joint committee of barking and dagenham, havering and ......jan 25, 2018 · herts – until 09/16....

Joint Committee of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

25 January 2018 1.30pm

Boardrooms, Becketts House, Ilford, IG1 2QX

Item Time Lead director

Attached, verbal or to follow

1.0 1.1 1.2

1.3

Welcome, introductions and apologies Declaration of conflicts of interest Minutes of the meetings held in November & December 2017 Matters/actions arising

1.30 Chair Attached Attached

Attached

2.0 2.1 2.2 2.3

Chair and chief officer reports Chairs’ report Accountable officer’s report Patient engagement report

1.35 1.40 1.45

Chairs JM SW/RC/KA

Attached Attached Attached

3.0 3.1 3.2

Governing body assurance Governing body assurance framework Barts Health Contract Briefing

2.00 2.10

MP LE

Attached

4.0 4.1

4.2

Corporate strategy and planning Emergency Preparedness, Resilience and Response update 18/19 operating and QIPP plans

2.20

2.30

MP

LE

Attached

5.0 5.1 5.2 5.3

Quality and performance Integrated performance report Finance risk overview Report Quality report

2.40 2.50 3.00

LE TT JH


6.0 6.1

6.2 6.3 6.4 6.5

Development/governance Terms of reference for Joint Committee, Quality & Safety Committee, Finance & Delivery committee and FRPB FRPB Chair’s report Finance & delivery committee chair’s report Audit & governance committee chair’s report Minutes of committees and relevant fora:

• Quality & safety committee• Patient engagement forum

3.10

3.20 3.25 3.30 3.35

MP

TT KP KP

Attached


7.0 AOB 4.00

8.0 Questions from the public 4.05

9.0 Date of next meeting – 29 March 2018 4.15

1

Glossary of terms and abbreviations

Term Explanation

AO Accountable Officer

ACS Accountable Care System

ADL Activities of Daily Living

APC Area Prescribing Committee

ASH Accredited Safe Haven

BCF Better Care Fund

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking, Havering and Redbridge University Trust

BPPC Better Payment Practice Code

CAPS Clinical Application Services

CCG Clinical Commissioning Group

CCS Complex Care Service

CD Clinical Director

CDOP Child Death Overview Panel

CEO Chief Executive Officer

CFO Chief Finance Officer

CHC Continuing Healthcare

CHS Community Health Services

CHSCS Community Health and Social Care Services

CIL Community Infrastructure Levies

CO Chief Officer

COO Chief Operating Officer

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CSU Commissioning Support Unit

2

CTT Community Treatment Team

CVS Council of Voluntary Services

CYPP Children and Young Person Plan

DOH Department of Health

DTOC Delayed Transfer of Care

ECG Electrocardiogram

EHC Education, Health and Care

ELHCPB East London Health and Care Partnership Board

EMT Executive Management Team

EoI Expression of Interest

EOL End of Life Care

FNP Family Nurse Partnership

FRPB Financial Recovery Programme Board

FRPDM Financial Recovery, Planning, Delivery and Monitoring

FT Foundation Trust

FYE Full Year Effect

GBAF Governance Board Assurance Framework

GP General Practitioner

H4NEL Health for North East London

HCAIs Healthcare Associated Infections

HE NCEL Health Education North Central and East London

HLP Healthy London Partnership

HSC Health Scrutiny Committee

HWBB Health & Wellbeing Board

IAPT Improving Access to Psychological Therapies

ICPB Integrated Care Partnership Board

ICM Integrated Case Management

ICSG Integrated Care Joint Health and Social Care Steering Group

IFR Individual Funding Request

IRS Intensive Rehabilitation Service

IST Intensive Support Team

3

JAD Joint Assessment and Discharge Service

JCC Joint Commissioning Committee

JEC Joint Executive Committee

JHWS Joint Health & Wellbeing Strategy

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPIs Key Performance Indicators

LAC Looked After Children

LAS London Ambulance Service

LETB Local Education and Training Boards

LMCs Local Medical Committees

LPC Local Pharmaceutical Committee

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

MASH Multiagency Safeguarding Assessment Hub

MD Managing Director

MLU Mid-wife Led Unit

MOU Memorandum of Understanding

MSRB Maternity Systems Readiness Board

NEL North East London

NELCA North East London Commissioning Alliance

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS National Health Service

NHSE NHS England

NHSI NHS Improvement

NICE National Institute for Health and Care Excellence

OFSTED Office for Standards in Education, Children’s Services and Skills

OD Organisation Development

ONEL Outer North East London

PALS Patient Advice and Liaison Service

4

PEFs Patient Engagement Forums

PELC Partnership of East London Cooperatives

PMCF Prime Minister’s Challenge Fund

PMO Project Management Office

POD Point of Delivery

POLCV Procedures of Limited Clinical Value

PPGs Patient Participation Groups

PSED Public Sector Equality Duty

PTL Patient Tracking List

QIPP Quality, Innovation, Productivity and Prevention

RAG Red, Amber, Green

RTT Referral To Treatment

SAB Safeguarding Adults Board

SCB Safeguarding Children’s Board

SCN Strategic Clinical Network

SDPB System Delivery Programme Board

SRO Senior Responsible Officer

STP Sustainability and Transformation Plan

TDA Trust Development Agency

TSCL The Transforming Services – Changing Lives

UCC Urgent Care Centre

UCL University College London

UCLP University College London Partners

UEC Urgent and Emergency Care

UTI Urinary Tract Infection

VFM Value for Money

WELC Waltham Forest, East London and City

WICs Walk in Centres

YTD Year to Date

5

1

Register of interests 2017/18 (Conflicts of interest remain on the register for a minimum of 6 months following expiry)

Last updated: January 2018

Name Role Organisation Nature of interest

Amendment and date

Dr Waseem Mohi

Chair Markyate Surgery Together First Limited London Wellbeing Care Ltd Kensington and Chelsea CCG

Sessional GP Shareholder (May 2014) Director GP partner

Peartree surgery, Herts – until 09/16. Added 20/4/14

Dr Ravali Goriparthi

Clinical director Tulasi Medical Centre Tulasi Properties Ltd Health & Happiness Clinic Ltd Barking, Dagenham and Havering LMC Royal College of General Practitioners

GP Partner. Spouse is practice manager (19/9/06) Director / Shareholder (1/8/16) Director / Shareholder (1/8/12) Member (7/9/09) Member

Lilly Pharmaceutical Company Limited-removed 1/12/16

6

2


Amendment and date

Together First Ltd

Shareholder (June 2017)

Dr Jagan John

Clinical director King Edward Medical Group LMC (Barking, Dagenham & Havering) North East London Foundation Trust Together First Limited (from May 2014) Health 1000 (December 2014) Prime Minister’s Challenge Healthy London Partnerships

GP Partner, other GPs are family members (2010) Member (2013) GPwSI in Cardiology BD CHS (2011) Shareholder Director Lead (2015) GP lead – self care

Dr Rami Hara

Clinical director Urswick Medical Centre Pharmaceutical companies Together First Limited (from May 2014) London Deanery

GP Principal Speaker fee - Chair and speaker at educational lectures/meetings Shareholder GP registrar trainer

7

3


Amendment and date

NHSE Barts Hospital & Queen Mary’s University

GP appraiser (mainly Havering) Undergraduate Tutor (18/10/16)

Dr Gurkirit Kalkat

Clinical director Thames View Health Centre Primary Clinical Partnership Ltd Apex Healthcare Ltd Queen Mary Medical School, London Together First Limited (from May 2014) BHR CCGs

GP Principal Director/owner or part owner/ Share holder Director/owner or part owner/ Share holder Honorary Lecturer Shareholder Area Prescribing Chair

Dr Anju Gupta Clinical director

Abbey Medical Centre Together First Limited

GP Principal and CCG lead for diabetes. Practice employs a GP who is the spouse of a BHRUT director Member (2014)

8

4


Amendment and date

NELFT NHSE Wilson Mason PLC Barking, Dagenham & Havering LMC

GPwSI – Diabetes (2009) GP appraiser (2013) Spouse employed as an architect and company undertakes NHS work (2015) Member (2015)

Dr Kanika Rai

Clinical director White House Surgery Together First MacMillan London Deanery Queen Mary’s University and Imperial College

GP partner. Sister is a GP a partner and is also a GPwSI dermatology. Brother is also a partner Shareholder (May 2014). Brother is also a director Cancer lead GP for B&D(2015-17) FY2 and GP trainer (2013) Undergraduate tutor (2007)

Sahdia Warraich

Lay member The Forum for Health and Wellbeing

Director (paid employee)

9

5


Amendment and date

The Forum for Health and Wellbeing Trading Ltd Heathwatch Redbridge London Borough of Redbridge Newham Deanery

Company Director Member (1/4/13) Spouse is a Councillor Trustee

Healthwatch Waltham Forest Removed 11/7/17 Healthy Island Partnership Removed 13/11/17

Kash Pandya

Lay member - Governance

Essex Ministry of Justice Advisory Committee Brentwood Citizen’s Advice Bureau Havering CCG Redbridge CCG PricewaterhouseCoopers Accenture University of Essex

Lay Member (2010-18) General advisor (2009) Lay Member Lay Member Kiren Pandya (son) Management consultant (2013) Anand Pandya (son) Solicitor Independent Audit Committee member (2013-19)

Hillcroft College for women, Surbiton – removed May 2017. Health & Safety Executive – removed May 2017. Berwin Leighton Paisner (BLP) removed May 2017. Her Majesty’s Inspector of Constabulary-removed Jan 2018

10

6


Amendment and date

Southend on Sea Borough Council

Independent Audit Committee Member (2016-18)

Charles Beaumont

Associate Independent Lay Voting Member for Audit Committee and Individual Funding Request Panel

None None

North Essex Partnership Foundation Trust – removed 25/4/17

Sharon Morrow Chief operating officer None

None

Tom Travers

Chief financial Officer Royal Free Foundation Trust Wife works in finance department

Jacqui Himbury Nurse director None

None

Gina Shakespeare

Director, Delivery & Performance (Interim)

Regina Shakespeare Consulting

Owner

Jane Gateley Director, Strategy & Integration

Hurley Group Partner is a director

Sarah See

Director, Primary Care Transformation

NELFT Churchill Medical Services, Chingford

Partner is an employee Family registered with the practice.

11

7


Amendment and date

Jane Milligan Accountable Officer,

NEL CCGs

North East London CSU NHS England Action for Stammering Family Mosaic Housing Association Stonewall Peabody Housing Association Board Chartered Physiotherapists St Paul’s Way Trust school

Partner is a substantive employee Partner on secondment - London Regional Director for primary care Partner is a Trustee Non-Executive director Ambassador Non-Executive Member (non-practising) Trust Governing Body Member

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1

Register of interests 2017/18 (Conflicts of Interest remain of the register for a minimum of 6 months following expiry)



Amendment and date

Dr Atul Aggarwal

Chair Maylands Healthcare Maylands Healthcare Ltd Parkview Dental Practice Essex Medicare LLP which owns Westland Clinic, Hornchurch. Space rented out to:- -InHealth (Diagnostic) (Jan 2014) -Nuffield Health (Brentwood) (Jan 2014) -Communitas Clinics (dermatology) (Aug 2014) Havering Health Limited

GP Partner (April 2013) Director and shareholder in onsite pharmacy (April 2013) Sister is NHS dentist within Havering (1996) Part owner Shareholder (Sept 2014). GP Partner at Maylands Surgery

Saag Properties Services LTD – removed Jan 2017 HAVCO - removed Jan 2017

13

2


Amendment and date

Barking, Dagenham & Havering LMC

– (Dr Kendall) is a director (Nov 2014) Co-opted member (2013)

Dr Alex Tran

Clinical director

Hornchurch Healthcare, The Medical Centre Hornchurch Healthcare Limited Havering Health Limited (from August 2014)

Principle GP Director Shareholder

NHSE & the Cancer Commissioning Board -removed Jan 2017

Dr Gurdev Singh Saini

Clinical director South End Road Practice National ME Charity St Francis Hospice Barking, Dagenham and Havering LMC Barking, Dagenham and Havering LMC Limited

Sessional GP (sept 2015) Chair Trustee Member Director

Lynnwood medical centre – removed Jan 2017

Dr Ochuko Maurice Sanomi

Clinical director

Rush Green Medical Centre Havering CCG

Partner (May 2000) GP Tutor / Education Lead

14

3


Amendment and date

Practice Based Clinical Services (PBCS) Ltd Inspirehealth Ltd (not trading) Local Medical Committee Havering Health Limited

Director & shareholder (2007) Director & shareholder (2013) Member Shareholder & member (Aug 2014)

Dr Ashok Deshpande

Clinical director Wood Lane Medical Centre (WLMC) Dermatology service (Communitas) Barking & Dagenham, Havering LMC Havering Health Limited Nuffield Health

General Principal & senior partner. Wife, daughter & son-in-law are GP partners at WLMC (1989) Weekly clinic conducted from Wood Lane Medical Centre. GP partner (daughter) covers dermatology sessions for Communitas Member Shareholder. GP partner at WLMC is chair of Havering Health Federation (August 2014) Wife works in gynaecology (2017)

15

4


Amendment and date

Ann Baldwin

Clinical Director The Central Park Surgery Barking & Dagenham, Havering LMC Havering Health Limited Havering CCG Royal College of General Practitioners, British Society of Rheumatology

GP Partner (2009) Chair (June 2015) Shareholder (Aug 2014) GP Appraiser (2012) Member (2012)

Kash Pandya


Essex Ministry of Justice Advisory Committee Brentwood Citizen’s Advice Bureau B&D CCG Redbridge CCG PricewaterhouseCoopers Accenture University of Essex

Lay Member (2010-18) General advisor (2009) Lay Member Lay Member Kiren Pandya (son) Management consultant (2013) Anand Pandya (son) Solicitor Independent Audit Committee member (2013-19)

Hillcroft College for women, Surbiton – removed May 2017. Health & Safety Executive – removed May 2017. Berwin Leighton Paisner (BLP) removed May 2017. Her Majesty’s Inspector of Constabulary-removed Jan 2018

16

5


Amendment and date

Southend on Sea Borough Council

Independent Audit Committee Member (2016-18)

Charles Beaumont


None None North Essex Partnership Foundation Trust -removed 25/4/17

Richard Coleman

Lay member - PPI

Richard Coleman Associates Ltd 1-2-1 Social Enterprise PricewaterhouseCoopers BHR CCGs

Director/co-owner. Spouse also a director/co-owner (April 2013) Associate providing mentoring on pro bono basis mentoring to the NHS (Oct 2014) Nephew is a partner (Aug 2013) Brother in law is Independent GP

Alan Steward

Chief operating officer

Steward and Steward Ltd

Director. Partner is also a Director

Tom Travers

Chief financial officer

Royal Free Foundation Trust

Wife works in finance department

Jacqui Himbury

Nurse director

None

17

6


Amendment and date

Gina Shakespeare



Owner



Sarah See




Jane Milligan Accountable Officer, NEL CCGs



18

7


Amendment and date

19

1

Register of interests 2017/18 (Conflicts of Interest remain on the register for a minimum of 6 months following expiry)



Amendment and date

Dr Anil Mehta

Chair

Fullwell Cross Medical Centre Metropolitan Police The cleaning company NHS England (Feb 2015) Healthbridge Direct (from September 2014) Fouress Enterprises Ltd

GP Partner Forensic Medical Examiner Owner - Sister in law GP Appraiser Shareholder Director

Dr Sarah Heyes

Clinical director

The Shrubberies Medical Centre Healthbridge Direct (from September 2014)

GP Partner/Principal Shareholder

Dr Muhammad Tahir

Clinical director Forest Edge practice, Hainault Health Centre

GP Partner

20

2


Amendment and date

Dagenham & Redbridge Football Club Redbridge local medical committee Healthbridge Direct (from September 2014)

Medical adviser & club doctor Member Shareholder

Dr Mehul Mathukia

Clinical director Mathukia surgery Dr Chawla & Partners Valia Consultancy – Healthcare & research consultancy PELC NOCLOR and NIHR Healthbridge Direct (from September 2014)

GP Principal GP Partner from 1/5/16. Brother is a GP Principal Director/Owner/Shareholder GP Locum GP research champion Share Holder

Dr Shabana Ali

Clinical director

Southdene Surgery Healthbridge Direct

GP Partner/Principal. Shareholder. Daughter

Daughter receptionist at Southdende surgery – removed Jan 2018.

21

3


Amendment and date

(from September 2014) North East London Foundation Trust Avicenna Ltd BMA RCGP NHSE

works is receptionist/admin. GP with special interest in cardiology Director. Husband is also a director Member Member GP appraiser (B&D CCG, Havering CCG)

Dr Syed Raza

Clinical director Seven Kings surgery Raza Syed Medical Ltd Healthbridge Direct (from September 2014) PELC

GP partner (Oct 2017) Director (June 2014) Employed at surgery that is a shareholder. Employed as locum in the Hub. Locum GP

Redbridge Fairness Commission – removed Jan 2017 Chadwell Heath surgery – removed Sept 2017

Dr Jyoti Sood

Clinical director Newbury Group Practice ESS Wanstead Ealing Hospital NHS

GP Partner (2003) GPwSI – Diabetes & Dermatology (2011) GPwSI – Diabetes &

Redbridge GP Alliance Federation – removed April 2017

22

4


Amendment and date

Trust Soods Limited – Locum agency NHS England London Deanery Imperial College Communitas Clinics (Havering) Redbridge LMC Care Quality Commission (CQC) Healthbridge Direct DMC Healthcare (1/8/17) Health Education England

Dermatology (2010) Director. Husband is a partner (2005) GP appraiser (2003) GP trainer (2004) Undergraduate GP trainer (2011) Provide minor surgery (2013) Member (Sept 2016) Special Advisor (Sept 2016) Shareholder (April 2017) GPwSI – diabetes and dermatology Associate director of education (Ilford & Romford)

Dr Anita Bhatia Clinical director Southdene surgery

GP partner

23

5


Amendment and date

Healthbridge Direct Mychem Ltd Phoenix Medics Ltd Essex Local Prescribing Committee

Shareholder (Sept 2014) Husband is owner/director of pharmacy – Mid Essex CCG Brother is a director – freelance GP-services to NHS/private sector Husband does remunerated ad-hoc work

Dr Shujah Hameed

Clinical director Castleton Road surgery Partners in Healthcare Healthbridge Direct PELC BHR GP Solutions

GP Partner Director (1/2015) Locum GP (1/2015) Locum GP (1/2015) Locum GP (1/2016)

Added May 2017. Locum GP at Castleton Rd – removed 24/5/17

Ah-Fee Chan

Secondary care consultant

North Middlesex University Hospital NHS Trust Nadia Medical Services Ltd (March 2015)

Consultant in Anaesthetics and Intensive Care Medicine Director of the company providing consultant services at a range of private facilities in London

24

6


Amendment and date

where practice privileges are given

Charles Beaumont


None None North Essex Partnership Foundation Trust – removed 25/4/17

Louise Mitchell

Chief operating officer None None

Tom Travers

Chief financial officer

Royal Free Foundation Trust

Wife works in finance department

Jacqui Himbury

Nurse director

None

Khalil Ali

Lay member

Dr Joseph’s GP practice, Collier Row, Romford St Francis Hospice, Havering Cancer Research

Family GP Spouse is donor Spouse is a donor

Kash Pandya


Essex Ministry of Justice Advisory Committee Brentwood Citizen’s Advice Bureau

Lay Member (2010-18) General advisor (2009)

Hillcroft College for women, Surbiton – removed May 2017. Health & Safety

25

7


Amendment and date

Havering CCG Redbridge CCG PricewaterhouseCoopers Accenture University of Essex Southend on Sea Borough Council

Lay Member Lay Member Kiren Pandya (son) Management consultant (2013) Anand Pandya (son) Solicitor Independent Audit Committee member (2013-19) Independent Audit Committee Member (2016-18)

Executive – removed May 2017. Berwin Leighton Paisner (BLP) removed May 2017. Her Majesty’s Inspector of Constabulary-removed Jan 2018

Gina Shakespeare



Owner



Sarah See




26

8


Amendment and date

Jane Milligan

Accountable Officer, NEL CCGs



27

Minutes of the Joint Committee of Barking and Dagenham, Havering and Redbridge

Clinical Commissioning Groups 30 November 2017

2.30pm Becketts House

Present Barking & Dagenham CCG Dr Waseem Mohi (WM) Clinical Director/Chair Dr Gurkirit Kalkat (GK) Clinical Director Dr Anju Gupta (AG) Clinical Director Dr Ramneek Hara (RH) Clinical Director Dr Ravali Goriparthi (RG) Clinical Director Dr Kanika Rai (KR) Clinical Director Sharon Morrow (SM) SRO – Unplanned care Sahdia Warraich (SW) Lay member – patient and public involvement Havering CCG Dr Atul Aggarwal (AA) Clinical director/Chair Dr Maurice Sanomi (MSan) Clinical director Dr Gurdev Saini (GS) Clinical director Richard Coleman (RC) Lay member – PPI & Vice Chair Alan Steward (AS) System OD and Transition SRO Redbridge CCG Dr Anil Mehta (AM) Clinical Director/Chair Dr Syed Raza (SR) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Shujah Hameed (SHam) Clinical Director Dr Jyoti Sood (JS) Clinical Director Dr Anita Bhatia (AB) Clinical Director Dr Shabana Ali (SA) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Khalil Ali (KA) Lay Member-PPI Louise Mitchell (LM) SRO – Planned care BHR CCGs Conor Burke (CB) Chief officer Tom Travers (TT) Chief finance officer Regina Shakespeare (RS) Interim Director of Delivery & Performance Jacqui Himbury (JHim) Director of nursing Kash Pandya (KP) Lay member – governance

In attendance Anne-Marie Keliris Company secretary – BHR CCGs Marie Price (MP) Director of corporate services – BHR CCGs Lee Eborall (LE) NELCSU Susan Lloyd (SL) LBBD Vicky Hobart (VH) LBR

28

2

Cathy Turland (CT) Healthwatch Redbridge Apologies Dr Ann Baldwin (AB) Clinical director Dr Ashok Deshpande (AD) Clinical director Dr Ah Fee Chan (AFC) Secondary Care Consultant Dr Alex Tran (AT) Clinical director

Item Action

1.0 Welcome and apologies The Chair welcomed members to the meeting and apologies for absence were noted.

1.2 Declarations of conflicts of interest

Dr Anil Mehta, The Chair of the meeting reminded members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of the BHR clinical commissioning groups. Declarations declared by members of the governing body are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link: http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm http://www.haveringccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

1.3 Minutes of the last meeting

The minutes of the meetings held on 26, 27 and 29 September 2017 were agreed as a correct record.

1.4 Matters/Actions arising

The joint committee noted the actions taken since the last meeting.

2.0 Chair & Accountable Officer’s Reports

2.1 Chair’s report The Chair presented his report covering the following areas: The governing body noted the report.

Working collaboratively North East London commissioning developments Financial situation System developments, including networks and localities Meetings

The joint committee noted the report.

29

http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm


http://www.haveringccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm


http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm


3

2.2 Chief Officer’s report CB presented his report covering the following areas:

BHR System Delivery Plan BHR Accountable Care System and Sustainability and

Transformation Plan (STP) CCG Development CCG Assurance Winter Planning Health and Wellbeing Board update

CB reported that this was his last meeting as accountable officer and thanked the members for their support. KA thanked CB on behalf of his lay member colleagues. The Chair also expressed his thanks on behalf the CCGs’ governing bodies. The joint committee noted the report. 2.3 Patient experience report KA presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:

The Joint Patient Engagement Forum (PEF) NHS England (NHSE) assessment against patient engagement

indicator – good rating Local updates CQC patient experience A&E report

The joint committee noted the report. Dr Gupta, Dr Rai and Alan Steward arrived at 2.55pm

3.0 Governing body assurance

3.1 Governing body assurance framework MP presented a report which outlined the key risks to the clinical commissioning groups in achieving its corporate objectives as identified in the governing body risk assurance framework. There are five risks on the GBAF which includes one risk newly escalated. Risk ratings are based on the October 2017 risk register. The five risks on the GBAF are :-

1. Risks to the delivery of the Clinical Commissioning Groups’ (CCGs) budget

2. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance

3. Barts Health (BH) performance against key targets, A&E and RTT 4. BH quality concerns

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4

5. BHRUT’s mortality rate is higher than expected and indicates the number of patients dying for certain clinical conditions is higher than the expected number of patient deaths.

KA referred to risk 5.7 and was alarmed to see BHRUT mortality rate is higher than expected and questioned when change is expected. JH reported that further detail is within the quality report and added that the Trust now have access to data that indicates that the level is decreasing but assurance will not be available until December when SHMI data is available. It was noted that the quality and safety committee will receive a report on this. SW commented that it was important that the lead commissioner meets with BHR CCGs to give assurance on Barts Health position. It was agreed to write to the lead commissioner to invite them to the next meeting. KP welcomed the month by month tracker, which was helpful to see improvements by year end. He added that he was concerned by the forecast for Barts Health given their unreliable performance and felt this should be reviewed. The Chair referred to the support that BHR CCGs gave to BHRUT recovery and suggested that any support offered to Barts Health is included in future reporting. LM agreed, she reported that the CCGs have shared their BHRUT recovery plan, and will include any update on this in future reporting. The Chair questioned whether there is confidence in Barts Health completing the demand and capacity modelling by March 2018 that achieves compliance with the RTT standard by September 2019. CB responded that this would be part of the request to lead commissioners to give assurance to the CCGs, along with finance, activity and performance information. The joint committee noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken.

LM LM

4.0 Corporate strategy and planning

4.1 NEL commissioning arrangements AS presented a report on the new commissioning and governance arrangements across North East London, following the appointment of a single accountable officer. The report specifically addressed:

Local decision-making and accountability. Resources and leadership. Governance and structures that ensure that each CCG will be fully

involved in decisions that affect their boroughs. Proposals for a commissioning strategy that provides assurance

that co-commissioning with local authorities for local services continues, but identifies and sets out services that would benefit from strategic alignment across NEL.

The initial Executive arrangements.

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5

The potential risks arising from these proposal and the mitigating actions.

Next steps to ensure that arrangements are implemented formally for 1 April 2018 with robust transition arrangements.

Detailed proposals will be brought to the December joint committee for decision on the governance and executive arrangements. SW requested clarification on line management arrangements for the single accountable officer. AS confirmed that this was held by the CCG Chairs and there had been agreement by the Chairs that this would sit directly with the Chair of Chairs. JJ referred to the Tower Hamlets CCG leading communications and engagement and questioned how this was agreed. AS confirmed that the Chairs had each agreed to lead on a particular area. MT referred to the cost allocation by weighted population and whether there is any timeframe to review this as BHR CCGs were under resourced and any change had risks attached. AS confirmed that it had been agreed to share any associated costs on a weighted population basis. He added that for 18/19 CFOs had been asked to review the best way to allocate costs. MM left the meeting at 3.35pm GS expressed concern that CCGs were losing their individual identity and that staff were being moved from Havering offices. He also raised concern that there is one managing director for BHR CCGs and other boroughs will have individual managing directors. MP reported on the consultations for administration staff and staff bases. It was also noted that there is no change to primary care staff teams who continue to be based at each head office. AS reported that managing director proposals reflect the current arrangements within each CCG. CB added that the BHR CCGs operating model is working well and other areas could be challenged to do similar. GS suggested that allocation of responsibilities needs to be clearer. AS agreed that there is a need to strengthen exact arrangements in the operating model and reported there is still further work to the done. KA welcome lay member involvement in shaping future working. KP welcomed the changes to governance arrangements to be reviewed in January and reported that the Audit Chairs will be meeting to discuss associated risks. TT requested clarity on funding for the Director of Strategic Commissioning role to ensure this is cost neutral. AS agreed to provide further information on this, adding it was an interim arrangement and that costs would be split on a weighted population basis.

AS

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The joint committee: • Noted the progress made and provide any comments • Approved the recruitment of an interim Director of Strategic Commissioning subject to confirmation of cost neutrality. 3.45pm Cathy Turland left the meeting.

5.0 Quality and performance

5.1 Integrated contract report RS presented the integrated performance report which included finance and activity, in its contracted services, to identify the key risks presented by that performance and provide assurance that those risks are being appropriately managed. The report is based on month 6 activity and month 7 finance information. The main points of note are: BHRUT: The BHRUT 2017/18 financial forecast across the three CCGs is £8.4m above plan. This over spend is driven by over performance in the following areas: elective, maternity, day cases and outpatients. One of the key drivers of the projected overspend is the increased average unit cost of non-elective activity compared to last year. An independent audit was commissioned to review non-elective case mix and price increases. The audit outcome is due to be finalised by the end of November. Following voluntary independent mediation entered into by the BHR CCGs and the Trust on 26 - 27 October, the mediator found in favour of the BHR CCGs on a number of items including recommending a cap on the level of unwell babies at 27% (compared with the current recorded levels of 60%), and recommending a re-basing of the Marginal Rate Emergency Tariff to reflect National Tariff Payment System (NTPS) Guidance. Based on the mediation outcome, and all other adjustments (for QIPP, metrics, penalties, automated claims and technical adjustments), the total net benefit to the BHR CCGs for quarter 1 is £6.8m. BHR CCGs wrote to the Trust on 10 November to finalise the quarter 1 reconciliation and as at 14 November, a Trust response remains outstanding. At the meeting of the Trust Board on 1 November, the Trust reported extreme pressure on its cash position and risk to liquidity due to unpaid over performance, a deterioration of creditor debt and additional supplier expenditure. BHR CCGs have paid the Trust in line with the cash profile agreed within the 2017/18 contract, and additionally supported the Trust with a £4m advance (paid on 12 October) pending conclusion of the contractual processes and an understanding of the Trust’s cash forecast. Modelling the impact of the quarter 1 mediation, and accounting for the £4m advance, BHR CCGs have a £3.36m credit due from the Trust. 4 contractual notices remain open and active with the Trust, however a period of purdah in respect of formal contract actions to support the mediation process had been agreed between Commissioners and the Trust which was originally agreed to end on the 31 October 2017 but remains in discussion. On performance, against constitutional performance measures, the Trust met all 8 cancer standards in the month of September and for quarter 2. RTT performance in September was 91.5% against the 92% standard. The monthly 52 week wait reported position indicates 15 patients having waited over 52 weeks in September, down from 17 in August. The 4 hour

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A&E performance in September was 87%, slightly below the recovery trajectory of 90%. Barts Health: The Barts Health 2017/18 financial forecast across the three CCGs is £7.4m above plan. Referrals are 12% lower year-to-date when compared to the same period in 2016/17. Despite the reduction in reported referrals, outpatient and elective activity are over plan year-to-date. The level of un-coded activity has reduced from 14% last month to 6.3% but still represents a financial risk of 16.3% of spend. Commissioners expect a further improvement next month. The quarter 1 reconciliation has been completed with a number of issues escalated to a Chief Officer meeting on 10 November. Unfortunately, these items were not concluded. Commissioners are due to propose that parties seek to appoint a technical mediator to help resolve the disputes relating to the quarter 1 reconciliation. On performance against constitutional performance measures, September performance against the 62 day cancer wait indicates an outturn of 95.9% and recovery of quarter 2 performance at 85.1%. The Trust underperformed against the 4 hour A&E standard and achieved 87.05% in October against the STF trajectory of 90.82%. The Trust has agreed to return to reporting in April 2018 and the Trust has confirmed that all 52 week waiters will be cleared by March 2018. NELFT: The mediated negotiation which took place on 6 - 7 November has been completed. The mediation outcome includes a reduction to the contract value of £1.6m (community and mental health elements combined) which reflects both QIPP delivery and Commissioner investments and set out requirements for more detailed reporting of costs by the Trust in the 2018/19. Following the mediated negotiation, outstanding matters for 2017/18 are being concluded through a contract variation. Quarter 2 IAPT performance shows good achievement of recovery targets for Havering and Redbridge. Barking and Dagenham missed the target of 50% with performance of 44%. IAPT Access targets not being met consistently. Against the 3.75% access target, Barking and Dagenham, Havering and Redbridge CCG performance is at 3.5%, 2.91% and 3.91% respectively. KA referred to £15m relating to other providers and suggested it would be useful to have more information on this. JJ expressed disappointment that BHRUT had not been willing to abide by independent auditors findings and questioned what the underlying issue to this could be. It was noted that with regard to mortality the CCGs needs to support the local provider by being clear about its position and its responsibility to its population. WM questioned when service line reporting for NELFT will be available. TT responded that fhe first cut will be available at end of January and the second cut at end of February. The joint committee noted the report and asked that the next report strengthen action taken. Susan Lloyd left the meeting at 4.00pm

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5.2 Finance & activity report TT presented the month 7 BHR CCGs finance and activity report which highlighted the revised forecast deficit position of £25.2m (slippage of £10.2m against plan) and year to date slippage of £13.8m (slippage of £5m against plan). These positions include the 17/18 in year deficit and the historic deficit reported by Havering CCG. The in-year forecast deficit is £20.4m and the year to date deficit is £11m. The revised forecast assumptions were subject to an independent review by Internal Audit and a sub group of the Audit Committee. The assumptions were signed off as a prudent view based on the latest view of contractual positions. The forecast position reported for the BHRUT contract is based on the technical view of the independent mediation entered into for Quarter 1. However, until the CCGs receive a confirmed position from the Trust in relation to the mediation there remains an element of risk within the reported position for BHRUT. For Barts there are contractual processes in place and the forecast is based on a technical view of the latest Quarter 1 reconciliation. A number of items are still not agreed with Barts and these will be escalated. This has resulted in forecast overspends at BHRUT of £8.4m and £7.4m at Barts. For other Associate contracts and Independent Providers the reported forecasts are based on the latest activity and referral trends. The other main areas of spend including Continuing Health Care (CHC), Prescribing and Primary care are broadly in line with plan, however B&D CCG are reporting overspends within CHC and prescribing. The forecast position across the entire QIPP portfolio includes QIPP delivery of £31.5m, a slippage of £13.5m against plan. Of this, £5m slippage relates to the QIPP in acute contracts and £5.3m relates to acute QIPP schemes that are not currently in contracts. (For more information on QIPP delivery please refer to pages 5 and 11 of the IPR). The two largest areas of risk continue to be acute contracts and QIPP delivery. The level of acute contract over performance reported at Month 7 is driven by the current level of activity and costs reported against the contracts. Whilst the forecast position includes a prudent view of acute performance and QIPP delivery there is a risk that activity growth will be in excess of the reported position and a risk that there will be further slippage against QIPP schemes. The revised net risk facing the CCGs at Month 7 is £6m. If the risks materialise, this will result in the CCGs in year deficit increasing to £26.4m. KA referred to spending money wisely 1 and questioned whether there have been any improvements in services since its implementation. TT confirmed there have been positive impact from schemes which are benefiting the CCG. It was separately noted there have been significant quality improvements in diabetes, although it was too early to tell if there had been any impact on reduced costs to acute services.

