part i agenda architects company secretary for husband's company 30/10/2015 30/10/2015 dr neel...

Meeting in Public of the Camden Clinical Commissioning Group Governing Body Wednesday 9 March 2016, 13:00hr The Wesley Hotel 81-103 Euston Street London NW1 2EZ

PART I AGENDA

Item Title Sponsor Action Paper Time Page

1. Introduction 1.1 Apologies for Absence Chair Note Verbal 13:00 -

1.2 Declarations of Interest Chair Note 1.2 13:02 5

1.3 Minutes of the Previous Meeting Chair Approve 1.3 13:05 7

1.4 Actions Log Chair Note 1.4 13:08 22

2. Chair, Chief Officer, Patient and Quality Reports 2.1 Chair’s Report Chair Note 2.1 13:10 23

2.2 Chief Officer’s Report Chief Officer Note 2.2 13:15 27

2.3 The Patient Voice Report Kathy Elliott Note 2.3 13:20 33

2.4 Quality and Safety Report Jo Wickens Note 2.4 13:30 47

2.5 Quality and Safety Strategy Jo Wickens Approve 2.5 13:40 67

3. Strategy 3.1 Improving Access to Psychological

Therapies in Camden Dr Jonathan Levy Approve 3.1 13:45 95

3.2 Camden Musculoskeletal Services

Dr Lance Saker Approve 3.2 14:00 159

3.3 Camden Operating Plan 2016/17 Chief Finance Officer

Note 3.3 14:15 241

3.4 Procurement of the NCL Integrated NHS 111 and GP Out of Hours Service

Dr Burgit Curtis Note 3.4 14:25 247

4. Finance and Performance

4.1 Draft 2016/17 Budget

Chief Finance Officer

Approve 4.1 14:30 267

4.2 Finance Report Chief Finance Officer

Note 4.2 14:40 275

4.3 Performance Report Chief Finance Officer

Note 4.3 14:45 289

4.4 Business Plan Report

Chief Officer Note 4.4 14:55 321

5. Governance

5.1 Localities Report Locality Leads Note 5.1 15:00 351

5.2 Board Assurance Framework Ellen Schroder Review 5.1 15:05 355

5.3 Information Governance Report Ellen Schroder Note 5.3 15:15 365

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5.4 Quality and Safety Committee –

Terms of Reference Jo Wickens Approve 5.4 15:20 369

5.5 Out of Hospital Strategic Board – Terms of Reference

Dr Lance Saker Approve 5.5 15:25 377

6. Committee Reports

6.1 Audit Committee Ellen Schroder Note 6.1 15:30 383

6.2 Commissioning Committee Dr Neel Gupta Note 6.2 15:33 387

6.3 Finance and Performance Committee Dr Ammara Hughes

Note 6.3 15:36 391

6.4 Health and Wellbeing Board

Director of Public Health

Note 6.4 15:39 395

6.5 Procurement Committee

Ellen Schroder Note 6.5 15:42 399

7. Any other Business

7.1 Draft Agenda May 2016 meeting Chair Note 7.1 15:45 401

8. Section B Committee Minutes For information

8.1 Audit, meeting of 30/09/2015 403

8.2 Commissioning, meeting of 16/12/20015 and 27/01/2016

411

8.3 Finance and Performance, meeting of 02/12/2015 and 13/01/2016

428

9. Questions from the Public Chair Verbal 15:50 -

NB: Members of the public are now given the opportunity to ask questions. These must relate to items that are on the agenda for this meeting and should not take longer than three minutes per person.

10. Date of Future Meetings

11 May 2016 1:00pm – 4:00pm

REGISTER OF INTERESTS A register of members’ interests is available on the Camden CCG website

http://www.camdenccg.nhs.uk/publications/camden-ccg-board-register-of-interests

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Ellen Schroder Vice Chair

Dr Caz SayerChair

Dorothy Blundell Chief Officer

Tyrieana LongBoard Secretary

Ian Porter Assistant Director

Corporate Services

Ian Boyle Chief Finance Officer

Dr Matthew Clark Secondary Care Clinician

Dr Ammara Hughes GP

Dr Lance Saker GP Clinical Vice Chair

Judith Hunt OBE Lay Member

Jane Davis OBE Registered Nurse

Dr Martin Abbas GP

Jo Wickens Practice Nurse

Dr Neel Gupta GP

Neeshma Shah Director Quality and Clinical Effectiveness

Kathy Elliott Lay Member

Dr Birgit Curtis GP Dr Jonathan Levy GP

Susan Achmatowicz Chief Operating Officer

Julie Billett Director of

Public Health

Cllr Sally Gimson Health and Wellbeing Board

Observer

Saloni Thakrar Patient Representative

Claire Chalmers-Watson LMC Observer

Rosemary Westbrook Local Authority Representative

Dr Connie Smith Healthwatch

Representative

Mike Cooke Chief Executive Camden

Council

Simone Hensby Voluntary Action Camden

Charlotte Mullins Director of Sustainable Insights

Gleny Lovell Chief of Staff

Sally MacKinnon Transformation

Programme Director

Presenter Presenter

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Working with the people of Camden to achieve the best health for all

Camden's Vision,

Mission and Values

Vision statement 'Working with the people of Camden to achieve the best health for all.' Values • Honesty • Integrity • Courage • Patient-sighted • Competency •Transparency • Collaboration • Adherence to NHS founding principles Vision/Mission (from 2014 AGM) 1. The emphasis of the NHS will have shifted: • Developing a systematic approach to prevention • Earlier diagnosis of disease • Reducing inequalities in health outcomes targeting vulnerable groups • Encouraging individuals to take greater responsibility for their health • Supporting self-management of illness 2. All patients will experience: • Compassionate, high quality, effective and efficient care pathways shaped by them • Care that is integrated and focussed around delivery of outcomes defined by them • Easy access to services delivered in ways and places convenient to them 3. For integration of care to be driven by: • Shared digital record for clinical records, data sharing, measurement and evaluation • Services to be commissioned and contracted in ways that drive partnership and integration 4. Long-term financial sustainability will be achieved by: • Clinically-driven focus on the quality of services • Delivery of effective (evidence-based) and efficient (right first time care) with savings achieved through cutting the 'cost of chaos’

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NAME TITLE NAME OF ORGANISATION AND NATURE OF ITS BUSINESS

POSITION HELD / NATURE OF INTEREST DATE DECLARED

DATE UPDATED

Haverstock Healthcare Ltd Swiss Cottage Surgery is a shareholder in Haverstock Healthcare Ltd 24/06/2014 02/10/2015

Swiss Cottage Surgery GP Principal 24/06/2014 08/04/2015West Hampstead Medical Centre GP Partner 04/02/2015 30/10/2015Haverstock Healthcare Ltd West Hampstead Medical Centre is a shareholder 04/02/2015 30/10/2015Camden Clinical Assessment Service Clinical Assessor 04/02/2015 30/10/2015KCA Architects Company Secretary for husband's company 30/10/2015 30/10/2015

Dr Neel Gupta Elected GP Representative The Keats Group Practice Salaried GP, no other interests declared. 01/09/2014 16/03/2015

Dr Ammara Hughes Elected GP Representative Bloomsbury Surgery Practice Partner 24/04/2013 22/04/2015

Haverstock Healthcare Ltd Bloomsbury Surgery Practice is a shareholder in Haverstock Healthcare Ltd

24/04/2013 22/04/2015

University College London Hospitals NHS Foundation Trust

Governor 11/11/2015

James Wigg Practice GP Partner 11/08/2014 18/03/2015

Haverstock Healthcare Ltd James Wigg Practice is a shareholder in Haverstock Healthcare Ltd 11/08/2014 18/03/2015

Dr Lance Saker Elected GP Representative Camden and Islington Local Authority Consultant in Public Health 02/04/2013 20/03/2015Hampstead Group Practice Salaried GP 02/04/2013 20/03/2015

Adelaide Medical Centre Partner 23/04/2013 08/04/2015

Haverstock Healthcare Ltd Adelaide Medical Centre is a shareholder 23/04/2013 08/04/2015

St. Mary's Hospital, W3 Husband (Huw Thomas) is a Consultant Physician 23/04/2013 08/04/2015

Joanne Wickens Elected Practice Nurse Representative

Bloomsbury Medical Centre - Camden CCG Member Practice

Employee - Nurse Practitioner 14/03/2013 02/09/2015

Julie Billett Director of Public Health Camden and Islington No interests declared 18/03/2013 16/03/2015Dorothy Blundell Chief Officer Camden CCG No interests declared 18/03/2014 17/04/2015Ian Boyle Chief Finance Officer Near Reality Training (NLT) Ltd Director and Minority Shareholder in Training Provider (East Midlands) 22/12/2015

Newham Hospital, part of Barts Health Paediatric Registrar 05/07/2014 07/04/2015The Portland Hospital Occasional Resident Medical Officer 05/07/2014 07/04/2015Welbodi Partnership - registered UK charity working in Sierra Leone

Chairman 05/07/2014 07/04/2015

Jane Davis OBE Registered Nurse Nursing and Midwifery Council Registrant Panellist for the Conduct and Competence Panels 09/04/2013 15/04/2015

Camden Patient and Public Engagement Group Member 18/05/2015 27/10/2015

Caversham Group Practice Patient Participation Group

Member 18/05/2015 27/10/2015

Kaeconsulting - independent consultancy Owner/Director 18/05/2015 27/10/2015UK Public Health Register (UKPHR) Assessor and Committee Member 18/05/2015 27/10/2015Faculty of Public Health Member 18/05/2015 27/10/2015

Judith Hunt OBE Lay Member Parliament Hill School Husband is a member of its Governing Body (Daniel Silverstone) 08/10/2013 13/04/2015

United Healthcare Ltd (UK PFI companies for Buckinghamshire Hospitals)

Chair 29/04/2013 21/04/2015

CAMDEN CLINICAL COMMISSIONING GROUP GOVERNING BODY MEMBERS' REGISTER OF INTERESTS 2016

Elected Voting Members

Dr Caroline Sayer Chair

Appointed Voting Members

Dr Martin Abbas Elected GP Representative

Dr Birgit Curtis Elected GP Representative

Dr Jonathan Levy Elected GP Representative

Dr Matthew Clark Secondary Care Clinician

Kathy Elliott Lay Member

Ellen Schroder Lay Member and Chair of Audit Committee

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NAME TITLE NAME OF ORGANISATION AND NATURE OF ITS BUSINESS

POSITION HELD / NATURE OF INTEREST DATE DECLARED

DATE UPDATED

Prostate Cancer Research Centre Husband (Tim Schroder) is Chair 29/04/2013 21/04/2015

Great Ormond Street Hospital Co-Chair, Clinical Ethics Committee 11/11/2015

Imperial College Healthcare NHS Trust Chair, Organ Donation Committee 29/04/2013 21/04/2015

Schroder Charity Trust Husband (Tim Schroder) is Trustee 29/04/2013 21/04/2015

Radcliffe Trust Charity Trustee 21/04/2015 21/04/2015

Camden Local Medical Committee Chair 25/04/2013 05/05/2015Parliament Hill Surgery GP 25/04/2013 05/05/2015Haverstock Healthcare Ltd Parliament Hill Surgery is a Shareholder 25/04/2013 05/05/2015Dictate - a company that does dictation outsourcing

Shareholder 25/04/2013 05/05/2015

Councillor Sally Gimson Health and Wellbeing Board Observer Governor Parliament Hill School 16/09/2015 16/09/2015

Member of Unison and Unite Unions 16/09/2015 16/09/2015Member of Co-operative Party 16/09/2015 16/09/2015

Simone Hensby Voluntary Action Camden Voluntary Action Camden Chief Executive 13/05/2013 16/04/2015Dr Connie Smith Healthwatch Representative Camden Healthwatch Chair of the Trustees for Healthwatch Camden. 26/03/2014 17/03/2015

Chomley Garden Surgery Practice Patient Participation Group

Representative 06/01/2016

Camden Patient and Public Engagement Group Co-Chair 06/01/2016

Camden Healthwatch Trustee 06/01/2016

UK National Thalassemia and Sickle Cell Group (NHS England)

Lay Member 06/01/2016

UK National Antenatal Screening Working Group (NHS England)

Lay Member 06/01/2016

NHS Health Checks Steering Group Camden Lay Member 06/01/2016

North East London and Tower Hamlets CCG Prescribing Adviser - Independent Contractor working 1 or 2 days per week

06/01/2016

Rosemary Westbrook Camden Local Authority Representative Director for Housing and Adult Social Care No interests declared 08/04/2014 17/03/2015

Susan Achmatowicz Chief Operating Officer Susan A2Z Limited (Management Consultancy Owner 12/05/2015 12/08/2015Mike Cooke Chief Executive London Borough of Camden No interests declared 13/08/2015 13/08/2015Gleny Lovell Interim Chief of Staff Action against Medical Accidents (AvMA) Brother in Law is Chief Executive of AvMa 27/10/2015 27/10/2015Charlotte Mullins Director of Sustainable Insights Camden CCG No interests declared 19/03/2015 19/03/2015Ian Porter Assistant Director Corporate Services Camden CCG No interests declared 15/10/2015 15/10/2015Neeshma Shah Director of Quality and Clinical Effectiveness Independent Consultant Occasional ad hoc consultancy work on sole trader basis 24/04/2013 12/08/2015

Patient Representative Saloni Thakrar

Attendees

Cabinet Member for Adult Social Care and Health, London Borough of Camden

Ellen Schroder Lay Member and Chair of Audit Committee

Non-Voting MembersClaire Chalmers-Watson LMC Representative

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CAMDEN CLINICAL COMMISSIONING GROUP GOVERNING BODY

Minutes of the Part 1 Meeting held on Wednesday, 13 January 2016

The Wesley Hotel, 81-103 Euston Street, London, NW1 2EZ

Present: Elected Voting Members: Dr Caz Sayer Chair Dr Martin Abbas Elected GP Representative and North Locality Lead Dr Burgit Curtis Elected GP Representative and West Locality Lead Ms Pat Elliott Elected Practice Manager Dr Neel Gupta Elected GP Representative Dr Jonathan Levy Elected GP Representative and South Locality Lead Dr Lance Saker Elected GP Representative and Clinical Vice Chair Ms Jo Wickens Elected Practice Nurse Appointed Voting Members: Ms Dorothy Blundell Chief Officer, Camden CCG Ms Julie Billett Director Public Health, Camden and Islington Mr Ian Boyle Interim Chief Finance Officer, Camden CCG Dr Matthew Clark Secondary Care Clinician Ms Jane Davis OBE Registered Nurse Ms Kathy Elliott Lay Member, Public and Patient Involvement Ms Judith Hunt OBE Lay Member Ms Ellen Schroder Vice Chair and Lay Member, Governance and Audit Non-Voting Members: Councillor Sally Gimson Health and Wellbeing Observer Dr Connie Smith Healthwatch Representative Ms Saloni Thakrar Patient Representative and CPPEG Co-Chair Ms Rosemary Westbrook Local Authority Representative, London Borough of Camden In Attendance: Ms Lyndsey Abercromby Acting Director of Commissioning, Camden CCG Ms Susan Achmatowicz Interim Director of Primary Care, Camden CCG Mr Mike Cooke Chief Executive, London Borough of Camden Mr Stuart Dalton Assistant Director Corporate Services, Camden CCG Ms Ebun Eno-Amooquaye Project Manager, Camden CCG (item 3.5) Ms Debbie Hawkins Head of PMO, Camden CCG (item 4.5) Ms Tyrieana Long Board Secretary, Camden CCG Ms Gleny Lovell Interim Chief of Staff, Camden CCG Ms Charlotte Mullins Acting Director of Sustainable Insights, Camden CCG Mr Ian Porter Chief Operating Officer, Camden CCG Ms Neeshma Shah Director of Quality and Clinical Effectiveness Dr Alex Warner Mental Health Clinical Lead, Camden CCG (item 3.2) Members of the Public Frances Lefford Caversham PPG Tony Marshall Press Officer, Camden Keep our NHS Public

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1. Introduction

1.1 Apologies for Absence 1.1.1 Apologies were received from Dr Claire Chalmers-Watson, Simone Hensby and Dr Ammara

Hughes. 1.1.2 The Chair introduced and welcomed Ian Boyle, Saloni Thakrar and Lyndsey Abercromby. 1.1.3 The Chair announced that it was the last Governing Body meeting for Pat Elliott, elected

Practice Manager and Stuart Dalton who was leaving to take up a new post closer to home at Nene CCG.

1.2 Declaration of Interests 1.2.1 The Register of Interests was considered. There were no new declarations of interest. 1.2.2 The Governing Body agreed to note the Register of Interests. 1.3 Minutes of the Meeting held on 11 November 2015 1.3.1 The Governing Body considered the minutes of the meeting held on 11 November 2015 and

requested three amendments at:

1. 3.1.3 c) To read: That the breastfeeding measures and other initiatives should not be restricted to the first 1,001 days work programme.

2. 3.2.5 – To insert that there would be a measurement of the impact of the LCS contract to be developed by the Sustainable Insights Team.

3. 3.3.5 h) To read that the Commissioning Committee would review the performance improvement plan.

1.3.2 Subject to the above amendments the Governing Body agreed the minutes of the

meeting held on 1 November 2015 were a true record. 1.4 Action Log 1.4.1 The Governing Body reviewed the Action Log and noted that all actions had been

completed. 1.4.2 The Governing Body agreed to note the Action Log.

2. Chair, Chief Officer, Patient and Quality Reports

2.1 Chair’s Report 2.1.1 Dr Caz Sayer presented the Chair’s Report. The GP education events were highlighted as a

valuable resource for practices and the Chair thanked Poppy Freeman and Jo Franks for their excellent work.

2.1.2 The Chair also highlighted the feedback from Mr Peter Muller in relation to the community

epilepsy service. She thanked those involved in the new service for the very real difference that they had made.

2.1.3 The Governing Body agreed to note the Chair’s Report.

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2.2 Chief Officer’s Report 2.2.1 Dorothy Blundell introduced the Chief Officer’s Report and highlighted the continuing work of

the North Central London Programme. The Governing Body seminars would be used to provide more detailed briefing for Members.

2.2.2 The London Health Collaborative agreement had been signed. Camden CCG was involved

in the NCL estates pilot which was in the process of being scoped. It was anticipated that further information would be available at the March 2016 Governing Body meeting.

2.2.3 Dorothy Blundell advised that further to the Care Quality Commission’s report on the London

Ambulance Service, the Quality and Safety Committee would monitor the quality aspects of the service for Camden patients.

2.2.4 The Governing Body agreed to note the Chief Officer’s report. 2.3 The Patient Voice Report 2.3.1 Kathy Elliott introduced the Patient Voice Report and provided an overview of developments

since the last Governing Body meeting. These were:

a) The December 2015 CPPEG open meeting and the Camden Care Planning Ambition for patients who have long term conditions. The issues of isolation experienced by patients and carers were highlighted.

b) One third of practices had agreed to promote the benefits of the Health Advocate Programme. General Practices continued to develop relationships with local voluntary and community groups

c) Collaborative working with other organisations was highlighted as a priority area d) That the ‘You Said: We Did’ approach was working effectively e) A meeting with council staff to discuss using community researchers to collate

patient experiences of district nurse and cancer services.

2.3.2 Governing Body members:

a) Welcomed the proposal to use community researchers, digital records and tools

for the purpose of research, engagement and consultation. b) Questioned the robustness of potential sampling and whether or not the tools had

been validated. c) Noted that the community research methodology was robust and there was also a

desire to use academic expertise. d) Noted that using community researchers would create jobs within Camden and

was often a route into employment for people who had not been recently employed.

