assumptions made around the probability of each event actually occurring. The underlying acute position has not yet been reported to NHSE, as agreed, due to the uncertainties around the value. However, when validated this could result in significant cost pressures for 2016/17, which could result in the reporting of an underlying deficit position. This will become clearer after validation and after receipt of 2016/17 planning guidance and allocations.

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10. 2015/16 QIPP / SAVINGS PLANS

Following RAG rating of the gross QIPP of £7.4m, identified for 2015/16, net QIPP of £6.3m was included in financial plans to achieve targets & assumptions in line with national guidance. A multi-disciplinary/agency panel subsequently met to independently RAG rate the schemes and confirmed the final value of £6.4m. Regular meetings are held within the CCG to review and agree project RAG ratings and assess the financial delivery. This includes monthly meetings held with Project Managers that inform the completion of the QIPP implementation and monitoring forms. Those schemes RAG rated red in the monthly assessment are presented to the Finance Sub-committee, in the monthly QIPP report. At month 8, forecast outturn QIPP delivery has been assessed at £5.32m (87%) of the RAG rated QIPP. The overall forecast position is a net under-achievement of £(0.80)m, which results in the CCG being RAG rated Amber by NHS England for QIPP delivery. Performance is reviewed every month in consideration of the latest intelligence on each scheme. The deterioration from plan is primarily as a result of the slippage on the Children’s Services scheme and underperformance on the Prescribing, AQP and GP referral scheme, partially offset by QIPP reserves and reductions in investment. Work continues on developing the GP referral scheme to ascertain the value of QIPP in 2015/16. The CCG continues to work with the CSU to accurately report acute QIPP schemes. QIPP information is provided to NHS England (NHSE) in the Non-ISFE return (Appendix 1). The return is split between transactional and transformational QIPP and by Acute, Mental Health, Community, Continuing Care, Primary Care, Other Programme services and Running costs. The recurrent / non-recurrent split across the categories is also shown. Health economy wide QIPP, in the form of efficiencies built into contracts, is also included within the dashboard.

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Table 8: Summary of 2015/16 QIPP schemes

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11. FINANCIAL MANAGEMENT

Better Payment Practice Code (BPPC)

Target One of the CCG’s financial targets is to ensure that at least 95% of NHS and non-NHS trade creditors are paid within 30 days of receipt of the invoice. Performance against this target is regularly reported to the local NHSE performance team, and the annual cumulative figure for the year is published in the Annual Accounts and Annual Report.

Table 9: Better Practice Payment Code (BPPC) performance

At month 8, all of the in-month targets have been met with only very minor movements in both the in-month and cumulative positions and no exceptional items to note. Generally, the CCG is consistently meeting the requirements of this target. The concern with respect to the target remains that NHS England takes their measurement straight from the ledger without making any technical adjustments, and this is known to be an inaccurate measure of performance. As this is one of the measurable targets for the CCG, it is important to ensure that these targets are continually met. Budget holders are constantly being asked to approve invoices in a timely manner or, if there is a problem, to place the invoice on hold until they have resolved the issue; this ensures that these invoices are removed from the calculation. These measures should help speed up the approval process and maintain the BPPC performance during the year.

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Cash Management

Cash Limit The CCG will not be receiving a formal cash limit again in 2015/16. Instead the organisation will be advised of a maximum cash drawdown (MCD) value to work within. At month 8, the CCG has been advised that its MCD is £286,032k and is reflected in the cash reporting process (see table 10). The MCD value is expected to be the figure prior to the topslice for prescribing spend. It is understood that as long as this value is not breached then the CCG will have met its duty in relation to cash. Table 10: Maximum Cash Drawdown

Cash Resource Limit 2015/16 Plan

Cash Report Sept 15 '£000

Cash Report Oct 15 '£000

Cash Report Nov 15 '£000

CCG cash requirement 281,505 286,347 286,190 286,032

LessPrescription Pricing Authority 31,907 31,907 31,907 31,907Other Central / BSA payments 156 156 156 156

Remaining Cash limit 249,442 254,284 254,127 253,969

Cash Drawings Table 11 shows the year to date cash drawings to Month 8 compared to the planned drawings for the same period based on the latest FIMS plan. The cash plan uses the maximum drawdown value, as advised above, (after the estimated adjustments for prescribing spend) as a proxy for the cash limit, and once completed will show the requirement does not exceed this value. At this point in the year, the CCG has drawn down very slightly more cash than planned (67.4% compared to 66.7%) in order to pay year end creditors and also to pay the initial payment to LBB in respect of the Better Care Fund (BCF). After reviewing guidance it is clear that the BCF should not have been paid at the start of the year and from 2016/17 will be paid monthly.

Table 11: Planned and actual cash drawings

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The cash balance at the end of month 8 was £182k. Month end cash is now measured against the NHSE guidance stating that it should be 1.25% or less of cash drawn down in the month. The revised guidance on cash management, received from NHSE, includes the requirement to calculate notional charges against differences in the drawdowns and values of payment runs, in order to show how the Department of Health are being charged by the Treasury for poor cashflow forecasting. The CCG receives weekly cash forecasting information which is being used to help the Chief Financial Officer and finance team ensure good cash flow during the month and to reduce the cash balance before month end. It is hoped that the cash target will be met for the remainder of the year. It has been agreed between the CSU and the CCG finance teams that additional information on payment runs and invoices which are approved ready for payment will be provided to the CCG team each week to further assist with cash flow issues. Debtors and Income Collection

Table 12: Aged Debtors Position

The level of aged debtors has decreased again this month which is positive. However, the value of debtors over 3 months old has again increased slightly this month, which is linked to the receipting issue for the London Borough of Bexley. There are 60 transactions making up the aged debt balance. The highest level of debt is with LBB and currently stands at £264k, of which £160k is over 60 days old. As previously reported, there has been some incorrect receipting applied to the LBB account which SBS and the CSU ARC team have been working with LBB to resolve and it is almost finalised. Once LBB has agreed with the revised allocation of cash, the CCG will be able to follow up on individual invoices for payment. Other debts over 60 days old with a large value are Physiological Measurements who have an outstanding debt of £18k, which is actively being followed up, as are the debts with The Hurley Group which total £17k. All other items over 60 days are less than £10k. The local CCG team are continuing to work with CSU colleagues to try to resolve any outstanding issues and ensure these items are paid as quickly as possible.

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Statement of Financial Position (Balance Sheet) The Statement of Financial Position is presented in table 13 in order to comply with good practice reporting. The CCG has a negative Balance Sheet as it has very few fixed assets, cash or debtors, but a high level of creditors at any time. It is unusual for an organisation to have a negative balance sheet, but most CCGs are in this position due to the nature of their business and the inability to hold many fixed assets. The Statement of Financial Position shown in this report is generated by Business Intelligence from the SBS ledger. Table 13: Statement of Financial Position

2015ADJ-15 Oct-15 Nov-15

Property, Plant And Equipment 261,126.41 270,229.33 282,845.10Non-current Assets Total 261,126.41 270,229.33 282,845.10Current Trade And Other Receivables 2,419,012.94 2,955,748.36 4,390,975.55Cash And Cash Equivalents 62,457.07 (67.21) 181,892.71Current Assets Total 2,481,470.01 2,955,681.15 4,572,868.26Current Trade And Other Payables (28,070,826.22) (26,189,036.07) (30,816,599.72)Current Other Liabilities (44,954.19) (987,430.76) (82,041.31)Provisions (108,000.00) (108,000.00) (108,000.00)Current Liabilities Total (28,223,780.41) (27,284,466.83) (31,006,641.03)NC Provisions 0.00Non-Current Liabilities: Total 0.00Grand Total (25,481,183.99) (24,058,556.35) (26,150,927.67)

2015ADJ-15 Oct-15 Nov-15

General Fund 25,481,183.99 24,058,556.35 26,150,927.67Financed by Taxpayers Equity: Total 25,481,183.99 24,058,556.35 26,150,927.67Grand Total 25,481,183.99 24,058,556.35 26,150,927.67

2016

2016

Closing Balance

Closing Balance

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12. PRIMARY CARE MEDICAL SERVICES FINANCIAL REPORT From 01/04/2015, the CCG has Level 2 delegated responsibility for co-commissioning. As part of this arrangement, the CCG receives budget reports for primary medical services in order to monitor the budgets, expenditure and QIPP with a view to potentially taking Level 3 responsibility in the future. Level 2 responsibility means that the primary medical services budgets remain with NHS England and the CCG are not exposed to any risk with regards to overspends and non-delivery of QIPP. However, NHSE have recently identified a large shortfall on QIPP across London and are now asking CCGs to jointly look at what can be done to close the gap (see further details below). The CCG are also part of the decision making process by virtue of governance arrangements which have been put in place. If the CCG were to take on Level 3 responsibility, then it would receive the allocation for these services, have these items recorded on the CCG’s financial reporting systems and have the entire risk associated with overspends and non-delivery of QIPP. At this stage, Bexley CCG has not signaled that it would like to move to level 3 for 2016/17. The total planned QIPP for Primary Care across the London Region is £12.7m of which £3.27m relates to South East London. There is now recognition that there will be a shortfall in this QIPP savings target after risk rating of all schemes. Following the national direction that all PMS premium savings must be re-invested within Primary Care within the same CCG area, the plans for cash-releasing QIPP are being re-visited. A review of the schemes that other NHS England regions have developed across Primary Care has been carried out and this identified very limited opportunities. The region will therefore be reliant on some of the national schemes to support QIPP delivery and this represents a significant risk to the financial position. At present at regional level, c£3m of the target £12.7m Medical services QIPP is supported by schemes. The region will be seeking further mitigations and non-recurrent measures to address the 2015/16 shortfall. NHS England has now received a report from the company commissioned to review QIPP. CCGs are awaiting further information. The Primary Care Technical Working Group will also discuss QIPP for 2016/17 onwards. The QIPP requirement in 2016/17 is likely be in the region of 0.5-1% given London’s capitation position. Following a review of the 2014/15 actual outturn to date, £1.2m (full year effect) of accruals have been identified for release to support the QIPP shortfall. Settlement of all of the prior year liabilities remains outstanding, in particular premises reimbursement for CHP & NHSPS landlords. Work is continuing to finalise all these areas as the validated information becomes available. As part of the Level 2 responsibilities, the CCG now receives budgetary information from NHS England which will form part of this finance report, to ensure that the Governing Body is aware of the information. Details received from NHS England in respect of the month 8 position is summarised below:

• The overall financial position for Bexley primary medical services shows a slight year to date overspend of £135k (0.8%) largely due to under achievement of QIPP

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savings to date offset by a slight underspend on core services and non-recurrent benefit from 2014/15 unused accruals. Other causes of the overspend are cost pressures emanating from QOF and discretionary payments such as locum GP cost for maternity cover.

• The forecast year end outturn variance based on month 8 is now an overspend of £185k (0.7%) comprising £296k QIPP under-achievement offset by an underspend on core services (£96k) and a non-recurrent £166k prior year accruals.

• Bexley’s weighted population has increased by 1.6% year on year from April 2014 to April 2015. There has been a growth of 0.2% (470 weighted population) year to 1st October 2015 (quarter 3).