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KP reported that the Audit & Governance committee had reviewed assumptions and were assured, although there were risks. He also questioned how the CCGs ensure that BHRUT deliver the joint QIPP programme. RS was pleased to report that at an operational level there had been good productive discussions and areas where not on plan eg dermatology there had been more practical dialogue. It was noted that there is a rigorous approach to the PID process and the Trust have taken an interest in this. CB thanked lead clinicians, RS and her team who have agreed 90% of QIPP and were the most delivered in London. The joint committee agreed the financial position and noted the action taken to achieve it. 5.3 Quality report JH presented a report which provided assurance that the CCG continues to measure and monitor the quality of the services we commission from all providers including:

London Ambulance Service GP service alerts BHRUT mortality performance, Never Events and delayed and

missed diagnosis NELFT Brookside unit

JJ welcomed the recent improvements in radiology. He questioned whether there are mandatory audits of private sector providers on a regular basis. JH responded that the CCG will be requiring all providers to undertake regular audits on quality of services provided and these will be linked to KPIs. CB was pleased to note the recent improvements at NELFT Brookside unit and the Chairs agreed to write to the Trust to congratulate the team. KA welcomed the improvements at LAS, adding the need to be mindful of years of poor performance for Redbridge and BHR patients. VH reported that a recent report on CAMHS to Health and Wellbeing Board had highlighted concerns. SM reported that Redbridge safety risks had been raised following a reduction in capacity. It was noted that a business case had been taken through FRPB to address this. JH added that a quality risk assessment with NELFT gave a high level of assurance of risk management and it was agreed to close oversight monitoring but will be re-escalated if required. The joint committee noted the report. 5.4 Safeguarding children annual report 2016-17 JH presented the safeguarding children annual report which reflects achievements, risks and all works completed in 2016-2017.

Chairs

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WM suggested it would be useful to see outcomes comparison to previous years. KR suggested that it would also be helpful to see reports from other boroughs as information sharing would be useful for all GPs. JJ questioned whether there was any scope for the ICPB to look at collaborative working on safeguarding. CB reported that the JCB were starting to look at children’s services – as this was a priority area for the CCGs and local authorities to work together on. The Chair commented on the remarkable increase in the number of unaccompanied asylum seeking children and the need to ensure that there are services for these children. JH agreed, adding that this data needs to be reviewed as we have not had this level of data in the past. The joint committee noted the annual report. 5.5 Looked after children annual report 2016-17 JH presented the looked after children annual report which reflects achievements, risks and all works completed in 2016-2017. SAli reported on improvements in Looked after children reports to general practice. JH welcomed the positive feedback. The joint committee noted the annual report. 5.6 Safeguarding adults annual report 2016-17 JH presented the safeguarding adults annual report which reflects achievements, risks and all works completed in 2016-2017. The joint committee noted the annual report.

JH JH

6.0 Development/governance

6.1 Integrating Governance Arrangements MP presented a report which proposed further integration of governance arrangements across BHR CCGs. The joint committee: Agreed that the Finance & Delivery and Quality & Safety Committees

become ‘joint’ rather than ‘in common’, with each developing revised

terms of reference, to come to the next meeting of this committee for final approval.

Agreed to consider final terms of reference for this committee at the next meeting, alongside the proposed terms of reference for the new NEL joint commissioning committee.

6.3 Finance & delivery committee chair’s report The Chair presented a report which provided key highlights of the finance and delivery committee held on 25 October 2017. The joint committee noted the report. 6.4 Audit & governance committee report

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KP presented a report which provided key highlights of the audit and governance committee held on 10 October 2017. The joint committee noted the report.

6.5 Work of the FRPB and Financial Recovery Programme TT presented a summary report which provided key highlights of the FRPB and financial recovery programme. The joint committee noted the report. 6.6 Minutes of sub committees: The joint committee noted the minutes of the:

Primary care transformation programme board held on 27 July 2017

Patient engagement forum held on 17 October 2017 Primary care commissioning committee held in September and

October 2017 Quality & safety Committee minutes held on 24 October 2017

7.0 Questions from the public

There were no questions from the public.

8.0 Date of the next meeting

14 December 2017

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Redbridge Clinical Commissioning Group Governing Body Meeting

30 November 2017 1.30pm Becketts House

Present: Dr Anil Mehta (AM) Clinical Director and Chair Dr Syed Raza (SR) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Shujah Hameed (SHam) Clinical Director Dr Joyoti Sood (JS) Clinical Director Dr Anita Bhatia (AB) Clinical Director Dr Shabana Ali (SA) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Conor Burke (CB) Chief Officer Kash Pandya (KP) Lay member - governance Khalil Ali (KA) Lay Member-PPI Tom Travers (TT) Chief Finance officer Jacqui Himbury (JH) Nurse Director Louise Mitchell (LM) SRO – Planned Care In Attendance: Marie Price (MP) Director of Corporate Services Anne-Marie Keliris (AMK) Company Secretary Cathy Turland (CT) Healthwatch Redbridge Sharon Morrow (SM) SRO – Unplanned Care Regina Shakespeare (RG) Interim Director of Delivery & Performance Dr Raj Kumar (RK) Clinical Lead for mental health Apologies: Dr Ah Fee Chan (AFC) Secondary Care Consultant Dr Muhammad Tahir (MT) Clinical Director

Item Action



The Chair reminded governing body members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of Redbridge clinical commissioning group. Declarations declared by members of the governing body are listed in the

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CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link: http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

3.0 Questions & comments from the public

The Chair welcomed questions and comments from members of the public who were in attendance adding that the issues would be picked up within the presentation of the main item on the agenda. Mrs Susan Winch-Furness asked the following questions and made the following statements: 1) Why has the CCG spent money on sending people to alternative

homes when beds were already paid for and lying empty at Meadow Court? This doesn’t make sense to me. The tax-payer is paying twice, is that correct? How is that value for money?

2) I received an email 14 months ago from the CCG – I have printed

copies for you – out of the blue telling us abruptly we would have to move loved ones. Is the Board aware of those plans to move people out of Meadow Court?

3) Why has the CCG been telling people – for example in the

consultation document – that dementia patients are not choosing to go to Meadow Court? Is the Board aware that the AQP list given to carers in recent years does not include Meadow Court as an option? How are people supposed to choose Meadow Court if the information about the home is hidden away? Does the Board think this is fair and honest statement to make to the public?

4) The CCG keeps claiming that no decision has been made yet. How

come several dementia patients have moved out recently under the impression that Meadow Court would be closing? In light of the risks associated with relocating dementia patients if the decision hadn’t already been made, surely the CCG should not be letting this happen?

5) In April 2015 we were worried that beds were becoming empty and no

new residents being admitted. Conor Burke came and talked to the relatives to give reassurance that the home was not closing. He said there had been a problem – patients were being assessed but not moved on into homes. ‘Someone had taken their eye off the ball’ he said, ‘but this has now been resolved and Meadow Court will start to fill up again’. The explanation Conor gave us is quite different from the one in the document in front of us and in the consultation document. Can the Board explain the discrepancy?

Jon Abrams asked to the following questions and made the following statements: 1) It was felt that there was not enough time to consider the report and

its recommendations or to make all the points he wanted to during the allocated time.

2) He felt the consultation was very depressing and was saddened that patients felt pushed out of Meadow Court.

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3) He referred to links to the Francis report on Mid Staffordshire NHS Trust and felt that there were questioned unanswered and the process lacked transparency and candour.

4) He felt that financial decisions were being made over quality of care and there was no time to do a proper analysis.

5) He referred to research on involuntary removal from nursing homes and the negative impact of this.

6) He questioned if the clinical panel had reviewed individual patient notes to assess needs.

7) He questioned if there had been an assessment of other homes levels of dementia care available.

Mr Garner asked the following questions and made the following statements: 1) He felt the document was dishonest and used many known tactics to

hide the truth. 2) He felt the report included irrelevant statistics and many important

points were missing and suggested the proposals were illegal. 3) He felt that the treatment of patients and relatives in the last four

months had been unacceptable and had been faced with aggressive and bullying lectures. He felt that any concerns raised were not answered and brushed aside.

4) A second meeting was farcical and was met with silence. 5) All relatives had been treated badly during consultation and the report

gives a distorted view. The Chair thanked the members of the public for speaking.

4.0 Proposed changes to services at Meadow Court nursing home

Dr Raj Kumar presented a report and business case which set out the proposed changes to the contract for Meadow Court nursing home, the consultation and engagement process which was carried out, a report on the consultation responses, the methodology used to reach the recommendation, the quality impact assessment and equality impact assessment. It was noted that Redbridge Clinical Commissioning Group (CCG) commissions 48 beds from Care UK at Meadow Court nursing home under a block contract arrangement and the current contract value is £2,993,192 per annum. The beds have historically been used for NHS continuing healthcare (CHC) patients with dementia and those with physical disabilities. Redbridge CCG is facing significant challenges to its budget and is currently in legal directions from NHS England as a consequence of the financial position. Commissioners are required to maintain a very close focus on where they are using their funds, ensuring that they are making the most effective use of every penny that goes into the local NHS. At the time the consultation launched, only 14 of the 48 beds commissioned by the CCG were occupied, meaning the CCG has been paying for 34 empty beds under the block contract. Dr Raza reported on the clinical panel and the concerns from families of patients. The clinical panel felt these concerns could be mitigated by the

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panel’s recommendations, which included: A commitment to early and ongoing engagement of carers, patients

and families in careful assessment and care planning before, during or after transfer to ensure patients are moved with care and in line with best practice.

Frequent and ongoing quality surveillance visits to enable ongoing monitoring of the quality of care before, during and after transfer, providing the mechanism to identify areas of concern quickly

Provide additional support to low income families, helping them to better understand and access the wider support available to them during the implementation process.

Ensure that there is a robust transfer and follow up process in place, overseen by a CHC nurse

Dr Bhatia questioned what the clinical evaluation process and panel entailed. It was noted that the clinical panel consisted of two clinical directors who were supported by a number of CCG officers and considered:

Experience of patients, families and carers Clinical impact Equality impact Impact on other services

Dr Ali questioned why there are 34 empty beds at Meadow Court. There are 39 homes available to patients, of which 34 offer dementia care services and patients are not choosing Meadow Court. Cathy Turland questioned how patients would know that Meadow Court is available if it is not on the list and what will now happen to non-Redbridge residents. She also expressed surprise that that the equality impact assessment on patient safety and experience was low and that the decision was being made on financial reasons which she felt was morally wrong. Cathy Turland also stated that she felt the report did not include the level of concern that has been raised by Redbridge Age Concern and One Place East. She reported that Healthwatch undertook a short call around to other homes and some were not accepting patients. SM reported that residents that have different commissioners were also consulted and appreciated that any decision will affect other patients. She added that the CCG regularly place patients in alternative homes that provide dementia and complex care and the continuing health care process enables the CCG to flex packages of care i.e. one to one care. Khalil Ali commented that it was important for the governing body to be assured that quality and standards of care are of the highest standard in all homes and would like to see a move towards an outstanding homes across Redbridge. Jacqui Himbury referred to a question from the public which highlighted research that older people have negative impact from moving homes. She also referred to the importance of the care planning process of moves to minimise anxiety which is paramount and gave assurance that the quality and safety committee will be considering details from any research critically.

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Dr Mathukia questioned whether there was any discussion with Care UK to negotiate the block contract. Sharon Morrow confirmed that negotiations had been ongoing but agreement could not be reached. Cathy Turland expressed concern that risk assessments had not already been undertaken. She also questioned what the plans are for the building. Dr Kumar responded that the building is owned by NELFT and the proposal being discussed today was about the contract with Care UK and not the building. The recommendation of the clinical panel was that the patients currently cared for in Meadow Court could be safely and appropriately cared for in other facilities, that the contract with Care UK for Meadow Court nursing home does not offer value for money and that the Governing Body should agree to end the contract. The governing body approved the recommendation to terminate the contract for Meadow Court nursing home with Care UK. The Chair thanked the governing body and members of the public for attending the meeting.

Meeting closed

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Minutes of the Joint Committee of Barking and Dagenham, Havering and Redbridge

Clinical Commissioning Groups 14 December 2017

1.30pm Becketts House

Present Barking & Dagenham CCG Dr Gurkirit Kalkat (GK) Clinical Director/Chair Dr Anju Gupta (AG) Clinical Director Dr Kanika Rai (KR) Clinical Director Dr Jagan John (JJ) Clinical Director Sharon Morrow (SM) SRO – Unplanned care Sahdia Warraich (SW) Lay member – patient and public involvement Havering CCG Dr Atul Aggarwal (AA) Clinical director/Chair Dr Maurice Sanomi (MSan) Clinical director Dr Ann Baldwin (AB) Clinical director Dr Ashok Deshpande (AD) Clinical director Dr Alex Tran (AT) Clinical director Richard Coleman (RC) Lay member – PPI & Vice Chair Alan Steward (AS) System OD and Transition SRO Redbridge CCG Dr Anil Mehta (AM) Clinical Director/Chair Dr Syed Raza (SR) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Shujah Hameed (SHam) Clinical Director Dr Anita Bhatia (ABh) Clinical Director Dr Shabana Ali (SA) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Louise Mitchell (LM) SRO – Planned care BHR CCGs Jane Milligan (JM) Accountable Officer Tom Travers (TT) Chief finance officer Jacqui Himbury (JHim) Director of nursing Regina Shakespeare (RS) Interim Director of Delivery & Performance Kash Pandya (KP) Lay member – governance

In attendance Conor Burke (CB) Interim Managing Director Anne-Marie Keliris Company secretary – BHR CCGs Marie Price (MP) Director of corporate services – BHR CCGs Apologies Dr Waseem Mohi (WM) Clinical Director/Chair Dr Ramneek Hara (RH) Clinical Director Dr Ravali Goriparthi (RG) Clinical Director

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Dr Gurdev Saini (GS) Clinical director Dr Muhammad Tahir (MT) Clinical director Dr Jyoti Sood (JS) Clinical Director Dr Ah Fee Chan (AFC) Secondary Care Consultant Khalil Ali (KA) Lay Member-PPI Matthew Cole (MC) DPH – LBBD Vicky Hobart (VH) LBR Cathy Turland (CT) Healthwatch Redbridge Lee Eborall (LE) NELCSU

Item Action



Dr Anil Mehta, the Chair of the meeting reminded members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of the BHR clinical commissioning groups. Declarations declared by members of the governing body are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link: http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm http://www.haveringccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

2.0 Questions from the public

The Chair welcomed members of the public to make statements and raise questions before any decisions were made by the joint committee. There were no questions from the public.

3.0 Spending money wisely 2– decision making business case

The six lead clinical directors Dr Bhatia, Dr Heyes, Dr Goriparthi, Dr Gupta, Dr Sanomi and Dr Deshpande presented the decision making business case for Spending Money Wisely 2.

As part of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups’ work to save £55 million in 2017/18, two rounds of consultation, branded ‘Spending NHS money wisely’ and ‘Spending NHS money wisely 2’ have been carried out. ‘Spending NHS money wisely 1’ resulted in savings of £3.03 million and the agreed changes were implemented in July 2017.

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RC questioned whether any lessons from spending money wisely 1 have been reflected in communications for phase 2. SH responded that feedback from spending wisely 1 had highlighted the limited number of responses from the BME community. It was reported that during phase 2 a number of meetings with harder to reach community groups were arranged to ensure these groups were able to respond to the consultation. AA questioned whether the proposed changes apply to new patients. LM responded that implementation would commence in January 2018 and any patients already on a pathway will complete their treatment. SR questioned how the potential impact on patients had been assessed. ABh responded that impact had been discussed in-depth by the clinical panel and scoring included equality impact, patient experience, clinical impact and impact on other services. SW questioned whether there was any information available on impact of spending money wisely 1 and whether there had been an increase in complaints. MP reported there had been a very small number of complaints and only a small amount of feedback so far. SW reported that the patient engagement forum had been generally supportive of the proposals and had highlighted the importance of equality of the 7 NEL CCGs to ensure that patients do not move across areas to access services. JM welcomed this feedback and would welcome the opportunity to review data to understand the number of patients that move CCG area to gain access to treatment. MM questioned what support will be provided for GPs. It was noted that support will be provided via GP education events and networks with a full communications strategy to support this. AB suggested that communications with pharmacies was also important to ensure they are aware of restrictions on prescribing. KP welcomed the report and appreciated the effort and rigour in the process. He highlighted the importance of communicating to the public and hard to reach groups. The Chair thanked members for their feedback and the clinical panel for the robust process followed. The joint committee approved the recommendations of the clinical panel to: Restrict the prescribing of: Antimalarial medicine Threadworm medicine Sleeping tablets (over the counter, for short-term use) Hay fever medicine Travel sickness medicine Vitamin D supplements (for maintenance only) Probiotic supplements Bath oils, shower gels and shampoo

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Skin rash creams Sunscreens

No longer fund: Earwax removal (aural microsuction) Some injections for lower back pain (disc, facet joint and epidural

injections) Osteopathy

Change the eligibility criteria for: Cataract surgery Routine podiatry

4.0 NEL Commissioning arrangements

JM presented a report which updated on the establishment of the new commissioning arrangements across north east London highlighting the following:

Recruitment of managing director and director of strategic commissioning roles.

Joint commissioning committee Operating model North East London CFO London devolution

The Chair questioned whether there are plans for inner NEL CCGs to have a joint committee. JM responded that there are a number of developments ongoing and during the work on the operating model a stocktake of current arrangements will take place. She agreed that there is significant learning from BHR that could be considered in other areas and joint arrangements where they make sense need to be explored across and within NEL. JM advised that these would be CCG-led decisions. SW questioned how involved CCG Chairs are with the new management team. JM assured the committee that the Chairs are fully involved and there is a bi-weekly meeting with the management team and CCG Chairs. 2.35pm Dr Raza & Dr Mathukia left the meeting. Discussion ensued on conflicts of interest of clinical directors working with federations. MP reported that the DoH have issued new guidance in the latter half of 2017 and a specific development session will be arranged with the joint committee to focus and explore conflicts of interest in more detail. ABh expressed disappointment at the lack of ownership and attendance of POLCE meetings by some colleagues in INEL. JM welcomed this feedback and the opportunity to support and the need to articulate what the key drivers are for this. JM recognised the excellent work in BHR and

MP

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felt there was significant learning that will be taken forward by the bi-weekly meeting with CCG Chairs and management team. JJ questioned the availability of a single CFO across north east London. JM reported that the CCG would not want to lose local finance grip and will still have finance leads in CCGs. It was noted that further work is required on this, including the governance aspect. 2.50pm Dr Gupta and Regina Shakespeare left the meeting. AB questioned whether there will be any constitutional changes required. MP reported that any changes should be presented to members committees in February/March, if required but did not expect any significant changes. CB highlighted the need to clarify the statutory duties of the CFO with an introduction of a CFO across NEL. KP agreed and also highlighted the importance of identifying resources for this role. The joint committee: Endorsed the shadow Joint Commissioning Committee Terms of

Reference. Agreed to recruit the substantive NEL Chief Financial Officer role

subject to clarification on the statutory duties within the job description, proposed arrangements and associated resources.

5.0 Date of the next meeting

25 January 2018

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BHR CCGs joint committee action log Action ref: Meeting

date

Action required Lead Required by Status

5.3 Quality report

12 July 2017

Crisis Team – JH reported that a number of serious incidents had highlighted access to the crisis team as a theme and this had been raised at the NELFT CQRM. A report will be presented to the quality and safety committee and governing body meeting updating on action taken to address access including a plan, timeline and learning.

JH September 2017

Updated November 2017 - To be discussed at December quality & safety committee. Update within quality report on agenda.

3.1 GBAF 30 November 2017

SW commented that it was important that the lead commissioner meets with BHR CCGs to give assurance on Barts Health position. It was agreed to write to the lead commissioner to invite them to the next meeting. The Chair questioned whether there is confidence in Barts Health completing the demand and capacity modelling by March 2018 that achieves compliance with the RTT standard by September 2019. CB responded that he did not have confidence in this and would be part of the request to lead commissioners to give assurance to the CCGs, along with finance, activity and performance information.

LM January 2018 Item on agenda.

4.1 NEL Commissioning arrangements

30 November 2017

TT requested clarity on funding for the Director of Strategic Commissioning role to ensure this is cost neutral. AS agreed to provide further information on this, adding it was an interim

AS January 2018 Issue being picked up between CFOs.

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Action ref: Meeting date


arrangement and that costs would be split on a weighted population basis.

14 December 2017

Development session to be arranged for Join Committee members to focus and explore conflicts of interest.

MP Being arranged for a Thursday in February.

5.3 Quality report

30 November 2017

CB was pleased to note the recent improvements at NELFT Brookside unit and the Chairs agreed to write to the Trust to congratulate the team.

Chairs/JH

January 2018 Completed.

5.4 Safeguarding child annual report

WM suggested it would be useful to see outcomes comparison to previous years. KR suggested that it would also be helpful to see reports from other boroughs as information sharing would be useful for all GPs. The Chair commented on the remarkable increase in the number of unaccompanied asylum seeking children and the need to ensure that there are services for these children. JH agreed, adding that this data needs to be reviewed as we have not had this level of data in the past.

JH JH

January 2018 In progress. The designated nurses are finalising a report for February QSC.

Barking & Dagenham CCG - CLOSED ACTIONS Action ref: Meeting date


2.3 Patient experience report

26 September 2017

Discussion ensued on the future of the patient engagement forum and the plans to reflect the new commissioning structure. MP agreed to provide the governance structure to the Chair.

MP November 2017

CLOSED Information on new arrangements shared.

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3.1 GBAF

26 September 2017

GK referred to supporting practices that do not have access to district nursing services to immunise house bound patients with flu vaccine. SM/GK agreed to discuss this outside the meeting. KP commented that it was refreshing to see the reduction in risks at the governing body level and reported that the finance and delivery committee continue to review 30 risks below this level. He also suggested that the target for the financial risk of 30 March was unrealistic, TT agreed to review this.

SM/ GK TT

November 2017

CLOSED NHSE are commissioning NELFT to provide a housebound service for people who are the district nursing caseload; the CCGs are commissioning a service from GPs for housebound patients who are not on the district nursing caseload. Revised GBAF on agenda.

5.4 Quality report

23 May 2017 Dr Rai raised further concerns with the GP alert process and suggested exploring different ways the process could be run. She also questioned whether CDs are aware of alerts and suggested that a pathway and protocol is required for GP alerts just as there are for specialities. KP reported that internal audit would be in touch with CDs who had raised concerns.

JH September 2017

CLOSED Within quality report on agenda.

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5.4 Quality report

23 May 2017 Dr John raised concern at BHRUT’s CQC mortality rates for UTIs and requested an urgent GB report including what the issues are and how they are being dealt with and suggested that BHRUT internal audit was required. SM reported that BHRUT will be reviewing the data by 1 June.

JH September 2017

CLOSED Within quality report on agenda.

6.1 Integrated contract report

18 July 2017 KR commented that she was unaware that IAPT will set up clinics within surgeries and suggested that this information should be circulated to practices to ensure they are aware. SM agreed to report this at the next PTI.

SM September 2017

CLOSED Verbal update at meeting.

6.3 Quality report

18 July 2017 Barts Health - CB advised that input to the contracting monitoring process via the lead commissioner has been escalated. CB suggested that the Governing Body consider inviting the lead commissioner to address the Governing Body.

CB September 2017

CLOSED To review this suggestion at the next meeting and determine whether this action is required. Agreed to invite lead commissioner to attend future meeting.

4.3 Quality report

26 September 2017

The Chair thanked the quality team for clearing the GP alerts backlog. He requested that the number of GP alerts with RAG ratings are included within the next quality report. JH reported that this would also be shared at the next PTI meeting and it

JH November 2017

CLOSED RAG ratings not included, however detailed report on GP

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was agreed to add this to the intranet for GPs who are not in attendance.

alerts in quality report on agenda.

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Havering CCG CLOSED ACTIONS



5.2 Contracting report

17 May 2017

It was agreed to discuss further at a future clinical directors meeting and share personal experiences of the service and CB agreed to challenge the urgent care board to consider approaches to improve utilisation of the urgent care centre.

AS TBC CLOSED This will programmed into a future Havering CDs meeting. Our system UEC improvement plan – agreed through the A&E Delivery Board - includes measures to improve UCC use. It is monitored at each meeting and has seen improvement in Quarter 1.

5.2 Contracting report

17 May 2017

The Chair referred to the IAPT KPI and reported that the waiting times for the crisis team were too long and there was no indication of this in the report. JH reported that this will be part of the next quality report due to the high number of GP alerts

JH September 2017 CLOSED Update within quality report.

5.3 Quality report

17 May 2017

The Chair suggested in preparation for winter a report on the review of pneumonia deaths should be escalated to the governing body for review.


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1.4 Matters arising

12 July 2017

NELFT survey – The chair reported that he had not seen this survey and questioned whether there is an opportunity to input into questions. He advised that there should also be a GP survey – AS agreed to investigate.

AS

September 2017 CLOSED The Chair has received a copy of the GP survey on MH services. The questions were developed with Dr Kumar as MH GP lead.

2.2 Chief officer report

12 July 2017

GS expressed concern that there had been no attendance from a NELFT mental health lead at the dementia partnership board. CB suggested writing to the Trust expressing disappointment.

CB September 2017 CLOSED Verbal update.

6.3 Quality report

12 July 2017

Discussion ensued on BHRUT mortality outlier status and JH reported on the action BHRUT are taking including setting up a multi-agency system wide group to review 30 mortality reviews. She added that this will be reflected on the GBAF at the next meeting. CB commented that it is the CCGs duty to improve quality. He added that system wide issues need to be adequately responded to and reflected on the GBAF with the CCG’s responsibilities and assuring the governing body. It was agreed that a report would be presented to the next meeting addressing BHRUT and the CCG’s role of system requirement and what we are doing to address wider system issues.


2.3 27 September 2017

MP agreed to share the summary of the adult inpatient survey with members.

MP November 2017 CLOSED Complete.

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Patient engagement report


27 September 2017

The Chair reported that there were issues with NELFT stating they would not undertake flu vaccinations for the housebound. The Chair agreed to discuss this further with TT after the meeting.

Chair/TT November 2017 CLOSED NHSE are commissioning NELFT to provide a housebound service for people who are the district nursing caseload; the CCGs are commissioning a service from GPs for housebound patients who are not on the district nursing caseload

Redbridge CCG – CLOSED ACTIONS



3.1 GBAF

26 May 2017

The Chair questioned whether a sixth risk was whether the WEL proposals for multiple ACS posed any risk and a seventh was primary care risk due to lack of GPs and district nurses and the ageing current professionals. MP advised it was a technical issue

MP July 2017 CLOSED

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registering risk but she would discuss these proposals with the relevant directors and report back to the risk lead.

4.2 Health & Wellbeing Strategy

26 May 2017

The governing body noted the draft and consultation period. The governing body also noted the required CCG input and responsibilities and agreed to receive the agreed strategy following consultation in July.

VH September 2017 CLOSED On Agenda

5.3 Contract report

26 May 2017

JH requested CDs provide any details of access issues re CAMHS as this linked to her responsibilities around Safeguarding Children and Sue Elliott would pick these up. ShH had letters transferring care from CAMHS to NELFT that he could forward on. JH would bring a report to the next meeting on any issues and explore if LBR dis-investment had an impact on provision and consider the risks.

SE/JH September 2017 CLOSED Update within quality report.

5.4 Quality report

26 May 2017

BHRUT was a CQC mortality outlier for UTI in May and fuller understanding was awaited on the cause. The CCG had been monitoring the upwards trend in SHMI data as this was the highest reported level in London. The Quality & Safety Committee was setting up a clinician to clinician meeting to understand this further, whilst noting a serious robust approach to mortality at the Trust was evident.

JH

September 2017 CLOSED Update within quality report

3.1 GBAF

20 July 2017

KA referred to A&E performance and questioned whether any thoughts have been considered on new LAS targets and what impact these could have. VH reported that these are focused on flexibility of response time to reaching patients rather than a direct impact on A&E performance. CB agreed he did not believe there was a direct impact but would ask for this to be reviewed.

CB/AS September 2017 CLOSED The new standards are not directly linked to Trust’s A&E performance. In theory, if call handlers are being given

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more time to assess calls then it could be expected that more alternative care pathways are utilised which should help Trust’s manage their A&E performance. An objective of the alternative care pathways is to reduce the number of ambulance conveyances to hospital so that LAS and the Trust can focus on emergency and life-threatening calls/ needs.


20 July 2017

CB suggested that an update on ICM should be presented to the next meeting.

CB September 2017 CLOSED Verbal update.

6.3 Quality report

20 July 2017

ShH referred to the Barts Health duty of candour target which was consistently not being met and questioned whether the Trust had

JH September 2017 CLOSED

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a plan for improvement. JH reported that Whipps Cross do have an action plan which has been reviewed and strengthened which has resulted in recent improvements and is on an upward trajectory. ShH also asked whether both Trusts are meeting their NHSI requirement to report serious incidents on STEIS and a follow up email. JH reported that BHRUT have a system in place and are compliant and Barts Health have a system but staff are not always using it. JH agreed to provide a status update after the meeting. JH would provide further detail following the meeting.

Email update sent to members

6.3 Quality report

20 July 2017

CB referred to the 60% of identified open alerts that are from Barts Health and asked whether the CCG can be confident that the clinical harm process will identify everyone affected. JH agreed to follow this up and report back.

JH September 2017 CLOSED Within quality report.

2.2 Chief Officers report

20 July 2017

CT reported that she had been receiving a number of concerns from patients about access to Barts Health services and was also concerned that patients are not receiving quality discharge information. CT agreed to write to CB with further detail.

CT (HealthWatch)

September 2017 CLOSED CT to gather further information and share.

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs From: Dr Waseem Mohi, Chair, Barking and Dagenham CCG Dr Atul Aggarwal, Chair, Havering CCG Dr Anil Mehta, Chair, Redbridge CCG Date: 25 January 2018 Subject: Chairs’ report

Executive summary

The report provides an overview of our key activities and those of the CCGs since the last Committee meeting in September.

Recommendations

The Joint Committee is asked to note the report.

1.0 Purpose of the report

1.1 To provide an update on activities since the last meeting and on key CCG news.

2.0 Working collaboratively

2.1 Our Barking and Dagenham, Havering and Redbridge (BHR) arrangements for working in an even more collaborative way are progressing well. Each programme area (planned care, unplanned care, primary care) now has a joint BHR team of clinical directors and officers. The teams have begun to work together effectively, focussing on delivery for the remaining quarter of the year and agreeing team and individual objectives for 2018/19.

3.0 North East London Commissioning Developments and BHR MD Recruitment

3.1 Our Accountable Officer has provided a detailed summary of progress since the last meeting in her report to this Committee. We continue to work closely with our fellow chairs in North East London (NEL) to lead the transition to the new commissioning arrangements across the seven CCGs.

3.2 We are in the process of recruiting to the substantive role of Managing Director (MD) for BHR, and welcome the input of local stakeholders in the process of selection.

4.0 Financial situation

4.1 Our focus remains on the considerable financial challenges for our patch, which despite a very good focus on QIPP delivery in 2017/18, remains at a high risk level, not least due to issues with

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regard to our main acute contract. The finance and performance reports on the agenda describe the issues and mitigations further. We were pleased to note the outcome of the recent Deloitte review which rated our arrangements and performance in relation to QIPP as being strong.

5.0 Election process for clinical directors

5.1 We are currently undergoing an election process for a number of clinical director roles in Barking and Dagenham and Havering. The outcome of the process will be reported to the next Joint Committee meeting.

6.0 Meetings

6.1 In addition to the many committee and NEL transition meetings that we attend, below is a summary of other meetings we have been to since the last joint committee meeting.

6.2 Fortnightly meetings of GB members and local CD meetings: We have held our usual local CD meetings focussing on ACS, locality and network developments, financial recovery and transformation programme performance. Following agreement about our new ways of working as reported to the last meeting we continue with our fortnightly meetings across BHR. We share updates on each programme, with a recent focus on the ‘improving referrals’ initiative within the planned care programme.

6.3 Health and wellbeing boards (HWWB): The Havering and Redbridge Boards meet on 31 and 22 January respectively. At the last meeting of the Barking and Dagenham HWBB on 16 January members discussed the Joint Strategic Needs Assessment (JSNA), the Suicide Prevention Strategy, HealthWatch work programme and Better Care Fund. The CCG Chair was unable to attend on this occasion.

6.4 Later this month we are due to meet with Jo Fielder, Chair of NELFT and more recently of BHRUT also. We welcome the opportunity to discuss current challenges for BHR and plans for future working, including accountable care developments.

7.0 Resources/investment 7.1 There are no additional resource implications/revenue or capital costs arising from this report. 8.0 Equalities 8.1 There are no direct equality implications arising from this report. 9.0 Risk 9.1 The CCG is managing a number of serious risks which are outlined in further detail in the

assurance section of this agenda. 10.0 Managing conflicts of interest

10.1 There are no conflicts of interest arising from this report. 17 January 2018

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs From: Jane Milligan, Accountable Officer

Date: 25 January 2018 Subject: Accountable Officer’s Report Executive summary

This report provides an overview of key activities undertaken by the Accountable Officer since the last meeting, with a specific focus on the developments within the North East London (NEL) Commissioning Alliance. Recommendations

The Committee is asked to: Note the progress report

1.0 Visit to Queen’s Hospital

1.1 Earlier this month I had an interesting weekend visit to Queen’s Hospital with Trust and CCG senior colleagues. We all know that winter is a challenging time for the NHS, and this year has been particularly busy. It was a helpful and interesting experience to see just how things are working on the ground in one of our busiest hospitals and to meet the staff who are doing such a good job. We were joined by the chief executive of the NHS, Simon Stevens, who also recognised the considerable work and effort that staff in the hospital and system colleagues are putting in.

2.0 Meeting with the new Chair of BHRUT

2.1 Joe Fielder, Chair of NELFT has recently taken on the additional role of Chair of BHRUT. Conor Burke, Interim MD and I met with him recently to talk through our shared plans and ambitions for our organisations and the wider BHR system. It was a positive meeting and we will continue to work closely with Joe in the year ahead.

3.0 Meeting staff and patient representatives in BHR

3.1 I was pleased to have the opportunity to meet with staff from the BHR CCGs on 16 January at the regular all-staff briefing. I heard about the work that colleagues have been involved in over the past year, particularly in response to the financial challenges faced in BHR. It was positive to see the clear commitment and engagement of staff in making improvements for local people.

3.2 Later that evening I met representatives from the CCGs’ three patient engagement fora, in their

new joint meeting. Again, it was a lively session, where I was able to share my plans and hear more about the patient perspective on the local NHS. There were lots of interesting questions and we had a good discussion about the role for patient engagement as we develop our arrangements across NEL, and through moves to a BHR accountable care system.

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4.0 Managing Director Update

4.1 The recruitment process for the BHR substantive Managing Director role in underway and I hope to be in a position to announce the successful postholder by the end of this month.

5.0 North East London Commissioning Alliance Update

5.1 I am happy to report that we have now appointed the last of the acting NEL Commissioning Alliance appointments with Les Borrett taking up the role of Director of Strategic Commissioning for six months. This key role will ensure that the transformation programmes across north east London are aligned and will deliver the Alliance’s ambitious improvement plans.

5.2 We are expecting the national commissioning planning guidance in January and he will also lead on making sure we meet those planning requirements including needs assessments and demand and capacity planning and that these are underpinned by robust commissioning and contracting with our major providers. Alongside the planning requirements, there is a NHS England (NHSE) London-wide meeting on 19 January to develop the proposals for assurance in 18/19 with all London STP leads, NHSE and NHSI.

5.3 As mentioned above the process for recruiting the BHR MD is underway. We will also soon be starting the permanent recruitment of the Managing Directors for the inner NEL CCGs. We are also developing the proposals around the Chief Financial Officer and will bring those proposals back to Governing Bodies for approval.

5.4 We held a further workshop to help establish the shadow NEL Joint Commissioning Committee (JCC). We ran this as an OD session and there was good representation from across all CCGs (chairs and lay members). We have agreed representatives from three of our eight local councils and I am following up with the leaders and chief executives to ensure we have full representation from our local council colleagues.

5.5 There was a significant appetite from all present to run – in shadow form - the next JCC so that it could work on a key area through the proposed governance to high light where further action was necessary. This would use an example form the proposed 18/19 NEL plans to test this out. As agreed, formal decision-making will start from April 2018. We are also aiming to have a wider stakeholder session in March to review the learning to date and launch the new arrangements for April 2018.