2.3.3 The Governing Body agreed to note the Patient Voice Report. 2.4 Quality and Safety Report 2.4.1 Jo Wickens presented the Quality and Safety Report and highlighted:

a) The Safeguarding Children Looked After Children Report and that the staffing

issues had been resolved b) The Safeguarding Adult audit tool and the results which were due to be considered

at the NCL Support and Challenge event in the spring.

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c) The success of the Domestic Violence Project. A request will be made to the Commissioning Committee in March 2016 to continue funding independent domestic violence advisors for another two years.

2.4.2 In response to questions raised the Governing Body:

a) Noted that the leadership concerns expressed in the Care Quality Commission’s

report in respect of the London Ambulance Service were not specific to waiting times or clinical harm.

b) Noted that further to the Referral to Treatment and Clinical Harm Review within acute services there was no evidence that patients had experienced harm as a result of waiting times. There had also been no alerts of patient harm from GPs who were notified when patients had been waiting 26 weeks for treatment. An external assurance process had been carried out at the Royal Free London.

c) Agreed that long waiting times was not satisfactory for patients and to continue pressing acute providers on waiting times

d) Noted that the leadership and accountability issues at Camden and Islington Foundation Trust (CIFT) were only in relation to safeguarding children and resource capacity.

e) Noted that there were fortnightly meetings held across North Central and East London to continually monitor waiting times and scrutinise case reviews.

f) Requested increased monitoring in relation to the increased risk for the assurance and monitoring of care homes. A lack of systematic reporting was reported as the reason for the increased risk. The quality team was working with council partners to receive the assurance data.

g) Noted that UCLH had been asked to provide a SMART infection control action plan with proposed implementation and completion dates

h) Welcomed the thoroughness of the Safeguarding Adult and Children report i) Noted that there was some variation in the number of referrals from GP practices to

the Identification and Referral to Improve Safety (IRIS) service which was not thought to be wholly related to the size of the practice. Additional investment would be used to fund GP practice training.

2.4.3 The Governing Body agreed to note the Quality and Safety Report. 2.5 Nurse Revalidation 2.5.1 Jane Davis advised the Governing Body that the Nursing and Midwifery Council (NMC) had

announced formally on 8 October 2015 that all nurses and midwives will have to revalidate to maintain their registration with the NMC to commence in April 2016.

2.5.2 The NMC statement on revalidation was shared with the Governing Body:

a) Revalidation is straightforward and will help nurses and midwives demonstrate that

they practise safely and effectively. The new process replaces the current requirements and nurses and midwives will have to revalidate every three years when they renew their place on the register

b) Revalidation builds on existing renewal requirements by introducing new elements which encourage nurses and midwives to reflect on the role of the Code in their practice and demonstrate that they are ‘living’ the standards set out within it.

c) Whilst revalidation is the responsibility of the healthcare professional, employers have a key role in helping to provide supportive environments and resources to ensure staff successfully revalidate and are registered to work in your settings.

d) Revalidation will help to encourage a culture of sharing, reflection and improvement amongst nurses and midwives and will be a continuous process that nurses and midwives will have to engage with throughout their career. It will allow nurses and midwives to demonstrate that they practice safely and effectively, strengthening public confidence in the nursing and midwifery professions.

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e) Revalidation is about promoting good practice across the whole population of nurses and midwives. It’s not an assessment of a nurse or midwife’s fitness to practise.

2.5.3 Jane Davis confirmed that the CCG had highlighted the requirement for revalidation at the

Care Quality Review Groups and would continue to seek assurance on nursing services at GP meetings and for services commissioned by Camden CCG. Two revalidation workshops had been held for Camden practice nurses.

2.5.4 The Governing Body welcomed the announcement and noted that locum nurses and

those employed by agencies would also be subject to revalidation.

3. Strategy

3.1 Primary Care Commissioning Intentions and the Primary Medical Services Review 3.1.1

The Chair invited Stuart Dalton to provide assurance on the management of conflicts of interest and adherence to the NHS England Statutory Guidance for the Governing Body and members of the public.

3.1.2 Stuart Dalton advised that it was appropriate for GPs to remain in the meeting for the

discussion on primary care commissioning intentions, in recognition that the CCG was a clinically led organisation and because no decisions were being made. The NCL Joint Committee would approve the long term primary care commissioning intentions.

3.1.3 Dr Neel Gupta introduced the paper and confirmed that since November 2015 the CCG was

a joint commissioner of primary care. Under the new primary care co-commissioning arrangements NHS England is leading a nationwide review of its Primary Medical Services (PMS) contracts with GPs. As part of the PMS contract review process, a set of primary care commissioning developments will be developed for 2016/17.

3.1.4 Dr Gupta confirmed that the purpose of the PMS review was to ensure that the funding is

aligned to services which best meet the needs of the local population and to reinvest PMS funds more effectively into GP services across Camden where there were gaps. He emphasised that no funding would leave Camden.

3.1.5 In December 2015 NHS England published new service requirements for PMS practices

which contained a number of key performance indicators (KPIs), including minimum standards and both mandatory and optional indicators. London CCGs have been requested to confirm by 16 February 2016 the range of KPIs which will form the basis of the commissioning intentions for PMS practices.

3.1.6 The initial financial implications of delivering the PMS contracts were highlighted as

described on page 63. Further financial modelling was expected to take place in the next two months.

3.1.7 The Governing Body:

a) Recognised the role of primary care in the Out of Hospital Strategy and the

importance of the PMS contract review process b) Noted that NHS England was the holder of the PMS contracts. The CCG’s role was

to shape the primary care services for the Camden population c) Noted that there were 15 Camden practices with a PMS contract. The CCG was

supporting practices with the review process but would not be involved in the contract negotiations

d) Noted that the NHS England offer was for all of London and provided a consistent approach.

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e) Noted the short timeline and key milestones. The review was due to be completed by 1 July 2016.

f) Noted that there was a difference in the funding arrangements for PMS and General Medical Services (GMS) contracts. PMS contacts provide greater flexibility to respond to local patients’ needs which attracts premium funding.

g) Noted that stakeholder engagement was taking place and that the commissioning strategy from the data that had been gathered was in the early stages of development.

h) Acknowledged that the communications around the PMS Review could have been better and that patients would need to be assured about any negative financial implications for Camden practices. The potential risk of de-stabilising general practices was acknowledged.

i) Recognised the lack of clarity regarding the PMS contract review and requested a paper on how the CCG supports primary care in its entirety, including financial information. The purpose of the document will be to provide greater clarity and address patient and member practice anxieties. Action 1: Susan Achmatowicz to provide a paper at the March Governing Body meeting.

3.1.8 The Governing Body agreed to note:

a) progress on developing a set of commissioning intentions for 2016/17 as part of the Primary Medical Services review process and

b) the required next steps in the PMS review, including CCG plans for further engagement with member practices and other key stakeholders throughout the review period to July 2016.

3.2 Value Based Commissioning for People Living with Psychosis 3.2.1 Further to the discussion at the September 2015 Governing Body meeting, Dr Jonathan Levy

presented an update paper on the value based commissioning (VBC) approach for people living with psychosis in Islington and Camden. The paper confirmed the outcome of the Provider Assurance Process and the detailed work undertaken to develop contract terms and establish an incentives framework.

3.2.2 With regard to the Provider Assurance Process, Dr Levy advised that the evaluation panel

recommended the appointment of Camden and Islington NHS Foundation Trust as the Lead Provider. The panel as particularly impressed by the Trust’s vision for the VBC model, demand management and cost containment.

3.2.3 With regard to the outcomes that had been developed to be incentivised and monitored

these were described and highlighted at Appendix 2. A composite measure for hospital admission rates had been developed with the support of the Sustainable Insight team.

3.2.4 Further to the request made at the December 2015 Commissioning Committee, Dr Levy

advised that gateways would be built into the contract negotiations. 3.2.5 The Chair thanked Dr Alex Warner and all those involved in developing the innovative and

new VBC approach which was expected to improve outcomes for patients living with psychosis. Questions were invited from Governing Body members. .


a) Praised the work that had been achieved b) Expressed a preference to incentivise outcomes to achieve improved system focus c) Identified that although the outcomes around admissions had been presented as

composite measures they were individual and separate d) Highlighted the difficulty of incentivising around hospital admissions if there was a

clear need for patients to be hospitalised e) Confirmed that it was possible to separate out the measures.

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f) Noted that although the single payment to the provider was similar to a block contract, the ability to demonstrate value for money and make a comparison of costs was possible within the contractual arrangement.

g) Noted that the majority of the contract (80%) was subject to the NHS standard contract provision. The remaining 20% was related to outcomes over the longer term.

h) Noted that the key issues raised by the Commissioning Committee had been addressed, in particular, clarification around the monitoring and incentivisation of outcome measures relating to admissions, defining a robust gateway process prior to contract signature and assurance around a detailed annual review process to determine the effectiveness of the planned approach.

i) Welcomed the outcome approach for patients. 3.2.7 The Governing Body agreed to:

a) Approve the Full Business Case considered in September 2015, including

committing the financial resource detailed in the Business Case; b) Approve the initiation of negotiations with Camden and Islington NHS Foundation

Trust as the preferred Lead Provider for the value based commissioning model for people living with psychosis;

c) Approve the preferred option presented for monitoring acute admissions without any incentive attached to these measures;

d) Noted the detailed work undertaken on contract terms in preparation for contract negotiation, and the process undertaken to link payment to outcomes and

e) Noted the principle that commissioners are not seeking to achieve savings from underperformance on outcome targets. Therefore in the event of underachievement, commissioners would seek to invest funding not paid due to underachievement, in other services that would support future achievement of the outcome. This may not necessarily be with providers formally involved in VBC.

3.2.8 Dr Neel Gupta and Dr Lance Saker voted against the preferred option for monitoring acute

admissions as described at item c) above. 3.3 Camden CCG Estates Strategy 3.3.1 Ian Boyle introduced a summary draft of the Interim Local Estates Strategy which captured

the current estate profile and examined the case for change in alignment to national NHS policies, including the Five Year Forward View. He advised that the estates plans had been requested by the Department of Health by 31 December 2015 and were in the initial stages of development.

3.3.2 The Interim Estates Strategy includes a framework to support out of hospital strategies and

the strengthening of primary care and its estate. It will also demonstrate a clear link to the wider NCL transformation work and transformation project timeframes. Community Health Partnerships will present a more detailed Estates Strategy later this month to GPs and Providers.


a) Noted the public asset overview and drivers for change b) Noted that the strategy would be shared with the public as part of the engagement

plan c) Noted that the specific practices mentioned on page 9 had been included because of

current ongoing work. Further feasibility studies would be developed d) Noted the potential for co-location of services and economies of scale.

3.3.4 The Governing Body agreed to note the summary of the Interim Local Estates

Strategy.

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3.4 Camden Musculoskeletal Service 3.4.1 Dr Lance Saker presented a provider performance update in respect of the community

Musculoskeletal (MSK) services and also some options for the Governing Body’s consideration to provide additional capacity for the community MSK Pain Assessment and Management Service (CPAMS).

3.4.2 The Governing Body agreed:

a) to note the contents of the Performance Improvement Plan and the assurance role of the Commissioning Committee in the ongoing monitoring of the plan

b) to approve option 2 to work with the existing provider (Connect) and invest an additional sum of £18,000, with £9,000 being agreed in full and the remaining £9,000 payment being contingent on the full recovery of the waiting list.

3.5 NCL Integrated Urgent Care NHS 111 and GP Out of Hours (OOH) Service Update Report 3.5.1 Dr Burgit Curtis introduced the above named report and highlighted the changes that had

been made to the NHS 111 and GP OOH service specification further to feedback from clinicians, commissioners, patients and the public.

3.5.2 With regard to the procurement process the Invitation to Tender (ITT) documents were

issued to shortlisted bidders from the pre-qualified stage on 3 December. Bids will be evaluated following closure of the ITT stage on 11 January 2016. The award criteria weighting will be based on 80% quality and 20% price.

3.5.3 Dr Matthew Clark asked about the inclusion of locally developed key performance indicators

(KPI) in the service specification. Ebun Eno-Amooquaye confirmed that a long list of KPIs had been developed and a shortlist would be drawn up by the end of February 2016 for selection.

3.5.4 The Governing Body strongly supported their approval of the KPIs to ensure that they were

focussed on quality and were workable and achievable. A specific measure on hospital admissions had been previously requested by the Governing Body.

3.5.6 The Governing Body agreed to:

a) Note the contents of the update report on the NCL Integrated Urgent Care NHS 111 and GP Out of Hours Service

b) Delegate to the Procurement Committee the review of locally developed key performance indicators, with support from the Sustainable Insight Team on the consistency of approach

c) Note that the award of the NHS 111 and GP OOH service contract to the preferred bidder would be presented at the March 2016 Governing Body meeting for approval.

d) Note that approval to award the contract to the preferred bidder would be required by all five CCG Governing Bodies prior to contract signing and mobilisation.

4. Performance and Finance

4.1 2016/17 Planning and Financial Allocations 4.1.1 Ian Boyle updated the Governing Body on the 2016/17 planning guidance and CCG

financial allocations.

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4.1.2 NHS England published the 2016/17 to 2020/21 financial allocations on 11 January 2016. The first three years are firm allocations and the remaining two years are indicative. As anticipated there has been a policy change in the allocation of funding with the adoption of a new formula. The new formula has been designed to more accurately reflect population changes and include a specific deprivation measure

4.1.3 The change in formula which has mainly resulted in increased weighting to rural areas

means that Camden will see minimal growth over the next five years. Other North Central London (NCL) CCGs will receive a greater financial allocation because their baseline position per head of population was further away from the new target that has been applied. Overall the NCL increase is below the national average in 2016/17 but above the national average in the period 2017/18 to 2020/21. Ian Boyle confirmed that the Finance and Performance Committee would consider the financial allocations in more detail.

4.1.4 With regard to this year’s planning round Ian Boyle advised that the CCG was required to

produce two separate but connected plans:

1. A five year sustainability and transformation plan (STP) and 2. A one year Operational Plan for 2016/17.

NHS England has requested that NHS organisations speed up the pace of transformation early in the New Year because they will only become sustainable if work is accelerated on prevention and care redesign.

4.1.5 The STPs are the single application and approval process for transformation funding for

2017/18 onwards. From April 2017 access to transformation funding is dependent on the credibility of the STPS. Key points for consideration will be:

The scale of the ambition The track record of progress to date The strength and unity of local partnerships The confidence in the implementation plan

The STPs will be submitted as “transformation footprints” and will need to be agreed by 29 January 2016. The development of new care models are expected to feature prominently within STPs.

4.1.6 The nine planning ‘must dos’ for local systems were outlined and confirmed in detail at page

134. In respect of the 2016/17 Operational Plans the plans will need to:

a) Reconcile finance with activity b) Demonstrate a planned contribution to efficiency savings c) Present plans to deliver the 9 must-dos d) Look at how quality and safety will be maintained and improved e) Identify and mitigate risks through a contingency plan f) Outline how they link up and support local emerging STPs

The 2016/17 Operational Plan will be regarded as year one of the five year STP.

4.1.7 In response to questions raised the Governing Body noted that:

a) There had been no specific reference to the Better Care Fund in the planning

guidance on financial allocations. However partnership working will feature in STPs. b) A meeting of all partners was due to take place on 20 January to confirm the

planning footprint c) There were large providers within NCL and a complex landscape with different

priorities within the 5 NCL CCGs

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d) The funding spread across NCL and acknowledged there were different challenges for inner London and outer London

e) There was a clear focus on efficiencies. 4.1.8 The Governing Body agreed to note the 2016/17 planning requirements and financial

allocations and to receive further updates as the planning round progresses. 4.2 Healthy London Partnership 4.2.1 Further to the discussion at the March 2015 meeting, the Governing Body received a report

on the Healthy London Partnership (HLP) which had been in place since May 2015. The report provided an update on:

Progress to date of the HLP programme Proposals for ongoing commitment to the programme and the proposed planning

process and timetables for 2016/17 and The proposed ongoing governance arrangements

4.2.2 In October 2014 the London Health Commission launched its report Better Health for

London which set out one overarching goal to transform London into the world’s healthiest major global city. Supported by ten accompanying aspirations for London where long-term progress was needed, the action required to achieve these aspirations was agreed across CCGs, NHS England London, the Greater London Authority, London Councils and Public Health England.

4.2.3 At the March 2015 meeting the Governing Body approved the development of thirteen

priority programmes, the interim London-wide programme governance arrangements and the maximum CCG transformation funding of 0.15% in 2015/16. The full progress report on the mobilisation of the thirteen programmes was provided at Appendix 1 and a six month progress report from the London Transformation Co-Chairs was provided at Appendix 2.

4.2.4 In terms of future commitment to the HLP programme, Camden CCG is being asked to

continue with an investment of 0.15% of allocation in 2016/17 and 2017/18. The planning arrangements will broadly follow the same process as previously and will be led by CCG Chief Officers.

4.2.5 With regard to the governance arrangements for the programme the Interim London

Transformation Group (ILTG) was established with wide representation across the health and social care system to provide strategic direction and to oversee programme delivery. The role of the ILTG and proposed ongoing governance arrangements were highlighted and described at page 147.

4.2.6 A programme board is now in place for each transformation programme. When considering

membership the ILTG agreed that to enable effective decision-making the membership would comprise accountable bodies and funders only, with the addition of a patient and public representative member. The draft terms of reference for the programme boards known as London Transformation Groups were supplied at Appendix 3.

4.2.7 The Governing Body agreed to:

a) Note the progress of the HLP programme to date b) Support the HLP in 2016/17 and 23017/18 including the proposed planning

process and financial assumptions c) The proposed ongoing governance arrangements.

4.3 Finance Report

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4.3.1 Ian Boyle introduced the month 7 Finance Report which had been considered at the December 2015 meeting of the Finance and Performance Committee. He advised that the CCG was on track to deliver the £8m control surplus as set out in the operating plan. QIPP performance was marginally behind plan by £300k at month 7. It was anticipated that the shortfall would be realised by the end of the financial year.

4.3.2 Ian Boyle advised that the Finance and Performance Committee had considered the month

8 position that morning and confirmed that the CCG was still on target to deliver the £8m surplus and QIPP efficiency savings.

4.3.3 In response to a question from Dr Matthew Clark about the £300k underspend in acute

expenditure, Ian Boyle advised that there was ongoing dialogue with regard to the processes and scope of where the underspend could be re-invested. He agreed to discuss in more detail outside of the meeting.

4.3.4 The Governing Body agreed to note the month 7 Finance Report. 4.4 Performance Report 4.4.1 The Chair welcomed and thanked Dorothy Blundell, Ian Boyle and Ammara Hughes for the

new format of the Performance Report. Ian Boyle requested feedback from members on the appropriateness of the detail and length of the report. He advised that he planned to integrate the Performance Report with the Finance Report.

4.4.2 As confirmed in the report’s executive summary there were two areas of good performance:

1. The 18 weeks referral to treatment (RTT) incomplete pathway and 2. The 31 day cancer wait subsequent treatment – chemotherapy and radiotherapy.

4.4.3 The areas of challenging performance were:

6 week diagnostic waits with a year to date (YTD) position of 97.2% against the target of 99%

Cancer Performance – The overall CCG position was reported as compliant with 5 of the 8 national standards being met. Performance at University College London Hospitals (UCLH) was a concern with 6 of 8 targets not being met

Improving Access to Psychological Therapies (IAPT) – The CCG was achieving the 6 week and 18 week waiting time targets. The access to service and moving to recovery indicators were below target.

A&E – The YTD CCG position is compliant with the 4 hours wait target. UCLH performance remains a key risk and a more ambitious recovery trajectory was put in place with the approval of NHS England.