Table 14 shows the financial position of primary medical services for Bexley CCG as at the end of June 2015.

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Table 14: Primary Medical Services Financial Position as at Month 8

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13. RECOMMENDATIONS

Members are asked to:

• DISCUSS & NOTE the Month 8 (November) and forecast outturn financial position are in line with the plan submitted to NHS England;

• NOTE the details of the 2015/16 allocations (programme and running costs) received and expenditure to date;

• NOTE the returns made to NHS England reporting the Month 8 financial position, QIPP delivery, use of 1% transformation fund, underlying position, mental health spend, information on penalties and Continuing Healthcare Retrospective claim cases plus the CCG’s risks and mitigations (Appendix 1);

• DISCUSS & NOTE the key risks, non-recurrent support and cost pressures identified to achieving the breakeven position in 2015/16 and the management actions being taken to address and mitigate these additional potential risks where possible;

• NOTE the potential underlying position for 2016/17;

• NOTE the financial position for month 8 (November) for primary medical services as provided by NHS England;

• NOTE the month 8 actual performance against the key national finance targets.

Appendix 1

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Month 8 Financial Position

Month 8 Running Costs

Appendix 1

31

Month 8 Activity

Appendix 1

32

Appendix 1

33

Month 8 Non ISFE Reporting

Non ISFE Reporting M08 2015-16_M08_N

Clinical Commissioning GroupNHS Bexley CCG 07N

Regional GeographyLondon Q71

RegionLondon Y56

MonthNov-15 08

Completed By:Julie Witherall

Email:[email protected]

Contact Number:0208 298 6252

Authorised By:

Theresa OsborneAuthoriser's Title:Chief FinancIal Officer

Appendix 1

34

Appendix 1

35

Month 8 Commentary

Appendix 1

36

Appendix 1

37

Appendix 1

38

Appendix 1

39

Appendix 1

40

Appendix 1

41

Appendix 1

42

Appendix 1

43

Appendix 2

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GLOSSARY OF TERMS BPPC BETTER PAYMENT PRACTICE CODE CAMHS CHILDREN’S AND ADOLESCENTS

MENTAL HEALTH SERVICES CCG CLINICAL COMMISSIONING GROUP CHC CONTINUING HEALTHCARE CIP COST IMPROVEMENT PROGRAMME CRL CAPITAL RESOURCE LIMIT CSU COMMISSIONING SUPPORT UNIT DES DIRECTLY ENHANCED SCHEME DVH DARENT VALLEY HOSPITAL FIMs FINANCIAL INFORMATION MONITORING

RETURNS FOT FORECAST OUTTURN GSTT GUY’S & ST THOMAS’ NHS FOUNDATION

TRUST HRG HEALTH RESOURCE GROUP ISFE INTEGRATED SINGLE FINANCIAL

ENVIRONMENT LA LOCAL AUTHORITY LBB LONDON BOROUGH OF BEXLEY LES LOCAL ENHANCED SCHEME LIS LOCAL INCENTIVE SCHEME LHNT LEWISHAM HOSPITAL NHS TRUST KCH KING’S COLLEGE HOSPITAL NHS

FOUNDATION TRUST KPI KEY PERFORMANCE INDICATOR MDT MULTI DISCIPLINARY TEAM NHSE NHS ENGLAND PMO PROGRAMME MANAGEMENT OFFICE PPA PRESCRIPTION PRICING AUTHORITY QIPP QUALITY, INNOVATION, PRODUCTIVITY

& PREVENTION QOF QUALITY OUTCOME FRAMEWORK RRL REVENUE RESOURCE LIMIT RTT REFER TO TREATMENT SBS SHARED BUSINESS SYSTEMS SLA SERVICE LEVEL AGREEMENT SLHT SOUTH LONDON HEALTHCARE NHS

TRUST UHL UNIVERSITY HOSPITAL LEWISHAM TSA TRUST SPECIAL ADMINISTRATOR YTD YEAR TO DATE


Consolidated Contracts Report – Month 7 and 8

This paper is for Information


That the Governing Body: NOTE the performance of the Acute, Community & Mental Health contracts shown in the attached.


GPs may be conflicted if providing anti coagulation services.

Executive summary

Headlines • As part of our Winter Pressures scheme funding the Consultant Led,

MDT supported “Hot Clinics” are now operational at QMH. • A Comprehensive Continence Service Review has been undertaken by

the Contracting team and the CCG is assured around the introduction and quality of products supplied. Comprehensive training has been provided to care homes. Administrative processes within the CCG have been streamlined to ensure correct point of delivery to Oxleas and this initiative has demonstrated improved quality outcomes at initial review.

• A 24 hour District Nursing service commenced during November within the Oxleas Adult Community services. The planned review of the Service Specification has commenced and the draft revision for the District Nursing Service is anticipated to be ready for stakeholder review during January 2016.

• DXS Electronic referrals from GP’s to Oxleas: The CCG is advised that the DXS system has been delayed for release until February 2016 due to a delay on approval from HSCIC. The 3 GP services that have yet to participate will be contacted directly in the New Year.

• Review and development aligned to new investment with the Greenwich and Bexley Community Hospice is underway.

• The MSK service will be producing monthly trajectories for all speciailities in order to improve waiting times.

ENCLOSURE: I (iii) Agenda Item: 12/16


• The CCG are in the process of arranging a further three way meeting in the New Year with both prime contractors (GSTT and KCH) to help parties move forward in a coordinated and transparent manner on their prime and sub-contractor reciprocal arrangements.

• The Ophthalmology board meeting’s with KCH are now operational occurring on a monthly basis with patient representatives present. Draft KPI’s were presented to King’s at the December meeting. A new IT system is being considered by King’s that will allow cohesive data capture. An update will be received from King’s at the January meeting.

• Work continues across the Mental Health Stocktake (with NHS England and our neighbouring CCGs), Transforming Care and implementation of the physical disability procurement.

• Care and Treatment plans have been completed for the three

patients currently in MH services that fall in scope of the Transforming Care program.

• An overspend with South London and Maudsley NHS FT (SLaM)

continues to be forecast as a result of continued increases in referrals from primary and secondary care.


Patients: Improve the health and wellbeing of people in Bexley in partnership with our key stakeholders.

People: Empower our staff to make NHS Bexley successful in engagement and commissioning services for the local population.

Pounds: Delivering on all of our statutory duties and become an effective, efficient and economical organisation.

Process: Commission safe, sustainable and equitable services in line with the operating framework and which improves outcomes and patient experience.


Key risks

Financial risks are associated with over performance, although these are within the forecasts, funding to cover them has had to be found elsewhere within the CCG’s budgets. No clinical risks have been introduced in these reports.

Equality

Services provided through the procurement process must deliver the requirements of equality and diversity.

Financial

The year to date variances are for noting with mitigating actions and assurances included.

Data Data has been received from providers’ reports.

Legal issues None.

NHS constitution

The rights of patients are enshrined within our contracts.

Engagement Not applicable.

Audit trail This report is also presented to the Finance Sub-Committee.

Comms plan Not applicable. Author: Jonathan Manuelpillai Alison Rogers

Clinical lead: Dr V Bhalla Dr N Kanani Dr S Deshmukh

Executive sponsor: Sarah Valentine Director of Commissioning

Date 11 January 2016

1

Contracts Monitoring Report January 2016

Section No. Description

1

Acute Contracting Report (Month 07) – provided by the South East CSU

2

Community Contracting Report Including Procurement Projects (Month 07 and 08)

3

Mental Health Contracting Report (Month 08) – prepared by the Integrated Commissioning Unit (ICU) between BCCG and London Borough of Bexley (LBB)

4

111 Contracting Report (Month 07) – provided by the South East CSU

5

LAS Contracting Report (Month 08) – provided by South East CSU

2

Acute Contracting and Performance Section 1

Provided by South East CSU

Bexley CCG Integrated

Bexley CCG Integrated Report

A consolidated view of CCG contracting performance

Month 7

2015-16 Acute Contracts

Modules Contents

Finance & Activity

4. CCG Overview 12. Dartford & Gravesham 14. Lewisham & Greenwich

16. King’s College Hospital 18. Guy’s & St. Thomas’ 20. Summary of key finance & activity drivers, commissioning / contractual actions

Context South East CSU provides Contract Management services on behalf of South London CCGs. This involves a range of activities including supporting the annual negotiation process, monthly and financial, performance and activity monitoring, and the query and claims management process. The purpose of this report is to provide a comprehensive understanding of the CCG’s contracting performance position. The report is modular and is constructed from a number of components. Modules

Full glossary is available on the SLCSU Portal:

http://nww.mdt.southlondoncsu.nhs.uk/integratedreport/glossary

• Finance data primary source is finance adjusted SLaM data.

• Activity data primary source is SUS (Referrals is PIMS).

• Performance data primary source is relevant national websites

(e.g. Unify2, Open Exeter, HPA HCAI database)

• Quality data primary source is Trust Scorecards

Glossary

Contents | Introduction | Glossary

Finance & Activity

Bexley CCG Integrated Report

The overall year-to-date contracts spend at M7 is showing an indicative £1.02m over plan position and projected forecast outturn 1% over performance of £1.8m ((excluding the accrued

variance position for KCH and GSTT in respect to contracted block arrangements for 2015/16).

Dartford & Gravesham NHS Trust (D&G): Contract YTD actual spend position at M7 is circa £18.3m and below plan by £22k. The main over performing areas are: Other (£654k),

Outpatient FA (£161k), Elective (£150k), Critical Care (£112k), Unbundled Diagnostics (£97k), Outpatient FUP (£87k), Maternity Pathway (£27k), and Out Patient Procedure (£13k) Notable

improvement around Maternity pathway (£138k) and Outpatient Follow up (£20k),

Lewisham & Greenwich NHS Trust (LGT): Contract YTD actual spends position at M7 is circa £32.3m (based on planned cap) with projected forecast outturn of £1.3m above plan. The

main over performing areas are; Emergencies (£1.8m), Critical Care (£681k), Elective (£656k), OPPROC (£292k), Maternity Pathway (£141k),Outpatients FA (£141K), A&E (£128K),

Unbundled Diagnostics (£109k), Drugs & Devices (£69k) and Outpatient follow up (£59k). Notable improvement around Emergency (£91k), Critical Care (£44k)

King’s College Hospital (KCH): Contract YTD actual spends position at M7 is circa £13m (based on profiled block). The largest overspends are within; Drugs & Devices £692k, Outpatient

Procedure £686k, Emergency £278k and Critical Care £52k. Notable areas below plan are Electives £611k, Outpatients FUP £400K, Outpatient FA £396K. notable improvement around

Critical Care (£257k).

Guy’s & St. Thomas (GSTT): Contract YTD actual spends position at M7 is £9.6m (based on profiled block). The over performance YTD are within; Drugs & Devices £288k, Critical Care £129k, Outpatient Procedure £101k, Non-Elective £57k and Maternity Pathway £36k. Other SLA (Acute contracts): The reported contracts position for out-of-area SLA providers at M7 is above plan YTD (£50K).

NCA (cost per case): The reported actual spend position for NCA or cost per case providers at M7 is £1.7m (15% above the indicative plan spend of £1.4m).