5.6 The stocktake of arrangements across NEL CCGs has started that will identify good practice for sharing and learning across CCGs and identify opportunities to collaborate and do once across NEL to improve efficiency and effectiveness. This is looking at CCG structures and functions, financial arrangements and position, the overarching commissioning strategies and approaches and the management of quality and performance, as well as corporate functions. This will be done in two phases. Phase one will report back by the end of January on where there are opportunities for learning and more collaboration. Phase two will then develop the detailed plans to deliver the opportunities for shared functions as agreed with the CCG Chairs and myself from Phase one.

5.7 With the establishment of the NEL Commissioning Alliance and its Joint Commissioning Committee, we are working to improve the overall NEL system governance to make this much more transparent and effective between the ELHCP (STP) Board and Executive, the Clinical Senate, the Commissioning Alliance’s Joint Commissioning Committee and the local system

delivery boards. I hope to bring proposals back to the next meeting of this Committee. I have established my Senior Management Team – with your local MD a key member – and this is now meeting weekly.

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5.8 Further to my update at the beginning of the report, I am continuing to get out and meet stakeholders and staff across North East London. By the end of January, I will have met with Healthwatches, staff meetings in all CCGs, attended patient engagement forums and the London-wide LMC, as well as met with Council chief executives.

6.0 Equalities

6.1 There are no equalities implications arising from this report. 7.0 Risk

7.1 There are no risks arising from this report. 8.0 Managing of conflicts of interest

8.1 There are no conflicts of interest issues relevant to this report. 9.0 Resources/investment

9.1 There are no additional resource implications/revenue or capitals costs arising from this report and no impact on sustainability.

17 January 2018

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Sahdia Warraich, Richard Coleman and Khalil Ali, Lay Members (PPE)

Date: 25 January 2018 Subject: Patient Engagement Report

Executive summary

This joint report summarises patient and public engagement, feedback and insight gathered since the last meetings. Areas covered:

The local Patient Engagement Forum meetings (PEFs) Joint PEF meeting VCS meeting in Havering The Networks Leadership Summit Spending money wisely public facing communications Community urgent care review – engagement with Healthwatch

Recommendations

The committee is asked to: Note and comment on the contents of the report


1.1 To provide a summary of the CCGs’ engagement with patients, the public and other stakeholders

since the last meeting. 2.0 Patient Engagement Fora (PEFs) Update

2.1 November saw a return to local PEF meetings as we alternate between joint and local meetings reflecting the strategic direction of the wider system. Presentations were given at all three PEFs around ‘Spending money wisely (SMW) 2’ and the latest CCGs’ financial update. PEF members were also shown a video recorded by Jane Milligan, our new accountable officer, primarily for staff, earlier that month.

2.2 Local issues were also discussed by members and a number of actions have been picked up by the CCG team as appropriate. These included practice staff and LD patients, cross borough fitness programmes, scope of SMW2, continuing health care (CHC) funding decisions, district nurses and the Meadow Court consultation.

2.3 A number of opportunities to take part in patient experience groups on a wider footprint have been shared with all PEF members this month.

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2

2.4 We continue to involve members of our patient engagement forums in various ongoing CCG procurement exercises – community ENT, community ophthalmology and low vision services being the latest. A simple toolkit outlining the requirements around this has been designed for the CCGs.

3.0 Joint Chairs, Vice Chairs and Lay Members ‘meeting’

3.1 The PEF Chairs, Vice-Chairs and Lay Members agreed the format and agenda of the January Joint BHR PEF meeting virtually over the holiday period. This enabled all to contribute.

4.0 Joint PEF

4.1 The second joint PEF meeting was held on 16 January, with a good attendance from members of all three CCG PEFs. Members received presentations from: Jane Milligan on her new role and the direction of travel for the NEL commissioning alliance; and Louise Mitchell on the CCGs’

plans for improving referrals. Both presentations were well received and led to lively discussions. The group considered the CCGs’ rating from NHS England (NHSE) for our patient and community engagement (mentioned below) and next steps, as well as ideas for future topics for the joint meeting.

5.0 CCG Assessment re Patient and Community Engagement Indicator 5.1 As reported at the last meeting NHSE has completed our assessment for the patient and

community engagement indicator in line with the requirements of the CCG Improvement and Assessment Framework (IAF) and wrote to all CCGs at the end of last year with the results. All three BHR CCGs received a GREEN rating with four out of five domains rated good or outstanding. NHSE provided feedback on areas of good practice and recommendations for improvement in future. They have also since sent a toolkit to engagement leads. The CSU communications and engagement team have produced an action plan to support the CCGs in making the necessary improvements to maintain or improve our performance and rating in future. Lay members and engagement colleagues will review and agree this in detail during February.

6.0 Havering VCS meeting

6.1 The PPE Lay Member for Havering CCG chaired the December Havering VCS meeting as usual. Following updates from those organisations present, along with a presentation on localities and social prescribing opportunities from Dr Dan Weaver, it was agreed by attendees that in future the CCGs would contribute to the wider Havering Compact meeting as appropriate and look to end the VCS meetings as these were seen as duplication.

7.0 The Networks Leadership Summit 7.1 Held on November 23, PPE Lay Members received presentations from GP Network Leads who

had completed their course on leadership. Each presenter demonstrated how they involved patients and considered their views on their respective projects. It is anticipated that the GP Networks, as prospective provider organisations, will develop patient engagement responsibilities and associated arrangements as they progress.

8.0 Spending money wisely public facing communications 8.1 Following December’s governing body decisions around further changes to prescribing and

selected procedures recommended by ‘Spending money wisely 2’, all practices and providers

have been sent a patient facing toolkit developed by clinical directors and the communications team. This includes web copy and letters explaining the changes to patients and the public.

9.0 Community urgent care review – engagement with Healthwatch

9.1 As part of the detailed review of community urgent care services, CCG staff leading this project have contacted Healthwatch leads to discuss the work to date and explore how all three

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3

organisations can be involved in engagement work that the CCGs are planning for the next few months. The aim is to build on the positive work the CCGs had working together with HealthWatch colleagues on the urgent and emergency care research study last year. The Community Urgent Care Programme Project Plan has a number of further engagement initiatives building on previous patient and stakeholders’ workshops.

10.0 Shadow Joint Commissioning Committee development 10.1 CCG lay members were invited to participate in the development work of the Shadow Joint

Commissioning Committee through an organisational development session across NEL on 10 January 2018.

11.0 Resources

11.1 There are no resource issues relevant to this report. 12.0 Equalities

12.1 Engagement in the borough should contribute to reducing inequalities in access to healthcare and support the CCG in meeting its equality objectives. This work is progressed through the CCG’s patient engagement forum structure and in collaboration with patients, the voluntary sector and other key stakeholders.

13.0 Risks

13.1 There are no identified risks in relation to this report. 14.0 Managing conflicts of interest 14.1 There are no conflicts of interest issues relevant to this report.

Author: Andy Strickland, Head of Communications, BHR CCGs Date: January 2018

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs From: Marie Price, Director of Corporate Services

Date: 25 January 2018 Subject: Governing body risk assurance framework report Executive summary

The governing body assurance framework (GBAF) have been reviewed to reflect the current significant risks to the three organisations. There are five risks on the GBAF. Risks ratings are based on the December 2017 risk register. The five risks on the GBAF are :-

1. Risks to the delivery of the Clinical Commissioning Groups’ (CCGs) budget 2. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care

performance 3. Barts Health (BH) performance against key targets, A&E and RTT 4. BH quality concerns 5. BHRUT’s mortality rate is higher than expected and indicates the number of patients dying for

certain clinical conditions is higher than the expected number of patient deaths.

Recommendations

The Committee is asked to: Note and comment on the current risks escalated to the GBAF and that assurance, levels, controls

and mitigating actions being taken are appropriate Raise and discuss other potential risks that may require escalation to the next GBAF or, where the

risk has reduced, de-escalation. 1.0 Purpose of the Report

1.1 The purpose of the GBAF is to outline the key strategic risks to the CCGs in achieving its corporate objectives and the controls in place to provide assurance that the risks are being managed.

2.0 Background/Introduction

2.1 The CCGs’ governing bodies have a responsibility to maintain sound risk management processes and ensure that internal control systems are appropriate and effective, and where necessary to take appropriate remedial action. The CCGs’ collaborative risk register consists of

risks that are local to the individual functions across the CCGs and risks that the CCGs have in common.

3.0 Current risks on the GBAF

3.1 There are five significant risks on the collaborative risk register that have been escalated to the GBAF. Appendix 1 shows the full detail of these risks. These fall under three of our five corporate objectives as follows:

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Corporate objective 1 - Secure financial recovery.

Risk 1.1: Significant risks to the delivery of the CCGs’ financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any acute over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCGs’ QIPP plans the CCGs will be in breach of financial control totals and c) risk of over performance in acute, continuing care or prescribing activity. Mitigation:

Implementation of our action plan from the Well Led Review overseen by BHR CCGs and associated System Delivery Framework and Plan, as a mechanism to drive system recovery

Fortnightly Financial Recovery Programme Board (FRPB) chaired by the Chief Financial Officer

Financial Recovery Planning, Delivery and Monitoring group (FRPDM) established with the responsibility for oversight of the QIPP development process and monitoring delivery against plan, reporting to the FRPB

Financial risk mitigation via our integrated financial strategy across north east London sustainability and transformation plan (STP) partnership (ELHCP) with continued development through the STP process

Aim to overachieve the QIPP requirement to provide stretch generating schemes and therefore savings over and above the £55m target

Revised year end forecast agreed with NHSE Forecast methodology assured through internal audit and a sub group of the Audit and

Governance Committee Implementation of quarter 1 reconciliations Escalation to AO/CEOs Jointly agreed independent mediation with BHRUT but not concluded and the CCGs have

written to BHRUT escalating to level 3 dispute resolution - expert determination. Collaborative objective 3: - Ensuring that we deliver on the objectives within our CCGs’ and

system wide transformation programmes

Risk 3.1: BHRUT's on-going failure to deliver A&E performance standards will impact on the delivery of services to patients. Mitigation:

BHRUT is being held to account via contract meetings including Service Performance Reviews (SPR) and Contract Quality Review meetings (CQRMs)

Fortnightly assurance calls and monthly escalation meetings with the Trust, BHR CCGs, NHS England (NHSE) and NHS Improvement (NHSI)

A ‘winter checklist’ has been completed to confirm how well progressed the BHR system is

against 69 specific items that NHSE and NHSI colleagues would like to see in place. A set of ‘winter contingencies’ have been produced which include radical actions in order to

ensure good performance levels in A&E throughout winter. Agreement of CCG resilience funds for winter 17/18 via FRPB Urgent additional arrangements for paediatrics redirection to GP hub to bridge prior to

introduction of 24 hour Urgent Care Centre (UCC) at Queens’ site. Queens urgent care centre (UCC) capital development is due to be completed by 10

January 2018 and will provide additional capacity and flow through the department

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Collaborative objective 5 - High quality, compassionate and safe care. Risk 5.4a and c. Barts Health (BH) performance – this risk groups together two performance areas that BH are failing to achieve, RTT and urgent and emergency care. There are also data quality concerns that present a further challenge for commissioners. The risks could threaten the long-term viability of the Trust and could put patients at risk and cause reputational damage. All mitigations actions for assurance against risks 5.4a, 5.4c and 5.6 are via the co-ordinating commissioner, Newham CCG. Risk 5.4a – BH has a significant RTT backlog and the PTL is currently being validated. The attribution of increased numbers of 52 weeks wait patients is not available (as at December 2017) and BHR CCGs are not sighted on our patients. There is therefore a risk that those patients would be subject to clinical harm and the CCGs are unable to assure themselves. Mitigation: RTT recovery is reflected in the improvement plan work being undertaken by BH with

oversight by the co-ordinating commissioner (Newham CCG) via the RTT and monthly performance meetings with the Trust.

The Trust is undertaking real time validation of the PTL until return to reporting Assurance sought via lead commissioner monthly in regard to the exact number of patients

waiting over 52 weeks who are residents of BHR Barts Health report 43 pathways waiting 52 weeks or longer for BHR CCGs in the

unvalidated month-end shadow unify report to NHSE for late 2017. To have completed demand and capacity modelling by March 2018 that achieves

compliance with the RTT standard by September 2019 Attendance by BHR CCGs’ quality lead at the patient safety/harm reduction group Commissioner and regulator parties are working with the Trust to develop a new dashboard

suite to provide further granularity at CCG, site and specialty level. This dashboard is to be finalised between all system partners and formally signed off at the RTT Recovery Board on 29th January 2018.

Risk 5.4c: Barts Health A&E - failure to deliver quality improvements in urgent and emergency care at BH (specifically at Whipps Cross hospital). Mitigation:

UEC plan agreed but subject to assurance through NHSE and NHSI Performance meetings including the Trust, commissioners and NHS Improvement (NHSI)

with regular updates at CRG meeting.

Risk 5.6: There is a risk that patients may receive poor quality of care and or suffer harm as a result of BH's failure to achieve quality indicators (never events, levels of healthcare acquired Infections (HCAIs) and management processes for serious incidents (Sis) and complaints. Mitigation:

Specific concerns have been formally escalated to the co-ordinating commissioner through the Quality Leads meeting

BHR CCGs' quality team attends Whipps Cross CQRM, which considers remedial action plans.

Risk 5.7: BHRUT’s mortality rate is higher than expected evidenced by summary hospital level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR) data. This indicates the number of patients dying in BHRUT for certain clinical conditions is higher than the expected number of patient deaths.

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Mitigation:

In August 2017 CCGs issued a Contract Performance Notice in respect pf non- assurance of BHRUT's mortality action plan

The plan has subsequently been revised and meetings held with the Trust to understand their action plan in full

The Risk Profiling Tool was applied to BHRUT during October and November Formal intelligence sharing process using the risk profiling tool results via two moderation

meetings that are now complete and were chaired by the NHSE Director of Nursing Completed the CQC mandated mortality reviews for patients who died of biliary sepsis,

urinary tract infections and sepsis Two mortality faculty members have been appointed and have received local training Wider clinical engagement and support to deliver the improvement actions through junior

doctor teaching sessions Internal workshop delivered to commence the design of a Biliary Sepsis care bundle and

re-design of access to endoscopic procedures Findings from the mortality reviews to be shared with the BHR Clinical Cabinet to agree

on system wide improvement actions to reduce patient mortality

3.0 Resources / investment

3.1 There are no additional resource implications/revenue or capital costs arising from this report. The cost of operating effective risk management arrangements is met from within existing resources.

4.0 Equalities 4.1 There are no equalities considerations arising from this report.

5.0 Risk

5.1 This report also links to the following GB papers being presented at this meeting and provide greater detail on key risks mentioned above and the organisations mitigations.

GBAF risk ref. 1.1 relates to the Integrated Performance report, Finance report and the FRPB Chair’s report

GBAF risks ref. 3.1 relates to the Integrated Performance report

GBAF risk ref. 5.6 relates to the Quality report

6.0 Managing conflicts of interest

6.1 There are no conflicts of interest considerations arising from this report. Attachments:

Appendix 1 - Governing body assurance framework and summary Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 09 January 2018

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Appendix 1 – NHS Barking and Dagenham, Havering and Redbridge CCGs

Collaborative objective 1: secure financial recovery. Risk Description:

Significant risks to the delivery of the CCGs' financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any acute over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCGs' QIPP plans the CCGs will be in breach of its financial control total and c) risk of over performance in acute, continuing care or prescribing activity.

Lead director:

Tom Travers Risk ref: 1.1

Initial

Risk

Rating

8/2015

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps Proposed

actions

Target

Rating

30/03/18 Control Assurance

Like

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d (4

) x

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5) =

Sev

ere

20 1 Weekly Financial Recovery Planning,

Delivery and Monitoring group (FRPDM) oversight of the QIPP development process and monitoring delivery against plan.

2 Fortnightly Financial Recovery

Programme Board (FRPB) Senior Executive meetings (revised TOR).

3 Formal escalation route to Finance and Delivery Committee

4 Clinical engagement and leadership

strengthening via the Joint Executive Committee (JEC) monthly, FRPB and F&D committee.

5 Independent review of finances jointly commissioned with NHSE

6 Monthly NHSE London Assurance

meeting

7 Formal contractual escalation and agreements for local mediated solutions

8 STP risk share agreement ratified and in

place for 17/18 presented to F&D committee.

1 Minutes of FRPDM meetings, risk log and mitigations for all schemes (I)

2 Minutes of the FRPB

Senior Executive meetings (I)

3 Minutes of the bi monthly

Finance and Delivery (F&D) committee (I)

Minutes of bi monthly Governing Body meeting (I)

4 Minutes of the JEC (I) 5 Report of the independent

review (E)

6 Minutes of the NHSE London assurance meeting (E)

7 Outcome letters following mediations (E)

8 As point 3.

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20 The integrated

performance report finance report and the FRPB Chair’s

report provides greater detail on the management of this risk.

1. Further schemes to be identified to cover the savings gap.

2. Further

activity growth beyond current projections

1. Working with providers and STP partners to identify additional schemes continues

2. Activity

management plan to be agreed with BHRUT by end of November. Agreement around a risk reserve supporting the activity management plan

Like

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) x

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5) =

Hig

h 10

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Corporate objective 3: Ensuring that we deliver on the objectives within our CCGs and system wide transformation programmes.

Risk Description: BHRUT's on-going failure to deliver A&E performance standards will impact on the delivery of services to patients.

Lead director: Steve Rubery Risk ref: 3.1

Initial

Risk

Rating

6/2013

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

16

1. Accident and Emergency Delivery Board (formerly the SRG).

2. Urgent and Emergency

Care (UEC) Programme Steering group.

3. Contractual meetings –

SPR / CQRM – and contractual levers.

4. Winter only - daily surge

calls with the Trust and reassurance with NHSE.

5. BHRUT and BHR CCGs

fortnightly assurance calls with NHSE and NHSI.

6. BHRUT and BHR CCGs

monthly escalation meetings with NHSE and NHSI.

7. Detailed A&E delivery

Board governed system plan with specific trigger points to prompt additional interactions based on performance and demand

1. Minutes of the fortnightly

Accident and Emergency Delivery Board. (E)

2. Minutes of the monthly

UEC Programme Steering Group. (E)

3. Minutes of monthly

contractual meetings – SPR / CQRM. (I)

4. Notes of daily surge

call. (E).

5. Notes of the calls (E).

6. Notes of the meetings (E).

7. This is written and shared with partners including NHSE and NHSI. Specific triggers points will be monitored daily by nominated leads from each organisation.

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The integrated performance report provides greater detail on the management of this risk.

BHR UEC programme established with four delivery work streams to deliver improvement and mandatory requirements and address all risks. Continued liaison with NHSE and the NHSI to provide assurance on delivery, particularly through winter surge arrangements.

Like

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) x

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3) =

Hig

h 1

2

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Collaborative objective 5: High quality and compassionate and safe care

Risk Description: (Two performance areas are grouped together here that BH are failing to achieve) Barts Health (BH) performance. BH continues to fail operational standards, a) referral to treatment times (RTT) and c) A&E, (specifically Whipps Cross). There are also data quality concerns that present a further challenge for commissioners. This could: Threaten the long-term validity of the Trust and put patients at risk and cause reputational damage.

Lead director: Steve Rubery Risk ref: 5.4 a and c – (groups the two performance risks together)

Initial

Risk

Rating

7/2014

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Like

lihoo

d (4

) x Im

pact

(5)

= S

ever

e 20

1. Monthly Collaborative

Commissioning Committee (CCC) meetings led by the co-ordinating commissioner, Newham CCG (Chief Officer) (CCGs only)

2. Monthly A&E Delivery Board meeting, led by BH Chief Executive, attended by Newham CCG on behalf of commissioners.

3. Bi-monthly Technical Sub Group

(TSG) and monthly Contract Review Group (CRG) meetings, led by Newham CCG, attended by BH.

4. Monthly RTT assurance meeting, led by Newham CCG, attended by BH, monitoring RTT performance and recovery - site specific remedial action plans (RAP) in place and monitored.

5. Monthly BH Internal (BHR CCGs) Escalation Review meeting receiving updates on performance (RTT, A&E, and diagnostics) and quality.

1. Minutes of the

CCC meeting. (E) 2. Minutes of the A&E

Delivery Board. (E) 3. Minutes of the TSG

and CRG. (E) 4. Minutes of the RTT

assurance meeting. (E)

5. Monthly BH

Internal Escalation Review meeting report. (I)

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The integrated performance report provides greater detail on the management of this risk.

1. Absence of

an agreed number of 52 weeks waiters for BH, breaching due to patient choice factors.

2. Absence of

agreement on a date for return to achieve compliance with the 92% standard for RTT.

Working through the lead commissioner to ensure provision of BHR number of over 52 week waiters on a monthly basis.

Co-ordinating commissioner continues in negotiation with BH on these two matters. The latest commissioner proposal was sent to the trust on 30 October 2017

Li

kelih

ood

(3)

x Im

pact

(4)

= H

igh

12

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Risk Description: There is a risk that patients may receive poor quality of care and or suffer harm as a result of BH's failure to achieve quality indicators (never events, levels of HCAIs and management processes for SIs and complaints).

Lead director: Steve Rubery NB: The Nurse Director retains overall

responsibility for Quality and Safety

Risk ref: 5.6 Initial Risk

Rating

2/2015

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps Proposed actions

Target

Rating

03/2018 Control Assurance

Like

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d (4

) x

Impa

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4) =

Hig

h 1

6 1. Contract performance notice

issued. 2. BH Contract Review Group,

attended by the lead commissioner on behalf of BHR CCGs

3. Monthly BH Internal (BHR

CCGs) Escalation Review meeting receiving updates on performance (RTT, A&E, and diagnostics) and quality.

4. Barts Health (Whipps Cross) monthly Clinical Quality Review and Oversight Assurance (CQROA) meeting with NHSI and NHSE.

5. Performance enforcement notices issued by the Care Quality Commission (CQC) following an inspection in July 2016.

6. Quality reports to every Quality and Safety (Q&S) Committee detailing issues, actions taken and impact.

7. Monthly SI panels including al NEL CCGs

1. Remedial action

plans and recovery trajectory. (E)

2. Minutes of monthly

CRG (E)

3. Letters of escalation

to lead commissioners (March 2017) (E)

4. Minutes of the CQROA meeting (E)

5. WX to self-assess

to determine if any notices can be closed

6. Minutes of the Q&S Committee

7. Minutes of the SI panel meetings. (E)

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The Quality report provides greater detail on the management of this risk.

1. Remedial action

plans for SI and Duty of Candour

1. Remedial action

plans received and reviewed by the lead commissioner and the CCGs and are non-compliant and the CCGs has escalated to the lead commissioner

Li

kelih

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(3)

x Im

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(4)

= H

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12

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Risk Description: BHRUT’s mortality rate is higher than expected (evidenced by SHMI and HSMR data) and this indicated the number of patients dying in BHRUT for certain clinical conditions is higher than the expected number of deaths

Lead director: Steve Rubery NB: The Nurse Director retains

overall responsibility for Quality

and Safety

Risk ref: 5.7 Initial Risk

Rating

7/2017

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps Proposed actions

Target

Rating

09/2018 Control Assurance

Like

lihoo

d (4

) x

Impa

ct (

5) =

Hig

h 2

0 1. Bi monthly Quality and Safety

(Q&S) Committee 2. Monthly Clinical Quality

Review Meeting (CQRM)

3. Escalation to the monthly contract review group (CRG)

4. Joint Committee Meeting of BHR CCGs bi monthly (GB)

5. BHRUT’s Mortality faculty developed from September 2017 and undertaking a number of thematic mortality reviews

6. Outputs of the Mortality faculty reviews informed the Trusts mortality improvement programme and plan.

7. BHRUT’s Mortality reviews presented to the Mortality Assurance Group (MAG)

8. Full compliance with the National Guidance on learning from deaths issued in March 2017 by the National Quality Board.

1. Minutes of the

Quality and Safety Committee (I)

2. Minutes of the

CQRMs (I)

3. Minutes of the CRG meeting (I)

4. Minutes of the GB meeting (I)

5. Reviews presented to CQRM

6. Mortality contract

performance notice (CPN) bi monthly meetings (I) and point 3

7. Learning from death policy published September 2017 (E)

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1. Not assured of the robustness of plans

2. 6 months lag in published data. Proxy data developed with BHRUT

1. Although SHMI

data has been published in December 2017 which shows slight improvement a comprehensive report regarding the plan and performance will be presented at the Q&S committee on 27 February 2018.

Li

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(2)

x Im

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(3)

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6

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Barking and Dagenham, Havering and Redbridge CCGs Governing Body Assurance Framework - overall summary (2016 – 2017)

Lead /

GBAF ref. Risk description (summarised)

Previous risk ratings Current

rating

End of year

forecast Target

risk

level April 2016

June 2016

July 2016

Sept 2016

Nov 2016

Jan 2017

April 2017

June 2017

August 2017

Oct 2017

Dec 2017

This time

Last time

T Travers 1.1

(was 6.1)

Risk of failure to deliver the CCGs’ budget plans. 16 16 20 20 20 20 20 20 20 20 20 16 16 10

S Rubery 3.1

Failure to deliver quality improvement in urgent and emergency care at BHRUT. 16 16 16 16 16 16 16 16 16 16 16 12 12 12

S Rubery 5.4, a & c

Failure of Barts Health (BH) to meet a number of operational standards, RTT & A&E, data quality and others.

20 20 20 20 20 20 20 20 20 16 16 10 10 12

S Rubery 5.6

There is a risk that patients may receive poor quality of care and or suffer harm as a result of BH's failure to achieve quality indicators.

20 20 20 20 20 20 20 20 16 16 16 12 12 12

S Rubery 5.7

BHRUT’s mortality rate is higher than

expected. The number of patients dying in BHRUT for certain clinical conditions is higher than the expected number of deaths

20 20 20 10 10 6

Risk Summary Number

Total risks last report 5 New risk(s) escalated 0 Risks de-escalated this report 0 Total GBAF risk this report 5

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NHS BHR CCGs Governing Body Assurance Framework - overall summary (2013 – 2016)

Lead /

GBAF ref. Risk Description

Initial rating (June 2013)

Previous risk ratings

Sept 2013

Jan 2014

Mar 2014

June 2014

Sept 2014

Nov 2014

Dec 2014

Feb 2015

May 2015

Aug 2015

Oct 2015

Dec 2015

Feb 2016

T Travers 1.1

(was 6.1)

Risk of failure to deliver the CCGs’

budget plans. 20 20 20 16

S Rubery 3.1

Failure to deliver quality improvement in urgent and emergency care at BHRUT

16 16 20 20 20 20 25 25 25 16 16 16 16 16

S Rubery 5.4, a, b

& c

Failure of Barts Health (BH) to meet a number of operational standards, RTT and A/E, data quality and others.

20 20 16 20 20 16 20 20 20

S Rubery 5.6

Quality standards not being met at BH - for C.Diff, and MRSA and FFT

16 20 20 20 20 20

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How to interpret the CCGs governing body assurance framework (GBAF):

Risk ref

This is a risk identifier attributed to the risk by the CCG risk lead

Lead director

This is the executive lead with responsibility for:- managing the risks to the corporate objectives and- liaising with the risk lead to ensure the GBAF is up to dateReporting to the CCG governing body or other committee on progress

Risk ratings:

The risk rating is derived from conversation between the lead director (or nominated deputy) and the risk lead. The risk score is calculated using the risk grading matrix. There are three types of risk rating used in the CCG GBAF.- initial risk rating: this grades the risk as if there were no remedial measures in place. This is called the ‘inherent risk’. - current risk rating: this grades the risk taking into account the remedial measures. The remedial measures should aim to 1, reduce the likelihood of the risk materialising, 2, reduce the impact of the risk if it does happen and 3, reduce both.- target risk rating: this is the level of risk that the CCG is prepared to accept and the level of risk that must be aimed for.

Risk description

For each risk note down:Who can be harmed and how can they be harmed if the risk materialises.Areas to consider are: harm/injury, objectives, claims or litigation, service disruption, staffing and competence, morale, financial, external assessment and adverse media interest

Controls

What is being done to reduce the likelihood and severity of the risk.One specific risk may be mitigated by a number of controls

Assurance

Assurances are inevitably ‘bits of

paper’ that act as evidence the

controls are in place. Examples include:Job descriptions /organisation chartsRegular reportsContracts / service level agreementsPolicies and proceduresMinutes / agendas / terms of reference

Gaps in controls

What more can be done to control the risk and what controls could be improvedGaps in assurance

What associated documentation will demonstrate that the controls are in place?

Proposed actions

Where gaps have been identified, list the actions required to put them into place. Ensure they have a named lead and target date

Risk

Ref

Lead

Director Risk Description

Initial

Risk

Rating

(June 13)

Controls Assurances

Current

risk

rating

Gaps

Proposed

actions

Target

Risk –

1/4/1

4

Control Assurance

3.3 MS

Commissioning

organisations

are not able to

run patient level

validations for

the first quarter

to validate non

contract activity

which will

present a

financial risk

15 Our current control is we have

issued instructions to the CSU

not to pay un-validated

invoices. Where we have a

contract we will pay in line

with the contract and monitor

activity.

Where there is no contract we

will develop an alternative

validation process. Until the

process is developed we will

not pay the invoices.

A regular weekly report

is being developed with

the CSU to report on the

progress.

The audit committee

will be updated on

performance to only pay

validated invoices.

15 A detailed

process for

non contract

invoicing

requires

urgent

development.

A regular

report will

be

produced

for the

audit and

governance

committee

Develop

new

validati

on

process

3

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs From: Lee Eborall, NEL CSU POD Director Date: 25 January 2018 Subject: Barts Health Contract Briefing for BHR CCGs Executive summary

The aim of this paper is to set out the headline issues and updates in relation to the actions being taken by the lead Commissioner of the Bart’s Health Acute Contract and to provide assurance to the BHR

CCGs’ Joint Committee that all appropriate contractual actions are duly being undertaken on behalf of all associates. The report covers the following key areas:

RTT Performance Cancer Performance A&E Performance and Winter Schemes Clinical Quality 17/18 Contract Issues/Year end close-down Current BHR Financial Performance 2018/19 Contract Refresh Update

Recommendations

The Committee is asked to:

Review the information contained in this report Endorse the actions taken by the lead Commissioner in relation to the 2017/18 risks and issues

and Note the progress on 2018/19 Contract Variation

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1.0 Introduction

The aim of this paper is to set out the headline issues and updates in relation to the actions being taken by the lead Commissioner of the Bart’s Health Acute Contract and to provide assurance to the BHR CCGs’ Joint Committee that all appropriate contractual actions are duly being undertaken on behalf of all associates. The Committee is asked to review the information contained in this report and endorse the actions taken by the lead Commissioner in relation to the 2017/18 risks and issues and note the progress on 2018/19 Contract Variation negotiations. The report covers the following key areas

- RTT - A&E Performance and Winter Schemes - Clinical Quality - 17/18 Contract Issues/Year end close-down - Current BHR Financial Performance - 2018/19 Contract Refresh Update

2.0 Performance

2.1 RTT - Referral to Treatment Time

Barts Health is not currently reporting nationally on RTT standards due to concerns on the quality of their data. Provisional data is however provided to commissioners. The Trust is preparing to return to reporting and is aiming to resume reporting in May 18 with April 18 data. In order to ensure that Data Quality is of a sufficient standard prior to reporting, the Collaborative is commissioning an external review of the Trust’s data quality and governance processes prior to resumption of reporting. This is in

the process of being procured and the review will start in February 2018. The long waiter trajectory clearance plan agreed with Commissioners was that all 52 week waiters (with the exception of Trauma & Orthopaedics and Oral Surgery) would be reduced to nil in December 2017 and overall clearance of 52 waiters (including Trauma & Orthopaedics and Oral Surgery) by March 2018 (subject to validation and patient choice). However, it is now clear the December 2017 deadline was not met and there is an increasing risk that the commitment to clear all patients waiting 52 weeks by March 2018 may not be achieved; this is due to a small number of patients (3 waiting over 52 weeks in plastic surgery due to clinical complexity and the impact of cancelled elective procedures as a result of winter pressures. In light of this, a formal letter has been sent to the Trust requesting a detailed review of the position against trajectory, backlog clearance and return to national reporting timeline. This review will include collaboration between the Trust, Commissioners, NHS England (NHSE) and NHS Improvement (NHSI). Depending on the outcome of the review, further decision making may be required as to any appropriate contractual action to be taken. A number of deep dive sessions have also been held recently with clinical specialty teams to gain assurance of their actions and progress around 52-week wait management. All patients waiting over 52 weeks are subject to a Clinical Harm review. The outcomes of these reviews are overseen by an NHS E chaired Clinical Harm Review Board attended by CCG Quality leads. No cases of moderate or severe harm have been reported for the period April 2017 – September 2017, with the exception of a single case within Paediatric Dentistry reporting moderate harm. The Trust report that the volume of ‘unknown’ pathways on the Patient Tracking List (PTL) has been increasing and operational team resource to support real time validation is challenged within the

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organisation. Additional resource from Cymbio Consulting (specialists in patient pathway and list management) has been procured by the Trust to reduce the volume of this cohort of patients on the PTL and the latest reports are showing a decrease on all sites. Commissioners received on 18 January 18 a clearance trajectory for ‘unknowns’ and the impact of this cohort of patients on long waits and the PTL

overall. This trajectory will be reviewed by commissioners prior to any response to the Trust. This operational risk continues to be monitored via the RTT, Cancer and Diagnostics Technical Sub Group and the RTT Recovery Board. This is also covered in the letter highlighting the current risks to delivery of the Trust commitments. 2.2 RTT Reporting suites:

The Trust submits high level weekly and month-end shadow Unify reports to Commissioner and Regulator partners on the overall PTL volume and un-validated 52 week waits. Commissioners and Regulatory partners have requested that the Trust combine these reports into one dashboard suite (with additional detail including site, specialty and CCG level breakdown). Trust Business Intelligence colleagues have agreed to share this revised dashboard with Commissioner and NHSI and NHS E partners on the 19th January 2018 in order for the final iteration signed off by the RTT Recovery Board prior to incorporation into business as usual reporting. It is intended that this dashboard will continue to be monitored via the RTT, Cancer and Diagnostics Technical Sub Group and upward to Contract Review Group. 2.3 A&E Performance and Winter Schemes

Barts Health underperformed against the Sustainability and Transformation Fund Trajectory (91.29%) for A&E all types week ending 31st December with 86.57% (unvalidated position). In addition, all sites under performed against their local site trajectories. Performance however is higher than in the same period last year (82.02%).

Provisional monthly reporting indicates an outturn position of 85.50% for December 2017 and a provisional Q3 outturn of 86.93% against a trajectory of 91.25% for the quarter.

Overall All Type attendances at Barts Health are up by 2.7%YTD compared to 2016/17 (YTD week ending 31st December 2017); attendances are up at each site with 5.2% increased all type attendances at Whipps Cross Hospital (compared to last year).

Similar themes of growth in admissions are reported at the Trust, with overall admissions 5.1% higher YTD compared to the previous period last financial year. Changes in recording at Whipps Cross and the increase in uptake of Ambulatory Care at both Royal London and Whipps Cross sites are contributing to the admissions over performance on these sites.

A dedicated Winter Room has been established led by Archna Mathur, Winter Director for WEL. The Winter Room monitors escalation triggers across the Trust and real-time data in the EDs on all three sites, ensuring actions are taken across the system to respond to those triggers. The Winter Room is also responsible for monitoring progress against the schemes outlined below. It is too early to judge the effectiveness of individual schemes however it is clear that the Trust is performing better than this period last year.