London Ambulance Service (LAS) – The YTD position for both response times is below target. North Central London CCGs are taking a much more ‘hands on’ approach with the LAS contract which is managed by Brent CCG.

4.4.4 With regard to quality there had been no reported cases of MRSA in month and the number

of C-Diff cases had decreased to 8. In October the number of mixed sex accommodation breaches had increased to 6. No patient safety concerns had been raised.

4.4.5 In response to a question from Dr Connie Smith about cancer performance, Ian Boyle

confirmed that the patient choice figures (89) quoted at page 8 were threshold numbers and were not designed to form part of the total number of breaches for the 2 week GP referral rate. Nevertheless the patient choice total was highlighted as being a high number of affected patients.

4.4.5 The Governing Body agreed to note the Performance Report and the actions being taken to

improve performance against the NHS constitutional and national targets.

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4.5 Business Plan Update Report 4.5.1 Dorothy Blundell introduced the above named report and thanked Debbie Hawkins and the

PMO team for the progress update on the achievement of Business Plan objectives. 4.5.2 Further to the launch of the Business Plan in July 2015, progress had been made across all

8 strategic objectives. Of the 53 live initiatives, 27 were progressing according to plan and 26 potentially required additional action and were rated as amber. The report contained a detailed update for all amber initiatives.

4.5.3 As described in the report two initiatives will no longer be reported as part of the Business

Plan as they are part of the wider NCL Programme and Strategic Planning. 4.5.4 The Governing Body:

a) Noted the higher volume of initiatives linked to strategic objectives C and D and that

this was reflective of the CCG’s strategic aim to improve health outcomes, address inequalities and integrate and enable local services to deliver the right care in the right setting

b) Noted there were fewer initiatives linked to strategic objective E but that they did not reflect all the CCG’s patient and public engagement activity

c) Noted the NHS England assurance with regard to the CCG’s public and patient involvement. The CPPEG elections, the patient representation within the CCG’s committee structure and increased lay member representation were cited as examples.

d) Requested further information on how initiatives were progressing in order to understand the detail behind the blue, green, amber and red status.

4.5.5 The Governing Body agreed to note the Business Plan Update Report.

5. Governance

5.1a Localities Report; 5.1.1a The Governing Body noted the summary of items discussed at the December 2015 locality

meetings. 5.1.2a The Governing Body agreed to note the Localities Report. 5.1b Locality Representation 5.1.1b Further to a reorganisation of duties of Governing Body members in October 2015, a

proposal was made to change the Governing Body Locality Lead Representatives to assist with succession plan and to take the opportunity to maximise member skills and interests.

5.1.2b The proposed changes are:

Position Current Representative Proposed Representative North Locality Representative Dr Lance Saker Dr Martin Abbas South Locality Representative Dr Ammara Hughes Dr Jonathan Levy West Locality Representative Dr Martin Abbas Dr Birgit Curtis

5.1.3b Member practices voted in favour of the change in Locality Leads in December 2015. The

Governing Body was asked to vote on the proposed change in line with the constitutional requirements.

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5.1.4b The Governing Body agreed to the above changes to Locality Lead Representatives by a unanimous vote.

5.2 Corporate Risk Register 5.2.1 The Governing Body reviewed the Corporate Risk Register which had been recently

updated. Two new risks had been added and 6 risks were proposed for renewal. 5.2.2 The Governing Body discussed the risks and agreed:

That risk 204 should remain on the Risk Register until the strategy is agreed To add a new risk in the event of not being able to agree the Sustainability and

Transformation Plan Action 2 : Stuart Dalton The risk of clinical harm for patients affected by poor waiting time performance could

remain on the Directorate Risk Register which was subject to scrutiny by the Audit Committee

5.2.3 The Governing Body agreed to note the Corporate Risk Register. 5.3 2016 Equality Information Report 5.3.1 Judith Hunt introduced the 2016 Equality Information Report which was the CCG’s fourth

report and more detailed than previously. The report confirms how Camden CCG has performed in meeting its legal duties set out in the 2010 Equality Act and the 1998 Human Rights Act, through the implementation of the Equality Delivery System 2 (EDS2) and the Workforce Race Equality Standard (WRES).

5.3.2 The Governing Body’s attention was drawn to page 12 of the report which set out how the

CCG complies with the Public Sector Equality Duty with the aim of embedding equality and diversity in all CCG activity, rather than just merely complying with the legislative requirements. Judith Hunt recommended that the Governing Body consider the report in detail and think about what else that could be done to help diverse communities at a Governing Body seminar.

5.3.3 The Chair thanked Emdad Haque, Equality and Diversity Manager for the comprehensive

report and agreed with the recommendation to devote time at a Governing Body seminar on equality matters. Action 3: Board Secretary to add to forward planner.

5.3.4 The Governing Body agreed to approve the 2016 Equality Information Report to be

published on 31 January 2016. 5.4 Commissioning Committee Terms of Reference 5.4.1 Neel Gupta introduced the above terms of reference which had been revised to reflect the

establishment of the Clinical Cabinet and its role to make recommendations to the Commissioning Committee on new and existing clinical pathways

5.4.2 The Chair requested that the Finance and Performance Chair was added to the Committee’s

membership with observer only status. 5.4.3 The Governing Body agreed to approve the revised terms of reference for the

Commissioning Committee. 5.5 Finance and Performance Terms of Reference 5.5.1 Ian Boyle introduced the above terms of reference which had been reviewed and updated to

reflect membership changes and also some minor amendments as described in the paper.

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5.5.2 Ellen Schroder highlighted that the quorum requirements included two elected members with only three elected members to draw from within the Committee’s membership. Ian Boyle noted that could be problematical and advised that the Committee would look at the quorum requirements again.

5.5.3 The Governing Body agreed to approve the revised terms of reference for the Finance

and Performance Committee. 6. Committee Reports

6.1 Commissioning Committee Report 6.1.1 Dr Neel Gupta introduced the above named report and highlighted the outline business case

for the development of a new Belsize Priory Health Centre to replace the existing facility. He advised that it was part of the CCG’s wider estates strategy.

6.1.2 The Governing Body agreed to note the Commissioning Committee report. 6.2 Finance and Performance Committee Report 6.2.1 The above report was taken as read. 6.2.2 The Governing Body agreed to note the Finance and Performance Committee report. 6.3 North Central London (NCL) Collaboration Board Report 6.3.1 The above report was taken as read 6.3.2 The Governing Body agreed to note the NCL Collaboration Board Report. 6.4 Procurement Committee 6.4.1 Ellen Schroder introduced the above named report and highlighted from the report that

Haverstock Healthcare will not issue dividends to its shareholders. 6.4.2 The Governing Body agreed to note the Procurement Committee Report.

7. Any Other Business

7.1 Draft March 2016 meeting agenda 7.1.1 The Governing Body agreed to note the planned items for the March 2016 Governing

Body agenda.

8. Committee Minutes

8.1 The Governing Body AGREED to note the approved committee minutes as listed on

the agenda.

9. Questions from the Public

9.1 Tony Marshall enquired about the number of bids had been shortlisted as part of the NHS

111 and GP Out of Hours procurement process.

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9.1.2 Dorothy Blundell advised that the CCG did not have that information. The bids were due to be evaluated following closure of the invitation to tender stage and due process would follow.

9.1.3 Frances Lefford asked about the patient representation on the NCL Joint Committee and

further details about the community researchers mentioned in the Patient Voice Report. The Chair advised that the governance arrangements for the NCL Joint Committee was still in its early stages and would come to the Governing Body for approval. The Chair asked that further information regarding the community researchers was provided outside of the meeting.

9.2 Farewell 9.2.1 On behalf of The Governing Body the Chair presented Pat Elliott with a bouquet of flowers

and paid tribute to the contribution she had made to the CCG. In particular she thanked Pat for the work she had done to develop relationships with GP Practices and Practice Managers. Her work has been widely respected and she will be sorely missed.

9.2.2 The Chair confirmed that an election would take place to fill the Governing Body Practice

Manager role in due course. 9.3 Meeting Close 9.3.1 There being no further business, the Chair closed the meeting at 15:55 These minutes are agreed to be a correct record of the Part 1 meeting of Camden Clinical Commissioning

Group held on 13 January 2016 Signed ………………………………………….. Date …………………………………

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Agenda Item: 1.4

CAMDEN CLINICAL COMMISSIONING GROUP GOVERNING BODY 2016 ACTION LOG - PART 1

Meeting Date Action

No. Action Lead Deadline Update

13 January 2016

1 Primary Care Provide a paper on how the CCG supports primary care in its entirety; to include financial information.

Susan Achmatowicz

May 2016 The Primary Care Team will provide a briefing for the Governing Body following the NHS England response to the Commissioning Intentions. The outcome will shape the future financial picture for primary care.

13 January 2016

2 Corporate Risk Register To add a new risk in the event of not being able to agree the Sustainability and Transformation Plan.

Stuart Dalton March 2016 A risk owner has been assigned and the risk is being monitored.

13 January 2016

3 Equality Report Schedule a Governing Body seminar to discuss the equality duty.

Board Secretary March 2016 Completed. A seminar has been arranged on 23 March 2016.

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Camden Clinical Commissioning Group Governing Body Meeting 9 March 2016

Report Title Chair’s Report Agenda Item 2.1 Date 25/02/2016

Lead Director N/A Tel/Email Report Author Dr Caz Sayer, Chair Tel/Email [email protected] GB Sponsor(s) (where applicable)

Tel/Email

Report Summary

The purpose of this report is to highlight the Chair’s business activities and to provide an update on key areas of work.

Purpose (tick one box only)

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of this report.

Strategic Objectives Links

The Chair’s business activities are linked to all of the CCG’s strategic objectives.

Identified Risks and Risk Management Actions

Where applicable any risks are identified within the report.

Conflicts of Interest

None

Resource Implications

Not applicable.

Engagement

Engagement activities are contained with the report.

Equality Impact Analysis

There are no equality impacts arising from this report.

Report History

The Chair’s Report is a standing item on the Governing Body agenda.

Next Steps None

Appendices

None

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1. Introduction

This is my regular written report to the Governing Body. The aim of the report is to update members on the business that I undertake on behalf of the CCG and to highlight key areas of work.

2. Announcements

I wish to confirm that Ellen Schroder will be departing Camden Clinical Commissioning Group at the end of March to take up a new role as Chair of the East and North Hertfordshire NHS Trust. We will be extremely sorry to see Ellen leave us but we congratulate her on her new appointment.

Ellen helped to steer us through our authorisation process and has chaired our Audit Committee since we formed Camden CCG, as well as making invaluable contributions to our procurement, governance, finance and performance work during her time here. As a respected and trusted member of our Governing Body, Ellen has built strong partnerships with peers across Camden and NCL commissioner and provider organisations.

I wish to extend my personal thanks and that of the CCG to Ellen and wish her all the best in the future. Executive Team Following a period of recruitment, I would like to welcome our new Executive Team members. We now have a permanent Executive Team in place and I very much look forward to working with them as we work together to achieve our strategic business objectives.

3. Practice Manager Elections

The process to elect a new Practice Manager began on 2 February 2016 and will be overseen by the LMC in line with our Constitution.

Following the nominations and selection process the ballot is expected to run from Monday 2 May to Friday 27 May 2016, with the result being ratified at the July 2016 Governing Body meeting.

4. Meetings and Visits

NCL Transformation Programme Board

The second Transformation Programme Board meeting was held on 24 February, to share the draft Clinical Case for Change and emerging themes for the overall case for change.

Governing Body Away Day

This session focused on learning from 2015/16 and the key achievements and challenges that we have experienced. Leading on from this we looked at the year-ahead and our approach to tackling gaps in the five year forward view (5YFV) covering health and wellbeing, care and quality and financial sustainability.

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5. Celebrating Success We have been working in partnership with local health and social care providers to develop the Camden Integrated Digital Record (CIDR), which launched in January. CIDR combines health and social care data from a range of providers across Camden. This is an important milestone for us as creating a digital record that combines data, offers people in Camden a number of benefits, including: improved safety of care, improved care experience and increased data accuracy. The CIDR team has been out training Camden GP practices over the last few months, and providing staff with information to help them discuss CIDR with their patients.

Another fantastic achievement has been the launch of our new GP website. The site went live in January and offers user improved functionality and a number of new features. So far it is attracting around 100 visits per day and feedback has been very positive, with comments about the site being easy to use and a good step up from the old version. The Quality and Safety Strategy has now been developed and is coming to the March Governing Body meeting for approval. The Strategy will put quality at the heart of all our commissioning and builds upon the structures and processes already embedded within the CCG to enable us to enhance and strengthen quality and safety through its implementation over the next three years. The barbers’ mental health initiative enjoyed regional and national publicity during February, featuring on the One Show and BBC London news. This is one of many innovative new projects aimed at improving how we engage with hard to reach groups on mental health issues. The ‘black barbers’ and other important community groups, including Bangladeshi Imams, have been trained to give mental health first aid. We have also joined forces with Muslim health professionals who provide advice within the community. We are also supporting a targeted mental health campaign aimed at reaching out to Irish women. The Sustainable Insights Team presented at two national conferences recently about Redesigning the Interface in Camden, which includes the embedding of Michael Porter’s value

and outcomes hierarchy work. The presentation brought the hierarchies to life using a reporting architecture for measuring outcomes, and the results chains methodology which Camden has used to measure outcomes and impact from the multiple commissioning interventions which take place. Feedback from the conference has been really positive with many CCGs wanting to visit Camden to hear more about the innovative work taking place. The Out of Hospital Strategy is being developed through a strong partnership of local providers and commissioners. To date we have agreed an outline strategy that includes: a case for change, shared outcomes, a clinical model of care and priorities for action. The partnership is working to the same timelines as the NCL Sustainability and Transformation Plan, with a first draft being available for wider consultation by the end of March 2016. The Strategy will aim to build primary and community capacity to undertake more delivery and support out of hospital. There will be a strong preventative element that will empower residents in the care of themselves and their family, more proactive diagnosis and management of conditions. This will prevent the escalation to a higher level and more consistent standardised pathways of care, that integrate services more effectively around the needs of residents.

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Report Title Chief Officer’s Report

Agenda Item 2.2

Date 29/02/2016

Lead Director N/A

Tel/Email

Report Author Dorothy Blundell, Chief Officer

Tel/Email [email protected]

GB Sponsor(s) (where applicable)

Tel/Email

Report Summary The Chief Officer’s Report highlights key issues for the Governing Body’s

consideration that are not covered elsewhere on the agenda.

Purpose (tick one only)

Information Approval To note

Decision



The Chief Officer highlights a variety of issues within the report and these may link with all strategic objectives.


Where applicable any risks are identified within the report.


There are no conflicts of interest arising from this report.


No direct implications, although each area described has resource implications for the CCG.

Engagement

Engagement activities are highlighted as appropriate.



Report History This report is a standing item on the Governing Body agenda.

Next Steps None

Appendices None

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mailto:[email protected]

1. Introduction

The aim of this report is to update the Governing Body on any issues that are not otherwise covered

on the agenda and are useful for the Governing Body to note.

2. Executive Team I am delighted to confirm that the recruitment of our senior executives is now complete and our Executive Team members are: Chief Finance Officer – Ian Boyle Chief Operating Officer - Susan Achmatowicz Director of Quality and Clinical Effectiveness – Neeshma Shah Director of Sustainable Insights Partnerships - Charlotte Mullins Transformation Programme Director - Sally MacKinnon I believe we have a talented team in place and we all very much look forward to working closely with the Governing Body and staff to deliver the CCG’s business objectives.

3. North Central London Programme

The NCL Collaboration Board met on 17 February where members were provided with an update on the four priority work programmes:

A. Acute services redesign: with an immediate focus on urgent and emergency care

B. Mental health: with an immediate focus on transforming inpatient care

C. Pathways: with an immediate focus on primary care, having common standards and reducing variation

D. System wide enablers: with an immediate focus on estates

The programme updates are included at Appendix 1.

With regard to the Estates programme the CCG Estates Strategic plans have been produced and estates leads within CCG’s, Local Authorities, Providers and other relevant bodies identified. Three workshops were planned throughout February and March to discuss the strategic plans in more detail. Each of the priority work streams are currently focused on defining the scope of the work required to meet the Sustainability and Transformation Plan.

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4. London Ambulance Service

Chief Officers were provided with an update on the Care Quality Commission’s Quality

Improvement Plan for the London Ambulance Service at their February meeting.

The Quality Improvement Plan has five work streams which are:

1) Making the London Ambulance Service a great place to work 2) Achieving good governance 3) Improving patient experience 4) Improving environment and resources 5) Taking pride and responsibility

Each work stream has a number of projects which have been agreed by the Trust Board. A clear programme of delivery, accountability and governance, supported by a Programme Management Office has been put in place to ensure delivery of the improvement plan. The Trust has put in place additional capacity and capability to support the delivery of the improvement plan, to be supplemented by additional support by the NHS Trust Development Authority.

5. Healthy London Partnership

Further to the discussion at the last Governing Body meeting, I am able to confirm that CCG Governing Bodies and NHS England (London) have broadly supported the principle of continuing to support the Healthy London Partnership by providing a commitment to continue funding the partnership for the next two financial years. The October to December quarterly progress report has been circulated separately.

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1

NCL CCG Collaborative ProgrammeProgramme Overview – Primary CareDate: February 2016 Appendix 1

Vision and Scope Objectives for 15/16 Current Team/ Resources

To ensure the sustainability of the NCL health economy and reduce the variability of services through an increase in the quality of the offer to patients, enabling all patients to access a wide range of integrated services from premises that are fit for purpose and with the support to manage their own care.

Delivery of new approaches to accessing care, hours, types of appointment and ways to contact the practice or receive care (face to face, online and by phone)

Establishing mechanisms for identifying and improving quality across NCL in a systematic and supportive manner.

Improvements to co-ordinated and proactive care for patients and developments in IT, Premises and Workforce to enable service change.

• Ensure primary care co-commissioning arrangements are effective in providing strategic leadership to primary care transformation in NCL.

• Ensure quality is improved across Primary Care• Develop a plan to implement Strategic Commissioning Framework for London in next

three years focussing on the following in 15/16:• Accessible care – Routine opening hours and extended opening hours

(tailored to local needs) in 80% of practices across NCL.• Coordinated care – Embed care and support planning across NCL.• Proactive care – targeted care to unregistered patients and those who do not

attend the practice.• Development of federated care networks across 80% CCGs in NCL.• Interoperability between practices across NCL (80% of practices sharing information).• Development of an estates strategy which is underpinned by up to date premises

audits for all practices in NCL and the application by at least 25 practices for improvement funding.

• Development of a programme of Workforce development working closely with the CEPN and focusing on recruitment and retention.

SRO Alison Blair,Islington CCG

Clinical Lead One per CCG

Programme Manager

Daniel Morgan,NEL CSU

Status Update

Activities completed in the previous period• Primary Care Programme Review held with NHS England on 5th November 2015• GP practice baseline survey against the Strategic Commissioning Framework completed in November 2015.• NCL primary care programme mobilisation workshop held on 9 December 2015. CCG primary care leads met to plan priorities for 2016/17.• NCL Primary Care Joint Committee met for the second time in January 2016. Agenda items included a practice merger (Islington), an APMS

contract variation (Camden) a practice closure due to retirement (Haringey); an NCL quality & finance update and an update on CCG PMS commissioning intentions.

• Draft CCG Estates strategies developed and submitted to the Department of Health in December 2015• A financial modelling approach for Strategic Commissioning Framework developed with the Healthy London Partnership in January 2016.• The January Primary Care Programme Management Group discussed the requirements of the 2016/17 NHS Planning guidance.