CCG overview | Finance

The key over-performance YTD by Point of Delivery (POD) across the 4 main local providers are:

Other: DGT (pre-impact of KPI application, penalties and other financial adjustments)

Electives: LGT (Colorectal Surgery, Medical Oncology, Gastroenterology) and DGT (Paediatrics, Breast surgery and Clinical Haematology)

Emergency: notably LGT (demand and capacity under review), KCH and GSTT

Maternity pathway: (notably D&G, GSTT and LGT)

A&E: mainly LGT (demand and capacity under review)

Outpatient (Fist Attendance): LGT and DGT (AQP impact)

Outpatient (Follow-Up): mainly D&G, LGT and GSTT

OPPROC: across all 4 providers (LGT and KCH {AQP impact})

Unbundled Diagnostics: D&G and LGT

Critical Care: across all provider GSTT, LGT , DGT and KCH

Direct Access: mainly DGT

Drugs & Devices; GSTT, KCH and LGT

All GUM (Genitor-Urinary Medicine) activities are recharged to London Borough of Bexley under the section 75 agreement.

CCG overview | Finance | Main providers (D&G, L&G, KCH, GSTT)

The External providers’ contracts figures below include the YTD reported spend position in M7 (where SLA values has been agreed or CCG financial

envelope for contract values are still being negotiated). The challenge scripts for prime contractor schemes created in 2014/15 will continue to be

run to ensure Prime Contractor activities are not included in the Acute Contract position where there is/are arrangement for activities to be billed

directly to the prime contractor.

Barts and The London NHS Trust (contract agreed c£1.01m incl GUM) YTD contract position is below plan by £91k. However, the over spend YTD

areas are; Other: HCTR2 - HEMS Consortia: Accident & Emergency £50k, Non-Elective: (£25k),Trauma & Orthopaedics by £11k. Deteriorated by

£35k from previous month mainly within Other by £18k, Elective £10k and Non-elective £10k.

BMI Healthcare: (contract agreed £260k): M7 actual position is marginally under planned £4k, Contract pre-adjusted position has deteriorated by

£17 from Month 6 mainly around Elective (£11k).

Chelsea and Westminster Hospital NHS Foundation Trust (contract agreed £167k incl GUM): YTD contracts spend in M7 is above plan by £21k. Over performance mainly within over performance mainly within Emergency (£4k) and Maternity pathway (£4k). Great Ormond Street Hospital for Children NHS Trust (contract agreed £200k): YTD contracts actual spend in M7 is £12k above plan. Over spend mainly within Electives by £26k (Rheumatology £23k). Imperial College Healthcare NHS Trust (contract agreed c£143k): YTD contracts actual spend in M7 is over plan by £28k. Over spend mainly within

Emergency notable over plan by £26k within: General Medicine £10k (RC14Z - IR Procedures - Vascular – Major).

InHealth (contract agreed £604k): M7 actual contracts YTD spend position is above plan by 12%. Bexley remain as an associate to South West

CCGs contract.

London Ambulance Service NHS Trust (contract agreed £7.6m): YTD contract plan spend of £4.4m in M6.

Maidstone & Tunbridge Wells NHS Trust (contract agreed £209K): YTD contract actual spend in M7 position is over plan by £22k, mainly within

Emergency: Trauma & Orthopaedics £9k, Clinical Haematology £6k).

Medway Foundation Trust (contract agreed £700k). Due to Trust’s PAS system implementation, Medway reported their first SLAM covering M1-7

(with no contract plans over performance mainly around Emergency £22k and Out Patient Follow Up £10k. Improved by £32k in Month 7

compared to previous month mainly around Elective.

Moorfields Eye Hospital NHS Foundation Trust (contract agreed £991k): YTD contract actual spend in M7 is £127k above plan. The over performance are mainly around Elective (£77k), Outpatient procedure (£36k).

London North West Hospitals NHS Trust (contract agreed £131k): Contract position at M7 is above plan by £33k, mainly within; Emergency £18k – FZ66A - Very Major Small Intestine Procedures 19 years and over with CC (£9k), Electives £15k - Colorectal Surgery £9K). Queen Victoria Hospital NHS Foundation Trust (contract agreed c£575k): YTD contract actual position in M7 is under plan by £42k. Improved by £37k from previous month notably within Elective £29k. Royal Brompton and Harefield NHS Foundation Trust (moved to NCA): contract actual SLAM reported spend YTD in M7 is marginally over (no

plan). Moved to NCA for 2015/16 with Month 6 YTD position broadly within expected plan position.

Royal National Orthopaedic Hospital NHS Trust (contract agreed £149K): YTD contract position is marginally over plan at Month 7 with the main

over spend area: Electives (Spinal surgery service - HC01Z - Extradural Spine Major 2 (£10k) and Drugs £2k.

St George's Healthcare NHS Trust (contract agreed £254k): YTD contract actual spend in Month 7 is £44k below plan. Overspend mainly in

Outpatient Procedure (£47k) : BCRAA Bi-Lateral Cochlear Implant Rehab £46k.

University College Hospital (contract agreed £751k): YTD contract actual spend in Month 7 is £56k above plan, over plan (Pre-adjusted). Mainly around Emergency £18k – FZ66A - Very Major Small Intestine Procedures 19 years and over with CC (£9k), FZ33C - Small Intestinal Disorders (excluding Inflammatory Bowel Disease) with length of stay 2 days or more (£4k),

Electives £15k - Colorectal Surgery (FZ73A – N/K - £13K, (FZ74A-N/K £9K).

CCG overview | Finance | Other contracts

Module | Finance & Activity

CCG overview | Activity | Referrals

Module | Finance & Activity | Interactive Activity Dashboard Available at: http://nww.mdt.southlondoncsu.nhs.uk/integratedreport/activity

The data behind the charts showing referral activity is provided to the CSU directly from the providers on a monthly basis, as an individual referrals dataset. To clarify these charts are not produced from MAR

returns, although the expectation would be that these two would align to some extent .Therefore this reflects a count of referrals received by the trust each month and, although they are Bexley patients, some

of this activity will fall under specialised commissioning and there will be an natural cohort of unattended and/or cancelled activity. This slide is a therefore a measure of demand on the service rather than

actual activity that will eventually be attributed to CCGs.

Dartford & Gravesham: In line with previous year with a slight drop of 1%

Lewisham and Greenwich: The year on year figure has dropped by -10% Owing to the installation of a new information system Lewisham were unable to provide a full data set of referrals for 15/16

Kings College Hospital: The data supplied for KCH shows a marked decrease in referrals for 15/16 however local knowledge tells us that this is not the case and the provider has been asked to revisit the

figures.

Guy’s & St. Thomas: The increase in referrals is mainly due to the Cardiology prime contractor scheme. Owing to this Cardiology referrals have risen since Sept 2014 where 235 referrals were received

compared to a previous average of around 40.

KCH variation due to coding of

MSK referrals in 14/15 but not

in 15/16 in full = -1108 av pm

GSTT variation due to coding of

cardio referrals in 14/15 but not

in 15/16 in full = -+334 av pm

http://nww.mdt.southlondoncsu.nhs.uk/integratedreport/activity

CCG overview | Activity | Main Providers (D&G, L&G, KCH, GSTT)


The problems with the Lewisham and KCH data have skewed the charts for M2 to M7. Outpatients

GP – First: An increase of 12% mainly in Audiology, Cardiology and Colorectal Surgery

C2C – First: An increase of 6% across several specialties

Other – First: Decrease of -24 % mainly in Breast Surgery, Dermatology and General Surgery

Other – Follow up: A decrease of -13% mainly in Diabetic Medicine, General Medicine, Ophthalmology and Trauma & Orthopaedics

Inpatients

Emergency: Increase of 13% mainly in W - Immunology, Infectious Diseases and other contacts with Health Services

Non-Electives: Increase of 1% across several specialties

Electives: Increase of 3% mainly in Q - Vascular System.

Additional CDU QEH emergency activity agreed

in plans but from May CDU activity is

significantly above the agreed levels – under

“deep dive” investigation with LGT. This has

been delayed and is now scheduled for

beginning of January 2016; we await results


CCG overview | Finance | Bridging analysis


CCG overview | Finance | Claims

The figures in these tables reflect the Claims issued to your Providers YTD, so they include M1

to M7 Raised Claims. Agreed, and Rejected and Closed claims reflect only the responses

received for M1 to M6, as the deadline for M7 responses is after the production of this report.

Open Claims may include figures covering all months, but this is a small residual amount that

remains open after recent quarterly closedown meetings between the CSU and Providers. For

D&G and LGT we will continue to follow due process and review future Trust responses on

these, but it is unlikely that there will be material additional financial adjustments due.

Finance colleagues will be able to provide you with an updated report as of M8/9 reporting of

the impact of these Claims in your underlying and previously reported financial position.

For Drugs related queries, details on Agreed or Rejected Claims should be sought from your

Medicines Management representatives.

For all other accepted claims, further checks are carried out at the Freeze position to ensure

either SLAM or SUS or both instances as the case may be reflect the necessary amendments,

when this is not the case the Providers are issued with further rechallenges but these are

obviously not reported here so as not to incorrectly inflate the figures reported. We can advise

the volumes of Freeze challenges issued to LGT and D&G are not substantial.

Claims classed under Other High Risk Queries (likely no Yield) represent data queries issued to

Providers where the CSU cannot at point of issuing these be completely confident that the

activity has been correctly coded and/or costed, hence Providers being asked to answer our

queries and confirm one way or the other. These are extremely likely not to produce any

financial yield.