On 22 November the Chancellor announced additional funding for the NHS in 2017/18, a significant proportion of this funding being to support new initiatives to improve A&E performance over winter and ensure delivery of at least 90% performance over Q4. Following submission of a number of provisional bids Barts Health were awarded a total of £2.5m, allocated as follows:

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Site Scheme Allocation

Flex capacity of 10 beds £ 400,000.00

Health Visiting support to Category 3 0-5s (Streaming) 29,000.00£

7-Day Paed CDU 100,000.00£

Pharmacy support for Category 3 (Streaming) 43,000.00£

572,000.00£

Paed CDU 5 x Beds 108,000.00£

Adult Escalation Beds x 25 Beds 619,000.00£

Paed Escalation Beds x 3 Beds 87,000.00£

Community Nursing Childrens Service 40,000.00£

854,000.00£

7-Day Ambulatory & Ultrasound Additonal 156,000.00£

IncreasedType 3 GP Capacity 82,000.00£

Admission Avoidance Nurse 17,000.00£

4x Additonal Paediatric Flex Beds and 20x Additional Medicine Beds819,000.00£

1,074,000.00£

2,500,000.00£ Barts Health Total

RLH Total

NUH Total

WX Total

RLH

NUH

WX

2.4 Cancer Performance

Barts Health recovered performance against the 62 day standard in July 17. The Trust met all the standards in October and November and is predicting compliance against the 62 day standard in December despite low treatment numbers. The Trust is also predicting compliance in Q3 and Q4 2017/18. As a result of strong performance across the STP in Q2 and beyond, there has been agreement via the London Cancer Board to release the NEL earlier diagnosis funding.

3.0 Clinical Quality

3.1 CQC Action Plans

CQC Action Plans have been updated to reflect the latest reports. The Actions Plans are reviewed in detail at site level Clinical Quality Review Groups (CQRGs).

Whipps Cross

Of the 51 actions on the Whipps Cross site, 16 are closed, 16 are green (on track) and 14 are amber (delayed but any risk mitigated). Progress is being made on moving the amber items to green. There are five red items which relate to:

3 items in End of Life Care –two actions which relate to inadequate pain relief for end of life patients. Regular audits, and rating of this action will be changed when consistent audit results indicate adequate pain management; one action which relates to consultant staffing ratio, a consultant post has been advertised and extra AHP support provided.

There are two red items in Outpatients and Diagnostics; one relates to safety equipment not always maintained or replaced to ensure the safety of patients or staff, in particular lead aprons, which provided

84

radiation protection – equipment being tested. Target date for completion of testing is 31/12/2017. The other action relates to limited oversight of the extent or depth of potential harm as a result of a recent information technology systems failure – Business continuity plan has been drafted and will be approved by Trust Executive in March?

RLH

Of the 11 actions, 2 are closed, 2 are green (on track) and 5 amber (delayed but risks mitigated. The action on Safeguarding training (adult and children) is rated red but progress has been made since the June inspection and will be reviewed at the sub-committee of the Quality and Safety Board with a view to changing to amber.

Newham

Of the 17 actions for the NUH site, 4 are closed, 8 are green and 2 are amber. There are 3 red items that relate to slow progress in the reduction in the number of overdue complaints in Children’s and Young People’s; the embedding of the compassionate care plan for end of life care patients and work to ensure consistent pain assessments for end of life care patients.

3.2 Summary Hospital Led Mortality Index – SHMI

The latest published data for Barts Health (July 2016 to June 2017 shows a ratio of 90.2 against a normalised standard of 100 with 403 less deaths than the expected number of 4128. Site level data is not available.

3.3 Contract Performance Notices (CPNs):

At the recent Barts Health KPI and CQUIN Review Meeting on 19th December, the Trust reported that there are 4 overdue Serious Incidents in November 2017; the same number reported in October 2017. The Waltham Forest Quality Lead has requested a detailed action plan to reduce this to nil – this will continue to be monitored and managed locally through the Whipps Cross Clinical Quality Review Group with escalation to the Barts Health KPI and CQUIN Review meeting held with the Trust on a monthly basis.

The Whipps Cross site reported a slippage of performance in November for the number of complaints responded to within 25 working days. The site reported 52% in November, down from 71% reported in October. The Trust will be working with Commissioners to review the Remedial Action Plan and performance trajectory in the coming months and this will continue to be monitored locally at the Whipps Cross Clinical Quality Review meeting. A deep dive review of SIs and complaints is being presented by the Trust at the next meeting of the group in order to understand current challenges and the steps being taken to address performance at a corporate level.

3.4 Discharge Summaries:

The Trust is undertaking a detailed review of the reporting of discharge summaries being issued each month as there is inconsistency in reporting at Trust and site/specialty level. At the last meeting of the KPI group the Trust advised that a dedicated work stream has been formed to review current performance challenges. The outcomes of which will be presented to the Trust’s Quality Board in February 2018 to outline the issues and remedial actions being taken to improve performance. A deep dive has been scheduled for the March meeting of the KPI CQUIN group for progress and outputs of the Trust Quality Board meeting.

3.5 SEPSIS:

The Trust confirm that all sites are collecting data to support the CQUIN; although there is site level inconsistency in terms of detail being collected. The Whipps Cross site submitted data and achieve the screening within 1-hour target. The Trust advise that an electronic pro forma is already in place at all sites; however, the Whipps Cross site are also piloting a paper based version as an additional aid to capture data.

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The Trust attained the Q2 milestone for empiric review (with 78% performance). Subsequent audit of case notes identified a number of patients whereby identification and subsequent treatment was delayed.

The Trust holds a Trust wide Sepsis and Antimicrobial Resistance Group which meets monthly to drive improvement and approach to sepsis management. An executive Director lead has been identified as well as named consultant leads at each site.

Progress against the CQUIN continues to be monitored via the KPI and CQUIN review group with regular updates to CRG for Quarterly CQUIN achievement.

The next deep dive to be scheduled for the April meeting of the KPI and CQUIN review group is Infection Control.

4.0 2017/18 Contract Issues / Year-End Deal 4.1 Q1 Reconciliation

The Q1 contract reconciliation was escalated to a Chief Executive (CE) level meeting between Jane Milligan, Single Accountable Officer for the NEL Commissioning Alliance and Alwen Williams, Chief Executive of Barts Health on the 20th December to discuss the escalated items around Palliative Care, Maternity and High Cost Drugs. It is however, agreed that further escalation, in line with national processes, should be avoided where possible and both parties have supported the idea in principle of a year-end deal based on Q2 negotiated locally.

The value of the escalated items in Q1 are valued at £235k for BHR CCGs, the majority of the value (£170k) relates to M1 and M2 maternity pathway activity added to M3 freeze. These challenges have been risk rated in the forecast position, with Maternity risk rated at 50%.

4.2 Re-admissions audit/Non Elective Coding

The readmissions audit has now been completed, and a final report has been produced by Monmouth Partners. A number of coding issues were identified during the course of the audit, however Barts are contesting the findings of the report. They are currently putting together a response to the audit by the end of this week contesting the findings of the report. Commissioners will be meeting Barts Health week commencing 15th January with the aim of progressing a joint position on the impact of the audit.

4.3 POLCV

NEL CSU has produced an audit specification, and a paper on the potential cost of delivering the audit. It is expected that the outcome of the audit will be applied through the monthly claims process to recover costs associated with activity undertaken throughout all of 2017-18 that does not meet the POLCV policy. NEL CSU are currently seeking quotes from potential auditing agents. The closing date for bidders to submit quotations was 12 January 2018. The mobilisation period is expected to begin at the beginning of February, with the audit taking place from mid-February. Final reports are expected by the end of March 2018.

BHR CCGs have requested that the Trust adopt the revised POLCV policy and discussions are underway via the lead commissioner to facilitate this.

4.4 Newham Rehabilitation

Newham CCG is undertaking a review of rehabilitation, including a review of the Elderly Rehabilitation wards at Barts Health (NUH site).

4.5 Whipps Cross A&E Audit

The Commissioners have produced an audit specification, and a paper on the potential cost of delivering the audit. The audit aims to establish whether the changes seen in the Healthcare Resource Groups (HRGs) distribution are due to changes in patient acuity, access to diagnostics, or coding practices. Commissioners are currently seeking quotes from potential auditing agents, using Contract Finder. The closing date for bidders to submit quotations was 12 January 2018. The mobilisation period is expected to begin at the beginning of February, with the audit taking place from mid-February. Final reports are expected by the end of March 2018.

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4.6 Whipps Cross HDU Audit

The Commissioners are developing an audit specification, and a paper on the potential cost of delivering the audit. The audit aims to establish whether the site is adhering to clinical protocols and thresholds for the new High Dependency Unit (HDU) beds.

4.7 Financial Performance

The financial performance based on M8 data is still being finalised but it is expected that the forecast outturn across the 12 CCGs will increase as a result of an adverse movement between M7 Flex and Freeze submissions and a higher than expected M8 Flex. The forecast for BHR CCGs is around £1m higher driven by non-elective activity, outpatient procedures and critical care. These three areas continue to be the key areas of financial over performance at around £1.5m each. There are also increases in maternity pathways as well as births in the month which have moved up towards plan. The other contributing factor to a potential £8m over-performance against the contract plan of £93.4m is unallocated QIPP of £3.4m.

Barts Health has stated that they have caught up on the activity lost as a result of the IT Cyber-attack by September 2017 through putting on additional outpatient capacity and theatre sessions.

Commissioners continue to manage financial risk by applying the available contract levers including claims, productivity metrics, Activity Query Notices and audits. Work is currently being undertaken to complete the Q2 reconciliation.

4.8 Year End Closedown

The Commissioners are working with the Trust to progress the Q2 reconciliation. Once completed, or progressed to a point where there is a clear position on all items, Commissioners will take a view on looking to close the year as soon as possible.

5.0 2018/19 Contract Refresh Update 5.1 Provider Intentions

A letter responding to the Trust’s Provider Intentions has been sent to the Trust responding to the intentions signalled by the Trust and asking for more detail on the proposed counting and coding changes. The letter also flags the outcome of the NEL Audit and the work ongoing to agree local variations for Ambulatory Care and Outpatients in the context of overall payment reform.

5.2 Contract Documentation

The Commissioners are compiling a draft contract variation containing the revisions to the contract as they are agreed (e.g. revised policies and agreements). Regular teleconferences/meetings are taking place to ensure that all schedules will be finalised at the point of signing the contract variation for 2018/19. The revised access policy has been received and will be included in the contract variation.

5.3 Service Specifications

Following consultation with CCGs, the only service specification that can be added at this point in time is the revised Maternity Specification which has already been agreed with the Trust. Any new additions or revisions to existing specifications will be included if they are available at a later date.

Potential additions for future Contract Variations will include Community Geriatrics at Tower Hamlets, Paediatric Eye for Waltham Forest, Newham vCKD and Ambulatory Care.

5.4 Information Schedule

Commissioners have provided a proposed revised schedule to the Trust on 1st November. The Trust broadly agrees with most revisions to the schedule but has asked for clarification and an opportunity to review some of the items. Parties continue to exchange correspondence to reach agreement on the outstanding areas.

5.5 IAP

Commissioners of the Barts Health NHS Trust acute contract have constructed an opening indicative activity plan (IAP) for 2018/19. The IAP builds on the projected outturn as per the Trust’s monthly reconciliation submissions, factoring in adjustments and contractual metrics to arrive at an opening position for the contract year. Following adjustments made as a result of claims, the NEL audit finding,

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the overseas patients adjustment, POLCV, the MSK adjustment for Newham, and QIPP (£3.2m for BHR CCGs).

The adjustment for 18/19 RTT backlog clearance agreed in the original 17/19 IAP has not been changed in the refreshed IAP and remains at £659k for BHR CCGs.

This proposal was shared with the Trust, and agreement was reached on the starting point (M1-5 FYE repriced) and most of the non-contentious activity adjustments before Christmas. The remaining adjustments will be subject to further negotiation.

5.6 Data Quality Improvement Plan (DQIP)

The proposed schedule was shared with the Trust on Wednesday 13 December and a discussion was had with the Trust on 15 December. A further escalation meeting was held on 18 January and a position agreed to resolve the two remaining items; Ambulatory Care coding and RTT flags on local data to enable tracking of backlog clearance.

5.7 Service Development Improvement Plan (SDIP)

Following discussions with the Trust, the Commissioners have written to request a review of the CCG priorities in the current SDIP to ensure they are still relevant. Feedback has been received by all CCGs with no changes requested by WF and minor amendments by Newham. Tower Hamlets has requested the addition of a 5 priorities covering local priority areas including Heart Failure, Anticoagulation, Ophthalmology, Respiratory and a review of the Minor Injury Unit at St Barts.

A meeting was held with Paresh Patel from Barts Health on 9th January to discuss the SDIP and it was agreed to have a final schedule by the end of January.

5.8 Quality, Innovation, Productivity and Prevention (QIPP)

The WEL Collaborative has facilitated a process whereby BHR and WELC QIPP leads have shared their proposed schemes for 2018/19 and any learning from existing schemes. Completed Project Initiation Documents (PIDs) and draft finance and activity templates for worked up QIPP schemes were due to be submitted to the Collaborative by Wednesday 13 December. The latest position for CCG PIDs was shared with the Trust by the Collaborative on 2nd January.

CCGs leads have highlighted that there remains a significant value of unidentified QIPP. At present, the QIPP values used in the IAP workings is taken from the values used to model the 2018/19 contract values when the contract was agreed.

5.9 KPIs

All elements of the schedule have been agreed, including the addition of RAG ratings and revised thresholds for 2018/19. The Emergency C-section indicator has been retained but as a reporting requirement only pending a development of a new indicator based on the Robson G1 indicator (for assessing, monitoring and comparing caesarean delivery rates). Two new KPIs related to a reduction in E-Coli bloodstream infections (baseline to be agreed) and End of Life Care based on the use of the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) audit are to be finalised by April 2018.

6.0 Conclusion and Recommendations

The Committee is asked to review the above information and endorse the actions taken by the lead Commissioner in relation to the risks and issues and note the progress on 2018/19 Contract Variation negotiations.

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Date: 25 January 2018 Subject: Update on Emergency Preparedness Resilience and Response (EPRR) Executive summary

Under the Civil Contingencies Act (2004) NHS organisations must show that they can deal with such incidents while maintaining services to patients. This work is referred to as ‘emergency preparedness, resilience and response (EPRR). CCGs have to meet a number of core standards and NHS England are responsible for ensuring that the CCG meets these. This report is to provide assurance that the CCG is aware of and undertaking its statutory duties in relation to EPRR. Recommendations

The Committee is asked to: Endorse the EPRR compliance rating of ‘Substantial’ Note the action plan developed in respect of the remaining two actions

1.0 Purpose of the Report

1.1 To provide assurance that the CCG is compliant in its statutory duties in relation to EPRR and request approval of the agreed compliance rating.

2.0 Background

2.1 The NHS needs to be able to plan for and respond to a wide range of incidents and emergencies that could affect health or patient care. Under the Civil Contingencies Act (2004) NHS organisations must show that they can deal with such incidents while maintaining services to patients. This work is referred to as ‘emergency preparedness resilience and response’ (EPRR). Under the Civil Contingencies Act (2004) emergency response organisations are classified into two types, Category One, primary responders and Category Two, supporting agencies.

2.2 While NHS England, as a Category One responder, bears the majority of responsibilities in preparing and responding to incidents and emergencies, the CCG, as a Category Two responder, has a duty to participate in preparations and provide a cooperative and supportive role to NHS England should an incident occur.

2.3 The Director of Corporate Services is now the Accountable Emergency Officer (AEO) for EPRR for the three CCGs and is responsible for ensuring that the CCGs’ roles and responsibilities in relation to EPRR are adhered to.

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3.0 EPRR activities

3.1 In order to provide assurance to NHS England on our adherence to EPRR core standards, an assurance meeting was held on 24 November 2017, where a compliance rating of ‘Substantial’

was agreed.

3.2 The CCGs have completed the work from last year’s action plan, so are rated ‘Green’ on all core standards expect for two. One is related to attendance at the Local Health Resilience Partnership. The regularity of these meetings are being reviewed by NHS England and once set the Director of Corporate Services in the new role as AEO will ensure attendance. The other is related to strengthening of the Pandemic Influenza plan, which has already been actioned. See appendix 2 for further information.

4.0 Resources/Investment

4.1 There are no additional resources or investment required and no impact on sustainability.

5.0 Equalities

5.1 There are no equalities considerations arising from this report.

6.0 Risk

6.1 There are no risks arising from this report. 7.0 Managing conflicts of interest

7.1 There are no conflicts of interest issues relevant to this report. Author: Lisa Wood, Senior Business Manager Date: 3 January 2018 Attachments:

Appendix 1: List of CCG statutory core standards for EPRR Appendix 2: BHR CCGs’ EPRR action plan

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Core standard Clarifying information

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Evidence of assurance

Self assessment RAG

Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months.

Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months.

Green = fully compliant with core standard.

Action to be taken Lead Timescale

Governance

1Organisations have a director level accountable emergency officer who is responsible for EPRR (including business continuity management) Y Y Y Y Y Y Y Y Y Y Y

2

Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response.

Lessons identified from your organisation and other partner organisations. NHS organisations and providers of NHS funded care treat EPRR (including business continuity) as a systematic and continuous process and have procedures and processes in place for updating and maintaining plans to ensure that they reflect: - the undertaking of risk assessments and any changes in that risk assessment(s)- lessons identified from exercises, emergencies and business continuity incidents- restructuring and changes in the organisations- changes in key personnel- changes in guidance and policy

Y Y Y Y Y Y Y Y Y Y Y

3

Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response.

Arrangements are put in place for emergency preparedness, resilience and response which: • Have a change control process and version control• Take account of changing business objectives and processes• Take account of any changes in the organisations functions and/ or organisational and structural and staff changes• Take account of change in key suppliers and contractual arrangements• Take account of any updates to risk assessment(s)• Have a review schedule• Use consistent unambiguous terminology, • Identify who is responsible for making sure the policies and arrangements are updated, distributed and regularly tested;• Key staff must know where to find policies and plans on the intranet or shared drive.• Have an expectation that a lessons identified report should be produced following exercises, emergencies and /or business continuity incidents and share for each exercise or incident and a corrective action plan put in place. • Include references to other sources of information and supporting documentation


4

The accountable emergency officer ensures that the Board and/or Governing Body receive as appropriate reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the organisation, significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standards.

After every significant incident a report should go to the Board/ Governing Body (or appropriate delegated governing group) .Must include information about the organisation's position in relation to the NHS England EPRR core standards self assessment.


Duty to assess risk

5

Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring whichaffect or may affect the ability of the organisation to deliver its functions.

Y Y Y Y Y Y Y Y Y Y Y Y Y

6

There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health ResiliencePartnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), and nationalrisk registers.


7There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with yourorganisation and relevant partners.

Other relevant parties could include COMAH site partners, PHE etc. Y Y Y Y Y Y Y Y Y Y Y Y Y

Duty to maintain plans – emergency plans and business continuity plans 8 Incidents and emergencies (Incident Response Plan (IRP) (Major Incident Plan)) Y Y Y Y Y Y Y Y Y Y Y Y

9 corporate and service level Business Continuity (aligned to current nationally recognised BC standards) Y Y Y Y Y Y Y Y Y Y Y Y Y10 HAZMAT/ CBRN - see separate checklist on tab overleaf Y Y Y Y Y Y11 Severe Weather (heatwave, flooding, snow and cold weather) Y Y Y Y Y Y Y Y Y Y Y Y Y12 Pandemic Influenza (see pandemic influenza tab for deep dive 2015-16 questions) Y Y Y Y Y Y Y Y Y Y Y13 Mass Countermeasures (eg mass prophylaxis, or mass vaccination) Y Y Y Y Y Y Y14 Mass Casualties Y Y Y Y Y Y Y15 Fuel Disruption Y Y Y Y Y Y Y Y Y Y Y Y Y16 Surge and Escalation Management (inc. links to appropriate clinical networks e.g. Burns, Trauma and Critical Care) Y Y Y Y Y Y Y Y Y Y Y Y17 Infectious Disease Outbreak Y Y Y Y Y Y Y Y Y Y18 Evacuation Y Y Y Y Y Y Y Y Y Y Y19 Lockdown Y Y Y Y Y Y Y20 Utilities, IT and Telecommunications Failure Y Y Y Y Y Y Y Y Y Y Y Y21 Excess Deaths/ Mass Fatalities Y Y Y Y Y Y

22 having a Hazardous Area Response Team (HART) (in line with the current national service specification, including a vehicles and equipment replacement programme) - see HART core standard tab Y

23 firearms incidents in line with National Joint Operating Procedures; - see MTFA core standard tab Y

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Ensure that plans are prepared in line with current guidance and good practice which includes: • Aim of the plan, including links with plans of other responders• Information about the specific hazard or contingency or site for which the plan has been prepared and realistic assumptions• Trigger for activation of the plan, including alert and standby procedures• Activation procedures• Identification, roles and actions (including action cards) of incident response team• Identification, roles and actions (including action cards) of support staff including communications• Location of incident co-ordination centre (ICC) from which emergency or business continuity incident will be managed• Generic roles of all parts of the organisation in relation to responding to emergencies or business continuity incidents• Complementary generic arrangements of other responders (including acknowledgement of multi-agency working)• Stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes• Contact details of key personnel and relevant partner agencies• Plan maintenance procedures(Based on Cabinet Office publication Emergency Preparedness, Emergency Planning, Annexes 5B and 5C (2006))


• Being able to provide documentary evidence that plans are regularly monitored, reviewed and systematically updated, based on sound assumptions:• Being able to provide evidence of an approval process for EPRR plans and documents• Asking peers to review and comment on your plans via consultation• Using identified good practice examples to develop emergency plans• Adopting plans which are flexible, allowing for the unexpected and can be scaled up or down• Version control and change process controls • List of contributors • References and list of sources• Explain how to support patients, staff and relatives before, during and after an incident (including counselling and mental health services).

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Arrangements include a procedure for determining whether an emergency or business continuity incident has occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the deployment of resources or acquiring additional resources.

Enable an identified person to determine whether an emergency has occurred- Specify the procedure that person should adopt in making the decision- Specify who should be consulted before making the decision- Specify who should be informed once the decision has been made (including clinical staff)


• Oncall Standards and expectations are set out• Include 24-hour arrangements for alerting managers and other key staff.

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Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical.

Decide: - Which activities and functions are critical- What is an acceptable level of service in the event of different types of emergency for all your services- Identifying in your risk assessments in what way emergencies and business continuity incidents threaten the performance of your organisation’s functions, especially critical activities


27 Arrangements explain how VIP and/or high profile patients will be managed. This refers to both clinical (including HAZMAT incidents) management and media / communications management of VIPs and / or high profile management Y Y Y Y Y

28Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content Y Y Y Y Y Y Y Y Y Y Y Y Y

• Specifiy who has been consulted on the relevant documents/ plans etc.

29 Arrangements include a debrief process so as to identify learning and inform future arrangements Explain the de-briefing process (hot, local and multi-agency, cold) at the end of an incident. Y Y Y Y Y Y Y Y Y Y Y Y Y

Command and Control (C2)

30Arrangements demonstrate that there is a resilient single point of contact within the organisation, capable of receiving notification at all times of an emergency or business continuity incident; and with an ability to respond or escalate this notification to strategic and/or executive level, as necessary.

Organisation to have a 24/7 on call rota in place with access to strategic and/or executive level personnelY Y Y Y Y Y Y Y Y Y Y

Explain how the emergency on-call rota will be set up and managed over the short and longer term.

31Those on-call must meet identified competencies and key knowledge and skills for staff. NHS England publised competencies are based upon National Occupation Standards .

Y Y Y Y Y Y Y Y Y YTraining is delivered at the level for which the individual is expected to operate (ie operational/ bronze, tactical/ silver and strategic/gold). for example strategic/gold level leadership is delivered via the 'Strategic Leadership in a Crisis' course and other similar courses.

32Documents identify where and how the emergency or business continuity incident will be managed from, ie the Incident Co-ordination Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist .

This should be proportionate to the size and scope of the organisation. Y Y Y Y Y Y Y Y Y Y Y Y

Arrangements detail operating procedures to help manage the ICC (for example, set-up, contact lists etc.), contact details for all key stakeholders and flexible IT and staff arrangements so that they can operate more than one control/co0ordination centre and manage any events required.

33 Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident. Y Y Y Y Y Y Y Y Y Y Y Y Y

34Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response.

Y Y Y Y Y Y Y Y Y Y Y Y

35 Arrangements to have access to 24-hour specialist adviser available for incidents involving firearms or chemical, biological, radiological, nuclear, explosive or hazardous materials, and support strategic/gold and tactical/silver command in managing these events.

Both acute and ambulance providers are expected to have in place arrangements for accessing specialist advice in the event of incidents chemical, biological, radiological, nuclear, explosive or hazardous materials Y Y

36 Arrangements to have access to 24-hour radiation protection supervisor available in line with local and national mutual aid arrangements;

Both acute and ambulance providers are expected to have arrangements in place for accessing specialist advice in the event of a radiation incident Y Y

Duty to communicate with the public37 Arrangements demonstrate warning and informing processes for emergencies and business continuity incidents. Arrangements include a process to inform and advise the public by providing relevant timely information about the nature of the unfolding event

and about: - Any immediate actions to be taken by responders- Actions the public can take- How further information can be obtained- The end of an emergency and the return to normal arrangementsCommunications arrangements/ protocols: - have regard to managing the media (including both on and off site implications)- include the process of communication with internal staff - consider what should be published on intranet/internet sites- have regard for the warning and informing arrangements of other Category 1 and 2 responders and other organisations.

Y Y Y Y Y Y Y Y Y Y

• Have emergency communications response arrangements in place • Be able to demonstrate that you have considered which target audience you are aiming at or addressing in publishing materials (including staff, public and other agencies)• Communicating with the public to encourage and empower the community to help themselves in an emergency in a way which compliments the response of responders• Using lessons identified from previous information campaigns to inform the development of future campaigns• Setting up protocols with the media for warning and informing• Having an agreed media strategy which identifies and trains key staff in dealing with the media including nominating spokespeople and 'talking heads'.• Having a systematic process for tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes.• Being able to demonstrate that publication of plans and assessments is part of a joined-up communications strategy and part of your organisation's warning and informing work.

• Ensuring accountaable emergency officer's commitment to the plans and giving a member of the executive management board and/or governing body overall responsibility for the Emergeny Preparedness Resilience and Response, and Business Continuity Management agendas• Having a documented process for capturing and taking forward the lessons identified from exercises and emergencies, including who is responsible.• Appointing an emergency preparedness, resilience and response (EPRR) professional(s) who can demonstrate an understanding of EPRR principles.• Appointing a business continuity management (BCM) professional(s) who can demonstrate an understanding of BCM principles.• Being able to provide evidence of a documented and agreed corporate policy or framework for building resilience across the organisation so that EPRR and Business continuity issues are mainstreamed in processes, strategies and action plans across the organisation. • That there is an approporiate budget and staff resources in place to enable the organisation to meet the requirements of these core standards. This budget and resource should be proportionate to the size and scope of the organisation.

• Being able to provide documentary evidence of a regular process for monitoring, reviewing and updating and approving risk assessments• Version control• Consulting widely with relevant internal and external stakeholders during risk evaluation and analysis stages• Assurances from suppliers which could include, statements of commitment to BC, accreditation, business continuity plans.• Sharing appropriately once risk assessment(s) completed

Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity.

Have arrangements for (but not necessarily have a separate plan for) some or all of the following (organisation dependent) (NB, this list is not exhaustive):

Risk assessments should take into account community risk registers and at the very least include reasonable worst-case scenarios for:• severe weather (including snow, heatwave, prolonged periods of cold weather and flooding);• staff absence (including industrial action);• the working environment, buildings and equipment (including denial of access);• fuel shortages;• surges and escalation of activity;• IT and communications;• utilities failure;• response a major incident / mass casualty event• supply chain failure; and• associated risks in the surrounding area (e.g. COMAH and iconic sites)

There is a process to consider if there are any internal risks that could threaten the performance of the organisation’s functions in an emergency as well as external risks eg. Flooding, COMAH sites etc.

Relevant plans:• demonstrate appropriate and sufficient equipment (inc. vehicles if relevant) to deliver the required responses• identify locations which patients can be transferred to if there is an incident that requires an evacuation; • outline how, when required (for mental health services), Ministry of Justice approval will be gained for an evacuation; • take into account how vulnerable adults and children can be managed to avoid admissions, and include appropriate focus on providing healthcare to displaced populations in rest centres;• include arrangements to co-ordinate and provide mental health support to patients and relatives, in collaboration with Social Care if necessary, during and after an incident as required;• make sure the mental health needs of patients involved in a significant incident or emergency are met and that they are discharged home with suitable support• ensure that the needs of self-presenters from a hazardous materials or chemical, biological, nuclear or radiation incident are met.• for each of the types of emergency listed evidence can be either within existing response plans or as stand alone arrangements, as appropriate.

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Core standard Clarifying information

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Evidence of assurance

Self assessment RAG

Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months.

Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months.

Green = fully compliant with core standard.

Action to be taken Lead Timescale

38Arrangements ensure the ability to communicate internally and externally during communication equipment failures

Y Y Y Y Y Y Y Y Y Y Y Y• Have arrangements in place for resilient communications, as far as reasonably practicable, based on risk.

Information Sharing – mandatory requirements

39

Arrangements contain information sharing protocols to ensure appropriate communication with partners. These must take into account and inclue DH (2007) Data Protection and Sharing – Guidance for Emergency Planners and Responders or any guidance which supercedes this, the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 ‘duty to communicate with the public’, or subsequent / additional legislation and/or guidance.

Y Y Y Y Y Y Y Y Y Y Y Y

• Where possible channelling formal information requests through as small as possible a number of knownroutes. • Sharing information via the Local Resilience Forum(s) / Borough Resilience Forum(s) and other groups.• Collectively developing an information sharing protocol with the Local Resilience Forum(s) / BoroughResilience Forum(s). • Social networking tools may be of use here.

Co-operation

40 Organisations actively participate in or are represented at the Local Resilience Forum (or Borough Resilience Forum in London if appropriate) Y Y Y Y Y Y Y Y Y Y

41 Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the CCA Y Y Y Y Y Y Y Y Y Y Y Y

42 Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained. NB: mutual aid agreements are wider than staff and should include equipment, services and supplies. Y Y Y Y Y Y Y Y Y Y

43 Arrangements outline the procedure for responding to incidents which affect two or more Local Health Resilience Partnership (LHRP) areas or Local Resilience Forum (LRF) areas. Y Y Y Y

44 Arrangements outline the procedure for responding to incidents which affect two or more regions. Y Y Y

45 Arrangements demonstrate how organisations support NHS England locally in discharging its EPRR functions and duties

Examples include completing of SITREPs, cascading of information, supporting mutual aid discussions, prioritising activities and/or services etc. Y Y Y Y Y Y Y

46Plans define how links will be made between NHS England, the Department of Health and PHE. Including how information relating to national emergencies will be co-ordinated and shared Y

47Arrangements are in place to ensure an Local Health Resilience Partnership (LHRP) (and/or Patch LHRP for the London region) meets at least once every 6 months Y Y

48Arrangements are in place to ensure attendance at all Local Health Resilience Partnership meetings at a director level Y Y Y Y Y Y Y Y

Training And Exercising

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Arrangements include a curent training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents

• Staff are clear about their roles in a plan • A training needs analysis undertaken within the last 12 months• Training is linked to the National Occupational Standards and is relevant and proportionate to the organisation type. • Training is linked to Joint Emergency Response Interoperability Programme (JESIP) where appropriate• Arrangements demonstrate the provision to train an appropriate number of staff and anyone else for whom training would be appropriate for the purpose of ensuring that the plan(s) is effective• Arrangements include providing training to an appropriate number of staff to ensure that warning and informing arrangements are effective


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Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work.

• Exercises consider the need to validate plans and capabilities• Arrangements must identify exercises which are relevant to local risks and meet the needs of the organisation type and of other interested parties.• Arrangements are in line with NHS England requirements which include a six-monthly communications test, annual table-top exercise and live exercise at least once every three years.• If possible, these exercises should involve relevant interested parties. • Lessons identified must be acted on as part of continuous improvement.• Arrangements include provision for carrying out exercises for the purpose of ensuring warning and informing arrangements are effective


51 Demonstrate organisation wide (including oncall personnel) appropriate participation in multi-agency exercises Y Y Y Y Y Y Y Y Y

52Preparedness ensures all incident commanders (oncall directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation. Y Y Y Y Y Y Y Y Y Y

• Attendance at or receipt of minutes from relevant Local Resilience Forum(s) / Borough Resilience Forum(s) meetings, that meetings take place and memebership is quorat.• Treating the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership as strategic level groups• Taking lessons learned from all resilience activities• Using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to consider policy initiatives• Establish mutual aid agreements• Identifying useful lessons from your own practice and those learned from collaboration with other responders and strategic thinking and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to share them with colleagues• Having a list of contacts among both Cat. 1 and Cat 2. responders with in the Local Resilience Forum(s) / Borough Resilience Forum(s) area

• Taking lessons from all resilience activities and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership and network meetings to share good practice• Being able to demonstrate that people responsible for carrying out function in the plan are aware of their roles• Through direct and bilateral collaboration, requesting that other Cat 1. and Cat 2 responders take part in your exercises• Refer to the NHS England guidance and National Occupational Standards For Civil Contingencies when identifying training needs.• Developing and documenting a training and briefing programme for staff and key stakeholders• Being able to demonstrate lessons identified in exercises and emergencies and business continuity incidentshave been taken forward• Programme and schedule for future updates of training and exercising (with links to multi-agency exercising where appropriate)• Communications exercise every 6 months, table top exercise annually and live exercise at least every three years

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Compliance Level

Evaluation and Testing Conclusion

Compliance Level agreed with NHS England

Full

Arrangements are in place that appropriately address all the core standards that the organisation is expected to achieve. The Board has agreed with this position statement.

Substantial

Arrangements are in place, however they do not appropriately address one to five of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed.

It was agreed that our compliance level is Substantial.

Partial

Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed.

Non-compliant

Arrangements in place do not appropriately address eleven or more core standards that the organisation is expected to achieve. A work plan has been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance.

Barking and Dagenham, Havering and Redbridge CCGs – Action Plan to meet outstanding EPRR Core Standards

Core Standard RAG rating agreed with NHS England

Action to be taken Timescale

Arrangements are in place to ensure attendance at Local Health Resilience Partnership meetings at Director level

RED Director of Corporate Services is the lead from Jan 2018 onwards will attend once new dates have been arranged by NHS England.

Ongoing through 2018

Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity (specifically related to Pandemic Influenza plan)

AMBER The CCGs have an approved Pandemic Influenza plan but NHS England have suggested some strengthening of the plan around mutual aid and recovery. The plan has been updated and will be approved at the next Quality and Safety Committee

February 2018

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs From: Steve Rubery, Director of Delivery and Performance

Date: 25 January 2018 Subject: 18/19 Operating and QIPP plans Executive summary

During December 2016, CCGs were required to complete a two year planning cycle, which would include 17/18 and 18/19. As part of this process CCGs issued two year a Operating Plan document, which included planning and delivery assumptions for overall performance (including QIPP). The planning cycle included a refresh period, prior to 18/19, which would be used to revise assumptions following the 17/18 period. CCGs are now undertaking a process to refresh plans, which will result in the issuing of a revised operating plan by 28 February. This refresh process is aligned to the overall East London Health and Care Partnership (ELHCP) process to ensure consistency across the north east London (NEL) sustainability and transformation plan (STP) footprint.

Recommendations

The committee is asked to:

Note the process for refreshing plans Receive a further report in 2 months 1.0 Purpose of the Report

1.1 The purpose of this report is to advise the committee of progress to date on the development of the 18/19 Operating and QIPP plans.