Activities due in the following period• London PMS offer to be finalised with LMC. NCL CCGs to include this in their PMS commissioning intentions by 19 th February. Will need to outline

plans for delivering the London PMS offer, plans for equalising PMS and GMS contracts and outline how it is expected that this will be funded.• NCL Primary Care Joint Committee will meet on 9th March. An April workshop is being planned to provide a forum for reviewing role of the

Committee; how this fits with the new NCL Transformation Board; a potential pipeline of work for 16/17 and the development of the STP.• Primary Care Programme Management Group planning a deep dive session on workforce issues.• Development of NCL primary care programme contribution to the NCL Strategic Transformation Plan.• NHS England guidance on the Primary Care Transformation Fund to be made available at the end of February 2016.

Summary of key issues/ actions/ decisions required

NCL Primary Care Joint Committee meeting on 9 March 2016.

CCG PMS review commissioning intentions to be submitted to NHS England by 19th February 2016.

Development of primary care programme contribution to the NCL Strategic Transformation Plan. This will particularly focus on how the Strategic Commissioning Framework will be delivered in NCL.

RAG Rating ‒ Green

Project Plan Financial Impact

Ownership & Governance

Stakeholder engagement & Interdependencies

Quality & Risk assessment

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NCL CCG Collaborative ProgrammeProgramme Overview – Urgent CareDate: February 2016

Vision and Scope Objectives for 15/16 Current Team/ Resources

NCL 5 CCGs have agreed to procure a new integrated 111 and OOH service under a single contract commencing October 2016. This has many benefits from an operational and clinical standpoint and will enhance the patient experience in a more streamlined pathway. NHSE are assured through the programme using 3 specific review gates.

To provide an Integrated 24 hour Urgent Care System to ensure that the patient is given the right care in the right place by those with the right skills, first time in response to their needs, in a financially sustainable UEC network.

• Undergo a 6 month procurement process in order to award the new contract

• Undergo a 6 month mobilisation period prior to contract commencement

• Commence a review of Urgent Care Services across Barnet, Enfield and Haringey start to be agreed.

• Establish the NCL Urgent and Emergency Care Network starting September 2015.

SRO Paul Jenkins, CO Enfield CCG

Clinical Lead Dr Sam Shah

Programme Director Graham MacDougall

Programme Manager Clare Kapoor

Procurement Marivie Papavassiliou

Contract Greg Hudson

January 2016 Status Update

Activities completed in the previous period• ITT stage closed 11th January.• ITT moderation meeting 1st February.• Integrated Urgent Care Commissioning Standards stocktake submitted 29th January.• NCL/SWL Pan London 111/OOH lessons learned workshop 3rd February.• NCL UEC Network meeting 14th January.• NCL UEC Network MH sub-group meeting 28th January.• NCL UEC Network plan for a plan development.• Pan London Network delivery plan workshop 4th February.

Activities due in the following period• 111/OOH OSCE process and bidders presentation 11th & 12th February. • NHSE assurance meeting checkpoint 2.• Sign current 111 and OOH contract extension documents (waiver).• Update at JHOSC meeting on the 11th March.• NCL UEC Network meeting 25th February.• Mental Health Crisis Care Summit 25th February.• Establish NCL UEC Network delivery plan working group.


1. Continue to develop UEC Network delivery plan. Year 1 plan submission deadline 31st

March.

2. NCL 111 OOH Procurement Board Report to the 5 GBs 3rd – 17th March.

3. Sign off of 111 OOH contract extensions by host commissioners.

4.

5.

Programme RAG Rating ‒ Green

Project Plan

FinancialImpact


Stakeholderengagement &Interdependencies


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NCL Collaborative ProgrammeProgramme Overview – Mental HealthDate: February 2016Vision and Scope Objectives for 15/16 Current Team/ Resources

1. Transform the nature, value and outcomes of local services close to home, through building partnerships that deliver around the needs of individuals and communities.

2. Work with individuals and communities to support good Mental Health resilience.

3. Build high quality specialist services for those with complex and intensive needs, that are as close to home as possible, and allow connection to local community services.

4. Develop alternative responses for service users with Mental Health needs who do not respond, or prefer not to engage with current commissioned services.

5. Develop systems of early interventions which ensure people with Mental Health crises receive a prompt and appropriate response

6. Breakdown barriers between mental and physical health in a way which delivers better outcomes for patients and better value to the system.

7. Workforce training to better equip health and social care workers to support patients with Mental Health needs.

Scope – scope to be finalised at meeting on 05/02

• Define the scope of work to be undertaken as part of the NCL Mental Health Programme

• Start high priority identified workstream

SRO Dorothy Blundell, Camden CCG

Clinical Lead Alex Warner

Programme Manager

Pippa Wady, Camden CCG

Status Update

Activities completed in the previous period

• Shared ambitions agreed by NCL Mental Health Programme Group• Workshop held on January 14th with commissioners, Local Authorities, clinicians, Mental Health

Trusts, Voluntary Sector and Service users to: understand the view from each setting, and identify what work needs to be done to address the triple aim

• Currently recruiting for a subject matter expert as programme director. This post is being advertised amongst the three Mental Health Trusts.

Activities due in the following period

• Finalising scope of programme by NCL and Mental Health Trusts• Following this the work streams can also be agreed upon, including priorities. This will form the

programme plan.


1. SRO with Mental Health Trusts to sign off programme scope

2. NCL Mental Health Programme Group to agree individual work streams

3. Identify resourcing requirements and how to meet these for identified work streams

RAG Rating ‒ Green

Project Plan Financial Impact


Stakeholder engagement & Interdependencies


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Report Title The Patient Voice Report

Agenda Item 2.3

Date 24/02/2016

Lead Director Dorothy Blundell,

Chief Officer Tel/ Email

[email protected]

Report Author Martin Emery, Deputy Head of Engagement

Francesca McNeill, Head of Communications & Engagement

Tel/ Email

[email protected] [email protected]

Sponsor(s) (where applicable)

Kathy Elliott, Lay Member, Communications and Engagement

Tel/ Email

[email protected]

Report Summary This paper provides a synopsis of the patient and public involvement

activity undertaken since the previous Governing Body meeting.



Decision

Recommendation The Governing Body is asked to note the content of the report.


Working with the people in Camden to achieve the best health for all is part of Camden CCG’s vision; and the completion of the work plan will help us to achieve our aspirations.

Identified Risks and Risk Management actions

Not applicable for the purpose of this report



Engagement This paper reports on engagement activity


No equality impact assessment is required for this report.

Report History The Governing Body receives a Patient Voice Report at each meeting.

Next Steps None

Appendices None

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The Patient Voice Report (March 2016)

Background The Camden CCG Business Plan objectives include: “Work jointly with the people and patients of Camden to shape the services we commission”. This paper covers work undertaken in the preceding two months, delivered against the work plan approved by the Governing Body (in 2014) and subsequent additional activity set within the 2015 Business Plan. It describes the actions undertaken since the last governing body meeting, related to:

1. Camden Patient and Public Engagement Group (CPPEG) 2. Business Plan Objective E: Work jointly with the people and patients of Camden to shape the

services we commission Priority 1: Develop a standard approach to patient involvement across all programmes

in service design, decision making and evaluation. Priority 2: Creatively and systematically capture the views of patients and from a range

of sources and embed patient feedback in all stages. Priority 3: Improve the two-way flow of information from patients’ representatives to the

wider CPPEG group, and to the PPGs to increase the patient voice in decision-making. 3. Communications & engagement team programme. 4. Engagement work across the CCG.

1. Camden Patient & Public Engagement Group (CPPEG) Since the last Governing Body meeting, CPPEG has held one operational and one open meeting for the public. The key themes and issues arising from these sessions are described below.

1.1 Operational meeting (11/01/16) Improving patient experience and discharge summaries at University College London Hospitals NHS Foundation Trust (UCLH): Patient experience As a result of the themes that have emerged from the UCLH Clinical Quality Review Group in relation to patient experience Lisa Anderson, Patient Experience Lead attended the meeting to present the plans to transform the experience of patients at the Trust. Lisa reported that the following initiatives had taken place to improve patient experience in both inpatient and outpatient settings:

o Inpatient setting o Introduction of ward welcome packs o The aims of the pack are: - to improve safety and comfort for inpatients (Inc. tooth brush, non-slip slippers);

- to improve performance on key national inpatient survey questions (information guide related to ward processes and a who’s who of staff supporting people during

their inpatient stay); - to ensure patients were always informed on how to raise concerns with staff (PALS & Complaints).

o Outpatient setting o While waiting to meet clinical staff offered alternatives to waiting in the hospital

(informing patients via text messages /bleep to come to clinic to see the doctor). o Playing calming music in patient waiting areas. o Improvement of the outpatient waiting areas.

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o Agenda setting with patients - asked by clinical staff “what do you want to talk about today”.

o Improved interaction with staff informing patients regularly about waiting times.

o Managing patient and carer feedback o Completed a review of how patient feedback was managed with the introduction of a

clinical lead for improving patient experience and the management of complaints and concerns.

o A more comprehensive database holding feedback given by patients and the public. o The introduction of quarterly reporting cycles with a more forensic analysis of the

feedback received.

A discussion followed and the CPPEG supported the actions taken by UCLH to improve the experience of patients in inpatient and outpatient settings. Lisa thanked CPPEG for their support and agreed to return at a future date to update members on progress made. To view the presentation you can click on the following link: http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/160111/NHS-UCLH-Patient-experience-improvement-final-11-January-2016.pdf

Discharge Summaries As a result of concerns raised from the UCLH Clinical Quality Review Group Danielle Morrell – Divisional Manager (Integration) attended the meeting to present plans on improving the quality of discharge summaries.

Position to date: Based on stakeholder & patient feedback UCLH reported that they have undertaken the following work to improve the quality of discharge summaries. Recent changes have included:

o Implementing ‘e-discharges’ (an e-summary is sent directly to practices for all patients in Camden).

o Reducing discharge summary duplication (this is mostly due to running two systems – further development of the e-messaging system will eliminate this).

o Improving quality of content and ensuring that all summaries are sent in a timely manner (regular audits of the data to check quality with feedback to staff).

A discussion followed and CPPEG supported the actions taken by UCLH to improve the quality of discharge summaries at UCLH, but concern was expressed about the length of time it had taken to recognise the problems. Danielle thanked CPPEG for their support and agreed to return at a future date to update members on progress made. To view the presentation you can click on the following link: http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/160111/NHS-UCLH-CPPEG-Discharge-summaries-final-11-January-2016.pdf Tableau Tool presentation (helping general practices give feedback on their delivery of CCG locally commissioned services): Richard Cartwright, Insights Manager at Camden CCG gave an overview of tableau and how data can be presented to general practices showing patient outcomes at both a Camden and general practice level.

A discussion followed and it was agreed that context would need to be added to any data and Camden level information would be disseminated to PPGs initially. Richard agreed to present information on MDTs at the Camden level for the initial dissemination of information. To view the presentation you can click on the following link:

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http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/160111/NHS-UCLH-Patient-experience-improvement-final-11-January-2016.pdf

http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/160111/NHS-UCLH-CPPEG-Discharge-summaries-final-11-January-2016.pdf

http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/160111/NHS-UCLH-CPPEG-Discharge-summaries-final-11-January-2016.pdf

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http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/160111/NHS-Camden-CCG-CPPEG-Data-outcomes-and-population-health-management-January-2016.pdf. 1.2 Open Meeting (11/02/15) CPPEG open meetings occur bi-monthly and allow an opportunity for members of the public to hear about and engage with the work of the CCG. The February meeting covered two main topics, Camden Integrated Digital Records (CIDR) (the integration of health and social care records across providers in Camden) and Aging Better in Camden (a service provided by Age UK Camden to support isolated elderly patients); 38 people attended the open meeting. Camden Integrated Digital Record (CIDR) Dr Ehsan Alkizwini, GP and CCG lead for CIDR, Nigel Slator, CIDR Programme Implementation Lead and Nick Murphy O ‘Kane, Information Governance Manager presented CIDR on behalf of Camden CCG. Dr Leon Douglas, Co-chair of CPPEG & PPG member introduced the presenters to the audience. To view the presentation you can click on the following link: http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/11022016/CIDR%20presentation.pdf

Key messages from the discussion around this item were: o Camden CCG has developed an online record that links health and social care data together,

working in partnership with health (acute, community & mental health) and social care providers in Camden.

o The key benefits are as follows: o Health and social care professionals being able to access the information required to

provide optimal care. o Potential safety benefits - as health and social care professionals will be more aware of

important information such as what prescription medications patients are taking. o Patients will not have to repeat information about themselves to multiple different

professionals.

o Confidentiality & security: o Access to the system and records within this are only provided to approved and

authorised users who are validated by their respective organisations. o Access and use of the CIDR system is auditable with regards access and usage of the

system. The internal audit functions have been developed in line with the NHS Care Record Guarantee.

o Opting out of the integrated record: o Patients can opt out entirely or can reduce specific information that can be viewed

within the system at any time after speaking to the health and social care provider.

o Patient & public engagement feedback: o In collaboration with London Borough of Camden, the CCG commissioned community

researchers to survey 270 residents across Camden. o Residents were asked a series of questions to gather awareness of CIDR,

views and opinions on consent and the benefits to integrating records (feedback to influence marketing campaign).

o Tested the leaflet with patients which will be posted to all Camden residents registered with a GP informing them about CIDR (Inc. the benefits, confidentiality, security and opting out).

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http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/160111/NHS-Camden-CCG-CPPEG-Data-outcomes-and-population-health-management-January-2016.pdf

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Feedback given: o Patient & public engagement: The CIDR presentation was positively received and the work

undertaken via the CCG and community researcher programme reassured the audience that when the leaflet is posted to households the information would be presented in an understandable way.

o The audience felt reassured by explanations given in relation to the consent process and safeguarding measures taken to secure patient information.

Action to be taken: o All GP registered patients would receive a letter with the information leaflet via the post after

the amendments had been completed following the feedback received from the community researcher’s programme.

Ageing Better in Camden: Corinna Gray, Partnership Development Officer, Age UK Camden, presented the Ageing Better in Camden initiative to the audience. Janet Guthrie, Chair of Age UK Camden and CPPEG member introduced the presenter and gave a brief overview of the project. To view the presentation you can click on the following link:

http://www.camdenccg.nhs.uk/Downloads/ccg-public/Get-involved/CPPEG/11022016/Ageing%20Better%20in%20Camden%20presentation.pdf

Key messages from the discussion around this item were: o Ageing Better in Camden is Big Lottery Funded and is a partnership of older people and

Camden organisations, working together to tackle social isolation and loneliness among older people.

o Age UK Camden is working in partnership with KOVE, Mary Ward Centre and the Community Centres consortium – C4 to deliver the service.

o The service: o Identifies older people who are socially isolated or at risk of social isolation. o Supports older people to get involved in their community in ways that suit them. o Provides activities (group based, participation).

Feedback given: o The presentation was well received and the audience felt reassured by the work undertaken to

help elderly people who were lonely and at risk of isolation. o The audience asked that the programme be promoted more with the CCG, local hospitals and

general practices to ensure that people are more aware of the service.

Next steps: o The Communications and Engagement team will raise awareness of the service via the PPG

newsletter, social media and raise awareness of the programme with the Health Advocates (who are supported by Voluntary Action Camden) to refer patients to the Aging Better programme.

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You Said (Messages from CPPEG) We did (Action taken / to be taken CPPEG Operational Meeting: improving Patient Experience and discharge summaries at University College London Hospitals NHS Foundation Trust (UCLH):

o CPPEG members welcomed the presentations and that UCLH management acknowledged that the patient experience had to improve.

Tableau Tool presentation (General Practice patient experience data)

o CPPEG members welcomed the presentation and agreed that initial dissemination of information would be presented at a Camden wide level initially to be presented to PPGs.

CPPEG Open Meeting: Camden Integrated Digital Record (CIDR)

o The CIDR presentation was positively received and work undertaken around communications and engagement reassured the audience that people would be informed and that issues around obtaining consent and safeguarding of information was being treated seriously.

o The audience welcome the use of local people to collate resident’s views of CIDR and testing the information leaflet.

Aging Better in Camden: o The audience welcomed the

presentation and the objectives and programmes of work for reducing loneliness and isolation for the elderly.

UCLH will Discharge summaries:

o UCLH agreed to forward audit findings for monitoring the accuracy and timeliness of discharge summaries to CPPEG for information.

o UCLH will attend a future CPPEG meeting to update members on the implementation of their action plan to improve patient experience and the quality of discharge summaries.

The CCG will o Discuss dissemination of MDT data at a

Camden wide level and how practices and PPGs will be informed with a feedback mechanism incorporated into the process.

The CCG with the assistance of CPPEG o Will test the system of sending Camden

wide data related to the MDTs to PPG’s o Will further consider sharing practice

level information with PPGs (e.g. frailty register or GP patient survey)

The CCG will o Disseminate the information leaflets to

Camden residents once amendments have been completed.

o The CIDR team have thanked Healthwatch Camden for the advice received in moving the CIDR programme forward.

o Share the learning from the community researcher project with CPPEG and PPGs.

The CCG will o Promote the service to general practices

and PPGs via locality meetings, PPG newsletter and social media.

2. Business Plan Objective E: Work jointly with the people and patients of Camden to shape the services we commission Priority 1: Develop a standard approach to patient involvement across all programmes in service design, decision making and evaluation.

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Progress to date: The Communication and Engagement Team currently support and advise staff undertaking Patient & Public Engagement activity, and to strengthen the process an online registration form to collate activity in real time is under construction and will be rolled out to Camden CCG staff (Including Joint Commissioning Staff) to complete from the 1st April 2016 (all new and current engagement activity will be registered).

Upon completion of the programme of work part B of the form will require staff to show how the engagement activity impacted upon commissioning intentions, service monitoring and procurement which reflects the information that the CCG has to submit to NHS England (London Region) on an annual basis.

A Patient Public Engagement pack for all CCG staff will be made available from the 1st April. The pack will inform staff of: (a) good practice in relation to undertaking Patient Public Engagement activity (b) the process for involving the Communications and Engagement Team (b) the role of CPPEG (c) the role of Healthwatch Camden (d) the role of London Borough of Camden (e) the role of the voluntary sector, local community groups and other health care providers.

The pack will be launched via a lunch time seminar presentation in March with a publicity raised via the Camden Eye (internal e-newsletter) and members of the Communication & Engagement Team attending staff meetings.

CPPEG members attended 12 CCG committee meetings since the last report. The reports are available by clicking on the following link: http://www.camdenccg.nhs.uk/public-engagement/cppeg-meetings.htm). A discussion of the committee reports took place at the CPPEG Operational Meeting on Monday 11th January.

Priority 2: Creatively and systematically capture the views of patients and from a range of sources and embed patient feedback in all stages

Progress to date: The Patient Voice Reports show the variety of methods that Camden CCG have undertaken to capture the views of the public which has resulted in the CCG receiving an assurance rating of good for our individual and collectives duties under patient and public involvement activity. We will continue to build upon this as our aspiration is to move from good to excellent. The patient and public engagement work plan for 2016/17 is scheduled to be presented at the May Governing Body and will focus on utilising the community researchers programme in collaboration with London Borough of Camden (local people trained in delivering qualitative and quantitative research methodologies), local conversation events with population groups, question time meetings with the Chair of Camden CCG and the roll out of a citizens panel in collaboration with London Borough of Camden.

A synthesis of patient engagement and feedback in relation to future primary care programmes is being drafted, with work at a draft form on children and young people, and mental health programmes which will be reported to CPPEG and Governing Body in May.

Priority 3: Improve the two-way flow of information from patient’s representatives to the wider CPPEG group, and to the PPGs to increase the patient voice in decision making

Progress to date: The first PPG newsletter was circulated in September and has been circulated monthly since with PPG Summit meetings also scheduled during 2016/17.