Detail

Summary

CCG overview | Finance | Claims

NHS Bexley CCG – Acute Contracts as at M7 (October 2015) have raised Claims and Challenges with provider Trusts to the value of £1,701,666. Currently there has been £309,480 agreed for M6, which gives an agreed rate of 18.1% against raised claims at M7. It should be noted that the claims raised figure is for M1-7, whereas the agreed figure is for M6 (with the exception of Dartford & Gravesham NHS Trust delayed M6 responses). The amount rejected by Providers and upheld as rejected for M6 was £782,882 resulting in £609,304 remaining open. There is a robust Challenge and Claims process undertaken by the CSU, with joint working with the CCG Analyst and Assistant Director of Commissioning and a monthly hard close process.(Hard close is the structured process, agreed with the Provider Trusts, of agreeing a figure at the end of each month/quarter to finalise all claims, challenges and queries. The agreed figure is signed off by the CCG and the period is then effectively closed---full process is attached). The CSU continues to work with the CCG to further enhance the challenge process, with the addition in 2015/16 of the claims letter and monthly hard close process. Work also continues to establish a robust challenge process around the Prime Contractor schemes especially with External Providers and Non Contracted Activity (NCA). The challenge process with Acute Provider Trusts mainly consists of two elements: - 1. Automated Challenges - these are raised by the CSU, based on agreed scripts, and challenge SUS and SLAM submitted information. They include:

Maternity Pathway - in particular duplicate charges from Providers and incorrect attribution of maternity diagnostics. Manual Non-SUS attributions: manual validation of non-SUS misattributions to ascertain that all non-SUS lines are attributed to the correct commissioner based on NHS Number/GP/Postcode

(responsible commissioner guidance/ rules). Automated SUS attributions – validation of SUS misattributions to ascertain that all SUS lines are attributed to the correct commissioner based on NHS Number/GP/Postcode (responsible commissioner

guidance/ rules). Specialist commissioning attributions (in particular Critical Care). Data Quality challenges including Consultant to Consultant which is part of the productivity metrics. Other financial challenges - includes a whole array of challenges for example multiple appointments, missing data, activity with no supporting spell etc. The list of challenges and rationale for them has

been reviewed and agreed with the Assistant Director of Commissioning and CCG Analysts. 2. Claims letter – this is an addition to the process in 2015/16 whereby formal ad-hoc letter s are sent to the Provider Trusts. The basis of this letter is to raise any additional questions or issues with the Trust

that are identified when reviewing the SLAM, for example large variance from plan, a spike in activity, an apparent change in case mix or to question any ‘soft’ information that has been raised at other meetings. The claims letter is unlikely to result in a large amount of financial adjustments; however it assists in understanding activity flow and changes which could be incorporated into future Commissioning intentions. The Assistant Director of Commissioning and CCG Analyst are able to feed into these letters any areas that they have identified and wish to be raised. Within the CSU each Team has a lead Provider, for example: Bexley CSU Contracting Team – Dartford and Gravesham Lewisham CSU Contracting Team – Lewisham & Greenwich

It is the responsibility of the team to raise challenges on behalf of Associates (where agreement is in place), respond and agree to the Trust responses. Bexley CCG feed into this process via the Bexley CSU Contracting team who inform the relevant CSU team of issues to be raised with providers. Exceptional commentary: In regards to GSTT and KCH, they will be reporting on Q2 activity once they have finalised their quarterly reconciliations.

The cumulative YTD contract reported spend position in M7 is below the agreed profiled plan by £22k. The YTD over-performance are notable within the following PODs; Other (£654k), Outpatient FA (£161k), Elective (£150k), Critical Care (£112k), Unbundled Diagnostics (£97k), Outpatient FUP (£87k), Maternity Pathway (£27k), and Out Patient Procedure (£13k). Notable improvement from previous month mainly around Maternity pathway (£138k) and Outpatient Follow up (£20k) and deteriorated mainly around A&E (£99k) and Drugs & Devices (£15k). Other Expenditure: Indicative overspends by £654k in Month 7, due to no actuals or financial adjustment reported against KPIs, EMR, EXBD and Re-admission in SLAM. Outpatient FA: Over plan by £161k mainly around Urology (£48k), Clinical Haematology (£31k) Paediatrics (£25k), Breast Surgery (£20k), Anaesthetics (£17k), Colorectal Surgery (£15k), Respiratory Medicine (£13k) and Gastroenterology (£12k). Under performance in General Surgery (£27k) and Geriatric Medicine (£11k). Electives: Over plan by £150k, Mainly around Paediatrics (£78k), Breast Surgery(£66k), Clinical Haematology (£23k), General Surgery (£22k), Obstetrics (£21k), General Medicine (£14k) and Geriatric Medicine (£10k). Under performance in Emergency by (£601k), A&E (£201k) and Drugs & Devices (£107K).

Critical Care: Over plan mainly around Critical Care Medicine by £112k.Critical Care Medicine: XC04Z - Adult Critical Care - 3 Organs Supported (£90k), XC05Z - Adult Critical Care - 2 Organs Supported (£16k).

Unbundled Diagnostics: Over plan by £97k mainly within Not A Treatment Function (£37k), Gastroenterology (£21k), General Surgery (£17k), Respiratory Medicine (£15k),Old Age Psychiatry (£13k) and Anaesthetics (£9k). Outpatient FUP : Over plan by £87k mainly within Urology (£30k), Paediatrics (£23k), Nephrology (£21k), Clinical Haematology (£20k), Breast Surgery (£14k) and Colorectal Surgery (£9k).

Maternity Pathway: Over plan by (£27k) mainly within Midwife Episode by (£137k) and Gynaecology (£5k). Under performance in Obstetrics by (£107k). Outpatient Procedure: Over plan by £13k mainly within Urology (£32k), Gynaecology (£20k), General Surgery (£11k) and Cardiology (£6k).

Dartford & Gravesham NHS Trust | Finance

Dartford & Gravesham NHS Trust | Activity


Outpatients:

GP – First: An increase of 12% mainly in Rheumatology C2C – Follow up: A decrease of 22 % mainly Pain Management and Trauma & Orthopaedics Other – First: An Increase of 18 % mainly in Ophthalmology Other- Follow Up: An Increase of 16% across several specialties

A&E

A&E attendance is down by 10% compared with the same period last year

Inpatients Emergency: A decrease of 11 %; small numbers across several specialties Non-Electives: In line with previous years Elective: In line with previous years


Lewisham & Greenwich NHS Trust | Finance

The reported contract position in M7 is above the agreed profiled plan by £779k, The YTD over performance are mainly within Emergencies (£1.8m), Critical Care (£681k), Elective (£656k), OPPROC (£292k), Maternity Pathway

(£141k),Outpatients FA (£141K), A&E (£128K), Unbundled Diagnostics (£109k), Drugs & Devices (£69k) and Outpatient follow up (£59k).There are on-going demand and capacity reviews to ascertain the correlation between A&E

performance and emergency spells, McKinseys workstreams etc., activity shift and cancer activity trend seen in elective procedures. The audit undertaken in December will determine the appropriateness of utilisation of CDU and NEL

admissions. Emergency: Over plan by £1.4m mainly around General Medicine (£106m), LA04D - Kidney or Urinary Tract Infections with length of stay 2 days or more with Major CC (£110k),Geriatric Medicine (667k), AA22A - Non-

Transient Stroke or Cerebrovascular Accident, Nervous System Infections or Encephalopathy with CC (£130k), General Surgery (£291k), Endocrinology (£154k), Pain Management (£110k), Paediatrics (£96k), Paediatric Medical Oncology

(£30k) and Gynaecology (£20k).

Critical Care: Over plan by £681k mainly within Critical Care Medicine by (£680k). XC04Z - Adult Critical Care - 3 Organs Supported (£429k), XC02Z - Adult Critical Care - 5 Organs Supported (£221k), XC05Z - Adult Critical Care - 2 Organs

Supported (£115k).

Elective: Over plan by £656k mainly within Colorectal Surgery (£161k), Medical Oncology (£156k), Gastroenterology (£146k), Clinical Haematology (£86k), Breast Surgery (£72k), Urology (£61k), Paediatrics (£52k), Ent (£51k), Gynaecology (£48k).

Out Patient Procedure: Over plan by £292k mainly around Dermatology (£95k), Urology (£91k), Gynaecology (£90k), ENT (£65k). Maternity Pathway: Over plan by £211k mainly around WASH Specialty £168k, Midwife Episode £78k. Outpatients first: Over plan by £141k mainly within Dermatology (£58k), Trauma & Orthopaedics (£40k), Gastroenterology (£34k), Gynaecology (£29k), Endocrinology (£25k), Urology (£19k). A&E: Over plan by £128k mainly around: VB04Z - Category 2 investigation with category 4 treatment (£162), VB07Z - Category 2 investigation with category 2 treatment (£51k), VB09Z - Category 1 investigation with category 1-2

treatment (£13k).

Unbundled Diagnostics: Over plan by £109k mainly around: Diagnostic Imaging: RA01Z - Magnetic Resonance Imaging Scan, one area, no contrast (£97k), RA13Z - Computerised Tomography Scan, three areas with contrast (£47k),

Lewisham & Greenwich NHS Trust | Activity


Outpatients:

GP – First: An increase of 7% mainly in Breast Surgery, Colorectal Surgery and Dermatology GP – Follow up: Decrease of -22% mainly Anticoagulant Service C2C – First: An increase of -2% across several specialties C2C – Follow up: Increase of 20% mainly in Anticoagulant Service and Urology Other – First: Decrease of -50% mainly in Trauma & Orthopaedics, Breast Surgery Dermatology and General Surgery. Other – Follow up: Decrease of -38% mainly in Trauma & Orthopaedics, Paediatrics and Diabetic Medicine. A&E

There has been a 2% increase in A&E compared with the same period last year although the scale of the chart makes the figures look more dramatic than it actually is

Inpatients

Emergency: Increase of 32% mainly W - Immunology, Infectious Diseases and other contacts with Health Services Non-Electives: Increase 15% across several specialties Electives: Increase of 1% Driven by HRG Q - Vascular System which has doubled compared to last year

Additional CDU QEH emergency activity agreed

in plans but from May CDU activity is

significantly above the agreed levels – under

“deep dive” investigation with LGT. This has

been delayed and is now scheduled for early

January 2016; we await results


For 2015/16 the CCG has agreed a block contract with King’s, with a fixed payment for the year thus providing financial certainty for both the CCG and the Trust. The contract was set based on a forecast assessment of 14/15 outturn plus an additional 3% growth, upfront adjustments for contractual KPIs and adjustments relating to the CCG’s Prime Contractor and Any Qualified Provider (AQP) initiatives. The reinvestment of any 'national performance penalties’ has been agreed as part of the block contract agreement. 2015/16 tariffs are based on the Default Tariff Rollover (DTR) therefore no CQUIN is applicable. A Local Incentive Scheme of 1.5% has been agreed. Month 7 Finance & Activity Position: The tables and graphs show the year to date service level agreement monitoring (SLAM) position by point of delivery (PoD) for finance and activity to show the underlying contractual position. The finance table then adjusts the position back to breakeven to reflect the block contract arrangement. Whilst the block contract agreement added growth, there is a strong likelihood of underlying over performance in 2015/16. Bar charts show the percentage variance against the year to date finance and activity plans across all PoD’s. Further analyses for four PODs are provided to show the 2015/16 plan, 2015/16 actuals, 14/15 The M7 SLAM position identifies the following points of interest:

• The underlying position, prior to the application of financial adjustments, is £871k or 6.7% over plan . It should be noted that this position masks a more significant level of underlying over performance once the plan is reduced to

remove the CCGs AQP contracted activity. • The contractual underlying position, reflecting agreed financial adjustments, is £541k over plan or 4.1% and includes a financial adjustment for Q2 national performance penalties. • There are a number of Bexley specific issues that affect the reported plan and actual position:

The Bexley plan is net of the MSK and Cardiology AQP activity, further assurance is required to ensure residual actuals are not reported in the acute positon. This will be managed via the BGL claims process.

For Ophthalmology, the AQP contract plan continues to be part of the acute contract block value. This will be removed via a contract variation following agreement of the value.

The over performance within Outpatient procedures is driven by an increase in non-PbR activity related to the lucentis pathway in Ophthalmology. There appears to be significant volitility at CCG level between PbR and non PbR recording. A joint review is underway with the agreed outcome being to agree a standard pathway for these patients and across sites for 16-17.

QMS drug costs in 15-16 have been reattributed to NHS E as of M5 freeze as they hold the budget in 15-16, nevertheless there remains a significant level of over performance within Drugs and Devices. An agreement is required regarding the billing of Cytokine Modulators which are billable outside of the MSK AQP contract (and are currently being billed through the acute contract).