2.1 Each year CCGs are required to undertake a detailed process to assure both themselves and regulators that credible plans are in place for the next financial year. Typically this includes the development of an Operating Plan document covering the CCG’s planning assumption for both finance and activity for the coming year, as well as expected levels of performance against a range of Performance and Quality indicators.

2.2 The Operating Plan also requires the inclusion of 18/19 QIPP plans. As part of the 17/19 Operating Plan document (issued in December 2016) CCGs had issued a combined Barking and Dagenham, Havering and Redbridge (BHR) QIPP assumption of £20m for 18/19, based on the delivery of £45m of QIPP across BHR within 17/18. Current QIPP performance indicates a forecasted year-end position of £32m delivered against the £45m QIPP plan for 17/18.

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2.3 NHS England (NHS) will use the Operating Plan submission as part of their ongoing role as

regulator of the CCGs, as such performance against plan will be monitored on a regular basis.

2.4 In advance of the 17/18 planning round; NHSE mandated that the contract and planning round would cover a two year period (17/18 – 18/19), this would include a refresh period during Quarter 4 of 17/18 which would give commissioners the opportunity to revise plans in light of the 17/18 actual position.

2.5 At the time of writing; NHSE have yet to issue revised timelines for the submission of 18/19

operating plans, however CCGs anticipate the need to issue final operating plans by 28 February, however this date should only be considered provisional at this stage.

2.6 In lieu of finalised regulator guidance, BHR CCGs have been working with the wider ELHCP to ensure that plans are developed in time for the expected regulator deadline. This working is being coordinated by the Operational Delivery Group (ODG), with weekly updates on progress being submitted by the BHR system. At a local level CCGs have implemented a new sub-group of the Financial Recovery Planning Delivery and Monitoring Group (FRPDM) which will act as a task and finish group to ensure all actions required to complete the Operating Plan occur and any issues or risk are appropriately escalated.

3.0 Contract round

3.1 As part of the two year contract, CCGs will be required to issue a contract variation which will be

used to refresh the existing 17-19 contracts with main providers.

3.2 The CCGs have initiated a process which will aim to have signed revised contracts by 28

February 2018 for BHRUT, NELFT and associates. This will include all national requirements and jointly agree indicative activity plans. For both the NELFT and associate contracts, CCGs expect to meet the 28 February deadline.

3.3 The CCGs and BHRUT have not agreed a Q1 (17/18) reconciliation position. During October

both parties entered into a local mediation process to resolve the outstanding issues, however the Trust did not accept the outcome report. This has meant that both parties have now entered the National Dispute resolution process, which will take place in March. CCGs are attempting to expedite this process, but this will pose a risk towards delivery of a signed contract by the 28

February.

3.4 The CCGs have implemented weekly monitoring processes to ensure all other actions required for the BHRUT contract have been progressed, to enable quick turnaround when the outstanding issues are resolved.

4.0 18/19 Operating Plan

4.1 CCGs will be required to issue a revised Operating Plan as part of the 18/19 planning round refresh. Two year plans have already been created as part of the 17/19 planning process, this will form the basis for any further submission.

4.2 The exact requirements of regulators have yet to be communicated (as of 8/1/2018), in the interim CCGs are assuming a similar format and set of information requests will be required, and are working towards similar timescales in terms of completion.

4.3 The Operating Plan submission will include assumed level of overall activity, by provider and

point of delivery. In addition to expected performance against a range of constitutional

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standards (A&E, RTT etc.) CCGs will be expected to show compliance against all constitutional standards, or describe a previously agreed recovery trajectory to reach compliance.

4.4 To date CCGs have undertaken work to review to begin development of the Indicative Activity Plan (IAP) which will describe the commissioner view of activity across all providers during 18/19, this will include assumptions resulting from any service change (for example QIPP schemes).

4.5 The CCGs will now focus on the following key actions in advance of submission of the finalised

operating plan:

4.5.1 Revising finance and activity planning models for 18/19, to be completed by mid-January.

4.5.2 Review of all underpinning growth, planning and performance assumptions made as part of the 17/18 Operating Plan submission to ensure these remain appropriate, this will be completed by the week commencing 8 January 2018.

4.5.3 Completion of the IAP, detailing all commissioner activity assumption for providers by the 19th January.

5.0 18/19 QIPP plan

5.1 At the start of 17/18 CCGs were anticipating the need to deliver a £20m QIPP plan for 18/19. However this was predicated on full delivery of a £45m QIPP programme throughout 17/18, and would be impacted by any deviation from our overall 17/18 financial plan. CCGs expect 17/18 to deliver £32m (across BHR), a shortfall of £13m. In addition CCGs have yet to agree a Q1 reconciliation position with BHRUT as part of the 17/18 contract, this is expected to impact on the overall CCG financial position.

5.2 Given the pressures noted above, the CCGs are planning for the need to deliver an 18/19 QIPP programme of £37m as a minimum. It is likely that this figure will increase, particularly in light of the ongoing BHRUT position.

5.3 To date CCGs have identified a total 18/19 QIPP opportunity of £32.9m, of which CCGs are

assured (i.e. has passed through the CCGs’ QIPP governance process) of £12.2m. CCGs will continue to adhere to the QIPP planning process applied in the delivery of the 17/18 Programme, which have been effective to date.

5.4 As part of a wider NHSE review of QIPP process and planning, Deloitte have undertaken a review of CCGs’ governance and ten highest value schemes throughout December. Feedback from this review process has been positive, with the CCGs’ governance process rated as Green in all review categories. Project documentation issued to Deloitte was also noted as being of a high standard, particularly at this stage of the planning cycle.

5.5 The CCGs will now focus on the following key actions in advance of submission of the finalised

operating plan:

5.5.1 Ongoing development of the pipeline schemes – CCGs have identified a pipeline of 15 QIPP schemes (accounting for £16m of total opportunity), which will be developed throughout January so that the can pass through assurance processes. This will be a priority work area for the FRPDM. Each pipeline scheme will be monitored by the FRPDM on a weekly basis, with an agreed timeline for development of the PID.

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5.5.2 Ensure the development of finance and activity sheets for each QIPP schemes to support the contract process. The PMO has agreed a timeline with CSU Business Intelligence (BI) team for the development of these documents, which will support the overall contracting process. For the majority of schemes this is expected to be completed by the end of January.

5.5.3 Review of additional opportunities – CCGs will continue to review all opportunities

for additional QIPP schemes, this will include working with ELHCP partners and review of best practice across the NHS.

6.0 Resources/investment

6.1 There are no additional resource implications/revenue or capitals costs arising from this report.

7.0 Equalities

7.1 There are no equalities implications arising from this report.

8.0 Risk

8.1 There are no additional risks raised through this report. 9.0 Managing conflicts of interest

9.1 There are no conflicts of interest raised through this report.

Author: James Gregory – Director of the Programme Management Office Date: 8 January 2018

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs (BHR CCGs)

From: Steve Rubery, Acting Director of Delivery and Performance Date: 25 January 2018 Subject: Integrated Performance Report 2017/18 (Month 8 Activity, Month 9 Finance) Executive summary

This report is provided to present the Joint Committee of BHR CCGs with an integrated view of performance, including finance and activity, in its contracted services, to identify the key risks presented by that performance and provide assurance that those risks are being appropriately managed. This report is based on month 8 activity and month 9 finance information.

This report concerns the CCGs’ main providers - Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS Trust (Barts Health), North East London Foundation Trust (NELFT), Partnership of East London Cooperatives (PELC) and the London Ambulance Service (LAS).

The main points of note are:

BHRUT: The BHRUT 2017/18 financial forecast across the three CCGs is £10.2m above plan. This overspend is driven by over-performance in the following areas: elective, maternity, day cases and outpatients. One of the key drivers of the projected overspend is the increased average unit cost of non-elective activity compared to last year. An independent audit was commissioned to review non-elective case mix and price increase. Evidence of increased coding of co-morbidities was identified and the CCGs are pursuing the recommendations outlined in the audit report.

Following voluntary independent mediation entered into by the BHR CCGs and the Trust on 26 - 27 October regarding the Quarter 1 position, the Trust has subsequently rejected the mediation outcome. Rejection of the outcome has triggered stage 3 of the contractual dispute resolution process, known as Expert Determination - this process will be binding on all parties and will be conducted in accordance with a nationally prescribed timetable. Work in underway to prepare briefings and supporting evidence for each item under dispute with submissions due to take place in early February and conclusion of the process being a binding outcome by mid-March. The Trust has agreed to the CCGs’ proposal that the Quarter 1 outcome be used as the basis for Quarters 2 - 4 2017/18.

Concurrently to this process, work is progressing on a refresh of the contract for 2018/19 including agreement on a mandated national variation to be implemented from 1 February 2018. The national variation introduces a number of new obligations including that, from 1 October 2018, providers need not accept referrals by GPs other than those made through e-RS, and a requirement to implement revised overseas visitor charging regulations.

Four contractual notices remain open and active with the Trust, however a period of purdah in respect

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of formal contract actions has been extended to support the expert determination process.

On performance, against constitutional performance measures, the Trust met all eight cancer standards in the month of November. RTT performance in November was 91.5% against the 92% standard. The monthly 52 week wait reported position indicates six patients having waited over 52 weeks in November, down from 14 in October. The 4 hour A&E performance in November was 80.2%, below the recovery trajectory of 91%.

Barts Health: The Barts Health 2017/18 financial forecast across the three CCGs is £8.0m above plan. Outpatient and elective activity are over plan year-to-date and are under review by the co-ordinating commissioner (Newham CCG). The level of un-coded activity has significantly reduced in recent months, with the level of uncoded activity in November at 3%. Three items have been escalated following the Quarter 1 reconciliation process. The most significant for BHR CCGs and Barking & Dagenham in particular is the maternity pathway claim based on a post freeze submission of £171k which has yet to be agreed. A local process for resolution has been agreed and work is underway to progress the Quarter 2 claims and refresh the forecast with a view to discussing a year end settlement with the Trust.

On performance against constitutional standards, the Trust met the 62 day cancer standard in October and November and the Trust is predicting compliance in December. Against the 4 hour A&E standard, the Trust achieved 88.25% in November against the STF trajectory of 91.67%. The Trust has agreed to return to reporting in May 2018 (April performance) however there is now increased risk in the ability to reduce all 52 week waiters to nil by March 2018. The co-ordinating commissioner has written formally to the Trust and a meeting is being convened between commissioners, regulators and the Trust to review the position against trajectory and return to national reporting timeline. NELFT: The mediated negotiation, which took place in November, has concluded with a contract variation signed by all parties which includes an amended contract value (a reduction to the contract value of £1.6m) which reflects both QIPP delivery and commissioner investments and set out requirements for more detailed reporting of costs by the Trust in this financial year.

Quarter 2 IAPT performance (latest reported position) shows good achievement of recovery targets for Havering and Redbridge. Barking and Dagenham missed the target of 50% with performance of 44%. IAPT access targets not being met consistently. Against the 3.75% access target, Barking and Dagenham, Havering and Redbridge CCG performance is at 3.5%, 2.91% and 3.91% respectively.

Recommendations

The Joint Committee of BHR CCGs is recommended to:

review the report; note the actions that are being take and; seek any further assurances they require in respect of risks and their management.


1.1 The purpose of this report is to inform the Joint Committee of BHR CCGs on the contract activity and performance for acute, community, mental health contracts including the LAS contract, and agree any actions required.


2.1 This is a report from the Acting Director of Delivery and Performance to inform the Joint

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Committee of BHR CCGs of the position of acute, community and mental health contracts including the LAS contract.

3.0 Report Content

3.1 Integrated Performance Report (IPR) 2017/18 (Month 8 Activity, Month 9 Finance). This report is a summary of an extensive IPR which is considered at several levels within the organisations.


4.1 Resources/investment in each service/provider are highlighted for each individual provider as required, under the relevant sections of this report.

4.2 The outcome of contractual performance has profound financial impact on the CCGs’ ability to

achieve financial balance.

5.0 Equalities


6.1 Risks and mitigations for each area of activity and finance service are highlighted for each individual provider, under the relevant sections of this report; for each CCG individually; and at a BHR level.


7.1 There are no conflicts of interest to note, related to this report.

Author: Acute and Non-Acute MDT, BHR POD, NEL CSU Date: 18 January 2018

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Joint Committee Of BHR CCGs

Contract Report 2017/18

For Internal Distribution Only

Report Publication Date: January 2018(Month 8 Activity / Month 9 Finance)

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Joint Committee Of BHR CCGs Contract Report 2017/18 - BHR CCGs

Executive Summary

The purpose of the report is to advise the Joint Committee of BHR CCGs members of the key risks in relation to the contract portfolio of the BHR CCGs. The key areas of risk

are summarised below and the actions/recommended actions being taken are listed on the next page. Joint Committee members are asked to:

•Note the contents of the report;

•Note the key risks that are being brought to their attention; and

•Advise on the appropriateness of the actions being undertaken.

BHRUT• Following the Trust’s rejection of the Q1 Mediation outcome, the parties have now entered stage three of the national dispute resolution process; Expert Determination. This will determine Q1 and the

outcome principles will also be used as the basis for closing quarters 2-4 of the 2017-18 financial year. An agreement has yet been reached as to how this will actually now be resolved via the national process.

• Work to agree a reconciled Q2 position has commenced. Where items have been raised for Expert Determination under the Q1 reconciliation process the Q2 position will be determined by the outcome of this process.

• The forecast outturn (FOT) deteriorated by £0.4m compared to the projected forecast last month, taking it to a total of £348.3m against a plan of £338.2m. • 4.6% of spells remains uncoded in the BHRUT (M8 flex position, this reverses the improvement seen in M7 (3.9% uncoded).• The Trust met all eight national cancer standards in November at aggregate level, including the 62 Day GP Referral standard. • The RTT standard was once again missed, with an RTT Incompletes performance in November of 91.5% against the standard of 92%.• A&E performance continues to be challenging. In November the Trust achieved 80.2% which is significantly below the STF trajectory of 91% and also below the national standard (95%).• Audits on Stroke and Non-elective activity have been completed. The report is due to be published this week, with recommendations in relation to the NEL activity being pursued.

Barts Health• Work is underway to agree a reconciled Q2 position. Where manual claims have been agreed in Q1, Q2 values have been included in full. Where not agreed in Q1 they have been risk rated. Automated

claims for Q2 are still being finalised and the value is based on those agreed in Q1. • After a significant improvement in the level uncoded activity in recent months, the position again deteriorated in M8 from 2.6% to 3%. • The impact and application of the output of the readmissions audit and findings in relation to coding of NEL activity are yet to be finalised with the Trust; who are undertaking their own review. • BHR and WELC QIPP leads have shared their 1st cut QIPP schemes for 18/19 with the Trust. Further detail is required in some areas before the detail can be included within contracts.

NELFT

• The mediated negotiation, which took place in November, has concluded with a contract variation signed by all parties which includes an amended contract value which reflects both QIPP delivery and commissioner investments and set out requirements for more detailed reporting of costs by the Trust in this financial year.

LAS

• The BHR CCGs performance at M8 flex YTD is £148k below plan, with most of this seen in Barking and Dagenham CCG (£118k below plan). It should be noted that Redbridge CCG is marginally above plan (£2k over).

QIPP

• QIPP is under delivering by £8m YTD, with a M9 forecast under delivery of £12.8m (NB numbers are for the BHR-wide CCGs’ position). This represents a deterioration of £0.3m from the forecasted performance at M8. The forecast outturn includes a prudent position on the delivery of pipeline opportunities and unidentified QIPP, which drives a higher level of assumed underperformance compared to the YTD position.

• Delivery against live schemes is positive at M9, with CCGs delivering £21.8m of a planned £29.8m (73.3% achievement against plan). CCGs are forecasting this level of performance will continue throughout 17/18.

• Delivery against pipeline opportunities and unidentified QIPP accounts for the majority of FOT underperformance (£11.2m against the forecasted £12.5m underperformance). The ‘Big Ticket’

initiatives previously governed by the System Delivery and Performance Board continue to be developed, noting that the Referral Management System business case has been approved by the Financial Recovery Programme Board (FRPB) and the scheme is being mobilised with financial support from NHSE following a successful bid by the SRO.

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Executive Summary – Actions being undertaken

3

BHRUT

• Following the Trust’s rejection of the mediation outcome for Quarter 1, stage 3 of the contract dispute resolution process - binding Expert Determination has been triggered. The Trust has confirmed they are in agreement to use the Q1 outcome as the basis for closing quarter 2-4 of the 2017-18 financial year. Preparation is underway to ensure evidence and briefing papers are pulled together to support this process.

• Non-elective and stroke audit reports findings suggest the Trust has enriched its coding practice in these two areas in comparison to 2016/17 Q1 data. The impact of this, HRG4+ changes and next steps will be outlined in the auditors’ report due to be finalised this week. Recommendations in relation to NEL prices increases will be pursued at pace to support the Expert Determination process.

• The Indicative Activity Plan (IAP) and other relevant elements of the 2017/19 signed contract is currently being refreshed for 2018/19. Proposed Key Performance Indicators and CQUINs for 2018/19 have been shared with the Trust.

• The RTT recovery trajectory has been issued will be formally discussed at the CRG on 25 January following a technical assurance process on Wednesday 17 January.• Activity Query Notices have been issued to Spire Roding, Holly House and Care UK in relation to activity in specialties over performing at M7 year to date. Meetings with the providers have been

scheduled to take place week beginning 15 January which will look to agree recovery actions to mitigate over performance.

Barts Health

• Three items have been escalated following the Q1 reconciliation process. The most significant for BHR CCGs and Barking & Dagenham in particular is the maternity pathway claim based on a post freeze submission of £171k which has yet to be agreed. A local process for resolution has been agreed and work is underway to progress the Q2 claims and refresh the forecast with a view to discussing a year end settlement with the Trust.

• First draft QIPP PIDS have been submitted the Trust. Final agreed schemes will be incorporated into the IAP which will be agreed by the end of February 18. CCGs leads have highlighted that there remains a significant value of unidentified QIPP.

• Reviews are underway to understand the drivers of over performance, particularly in Outpatient Procedures and NEL. Commissioners are aware that the NEL numbers will be effected by the coding issues identified as part of the readmissions audit.

NELFT

• Following the signed contract variation based on mediation a reduction to the contract value of £1.6m (community and mental health elements combined) reflecting both QIPP delivery and Commissioner has commenced with a further requirement for a more detailed reporting of costs by the Trust to be reported in 2017/18.

LAS

• CCG-level performance reporting is currently unavailable, and the LAS are working with Commissioners to review and design the appropriate suite of reports to capture the new range of metrics. The causes of over performance for Redbridge CCG will be discussed via the UEC forums to ensure mitigations are in place.

QIPP

• As reported last month, there is ongoing work to assure the delivery of existing schemes and identification of system wide ‘big ticket’ opportunities. CCGs and BHRUT have

commenced initial work to align PMO processes to support an enhanced reviews of QIPP performance, with a view to enable more robust interventions, this is expected to be in place to support the 18/19 QIPP planning process.

• Consultation on Phase 2 of “spending money wisely” has finished, and the decision ratified. This will deliver a part year impact from M11 onwards. • Work continues on the ELHCP-wide Procedures of Limited Clinical Effectiveness (PoLCE) review. The Clinical Panel has almost completed its review and proposals, including the

financial and activity impact and the governance of decision making process are now under consideration by the Single AO. • An agreement to ensure referrals comply with the MSK, Gastroenterology and Dermatology schemes through closing the alternative referral route has been agreed via FRPDM and

subsequently with BHRUT. Referrals that do not comply with the agreed referral pathway will be redirected by BHRUT (clinical exceptions apply), further communication will take place with GPs in January. CCGs and BHRUT are now working together to operationalise changes.

• QIPP planning for 2018/19 continues, with £32m of schemes identified so far (note this includes unassured schemes at an early stage of development).

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CCG Overview – Financial Summary – Reported

4

Data Source: NHSE Return

Key Messages

• The BHRUT 2017/18 forecast outturn is £10.2m above plan. This continues to be driven by NEL, Elective, Maternity, Day Cases and Outpatient activity.

• YTD QIPP performance at month 9 indicates an achievement of £21.9m against a planned £29.8m (a variance of £7.1m).

• The Barts reported forecast is now £8m above plan. High cost critical care patients, NEL activity and Outpatient Procedures continue to drive this position.

• There is continued overspend on the Homerton contract, which relates almost exclusively to IVF and maternity related activity. Reductions in the cost per patient for IVF referrals post August should reduce in line with the implementation of the service restrictions/spending money wisely service restrictions.

• The expected reduction in referrals to the Independent Sector, which should have followed the cessation of referral redirects from BHRUT at the end of Q4 2016/17 has not been realised. The continued over performance against plan has seen the forecast increase by a further £0.8m this month. Work remains on going to investigate current activity and referral levels. Due to the continued increase in expenditure the forecast has been adjusted up accordingly and Activity Query Notices (AQNs) have been raised.

• Moorfields continue to over perform in high cost drugs with associated activity increases. This is partially driven by increased activity as a result of the NHS E Diabetic Screening programme which identifies more patients.

• The CCG’s have seen increased Critical Care

activity across a number of Associate providers, although the forecast for Critical Care remains below the consolidated annual plan.

Note. Overspends are shown in red in brackets, whilst numbers in black represent an underspend. This convention is used throughout this report. All financial values are reported in £’000s.

The only exception to this convention is slide 26 (ELHCP Overview) which presents the financial position on an STP-level and therefore follows STP conventions (red text for an overspend, negative values in black text for an underspend).

Rag

Plan Actual Variance Plan Actual Variance Plan Outturn Variance Rating

STP Acute Trusts 34,163 38,485 (4,322) 330,610 343,988 (13,379) 439,757 459,181 (19,423)

Other Acute Trusts 3,744 4,259 (516) 37,189 38,767 (1,578) 49,615 51,570 (1,954)

Other Acute 6,871 5,803 1,068 63,977 66,669 (2,692) 86,963 96,359 (9,395)

Acute Commissioning Total 44,777 48,547 (3,770) 431,775 449,424 (17,649) 576,336 607,109 (30,773)

Mental Health 8,198 8,544 (346) 71,192 69,800 1,392 94,611 93,469 1,142

Community 7,009 7,180 (170) 63,849 63,966 (117) 84,877 85,935 (1,058)

Continuing Care 5,052 4,289 763 44,094 44,653 (558) 59,019 59,454 (435)

Primary Care 11,233 10,398 835 95,611 94,107 1,504 126,184 123,439 2,745

Other 12,460 11,174 1,287 111,968 103,444 8,524 163,381 145,219 18,162

Total 88,729 94,185 (5,456) 818,490 825,394 (6,904) 1,104,408 1,114,625 (10,216)

Rag

Plan Actual Variance Plan Actual Variance Plan Actual Variance Rating

BHRT 26,708 28,320 (1,612) 253,944 260,087 (6,143) 338,190 348,343 (10,153)

Barts Health NHS TRUST 6,848 9,402 (2,553) 70,482 76,652 (6,171) 93,353 101,313 (7,960)

Homerton 1,864 764 1,100 6,184 7,249 (1,065) 8,214 9,525 (1,310)

Guys & St Thomas 483 605 (122) 4,804 5,051 (248) 6,408 6,640 (232)

Mid Essex 377 430 (53) 3,737 3,780 (44) 4,988 5,021 (33)

Moorfields 687 701 (14) 6,819 7,255 (436) 9,100 9,779 (679)

UCLH 696 736 (40) 6,899 6,777 121 9,207 9,162 45

London Ambulance Service 2,423 2,423 0 21,806 21,806 0 29,074 29,074 0

Spire Healthcare 714 1,108 (394) 6,424 8,663 (2,239) 8,566 10,092 (1,526)

Other Acute 3,977 4,059 (83) 50,678 52,103 (1,425) 69,235 78,160 (8,925)

Total 44,777 48,547 (3,770) 431,775 449,424 (17,649) 576,336 607,109 (30,773)

In Month Year to Date Annual Forcast

In Month Year to Date Annual Forcast

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Service Delivery Plan (QIPP) – Delivery

5

Data Source: BHR CCGs and NHSE Assurance Meeting Report

Notes

Summary: There has been an deterioration of £0.3m between Month 8 and Month 9 forecast positions. The key risks in QIPP delivery remain within the Planned Care Programme (the single largest target value). Concordance with CCG commissioned pathways including MSK is highly variable and remedial actions are being taken. No progress has been made in month in identifying viable QIPP schemes for demand treated at Barts Health.

QIPP achievement is monitored on an individual scheme basis and reported at transformation level. SUS data is used to monitor individual schemes which are activity driven in nature, with flex and freeze data used to calculate YTD achievement. Where SUS data cannot be used to monitor a scheme, an accruals basis is used.

Transformation ProgrammeFull year plan

FOT at month 9

FOT variance

YTD plan YTD actual YTD variance RAG Rating

£000’s £000’s £000’s £000’s £000’s £000’s

Planned Care 8,604 5,644 (2,960) 5,589 2,920 (2,669)

Unplanned Care 7,046 7,079 33 4,287 5,180 893

Medicines Management 5,394 6,290 896 3,751 4,412 661

IT 188 - (188) 125 - (125)

Primary Care 74 74 - - - -

Contracts 6,600 7,144 543 5,130 5,739 609

Estates 1,932 1,932 - 1,449 1,449 -

Corporate 63 71 8 47 52 5

Subtotal 29,901 28,234 (1,667) 20,379 19,752 (626)

Barts Health QIPP 3,987 - (3,987) 2,658 - (2,658)

System Delivery 1,115 - (1,115) 743 - (743)

Pipeline 1,593 - (1,593) 1,062 - (1,062)

Investment Fund 4,040 4,040 - 2,100 2,100 -

Unidentified 4,462 - (4,462) 2,888 - (2,888)

Grand Total 45,098 32,274 (12,824) 29,829 21,852 (7,977)

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Service Delivery Plan (QIPP) – Delivery

6

Key Messages

Overall SDF Programme

• Current QIPP performance at month 9 indicates an achievement of £21.9m against a planned £29.8m (a variance of £7m). Overall an slight deterioration compared to the reported position at M8, FOT position now stands at £32.3m and projected deterioration of £0.3m. This deterioration in FOT is driven by a reduction in the expected month 9 POLCE and Service Cessations positions, however this was partially mitigated by an improved Medicines Management position.

Planned Care programme

• Eight schemes are live with four under exception. Escalated schemes are MSK, gastroenterology, dermatology and Service Cessation.• Phase two of spending money wisely has now completed the consultation process, with the CCG expected to make a decision in December, assuming proposal are agreed, this

would lead to an approximate £150k in year benefit. • Key risk relate to lower than planned referrals into the community services, for gastroenterology, MSK and dermatology, for month 9 MSK performance is a significant outlier.

Referrals are now mandated to flow into the respective triage services (clinical exception apply) with BHRUT agreeing to redirect referrals that do not comply. • Rates of IVF activity (now restricted to one cycle) are higher than anticipated, particularly at the Homerton. CCGs have issued an exception report and recovery plan to the

FRPB.

Unplanned, Complex and Mental Health

• One Urgent Care scheme remains under exception (A&E front door), work continues to address under performance against this area. • Performance against the A&E front door scheme has been discussed with the Trust as part of the ongoing PMO-PMO work, this will lead to a recovery plan. Responsibility for

delivery of this QIPP sits with BHRUT. Recent performance ( based on provisional December data) shows significant improvement.• All other Complex and Mental Health schemes are delivering to plan year to date.

Medicines Management

• Provisional M9 data indicates a £500k improved position compared to M8, this is due to better than anticipated performance against the Pregabalin line. All other elements of the plan are delivery as expected.

ELHCP-wide PoLCE Initiative

• The Clinical Panel has now started to meet and assess and score the evidence packs.• Key risks are: variable appetites for review of access thresholds across ELHCP and support for a nationally funded QIPP Programme.

Managing Elective demand

• Progression of modelling an ‘at scale’ System wide Referral Management System. Jointly developed outline business case with BHRUT and CCGs SROs. Business case has been agreed by the SDPB and CCGs FRPB to proceed to the next stage of development, this will include development of a full implementation plan.

• The first GP delivery Dashboard has now been issued to all practices. • A project initiation document for the GP incentive package to support Primary Care has been assured. Initial rounds of negotiation are under way between CCGs and Provider

leaders.

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CCG Overview – Performance by Programme – All Providers

7

Planned Care

Over performance is seen in elective ophthalmology, with costs up 52.7% and activity up 55.9% in comparison to the previous year. Please note this is comparing actual spend this year to last year.

BHRUT achieved 91.5% for the November RTT performance against the 92% standard, compared to 91.1% in October. December’s unvalidated performance is 89.6%. The Trust has indicated that elective cancellations in December due to winter pressures is likely to impact on RTT performance by -0.2% for every day outpatient clinics are cancelled.

QIPP

Demand Management - QIPP related schemes to reduce referrals into secondary careincluding gastroenterology, MSK and dermatology, have not delivered to the expectedlevels. The FRPB has now agreed to mandate compliance with these pathways in allinstances (excluding 2WW and agreed clinical exceptions), this will be communicated to allGPs in January. BHRUT have been engaged in this decision and will be actively required toredirect inappropriate referrals, both parties are now developing plans to operationalise this.

POLCE & Cessations/Restrictions: The consultation for phase 2 of SMW has now closed,CCGs will make a formal decision on this in December. POLCE performance in month 9 hasdeteriorated, due to activity from the Independent sector, this is now under review. Year todate POLCE performance remains better than plan. There has been a deterioration againstthe Service Cessation scheme, due to IVF activity, this now under review and an exceptionreport/recovery plan has been issued.

Other: All other schemes within planned Care are delivering to plan, with no issues of note.

Unplanned Care

Over performance is seen in non-electives across all providers, with the main specialty level drivers being geriatric medicine (44.9% up in costs, 8.1% down in activity) and endocrinology (139.4% up in costs, 46.3% up in activity). Please note this is comparing actual spend this year to last year.

BHRUT validated 4 hour performance for November is 80.2% against a STF trajectory of 91%. December performance is 76.68% against the STF trajectory of 90%. There are ongoing workforce issues. PELC commenced delivery of the streaming function within ED and this increased streaming to 24/7. The expanded UCC service at Queens opened on the 10.01.18.

QIPP

A&E front door: The scheme remains under exception, however the level of redirectionweekly target was achieved consistently throughout December. Work continues to achievethis level of redirection on a weekly basis. BHRUT carry 100% of the risk for financialdelivery against this scheme.

KGH UCC: Scheme continue to deliver, both in terms of expected activity reduction andwith regard to weekly UCC utilisation rate.

111: The scheme continues to deliver marginally better than plan. BHRUT and CCGs areundertaking an audit to triangulate reported reductions via 111 and A&E attendances,which should confirm the effectiveness of the scheme.

Mental Health

The ambitions of the national Mental Health Five Year Forward View form the basis of BHR CCGs’ mental health programme priorities for 2017/18 and focus on the following areas:• Maintaining the low acute psychiatric bed base, and ensuring that patients needing acute care are not placed out of area.• Improving services for people experiencing mental health crisis, including home treatment teams provision, enhanced mental health liaison services at acute hospitals, and 24/7

access to information and advice.• Improving access to talking therapies, moving towards closer integration with physical health care provision.• Sustaining recovery rates and waiting time performance for people referred to talking therapies .• Improving the physical health of people with severe mental illness.• Improving psychological interventions for people with psychosis, bi-polar disorders and personality disorders.• Implementing the Transforming Care Programme for people with learning disabilities to develop viable alternatives to inpatient care wherever possible.• CAMHS transformation, including increasing the numbers of children and young people in receipt of mental health services, and improving access to eating disorder services.

There has been overall progress on the delivery of these priorities. However, remaining challenges are in the consistent delivery of the IAPT Access and Recovery targets and in thedelivery of the Redbridge CAMHS service. Both of these areas are being addressed through SPR (and through CQRM in the case of CAMHS).

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Joint Committee Of BHR CCGs Contract Report 2017/18 - BHR CCGs 8

Finance

BHRUT

The forecast at M9 (overspend of £10.2m) is currently reported following a risk assessment of outstanding areas of dispute and includes an additional MRET adjustment of £3m and successful challenges at £13.6m. Overspends have been identified in the unadjusted position in antenatal, day cases, elective, non-elective and outpatients. The key areas identified are: Maternity - Activity levels are up 2.3% and costs have increased by 5%. Whilst the increase in the cost of deliveries appears to be in line with other providers (and driven by the national changes to Guidance), analysis suggests a change in antenatal pathway case mix, with shifts from standard and intermediate pathways to intensive pathways. This has been raised with the Trust. RTT – Activity in Planned Care PODs (Outpatients, DC, Elective) is continuing to increase in line with previous months. Critical Care – has started to increase over the last couple of months although it is still forecast to underspend in the year. Drug Spend - Increasing due to IR specialised commissioning transfers in gastroenterology and rheumatology. NEL – stroke, respiratory, nephrology, A&E, ambulatory care,geriatric medicine, vascular, general surgery, sports medicine and endocrinology have all seen a significant forecast increase over budget of £17.8m (17.23% up). After removing the stroke increase, HRG4+, growth and sepsis the real increase is £6.7m (7.64%) and Activity is 2.04%.

Barts Health BHR CCGs are reporting a forecast over performance of £8.0m which is a deterioration of £1m against last month. YTD over performance of £6.1m continues to be driven by unplanned care (NEL Inpatients of £1.1m and critical care of £1m) and planned care (outpatients including outpatient procedures £1.6m, and elective inpatients £0.2m. The adverse movement in the month was the result of an increased spend in non elective £0.3m, critical care £0.2m and outpatient procedures £0.1m. There was also an increase in the combined reported spend in both maternity pathways and births of £0.2m. However, these remain below planned levels at this time. Uncoded activity in the month has a financial value of £0.28m (£0.23m last month) out of a total spend of £4.4m across the relevant PODs. Three items have been escalated following the Q1 reconciliation process. The most significant for BHR CCGs and Barking & Dagenham in particular is the maternity pathway claim based on a post freeze submission of £171k which has yet to be agreed. A local process for resolution has been agreed and work is underway to progress the Q2 claims and refresh the forecast with a view to discussing a year end settlement with the Trust. As proposed by the CCG, £1.2m QIPP savings against the current YTD projection are assumed in the final outturn position.

Activity

BHRUT

Over performance in most outpatient and elective planned care areas mainly attributed to additional demand, with RTT and QIPP performance contributing to a lesser extent. Over performance continues to be seen in unplanned care primarily associated with stroke and sepsis activity, though significant increases are seen with costs. NEL and stroke audits have been completed and the auditors report has been shared with the Trust for factual accuracy. Barts HealthUnplanned Care is 4.9% above plan (4.6% last month) and is driven primarily by a 41% over performance in Critical Care. It is possible that this will reduce at freeze as spells are reattributed to Specialised Commissioning along with related critical care bed days but this is less likely than earlier in the year as the level of uncoded is lower. Uncoded activity is 3% (2.6% last month) .Elective uncoded activity is up from 7.3% to 8.5% and Non elective is up from 3.8%, to 4.6%A&E activity is 4.9% above plan (4.6% last month) after adjusting for zero cost streamed away activity. Planned inpatient care is around 1.2% above plan (0.8% last month) and continues to be driven by Elective inpatients rather than Day Cases. Outpatients as a whole are 9% over YTD. First attendance are 7% above plan, despite a reduction in reported referrals and the potential impact of the cyber attack. Follow ups increased slightly from 0.6% over to 1.4% .Births continue to be under plan in the year to date at 6.2% as against 6.7% under plan last month. Antenatal pathways are 1% under plan. Post natal pathways are still significantly over plan, 124%, and are subject to a claim related to an increase level of activity in month 4. To date the Trust have not substantiated this spike in activity.