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An example of the two communications has resulted in a PPG member responding to a patient call which has resulted in them assisting the commissioning team in supporting us with the district nursing services review and Camden residents participating in online surveys. A feedback form has also been disseminated to PPG members and the general public following the CPPEG open meetings which gives people the opportunity to influence topics of discussion for CPPEG and future agenda items. It is important to note that the community researchers’ programme and citizens’ panel feedback will also give more opportunity for the citizens’ voice in decision making moving forward.

The co-chairs of CPPEG also have a seat on the Governing Body which strengths the public’s voice with the Governing Body member responsible for Patient & Public Involvement and Chair of Healthwatch Camden already being established members. Section 3 & 4 of the report also demonstrates how the CCG is connecting to local people around patient and public engagement activity. Preparations are underway for the second PPG summit in March.

3. Communication and Engagement Programme Since the last Governing Body meeting, the Communications and Engagement team has delivered a range of Patient Public Involvement (PPI) activity and disseminated a monthly newsletter to PPGs. The newsletters may be accessed by clicking on the following link: http://www.camdenccg.nhs.uk/Downloads/ccg-public/your-say/PPG-Newsletters/NHS-Camden-CCG-PPG-newsletter-29-January-2016.pdf IKWRO – Iranian and Kurdish Women’s Right Organisation (www.ikwro.org.uk) The Deputy Head of Engagement and Lead GP for Women’s Health are liaising with the training team to introduce training for GP trainees to help them support women who have experienced ‘honour’ based violence, domestic violence, forced marriages, child marriage and Female Genital Mutilation.

Winter and Local Services Campaign The Communications and Engagement Team have sought insight from Camden residents to ensure that feedback is being used to inform the development of the campaign and evaluate its impact. This includes two independently conducted, 500 person street surveys and focus workshops/peer research with three of the campaign’s audience groups (a final report will be reported to CPPEG and Camden residents in May). PPG members and the general public via Voluntary Action Camden’s e-newsletter were also sent a campaign toolkit in December 2015 containing materials such as posters and leaflets and asked to support dissemination of the campaign messages.

Procurement of Citizens Panel The Communications & Engagement Team are supporting the CCG in establishing a citizen’s panel in collaboration with London Borough of Camden Council. The panel will consist of 1,000 Camden residents and they will assist the CCG in decision making, obtaining feedback and could potentially be involved in the design of pathways and services.

The procurement process has now started and provider interviews will be held the week beginning Monday 22nd February with the Deputy Head of Engagement, Lay Governing Body member responsible for Patient and Public Involvement and the Citizens Panel Lead on the procurement panel, with colleagues from London Borough of Camden Council.

Out of Hospital Strategy Under the leadership of the Director of Transformation, Camden CCG is developing a strategy, working with all key stakeholders in Camden. The ‘Out of Hospital’ (OOH) strategy will respond to issues identified in NHS England’s Five Year Forward View: (the health and well-being gap, the care and quality gap and the funding and efficiency gap).

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http://www.camdenccg.nhs.uk/Downloads/ccg-public/your-say/PPG-Newsletters/NHS-Camden-CCG-PPG-newsletter-29-January-2016.pdf

http://www.ikwro.org.uk/

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Although at an early stage, to ensure good patient and public engagement the Director of Healthwatch has joined the Out of Hospital Strategic Board and the Co-chair of CPPEG and PPG member has become a member of the operational group. More extensive patient engagement activities are planned and this will be reported to CPPEG and the Governing Body at future meetings.

Aging Better in Camden (The aim of the service is to reduce loneliness and isolation of elderly people in Camden). The Deputy Head of Engagement met with the programme developing lead for Aging Better in Camden and agreed to support the promotion of the service both within and outside of the CCG.

PPI Statutory Obligations Report 2015/16 The Deputy Head of Engagement met with NHS England (London Region) to discuss the assurance rating and how the CCG could move from good to excellent and the following feedback was given which will be incorporated into the patient engagement work plan for 2016/17.

o Introduction of an induction pack for new starters explaining the process of patient engagement and a who’s who of local stakeholders in Camden (the launch will include existing members of staff).

o Implementing a registration process for ensuring that patient & public engagement activity is systematic, robust and records the impact that the activity had on commissioning intentions.

Camden Integrated Digital Records Engagement Events The CIDR team supported by the Communications & Engagement team have visited the following PPGs in February to inform people of the role of CIDR.

o Fortune Green PPG o Keats Group Practice PPG o Abbey Medical Centre PPG o CHIP PPG o James Wigg PPG o CPPEG open meeting

The following groups to date have also been informed of CIDR (Healthwatch Camden, Camden LGBT forum, Somali Cultural Centre, Bengali Workers Association, Chinese Community Centre, African Health Forum, Older People’s forum, SURGE, learning disability forum, Sensory Needs forum and the mental health forum).

MIND in Camden The Deputy Head of Engagement met with the Director of MIND to discuss mental health service user needs and TAP (Team Around the Practice). As a result of the discussion a Question Time Surgery with the Chair of Camden CCG has been arranged for March 2016 and mental health lead for TAP at the CCG has been informed that referrals from the West Locality are not as frequent as the other localities.

Collaborating with Healthwatch Camden via the lunch time seminar programme Healthwatch Camden will present the findings of the mental health programme audit, Patient & Public Involvement ladder of participation and good practice principles to follow at the lunch time seminar scheduled for Tuesday 23rd February.

Central Saint Martin’s Art College (Photography project) In collaboration with Central Saint Martin’s Art College students the Communications and Engagement team are planning to establish a portfolio of photographs of local people in Camden to build a library of photographs of local people and general practice staff, ensuring that future publications of CCG material has images with a more local feel.

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Bengali Stakeholder group The Chief Operating Officer and Deputy Head of Engagement attended a meeting with London Borough of Camden and Healthwatch Camden to learn from the Camden Bangladeshi population in relation to how their health and wellbeing can be improved. Following the discussion a meeting was arranged with Healthwatch Camden to discuss how stigma around mental health for the Bangladeshi community can be addressed.

Camden Intergenerational Network The Communications and Engagement team have joined Age UK Camden and London Borough of Camden to develop and promote ‘good practice guidelines for intergenerational working’ between young adults, adults and the elderly population.

Camden Special Parents Forum The Deputy Head of Engagement attended a Camden Special Parents meeting (parents of children who have learning disability or a long term health condition). Actions following the meeting related to the Communications and Engagement team presenting the findings to the Governing Body and General Practitioners at locality meetings.

o Parents had reported that isolation was a major concern (please note similar feedback was given by adults who had a long term condition at a patient outcomes workshop in December. It is important to note that in Camden isolation has been reported at a national survey level when compared to other Local Authority levels).

o Families were concerned that across the health system that there was a need for longer appointments which would give sufficient time to discuss both the children’s health and wellbeing but their own as well.

o Families felt that across the health system those health professionals generally should have a better awareness of disability issues, from receptionists to specialists.

o It was noted that there are no ‘changing places’ facilities in Clinic 1 at the Royal Free Hospital NHS Foundation Trust, the main paediatric clinic in Camden, nor in UCLH. Parents felt that they should be recognised as experts in their child’s condition and respected as such.

Cocoon (local charity established to support mums and dads who have post & pre natal depression) The Lead GP for Women’s Health and Deputy Head of Engagement meet with the Director of Cocoon to discuss how pre and post natal care can be improved, the feedback given will be report to the Maternity Lead for North Central London and GP lead for Children to discuss how can be improved for the vulnerable group of people.

Lunch Time Seminar (Accessible Information Standard) The Equality and Diversity Lead for NELCSU and Deputy Head of Engagement presented the accessible information standard that all public sector organisations will have to adhere to from the 31st July 2016. In summary NHS England has defined the standard as follows:

o To make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need.

o Public sector organisations must ensure that people get information in different formats if they need it, for example in large print, braille, easy read or via email.

o Public sector organisations should make sure that people get any support with communication that they need, for example, support from a British Sign Language (BSL) interpreter, deaf blind manual interpreter or an advocate).

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Camden Disability in Action The Deputy Head of Engagement met with a representative from Camden Disability in Action (local charity) which has replaced DISC as the Camden group established to champion the voice of local people who have sensory impairment or disability. As a result of the discussion the Development Worker will request that the Trustees support the proposal for a representative to join CPPEG and the Deputy Head of Engagement would ask CPPEG approve the proposal as well.

Camden Patient & Public Engagement Group PPG member elections: Expressions of interest have been received from PPG members wishing to join CPPEG which has resulted in the need for elections for the North, South and West Locality. The timeline for the election is as follows:

o Statement and photograph to be submitted by Monday 29th February. o PPG members are the electorate and they can cast their vote between Monday 7th March to

Thursday 31st March (votes can be received by email or post). o Results of the election will be announced on Friday 8th April (this will allow for time to check

with the practice managers to ensure that the electorate are PPG members). o An induction will be planned for new members

You Said (Messages from communications & Engagement Programme)

We did (Action taken / to be taken

IKWRO – Iranian and Kurdish Women’s Right Organisation (www.ikwro.org.uk)

o IRWRO have asked the CCG to assist them with connecting with local community groups and clinical staff to ensure that women are supported appropriately and referred via the correct pathways for care and safety.

Winter and local services campaign

o Insight from Camden residents to ensure that feedback is being used to inform the development of the campaign and evaluate its impact has been sought with an independently conducted 500 person street surveys and focus workshops/peer research with three of the campaign’s audience groups.

Procurement of Citizens Panel o 1,000 Camden residents will strengthen

the citizen’s voice and build upon the work of CPPEG, PPGs, and the currently patient engagement activities that are currently taking place within the CCG.

Camden CCG has o The Deputy Head of Engagement and

Lead GP for Women’s Health are liaising with the training team to introduce training for GP trainees to help them support women who have experienced ‘honour’ based violence, domestic violence, forced marriages, child marriage and Female Genital Mutilation.

o IRWRO have been connected to the Somali Cultural Centre, Voluntary Action Camden Health Advocates and the Community Centres Consortium C4.

Camden CCG will o Present the findings of the survey and

focus groups at a future CPPEG operational and open meeting.

o Use the feedback received to influence future winter campaigns.

Camden CCG will o Interview potential providers the week

beginning Monday 22nd February and the recruitment of residents will follow in spring 2016.

o The feedback received from the Citizens Panel will influence the CCG programmes of work and will be reported to CPPEG on a quarterly basis.

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http://www.ikwro.org.uk/

12

Out of Hospital Strategy o Under the leadership of the Director of

Transformation Camden CCG is developing a strategy, working with all key stakeholders in Camden. The ‘Out of Hospital’ (OOH) strategy will respond to issues identified in NHS England’s Five Year Forward View.

PPI Statutory Obligations report 2015/16 o The Deputy Head of Engagement met

with NHS to discuss how the CCG could move from good to excellent in relation to our assurance rating.

Camden Integrated Digital Records (CIDR) engagement events

o To date the CIDR team have visited the following PPGs in February to inform people of the role of CIDR. o Fortune Green PPG o Keats Group Practice PPG o Abbey Medical Centre PPG o CHIP PPG o James Wigg PPG o CPPEG open meeting

MIND in Camden o The Deputy Head of Engagement met

with the Director of MIND to discuss Team Around the Practice (TAP) and the need for the West Locality General Practices to increase the number of referrals.

Healthwatch Camden lunch time seminar PPI presentation

o Healthwatch Camden will present a summary of their PPI audit findings and PPI ladder of Participation.

Camden Special Parents Forum o Parents of children with long term

condition reported concerns about isolation for families, training for receptionists and clinical specialist and longer appointments for consultation.

Camden CCG will o Use the community researchers and

citizens panel once established to ensure that Camden residents are involved in the direction taken by the out of hospital strategy.

Camden CCG will: o Introduce an induction pack for new

starters focusing on information staff of good practice in relation to patient & public engagement (Including informing of existing staff via directorate meetings and lunch time seminar launch).

Camden CCG will: o Will continue to raise awareness of

CIDR by attending PPG and local community group meetings.

o Will amend the information leaflet following the feedback received from residents via the community researcher programme.

o Will forward a letter with the information leaflets to all Camden residents informing them about CIDR, (Inc. the benefits, opting out, confidentiality and security).

Camden CCG has:

o Arranged a question time surgery with the Chair of Camden CCG.

Camden CCG will: o Add the recommendations to the

Patient & Public Engagement Induction Pack.

Camden CCG has:

o Reported the feedback to the RFH and UCLH for comment and feedback to be sent to the Camden Special Parents Forum.

o Arranged a question time surgery with the Chair of Camden CCG.

Camden CCG will: o Report the feedback to the Governing

Body and General Practitioners via locality meetings.

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Cocoon o The care for mums and dads suffering

from pre and post natal depression needs to improve.

Camden Disability in Action (CDA) o CDA has been established to represent

and advocate on behalf of people who have disabilities in Camden.

Camden CCG will:

o Report the feedback to the maternity lead for NCL and lead GP for Children at Camden CCG & discuss whether the children’s community centres can hold separate clinics for mums who have depression.

Camden CCG will: o Invite a representative from Camden

Disability in Action to join CPPEG to ensure that the views of residents who have a sensory impairment, physical or mental disability are heard.

4. Engagement Work across the CCG

Mental Health Programme The Mental Health team have support Camden Barbers project whereby local barbers from the Afro-Caribbean community are trained on raising awareness of mental health issues with their customers reducing stigma of mental health.

Frail & the Elderly Programme The Frail and Elderly team has secured investment for an innovative patient engagement and insights project. The project seeks to identify transformational engagement approaches for the pre-frail and frail population ensuring that patients are able to give feedback in relation to the frail and elderly care pathway (Including both clinical and patient outcomes).

Children & Families Programme The Children and Families team has established a Parent Advisory Group which has been in operation since January. The group has been established to ensure that parents have the opportunity to help shape services by improving health outcomes for children. Since establishment parents have helped create a parent friendly leaflet for resilient families, learnt about the DIY health education pilot the CCG is running and have subsequently volunteered to sit on the procurement panel to select a provider to deliver the pilot. In the last two months the Children’s and Families team have attended two parent groups organised by families in Focus and Family learning to recruit parents, and the Lay Governing Body member responsible for Patient & Public Engagement at the CCG has been invited to a February meeting to embed the relationship with the group and the CCG .

Primary Care Programme Somers Town Medical Centre Engagement The primary care team with the assistance of the communications and engagement team are assisting NHS England (London Region) ensuring that patients and local stakeholders are being consulted on options for the long term future of Somers Town Medical Centre. NHS England and Camden CCG have written to all registered patients at the practice during (week beginning 1st February), asking for their feedback on two options: procuring another GP provider and list dispersal. Two drop-in events took place on the 10th and 17th February (4-7pm) at which patients could ask NHS England and Camden CCG questions and meet Haverstock Healthcare who are currently providing a caretaker GP service at the practice.

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Healthwatch Camden and Camden ward councillors have attended the events which have been advertised through patient and stakeholder letters, posters in community locations, website and social media updates.

Long Term Conditions & Cancer Programme Representatives from the Long Term Conditions and Cancer team and general practices attended a redesigning workshop with UCLH and Macmillan Cancer to develop supported self-management follow-up for certain groups of people who have completed treatment for cancer. The following key points were raised and will be integrated into developing self-management:

o The importance of clearly outlined plans for actions and responsibilities communicated to both the patient and the GP.

o A robust IT system and adequate safety netting are essential to ensure patient safety. o Follow-up protocols need to be flexible and individualised. o There must be a single point of access phone number with a guaranteed rapid response for

both patients and GPs to use. o There must be capacity within the service to see patients urgently.

You Said (Messages from engagement work across the CCG)

We did (Action taken / to be taken

Parents Advisory Group o The group has been established to

ensure that parents have the opportunity to help shape services by improving health outcomes for children.

Primary Care Programme (Sommers Town Medical Centre Engagement)

o The concerns of patients are listed to through the engagement exercise.

Long Term Conditions Patient Outcomes workshop

o To discuss how staff from general practice, UCLH and Macmillan Cancer can work together to achieve this in a way that improves patient experience.

Camden CCG will o Connect the group with the Special

Parents Forum to ensure that the parent’s voice is strengthened and their voice is relayed to the CCG Children and Families team.

o Lay Governing Body member to attend the March Parent’s Advisory Group.

Camden CCG will o Present the findings at the future

CPPEG and PPG summit meetings.

Camden CCG will o Ensure that PPG members and patients

are given the opportunity to contribute to the design of supported self-management for cancer groups.

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1


Report Title Quality and Safety Report

Agenda Item 2.4 Date 24 February 2016

CCG Clinical Lead

Joanne Wickens Tel/Email [email protected]

Lead Director Neeshma Shah, Quality and Clinical Effectiveness


Report Author Wanda Palmer Tel/Email [email protected]

Report summary This report provides a summary of the key topics and quality issues discussed

by the Quality and Safety Committee at the meetings held in November and December 2015, and with Providers. It highlights issues of note to the Governing Body. Key points to note are tabulated in Appendix 1 (Acute) and Appendix 2 (Mental Health and Community). Issues of note are:

Confidence in UCLH’s ability to sustainably meet its cancer and diagnostics performance metrics.

Improvements in maternity at RFL post a deep dive Concerns relating to RFL Never Events The management of Serious Incidents at CIFT

Purpose


Decision

Recommendation The Governing Body is asked to NOTE the content of this report


The report on outputs from the CCG Quality and Safety Committee supports delivery of the following strategic organisational objectives: Objective A: Commission the delivery of NHS Constitutional rights and pledges Objective B: Improve the quality and safety of commissioned services by identifying gaps and concerns in service provision, and seeking assurance on quality and safety improvements related to these. Objective C: Improve health outcomes, address inequalities and achieve parity of esteem by seeking evidence from providers and partners relating to better outcomes for patients.


Provider management of quality and safety issues affecting patient care and experience are managed through regular clinical quality review (CQR) meetings and regular liaison with respective provider leads. No reports have been received to date from NHS England on primary care contractors. The issue has been raised with NHS England.


None

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2


An equality impact assessment has not been conducted as it is a summary report and record of the key outcomes of the Quality and Safety Committee meeting.

Report History The Governing Body receives a summary report of the work of the Committee at

each meeting.

Next Steps None

Appendices Appendix 1: Acute Service Providers Appendix 2: Community and Mental Health Service Providers

Glossary A&E Accident and Emergency BCF Barnet Chase Farm Hospital CDAT Complex Depression, Anxiety and Trauma C.Diff Clostridium Difficile CQC Care Quality Commission CQUIN Commissioning for Quality and Innovation CQRG Clinical Quality Review Group CIFT Camden and Islington Foundation Trust CNWL Central North West London Foundation Trust FFT Family and Friends Test MSA Mixed Sex Accommodation MRSA Methicillin resistant Staphylococcus Aureus NE Never Events RFL Royal Free London Foundation Trust SI Serious incidents T&P Tavistock and Portman Foundation Trust UCLH University College London Hospital Foundation Trust

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Executive Summary

The Quality and Safety Committee meetings in January and February 2016 considered provider quality and safety against the CQC domains of safe, effective, responsive, well led and caring.

In addition the Committee received reports from commissioning partners on Great Ormond Street Hospital, Connect MSK, Team around the Practice and Continuing Health Care. Safeguarding children, safeguarding adults and the draft CCG Quality Strategy were also discussed.

Key points and actions from these reports and discussions at Committee are articulated below.

Safeguarding Children The Committee noted feedback from the November 2015 Camden Safeguarding Childrens’ Board and discussed the following areas:

The SILP (Significant Learning Event Process) integrated action plan was accepted by the Board. The arrangements for monitoring and implementation of the action plan were agreed.