The level over performance in Emergency has improved between M6 (14.5%) and M7 (7.9%). The over performance relates to a combination of the impact of new emergency care pathways (e.g. PRUH CDU) and increased rates of admissions.

Challenges

The Q2 reconciliation position is almost concluded. Any adjustments not automatically made by the Trust within the slam position will be adjusted by the CSU. This is due to be finalised with the Trust no later than the 18th December. The final position and associated narrative will be circulated to Associates and reflected in the baseline data for 16-17 contract plans.

King’s College Hospital | Finance

King’s College Hospital | Activity


Outpatients:

GP – Follow up: An increase of 19% compared with the same period last year. Mainly in Pain Management and T&O C2C – Follow up: Decrease of -4% compared with the same period last year. Mainly in Trauma & Orthopaedics C2C – First: An increase of 35% compared with the same period last year. Mainly in Gynaecology Other- First: A decrease of -56% compared with the same period last year. Mainly in Gynaecology and Trauma & Orthopaedics Other- Follow Up: A decrease of -16% compared with the same period last year. Mainly in Trauma & Orthopaedics A&E There is duplication of A&E figures for month 7 14/15. Therefore the peak in the chart is a data quality issue.

Inpatients

Emergency: Increase of 6% small numbers not relating to any particular HRG Non Elective: Decrease of -10% small numbers not relating to any particular HRG Elective: Increase of 10% mainly HRG H - Musculoskeletal System


For 2015/16 CCGs in South London and Surrey have agreed a combination of block and cost & volume contracts with Guy’s & St Thomas’. Where block contracts have been agreed, contracts were set based on a forecast assessment of 14/15 outturn plus growth. The reinvestment of any 'national performance penalties’ has been agreed as part of the block contract linked to the delivery of GSTT recovery plans. For all contracts, 2015/16 tariffs are based on the Default Tariff Rollover (DTR) therefore no CQUIN is applicable. A Local Incentive Scheme of 1.5% has been agreed. Month 7 Finance & Activity Position

The tables and graphs show the year to date service level agreement monitoring (SLAM) position by point of delivery (PoD) for finance and activity to show the underlying contractual position. The finance table then adjusts the position back to breakeven to reflect block contract agreements where applicable. Whilst block contract agreements included growth, the overall demand the Trust is experiencing, particularly for elective work, is significant so there is a strong likelihood of underlying over performance in 2015/16. Small contracts will also be particularly prone to month on month fluctuations. Bar charts show the percentage variance against the year to date finance and activity plans across all PoDs. Further analysis for four PODs is provided to show: the 2015/16 plan; 2015/16 actuals; 14/15 actual outturn on a monthly basis; and also a cumulative year to date position.

The M7 SLAM position identifies the following points of interest: • The underlying contractual position is an under performance of £186k / 1.9%, an improvement on last month’s position of 0.9%, under plan. The underlying position prior to the application of contractual adjustments, such as

penalties, is a lower level of underperformance at £168k / 1.7%. The reported position does not include prime contractor arrangements. The underlying position is important in terms of planning for 2016/17. • Elective underperformance has marginally increased and the Outpatient Procedure over performance has stayed the same in percentage terms despite RTT / backlog pressures expected to impact on planned care. Dermatology

is the largest Outpatient Procedure over performance against plan.

The Critical Care over performance has increased, from 17.7% to 23.9%. This PoD is subject to volatility and in addition NHSE/CCG attribution may change from flex to freeze if the related hospital spell is un-coded at flex.

The Emergency under performance has increased this month. Emergency Plastic Surgery continues to be significantly over plan despite the overall underperformance in this PoD. A successful challenge has been raised in relation to the Plastics reporting.

• The Drugs & Devices position has improved slightly this month. Thoracic aortic stents are the largest over performance in this PoD. Markedly increased Thoracic Aortic Stent activity across South London and Surrey in Q2 has been queried with the Trust but appears to be genuine activity.

• Amputee Rehabilitation and Patient Transport are the largest under performances against plan in Other.

Claims adjustments, both Q1 and estimated Q2 have been applied to Other.

Challenges The Q2 reconciliation position is almost concluded. Any adjustments not automatically made by the Trust within the SLAM position will be adjusted by the CSU. This is due to be finalised with the Trust no later than the 18th December. The final position and associated narrative will be circulated to Associates and reflected in the baseline data for 16-17 contract plans.

Guy’s & St. Thomas’ | Finance

Guy’s & St. Thomas’ | Activity


Outpatients:

GP – First: Increase of 37% mainly in cardiology GP – Follow up: Increase of 3% small numbers not relating to any particular TFC C2C – Follow up: Increase of 7% small numbers not relating to any particular TFC There is a notable peak in month 11 for C2C This due to a reporting fault at GSST whereby the system allocated this activity assigned to CCG rather than specialist. We are working to rectify this. Other – First: Increase of 35% small numbers not relating to any particular TFC

A&E

There is a 4% increase compared to last year.

Inpatients

Emergency: Increase of 19%. Small numbers, not driven by any particular HRG Non electives: Increase of 14%. Very small numbers, not driven by any particular HRG. There is a peak in July 2015 but again this is small numbers Electives: Increase of 7%. Very small numbers, not driven by any particular HRG. There is a peak in July 2015 but again this is small numbers


Performance issue Commissioning action Contractual action

Over performance - activity management review Lewisham & Greenwich NHS Trust

Joint commissioner activity management review on the level of over performance at Lewisham & Greenwich NHS Trust is on-going.

In Progress

Contract Variations Dartford & Gravesham NHS Trust CV3 –CQUIN schemes; agreed; CV4 –RTT changes; agreed; CV 5 SETAP revision; in progress

The CSU is awaiting confirmation of agreement of the and the additional contract variation with Dartford & Gravesham NHS Trust to reflect the national CQUIN and local incentive schemes for 2015/16.

Anticoagulation service Dartford & Gravesham NHS Trust

Commissioners are considering the clinical impact/ pathway changes to Tier 1 and 2 anticoagulation services transferring to the local service providers from 1 April 2016 as Dartford & Gravesham NHS Trust will only receive referrals for Tier-3 patients requiring on-going management of care in hospital setting.

Discussions will continue as per the 2016/17 contracting round

A&E performance Dartford & Gravesham NHS Trust Performance in A&E fell to 80% in November, and is the fifth consecutive month where performance is below 95%.

The CSU is seeking to understand the alliance with wider system groups and networks and the provider to support delivery.

The CSU, on behalf of the CCG, will issue a Performance Notice and seek remedy by the end of the year, working collaboratively with Kent CCGs to agree the Remedial Plan to support remedy.

Diagnostic Imaging activity Dartford & Gravesham NHS Trust Activity is over plan and estimated to be approx. £150k above plan at year end. This is currently unexplained by the Provider.

The CSU, on behalf of the CCG, will issue an Activity Query Notice, and will require the Provider to formally investigate this over performance and advise.

2016/17 All Providers The CSU has commenced the contract negotiation process with all providers and will up-date on headline issues/ developments and outcomes throughout the process.

In progress

Finance | Summary of key drivers, commissioning and contractual actions


22

Community Contracting and Performance Section 2

This report provides exception reports on key indicators and contracting issues that have arisen since the last report to the Finance Sub Committee on November 2015.

This report has been structured as follows:

2.1 Executive Summary

2.2 Oxleas Community Contracts

2.3 Prime and Lead Contractor Contracts

2.4 Urgent Care Services and Out of Hours

2.5 AQP contracts

2.6 Other Community Contracts

2.7 Procurements

23

2.1 Executive Summary Headlines

• As part of our Winter Pressures scheme funding the Consultant Led, MDT supported “Hot Clinics” are now operational at QMH.

• A Comprehensive Continence Service Review has been undertaken by the Contracting team and the CCG is assured around the introduction and quality of products supplied. Comprehensive training has been provided to care homes. Administrative processes within the CCG have been streamlined to ensure correct point of delivery to Oxleas and this initiative has demonstrated improved quality outcomes at initial review.

• The 24 hour District Nursing service commenced during November within the Oxleas Adult Community services. The planned review of the Service Specification has commenced and the draft revision for the District Nursing Service is anticipated to be ready for stakeholder review during January 2016.

• DXS Electronic referrals from GP’s to Oxleas: The CCG is advised that the DXS system has been delayed for release until February 2016 due to a delay on approval from HSCIC. The 3 GP services that have yet to participate will be contacted directly in the New Year.

• Review and development aligned to new investment with the Greenwich and Bexley Community Hospice is underway.

• The MSK service will be producing monthly trajectories for all speciailities in order to improve waiting times.

• The CCG are in the process of arranging a further three way meeting in the New Year with both prime contractors (GSTT and KCH) to help parties move forward in a coordinated and transparent manner on their prime and sub-contractor reciprocal arrangements.

• The Ophthalmology board meeting’s with KCH are now operational occurring on a monthly basis with patient representatives present. Draft KPI’s were presented to King’s at the December meeting. A new IT system is being considered by King’s that will allow cohesive data capture. An update will be received from King’s at the January meeting.

2.2 Oxleas Community Contracts 2.2.1 Adult Community Health Services.

The Oxleas consolidated Adult Community Contract 2015-16 comprises of the following:

• Adult Community Health Services

• Neuro-Rehabilitation (level 3)

• Integrated Care

Adult Community Nursing Services where key performance indicators (KPIs) demonstrate change over the past 3 months. For SLT 1: Speech and language therapies this represents attainment of target status for the first time in year. DN3 (incidence of pressure ulcers) has remained on target since April but shows a trend of a positive decrease in incidence. The lower recorded use of Agency staff is encouraging but will require careful monitoring throughout a traditional holiday period.

New

CODEQuality Requirement THRESHOLD Measure FREQUENCY September October November Comments

SLT1

New high risk Patients referred

with dysphagia to be seen

within 10 working days of

referral

95%

Number of new high risk patients

with dysphagia seen within the

timeline as a proportion of the

total number of patients referred

for dysphagia

Monthly 93.0% 88.0% 100.0% 18 out of 18 - November

PD2

Patients on the Podiatry

caseload who are due a follow-

up appointment should not be

waiting more than 10 calendar

days from provider cancellation

of their original appointment

100%

Number of patients seen within 10

calendar days post cancellation of

their appointment as a proportion

of all cancelled follow-up

appointments.

Monthly 100.0% 100.0% 95.6% 44 out of 46 patients - November

PD4

Patients with a diagnosis of

Type 1 & 2 diabetes on the

podiatry service case load to

receive a foot check within 18

months as per NICE guidance

95%

Number of patients with Type 1

and 2 diabetes on the Podiatry

service case load who receives a

foot check within 18 months as a

proportion of total number patients

in the cohort

Monthly 92% 94% 94%

723 out of 772 - excludes 8 people who are

uncontactable, in hospital, or DNA last appointment.

The remaining patients will receive their foot check at

their next appointment.

DN3 Incidence of pressure ulcer Report only

Percentage of patients on the DN

caseload with a pressure ulcer of

grade 2 or higher


DN6

Increase in the number of

patients who died in their

preferred place of death.

Over 70% but

Working towards

85%

Percentage of patients on an End

of Life care pathway who died in

their preferred place of death.