Performance

A&E - BHRUT validated 4 hour performance for November is 80.2% against a STF trajectory of 91%. Barts Health achieved 88.25% against the monthly STF trajectory of 91.67%. RTT – BHRUT achieved 91.5% for November against the 92% standard. Whereas Barts Health, who will not meet the milestone to clear all 52 week waits (with the exception of T&O and oral surgery) by December 2017. Cancer – BHRUT met all eight cancer standards in November with the 62 day standard which achieved 88.1% against a target of 85%. Urology as a tumour site achieved the 62 day standard in November as agreed in the revised trajectory. Barts Health met the standard in October and November. The Trust is also predicting compliance in December despite low treatment numbers. Diagnostics: Performance remains below the 99% standard in October (98.06%) and November (provisional reporting for November is 98.16%).

Acute Contract Performance – BHRUT and Barts Health

108


Contract Performance – Key associates and Independent Sector

9

Finance

Basildon has seen an increase in Critical Care and NEL this month in B&D, increasing the forecast by £69k Homerton are still seeing an increase in referrals. Daycases, electives, outpatients, diagnostics and non-electives activity increases have also been seen YTD.North Middlesex has seen an increase in Critical Care, Daycases and Outpatients. This has increased the forecast by £49k Royal Free has seen an increase in NEL and PTS, although PTS costs are being disputed with the Trust as new contract not agreed.Guys & St Thomas' - Spend is increasing in Critical Care due to high cost patient. Patient has left ITU after 3 months but has increased forecast by £147k in Havering.University College London has seen an increase in Critical care due to high cost patients who remains in ITU. Increase in forecast of £110k.Care UK, Spire, Holly and the Roding - the redirect program ended in April though demand has not decreased accordingly. Further work is being carried out to understand why the expected demand management reductions are not being achieved. Forecast spend has increased this month by £0.8m. The forecast has been reviewed further and increased accordingly.

Activity

• Associate over performance in activity continues to increase. The impact is seen across all PODs• Homerton is still over performing in all areas with year to date forecasted activity 14% over plan• Moorfields continues to see high level of activity in particular Retinal Tomography , Eylea injections , cataract, glaucoma and retinal procedures • Independent Sector as in pervious months, the over performance has continued across all independent providers. • Outpatient follow ups and Day cases have seen the highest increases, with activity over plan by 3.3k (15%) and 2k (25%) respectively • Trauma & Orthopaedics is the most over performing specialty (21%) across all PODs• NELTC is seeing 17% over performance against last year activity, with day cases over performing by 36% and outpatient follow-ups by 29%• Spire Roding is over performing by 22% overall, with day cases over plan by 31% and outpatient procedures 47%• There is a high demand on diagnostic imaging with activity year-to-date over plan up by 3103 ( MRI, ultrasound scan) with plan set as nil

Performance

• Guys and St Thomas’ have not met the RTT performance standard this year for BHR CCG patients. As of November 2017 there are 851 BHR CCG patients waiting on the incomplete pathway with 117 waiting over 18 weeks with performance reported as 86.25%. Basildon has also not met the RTT performance standard this year for BHR CCG patients. As of November 2017 there are 738 BHR CCG patients waiting on the incomplete pathway with 150 waiting over 18 weeks with performance reported as 79.67%.

• Royal Free hospital is facing difficulties in meeting the 18 and 52 week RTT standards. NCL CCGs are taking steps to monitor progress. • As of November 2017 there are currently 2 BHR CCG patients waiting over 52 weeks at Royal Free as of November 2017. This consists of 1 Havering CCG patient in Dermatology

and 1 Redbridge CCG patient in Urology. • Diagnostics – North East London Treatment Centre has not achieved the diagnostics standard for BHR CCG patients in November 2017. Performance is reported at 96.1% against

the 99% standard with 5 breaches in MRI, 4 in non-obstetric ultrasound and 1 in colonoscopy.

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Mental Health Contract Performance – North East London Foundation Trust

10

Finance

Following the mediation in November, the outcome of which included a reduction to the 2017/18 contract value of £1.6m (community and mental health elements combined) reflecting both QIPP delivery and Commissioner investments and which set out requirements for more detailed reporting of costs by the Trust in the 2018/19, a contract variation has been issued and signed by commissioners and the provider.

Activity

• Mental Health Tariff live trading is being applied to three clusters. M7 data shows, after the application of the risk share, an overall financial benefit to the CCGs of £3,314.

• Mental health tariff cluster based activity plans do not include IAPT services. Activity and performance of IAPT services are based on % access rates calculated by a monthly attainment target for each CCG of 1.25% of expected population prevalence of people with common mental health disorders. For M8, the Redbridge IAPT access performance of 1.39% is above target for the first time in 6 months. Similarly, Barking and Dagenham’s IAPT access performance of 1.31% is above target for the first time in 4 months. However, Havering’s IAPT access performance of 1.22%, although significantly recovered from the last two months, remains just below the target. Achievement of the IAPT access target is mainly dependent on increasing referrals to the services. At Q2, the 50% IAPT recovery target continues to be met in Havering although, at 50.13%, only just. In Barking and Dagenham and Redbridge the IAPT recovery target has once again been missed at 42.86% and 46.33% respectively.

• Q2 and M6 main mental health performance indicators were presented for initial review to SPR on 15 December 2017. Q2 will be closed down and M7 presented at SPR on 12 January 2018.

• Following two quarters of good performance, Q2 IAPT Recovery performance shows a marked downward turn with Havering only marginally achieving the target at 50.13% while Barking and Dagenham and Redbridge fail at 44.4% and 48.24% respectively. The IAPT Access targets are still not being met consistently. In Q2, the 3.75% target was missed across BHR as follows: Barking and Dagenham 3.42%, 3.65% and Redbridge 3.32%

• M7 inpatient occupancy rates at Goodmayes Hospital remain high for adults of working age, especially female patients for whom occupancy rates have been over 100% for two consecutive months. (Occupancy over 100% is through the use of beds vacated by patients on temporary home leave.) Although there is a risk of out of area placements being required, NELFT continues to manage the risk and to avoid such placements. The inpatient occupancy rates for older adults has moderated to within the required threshold.

• M8 dementia diagnosis rates continue below target in Havering. However, Redbridge and Barking and Dagenham maintain their consistent achievement of the target. • The M7 Early Intervention in Psychosis (EIP) target (at least 50% of patients receiving a NICE treatment within two weeks) shows the maintenance of the consistent achievement of

this target in each borough. • Two other Q2 KPI failures were presented to SPR on 15 December and will be closed down at SPR on 12 January as follows:

- Routine referral to treatment waiting times for Tier 3 CAMHS 95% within 18 weeks: Redbridge performance 92.4%- CAMHS - Eating Disorders 90% of routine referrals receiving a NICE concordant treatment within 4 weeks of first contact: Barking and Dagenham 62.5%, Havering 81.8%,

Redbridge 57.1%. It should be noted that the 90% target was set in the contract in preparation for the 90% target being required nationally by 2020. • Q2 CQUINS have been submitted and no deficiencies have been identified.

Performance

110


Activity

• Year to date activity across adult and children’s services highlight a 0.6% over performance based on M8 flex activity data. The plan and variances to date include a broad range of over and under performance against annual activity plans.

• NELFT is undertaking work and analysis to revise the current straight line activity plan to reflect seasonal variation where applicable. This work stream has been phased with the children's reporting to be adjusted in M9. The revised contracted activity plan will inform a contract variation to reflect seasonal variation in 2018/19.

Community Contract Performance – North East London Foundation Trust

11

Finance

Following the mediation in November, the outcome of which included a reduction to the 2017/18 contract value of £1.6m (community and mental health elements combined) reflecting both QIPP delivery and Commissioner investments and which set out requirements for more detailed reporting of costs by the Trust in the 2018/19, a contract variation has been issued and signed by commissioners and the provider.

Performance

NELFT key performance indicators (KPI) and CQUIN performance is reported quarterly in line with contractual targets and the quarterly SPR closedown process.

Performance Management

M8 performance data has been received and position will be reviewed and agreed at the Service Performance Review (SPR) meeting on 12 January 2018. The performance is summarised below:

• 18 week Referral to Treatment (RTT) across adult services meets the 92% national target. • Inpatient occupancy rates across general rehabilitation remains high at 89.8% on average in month. Stroke ward occupancy has increased to 89.8% from 60.9% in the previous

month and is reflective of the current levels of demand.• Average length of stay across both the general rehabilitation wards (Japonica and Foxglove) highlights that Japonica is over the benchmark standard of less than 21 days for the

period at 23.5 days, with Foxglove within benchmark and showing an improvement from previous month at 17.3 days. Jointly the rehab wards reflect 20.4 days and is reflective of the current level of patient acuity.

• Average length of stay on inpatient stroke ward shows a deterioration at 31.3 days from 27.2 days in the previous month and is above the benchmark standard of 28 days. The variability of this position is mostly due to the small bed base and patient acuity.

• Acute admission avoidance; CTT/LAS – 70 patients kept at home in period which represented 73% of calls attended in the period, CTT Acute hub; continuing over performance against target with 92% of referrals recorded as preventing an acute admission.

• Community beds transfer rates from accepted referral remains with 3 day KPI target at 1.1 day in the period.• Intensive Rehabilitation Service (IRS) Inreach to BHRUT wards to identify patients for intensive support to reduce LoS identified 97 patients against a target off 100 in the period. • Child Protection Medicals completed within 48 hours was 100% across BHR, with a noted increase in demand seen in Redbridge.• 90% of Initial Health Assessments for Looked After Children across BHR were completed in 20 days of the correct paperwork being received by Community Health Services.• Paediatric Therapy waiting times remain high, with Occupational Therapy at an average of 44 weeks to 1st appointment and Speech and Language at 19 weeks. Barking and

Dagenham services noted as the main driver with substantial waits for these services. These services are subject to business cases and a proposed redesign to manage demand.

111


Contract Performance – NHS 111 and London Ambulance Service

12

Data Source: LAS Performance Reports, LAS Monthly Activity Report

Finance

NHS 111

In M8 the BHR spend is at £2.25m, which is above plan by £267k.

In M8, there has been a small over performance compared to same time in 2016/17. This increase in activity is in line with commissioner's anticipation and sufficient budgetary provisions have been made to cover the cost of the additional activity.

LAS

Pan-London costs reported in the M8 flex YTD position is £2.8m (2.3%) above plan. Over performance costs are calculated using the incident rate of £211, and as over performance is within 3%, the costs are not capped as per the contract. NEL continues to be the best performing STP in regards to activity and finance, and CCGs have received Q1 and Q2 invoices / credits accordingly. The BHR CCGs performance in the same period is £148k below plan, with most of this seen in Barking and Dagenham CCG (£118k below plan). It should be noted that Redbridge CCG is marginally above plan (£2k over).

Activity

NHS 111

The Year To Date (YTD) activity at M8 (185,403) is 20% over plan and the rate of growth in call volume in M8 has slowed down compared to first 6 months of 2017/18. The trajectory of slowdown of growth in call volume is consistent with the expectation because the increase in demand up until M6 was in part, attributable to the reconfiguration of a mobile network in M7 of the previous financial year (2016/17).

In BHR for week ending 31 December 2017, PELC achieved 50.7% calls directed to a clinician in the Clinical Assessment Service (CAS) within NHS 111 service. This comfortably meets the Integrated Urgent Care (IUC) target of 40%. In last 4 weeks PELC has been consistently achieving 46-50% of calls directed to GPs in CAS.

LAS

The CCG M8 flex YTD position is reported at 1.1% below plan (65,366 activities against a plan of 66,066). STP and pan-London positions are reported at 1.4% (161,371 incidents against a plan of 163,689) below plan and 2.3% (746,139 incidents against a plan of 730,253) above plan, respectively. M8 flex is the first month of data following the switch to the Ambulance Response Programme (ARP), and the LAS have indicated that there may be more change at the freeze point than we would normally expect. The commissioning team will monitor and report any change between flex and freeze at the next Finance & Information Group (FIG) meeting on 31 January 2018.

Performance

NHS 111

PELC posted satisfactory operational performance for key metrics in M8; it has achieved 95.1% of calls answered within 60 seconds and a 1.8% call abandonment rate. These key indicators fall comfortably within contractual thresholds (>95%; <5%) for the month. PELC has consistently been one of the best performing providers in London and in the country.

LAS

Pan-London National Standards were achieved across Cat 1, Cat 2 and Cat 4 90th centile for M8. LAS are currently running in third position against Cat 1 performance against the 8 national ambulance Trusts currently reporting under ARP. There have been an increased number of Cat 2 incidents than expected, with a reduction in Cat 3 and Cat 4 incidents. CCG-level reporting is currently unavailable, and the LAS are working with Commissioners to review and design the appropriate suite of reports to capture the new range of metrics.

112

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs From: Tom Travers, Chief Finance Officer

Date: 25 January 2018 Subject: Finance Risk Overview Report (December 2017 – Month 9 (Month 8 data) Executive Summary The Month 9 Risk Overview Report should be read in conjunction with the detailed Integrated Performance Report (IPR) (Month 8 activity / Month 9 finance). At month 9 BHR CCGs have reported a forecast deficit position of £25.2m (slippage of £10.2m against plan). The in-year forecast deficit is £20.40m with a year to date deficit of £14.6m. The forecast deficit is in line with the position reported and agreed with NHSE at Month 7. However, the level of gross risk and mitigated risk has significantly increased. The forecast position reported for the BHRUT contract is based on the technical view of the independent mediation entered into for Quarter 1. This has resulted in a likely forecast overspend of £10.2m. However, the Trust has now written to the CCGs stating that they do not agree the outcome of the mediation. The CCGs have initiated the next stage in the contract process, which is expert determination. In conjunction system regulators (NHSE and NHSI) are discussing the health economy financial position and year-end scenarios. The BHRUT position significantly increases the level of risk inherent within the CCGs’ forecast. Any movement from the reported position will result in a risk to the CCGs’ control total as all reserves and contingencies are released in the reported position. STP reporting shows a contract triangulation gap with BHRUT of circa £20m. For Barts there are contractual processes in place and the forecast is based on the lead commissioner’s view of the extrapolated Quarter 1 position. This contains an assumption with regard to some challenges that are yet to be agreed. The reported forecast overspend is £8m. A similar downside forecast has been calculated which is £4.5m higher than this reported position. Other Associate contracts and Independent Providers have reported forecasts based on the latest activity and referral trends. A risk has been identified in relation to independent sector activity which has seen a month by month deterioration of the forecast. This will be further analysed through contractual processes. Assessment of risk arising from the Month 9 position suggests an unmitigated risk for BHR CCGs of circa £20m. The outcomes of the contractual processes outlined may impact this probability analysis. If the risks materialise, this will result in the CCGs’ in-year deficit increasing to £40.4m. The other main areas of spend are showing variances as a result of QIPP slippage, investment slippage and pressures on Continuing Healthcare (CHC) packages of care. The forecast position across the entire QIPP portfolio includes QIPP delivery of £32.3m, a slippage of £12.8m against plan. Of this, £6.2m slippage relates to the QIPP in acute contracts and £4m relates to acute QIPP schemes that are not currently in contracts. (For more information on QIPP delivery please refer to the IPR).

113

1 Purpose of Report

The purpose of this report is to brief the Committee on the overall financial position as at the end of December 2017 (Month 9).

2 Background/Introduction

As at the end of Month 9 the CCG reported a deficit of £18.1m with a forecast year end deficit of £25.2m against resource limit (this includes the 17/18 in-year deficit and the historic deficit reported by Havering CCG). 3 Month 9 Financial Indicators

See table on next page for detail.

Recommendations

The Committee is asked to: Agree the financial position noting the risks within it.

114

MONTH 9 FINANCIAL INDICATORS

Indicator In Year Target

In Year

Actual Variance Key Messages

£'000 £'000 £'000

Financial position year to date (7,649) (14,553) (6,904)

At month 9 BHR CCGs have reported an in year deficit of £14.55m. This represents slippage

of £6.9m against plan. The position is therefore red rated. The two largest areas of

overspend are acute over performance and QIPP slippage.

Acute contract over performance is a major risk and is driven by the current level of

activity and cost reported against both the BHRUT and Barts contracts. Commissioners

have had to make a large number of adjustments to trust data to achieve the current

reported position. There is a risk that activity growth will continue to impact on the

position.

Financial position forecast outturn (10,200) (20,416) (10,216)

The forecast outturn deficit has moved from the planned deficit of £10.2m to £20.4m. A

number of risk mitigations are included in this position. Forecast overspends have been

reported againt the main contracts, £10.2m with BHRUT and £8m with Barts. This position

includes a high level of risk as described above. These pressures have been negated by

the release of the commissioning reserve, contingency and non recurrent items available

to the CCG.

Savings Year to date 29,829 21,852 (7,977)The year to date savings position shows an under achievement of £8m. The position has

been calculated using month 8 flex data and proxy data.

Savings forecast outturn 45,098 32,274 (12,824)The savings forecast outturn projects a £12.8m slippage. This position is broadly in line

with the level of assured savings schemes

Risks and Opportunities (19,996)

The likely risks facing the CCGs at month 9 amount to £20m; there are no mitigating

reserves as they have all been entered into the reported position, resulting in a net risk of

£20m.

Worst Case Forecast outturn (10,200) (40,412)If the risk position fully materialises the CCGs will record an in year worst case forecast

outturn of a £40.4m deficitRed

Rating this month

Red

Red

Red

Red

Red

115

REVENUE POSITION

Annual

Budget

YTD Budget YTD Actual YTD

Variance

Forecast

Outturn

Variance

to FOT

QIPP

Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 338,190 253,944 260,087 (6,143) 348,343 (10,153) (2,744)Barts Health NHS TRUST 93,353 70,482 76,652 (6,171) 101,313 (7,960) (3,686)Homerton 8,214 6,184 7,249 (1,065) 9,525 (1,310) (26)Other Acute 127,603 95,733 105,029 (9,295) 140,020 (12,416) 257Acute Reserves 13,769 8,529 407 8,122 8,707 5,063 0Other Acute QIPP Plans (4,794) (3,096) 0 (3,096) (798) (3,997) (3,997)Acute Commissioning Total 576,336 431,775 449,424 (17,649) 607,109 (30,773) (10,196)

Mental Health 94,611 71,192 69,800 1,392 93,469 1,142 389Community 84,877 63,849 63,967 (117) 85,935 (1,058) (1,003)Continuing Care 59,019 44,094 44,653 (558) 59,454 (435) 930Primary Care & Prescribing 126,184 95,611 94,107 1,504 123,439 2,745 725Primary Care Co-Commissioning 100,334 75,246 73,984 1,261 98,684 1,650 0Other Programme Services 36,646 20,236 19,530 705 33,745 2,901 0Programme Reserves and QIPP Investments 19,202 9,827 (1,014) 10,842 1,921 17,281 0QIPP Disinvestments (9,619) (5,954) (1,670) (4,284) (5,950) (3,669) (3,669)Running Costs 16,819 12,613 12,613 0 16,819 0 0Total BHR CCGs Expenditure 1,104,408 818,490 825,394 (6,904) 1,114,625 (10,216) (12,824)

2017/18 Allocation (1,094,208) (810,840) (810,840) 0 (1,094,208) 0

2017/18 Control Surplus / (Deficit) (10,200) (7,649) (14,553) (6,904) (20,416) (10,216)

2017/18 Allocation including historic deficit (1,089,448) (807,270) (807,270) 0 (1,089,448) 0

Control Total Surplus / (Deficit) (14,960) (11,219) (18,123) (6,904) (25,176) (10,216)

116

MAIN EXPENDITURE VARIANCES

Acute Contracts

The CCGs are reporting a forecast overspend of £10.2m with BHRUT. Unadjusted data suggests a significant underlying overspend of £40.3m. The CCGs have made a number of adjustments to the Trust’s data which include claims and challenges (£13.6m), QIPP delivery assumptions (£8.7m) and other technical adjustments (£7.8m).

The forecast position reported for the BHRUT contract is based on the technical view of the independent mediation entered into for Quarter 1. However, the Trust have written to the CCGs stating that they do not agree the outcome of the mediation. The CCGs have written to the Trust outlining the next stage in the contract process, which is expert determination. In conjunction system regulators (NHSE and NHSI) are discussing the health economy financial position and year-end scenarios. The risk section provides further information with regard to downside scenarios.

There are a number of Contract Performance Notices (CPNs) and clinical audits which are detailed in the IPR report. Further BHRUT information can be found within the IPR.

The CCGs are reporting a forecast overspend of £8m with Barts. Unadjusted data suggests an underlying overspend of £13.5m. The CCGs have made a number of adjustments to the Trust’s data which include claims and challenges (£1.8m), QIPP (£1.3m) and other technical adjustments (£2.4m).

The variance reported at Month 9 relates to non-elective, critical care, outpatients, additional bed days and QIPP slippage (Further Barts information can be found within the IPR).

Homerton is reporting a forecast overspend of £1.3m, relating to maternity and IVF cycles. Other Acute areas are forecasting an overspend position of £12.4m. There are adverse

variances reported against a range of associate contracts, largely relating to critical care. However, the largest adverse variances reported at Month 9 are against the Independent Providers. The Independent Providers have not seen the material reduction in referrals expected following the cessation of referral redirects from BHRUT at the end of 16/17. The forecast has been adjusted to reflect current activity and referral levels.

There is also forecast QIPP slippage of £4m against other acute QIPP commitments. The QIPP slippage and acute over-performance is partly mitigated by an acute reserve.

This has released £5m into the forecast position. The overall acute forecast position is, therefore, a £30.8m overspend, of which £10.2m is

assessed to be due to QIPP under delivery. Mental Health

Mental Health shows a forecast underspend of £1.1m at Month 9. As reported in previous months this relates to slippage against Mental Health investments, including those agreed with NELFT as part of the contract mediation process. Of the total underspend £0.39m has been classified as a QIPP saving (includes the NELFT contract and Meadow Court).

Community

Community shows a forecast overspend of £1.1m. The main pressures relate to QIPP slippage and pressures against the insulin pump budget.

The annual QIPP target with NELFT is £2.2m. QIPP has been delivered in both the Community and Mental Health element of the contract. QIPP slippage against the Community contract is reported as £1m. However, this is offset by the over achievement of £0.9m against the Mental Health contract (refer to the IPR for detail on the NELFT contract).

117

Continuing Care

The forecast position show overspends of £0.4m. The position is driven by a range of factors - QIPP over achievement offset by use of

agency staff and activity over-performance at Barking and Dagenham CCG. Primary Care & Prescribing

Across BHR, Primary care and Prescribing are forecast to underspend by £2.7m. The forecast is based on a moving average methodology using Month 7 PPA information extrapolated forward. The impact of drug concession prices is being further analysed by the Medicines management team, this may further impact outturn in future months. Price concessions relating to Months 10 to 12 are included in the risk profile of the CCGs.

Primary Care Co-Commissioning

As flagged in previous reports Primary care co-commissioning is forecast to underspend by £1.6m, this includes a number of assumptions with regard to investments and prior year payments. There are a number of work streams and outstanding items within Primary Care, including outstanding premises issues and the investment of Redbridge CCG growth monies. Further updates will be reported at the Primary Care Commissioning Committee.

Running Costs

The CCGs have a running cost allocation of £16.8m. The current forecast is to plan.

Annual

Budget


Variance

Forecast

Outturn

Variance to

FOT

QIPP

Variance

£000 £000 £000 £000 £000 £000 £000

Pay 7,131 5,348 5,348 0 7,328 0 0

Non Pay 1,978 1,484 1,484 0 1,781 0 0

CSU 7,710 5,783 5,783 0 7,710 0 0

Total Running Cost 16,819 12,614 12,614 0 16,819 0 0 Other Programme Services / Reserves / QIPP Investments and Disinvestments

The main budgets held under “Other Programme Services” includes budgets for Better Care Fund (BCF), 0.5% uncommitted risk reserve, Property Services and other programme services. Within other programme services there is a significant forecast overspend relating to the corporate IT department.

In total there has been £17.3m released into the financial position from programme reserves and QIPP Investments. This relates to the release of contingency (£5m), brought forward creditors, release of provisions and savings shown against other investments.

Further detailed information across all contracts is found in the Performance Report.

118

RISK ANALYSIS

Full Risk

Value

£000s

Probability

of risk

being

realised

%

Potential

Risk

Value

£000s

RISKS

Acute SLAs

BHRUT Contract Risk 19,573 55% 10,771

Barts Contract Risk 5,287 85% 4,486

Other Acute Risk 500 50% 250Mental Health SLAs 0 50% 0

Continuing Care SLAs 400 50% 200

QIPP Under-Delivery 3,474 50% 1,737

Prescribing 5,105 50% 2,553

TOTAL RISKS 34,339 19,997

MITIGATIONS

Contingency Held 0 100% 0

TOTAL MITIGATIONS 0 0

NET RISK / HEADROOM (34,339) (19,997)

Forecast Outturn Underspend / (Deficit) 0 (20,416)

RISK ADJUSTED CONTROL TOTAL (34,339) (40,413) The risk analysis above shows the risks to the CCGs that are not reported within the Month 9 position. A full risk is estimated, with a probability applied to give a risk adjusted value. Acute SLAs

The fact that BHRUT has not agreed the outcome of the mediation significantly increases the level of risk inherent within the CCGs’ forecast. There is a contract triangulation gap with the Trust of £19.6m. A downside view of the contract position has been calculated, resulting in a potential risk to the reported position of £10.8m.

For Barts there are contractual processes in place and the forecast is based on the lead commissioner’s view of the extrapolated Quarter 1 position. This contains an assumption with regard to some challenges that are yet to be agreed. The reported forecast overspend is £8m. A similar downside forecast has been calculated which is £4.4m higher than this reported position. Other Associate contracts and Independent Providers have reported forecasts based on the latest activity and referral trends.

Across the two main contracts the gross risk now totals £24.9m. This has a significant impact upon the total risk faced by the CCGs, which is estimated at £34.3m. The total unmitigated risk for BHR CCGs is now in excess of £19.9m. The outcomes of the contractual processes outlined may impact the probability analysis and a movement away from the forecast position will result in a risk to the CCGs’ control total.

Other acute SLA risks relate to the growth in activity seen in the independent sector.

119

Continuing Care

The continuing care risk relates to a potential increase in costs later in the financial year as a result of discharge to assess schemes.

QIPP under Delivery

Outstanding risk is based on an estimate of further slippage in the forecast QIPP delivery assumptions.

Prescribing

Outstanding risk is based on an estimate of further price concessions in Months 10 to 12. Mitigations

Due to the financial position the CCGs face, the contingency has been released into the financial position. This means that no further contingencies are available to offset the financial risk

The risk analysis will be further informed by the conclusion of the ongoing process in relation to the BHRUT contract.

If the risks detailed above materialise this will have an adverse impact on the current reported position and will result in the CCGs in-year deficit increasing to £31.1m.

UNDERLYING POSITION

2017/18 Forecast at

M09

Remove

Non

Recurrent

Budget

(b/f

surplus)

Other Non

Recurrent

Spend

Non

Recurrent

QIPP

Schemes

FRP Full

Year

Impact

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m

Total Allocation 1,094.2 (6.9) 0.0 0.0 0.0 0.0 1,087.3

Total Spend 1,114.6 (6.9) (6.1) 6.5 (12.1) 1.2 1,097.3

Surplus / (deficit) (20.4) - 6.1 (6.5) 12.1 (1.2) (9.9)

The underlying position at Month 9 has worsened compared to earlier in the year and reflects the fact that the in-year forecast deficit has moved from £10.2m to £20.4m.

Methodology

The start point is the Month 9 forecast. Non recurrent budget allocations and spend of £6.9m are removed plus other non-recurrent spend of £6.1m. Other non recurrent spend includes the removal of the 1% non recurrent reserve and other non recurrent investments.

120

Non recurrent QIPP and the full year impact of 17/18 schemes are factored into the position to give the 2017/18 underlying position. At Month 9 it is expected that this will be a deficit of £9.9m.

Risk to the Underlying Position

Any further QIPP slippage will negatively impact the in-year and underlying position. Furthermore, the underlying position assumes a full year impact of schemes of £12.1m.

Any variations to this will negatively impact the position. The ongoing process in relation to the BHRUT contract will impact the underlying position.

Any materialisation of the risks flagged elsewhere in the report will have a negative impact on the underlying position.

The underlying position is based on the current forecast outturn. Any changes to the forecast position will impact the underlying position.

2018/19 PLANNING UPDATE

The 2018/19 plan is in the process of being updated to include the revised forecast outturn and underlying position contained in this report.

It is expected that NHSE will issue revised planning guidance during January and that there may be changes to some of the business rules.

Within the financial plan QIPP plans are being worked up through the Financial Recovery Planning Delivery and Monitoring (FRPDM) process.

A detailed planning paper will be presented to the Finance and Delivery Committee in February 2018, with an update to the Joint Committee on 25 March 2018.

FINANCIAL ACCOUNTING METRICS

Cash Position at 31st December 2017 The CCGs draw down cash from the Department of Health each month to pay invoices and staff salaries. The CCGs are required to end each month with an actual cash balance that is less than 1.25% of the main cash drawdown for that month. Throughout December 2017, the CCGs continued to operate within their expected cash envelopes, and were not overdrawn on their bank accounts at any point. The CCGs are working closely with NEL CSU to ensure accurate and robust cash forecasts are in place, and that there continues to be appropriate cash and treasury safeguards. A summary of the cash position for the three CCGs is shown below, and further detail is provided at Appendix 4.

Barking & Dagenham

CCG Havering CCG Redbridge CCG

Closing cash balance at end of month

£88k £62k £345k

Closing cash balance less than 1.25%?

Y Y Y

Amount drawn down to date £201,000k of a full year forecast of £279,010k

£272,650k of a full year forecast of £369,850k

£253,500k of a full year forecast of £348,430k

121

Invoice payment performance measure – Better Payment Practice Code (BPPC)

The BPPC requires the CCGs to pay all valid invoices by the due date, or within 30 days of receipt of a valid invoice, whichever is later. The CCGs are working closely with NEL CSU to ensure all valid invoices are being cleared in line with this target. The cumulative BPPC figures for non NHS and current months for Barking & Dagenham CCG invoices has dropped due to a number of invoices uploaded onto the Oracle system with incorrect “received” dates. Correction of the date for prior months will make a significant difference to performance, and the CCGs will discuss making an adjustment for this with its external auditors. A summary of the year to date results is shown below, and further detail can be found at Appendix 5.

122

OVERVIEW

No Indicator Month 2 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12

1. Financial position year to date Amber Amber / Red Red Red Red Red Red Red

2. Financial position forecast outturn Amber Amber / Red Red Red Red Red Red Red

3. Savings Year to date Green Amber Red Red Red Red Red

4. Savings forecast outturn Red Red Red Red Red Red Red

5 Risks and Opportunities Red Red Red Red Red Red Red

6 Worst Case Forecast outturn Red Red Red Red Red Red Red

Month 3

Amber

Red

Red

Red

The financial position of the CCGs is extremely challenging. The forecast QIPP slippage at Month 9 and contract over-performance means that the CCGs have released available contingencies into the position. The forecast position was revised in Month 7 and a deficit of £25.2m (in-year deficit of £20.4m) was reported to NHSE. The financial position for the year to date and forecast position remain at Red. Any further QIPP slippage or increased over spends against acute contracts may impact on this further.

The table above shows the finance dashboard on a month by month basis. All financial indicators are reported as Red. This is as a result of the risk

around the BHRUT and Barts contracts. The unadjusted data from BHRUT shows a significant and unusual forecast overspend. The position reported at Month 9 includes the CCGs’ view of the mediation panel’s decision on the treatment of claims and other challenges. The Trust have not accepted the outcome of mediation. Until the outstanding issues on this contract are resolved there is a significant risk that the CCGs’ financial position (both in-year and underlying) may deteriorate further.

123

4 Financial Summary

The financial position of the CCGs is extremely challenging. The forecast QIPP slippage and contractual performance at Month 9 means that the CCGs have released available contingencies into the position. The current reported position at BHRUT, Barts and other acute providers do not allow the CCGs to meet their control totals and a revised forecast deficit of £25.2m has been submitted to NHSE.