The Camden Safeguarding Adult Partnership Board annual report was presented and there was a discussion about shared themes from both Boards. Future possible joint work streams were discussed.

A presentation about the development of Camden Early Help Service was shared, and feedback from a service user consultation demonstrated a small response rate but indicated that families felt the interventions received were right for them.

The Corporate Planning annual report for Looked After Children was presented and this highlighted the decrease in numbers and changes across age groups. The Board requested evidence of further assurance in regards the quality of decision making, reasons for children being accommodated and more detailed analysis on those children who go missing.

The CSCB data set was reviewed and there was a discussion about future amendments which could improve the identification of trends and provide further assurance.

Safeguarding Adults The Committee noted the feedback from the Safeguarding Adult Board:

Public Health presented data and information relating to Female Genital Mutilation and the Board agreed that further consideration should be given to the impact on adults within the borough.

Camden and Islington NHS Foundation Trust provided an update to the Board on actions taken following the recent Domestic Homicide Review. The Board requested further assurance that actions had been embedded at practice level, and that there were robust systems in place to ensure that patients who need a bed will have access to appropriate inpatient facilities.

The new London Multi-Agency Safeguarding Adults policy and protocols were discussed, and a plan to localise the document for use in Camden was agreed. A small working group with representation from Camden CCG and Adult Social Care were tasked with taking this work forward.

The SAPB integrated performance dashboard was discussed, and partners considered the impact of a number of differing dashboards and metrics health providers may be asked to complete. It was agreed to take a pragmatic approach to reduce the burden on data collection and reporting for providers.

New posters, focussing on ‘friend abuse’ were presented to the Board and signed off for publication.

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Team Around the Practice (TAP) The Committee discussed the following areas:

The service is being delivered in practices by the Tavistock and Portman NHS Foundation Trust. The TAP service was officially launched at an event in November 2015, which was well attended

and received positive feedback. A set of CQUINS and KPIs have been developed specifically for the service. These are all being

met or exceeded, with the exception of physical health, which is being negotiated to determine the best way of collecting data and implementing this for the benefit of patients.

All training is up to date and there are no safety concerns. The service is available to all practices in the borough, and those who have TAP workers within

practices report positive outcomes and experience. The Committee sought clarity about evidence on whether complaints are being managed

effectively, and assurance was gained from GP feedback. It was agreed that the mechanisms for managing actual and potential complaints is effective.

The Committee agreed to receive updates for quality and safety of this service every six months.

Continuing Health Care The Committee noted the report and discussed the following areas:

The Committee noted the report, which was presented for the first time.

Clarity was sought about the action plans for areas highlighted through the CHC Assurance Framework as requiring improvement.

The Committee were informed that CHC reports will come to the CNWL CQRG for noting and this has been incorporated into the 16/17 forward planner, in order to provide assurance on the quality, safety and clinical effectiveness of the service being delivered.

The Committee noted that NHS England are holding a CHC deep dive, and joint commissioners have prepared evidence to support this with input from Camden CCG Quality and Safety Team.

Connect MSK The Committee noted the report and discussed the following areas:

The Committee noted the performance data relating of this service. Numerical data was presented on complaints and incidents; the committee requested additional

assurance that issues, themes and trends relating to complaints and incidents are being analysed by the service and that respective mitigation and improvement plans are in place. It was requested that this information and analysis is included in future reports.

It was noted that audit scores are all reported at 100%, however this is not supported by narrative nor any evidence.

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Great Ormond Street Hospital (GOSH) A report was presented to the Committee by NHS England, and the Committee’s attention drawn to:

The Trust’s use of the WHO safer surgery checklist. Following the recent CQC inspection, a quality summit is due to take place in February. Safeguarding training was highlighted as an area for improvement, and the Committee noted that

this was on track to meet requirements. It was noted that there are some issues with data quality within the Trust, and data capture

systems do not always pick up patients within all pathways. This is a longstanding issue which the Trust is working to resolve.

The Trust has a new Medical Director in post, who is restructuring his senior and executive team to enable effective delivery in the long term.

Medicines Management Committee The Committee received and noted the minutes. CCG Quality Strategy The Committee received the draft strategy and recommended its approval, and thanked Neeshma Shah for incorporating GP, CCG and service user feedback into the document. The Quality Strategy will be presented to Governing Body in March 2016 for final approval.

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Appendix 1: Acute Services

University College London Hospital (UCLH) Royal Free London (RFL) Are Services

Safe? Serious Incidents: The committee received data that the Trust reported seven serious incidents in December 2015 and five in January 2016. The committee requested clarification of what a treatment delay means. The report author confirmed that one was a delay in post-operative follow up and the second a delay in diagnosis which delayed treatment. The CQRG received UCLH’s quality and safety newsletter and was commended on the content and the Trust wide learning that could be achieved. Never Events: No Never Events were reported by the Trust in this reporting period.

Infection Control: At the end of December 2015 the Trust had identified 22 Clostridium Difficile lapses in care, with 17 root cause analysis investigations yet to be completed. The committee noted that the CCG Quality and Safety Manager and the CSU Infection Control Specialist review all RCAs and have regular meetings with the Trust where the formal outcome of each RCA is agreed. Referral to Treatment (RTT) and Clinical Harm Review: The committee noted that UCLH have implemented a new process for assessing clinical harm for patients who have extended waits.

Serious Incidents: The committee received data that the Trust reported five serious incidents in December 2015 and five in January 2016. Five of these serious incidents were reported at the Hampstead site. Monthly reports are submitted to CQRG with the overall Trust performance against the national standards for serious incident management. Reports also include information about the learning from serious incident investigations, and how the learning is disseminated and acted upon to reduce the risk of similar incidents occurring in the future. Never Events: No Never Events were reported by the Trust in this reporting period. The committee raised concerns that the Trust has reported seven Never Events in year to date, and has been noted by the CQC as part of its intelligent monitoring. The Trust’s safer surgery programme is underway to investigate themes and focused on ensuring that procedures were being followed. The Trust invited commissioners to meet key leads and learn more about the trusts programme Infection Control: The committee noted that the Trust reported 11 lapses in care for Clostridium Difficile in December 2015, of which seven were on the Hampstead site.

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The Trust report that no patients waiting more than 18 weeks have experienced harm as a result of the waits. It was raised by the committee members that though any clinical harm has not been identified, patient experience reflects patient dissatisfaction and concerns. The Trust has agreed that each clinical speciality team will define high risk pathways in which an extended wait may potentially lead to clinical harm. Safety Thermometer – VTE, Pressure Ulcers and Falls: The committee was informed that UCLH now has a Darzi falls reduction nurse in post, who is leading on raising awareness and implementing learning in relation to falls. The Trust is engaged with partner providers and regularly attends the Camden CCG pressure ulcer group, which meets quarterly to share information, challenges and learning from pressure ulcer cases. Quality Alerts: Southwark CCG raised one alert in the reporting period. No alerts were received from Camden GPs. The alert raised concerned the prescription request for an unlicensed medication by UCLH for a Southwark patient. This matter has been resolved. Workforce The committee received information pertaining to the Trust safer staffing Board report.

Referral to Treatment (RTT) and Clinical Harm Review: Information about RTT and clinical harm review are due to be presented to CQRG in January 2016. The focus of the report will be the lessons learned from the Barnet and Chase Farm process meetings, which are led by the Trust Medical Director. Safety Thermometer – VTE, Pressure Ulcers and Falls: The committee noted that the Trust has improved in terms of VTE assessment and is now meeting the 95% assessment target. The Trust is engaged with partner providers and regularly attends the Camden CCG pressure ulcer group, which meets quarterly to share information, challenges and learning from pressure ulcer cases. Quality Alerts: Camden GPs raised three alerts about Royal Free London in October and November 2015, with no emerging themes identified. Workforce The committee noted that there is a high turnover rate at the Hampstead site, which is outside of agreed trajectory and planning. Feedback was given that the Trust has a robust nursing recruitment plan in place, which it is anticipated will address the shortfalls reported.

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Are Services Well Led?

Care Quality Commission: The committee discussed the recent Mental Health Act Commission CQC inspection to the Trust Emergency Department. Concerns were raised that the Trust had reported there was no access to advocacy services for people being detained under the Mental Health Act. The committee’s Local Authority representative explained that there had been some changes in the delivery of advocacy services, and that challenges were experienced during the changeover from one service to another. Assurance was received that accessible and appropriate advocacy services are now in place. The Trust acknowledged there had been some useful learning from the issues identified during the visit.

Care Quality Commission: Feedback was given to the committee that the Quality and Safety Team and the NCL Directors of Quality have had the opportunity to provide feedback reports and to meet with the CQC prior to the visit, which commenced on the 2nd of February. It was highlighted that there were a number of key achievements included in the report to the CQC, as the Trust has made significant progress around integration of quality and governance systems and processes since the acquisition of the Barnet and Chase Farm sites.

Are Services Responsive?

Mixed Sex Accommodation Breaches (MSA): The committee was informed that UCLH reported 12 breaches in December 2015. The Trust continues to report that breaches are linked to capacity within the UCH tower and patients cannot be moved for clinical reasons.

Mixed Sex Accommodation Breaches (MSA): The committee was informed that RFL reported 12 breaches in December 2015. Two of these breaches occurred at the Hampstead site.

The Trust vacancy level remains above the national target, however safer staffing data does not indicate significant concerns at ward level. The committee noted that the Trust is actively recruiting nurses from mainland Europe and the Philippines. Concerns were raised about the impact of Government proposals to limit international recruitment and retention for those earning less than £35000 per annum. The committee were informed that the Trust has formally written to the Department of Health to highlight the importance of the NHS being able to recruit clinicians internationally.

At this stage it is not possible to assess the impact of the recruitment drive and this will continue to be monitored.

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The committee felt that the numbers of breaches are high, and it was queried whether all breaches could be attributed to demand on Critical Care and ITU beds. It was agreed that further assurance and evidence will be sought from the Trust. NHS Choices Feedback: The committee was informed that five reviews were put onto NHS Choices for UCLH in December 2015 and January 2016, all of which rated the Trust well overall, with two reviewers rating the Trust as 5/5. Key messages from the reviews are:

Lack of communication between departments. Delays in receiving appointments. Cancer waiting times and decision making regarding

treatment. The Urology department is the subject of reviews

from patients. Communication and treatment delays are common themes across quality and safety reporting, and the feedback from patients indicates that the Trust is not providing adequate assurance around cancer services, particularly urology. The committee noted that the CSU cancer specialist is working closely with the Trust to monitor progress and support effective resolution to the issues raised.

The Trust reports that it is reviewing the flows from the Emergency Department and giving additional focus to reducing delayed transfers of care in partnership with the SRG. NHS Choices Feedback: The committee was informed that one review was put onto NHS Choices for RFL in December 2015. This related to receiving multiple communications and appointments for the skin cancer clinic, with mixed messages about whether the treatment had been successful. The Trust has apologised to the patient and is investigating the complaint.

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Are Services Effective?

Cancer: The Trust continues to fail on a number of its cancer metrics, and has been asked to review its action plans relating to cancer metrics. The CCG is not assured that the Trust’s recovery plan relating to cancer waiting times is making a sustainable impact to improve its position. The CCG continues to provide support and constructive challenge at the monthly cancer quality review meetings which is chaired by the CCG and supported by the cancer commissioning team, and at the weekly patient tracking list meetings. Some concern has been expressed over the quality of the RCAs undertaken for those patients who have breached the cancer metrics, and the timeliness of the CCG receiving the RCAs prior to the meeting. The CCG has requested tumour site level business continuity and resilience plans, including inter-trust protocols as the RCAs indicated repeated challenges in workforce, and capacity issues. Concerns were raised by the committee as to whether UCLH are in a position to meet the required gateways to become the regional centre for cancer. It was agreed to seek clarification from NHS England on this. The committee received assurance that the CCG was sighted on the number of patient breaches on a weekly basis. Maternity: The Trust have reported good compliance against the Morecombe Bay recommendations, having established core processes to deliver effective clinical governance and education in maternity services.

Cancer: The committee noted that the breaches for Cancer are mainly in relation to 62-day waits, with the Trust achieving the 2 week and 31 day waits metrics. The Trust continues to share weekly patient tracking list updates with the CCG. The Trust has convened fortnightly cancer recovery meetings, is developing timed pathways and tumour specific plans, introducing direct to test for endoscopy, has recruited additional staff and undertaken a capacity and demand evaluation. Results from the Haematology Peer Review were shared at the CQRG, further evidence and planned actions had been since provided to the review group and all outstanding issues had been closed. The committee received feedback that an external review system is in place in order to provide additional assurance. Maternity: The committee noted that the maternity deep dive, led by Barnet CCG, has led to system reviews and improvements. Further assurance around maternity services, which are showing improvement, is being received through CQRG and the Maternity sub-group.

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The Trust continues to report high numbers of Caesarean Sections, which they believe is due to the complexity of the patient group. Additional information and evidence has been requested in the form of an audit examining the complexity of cases at a granular level. Sentinel Stroke National Audit Programme: The committee noted that stroke performance is a key area of focus, and that the Trust provided a report to the January CQRG in relation to performance against the audit criteria. A programme of quality visits has been agreed across NCL to stroke units.

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Appendix 2: Mental Health and Community Services

Camden and Islington NHS Foundation Trust (CIFT) Are Services

Safe? Serious Incidents (SI): The committee noted that the Trust reported nine serious incidents in November 2015. Five of these SIs affected Camden, with these being two service user deaths, two episodes of significant violence to staff and identification of asbestos in a hospital building. The committee raised concerns about the management of SIs within the Trust, which has been highlighted as an ongoing issue in previous committee meetings. Of note are the number of overdue reports, which continues to increase despite assurances from the Trust previously that new governance systems are in place to address this. The Trust, Islington CCG and the CSU Patient Safety Team are working together to establish improved ways of working in order to address the concerns, and SIs are reported through a tracker to each CQRG meeting. Camden CCG continues to raise concerns through the lead commissioner model. Incidents: The committee noted that the Trust are reporting an increased number of violent incidents. Feedback was given to the committee that the Trust has implemented additional support structures for staff, including police surgeries and additional training on personal safety and the management of violence and aggression. The risk of serious harm as a result of violent incidents has been added to the Trust risk register and is monitored and reviewed through internal governance structures. Third Thematic Review: The third thematic review continues, with Quality and Safety and Clinical Lead representation from Camden CCG. A plan is in place to review 26 cases at individual level, in order to establish any themes, trends and additional learning to support improvements.

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Quality Alerts: The committee were informed that four alerts were received about CIFT in November and December 2015. There is a clear theme within the alerts around communication with GPs and following discharge pathways. In addition to quality alerts, concerns have been raised by member practices in Camden about access to crisis services and the role of assessment teams. Concerns were raised by the committee that the Trust were reporting that they had not identified any themes from quality alerts thus far, and this has been raised with the Trust through CQRG. It has been agreed that themes from feedback from commissioners and GPs will be shared with the CQRG at the next meeting. A meeting is scheduled on 16th March for Camden CCG Clinical Leads and the Head of Quality and Safeguarding to discuss crisis service pathways, roles and responsibilities with senior representatives from the Trust. Safeguarding: The committee was appraised of the concerns pertaining to safeguarding capacity at the Trust, as the recently recruited safeguarding manager has resigned their post. The committee were informed that although a new manager has been recruited, interim arrangements are being held by the Head of Social Care currently. It was noted that the Trust has not set up a reliable system to capture training, case conference and supervision data, and NHS England returns indicate that no Prevent training has taken place, despite sessions being arranged. The committee agreed that it is not assured with the current safeguarding arrangements that the Trust is meeting statutory duties. The safeguarding leads for Camden and Islington CCGs have met with the Trust and agreed a reporting and assurance schedule with regards this. Delayed Mental Health Assessments In Emergency Departments: The committee noted that there are delays in Emergency Departments for Mental Health Act assessments, which have increased throughout the year. The committee were informed that the Local Authority has agreed to support the Trust with this, with the provision of Approved Mental Health Practitioner availability as a back-up when capacity is reduced.

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The committee noted that Joint Commissioners for mental health have requested a deep dive be completed to investigate this issue further.


Workforce: The committee received workforce information about vacancy rates, which rose to 9.2% in Q2 2015/16; data received from the Trust shows that all Band 5 posts have now been recruited to and the Trust is meeting safer staffing standards. The committee highlighted that there appear to be long running challenges with staff recruitment as well as the degree of turnover at the Trust. This has been raised as a quality concern at CQRG, and the committee noted that further assurance is still required on workforce and capacity. CQC Inspection: The committee was informed that the CQC will be inspecting the Trust in February 2016, and that Camden CCG has contributed to the CQC feedback co-ordinated by the Islington CCG Quality Team. Following CQC inspections at some sites in Summer of 2015, the issue of risk assessments and plans not being in date or reviewed was raised. The committee sought clarification on the action from this, and were informed that the Trust completed an audit of community team case notes, which was reviewed at CQRG and provided some assurance.


This domain was not reported on to committee in January and February 2016 for CIFT.


This domain was not reported on to committee in January and February 2016 for CIFT.

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Tavistock and Portman (T&P) Are Services

Safe? Serious Incidents:

The investigation report into the suspected suicide of a patient waiting for therapy has now been received and reviewed. The committee were informed that the report was detailed, the investigation robust, and the process completed to a high standard.

Safeguarding Adults:

The committee was informed that the Trust is demonstrating continued improvement in delivery against the safeguarding agenda, and assurance has been received that all procedures are being implemented in line with requirements under the Care Act 2014.

Following the incomplete submission of metrics reported previously, the committee was provided with assurance that the Trust has now submitted all requested data sets.

Infection Control:

Assurance was sought from the Trust in relation to the annual report on infection control.

The report details mandatory training compliance, and this is reported annually. The Trust advised that they do not undertake handwashing audits or have physical contact with patients requiring infection control guidance to be considered.

In collaboration with the CSU infection control specialist, the CCG has confirmed infection control reporting and audit requirements with the Trust, in line with the Code of Practice on the Prevention and Control of Infections (2015). The Trust will review the guidance and provide assurance that infection control standards are being met.

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Care Quality Commission:

The committee noted that the Trust have provided evidence to commissioners that they had robust systems and processes in place to prepare for the CQC inspection, which took place in January 2016.

No feedback has been received to date, and this will be reviewed once formal CQC response has been received by the Trust.

Supporting Choice in Mental Health:

The committee noted that the Trust does not use Choose and Book, instead ensuring that all prospective patients are offered a choice of appointment time when first contacted.

The CSU mental health specialist has provided guidance and support to the Trust on Supporting Choice in Mental Health, and reports assurance against this.


Mental Health FFT: The committee noted low response rates to the FFT (73 of 1993 patients), although acknowledged that of those who had responded, over 90% would recommend services to friends and family. The committee requested information about next steps, and was informed that the Trust will present a themed, in depth patient experience report to CQRG, using information and data from a number of patient feedback sources. Staff FFT: The committee was informed that 129 staff responded to the FFT, and that the Trust is triangulating this information with the results of the staff survey. NHS Choices Feedback: The committee received the data that five reviews have been put on NHS Choices for the Trust since the last reporting period. It was noted that there was one positive review, and that there are no themes or key issues arising from the feedback reviews.

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The committee requested that further assurance is sought from the Trust as to how they respond to NHS Choices reviews, as it was noted that there is currently no evidence on NHS Choices that three of the negative reviews have been acknowledged and responded to. It was discussed that Trust responses on the system has been raised as a concern previously at CQRG, and the Trust have reported some difficulties with inputting to the system, however have advised that all reviews are considered alongside other patient feedback, and will be included in the themed patient experience report and used to drive service improvement.