G9Reduction in the number of “Did

not attend appointment”Less than 7.5% (NAT)

Percentage of “Did not attend”

appointments by patients across

all services as recorded on RiO

Monthly 2.60% 2.74% 2.30%

G1 Number of complaints Less than 15 per monthNumber of complaints received in

the contract monthMonthly 2 1 0 There were 0 complaints in November

G2Ensure that complaints are

resolved within 25 working days85%

Number of complaints resolved

within 25 working days as a

proportion of the number of

complaints received in the period

Quarterly 62.5%

5 out of 8 Complaints Investigated within the

timeframe. In 3 instances additional time was required

to thoroughly investigate complaints as they were

complex/multi agency. The complainant is always

contacted in these circumstances.

G6Reduction in the use of Agency

staffLess than 15%

Total agency and bank staff

employed hours as a percentage

of total staff hours (clinical staff

only)

Monthly 18.00% 17.00% 13.10%

Neuro Rehab Bed in-patient activity

The CCG has been closely monitoring the use of both neuro rehab and its SUSD beds in terms of occupancy. In November the CCG

has agreed with Oxleas flexibility on these beds that allows them to be filled with Step Up Step Down patients when no suitable neuro

rehab patients need the beds. In addition Oxleas with Lewisham & Greenwich Trust has expanded the community bed capacity.

2015/16

April-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15

available bed days (4 beds) 120 124 120 124 124 120 124 120

occupied bed days 53 85 57 55 64 55 94 41

No of admissions in month 3 1 3 3 3 4 1 2

Total patients in beds in month 5 5 5 5 4 6 5 4

Number of Discharges in month 1 3 2 4 2 2 3 3

average length of stay (in month) 22 26 23 13 23 22 29 24

bed occupancy 44% 69% 48% 44% 52% 46% 76% 34%

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2.3 Prime and Lead Contractor Contracts

2.3.1 MSK Prime Contractor Service with Kings FT

Contractual and financial matters MSK is a five year block contract, containing annual savings for Bexley CCG. We have finalised with KCH the monthly reconciliation process for small value activity that is charged to the CCG and recharged to KCH. The number of hospitals in the recharging process is diminishing as KCH is liasing directly regarding payments with these providers. Performance and Quality Patient experience scores continue to be high in MSK community services. These are monitored through contractual meetings, at which several patient representatives are present. The MSK prime contractor model is generating interest in several CCG’s and both KCH and the CCG are happy to share their experiences and knowledge with interested parties. How likely are you to recommend our outpatient department to friends and family if they needed similar care or

treatment?

How long after the stated appointment time did your appointment start?

27

If you contacted the King's Appointment Centre about your outpatient appointment, how would you rate the service

you received?

Were you involved as much as you wanted in decisions about your care and treatment?

Overall, were you treated with respect and dignity in the outpatient department?

During your visit were you treated with kindness and understanding by reception staff?

28

KPIs

The latest dashboard for MSK services shows a number of items that have improved,

The pain service is currently under discussion with Kings.

Local Quality Measures

Indicator Measure Target Sept 15 %

Oct 15 %

Nov 15 %

Patients seen/ Total

Average wait (days)

Physiotherapy

Urgent: To be seen within 10 working days

95% 96 97 96 N/A

Routine: To be seen within 20 working days

90% 63 95 97 N/A

T&O


95% 50 20 30 3/10 11.4


90% 50.3 66.2 78.6 92/117 22.5

Pain Services


95% 0 33.3 12.5 1/8 28.6


90% 7 4.9 13.6 15/110 47.4

Rheumatology


95% 79.3 69.6 74.1 20/7 9.2


90% 42.7 56 57.9 62/107 16.8

Physiotherapy

First appointment, 28 urgents in month.

Pain Service

Service redesign is underway to increase capacity with an aim to improve this by April. KCH are currently recruiting to a substantive post.

KCH has been asked to submit a monthly trajectory to bring the waiting times within target. A weekly monitoring report also monitors the reduction in the backlog. KCH reports that targets are not being achieved largely due to the booking process at BHL. The CCG is actively working with KCH to explore a number of options in order to achieve these targets. KCH intends to triage and book patients via an internal KCH service from 1 s t A p r i l 2016. See also Referral Management under section 2.3.3.

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2.3.2 Cardiology Prime Contractor Service with Guy’s (GSTT)

Contractual and financial matters The Cardiology contract is a five year block, with annual savings built in for the CCG. The Contracts team plans to hold a follow up Prime Contractors ‘three-way’ meeting in January, with both GSTT and KCH. The CCG is attempting to facilitate the progress of both parties towards signature of their respective sub contracts with each other. Remaining obstacles have been identified, with a plan for resolution.

Quality and KPIs Below is an extract from the November 2015 cardiology dashboard.

Standard Targ

et RAG Frequency Commentary

5. % of referrals received via Choose and Book

100% Monthly 100%

6. % of referrals triaged within contractually agreed time standards

100% Monthly 100% daily triage by consultant of the week from Mon - Fri

7. Number of Choose and Book Advice & guidance request received, time taken to respond and outcome

100% Monthly 62% within C & B standard (3 days) November: 13 requests, 8 responded within 3 days - negative report of late responses sent from C&B for JE & GCW to address

8. % of patients receiving diagnostic tests who are seen within 4 weeks

100% Monthly 74% within 4 weeks. PML report 376 of 509. Improving trend since: July 38%, Aug 51%, Sept 65%, Oct 72%

9. % of patients requiring Consultant appointment (other than rapid access chest pain) who are seen within 4 weeks

100% Monthly 100% unless AECG or echo required first. Those requiring separate diagnostics first were all booked within 7 weeks.

10. % of rapid access chest pain patients who are seen within 2 weeks

100% Monthly 100% (average during November was 11 patients per week)

12. % clinic letters sent within 5 days

>70% Monthly <50% The longest waits reduced to 15 days by the end of Nov. To reduce further by increased digital transcription.

GSTT has agreed an action plan with PML to achieve waiting times. The action plan indicates some improvement, but has not achieved contractual targets. The CCG had already warned that a Contract Performance Notice (CPN) would be issued unless the waits had been achieved by November. The CPN will be raised in 1st week of January.

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2.3.3 Ophthalmology “Lead Contractor” contract with Kings FT Contract/signature update

A details of a formal agreement has been reached with KCH whereby the original

savings plan will be spread over two years and the contract extended for a further year.

During the extension year KCH will be asked to look at providing a QIPP saving plan

around the reduction in tariff which could be applied to community clinics. The

Ophthalmology Board Meetings are being held on a monthly basis with a number of

representatives present. As the meetings are in their infancy it is anticipated that more

information will be available within this report as the meetings become more established .

Referral Management Serivce for Ophthalmology and MSK

contracts:

As of April 2016 the current referral management service will be replaced by a

comparable KCH service. This will affect patients on the MSK and Opthalmology

pathway. Plans and processes have been developed by KCH in order to ensure a smooth

handover. A Referral Management Service Workshop was hosted by KCH on December

3rd where a number of stakeholders were present

2.4 Urgent Care Services and OOH

2.4.1 Overview – Hurley Group

Urgent Care attendances are still above planned levels. However, the over-performance

levels at QMH and Erith UCC sites are being analysed and discussions are being held

with Hurley Group. Revised activity data has been provided that removes non-

urgent activity such as in-hours re-dressings and non Bexley patients. The CCG has

iterated that such activity does not fall under the charging for the contract.

The CCG is working with the Hurley to establish a Clinically Safe protocol to ensure non-

urgent activity is re-directed safely to a more appropriate setting. 2.4.2 Future Development and Risks

The CCG have requested that the action plan relating to the care of paediatric patients be

revised by the Hurley Group.

Hurley have submitted plans for dividing a large clinical room into two, creating an office

accessible only through the Reception, and freeing the former office to become an

additional clinical room, allowing one room to be dedicated to paediatric patients.

Discussions are being held with Oxleas, the landlords.

Developments at QMH will include moving the UCC (these have been part of the planned

31

redevelopment of the QMH site), and any impact on patient services will be carefully

managed. No building work will take place until the current asbestos removal program is

complete.

Patient representatives have been identified for the Hurley Board Meetings and it is

anticipated that they will be joining the meetings in the New Year.

2.4.3 UCC/OOH

October Monthly Data Bexley Activity Only

Site Illness Injury Redressing Total

QMH -UCC 1600 936 138 2674

Erith-UCC 2139 878 240 3257

Total UCC 3739 1814 378 5931

QMH-OOH 766 174 321 1261

Paeds Summary (Less or equal to 18 Years Old)

Site Paeds Bexley

only

Total Patients Seen (Inc non-Bexley)

% Paeds

QMH UCC 1000 5412 18%

Erith UCC 1326 3917 34%

QMH OOH 343 1342 26%

Total 2669 10671 25%

Bexley Activity Only

Site Adults Paeds Total

QMH UCC 1674 1000 2674

Erith UCC 1931 1326 3257

QMH OOH 918 343 1261

Total 4523 2669 7192

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2.5 AQP contracts

2.5.1 Audiology

The 2016/17 re-commissioning process for the Adult hearing services is currently underway. In lieu of the recent national action plan and guidance issued by NHS England/ Department of Health, (post Monitor’s review), new clinical guidelines and quality standards for managing age-related hearing loss will be made available for local derogation in 2016 and will be included in the specification of services.

2.5.2 Termination of Pregnancy Services (TOPs)

The pan-London re-procurement arrangement for termination of pregnancies will now

commence late in 2016 with new service provision to start from 1 April 2017. Some Clinical

Commissioning Groups (CCGs) across London, under the AQP scheme have issued a

contract waiver to accredited providers to extend the current contractual agreement by 12

months. The commissioning team at Bexley is now examining the procurement options

whether to undertake a re-procurement or to issue a contract waiver for 1 year duration

with the view to join the collaborative London-wide re-procurement in 2017/18.

Marie Stopes is overperforming at 108.28% of their budget at month 8. However, this is offset by the lower expenditure of the other TOP providers.

2.5.3 Anti Coagulation Services

The Anticoagulation collaborative is currently above target for month 8. The contracts and commissioning team are looking to see if the increase in numbers is attributed to patients moving out of the acute sector.

2015/16

Monthly

AQP

Costs

Tenders have been received for the Anticoagultion services.

2.5.4 Dermatology, Gynecology, Urology and Minor Surgery AQP’s

This chart below shows YTD at M8 spend for each AQP contract by provider and specialty. We can therefore demonstrate that care is beginning to shift from an acute setting into a community setting, closer to the patient’s home. Please note some

AQP Service AQP Providers Quarter 1 Quarter 2 Month 7 Month 8 YTD

% of total contract

cost

BPAS £20,910 £18,921 £4,249 £6,142 £50,222 25.11%

Marie Stopes

International£84,409 £81,375 £23,971 £26,805 £216,560 108.28%

Fraterdrive Limited £0 £1,189 TBC TBC £1,189 0.59%

Total £105,318 £101,485 £28,220 £32,947 £267,971

Specsavers

Hearcare£78,790 £83,729 £14,220 £38,740 £215,479

Lewisham &

Greenwich Trust£43,479 £37,805 £14,088 TBC £95,372

Hearbase Ltd £2,297 £1,073 £389 £0 £3,759

Inhealth Ltd £4,879 £3,111 £3,847 TBC £11,837

Total £129,445 £125,718 £32,544 £38,740 £326,447

Anticoagulati

on

Bexley

Anticoagulation

Collaborative

£186,094 £172,943 £58,253 £58,145 £475,43592.69%

Termination

of Pregnancy

Direct Access

Hearing

33

M8 provider data is currently still being chased.