5 Resources/Investments n/a

6 Equalities n/a

7 Risk Financial risk is reported in section 3 of the report.

8 Managing conflicts of interest

n/a Attachments:

1. Appendix 1 – CCG Revenue Position 2. Appendix 2 – CCG Risk Position 3. Appendix 3 – CCG Underlying Position 4. Appendix 4 – CCG Cash Position 5. Appendix 5 – CCG Better Payment Practice Code

Author: Tom Travers, Chief Finance Officer Date: January 2018

124

Annual

Budget


Variance

Forecast

Outturn

Variance

to FOT

QIPP

Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 154,421 115,950 118,856 (2,907) 159,259 (4,838) (1,408)Barts Health NHS TRUST 9,116 6,987 9,022 (2,035) 11,223 (2,107) (1,169)Homerton 1,460 1,100 1,311 (211) 1,713 (253) 24Other Acute 46,971 35,253 38,795 (3,541) 51,765 (4,793) 39Acute Reserves 6,813 3,858 407 3,451 4,231 2,583 0Other Acute QIPP Plans (1,813) (1,198) 0 (1,198) (551) (1,263) (1,263)Acute Commissioning Total 216,968 161,950 168,391 (6,441) 227,639 (10,671) (3,777)

Mental Health 32,184 24,006 22,981 1,025 31,126 1,058 319Community 29,655 22,308 22,626 (318) 30,294 (638) (382)Continuing Care 20,590 15,451 15,559 (109) 20,740 (149) 24Primary Care & Prescribing 47,523 35,986 34,934 1,052 45,896 1,627 285Primary Care Co-Commissioning 33,687 25,263 25,270 (6) 33,637 50 0Other Programme Services 11,341 6,160 5,885 (3,475) 10,663 678 0Programme Reserves and QIPP Investments 6,877 3,693 (58) 3,751 983 5,894 0QIPP Disinvestments (2,979) (1,827) (532) (1,295) (1,917) (1,063) (1,063)Running Costs 5,755 4,316 4,316 0 5,755 (0) 0Total BHR CCGs Expenditure 401,601 297,305 299,372 (2,067) 404,815 (3,214) (4,593)

2017/18 Allocation (396,667) (293,605) (293,605) 0 (396,667) 0


2017/18 Allocation including historic deficit (391,907) (290,035) (290,035) 0 (391,907) 0

Control Total Surplus / (Deficit) (9,694) (7,271) (9,337) (2,067) (12,908) (3,214)

Appendix 1: CCG Specific Revenue Position

Barking and Dagenham CCG Annual

Budget


Variance

Forecast

Outturn

Variance

to FOT

QIPP

Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 92,230 69,258 72,461 (3,203) 97,024 (4,793) (600)Barts Health NHS TRUST 22,298 16,814 17,826 (1,012) 23,751 (1,453) (786)Homerton 2,231 1,683 1,977 (295) 2,633 (401) 17Other Acute 31,742 23,790 25,039 (1,249) 33,354 (1,612) 59Acute Reserves 3,191 2,115 0 2,115 1,939 1,252 0Other Acute QIPP Plans (1,477) (945) 0 (945) (146) (1,331) (1,331)Acute Commissioning Total 150,215 112,715 117,303 (4,588) 158,554 (8,339) (2,641)

Mental Health 31,399 23,418 23,040 378 31,231 168 314Community 31,790 23,917 23,972 (55) 32,204 (415) (289)Continuing Care 15,534 11,650 12,342 (692) 16,386 (852) 153Primary Care & Prescribing 32,868 24,908 24,956 (47) 32,765 103 194Primary Care Co-Commissioning 30,048 22,534 22,465 69 30,048 0 0Other Programme Services 11,222 6,014 6,151 (4,105) 10,775 447 0Programme Reserves and QIPP Investments 5,965 3,085 (883) 3,967 249 5,716 0QIPP Disinvestments (2,851) (1,773) (528) (1,245) (1,894) (957) (957)Running Costs 4,554 3,415 3,415 0 4,554 0 0

Total BHR CCGs Expenditure 310,743 229,884 232,234 (2,350) 314,872 (4,128) (3,224)

2017/18 Allocation (307,953) (227,793) (227,793) 0 (307,953) 0


Havering CCG

125

Annual

Budget


Variance

Forecast

Outturn

Variance

to FOT

QIPP

Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 91,539 68,736 68,769 (33) 92,060 (522) (737)Barts Health NHS TRUST 61,939 46,681 49,804 (3,123) 66,339 (4,400) (1,731)Homerton 4,523 3,402 3,961 (560) 5,179 (656) (67)Other Acute 48,890 36,690 41,194 (4,505) 54,901 (6,011) 159Acute Reserves 3,765 2,556 0 2,556 2,538 1,227 0Other Acute QIPP Plans (1,504) (954) 0 (954) (102) (1,402) (1,402)Acute Commissioning Total 209,152 157,110 163,729 (6,619) 220,916 (11,763) (3,778)

Mental Health 31,028 23,768 23,779 (11) 31,113 (84) (245)Community 23,431 17,624 17,369 255 23,437 (5) (333)Continuing Care 22,895 16,994 16,751 242 22,328 566 753Primary Care & Prescribing 45,794 34,717 34,218 499 44,779 1,015 245Primary Care Co-Commissioning 36,599 27,448 26,250 1,198 34,999 1,600 0Other Programme Services 14,083 8,062 7,494 (2,555) 12,307 1,776 0Programme Reserves and QIPP Investments 6,360 3,050 (74) 3,123 689 5,671 0QIPP Disinvestments (3,788) (2,355) (610) (1,745) (2,139) (1,649) (1,649)Running Costs 6,510 4,882 4,882 0 6,510 (0) 0Total BHR CCGs Expenditure 392,064 291,300 293,788 (2,488) 394,938 (2,874) (5,007)

2017/18 Allocation (389,588) (289,443) (289,443) 0 (389,588) 0


Appendix 1: CCG Specific Revenue Position

Redbridge CCG

126

Full Risk

Value

£000s

Probability

of risk

being

realised

%

Potential

Risk

Value

£000s

RISKS

Acute SLAs 7,698 77% 5,891


QIPP Under-Delivery 1,165 50% 583

Prescribing 2,110 50% 1,055


MITIGATIONS





RISK ADJUSTED CONTROL TOTAL (11,095) (12,939)

Appendix 2: CCG Specific Risk Profile

Barking and Dagenham CCG

Full Risk

Value

£000s

Probability

of risk

being

realised

%

Potential

Risk

Value

£000s

RISKS

Acute SLAs 6,093 67% 4,105


QIPP Under-Delivery 733 50% 366

Prescribing 1,354 50% 677


MITIGATIONS






Havering CCG

Full Risk

Value

£000s

Probability

of risk

being

realised

%

Potential

Risk

Value

£000s

RISKS

Acute SLAs 11,569 48% 5,512


QIPP Under-Delivery 1,575 50% 788

Prescribing 1,642 50% 821


MITIGATIONS






Redbridge CCG

127

2017/18 Forecast at

M09

Remove

Non

Recurrent

Budget /

Spend

Other Non

Recurrent

Spend

Non

recurrent

QIPP

Schemes

FYE of

QIPP

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m

Total Allocation 389.6 (2.3) 0.0 0.0 0.0 0.0 387.3

Total Spend 394.9 (2.3) (0.9) 2.3 (6.0) 0.5 388.5

Surplus / (deficit) (5.4) - 0.9 (2.3) 6.0 (0.5) (1.2)

Appendix 3: CCG Specific Underlying Position

Barking and Dagenham CCG

2017/18 Forecast at

M09

Remove

Non

Recurrent

Budget

(b/f

surplus)

Other Non

Recurrent

Spend

Non

Recurent

QIPP

schemes

FRP Full

Year

Impact

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m


Total Spend 314.9 (2.2) (1.7) 1.9 (2.4) 0.3 310.7

Surplus / (deficit) (6.9) - 1.7 (1.9) 2.4 (0.3) (4.9)

Havering CCG

2017/18 Forecast at

M09

Remove

Non

Recurrent

Budget /

Spend

Other Non

Recurrent

Spend

Non

recurrent

QIPP

Schemes

FYE of

QIPP

FYE of

Investments

2017/18

underlying

position

£m £m £m £m £m £m £m


Total Spend 404.8 (2.3) (3.5) 2.3 (3.6) 0.4 398.1

Surplus / (deficit) (8.1) - 3.5 (2.3) 3.6 (0.4) (3.8) Redbridge CCG

128

APPENDIX 4

Cash Position

129

APPENDIX 5 Better Payment Practice Code Performance

130


From: Jacqui Himbury, Nurse Director

Date: 25 January 2018 Subject: Quality Report Executive summary This report provides an update to the joint committee on the clinical quality matters, risks and actions that the Clinical Commissioning Groups (CCGs) continue to manage, working with our providers to seek continuous quality improvements. This paper builds on the issues and risks that have been reported in previous papers and also informs the joint committee of two new risks for our internal quality assurance processes. The report is divided into two sections: Section 1: Quality matters and issues that give an indication of how the BHR system is performing and the system wide risks that are being managed collectively in collaboration with partners. The focus of this report is Commissioning for Quality and Innovation (CQUIN) performance and the outcome of the Quality Risk Profiling Tool (QRPT) that was completed with for BHRUT will all system partners. Section 2: Focuses on the quality priorities and performance of our main providers and the issues we are currently monitoring and managing through the Clinical Quality Review Meetings (CQRM). This is mortality reporting, the management of never events, serious incidents and incidents for BHRUT and for NELFT, the workforce risks (safer staffing), access to increasing access to psychological therapies (IAPT) and the Access and Assessment Brief Intervention services (which are crisis intervention mental health services) and the management of patients with mental illness to reduce the number of unexpected deaths. The forthcoming NELFT Care Quality Commission report and anticipated outcome is also reported. Recommendations

The Committee is asked to:

Note the actions being taken to date to mitigate the identified quality performance risks Suggest any further actions that the CCGs should consider to address the performance

and quality risks for local people


1.1 This report is presented to the joint committee to ensure that members are fully briefed and

assured on the actions being taken to manage the quality challenges and risks that the CCGs are addressing through our range of commissioning activities. Areas of good quality practice

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are also reported as it is important we recognise and celebrate achievements to have a full understanding of the quality of our commissioned services.

1.2 This covers both strategic and operational quality issues and details how they are managed so that the people we commission services for receive the best possible care, delivered in a way that is safe and effective while providing value for money.

2.0 Introduction

2.1 Seeking continuous quality improvements for patients continues to be a high priority for the

CCGs, and many of our specific quality improvement and assurance activities are aimed at achieving this, particularly our actions that deliver improved provider quality performance, which we assure and monitor through our established contract monitoring processes for our main providers.

2.2 This report is divided into two sections:

Section 1 – Quality matters and issues that give an indication of how the BHR system is performing and the risks that are being managed collectively. This report focuses on CQUIN performance for BHRUT and NELFT and the outcome of the Quality Risk Profiling Tool that was completed for BHRUT in December 2017.

Section 2 – Focuses on the quality priorities and performance of our main providers and the issues we are currently monitoring and managing through the CQRMs, this includes mortality levels, the continued management of never events, serious incidents and incidents for BHRUT. For NELFT the workforce risks (safer staffing), access to IAPT and the Access and Assessment Brief Intervention services (which are crisis intervention mental health services) and the management of patients with mental illness to reduce the number of unexpected deaths. The forthcoming Care Quality Commission report and anticipated outcome is also reported.

3.0 Section 1

Commissioning for Quality and Innovation (CQUIN) performance

3.1 The 2017/19 CQUINs are nationally set and are intended as two year CQUINs. The aim is to support national strategic quality priorities and to promote collaboration and joint working across system organisations. For the first time NHS England has published a two year scheme, which has provided greater certainty and stability on the CQUIN goals and intended outcomes.

3.2 The CQUIN scheme is intended to deliver clinical quality improvements and drive transformational change and is designed to support the Five Year Forward View and directly link to the NHS Mandate. Therefore they now focus on two areas:

3.2.1 Clinical quality and transformational indicators – 13 indicators have been defined which aim

to improve quality and outcomes for patients including reducing health inequalities, encourage collaboration across different providers and improve the working lives of NHS staff.

3.2.2 Supporting local areas – Sustainability and Transformation Plans and local financial sustainability are the key focus areas.

3.3 This report focuses on the performance of BHRUT and NELFT to deliver the clinical quality and

transformational indicators during the first two quarters of 2017/18. These new indicators focus on:

Improving the outcomes and experience of patients with mental health needs Enabling GPs to have better access to consultants to determine the best course of

action for their patients and make it easier for GPs to access appointments for their patients

Provider collaboration to support patients in hospitals to get back home in a safe and timely manner

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Patients accessing advice and referral to services to prevent ill health related to tobacco and alcohol

Community services placing a greater emphasis on wound care leading to better patient and system outcomes

Empowering staff to help patients take more control of their own existing long term conditions; and

Supporting patients to move through the urgent care services in a way that meets their clinical needs.

3.4 During the first two quarters of 2017/18 both BHRUT and NELFT have significantly improved

performance across all CQUINs compared to previous years and both organisations have very clear delivery plans in place that have been robustly assured by commissioners.

3.5 BHRUT are on track to achieve 100% delivery for Q2 CQUIN, pending one item of clarification from NHSE, having already achieved 100% for Q1.

3.6 NELFT community health services achieved 100% in Q1, with Q2 highlighting a partial achievement in respect of ‘Preventing Ill health by risky behaviours; tobacco screening’ in

Havering and Redbridge resulting in a minor financial sanction of £289.

3.7 NELFT mental health services achieved 100% performance during Q1 and Q2.

3.8 The CCG is forecasting that both organisations will deliver 85% of their overall CQUIN targets at the end of Q4. The CQUIN that is proving challenging to deliver is flu vaccination to front line staff, although there has been an improvement on 2016/17 performance.

4.0 BHRUT Quality Risk Profiling

4.1 The CCGs continue to have serious concerns about several quality performance indicators that

are used in the overall assessment of the quality of care provided by BHRUT. These concerns are predominately about mortality and the Trust’s mortality reduction improvement plan, never events, radiology serious incidents and workforce risks.

4.2 Following a detailed discussion of the patient safety risks at the QSC it was agreed that these

risks would be escalated to NHS England (London) as our regulator and NHS Improvement as the Trust’s regulator. The CCGs escalated the risks to both organisations in October 2017.

4.3 The outcome of the escalation was a recommendation that the BHR system and the Trust use a

quality risk profiling tool to assess the level of risk against 124 indicators of quality. This is a tool developed by NHSE and is called the Quality Risk Profiling Tool.

4.4 The Quality Risk Profiling Tool (QRPT) is a risk profiling tool to assist clinical commissioners and

providers in assessing risks to quality and patient safety across all domains of the CQC framework and across individual organisations. The tool provides a structured framework to ensure a consistent approach to assessing the level of risk by all stakeholders.

4.5 The tool enables the level of risks for specific indicators of quality to be identified using a

systematic risk-based methodology, which identifies where further assurance or support may be required. It also allows and enables a basis for shared understanding, ownership and decisions to be made that are proportionate to the level of quality risk where concerns have been identified.

4.6 BHR CCGs and the Trust completed their individual versions of the tool during October. BHR

CCGs led a process to complete the tool with stakeholder contributions being provided by NHSE, NHSI, Healthwatch, Health Education England and the CQC. This enabled the system to reach an

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agreed consensus on the level of overall organisational risk and agreement on the indicators that presented the highest level of risks.

4.7 Following completion of the tool process, two moderation meetings were held with all stakeholders

and the Trust in November and December. The purpose of the meetings was to review jointly with the Trust the overall level of quality risk for BHRUT and to agree the areas of highest risk and what mitigating actions should be implemented to reduce risk and increase assurance. The areas of high risk are those that have previously been identified through our early warning system and contract monitoring processes and include the risks that have previously been reported to the joint committee. The top three risks confirmed at the close of the second meeting were non-elective and urgent care pathway performance (including the emergency departments), the Trust’s mortality levels and workforce issues such as retention and recruitment of staff across all clinical disciplines, especially emergency department consultants and registered nurses. It was confirmed that our system has strong mitigating actions in place, therefore all stakeholders were in agreement with the overall organisational quality risk rating at the Trust and agreed that we would not proceed to a Risk Summit.

4.8 The overall level of risk based on the outcome of the QRPT process was jointly agreed as 9 out of

a potential 20. It was also agreed the outcome of the meeting was very positive and demonstrated that the Trust and all partners had a shared understanding of the risks. The top three risk areas need to be kept under constant review with actions put in place by all agencies to support improvement. There is a system partners meeting agreed for February to confirm to review the risks and agree next steps.

5.0 Section 2: Provider Operational Quality Improvements and Challenges 5.1 BHRUT 5.1.1 Mortality Performance. The CCG continues to monitor and review the Trust’s mortality data on

a monthly basis. This is the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital-level Mortality Indicator (SHMI). We review the data by site and by weekday and weekend and at speciality level.

5.1.2 The December SHMI data report confirms the Trust have made a very slight improvement in

performance. Performance is 103.9 as at December 2017 compared to 104.2 in June 2017, this is within the “as expected” range.

5.1.3 The trend data from April 13 to March 17 is on the following table.

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5.1.5 Although the Trust have made a very small improvement in overall SHMI data performance,

there are still specialities which have a higher number of actual (observed) to expected deaths. 5.1.6 The Trust now have a completed detailed action plan to direct and oversee governance

processes and address specific diagnosis groups that are in need of improvement. The improvement actions are approved internally within the Trust by the mortality assurance group. The required improvement actions are derived from mortality clinical reviews and ratio data. Commissioners are not fully assured that the improvement plan will deliver the required improvements across all clinical specialities and continue with the enhanced monitoring arrangements that are currently in place.

5.1.7 During November and December the Trust have completed the following actions:

Completed the CQC mandated mortality reviews for patients who died of biliary sepsis, urinary tract infections and sepsis. The response was sent to the CQC on 5 December 2017 and shared with commissioners. We are waiting for the CQC to confirm if the response fully meets all the requirements outlined in the three mortality outlier alerts that were issued to the Trust in 2017.

Two mortality faculty members have been appointed and have received local training. Wider clinical engagement and support to deliver the improvement actions through

junior doctor teaching sessions. There has been an internal workshop to commence the design of a biliary sepsis care

bundle and re-design of access to endoscopic procedures.

5.1.8 The system wide next steps are for the findings from the mortality reviews to be shared with the BHR Clinical Cabinet to agree on system wide improvement actions to reduce patient mortality. This work will be progressed using the findings from the NELFT mortality review work programme.

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5.2 Never Events: The Trust continue to implement their composite improvement plan developed following recent Never Events. The Trust have not reported any Never Events since July 2017 therefore the CCG QSC is assured that the Trust’s plan is delivering the required improvements and that the organisation has learned from the Never Events.

5.3 Serious Incidents and Incidents: The impact of the Trust’s improvement plan is clearly

evident when reviewing the data for serious incidents and incidents. Improvement in the reporting and management of all incidents to improve patient safety has been one of the top priorities for the Trust over the past two years and we are now seeing significant improvements in this quality indicator.

5.3.1 The Trust continue to adhere to the NHS National Serious Incident Framework and are fully

compliant with all the requirements, including reporting and investigating all incidents. They do not have any overdue serious incident reports and the number of reports that commissioners approve without requests for further information has reduced.

5.3.2 Incident reporting on the National Reporting and Learning system continues to be above the

national average at 44.75 incidents per 1000 bed days. This is an improvement of 2% in October. This metric indicates that the Trust are improving the culture of reporting and becoming more open and transparent. Higher levels of incident reporting is positive.

5.3.3 In October 74% of patient safety incidents are reported as “no harm” incidents. This is a very

slight deterioration compared to September. The Trust clinically review all individual incidents that are reported as causing harm and following the “round table” reviews in October three incidents were subsequently reported as Serious Incidents.

5.3.4 The CCG/BHRUT serious incident panel jointly review all serious incident reports and

recommendations and escalate themes and/or trends to the Clinical Quality Review Meeting. A very concerning trend that was identified in August 2017 and reported to the Joint Committee at the last meeting is the increasing number of serious incidents being reported because of missed or delayed cancer diagnosis. The Serious Incident reports have identified that radiological investigation incidental findings were not always reported.

5.4 NELFT 5.4.1 Access and Assessment Services 5.4.2 In May 2017 the quality key line of enquiry tracker identified that NELFT had reported a higher

number of serious incidents in the category of unexpected deaths compared to previous reporting periods. The category of unexpected deaths includes potential suicide, suicide and self-harm. Following analysis of the serious incidents and quality risk profiling (including analysis of GP service alerts) five deep dive reviews were conducted, three by NELFT and two by the CCG/CSU. The purpose of the reviews was to confirm the level of risk for patients with mental health needs, and if necessary to implement mitigating actions and identify any learning.

5.4.3 The three reviews completed by NELFT are:

A review of all unexpected deaths of people accessing IAPT services in Havering A thematic review of suicides/potential suicides of people referred to or using the

Assessment and Brief Intervention Services (AABIT); And; a thematic review of all unexpected deaths.

5.4.4 The final reports from these reviews were shared with commissioners at the Clinical Quality

Review Meetings along with a very detailed and comprehensive action plan to deliver the required quality improvements and improve patient safety.

5.4.5 In November 2017 the CCGs completed a final review to evaluate and triangulate the findings

from all the reports, in addition to benchmarking practice against local and national guidance (“Preventing Suicide in England” January 2017 National Strategy and the ‘National Confidential Inquiry into Suicide and Homicide by people with a mental illness’ October 2017).

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5.4.6 As part of this review NELFTs action plan was quality assured by the quality teams in the CCG

and CSU. The plan was found to be comprehensive and addressed findings and root causes identified in all the serious incident reports and deep dive reviews, although there are defined areas that require strengthening. Quality monitoring and improvement for the prevention of suicide and/or self-harm will remain a priority for the CCGs. The focus for the next three months is:

The quality and documentation of risk assessment and taking action on the outcome Clinical compliance with high risk pathways: And: the effectiveness of multi-disciplinary working particularly with people a dual

diagnosis. 5.4.7 It is recognised that the number of people committing suicide in London is decreasing and

NELFT are not an outlier, there have not been any Regulation 28 reports related to suicide for a year and the CQC have not reported specific concerns.

5.5.7 The overall final paper was presented to the December Quality and Safety Committee for

assurance on actions taken, mitigation of risks and confirmation of next steps. A further report on progress of the action plan and impact of the actions on the number/themes of unexpected deaths will be taken to the February Quality and Safety Committee.

5.6 Workforce Risks 5.6.1 As has been previously reported to the Committee, significant risks that NELFT are managing

are related to their workforce and safer staffing. The risks are specifically related to recruitment and retention across all staff groups, vacancies and sickness rates.

5.6.2 Commissioners review the workforce risks at every CQRM and are assured of the robustness

of the plan in place to mitigate the risks and to improve performance across the range of workforce KPI’s.

5.6.3 NELFT mitigate the risks and achieve safer staffing levels for all inpatient wards through the use

of bank and agency staff. This has significant financial implications and also presents, to a lesser extent, risks for patient safety. There is currently an organisational plan to reduce agency spend which is now beginning to demonstrate results. Since May 2017 there has been a significant decrease in agency spending and the level of agency use is at the lowest level since reporting on this metric began in quarter 3 2015/16. For the month of October 2017 NELFT did not use any agency Health Care Assistants and overall only 4% of shifts are now covered by agency staff. This is a significant achievement.

5.6.4 In addition to this achievement, none of the wards are in the top twenty areas for agency spend

across the organisation. 5.7 CQC Report 5.7.1 The CQC reports are due to be published on 18 January 2018. NELFT have received three

final reports NELFT and are therefore anticipating an improvement in the overall organisational rating from “Requires Improvement” to “Good”. When the report is published commissioners will review the content and take the appropriate actions depending on the findings.

6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capitals costs arising from this report.

7.0 Sustainability 7.1 If we achieve the quality improvements detailed in this report the positive impact will be on

sustained quality improvement and an improvement in patient experience.

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8.0 Equalities 8.1 This report has considered the CCG’s equality duty and where relevant has identified relevant

actions which address any likely impact on equality and human rights. 9.0 Risk 9.1 Risks exist related to the delivery of the CCGs early warning systems, specifically the processing

of GP service alerts and completion of the key line of enquiry tracker. The key line of enquiry tracker is our quality analysis and risk profiling tool. Strong mitigating actions are in place while permanent solutions are identified. The timeframe for implementing the required changes is 1 March 2018.

9.2 Failure to ensure that there are improvements to the quality performance of commissioned

services may result in a failure to manage and mitigate risks with potential harm to patients and reputational damage to the CCG. The CCG quality surveillance and management system provides mitigation to this risk. The management of this risk is assured by the Quality and Safety Committee.

9.3 Some patients may not be receiving the quality of care at the level which the CCG commissions,

and therefore may have a poor experience of using the services we commission. 9.4 Mitigating actions for the above risks have been specified in the body of the report. 10.0 Managing conflicts of interest 10.1 There are no conflicts of interest raised in this report.

Author: Jacqui Himbury, Nurse Director Date: 09 January 2018

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Date: 25 January 2018 Subject: Terms of Reference Updates Executive summary

Following the last meeting where it was agreed that the CCGs would establish joint committees for Finance and Delivery and Quality and Safety rather than retain the ‘in-common’ arrangements, revised terms of reference were developed, considered and agreed by the respective committees. This included the Financial Recovery Performance Board (FRPB). The amendments, which relate to BHR wide membership and quorum, are summarised within the report for the Joint Committee’s approval. The Committee also agreed to receive terms of reference for the Joint Committee of BHR CCGs at this meeting. However given developments for the NEL Joint Committee are still being progressed to allow for wide engagement, it is proposed that the BHR Joint Committee continue to operate in line with the governing body ‘terms of reference’, with the addition of the Director of Delivery and Performance as a

member as previously agreed. Given the NEL developments it is also proposed to include the Managing Director as a member. It is also proposed that given previous quoracy issues with regard to clinical directors (CDs) and potential vacancies in two of the BHR CCGs, that this element of the quorum be revised. The number of CDs as members on the Committee is unchanged and all CDs remain as full members. However it is suggested to amend the quorum from four to three clinical directors per CCG. This is simply a practical proposal to enable decision making to take place at meetings. Recommendations

The Committee is asked to: Approve the proposed amendments to the terms of reference as set out in sections 3-6.


1.1 To seek approval of the revised terms of reference for the Finance and Delivery and Quality and Safety Committees and Financial Recovery Performance Board (FRPB).

1.2 To seek agreement to the inclusion of the MD as a member of the Joint Committee and to revise the quorum for clinical directors.

2.0 Introduction

2.1 At the last meeting of the Committee it was agreed to establish joint committees for Finance and Delivery and Quality and Safety and to develop revised terms of reference to support these changes. The Committee also agreed to consider terms of reference for its joint committee. The

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proposed changes to the terms of reference for those Committees are outlined in the next section.

3.0 Finance and Delivery committee

3.1 The proposed changes to the terms of reference include: Revised membership Chief finance officer Three CCG Chairs Four clinical directors – across BHR Lay member, governance Director, Delivery and Performance Lay member, PPI Quorum- -Four members including a requirement for one BHR Chair, one BHR Clinical Director, the Lay Member, governance or the CFO

4.0 FRPB

4.1 Revised membership Chief Financial Officer Accountable Officer or Managing Director Three CCG Chairs Four Clinical directors – across BHR Director, Delivery and Performance Nurse Director Lay member, governance Lay member, PPI Quorum-Four members including requirement for the AO/MD or CFO, 1 BHR Chair, I BHR Clinical Director, I Lay Member who can act for all BHR CCGs

5.0 Quality and Safety Committee

5.1 Revised membership Secondary care consultant (Chair) BHR Director of Delivery & Performance (vice Chair) Nurse Director Lay member Four clinical directors – across BHR

Quorum-Four members including requirement for two BHR Clinical Directors 6.0 Joint Committee – this meeting

6.1 It was proposed to consider the terms of reference (TORs) for the BHR CCGs Joint Committee in tandem with the NEL Joint Committee TORs. However, to ensure wide engagement in the development of arrangements for the NEL Committee, there has been a recent workshop, with a further one planned for February. Given it is proposed that the BHR Joint Committee TORs be developed and considered in line with these, it is proposed that these be presented to the next meeting.

6.2 In the meantime, some minor amendments are proposed. To reflect the new NEL commissioning arrangements with a Single Accountable Officer and BHR MD, it is proposed that the new post of MD be included as a member of the Committee. Also, given the current clinical director election process, which may result in some vacancies, and previous issues with quoracy, it is proposed to continue to retain full membership of all CCG clinical directors on the Joint Committee, but for

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practical reasons and to support the ability to make decisions, to reduce the quorum requirement to three CDs (which can include each Chair) per CCG rather than four.

7.0 Equalities


8.1 There are no risks arising from this report.


9.1 There are no conflicts of interest issues relevant to this report. 10.0 Resources/investment

10.1 There are no additional resource implications/revenue or capitals costs arising from this report and no impact on sustainability.

Author: Anne-Marie Keliris, Company Secretary Date: January 2018

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From: Tom Travers, Chief Financial Officer Chair of Financial Recovery Programme Board (FRPB)

Date: 25 January 2018 Subject: Work of the FRPB and Financial Recovery Programme Progress Summary Executive summary

During 17/18 the BHR CCGs are required to deliver £45m of savings, in year. The position at the beginning of January is that £32.859M savings scheme opportunities have been approved by the CCG. A pipeline of new opportunities is identified and new schemes continue to be brought through the approval process. Recommendations

The Committee is asked to note the report.


1.1 To update the Committee on the progress of the 17/18 Financial Recovery Programme and work of the FRPB.


2.1 The financial challenges facing the BHR health system, following agreement of 2017-19 NHS contract values, are significant, requiring BHR CCGs to save £45m to deliver a planned £10.2m deficit across BHR. Work is continuing under the direction of the Financial Recovery Programme Board (FRPB) to deliver savings schemes to meet this target.

2.2 Under the FRPB’s Terms of Reference a high level summary of the progress on the financial recovery will be regularly provided to the Governing Bodies/Joint Committee.

3.0 Delivery progress

3.1 Significant progress continues to be made on the savings programme: a total of 34 savings schemes are now approved by the CCGs and the total CCG assured savings figure is £12.240K. The total QIPP opportunity identified is £32.9m

3.2 In common with all CCGs across London an audit on the CCGs’ Governance and Process

surrounding QIPP has been carried out on behalf of NHS England by Deloitte. The audit’s

finding in respect of the CCGs’ process for the identification, delivery and oversight of QIPP

schemes was positive and overall a green rating was conferred.

3.3 A sub-group of the FRPDM has been established led by the Director of the PMO to plan for next year and ensure that saving plans, a refreshed operating and CQUINs are in place. It is

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anticipated that a planning guidance will be forwarded by NHS England during the latter half of January with a refreshed operating plan required from the CCGs in early February. Currently 49 projects have been identified, of which 33 carry forward from 17/18. The current level of saving identified is £32,859M.

3.4 Work to implement the Referral Management System, which is now called ‘Improving Referrals Together’ has commenced. This scheme is one of the joint schemes developed together by the CCGs and BHRUT and is being led by the Planned Care Programme Lead with input from BHR CCGs’ clinical directors and the BHRUT Chief Operating Officer.. The project is planned to go live in 18/19.

3.5 Following discussion at the FRPB in December, work has commenced to have a single point of referral for the MSK, gastroenterology and dermatology pathways, This will improve the level of compliance with the community pathways introduced as savings schemes in 17/18, resulting in savings in these areas in 18/19


4.1 There are no additional resource implications/revenue or capitals costs arising from this report.

5.0 Equalities

5.1 There are no additional equalities implications arising from this report. All savings scheme are required to have an Equalities Impact Assessment completed as part of the approval process.

6.0 Risk

6.1 There are no risks arising from this report. Risks to project delivery are held in individual project risk registers. It is noted that there is an overriding risk, held on the CCGs’ corporate risk register

around not achieving the savings target. 7.0 Managing conflicts of interest

7.1 There are no conflict of interest in regards to this paper. Author: Jeremy Kidd, Head of PMO Date: 09.01.18

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To: Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs From: Kash Pandya, Chair of BHR CCGs Finance & Delivery Committee Date: 25 January 2018 Subject: Feedback report from the December 2017 BHR CCGs Finance & Delivery

Committee meeting Summary The Finance & Delivery Committee meeting minutes are provided to each of the 3 CCGs Governing Body meetings. To provide additional assurance to the Governing Bodies, this brief feedback report provides key highlights from the meeting:- Finance risk overview report - Committee members were given an update on all the financial risks that the CCGs are facing and members agreed that the financial situation remains a matter of extreme concern. Updates were provided on the mediation process with both BHRUT and NELFT and in addition, updates were given on the contracts with Barts Health, the Independent Sector and on the other main areas of spend. The Committee gave its full support to all the actions being taken. Integrated Performance Report (IPR) – Committee members were presented with an updated IPR and reviewed and discussed the content. A deep dive report was presented on day cases and Committee members were also provided with an analysis on RTT waiting times which they found extremely helpful. Financial Delivery and Performance Risk Report - the Committee discussed the report and noted the key risks. Full support was given to the mitigating action being taken. Terms Of Reference – the Committee reviewed its terms of reference and the changes to the membership were agreed. Recommendation:

The Joint Committee of BHR CCGs is asked to note this feedback report and the December committee minutes which provide more detail on all the matters considered.

5 January 2018

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Draft Minutes of the BHR CCGs Finance & Delivery Committee held on Thursday 21 December 2017, Becketts House

Members:-

B&D CCG Havering CGG Redbridge CCG Kash Pandya (KP) Lay Member, Governance and F&D Committee Chair

Kash Pandya (KP) Lay Member, Governance and F&D Committee Chair

Kash Pandya (KP) Lay Member, Governance and F&D Committee Chair

Rob Adcock (RA) Deputy Chief Finance Officer



Dr Jagan John (JJ) Clinical Director

Dr Alex Tran (AT) Clinical Director

Dr Mehul Mathukia (MM) Clinical Director

Dr Ann Baldwin (AB) Clinical Director

Gina Shakespeare (GSh) Director, Delivery & Performance



Khalil Ali (KA) Lay member PPI



Attendees:- Ali Kalmis (AK), Director, Acute Contract Management, CSU Dion Davis (DD), CSU representative Anna McDonald, Business Manager, BHR CCGs (AMc)

Apologies - members Tom Travers (TT) Chief Finance Officer, BHR CCGs Dr Waseem Mohi (WM) Chair, B&D CCG Dr Atul Aggarwal (AA) Chair, Havering CCG Dr Gurkirit Kalkat (GK) Clinical Director, B&D CCG Dr Maurice Sanomi (MS) Clinical Director, Havering CCG Dr Jyoti Sood (JS) Clinical Director, Redbridge CCG Dr Sarah Heyes (SH) Clinical Director, Redbridge CCG Dr Muhammad Tahir (MT) Clinical Director, Redbridge CCG Apologies - attendees Dr Anita Bhatia (AB) Clinical Director, Redbridge CCG 1.0 Welcome and apologies Action

The Chair welcomed everyone to the meeting

1.1 Declarations of interests

The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs. No additional declarations of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.


The minutes of the meeting held on 25 October 2017 were agreed as an accurate record.

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1.3 Matters arising/actions log

The actions log was reviewed:- Finance risk over view report – it was agreed that the data received from BHRUT has improved and GSh confirmed the amount of un-coded data has gone down. Action closed. Hospital letters not being received – AK to confirm that the action from the October meeting for LE to share the paper he presented as requested has been completed. The Chair confirmed the action in regard to this Committee could be closed. Action closed. NHS standard contract – AK explained the problems in establishing where the Trust is in terms of delivering each of the standards and advised that she is waiting for a response. JJ said this links in to issues with IT and explained that he is receiving discharge summaries directly into his system and asked for a status of the IT integration with the Trust. AK to find out for the next meeting also provide a paper explaining where we are with the changes to the contract, what the blockages to the changes are and who is responsible. AK to also confirm that the action from the October meeting for LE to share the paper he presented in October has been completed. Action: AK AB said there should only be one route for discharge summaries etc and raised her concerns about the confusion and possible duplication. Some practices are set up but not all the ‘boxes’ haven’t been activated. The Chair recalled that the same issue had been discussed at another meeting he had attended. PwC report (Joint delivery arrangement review) – The Chair asked for this to remain open so that the Committee continues to receive progress updates. Action open. Finance risk register – an update on this action was received outside of the meeting. The Chair had made a request at the October meeting for a matrix showing progress made and also an additional column showing outcomes/achievements. The request was carefully considered by GSh and PD and it was agreed that rather than creating a separate matrix, the process going forward will be that once a current deadline given in the ‘mitigating actions’ column has been met, the narrative will always be updated to include the next steps and a new deadline will be added if appropriate. Action closed. The remaining actions were closed with updates noted on the log.