Waiting Times: The committee noted that the Trust did not meet waiting time targets in Q2 2015/16 and discussed the need for transparency on the causes of the waiting time breaches. The committee was informed that there had been a capacity issue as well as an increase in referrals, coinciding with school holidays. The actual numbers of breaches are low, however the committee has requested that the Trust complete workforce planning to reduce waiting times, especially during holiday periods. CQUINS: The committee noted the updated position, which shows that the Trust is not currently meeting indicators. Feedback was given from CQRG that the Trust has highlighted some data quality issues as it moves to a new electronic patient record system, and that the reported data may be compromised as a result.

The committee and CCG Quality and Safety and Contracting teams are currently not assured that the Trust will achieve all CQUINS for 2015/16, and noted plans to meet with the Trust outside of the established monitoring processes to discuss the physical health CQUIN, which has been challenging for the Trust due to difficulties when recruiting a physical health nurse. It was noted that this role is now filled and a nurse in post.

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Central and North West London Community Services (CNWL) Are Services

Safe? Serious Incidents: The committee received the data that Camden Provider Services has 32 reported SIs, of which 30 are pressure ulcers. All investigations are either completed or on track to be completed within agreed national timeframes. The Trust is engaged with partner providers and regularly attends the Camden CCG pressure ulcer group, which meets quarterly to share information, challenges and learning from pressure ulcer cases. Assurance was received at CQRG that lessons are learned from incident investigations and that systems and processes are being updated and embedded. Safeguarding: The committee noted that the Trust is evidencing delivery against statutory safeguarding requirements. A verbal update was received that Camden Provider Services and the CCG Head of Quality and Safeguarding will be working together to deliver a workshop at the forthcoming Safeguarding Adult Board conference in March 2016. The workshop will focus on how community nursing services can learn from serious case reviews and the implementation of the safeguarding pressure ulcer protocol.


Workforce: The committee received information about Camden Provider Services workforce, and noted that staffing is meeting the required levels for safety. A verbal update was given to the committee about the continued recruitment programme in the Trust, and specifically for community services, which includes a stall at the RCN conference and consideration of how an apprentice type scheme could be used to develop nurses and meet gaps in service identified such as the numbers of nurse prescribers.

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Quality Visits: The committee received feedback from the quality visits, which involved over 40 stakeholders including commissioners, Healthwatch and service user representatives. The committee noted that those involved in the quality visits were given open access to all areas, including observing clinics where patients consented for this to happen. It was noted that there were positive messages around governance and patient experience, and some areas of improvement which included the physical environment, staffing levels and staff attitude. The initial feedback corresponded with the self-assessments teams had completed prior to the visits, indicating that the Trust has good oversight and understanding of gaps and areas for improvement at team level. The areas for improvement have been highlighted previously through quality and governance reporting and PLACE inspections, and local services are currently considering how improvements will be made to respond to the feedback received by the visits.


Quality Alerts: The committee noted that one quality alert had been received relating to prescribing requests in Heart Failure Services. It was noted that the service are requesting that GPs prescribe due to a lack of nurse prescribers in the team, and that the service has made a commitment to train all team members to be prescribers. The committee requested further assurance that systems are in place to ensure heart failure patients are treated and monitored effectively by the service, and noted that the lead consultant is proactive in supporting the nursing team in managing complex cases. Quarterly Complaints Report:

The committee noted the update from CQRG, and received assurance that Camden Provider Services share complaints and concerns information with commissioners in an open and transparent manner; including being responsive to additional information requests.

It was noted that reports include examples of complaints and concerns, which recommendations, and that further assurance is to be sought with regards outcomes from the recommendations and the impact on service delivery for Camden patients.

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Report Title Quality and Safety Strategy


CCG Clinical Lead

Joanne Wickens Tel/Email [email protected]

Lead Director Neeshma Shah, Quality and Clinical Effectiveness


Report Author Neeshma Shah Tel/Email [email protected]

Report Summary This strategy document sets out Camden CCG’s aspirations and expectations

around quality improvement and safety across all those providers we commission services from which we believe will be welcomed and embraced by both service users and providers.

Purpose

Information Approval

To note Decision

Recommendation The Governing Body is asked to approve the Quality and Strategy


The focus of this Quality and Safety strategy is to support the achievements of the CCG’s corporate objectives and vision for the residents of Camden and the wider community for whom we commission services. Therefore this Strategy builds upon the structures and processes already embedded within the CCG and enables us to enhance and strengthen quality and safety through the implementation and further development of this Strategy over the next three years.


We understand, that quality and safety are not achieved by a reports and assurance processes alone. More important is engendering an open culture where everyone is encouraged to reflect on their practice, discuss mistakes, measure outcomes and constantly seek to improve.



Engagement

The Strategy has been developed in consultation with the Governing Body, CPPEG and the Localities.


Implementation of this Strategy will require leadership and input from the CCG’s quality and clinical effectiveness teams to embed quality improvement across the CCG and make it everyone’s business.


Successful implementation of the policy will directly improve outcomes for disadvantaged groups. Focus on safeguarding is designed to protect vulnerable groups both adults and children. The Board Assurance Framework supports the delivery of the equality and diversity plan.

Report History This is the first presentation of the Strategy to the Governing Body.

Next Steps Implementation progress will be incorporated and reflected in the Quality and Safety Report to the Governing Body.

Appendices None

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February 2016

Quality and Safety

Strategy 2016-2019

Working with the people in Camden to achieve the best health for all

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Document control

Date Version Action Amendments

1 First Draft

1.1

Update post seminar with the Governing Body on 25 November 2015

Section 1.1

1.2

Update post engagement events at Locality meetings and CPPEG in December 2015

Section 4 and 7

1.3 Update post Quality and Safety Committee

Section 5 and Foreword

1.4 Added forewords

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Foreword Since the establishment of Camden Clinical Commissioning Group, our vision and mission has clearly identified the delivery of safe, effective and responsive services as our most important responsibility. Quality, which includes all of these and importantly patients’ experience of services should be at the heart of all our commissioning. Every patient’s legitimate expectation and assumption should be that services provided to them are safe, high quality and place their well-being at the heart of them and this is articulated in the NHS Constitution which we as commissioners have a duty to deliver. Clinical commissioning seeks to bring a strong clinical understanding, based on evidence and focussed around the principles of quality improvement, standardisation and measurement, to the continuous assessment and improvement in quality. The focus of this quality strategy is to support the achievements of the CCG’s corporate objectives and vision for the residents of Camden and the wider community for whom we commission services. Therefore this Strategy builds upon the structures and processes already embedded within the CCG and enables us to enhance and strengthen Quality and Safety through the implementation and further development of this strategy over the next three years. This strategy document sets out our aspirations and expectations around quality improvement and safety across all those providers we commission services from and we believe will be welcomed and embraced by both service users and providers.

Caz Sayer Chair

Dorothy Blundell Chief Officer

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Contents

Quality and safety monitoring cycle 5

1. Introduction 6

2. Definition and scope 8

3. Quality of commissioned services 13

4. Quality improvement in primary care 21

5. Quality in Care Homes and for Individual Placements 21

6. Building block for quality assurance and improvement 22

7. Supporting innovation 25

8. Implementation, monitoring and review 25

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Quality and safety monitoring cycle

Contract with Provider that specifies standards and quality metrics

Service specification quality schedule

Contract and Performance monitoring meetings

Clinical Quality Review Group meetings

Review performance of services.

Activity and financial performance.

Quality indicators: Commissioning for Quality and Innovation (CQUINs) and Patient Reported Outcome Measures (PROMs).

Peer reviews. CQC inspections.

Patient safety aspects Patient / Camden Patient

and Public Engagement Group/ GP feedback.

Avoidable harm. Serious incidents and Never

Events. Incidents and near misses Complaints. Quality surveillance e.g.

alerts, Care Quality Commission reports, walk rounds.

Serious case reviews.

CCG Quality and Safety Committee receive monthly reports

Camden CCG Governing Body

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1.0 Introduction 1.1 Our ambition

Our ambition is whenever anyone in Camden needs or accesses care that it is safe and of the highest possible quality. This ambition applies to care in the broadest sense, from preventative programmes, to primary, community, social and hospital care. As an organisation we are committed to taking a multifaceted approach to maintain our focus on quality and safety throughout the commissioning cycle. Indeed any contract that does not include appropriate assurance and reporting relating to quality and safety will not reach our internal process for sign-off.

It is essential that quality and safety is seen from the patient’s perspective. We have strong patient involvement throughout our organisation, to ensure the patient’s voice is integral to the design of the services we commission and how we monitor them. Our outcomes for the quality and safety of the services that we commission have been developed alongside our patients.

We understand, that quality and safety are not achieved by a reports and assurance processes alone. More important is engendering an open culture where everyone is encouraged to reflect on their practice, discuss mistakes, measure outcomes and constantly seek to improve. Safe and high quality care is never static; it is achieved through a constant and iterative process. We are committed to supporting our providers though this processes

Finally, we are acutely aware that patients are most vulnerable to unsafe and poor quality care as they move between different parts of the healthcare system. To ameliorate this risk and help to tackle the inevitable silos within the health system, we will facilitate a quality programme that brings together providers from across the patient pathway.

1.2 Our Population

Camden has an estimated population of 220,338 according to the 2011 census. This is expected to rise to 245,100 by 2023, an increase of 8.5%. The age and gender of the Camden population is very similar to that of London overall, and relatively younger than England with a greater proportion of younger adults aged between 25 and 40. Camden has a diverse variety of ethnic groups and cultures – nearly 35% of the overall population is from a black minority ethnic group background, the largest groups being Bangladeshis, black African and Irish. Camden is ranked the 15th most deprived borough in London; deprivation levels are linked to numerous health problems including chronic illness and lower life expectancy as well as unhealthy lifestyles including obesity, smoking, alcohol and substance (drugs) misuse, including over the counter drugs.

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Change that is locally led, patient centred and clinically driven 1.3 Our priorities

Each year the CCG’s Operating Plan1 outlines what the CCG plans to commission based on the needs of its population and how The CCG plans to meet national outcomes and priorities.

The CCG’s aspirations are:

To shift the emphasis of the NHS to develop a systematic approach to prevention, earlier diagnosis, reducing inequalities in health outcomes targeting vulnerable groups, and supporting individuals to self-care and self-management of illness.

1 Camden’s operating plan 2015/16 http://www.camdenccg.nhs.uk/Downloads/ccg-public/Publications/policies/Camden%20CCG%20Annual%20Operating%20Plan%20201516.pdf

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http://www.camdenccg.nhs.uk/Downloads/ccg-public/Publications/policies/Camden%20CCG%20Annual%20Operating%20Plan%20201516.pdf

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To ensure that all Camden patients will experience compassionate, high quality, effective and efficient care pathways shaped by involving them, care that is integrated and focussed around delivery of outcomes defined by them, and providing easy access to services delivered in ways and places convenient to them.

For integration of care to be driven by shared digital record, data sharing, measurement and evaluation, and the commissioning and contracting of models of service that drive partnership and integration.

Achieving long term financial sustainability by a clinically driven focus on the quality of services, and getting the basics right the first time, every time to cut the ‘cost of chaos’.

The CCG’s Business Plan2 sets out its priorities in eight objectives. The objectives form a comprehensive view of how Camden will achieve its vision. The Plan reflects the clinically driven focus on the quality and safety of services that are informed by evidence base. Objective B has a specific focus on ensuring that every CCG commissioned service has a quality and safety schedule, and standards that the respective provider will provide assurance against. All constitutional rights and transformation programmes will aim for right care, in the right place, by the right staff, at the right time. There will be clearly defined pathways, sufficient capacity and skills, underpinned by quality of care measures and feedback.

2.0 Definition and scope 2.1 Quality in healthcare

In The Next Stage Review (DoH, 2008)3 Lord Darzi concluded that if quality was to be at the heart of the NHS then it needed to be understood from the perspective of patients. When analysing aspects of their care patients made many comments and criticisms that could be grouped into the following three areas:

1. Safety – patients need to be assured that they will not come to harm and that service providers have systems in place to safeguard them.

2 Camden’s Business Plan http://www.camdenccg.nhs.uk/Downloads/ccg-public/your-say/13th%20July/Item%203.2a%20FINAL_camden%20business%20plan%20-%20document%20for%20wider%20distribution.pdf

3 Lord Darzi. (2008). High Quality Care for All: NHS Next Stage Review Final Report, Department of Health. Available at http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825

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http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825


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2. Patient Experience – patients wanted to be treated with compassion, dignity and respect at all times, receiving care that is personal and inclusive to them.

3. Clinical Effectiveness – healthcare services should be informed by the best available evidence and delivers the best clinical and patient related outcomes.

Figure 1. Domains of Quality

The CCG will ensure that both quality improvement and quality assurance are embedded in contracts with providers, and in the delivery of care provided by its membership practices.

2.2 Quality Improvement

Improving quality is about making healthcare safe, effective, patient-centred, timely, efficient and equitable4. Quality improvement draws on a wide variety of methodologies, approaches and tools which focus on: Understanding the problem – what is the data telling you and how will you use

it? Understanding the processes and systems within the organisation, particularly

patient pathways.

4 Quality Improvement made simple, The Health Foundation 2013. http://www.health.org.uk/sites/default/files/QualityImprovementMadeSimple.pdf

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Choosing tools to bring about the change, including leadership and clinical engagement, skills development, and staff and patient participation.

Carrying out equality analysis to address any unintended negative or disproportionate impact on patients, and to advance equality and inclusion.

2.3 Drivers for Quality

In developing this strategy, both national and local drivers for change have been considered.

2.4 National Context

The quality and safety of care delivered by the NHS has come under intense scrutiny following a range of high profile national reviews and investigations5.

The NHS must learn and respond to the recommendations from these reviews; improving quality and healthcare outcomes remains the primary purpose of all NHS funded care and is the responsibility of everyone working in the NHS. Key messages for the NHS arising from these reviews include: An emphasis on people over targets – “hitting the target and missing the point”. Care and compassion, safeguarding the most vulnerable within society. Openness, transparency and candour. Leadership, both clinical and managerial, from ‘ward to board’, to drive quality

improvements. Listening to patients, staff and people involved in using the services. Collaboration between providers, commissioners, regulators and patients. The Health and Social Care Act 20126 created a new architecture for the NHS within which CCGs must operate. The Act defines the responsibilities of CCGs as securing the best possible health outcomes within the resources available.

5 Robert Francis. (2010). Francis Inquiry reports volume 1 and 2, Department of Health. Available at http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018. Keogh review into quality of care and treatment provided by 14 hospitals in England http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf Don Berwick’s A promise to learn – a commitment to act – improving patient safety in the English NHS https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf Transforming care: a national response to Winterbourne View hospital – final report https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf 6 Health and Social Care Act 2012. The Health and Social Care Act 2012 is available at: http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted

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http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf

http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted

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Cultures, values and behaviours are essential in safeguarding quality and securing positive outcomes. The CCG has developed relationships with key stakeholders, including:

Patients and the public, including Camden Patient and Public Engagement Group (CPPEG)

Health and Wellbeing Board Local Authority / Public Health Camden’s membership practices Local Healthwatch Voluntary Sector The Care Quality Commission Associate CCGs NHS England Providers Monitor

The CCG will ensure that these relationships are maintained and enhanced to support the CCG to discharge its duties around quality assurance and quality improvement.

2.5 Local context

The Health and Wellbeing Board (HWB) influences local commissioning decisions, linking patient centric health and care improvement strategies. Camden’s HWB’s strategic aims link with the NHS Outcomes Framework domains: To prevent health issues from developing and getting worse. To promote better health so that inequalities do not emerge in the first place. To improve outcomes whether focusing on recovery or helping people live well

with a condition. These fit like a glove with the CCG’s focus on improving its focus on prevention, self-care, reducing inequalities and improving outcomes after diagnosis of a condition. The CCG will have a sustained and consistent focus on quality throughout the organisation including at the Governing Body level and its membership practices. Strong partnerships exist around the safeguarding of children and vulnerable adults, with participation in the work of both the Children’s’ and Adults’ Safeguarding Boards and their subgroups. The CCG is an active member of the local community safety partnership group, and has commissioned the IRIS (Identification and Referral to Improve Safety) programme to support its membership practices respond to domestic violence and abuse.

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2.6 Quality assurance

Quality assurance is the process of holding providers to account for service delivery. Quality assurance is the systematic process of monitoring and evaluation of services against a commissioned specification to ensure that the care is being provided to the desired essential standards. A quality assurance system must support the actions of those working at the front line and of those who manage and lead organisations that deliver care. Such a system requires a wide range of approaches and collaboration across organisations including regulators, health education, commissioners and patients to review available sources of information and intelligence.

The CCG has a key role as a commissioner under its constitution to drive continuous quality improvement which is defined as ensuring that service delivery achieves better outcomes for patients. The NHS Outcomes Framework sets out these improvements under five domains, and can be grouped to match the 3 patient identified domains of quality and safety.

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3.0 Quality of Commissioned Services 3.1 Scope of Commissioned services

The CCG commissions hospital, community, mental health, maternity and emergency services from a range of providers. Quality assurance processes form part of the commissioning and contracting arrangements with all these providers. A number of services are commissioned in partnership with the Local Borough of Camden under section 757 arrangements, which are arrangements between NHS bodies and local authorities. It is our intention to work with our partners to apply the principles defined in the Quality Assurance Framework as outlined below. We will work with other commissioners to ensure that there is consistency in the way we hold providers to account for their performance around quality and safety.

7 Arrangements between NHS bodies and local authorities , NHS Act 2006 http://www.legislation.gov.uk/ukpga/2006/41/section/75

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3.2 Quality improvement in commissioning

At the heart of every commissioner – provider interaction should be discussions about what is being done to improve quality. The commissioners’ role includes: Building measures of quality and safety into commissioning specifications,

and where appropriate, incentives and penalties. Putting in place effective monitoring and management that assess quality and

patient safety processes. Putting an emphasis on assuring quality and safety in evaluating current and

potential providers. Looking at governance and leadership on these issues. Providers’ self-assessment of how care is provided on the ground, and how

the culture and values of the organisation are expressed in behaviour. Seeking assurance from providers that they are implementing the Equality

and Delivery System (EDS) and the Accessible Information Standard. 3.3 Quality Assurance Framework

The CCG recognises that a framework is necessary in order to provide effective quality assurance and improvement in a consistent way. This framework should address quality and safety oversight in existing and future commissioned services, such as co-commissioning arrangements with NHS England8, with North Central London CCGs, and health and social care devolution9.

The framework has been guided by the recommendations from the national reviews, and adopts the four stages from the Keogh reviews; it demonstrates a collaborative approach which is inclusive of patients, partners and providers, underpinned by transparency, effective communication and challenge between the CCG and its providers.

The framework will support CCG staff to have a shared understanding of quality and safety and will enable: The monitoring of performance of quality and safety against agreed standards

and outcomes, including access. Effective surveillance of safety, clinical effectiveness, leadership and culture,

responsiveness, patient and carer experience. Quality and safety to be embedded in the commissioning cycle.

Stage 1: Quality Data Analysis Stage 2: Triangulation

8 Primary Care co-commissioning https://www.england.nhs.uk/commissioning/pc-co-comms/

9 Cities and Local Government Devolution Bill 2015-16 http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7322

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Stage 3: Multi-disciplinary Reviews Stage 4: Supporting Improvement No quality framework can offer a definitive conclusion about the quality of care provided. The methodology allows for questions to be raised, exploratory reviews to be undertaken and improvements to be supported.