Provider Speciality POD Activity Value

Communitas Dermatology Firsts 260 £30,943

Follow ups 91 £3,249

OPROC 33 £4,249

Total 384 £38,441

DGT Minor Surgery Firsts 52 £8,609

Follow up

Daycase 31 £22,392

Diagnostics 1 £123

Total 84 £31,124

DGT Urology Firsts 35 £5,308

Follow up 34 £2,953

Diagnostics 6 £431

Total 75 £8,692

DGT Gynaecology Firsts 42 £6,670

Follow up 9 £918

OPROC 12 £1,862

Total 63 £9,450

Oxleas Gynaecology Firsts 108 £11,988

Follow ups 49 £3,381

OPROC New 67 £16,817

OPROC F/up 14 £2,926

Total 238 £35,112

LGT* Gynaecology Not specified £14,402

Total £14,402

GRAND TOTAL 844 £137,221

The CCG is undertaking due diligence to ensure that utilisation of these services increases. Also that services offer the capacity to ensure delivery against CCG plans. This will include communications to GPs to increase quality and number of referrals into these services, to ensure that a further shift from acute settings is evidenced. The CCG ensuring with the providers that the entire patient journey is captured within the AQP pathway and not fragmented into more complex acute pathways. We envisage that quality reporting against these providers will commence in January 2016. In addition the CCG is currently looking at options for increasing the number of dermatology clinics within the community, via an expansion of the existing AQP procurement arrangements.

2.6 Other Community Contracts

2.6.1 Pulmonary Rehabilitation

Respiricare will be running additional Pulmonary Rehabilitation courses to clear the

34

inherited waiting list from the previous provider. There will be a total of 4 courses running during January – March 2016 with additional assistants to support larger attendance at the courses.The aim for the 2016-17 is patients being assessed and placed on a course within 9 weeks of referral as per the contract agreement.

Pulmonary Rehabilitation referrals

There will be a total of 4 courses running during January – March 2016 with additional assistanst’s to support larger attendance at the courses.

2.6.2 Greenwich and Bexley Community Hospice

There has been an additional in-year and recurrent investment of £100,000 (full year

investment) agreed in order to maintain the temporary additional 2 in-patient beds. This will

support a key outcome target of ensuring that the end of life care support for Bexley

resident is able to deliver greater care capacity for those people with non- cancer

conditions such as respiratory illness and frailty.

The CCG and end of life clinical lead continues to work in supporting the hospice to

develop its services. The December 8th FSC meeting agreed a developmental program

commencing within this financial year, initiating strengthened community links that will

support the provision of extended services for people whose preference is to die within

their own homes. Two further developmental schemes are anticipated to commence early

2016/17 financial year In addition to this our medicine management team will be working

closely with the hospice and the CCG has agreed it will be funding the palliative care drugs

for Bexley residents at the Hospice.

Activity data presented from April to November 2015

Greenwich & Bexley Hospice Activity Data Qtr 1 Qtr 2 Oct-15 Nov 15

Total Referrals Inpatient Unit 94 89 24 22

Day Care 34 24 7 12

Community 179 181 64 60

Hospital 130 128 59 36

Lymphoedema 23 27 9 6

Rehabilitation 92 80 28 18

35

Total 552 529 191 154

Inpatient Admissions 71 57 19 16

Inpatient Discharges 36 15 6 6

Inpatient Deaths 37 40 12 10

Average Bed Occupancy 223.0% 252.9% 98.8% 99.0%

Average days Length of Stay 29 39.7 12.5 14.6

Outpatient Admissions Community 149 113 37 44

Hospital 114 107 51 33



Total 338 283 106 106

Number of Outpatient Deaths Community 95 106 38 32

Hospital 43 44 18 17

Lymphoedema 4 6 0 0


Total 158 176 63 55

Number of OP Discharges Community 36 30 4 5

Hospital 58 63 27 23



Total 146 149 45 44

Total Numbers Attending Day Care 316 288 111 97

Number of Day Care Deaths 5 4 3 0

2.6.3 Mildmay HIV Rehabilitation

There has been a rapid increase in the numbers of people living with HIV in Bexley which is

reflected in the current activity run rate for patients requiring inpatient/ day care/ respite

care for neurocognitive and complex symptom control/ physical rehabilitation at Mildmay.

The London Borough of Bexley’s JSNA reported that the number of people living with HIV

in Bexley has increased by 53% in the last five years (compared to 30% for England). A

public health awareness campaign is underway with free HIV home-sampling launched by

London Borough of Bexley to improve HIV testing and support early medical treatment/

intervention. A full business case for the Mildmay contract has been presented to Finance

Sub-Committee in December 2015.

36

2.7 Current Procurements 2.7.1 Following the approval for the AQP re-procurement for adult hearing services by the Governing Body, a project timetable has now been drawn up in order to ensure the delivery of the procurement prior to April 2016. Although there has been a slight delay, the AQP documents will be issued this month (w/c 8th January 2016). 2.7.2 Following the approval for the AQP re-procurement for termination of Pregnancy services by the Governing Body, subsequent discussions have been held regarding possibly having a pan-London procurement, which would give benefits in terms of market leverage, economies of scale, and sharing the burden of procurement administration. Timescales have now been finalised by the pan London group, and it is planned that a contract will be in place for 1st April 2017. In the interim Bexley are to re-advertise their current AQP so that additional providers can be invited to join. 2.7.3 The procurement of circa 20 beds for older people with dementia has now commenced. A Pre-Qualification Questionnaire has been issued, with a return date of January, a planned issue date for the Invitation to Tender in February, and a new contract to be in place for April 2016. 2.7.4 The procurement for Anticoagulation Services has commenced, the Pre-Qualification responses have been evaluated, the tenders have been returned, and a recommendation is due to go to the next meeting of the Governing Body. 2.7.5 The SE London 111 procurement is still in progress. However, the procurement

process has been delayed at the request of NHS England as they want to steer the

outcomes of the 111 re-procurements nationally. It is expected that the procurement

process will commence in March 2016. The procurement process is being managed by

South East CSU. Key risks caused by the delay have been identified and are being

managed by South East CSU.

37

Mental Health Contracting & Performance

Section 3 (Month 08 – November 2015)

Provided by the Integrated Commissioning Unit (ICU) for the CCG & LBB

This report on the mental health contracts performance has been structured as follows:-

3.1 Executive Summary

3.2 Financial Update

3.3 Mental Health Main Contracts

3.4 New Mental Health Access requirements (2015 / 2016)

3.5 Procurements

38

3.1 Executive summary

Work continues across the Mental Health Stocktake (with NHS England and our neighbouring CCGs), Transforming Care and implementation of the physical disability procurement.

Care and Treatment plans have been completed for the three patients currently in MH services that fall in scope of the Transforming Care program.

An overspend with South London and Maudsley NHS FT (SLaM) continues to be forecast as a result of continued increases in referrals from primary and secondary care.

3.2 Financial Update

3.2.1 All main budgets remain on track. SLaM continues to face overspend (see

below). 3.2.2 Actions are underway to transfer commissioning responsibility for out of

Borough s117 MHA patients to local CCG’s in line with responsible commissioner guidance.

3.3 Mental Health Main Contracts

3.3.1 Oxleas MH FT – Adult Mental Health Services Performance targets and clear definitions for shadow reporting in First Episodes of Psychosis are now available however formal guidance on reporting has yet to be issued by NHSE – this was expected in October but remains unavailable at present as final work continues to be done. Oxleas are confident that the proposed targets are already being met however guidance is awaited to define clearly the Child & Adolescent Mental Health (CAMHS) reporting expectations. Work has commenced with winter pressures and MH liaison review. 3.3.2 MIND in Bexley – IAPT Mind in Bexley have a 2015-16 contracted target of 3711 people (15% annually – 3.75% per quarter) of those in Bexley with a mental health condition entering first treatment. November 2015 has seen the monthly access target of 309 exceeded with 332 (un-cleansed data) people entering first treatment. At the end of November 2015, a total of 2486 people have entered first treatment. As at the same point in 2014/15, first treatment numbers stood at 1943. This evidences that the additional 2015/16 CCG investment of £67k is delivering the

39

desired performance outcomes. As at the end of the current reporting month, NHS Bexley CCG no longer has a First Treatment deficit with the overall First Treatment target - to date this has been exceeded by 14. The recovery rate in November has increased to 46% (45% in October). The CCG are now providing monthly IAPT reports to NHSE. 3.3.3 MIND in Bexley – Day Recovery & Employment Hub 3.3.4 Referral levels for this service remain high and during quarter 2, 326 new referrals were received.

3.3.5 Mind in Bexley have now produced a Recovery Prospectus and this can be accessed online.

The quarter 2 Quality Premium return was reported at 47% (service users from the caseload being supported in paid/unpaid work) against an annual target of 18%. The money management element of this service has engaged with 169 service users in quarter 2 and represented at 20 benefit tribunals, with a 100% success rate. In order to accommodate the demand for this service, Mind in Bexley have introduced introductory group sessions (approximately 2 per week) which allow greater numbers to initially access and learn about the service, before receiving 1-2-1 time with staff to decide and plan support, activities and groups they wish to attend. The quarter 2 contract meeting is took place on 7th December. No concerns raised though work is ongoing to revise and tighten KPI’s. Quarter 3 monitoring data will be submitted in January 16. 3.3.6 MCCH (Chapel Hill) - Mental Health Recovery Bed occupancy at Chapel Hill has increased from 78% in quarter 1 to 89% in quarter 2% for Quarter 2. The Chapel Hill service recorded 100% availability throughout the quarter and bed void days have reduced from 358 in quarter 1 to 181 in quarter 2. 183 respite and rehabilitation days were provided during the quarter – 66% utilisation. 3 service users have successfully moved on from the service Quarterly monitoring and monthly liaison through the Mental Health Placement and Advisory Panel will seek to increase potential referrals to the service with the ICU maintaining close links with sources of referral (Oxleas and OOB placement review). During the quarter, 3 new service users have been accepted and the service

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continues to provide trial support sessions and introductory outreach to prospective new tenants. 2 service users were successfully discharged into their own/supported accommodation. The quarter 2 contract meeting took place on 24th November. Quarter 3 monitoring data will be submitted in January 16.

3.3.7 Kent and Medway Partnership Trust – Acute Liaison Service During quarter 2, KMPT delivered a total of 122 client contacts against the monthly contracted target of 103 (119%). The quarter 2 saving to the CCG is recorded at £14,652. With no contract in place, the quarter 1 and 2 cost of service to the CCG would have been £63,070, against the overall contract value of £70,750. Work will commence with Kent commissioners to address the requirement for a more robust and integrated MH liaison service at both DVH and QEH. AD Finance and Health of Integrated Commissioning will be meeting with Kent colleagues to consider the options for joint commissioning MH liaison at DVH in November 2015. Quarter 3 monitoring data will be submitted in January 16. The quarter 2 contract

meeting took place on 24th November.