AK AK AK TT

2.0 Performance

2.1 Finance Risk Overview report – month 6 (month 5 data) The CCGs have reported a forecast deficit of £25.2m at month 8. This represents a slippage of £10.2m against plan and includes the 17/18 in year deficit and the historic deficit reported by Havering CCG. RA updated the Committee on the mediation process undertaken with BHRUT and explained the Trust has written to the CCGs stating that they do not agree to the

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outcome of the mediation and this significantly increases the level of risk inherent within the CCGs forecast. The CCGs have responded back outlining the next stage in the contract process which is ‘expert determination’. In the meantime, NHS England (NHSE) and NHS Improvement (NHSI) are having discussions on the health economy financial position and year-end scenarios. The reported forecast overspend for Barts Health is £7m. Other Associate contracts and Independent providers have reported forecasts based on the latest activity and referral trends. The other main areas of spend are showing variances as a result of QIPP slippage and investment slippage. Other areas noted were Continuing Healthcare (CHC) and prescribing where B&D CCG is reporting an over spend. The total risk faced by the CCGs is estimated at £21.3m. The Chair requested that a separate line is included in the report going forward under ‘running costs’ on BHR CCGs contribution to the STP/NEL Partnership. JJ questioned where the Independent activity is being generated from and AK responded that all the data received states ‘GP referral’. JJ raised his concerns about the response given and gave his view of what is happening. He said patients are being discharged from the Independent Sector and then when something goes wrong, GPs are being asked to generate another referral back to the Independent Sector which is then recorded as a new referral. AT confirmed that he has experienced the same thing. AK to look into this and try to link episodes and will report back at the next meeting. GSh confirmed that an activity query notice (AQN) has been issued to the Independent Sector and asked AK to link these concerns into the current lines of enquiry. GSh added that issues like this demonstrate the need to have a CD in attendance at meetings held with providers. The Chair asked for the Committee to be sighted on the assumed position for 18/19 and RA confirmed the 18/19 plan will be included on the next agenda for discussion. KA suggested that a level of ‘over-planning’ is needed. MM asked what the next steps will be following BHRUT’s rejection of the mediation recommendations. GSh responded giving details of the next stage and of the discussions taking place with NHSE and NHSI. The Chair thanked GSh for the helpful update. AB questioned what else can be done in regard to the QIPP delivery plan and suggested looking at local QIPP schemes. GSh said the Informal Joint Executive Committee (IJEC) meeting that was scheduled to follow on after the Committee meeting provided the ideal opportunity. JJ gave his view that the level of risk is moving into primary care. The Committee noted the updated financial position. 2.2 Integrated Performance Report (IPR) GSh updated the Committee on the latest A&E waiting times at BHRUT which continue to be challenging and confirmed that NHSE and NHSI would be visiting both A&Es sites. An update was also given on the paediatric streamlining being introduced and the issues with clinical governance sign off. RTT performance is a concern as the Trust is underperforming against the 92% standard for the 52 week wait. It was noted that the Trust is doing well in regard to meeting national cancer standards. GSh added that external assurance is being sought on how the Trust is managing its Patient Tracking List (PTL). GSh confirmed that ‘winter monies’ have now been received and that extra beds were being opened by NELFT. JJ advised the Committee that he is now part of the Urgent & Emergency Care Programme

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following the clinical lead restructure and that he has asked for a meeting between our clinical leads and the Trust’s to be organised for early in the new year. One of the things they will be looking at are the ‘peaks and troughs’. He suggested that much more radical thinking is needed across the system as a whole and gave examples of what is currently happening at GP practices in Kent where GPs are only seeing emergency patients for a 3 week period and cancelling everything else and also Sweden where they have an A&E dedicated to mental health. GSh added that having closer co-ordination between clinicians to think about more imaginative solutions would be very welcome. The other main points discussed were in relation to Barts Health - it was confirmed that the Qtr1 reconciliation has been completed and it was noted that the most significant issue for BHR CCGs, in particular for B&D is the maternity pathway. QIPP planning for 18/19 is continuing and £27m has been identified so far. The Committee noted the report and supported the mitigating action being taken. 2.2.1 NELFT contract - update on outcome of the mediation process RA confirmed that the mediation process had been successful and that a contract variation agreement has been issued to them. It was agreed that assurance was needed on value for money and the Chair requested a report on service line reporting for the next meeting. AB asked about the physiotherapy review and RA confirmed that it will be discussed at a meeting of the Financial Recovery Programme Board (FRPB) in January 2018. 2.3 System delivery Framework The report provided the Committee with a progress summary. The critical issues were noted as; confirming the next steps following BHRUT’s response to the mediation outcome; continued work to build the 18/19 QIPP position; focus on Planned Care Demand Management through the mobilisation of Referral Management Systems; an agreed action plan on the MSK, Dermatology and Gastro pathways; negotiations on the GP bundle and the issuing of an activity query notice to the independent providers. It was agreed that there was nothing more to add under this item that hadn’t already been discussed earlier on the agenda.

TT/RA

3.0 Breakdown of RTT waiting times

The Chair fed back on concerns that AA had raised with him earlier on in the day about the accuracy of the numbers provided in the report. JJ advised the Committee that when patients fail to get an appointment, they are told to go back to their GP which results in the GP referring to the Independent Sector as GPs feel there is no point referring to BHRUT because patients aren’t getting appointments there. GSh reminded the Committee that it’s the ‘clock start’ that’s being measured in RTT and not referrals and added that the Choose & Book (C&B) system measures slot issues which are then monitored in the weekly RTT reports. GSh asked AK to provide a report on slot issues for the next meeting so that any ‘hot spots’ can be looked into more closely. The content of the report was noted and the Chair thanked the CSU for the helpful report.

AK/CSU

4.0 Day cases deep dive

DD presented the report which had been requested in response to significant year to date over performance in day case activity. The content of

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the report was discussed and members agreed that the total activity in the system has increased. A discussion about the DMC pathway took place and AB asked if it would be possible to look at what procedures are being performed in the different specialities such as dermatology and establish why they aren’t being carried out in the community service. AK said she would produce a briefing note. The Chair thanked the CSU for the comprehensive report.

AK

5.0 Financial Delivery and Performance risk report

The report outlined the highest service risks and the highest rated financial risks across BHR CCGs. The report was reviewed and the Committee accepted the assurances given in the report and agreed the actions being taken to reduce the impact to the CCGs. JJ added that he would like a summary that provides key headlines of all the underlying issues facing the CCGs that can be shared with GPs. GSh responded saying that it was her understanding that part of the role of a CD is to provide feedback to GPs following the meetings they attend. The Chair decided that it would be helpful to consider again the briefing paper for CDs to give feedback and that this item should be brought back to the next meeting for further consideration.

KP/TT

6.0 Procurement Oversight Group report

GSh presented the report and updated the Committee on the progress made to date on the procurement pipeline. Assurance was given to the Committee that the CCGs are improving the planning and prioritisation of procurement activities, risk assessing each procurement and escalating risks where necessary.

7.0 F&D Committee Terms of Reference (ToR) - amended

The ToR were reviewed and the Chair confirmed that the vice-chair would be decided on the day of the meeting. The Committee agreed the revised ToR.

8.0 Items for noting

8.1 Notes and actions from the F&D sub-group The Committee noted the papers. 8.2 Procurement Oversight meeting minutes The committee noted the minutes. 8.3 BHR local Estates Forum minutes The Committee noted the minutes.

9.0 Any other business

It was noted that it was GSh’s last day working for BHR CCGs and the Chair thanked her for all her hard work.

10.0 Dates of next meetings: F&D sub-group – 18 January 2018 F&D Committee – 27 February 2018 – Maritime House, Barking

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From: Kash Pandya, Chair, Audit & Governance (A&G) Committee

Date: 25 January 2018

Subject: Feedback from the 5 December 2017 Audit & Governance Committee meeting

The following key matters discussed at the A&G Committee meeting on 5 December 2017 are drawn to the attention of BHR CCGs Joint Committee:-

The A&G Committee meeting was attended by John Roome, Audit Chair from North East London Foundation Trust (NELFT). His attendance as an observer was arranged to strengthen relationships and joint working, where appropriate, between the two organisations. His feedback about the meeting was positive and good practice was shared about risk management arrangements. I will be attending the NELFT Audit Committee as an observer on 23rd January 2018.

The Director of Primary Care, Sarah See, shared the risks facing her directorate and the action being taken to mitigate them, in particular with regards to funding of the PMS reviews and the implementation of the GP bundle.

Internal audit and Local Counter Fraud Service work plans for 2017/18 are on track. Internal Audit have issued a number rating for the budgetary control audit because of the financial challenges facing BHR CCGs.

The Committee met BHR CCGs new external auditor, Neil Thomas, a partner at KPMG. He explained that their first audit would need to consider several key risks, in particular the financial position of the CCGs at 31 March 2018 and its potential impact on their audit opinion.

The Committee noted the appointment of a Single Accountable Officer for NEL and the development of new governance arrangements. The Committee asked that it be updated on these developments to enable it to be satisfied that BHR's statutory position was being adequately safeguarded within these new arrangements.

The Committee considered the corporate risk register and the high numbers of red risks facing the CCGs and whether risk appetite towards them needed to be reviewed. The Committee suggested that a new risk about the new NEL governance arrangements and its impact on the CCG be considered and whether risk management training could be organised for GB members and relevant officers. Officers have agreed to consider the suggestions made.

The Committee approved the updated Anti-Fraud & Corruption and Complaints Policies and agreed to undertake a separate review of information governance and financial policies through a virtual meeting.

The Committee remains concerned about the uncertain and extremely difficult financial position of BHR CCGs given the failure as yet in reaching an agreed financial end of year position with BHRUT and Barts Health. It supported the actions being taken by officers to resolve them.

The Committee agreed, with some minor amendments, the end of year financial accounts and annual reports plan for 2017/18.

11 January 2018

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Draft Minutes BHR Audit Committee 24 May 2017 v1

DRAFT Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs

Audit &Governance Committee held on 5 December 2017 at Becketts House 9.30-12.00

Present –Members

Kash Pandya (KP) BHR audit chair, lay member for Audit & Governance Khalil Ali (KA) Lay member PPI Redbridge CCG Charles Beaumont (CBe) BHR co-opted member for Audit & Governance Sahdia Warraich (SW) Lay member PPI Barking & Dagenham Richard Coleman (RC) Lay Member PPI Havering CCG In attendance-Officers

Tom Travers (TT) BHR chief financial officer Rob Adcock (RA) BHR deputy chief financial officer Sarah See (SS) part BHR Director of Primary Care Transformation Pam Dobson (PD) 1 item BHR deputy directorate corporate service Sanjay Patel (SP) part BHR Angela Ward (AW) BHR company secretary In attendance-auditors

Neil Thomas (NT) External auditor, KPMG Nick Atkinson (NA) Internal auditor, RSM John Elbake (JE) Internal auditors , RSM John Roome (JR) NELFT Audit Chair Apologies

Marie Price (MP) BHR Director of Corporate Services Action

9.00- 9.30

Committee Members held a short private meeting and they then held a short introductory meeting with Neil Thomas the new External Auditor from KPMG.

28/17 Welcome and Apologies for absence Apologies for absence were received from Marie Price. The Chair welcomed John

Roome the NELFT Audit Chair who was attending as an observer.

29/17 Declaration of Interests (DOI) No further declarations of interests were declared other than those on the three

registers presented.

30/17 Minutes of meeting held on 10 October 2017. The minutes of the previous meeting were agreed and would be signed by the Chair

as a correct record. JR requested further information on mental health out of area placements as referred to in Jacqui Himbury’s risk report. AW would request further detail.

AW

31/17 Matters Arising Updates were given on three actions:

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47/17 Deloitte’s end of year report-NA updated that a decision had been taken for Deloittes to provide a one year review now. The report would not refer to fraud but this was being strengthened as CCU had now an in- house counter fraud service. Action Closed. 19/17 QIPP-NA and TT had agreed revised wording in the final QIPP review report. TT added there was overall slippage but it was encouraging to note that 90% of target had been achieved. Action closed. 22/2 BCF- FON would be asked to confirm that he had shared his BCF report with Jane Gateley (since confirmed). Action closed.

AW

31/17 Directorate Risk Briefing Sarah See attended to highlight her Directorate’s key risks.SS described the current

position on the PMS review and the impact of moving PMS to the GMS level had on Barking & Dagenham and Havering, by not offering a premium to GMS practices. Redbridge was not so impacted due to their growth monies and they could offer premiums through the transition/equalisation period. All practices affected had been visited to risk-assess, particularly noting impact on staffing levels and being aware of expected winter pressures. There was talk of practice redundancies and only being able to fulfil core tasks. At the recent meeting with B& D and Havering LMC there was discussion on dispute and litigation on CCG actions and this significant risk was being discussed at the forthcoming LMC. There was a risk of less appointments being available and increased impact on A& E. Noting the shortage of GPs and practice nurses, there were workforce initiatives in place and solutions being sought on ways of working. A risk summit had been requested with NHSE. SS described a new CQUIN initiative to purchase secondary care consultant advice to GPs in the aim of reducing un-necessary referrals. Practices had requested funding to undertake their side of the conversation, which was not available. Member s discussed the best outcome for patients of where they were treated but this could lead to more GP appointments. The Chair highlighted the risk to contract agreements due in March. RC shared the concerns raised and the negative impacts on other parts of the system and welcomed the risk summit. TT quantified the cost of the issues raised as £1m in the first year rising to £2m. NA added that for benchmarking he was aware some CCGs were spending over the £85 cap but these were not under Legal Directions. KA added that sustainable solutions were vital through the 5 year forward plan, building on and embedding the recognised best achievements. SS was asked to send a briefing note to the next meeting or before to the Committee up to date on the risk mitigation.

SS

32/17 Internal Audit

32.1 BHR Progress The budget setting report had been issued with a reasonable assurance opinion. This was based on the financial challenge and actions in place to mitigate risk and had led to one low risk recommendation. NA acknowledged that there appeared not much else that could be done to mitigate risk further. Pre-HOIAO no management issues were found and all recommendations due had been implemented. IA had been asked to review a complaint about a subject access request and this was found to be generally sound and NA would discuss the outcome further with MP. KP would receive a copy of the report. The Chair questioned the amber rating in the budget report and

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NA outlined the three facets of design, application and system effectiveness and a green could only be achieved on the latter. To understand how to improve on effectiveness if you looked at benchmarking it would be about the BHR scale of challenge and flex in the local health economy. Despite everything that could be done was being done it might not be enough to meet the QIPP control total. TT emphasised that QIPP had to be delivered in partnership and he updated on the BHRUT financial position and the arbitration arrangements. KA raised building in duty of care/ public engagement to future IA plans. NA responded that the plans aligned to corporate objectives and these could cover these areas, an assurance map could be provided to demonstrate how these were achieved. The Chair requested that the IG Toolkit sign off be addressed a little earlier this year as last year had been pressured. Leads were to be reminded of the training timetable. 32.2 CSU Progress There were no new CSU review reports and the recommendations due had all been implemented. The Chair referred to the attachments under ‘items for Information’ and asked for the good practice briefings to be shared e.g. procurement, cyberfraud, DOI. Internal Audit was thanked for their progress reports.

NA RM/PD AW

33/17 External Audit NT and TT had held a useful planning meeting and a meeting with the Audit Chair

would follow shortly. Key issues emerging were; The Financial position and impact on the Financial Statements and VFM

conclusions Primary Care Co-commissioning and past difficulty in obtaining information at

year end Understanding the risk to completion and agreeing balances Governance arrangements for Accounts sign off

It was noted that the handover meeting between E& Y and KPMG had not yet occurred. The Chair welcomed KPMG as the newly appointed external auditors noting it was helpful to have the same auditors across NEL. He requested that NT highlight any issues as they arose.

34/17 Governance 34.1 Single AO and governance arrangements

MP had provided a summary of recent activity and referred to recent GB reports. The Chair welcomed the new joint committee arrangements for BHR governing bodies. Noting the new AO had started SW awaited the new management structure and confirmation of Chairs and management leads. RC raised the new MD role and noted that interim arrangements in the 7 CCGs differed with the Remuneration Committee meeting to agree some further matters. It was hoped that only a few constitutional changes would be required. Updates would follow. The progress report was noted. 34.2 Committee Terms of Reference Review JE agreed to benchmark the current TOR. NT suggested consideration be given to adding opportunities for virtual meetings, conference calls and to address what

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policies the Committee could approve. This would be brought back to the next meeting with STP level arrangements were clearer. 34.3 Risk Register PD presented the BHR collaborative risk register. All Directorates/departments had their own registers and highest risks were escalated up to the corporate register. Review meetings were held monthly and risks presented to EMT meetings and the register was also discussed at the recent GBs meeting. GS had carried out an overall review and reduced risks down from 40 to 25. KA referred to the new quality assessment tool for CCGs and Trusts that included moderation meetings to review each other’s scorings and allowed a shared understanding of perspectives. PD would meet with JH to understand how the tool was applied. The Chair noted that a training event for senior manages was being arranged on application of the COI policy and the national mandatory training model was due shortly after being delayed. NA observed that there was a common thread of finance and quality in the red ratings. He suggested a risk rating for the reconfiguration around the new AO management structure should be added. Members discussed tolerance levels and risk appetite. He suggested looking at how the RAG position could be tracked to show improvement over a 3 year period with links to corporate objectives and IA planning and this would demonstrate the effectiveness of mitigation. PD accepted that plotting the GBAF over time for stagnation or improvement was important. SW questioned the impact of workforce of the recent re-structuring, noting change in progress. It was noted the vacancy rate had improved as appointments had been made. RC agreed that shifts were occurring which carried an element of risk. The Chair felt the GBAF could portray 4 key areas of risk as discussed as others were sub-sets of these. Further consideration would be given to format. 34.4 Anti-Fraud & Bribery Policy v3 LCFS had updated v2 of the policy to take account of any legislative change, reporting lines and make this a BHR policy. This policy would be shared with staff, GB Members and practices where there was a decision making relationship with the CCG. The Committee approved v3 of the policy documentation. 34.5 Complaints Policy The revised policy took account of working arrangements and there was a link to the fraud and bribery policy. The term vexatious complainant had been revised to habitual, . There would be reference added that provider complaints (Trust or GP) needed to be forwarded on and that would be emphasised. Also (p11) that trend reports would go to the quality and not the audit committee but it was useful for this committee to know overall number each year. Regulations did not set target response times but the CCGs had agreed on 25 working days but 20 days for MPS to allow some response to their constituents. However if the complaints was complex, multi-agency agreement on timescales would be agreed mutually with the complainant. It was confirmed that the new MD would now sign off complaints. KA questioned whether there was learning from complaints and we could demonstrate ‘you said/we did’ in our engagement documents. RC called for patient survey. PD responded that complaint’s learning was followed up by individual departments such as CHC. The complaints policy was approved.

PD/JH MP/AW PD PD/MP

35/17 Finance

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35.1 Finance Risk Report TT updated he Committee since the report to the recent Governing Bodies. NHSE had required us to fix the forecast and £10.2m variance to plan had been set. The risks within were acute as Barts Qtr 1 reconciliation was still not complete. The current risk range was estimated at £4-£12m. and BHR had opted for £7.4m.in their fixed forecast. BHRUT was more critical. The figure was £8.4m informed by the outcome of mediation but the Trust had declined to abide by that mediation outcome. The outcomes of clinical audits were excluded from mediation. Jane Milligan and Conor Burke had met and proposed expert determination. As the significant financial risk needed closure as soon as possible. QIPP was stable but no new schemes were identified and delivery was good. The level of risk with BHRUT had clearly been heightened. It would take until January to appoint an independent expert in determination. NHSE and NHSI were informed of the current position. The BHR Finance & Delivery Committee was also aware. The Chair noted that with Barts and BHRUT could lead to a variance of £15m and BHR had acted in good faith in terms of £4m assistance to BHRUT’s cash flow. NEL Risk sharing was discussed where each CCG paid 0.5% in but it was not yet clear how surpluses could be used. The CCGs would focus on delivering QIPP and preparing for 2018/19. The Committee recognised the challenges and supportive action. Timetable for Accounts & Annual Reports Submission Again the timetable was shorter than the previous year and key meetings had been set to meet the challenging deadlines. There was good news in that the Accounts Manual appeared unchanged. Work was ongoing with CSU on current checks/balances compared 2015/16. A revised timetable with some tweaking of the final dates proposed by the Chair. 35.3 Updated Detailed Financial Policies (SFIs) The revision took account of changed management arrangements and programme directors and the scheme of delegation had been updated with good practice from internal audit. The policy was being refreshed now in preparation of alignment across NEL. NT questioned whether the Committee should be approving these policies and the Chair/TT and MP would discuss this further. The policies were therefore not approved at this time. 35.4 Prescribing Rebate Scheme Income SJ from medicines management presented the outcome of 2016/17 rebates scheme. This was lower than last year but opportunities were reducing as national prices had been reduced, however more schemes were underway. It was noted that this was not part of the delegated budget and income was directed to QIPP savings and most appropriate for the audit committee. This was the top Freedom of Information request but account had to be taken to COI and limited information provided. SJ explained that take up reflected medications linked to the population profile. The annual report was approved. 35.5 Tender Waivers The Chair stressed that he was not supportive of single tender waivers and was requesting that they diminish in the new year. The Committee could note that they had occurred and only question the process.

RA/AW KP/TT/MP

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35.5.1 Medefer Gastroenterolgy Pathway The Committee noted this waiver for extending this service to run a more effective pilot. KA raised willingness to refer to Medifer and this would be discussed at the next PCCC and FRPB. The waiver was noted. 35.5.2 Management Consultant This approach was taken following a review by Deloittes, recommending a post of Director of Delivery and Performance. Recruitment to a substantive post was commenced but the vacancy was filled on an interim basis to assist financial recovery and turnaround whilst the post was filled. The Remuneration Committee had discussed this post and remuneration. CBe questioned whether IR35 applied and it was noted the person was employed by their own agency into a (identified or unidentified post). TT stressed the post covered three CCGs and the Chair asked for this point to be clarified in the report. The waiver was noted. 35.5.3 Programme Director Urgent and Emergency Care The report outlined the need for a single tender waiver to appoint a new interim Director from MCK consultancy agency. BHRUT had been categorised as the highest level of escalation (Cat 4) by NHSE for delivery risk. This winter Director post was on the payroll and cost shared between BHR and BHRUT. The Chair called for a review of their achievements in due course.TT advised of first tranche winter funding received at STP level but only for Category 4 systems ie. BHR and rules for its use would apply. The waiver was noted. The Chair questioned if and where Chairs Actions were reported and the secretary would advise outside of the meeting.

TT ?PD KP/AW

36/17 Any Other Business There was no other business.

37/17 Items for information 37.1 IG Steering Group meeting

The notes of the meeting held on 20th October 2017 were noted. The Chair wished to attend a meeting and would be furnished with dates. 37.2 NAO briefing The contents were noted and would be shared with the relevant departments 37.3 NAO round up The National Audit Office bi-annual news round-up that related to Audit Committee was noted. 37.4 RSM News Briefing The IA briefing was noted.

AW

38/17 Key Messages for GB

The Chair would provide these for the Secretary to forward to the January Governing Bodies.

39/17 Date of Next Meeting

The next meeting was arranged for 13 February 2017.

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Signed………………………………………………..Date………………………….

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Draft Minutes of the BHR CCGs Quality & Safety Committee – Part 1 Tuesday 19 December 2017 at Becketts House 1.30– 3.30pm

Members: Ah Fee Chan AFC) Gina Shakespeare (GS) Sue Elliott (SE) Dr S Heyes (SH) Dr R Goripathi (RG) Attendees: Erin Brennan-Douglas (EBD) Quality Manager Mark Gilbey-Cross (MGC) Designated Adult Safeguarding Manager, BHR CCGs Belinda Krishek (BK) Chief Pharmacist BHR CCGs Angela Ward (AW) Company Secretary BHR CCGs

Apologies Jacqui Himbury Dr A Bhatia Dr R Hara Dr K Rai Sahdia Warraich

1.0 Welcome and apologies Action

The Chair welcomed everyone to the meeting. A revised Committee membership had recently been proposed that required 2 CDs to be present to be quorate. The meeting was declared quorate and this would be discussed further under item 1.4 on Terms of Reference. Apologies were received from Jacqui Himbury, Dr Bhatia, Dr Hara, Dr Rai and Sahdia Warraich.

1.1 Declarations of interests

The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs. No additional declarations of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.


The minutes of the meeting held on 24 October 2017 were agreed.

1.3 Matters Arising Action Log 10.0 Quality risk register-The Diabetic Charcot pathway report was

planned for the February meeting. Action open

JH

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5.0 Mandatory training Adult Safeguarding- LW was being asked for a list of the CDs who had not completed the training. It was noted that the training was part of the GP’s annual appraisal and the practices used Blue-stream but not Actus and may have already completed the training. RG did not believe he had been asked to complete anything other than IG modules. MGC would investigate further and attempt to collate and validate what had been completed. Action Open. 11.0 Domestic Violence abuse Policy- this action was completed. Action closed. 12.0 Primary Care SI Report- GS/SE would discuss whether this awaited report could be circulated before the next meeting. Action open. 14.1 Committee Attendance- Since the last meeting there had been a useful discussion with CDs on their portfolios, which had been refreshed to match interest/capacity. A flexible approach to representing the BHR CCGs was agreed which would assist achieving a quorum. SH added that a pre-meet may be useful and early sighting of any large reports to enable constructive discussion of agenda items. GS added that earlier exposure to members of key issues would be helpful to improve being better informed to be able to reach formal agreement at the meetings. It was likely that Tuesdays would remain the Committee date as the corporate day, Thursday would be too time limited and the chosen 2017/18 meeting dates would be confirmed at the next meeting. 14.2 CAMHS- MT had raised CAMHS access issues at IJEC and new investment was noted. Details would be circulated to Members. Action Closed.

MGC/LW GS/SE SE

1.4 Concordia Clinical Harm Review

An update was provided on the one patient identified in the review where it was not clear whether there was missed pathology or risk of clinical harm. Of concern was the difficulty both the diagnostic company and the CCG had in communicating with the practice but there had been some long term sickness there. The practice had now reviewed the patient records and had forwarded a report listing the chronology of events. From that review it was clear the patient did not have cancer but had other long-term health issues and had received regular tests and monitoring over the last 2 years. The Committee were satisfied that the enquiries could now be closed.

2.0 Revised Terms of Reference

There were draft changes to the TOR that included changes to Committee membership. There had been a review of CD portfolios and areas of interest and 4 CDs had been appointed to the Committee. Dr Heyes and Dr. Bhatia from Redbridge, Dr Hara and Dr Rai from B& D CCG with no CDs from Havering. Those four CDs would represent all three CCGs and their quorum would be 2 in attendance of the 4. The Executive Director of Delivery and Performance and a Lay Member had also been added. The draft was agreed and would be ratified at the next GB meeting. The frequency of meetings was under discussion due to agenda size and MP would be asked for an opinion.

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GS proposed that CQUINs for the 2018/19 contracts appear on the next agenda.SH questioned whether there was an opportunity for local shaping at the Committee e.g. smoking cessation and opportunity for joined up approach across providers. SH raised the ‘advice and guidance’ service from secondary care consultants, specialties as yet unspecified, and ask for an update next time. SE would arrange some FAQs to be circulated (from Graham Dougall).

JH SE

3.0 Primary Care SI Final report- In the absence of the Nurse Director this report was not available and

item was postponed to the next meeting.

JH

4.0 Quality Impact Assessment (QIA) process In the absence of the Nurse Director this report was not available and

item was postponed to the next meeting. JH

5.0 Meadow Court assurance report This report followed a GB decision to discontinue with the contract for beds

at Meadow Court as those that currently reside there can be safely and appropriately cared for in other homes and the contract with Care UK no longer represented value for money. Before that time a small number of residents and their families chose not to wait for the decision and transferred to other providers. The CCG had been informed that subsequently two of these residents had died and suggestions made this could have related to the move. As a result of the concerns raised an investigation was held to determine if there were any safeguarding issues. It was found that there was no evidence to support the opinion, with two different providers involved, both residents assessed by the new providers prior to transfer. One resident was assessed as requiring end of life care and the other a long history of UTI, which subsequently led to his death. Meadow Court did not halt either transfer on the grounds of the residents being too unwell to move. Nor did the new providers refuse to accept admission. The author of the review concluded that they could not find any definitive links with the deaths and the transfer. It was noted the reviews described above were preceded by a literature review of research that focused on links between transfer and increased mortality. There was a generalised view that moving was stressful for any age group and a view expressed that with older people it carried a risk to life and health, but this has not been quantified. The report concluded with some recommendations for all future transfers between care providers. It was acknowledged there were systems in place but the CCG recommendations would add clear and documented requirements. GS added that this had been a difficult decision for the GB to take, noting for families this was a known and trusted environment. SH added that she understood that there were 9 patients remaining in the 48 beds paid for and the provider had offered no flex. The Committee in agreeing the report requested that the fitness to move assessment be held no earlier than 7 days prior to transfer and if the GP,

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old or new provider, had concerns this needed to be discussed to form the judgement.

6.0 Nursing Homes Quality Assurance This matter was raised at the last meeting and new arrangements outlined.

MGC added that a Care Home with Nursing Strategy had been developed and agreed at a previous Q&S Committee. Discussions are now taking place with colleagues within Planned Care, Unplanned Care and Individualised Care teams to agree how the detail of the strategy will be taken forward.

7.0 BHRUT SI-Child Death Review SE provided a brief update on a child death from asthma and advised that

a round table event was due shortly. There would be investigation through the GP, school and family. There would be work with parents, pharmacies and schools around asthma treatment techniques and raising awareness. There was much being done through a multi-faceted approach and a HLP single asthma plan being developed. Newly diagnosed cases would have a care plan and available through a phone app. RG raised the childhood asthma care pathway and the national issue of over-use of inhalers and BK added that training was provided but would need to be updated following receipt of new NICE guidelines. BK would add something to the GP Newsletter. SH added that children with parents living apart and also using inhalers at school were difficult to monitor and could be a risk. SE would provide a further update in March.

SE

8.0 PELC Safeguarding Review assurance report The report outlined how BHR, WF, West Essex as commissioners

requested assurance on safeguarding from PELC. There had been some concerns raised on the quality of reporting and data/narrative match. The CCGs conducted a review of PELC policies and procedures training and reporting. The review was conducted by the designated professionals for both adults and children and was ross-referenced with legislation and guidance. The review led to a commentary to PELC and recommendations CCG staff had attended the PELC CQRM. The response by PELC was provided and the next steps would include monitoring of the PELC action Plan before it could be closed. Reporting would continue to the SAC. The outcome of the review and next steps were noted.

9.0 London Ambulance Service assurance report The assurance report was noted.

10.0 Mortality progress assurance report In the absence of the Nurse Director this report was not available and item

was postponed to the next meeting and the Chair asked to be copied in to a report when ready if before the next meeting.

JH

11.0 Housebound flu vaccination planning SH had raised the issue again of a late business plan each year for

housebound flu vaccinations carried out by practice nurses. It was

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understood that the funding was not known until after the winter and those vulnerable group could be late in being protected and could lead to quality and safety issues. Whilst many of our GPs adopt best practice and proceed to administer the flu jab at the practice expense, SH was hearing that this good-will was becoming exhausted. It was agreed this would be added to the Committee planner for raising earlier this year in July.

AW

12.0 Quality Strategy implementation briefing In the absence of the Nurse Director this report was not available and item

was postponed to the next meeting. JH would be asked to email a briefing between meetings if there was anything to report before February.

JH

13.0 Any Other Business There was no other business.

The Chair, on behalf of the Committee wished to record the Committee’s thanks to Gina Shakespeare and Erin Brennan-Douglas for their input, noting this was their last meeting as they were leaving in December.

14.0 Items for information 14.1 Safeguarding Assurance minutes of 15 November were noted

14.2 BHRUT SI Panel meeting minutes of 16 October were noted 14.3 NELFT SI Panel meeting minutes of 18 October were noted. 14.4 BHRUT CQRM Minutes of 13 November were noted 14.5 NELFT CQRM minutes of 15 November were noted. 14.6 WX CQRM minutes of 16 November were noted. 14.7 Q & S Committee Draft Forward Plan was noted and further additions would be made.

15.0 Next Meeting

The next meeting was arranged for 27 February 2017.

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Barking and Dagenham Patient Engagement Forum 16 November 2017 Maritime House, Barking

Attendees David Elliott Jacquie MacLeod Ken Peter Hopper Dorothy Stokes Mary Parish Christine Brand Nicholas Hurst Manisha Modhvadia (Healthwatch representative) Sahdia Warraich (lay member)

CCG staff in attendance Zoe Anderson Lima Khanom James Gregory Jeremy Kidd

Apologies Ron Wright

Items

1. SMW 1 & 2 update/overview

Zoe Anderson presented on the ‘Spending NHS money wisely’ (SMW) consultations. Decisions will be reached on SMW2 in December and the PEF will be kept informed. Fewer responses have been received from B&D residents, despite efforts being made to improve the response rate. It was suggested the CCGs look at engaging with homeless and the Roma/traveller community.

2. CCG Finance update

James Gregory presented on the financial recovery programme. The CCGs face a very challenging financial situation, needing to make savings of £55 million. B&D’s share is £15.3 million. It was suggested the CCGs look at the paper from NEFLT on bank staff, GP premises and empty space in Barking Community Hospital.

3. Jane Milligan – Single AO for NEL CCGs

A video update from Jane Milligan, single accountable officer (from 1 December 2017) was shown. Jane will attend the January joint PEF. All to consider questions they might want to ask her.

Feedback was provided that the STP community council was far too big and did not work to support the need of the group. There was too many people so it was felt that individuals could not make an impact.

4. CCG lay member’s report

Sahdia Warraich provided a verbal update.

5. Healthwatch report

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Manisha Modhvadia provided a verbal update. Healthwatch wants to find out how well they are doing and gather feedback. Links to surveys to be circulated. The Healthwatch website is also being revamped – CCG to provide content to be added.

It was suggested that Healthwatch look into the variance across boroughs for the home treatment service as part of their work into dementia services.

6. AOB

PEF to arrange a Christmas get together in December

Joint PEF – it was agreed to request a system for rotating chair for the joint PEF meetings be arranged. B&D PEF members need to consider how they prepare for the joint PEF and present a ‘united front’.

7. Next meeting

Next joint PEF meeting – January 2018 (date TBC)

Agenda items:

Jane Milligan, accountable officer for NEL CCGs Mental health transformation plan

Next B&D PEF meeting – 22 March 2018

Possible agenda items:

Care City (John Craig) Youth forum presentation and video

Action log

Action Lead

Financial recovery

Ensure patients have an explanation when they are denied CHC funding Look at paper from NEFLT on bank staff

Empty rooms in Barking Community Hospital on Thursdays

JG

Healthwatch want to find out how well they are doing and gather feedback. Share survey links with PEF members

ZA

Arrange a system for rotating chair for the joint PEF meetings ZA

Members to consider how to best manage joint PEFs to ensure B&D is well represented

All

Healthwatch to consider looking at home treatment teams as part of its work programme

MM

Feedback to ELHCP that the STP community council was far too big and did not work to support the need of that group. There were too many people so it was felt that individuals could not make an impact.

ZA

Provide language on CCG for Healthwatch’s revamped website LK

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Havering CCG Patient Engagement Forum 29 November 2017 Imperial Offices, Romford

Attendees

Anita Thomas

Pat Birch

Alan Surtees

Gwen Kirby-Dent

Richard Coleman (Lay Member) (RC)

Susan Bryant

Peter Bryant

Helena Cowin

CCG staff in attendance

Andy Strickland (AS)

Jeremy Kidd

Ellie Durie

Apologies

Peter Willing

Carole Loveday

Ian Buckmaster

Roy Carter

Jacky Danilovic

Jim Crouch

Kim Hills

Daisy Robins

Items

1. SMW 1 & 2 update/overview

Andy Strickland presented on the ‘Spending NHS money wisely’ (SMW) consultations. Decisions will be reached on SMW2 in December and the PEF will be kept informed. A larger number of responses has been received than in SMW1. GPs will receive a toolkit of the changes once decision has been made by the governing bodies. PEF member asked if asthma inhalers were included as per emails with AS. AS confirmed that they aren’t. Action: Final decisions to be cascaded to members

2. CCG Finance update

Jeremy Kidd presented on the financial recovery programme and answered members’ questions. The CCGs face a very challenging financial situation, needing to make savings of £55 million. Havering’s share is £22.3 million. Some PEF members felt that the strain on NHS finances was not the result of Havering having the largest, older population in London, but other factors.

3. Jane Milligan – Single AO for NEL CCGs

A video update from Jane Milligan, single accountable officer (from 1 December 2017) was shown. Jane will attend the January joint PEF. Action: All to consider questions they might want to ask her.

4. CCG Lay Member’s report

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The Chair, Richard Coleman, provided a verbal update on the CCG’s wider strategic work and the future within NEL and the development of accountable care. The Joint PEF echoes this direction of travel.

5. Joint PEF Several PEF members attended the Joint PEF and recognised the benefits of senior CCG and other staff being able to attend and attend one meeting instead of three. However, Havering attendees expressed concerns over personal safety and walking in Ilford at night. Action: PEF members weren’t sure what was achieved but said they would ‘persevere’.

6. Local issues

The experience of a PPG member living on the border of B&D and Havering whose son had been refused an NHS funded gym membership was raised. The issue of practice staff with challenging English language skills was raised by one member as this was impacting on her experience of primary care. Action: both issues to be picked up by CCG.

7. AOB

8. Next meeting

Next joint PEF meeting – 16 January 2018


Jane Milligan, accountable officer for NEL CCGs Referral management workstream

Next PEF meeting – March 2018 tbc


tbc

Action log

Action Lead

KGH update

Cascade latest update from ELHCP re KGH A&E

AS

Look into the Havering/B&D border issue re patient care and gym membership

AS/RC

Look into the issue of practice staff being proficient in English AS

Members to persevere with the alternate Joint PEFs and to think of questions for Jane Milligan

All

Cascade decisions of governing body re SMW2 when made AS

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