3.3.8 Out of Borough Service Provision

CCG Mental Health and Learning Disability Placements (Out of Borough

/ Spot Purchase

South London and Maudsley NHS FT Diagnosis /

Primary Presentation

No of Service Users

Notes

Autism 2

Both users under review

every 6 months and alternatives

being sought to repatriate appropriately

when possible

Mental Health 11

All patients appropriately placed and

under review

Learning Disability

2 2 well placed in long term

services

£150,000.00

£200,000.00

£250,000.00

£300,000.00

£350,000.00

£400,000.00

£450,000.00

£500,000.00

Ap

r

May Ju

n

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

South London and Maudsley 2015/16

Forecast Outturn to Year End

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3.3.8.1 South London and Maudsley NHS FT (Tertiary MH) At the end of November 2015 the forecast overspend to EOY now stands at 80%. Best efforts are being undertaken to reduce the costs where possible however continued increases in referrals from primary can secondary care and continued treatment of those already within the SLaM services will continue to add pressure to costs. Close monitoring will continue to take place with formal meetings with SLaM planned on a monthly basis for the foreseeable future. Support from Oxleas MH FT in triage will also aim to cap the current forecast overspend through triage support however referral rates of new patietns and those reminaing in what tends to be long term treatment (eating disorders as an example) is placing further pressure on this budget area. 3.3.8.2 Spot Purchased Placements (Mental Health) NHS Bexley CCG currently commissions very few out of Borough spot purchased placements although there has been some pressure on those with long term mental health problems who are aged (on average) >50 years old.

Invariably such patients require stable support provided through registered residential care and three such patients have been identified and will be presented at Mental Health Placements and Advisory Panel in October with the expectation of costs in the region of £800 per person per week (potentially with a 50% offset to London Borough of Bexley under s117 Aftercare). A list of out of Borough s117 patients has been compiled and a review of the funding of these placements has commenced in response to pressures that may be received from non – Bexley placements within in borough.

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3.4 New Mental Health Access Requirements

The requirements are as below and form part of both monthly activity reporting and key performance / quality indicators for Oxleas NHS FT, MIND in Bexley and providers to which these targets relate.

Service Area

Requirement Current performance RAG

IAPT

15% prevalence (3.75% per quarter)

In Quarter 2 2015-16, the 3.75% access target was met, with 928 people entering first treatment (against the quarterly target of 928).

50% recovery rates Quarter 2 reports 46% on an increasing

trajectory.

75% of adults to have 1st treatment session within 6 weeks of referral,

96.8% of people seen within 6 weeks

A minimum of 95% are to be treated within 18 weeks

99.6% seen within 18 weeks

DEMENTIA

Prevalence of 2945 patients diagnosed in 2015/16 (67% diagnosis rate required)

Currently 66.7% performance (end of September)

EARLY INTERVENTION IN PSYCHOSIS

50% of people experiencing a 1st episode of psychosis will receive treatment within 2 weeks

No formal guidance issued by NHSE yet however Oxleas are currently exceeding this target (currently 65% of patients treated within 2 weeks)

LIAISON PSYCHIATRY

IN ACUTE HOSPITAL SETTINGS

(ALL AGES)

Improved access to liaison psychiatry by 2020 across all groups to reduce admissions, reduce LOS

Currently working with Greenwich and Lewisham CCG’s to develop a co-commissioned plan towards Core 24 liaison Liaising with Kent CCG’s to work towards Core 24 liaison

All of the above requirements will be integrated into contract variations with conditional sanctions should targets not be achieved. The ICT continues to liaise with Oxleas to assure preparedness of the Trust for the shadow reporting of Early Intervention in Psychosis as from November 2015.

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3.5 Procurements

Pengarth A small (6 bed) LD rehabilitation service to support Local College First has been tendered. MCCH will be mobilising the service as from October onwards with full operational delivery expected in January 2016. Physical Disability and Sensory Impairment Services Five PQQ submissions have been received for this contract. These will be evaluated during January 2015 and shortlisted for Invitation to Tender as appropriate. Mind InBexley – IAPT and associated services The contract for IAPT and associated services ends in March 2016. Finance sub-committee have approved approve a contract extension for 2016 / 17 during which time the services will be retendered with operational delivery with the successful Provider to commence on 1 April 2017. Further updates will be provided in due course.

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111 Contracting & Performance

Section 4

Provided by SECSU

4.1 SEL 111 Performance Report November 2015

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4.1 SEL 111 Performance Report November 2015

111 KPIs from February 2015 to November 2015 (Unify Sit Rep Data)

In the last 10 months there has been a 5.75%1 increase in the percentage of calls passed to a clinical advisor for triage. In the same period the

call volumes reduced by 9.75%. This suggests that the service would currently require a higher ratio of clinical advisors to call handlers, when

compared to February 2015.

In the last 10 months the percentage of triaged calls dispatched to 999 was highest in November 2015, 9.52%, which is well above the average

of 8.01%.

Exception report for November 2015

66.86% of call backs were completed in 10 minutes, the contract states that 100% of call backs should be completed in 10 minutes.

Reasons for exception

Call backs in 10 minutes: Commissioners have agreed a let for a pilot to prioritise call backs.

1 All figures rounded to two decimal places

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Service update for impact on urgent care system This graph shows dispatches of red and green ambulances have been increasing since August 2015; in November 2015 the total number of calls

resulting in an ambulance dispatch reached the highest point since February 2015.

The table below shows a breakdown of 111 referrals by 999 and ED dispositions as a percentage of all triaged calls

The emergency department calls count the NHS Pathway’s dispositions called “Emergency Treatment Centres”. This includes the disposition codes

below. They may be referred to a UCC, ED or other acute service, depending on the profiles of services on the local Directory of Services.

Dx02 Attend Emergency Treatment Centre within 1 hour Dx03 Attend Emergency Treatment Centre within 4 hours Dx89 Attend Emergency Treatment Centre within 12 hours Dx92 Attend Emergency Treatment Centre within 1 hour for Mental Health Crisis Intervention

Dx94 Attend Emergency Treatment Centre within 1 hour for Sexual Assault Assessment

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From April 2015 to July 2015 referrals to emergency treatment centres were increasing, however, since July 2015 the rate of referrals to emergency treatment centres has fallen but hasn’t yet recovered to its pre April 2015 rate. The number of ambulance dispatches has risen slightly over the same period.

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The tables below show average calls per day for each month signposted to urgent care services located in South East London

- Having received an NHS Pathways emergency treatment centre disposition

54

- Having received an NHS Pathways primary care disposition

50

LAS Contracting & Performance

Section 5

5.1 Bexley CCG LAS Performance Dashboard

5.2 CAT A Performance Charts

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5.1 Bexley CCG March 2015 to Oct 2015 LAS Performance

Dashboard

Target

Monthly

Trajectory

(LAS)

Current

Month

Performance

YTD

Trajectory

(LAS)

Current YTD

Performance

75% 82.9% 63.9%

75% 61.2% 65.0%

95% 92.4% 93.7%

90% 41.6% 42.2% 50.5% 49.8%

99% 64.8% 67.2% 73.0% 73.5%

90% 50.9% 60.9% 52.5% 62.4%

99% 70.7% 80.1% 73.8% 81.4%

90% 73.0% 83.6% 73.5% 80.2%

99% 82.9% 87.9% 84.6% 88.1%

90% 52.1% 60.2% 55.7% 60.6%

99% 75.4% 81.4% 79.8% 84.2%

NHS Bexley CCG

Green 1 Performance (20 minutes)


Green2 Performance (30 minutes)




Performance Dashboard

Red 1 Performance (8 minutes)

Red 2 Performance (8 minutes)


Cat A Performance (19 minutes)


November Performance:

LAS continues to experience pressure across the system. The Trust remained at REAP level 4 (severe). Our weekly tri-partite updates continue

with our lead Commissioner, NHSE and the TDA.

• Red 1 (8 minute) monthly performance was 67.8% which is below the national standard of 75%

but in line with the revised monthly trajectory of 67.4%

• Red 2 (8 minute) monthly performance was 63.8% which is below the national standard of 75%

and below the revised monthly trajectory of 67.4%

• Category A19 monthly performance (19 minutes) was 92.8% which is below the national standard of 95 %

Hear and Treat numbers for November: 12,058 incidents resolved

Priority remains around safety and minimising the impact on quality – managed through a series of internal governance programmes and

external stakeholder engagement. We ask CCGs to continue to raise the profile around wider system pressures, in particular:

- Reduction of 111 conversions to 999 across London;

- Work with SRGs/ UCBs to understand, review & reduce demand.

Finance:

• System Resilience 2014/2015 - £1,359,726.00 (Barking & Dagenham CCG) – Disputing the invoice as advised they do not have an agreement

with the commissioners.

• SLA income 2015/16 (due 15 December 2015) – £14,221,919.48 (20 CCGs)

• Transformation 2015/2016 quarter 1 (April – June) - £1,437,310.99 (17 CCGs)

• Adrenaline Research Trial 2014/2015 - £11,468.31 (12 NEL CCGs) – This amount is being disputed as they advise correct process for authorising

the work was not being followed. (CV in place Nov. 2014)

• CQUIN 2015/2016 quarter 1 (April – June) - £25,536.17 (Waltham Forest CCG)

• CQUIN 2015/2016 (July & August) - £29,338.70 (2 CCGs)

• CQUIN 2015/2016 (September) - £8,955.49 (Haringey CCG)

• CQUIN 2015/2016 (October) - £37,411.05 (4 CCGs)

• CQUIN 2015/2016 (November) - £37,433.00 (4 CCGs)

• CQUIN 2015/2016 (December) - £166,455.00 (19 CCGs)

• Remaining 50% CQUIN 2015-2016 Quarter 1 (April- June) - £75,387.00 (3 CCGs)

LAS Messages

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5.2 CAT A PERFORMANCE CHARTS FOR October15

CCG Category Red 1 Performance Chart

CCG Category Red 2 Performance Chart

CCG Category A (R1 &R2) Performance Chart

CCG Category Cat A (R1 & R2) within 8 minutes and category A within 19 minutes Performance

Cat A

Incidents

within 8

mins

% within

8 minsytd Incidents

within 8

mins

% within

8 minsytd Incidents

within8

mins

% within

8 minsytd

within

19 mins

% within

19 minsytd

NHS Bexley CCG 33 18 54.5% 60.6% 1077 702 65.2% 65.6% 1110 720 64.9% 65.5% 1042 93.9% 94.0%

All CCGs (LAS) 1216 852 70.1% 67.0% 42600 27620 64.8% 65.0% 43816 28472 65.0% 65.0% 40708 92.9% 93.4%

Cat A sub category Red 1 Cat A sub category Red 2 Cat A 8 performance Cat A 19 performance

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Calls Resolved by Telephone Advice (LAS)

The following graph shows the number of calls resolved through telephone advice without the further neeed for transport

Activity totals include incidents, Hear & Treat and Surge