3.2.1 Stage 1: Data Analysis

The CCG receives a range of data relating to a variety of indicators on the quality of commissioned services. Key performance indicators (KPIs) included within the quality schedule in the standard NHS contracts are regularly monitored and scrutinised. To ensure that the focus is on people and not just targets, analysis of data will seek assurances about and hold providers to account within the domains used by the Care Quality Commission.

Safe By safe, we mean that people are protected from abuse and avoidable harm.

Effective

By effective, we mean that people's care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available

evidence.

Caring By caring, we mean that staff involve and treat people with compassion,

kindness, dignity and respect.

Responsive By responsive, we mean that services are organised so that they meet people's

needs.

Well-led

By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports

learning and innovation, and promotes an open and fair culture.

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The CCG will monitor: Safety, including avoidable harm, and the reporting, management and learning

from serious incidents. Clinical effectiveness based on outcomes, integration of care, compliance with

nationally evidenced informed practice. Patient experience, including real time feedback, from surveys and complaints. Experience of patients from vulnerable and protected characteristics. Duty of candour, openness and transparency. Safeguarding alerts and metrics. Safe, effective transfers of care with comprehensive discharge

communication. Workforce metrics. Staff experience. Leadership and culture.

This information gathered directly from providers will be supplemented with other intelligence to support triangulation of information (stage 2).

3.3.2 Stage 2: Triangulation

Quality and safety information should not be reviewed in isolation, and due consideration should be given to provider workforce and, cost and efficiency programmes. Triangulation is an opportunity to benchmark providers, review trends and identify concerns if a provider is an outlier. Patient and public feedback on their experience of commissioned services is one of the most valuable data to incorporate in this stage. CPPEG consists of a group of patients who are members of local general practice patient groups (commonly known as PPGs) who support the Clinical Commissioning Group in ensuring the patient voice plays a key role in our decision-making. A CPPEG representative is core member of: The CCG’s Governing Body, and its governance structures such as Quality and

Safety Committee, Audit Committee and Procurement Committee. The Medicines Management Committee, UCLH and CNWL Clinical Quality

Review Group.

Patient experience captured through the Family and Friends Test (FFT), Patient Advisory and Liaison service (PALs), surveys and complaints provides a range of intelligence in addition to that monitored against key performance indicators. The CCG actively raises awareness and encourages reporting such feedback by providing links on the CCG website to local providers’ sites on the NHS Choices

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website. Providers are asked to analyse all their data on patient experience10 to provide an enhanced understanding of the care they provide and to identify targeted improvements.

The CCG has a quality alert system (QAS) whereby GP practices can provide intelligence and concerns related to the care received by their patients, as recommended in the Francis Report11: “GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern, so that they do not merely treat each case on its individual merits. They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers in order to make patient’s choice a reality. A GP’s duty to a patient does not end on referral to hospital, but is a continuing relationship. They will need to take this continuing partnership with their patient’s seriously if they are to successful commissioners.”

10 This includes regular reports on complaints, PALs, claims, litigation, Friends and Family Test, National patient surveys, CQC inspection reports, feedback received on NHS Choices.

11 Robert Francis. (2010). Francis Inquiry reports volume 1 and 2, Department of Health. Available at http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018

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The quality alert system provides early warning of any failures; specific issues are followed up with the provider concerned and the outcome shared back with GPs. Trends and themes from these alerts are shared with the GP practices via a monthly newsletter. There is real time review of the quality alerts and they are raised with the individual providers, and incorporated into the provider updates received by the Quality and Safety Committee. Quality Surveillance Groups, at local area team footprint, provide a forum to share intelligence and raise concerns relating to health and care providers. The group’s membership consists of Regulators, Health Education England, local Healthwatch, clinical commissioners, local authority commissioners and NHS England. Planned deep dives into topical issues provides further assurance at these meetings. CCG quality and safety team staff review provider Board papers to learn of the issues relating to quality and safety performance that provider Boards are being notified of, and the emphasis each provider places on quality and safety. Any quality and safety concerns are shared with the contracts and performance teams to ensure that appropriate levers are applied, and the information is considered in future procurements.

Any intelligence gathered from triangulation provides an evidence base to generate key lines of enquiry for the multi-disciplinary review process (stage 3).

3.3.3 Stage 3: Multidisciplinary Reviews

Multidisciplinary reviews are supported by a range of individuals from clinical and professional backgrounds who review evidence presented to them. There are a number of existing meetings between the CCG and providers that fulfil the requirements of a multidisciplinary review as follows: Regular (monthly or 6 weekly, depending on the services provided) clinical

quality review group (CQRG) meetings. Membership of these consists of clinicians, and executive and patient representatives from both commissioners and providers. A forward planner ensures that all quality metrics are reviewed in a planned way, allows quarterly focus / deep dives on cancer, maternity, infection control, patient feedback, progress against the provider’s Quality Account priorities and time to discuss any immediate concerns. Quarterly deep dives are supported by commissioner subject matter experts.

Sub groups that provide a forum for commissioners and providers to discuss

specific subject matter issues in greater depth which provide the CQRG with assurance of quality and safety. Examples of these include the provider infection prevention and control, maternity, and cancer sub-groups.

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A Serious Incident panel meets monthly to review provider’s final reports on serious incidents and never events. The panel has representatives from all five North Central London (NCL) CCGs, the North and East London Commissioning Support Unit (NELCSU) patient safety team and subject matter experts. The process provides a perspective on safety incidents, the investigation process, actions taken and lessons learned by the providers.

The National Reporting and Learning System (NRLS) collates information on

all reported incidents resulting in low harm to serious harm. Trends and themes are available on a 6 monthly basis, and inform local and national learning from incidents.

Commissioner walk rounds provide an opportunity to observe the care provided

and an opportunity to speak with both staff and patients.

Healthwatch targeted visits which observe care provided and provider processes.

NCL joint formulary committee and local drug and therapeutics committees which provide assurance relating to medicines governance.

Regional patient safety, maternity, and safeguarding, and strategic planning

footprint level surveillance group meetings which provide another multidisciplinary opportunity to provide assurance, identify concerns, and discuss improvement strategies.

At a NCL strategic planning group footprint, the respective CCGs’ directors of quality meet monthly to benchmark and share intelligence on providers for whom they are lead commissioners.

Safeguarding Boards meet regularly with commissioner and provider

representation from within the borough boundaries, providing assurance of safeguarding practice, case reviews, adult reviews and shared learning.

Senior clinical and executive leadership meetings.

3.3.4 Stage 4: Supporting Improvement

Safeguarding quality and safety is everybody’s business and in this context the CCG will work with its providers to: Support them in improving areas of underperformance that impact on patient

experience, safety and effectiveness.

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Incentivise sustainable improvement in agreed areas through the contractual process in the use of CQUIN (Commissioning for Quality and Innovation) payments.

Support work on integrated models of care that are centred on the patient’s needs, providing the right care, at the right time, in the right place, by the right staff.

Recognise that the maintaining quality and safety as patients transition between providers is critical and support schemes to facilitate this transfer.

Improving the quality of care and reducing variation in outcomes provided by the CCG’s membership practices.

In his review Don Berwick’s assessment of improving quality suggests that improving quality and outcomes of care does not cost more, in fact quite the opposite. Efficiency supports quality improvement based on evidence that efficiencies are realised from having reviewed systems and processes, and embedding these improvements as part of daily care. Another important contribution is that of workforce planning and development – a capable, competent and motivated staff delivers sustainable change, and supports continuous improvement. The CCG will support its staff to attain this status. The public and patients also have a part to play in quality improvement from adopting healthier lifestyles, maintaining their well-being, and taking ownership of already diagnosed conditions with the help of health and care professionals by using self-management options.

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4.0 Quality improvement in primary care

More than 90 percent of all healthcare contacts in England and 300 million consultations annually occur in primary care. The GP member practices of the CCG are clinical commissioners and also responsible for the provision of quality primary medical services, providing safe, effective care and offer a positive experience of care. The Health and Social Care Act put a legal duty for CCGs to support quality improvement in general practice. One element that has been highlighted consistently is the variation in general practice. The CCG will work with NHS England as co-commissioners of primary care to support improvements in General Practice under the domains of quality: Patient experience, using data sources such as the GP survey, GP FFT, and

timely complaints handling and outcomes. Clinical effectiveness such as Quality and Outcomes Framework (QOF) clinical

markers, locally commissioned service outcomes. Safety such as managing and learning from incidents and significant events,

and safeguarding vulnerable adults and children. Patient equality information to support planning quality improvement At the time of writing this strategy the arrangements within co-commissioning of quality improvement in primary care, including the agreed measures to be monitored, have not yet been finalised.

5.0 Quality of Adult Social care provision 5.1 Context

In addition to the overseeing the quality of health care procured through our joint commissioning functions, which falls within this framework (and covered by the approaches outlined above), we recognise that health and social care work together to support some of the most vulnerable people in the community and in local care homes. All home care and care home providers must be registered with the CQC and meet minimum standards in order to operate. The CQC operate a separate set of standards for social care provision, but this is closely aligned with the health framework outlined above. Camden Council operate its own quality assurance processes for these services and those provided in the wider community, but joint working (both informally and formally) is essential to ensure that the residents of Camden with support needs receive good quality care.

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5.2 Scope of services

Camden Council commission or provide a range of services in the community, in residential care and in nursing homes.

5.3 Quality Assurance Framework

The Council has a range of measures in place to monitor the quality of the services it funds, and we will work together to share information and develop joint intelligence on both providers of services and to support the individuals receiving care. These include:

A quality assessment framework (QAF) is being developed for home care (which will also be extended to include residential and wider community services). The QAF will set a baseline for each provider and enable the Council to determine quality improvements in the provision of care over the life of the contract, and will lead to an action plan to ensure continual improvement.

The Council is currently procuring and developing a contract monitoring management tool (Firefly) which will enable regular reporting of performance directly from the providers. This will capture performance against the key performance indicators. Checks will be in place to validate the information provided, enabling earlier identification of poor performance and risk which will prevent the escalation to safeguarding/establishment concerns.

Recording and reporting for "quality alerts" and soft concerns about providers to flag trends and inform monitoring.

Development of consistent customer satisfaction surveys. New approaches to working together on medicines management for residential,

nursing and extra care services, including improved reporting Establishment concerns and suspension protocol jointly agreed between the

Council and the CCG. Working with the Safeguarding Adults Partnership Board to implement and

deliver the pressure sores pathway across residential settings and in local acute trusts.

6.0 Building blocks for quality assurance and quality improvement 6.1 Leadership

One of the key factors cited in the recent national reviews into organisational failings in healthcare was that of leadership and its link to the organisation’s focus on quality and safety.

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Leadership was highlighted at all levels - clinical, executive and Board, often termed as ‘from ward to board.’ Demonstrating these leadership qualities and behaviours applies both to commissioners and providers.

6.1.1 Leadership from the Governing Body

The Governing Body has a keen interest in quality and safety and hold the CCG to account for ensuring that quality assurance and quality improvement are at the forefront of everything the CCG commissions.

The Governing Body understands that to ensure our patients always receive safe and high quality care, a reflective, transparent and no blame culture are paramount. The Governing Body aspires to role model this culture during Governing Body Meetings and at the Quality and Safety Committee. Furthermore, The Governing Body expects that this culture will extend to the way our team challenge and support our provider organisations. The Governing Body consists predominately of clinicians working within the local health care system, in many cases having first-hand experience of the quality and safety issues. This local knowledge, alongside the collective experience of the full governing body, provides an additional nuance to how we commission high quality a safe services for our patients. Meanwhile, the lay membership of the Governing Body consistently challenge their clinical colleagues to ensure that the patient’s perspective is at the heart of everything that we do. The Governing Body secondary care nurse and clinical lead for safeguarding quality and safety have specific roles in scrutinising the quality and safety agenda and are directly involved in all 4 stages of the quality assurance of providers. They are also members of the Quality and Safety Committee of the Governing Body, which maintains the quality, safety and safeguarding oversight of care provided locally. Finally, the Governing Body understand the importance of continuous quality improvement and has a quality improvement sponsor who ensures there is a culture of continues improvement across the patient’s pathway of care. The Governing Body has set a zero risk appetite in the Risk Strategy in relation to Safety and therefore this strategy reflects that there should be no compromise in relation to safety matters and Governing Body wish to have sight of issues or risks that relate to patient safety.

6.2 Safeguarding

The CCG Governing Body affords a high priority to the safeguarding of children and vulnerable adults, receiving assurance via the Quality and Safety Committee and directly receiving annual reports.

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The CCG has statutory responsibilities in relation to safeguarding and the CCG’s respective safeguarding team takes the lead role in ensuring that these responsibilities are met. Designated Safeguarding Professionals provide safeguarding leadership across the health economy, their functions include reviewing safeguarding arrangements within commissioned health services to determine whether providers are meeting their statutory responsibilities and holding providers to account if any deficiencies are identified. The CCG supports GP practices to improve the quality of their safeguarding arrangements which includes access to safeguarding training, providing case review advice and progressing safeguarding practice development. The CCG has commissioned the IRIS (Identification and Referral to Improve Safety) programme to support its membership practices respond to domestic violence and abuse. A series of GP Safeguarding Leads Fora is held throughout the year to provide an opportunity to share key safeguarding information including lessons learnt from national and local case reviews.

6.3 Medicines Optimisation

The CCG has an embedded focus on medicines optimisation that is informed by robust evidence base, and safe. The aim is to maximise the positive outcomes that a patient derives from medicines and the value the local population experiences from the CCG’s investment in medicines, including access to innovative treatments. Medicines optimisation contributes to all five domains of the NHS Outcomes Framework. Managing medicines optimisation consists of: Aiming to understand the patient’s experience, as this will influence their

concordant use of medicines. Robust evidence informed choice of medicine so that transfer of care across

the integrated pathways is seamless. Ensuring the safe use of medicines as possible, including good antibacterial

stewardship. Making medicines optimisation part of routine practice, leading to reduction in

variation and optimising value.

The CCG’s medicines management committee oversees the decision making and governance associated with the commissioning of medicines in the local health economy.

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7.0 Supporting Innovation

The National Information Board in its Personalised Health and Care 2020: A Framework for Action and Camden's Joint Digital Strategy outlines the vision for using Data and Technology to transform outcomes for patients and citizens. From March 2018, all individuals will be able to record their own comments and preferences on their care record, with improvements in quality of care through maximising the use of digital technology.

The establishment of new models of care to improve the integration of care will also encourage all the providers involved in the individual’s care to share relevant results and data that will contribute to optimising care. These models need to be supported by good governance and where the local health and care providers share the learning and contribute to the cycle of continuous improvement.

8.0 Implementation, monitoring and review To ensure accountability, implementation, monitoring and review will be monitored by the CCG Q&S Committee and a progress report provided to the Governing Body on a yearly basis. However, to ensure delivery of the quality agenda and corporate objectives we require a commitment to a quality focused culture throughout the CCG and look to the leadership of committees and groups to take responsibility for quality and safety, in particular:

Executive and Senior Management Team Commissioning Committee Finance and Performance Committee Audit Committee Quality and Safety Committee Procurement Committee

The CCG itself has also to demonstrate that it is operating effectively to commission safe, high quality and sustainable services within their resources and internally it will demonstrate this in a variety of ways:

Internally focussed quality reviews Risk registers CCG Assurance Framework

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The CCG has gaps in its oversight of quality and safety of commissioned services, and needs to:

Recognise the risks associated with new models of integrated care and have

good processes in place to receive assurance from these providers to safeguard patients.

Embed quality and safety assurance and improvement processes in every service re-design, including locally commissioned services from primary medical care providers.

Report on quality and safety assurance for services within section 75. Report on quality and safety assurance and improvement for care homes and

domiciliary care. The CCG will need to develop a quality assurance framework for Primary Care as the co-commissioning agenda becomes better defined in the shared roles and responsibilities across the CCG and NHS England. This proactive and reactive management of risks means that the CCG is able to provide a dynamic and continuous quality improvement process for the systematic identification and analysis of all risks. Relevant stakeholders are made aware of the significant risks through the CCG Governing Body.

Quality performance measurement and metrics

The CCG monitors and reviews its performance in relation to Quality and Safety and the continuing suitability and effectiveness of the systems and processes in place to manage associated risk through the oversight of the CCG Governing Body, Executive Team and the Governing Body Committees as detailed within this Strategy.

The availability of meaningful, relevant and timely information in relation to safety and quality is essential to monitor a range of clinical indicators that provide assurance and direction in the analysis of clinical outcomes and the identification of learning. We use a range of processes in order to monitor and assess safety and quality. We synthesize information from a range of sources including audit, benchmarking, observation (unannounced inspection), feedback from patients and staff, which is presented in dashboards at Trust, Division and ward level.

The implementation of this Strategy for Quality and Patient Safety will enhance and promote the commissioning and delivery of safer, clinical effective care and services; whilst driving improvements in patient and staff experience and importantly the quality of care.

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Once the Strategy has been approved by the CCG Governing Body, the:

CCG Quality Team will ensure the Strategy is communicated internally and placed on the intranet for access.

An annual report on Quality and Safety will be produced by the CCG Quality Team following the end of each financial year. The report will be received and reviewed by the Clinical Governance Committee and approved by the CCG Governing Body.

The Strategy itself will be reviewed no later than 30 April 2017.

Conclusion – To Ensure the CCG Commitment to Quality and Patient Safety

The CCG will:

Continuously strive to commission quality services that are safe, clinically effective and delivered by competent, caring and compassionate health and social care staff to ensure that the patients have a positive experience of care.

Design and commission quality services with Patients for Patients that are safe, evidence based and provide a personalised responsive service.

Be mindful of Patients, Families and Carers time and their need for accessible care delivered in high quality health care facilities closer to home.

Expect that Patients, Families and Carers are treated at all times with privacy and dignity.

Initiate and drive improvements in quality through contracts and incentive schemes.

Actively seek assurances on the quality and safety of services commissioned on behalf of the resident population of the Wigan Borough.

Analyse and assess relevant information and data, triangulating with this other intelligence.

Monitor standards of Quality and Safety to ensure that we are responsive and reactive to change within our commissioned services.

Continually reassess, provide feedback and support to our Providers.

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Report Title Improving Access to Psychological Therapies (IAPT)

Agenda Item 3.1

Date 26 February 2016

Lead Director Susan Achmatowicz Chief Operating Officer

Email [email protected]

Report Author Liz Crisp Debbie Holt

Email [email protected]; [email protected]


Dr Jonathan Levy Email [email protected]

Report Summary

Improving Access to Psychological Therapies (IAPT) is an NHS England (NHSE) mandated programme and, therefore is a ‘must do’ for Camden CCG. There has been a significant expansion in access to psychological therapies since IAPT’s inception in 2008, including the introduction of a clear set of access, waiting times and recovery targets closely monitored by NHSE.

Camden currently has two IAPT service elements brought together under one single care pathway, including:

A block contract with Camden and Islington Foundation Trust (CIFT) for the iCope service, accountable for 9.79 per cent of the 15 per cent access target;

An Any Qualified Provider (AQP) framework delivered by seven providers delivering 5.21 per cent of the 15 per cent access target.

This business case sets out options for the future commissioning arrangements for Improving Access to Psychological Therapies in Camden from April 2017 aligned to the Five Year Forward View (FYFV) and Monitor guidance regarding contracting.


Information Approval

To note Decision

Recommendation The Governing Body is asked to approve the following recommendations:

1. continued investment of £18,690,000 (£2,670,000 per annum) for psychological therapies in primary care from April 2017;

2. of the above amount, £16,209,564, (£2,315,652 per annum) to be allocated to procuring a 7 year (3+2+2) contract for IAPT steps 2-3 with appropriate break clauses;

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3. proposal to take out Step 4a1 from the current IAPT service configuration and reinvest this activity and remaining £354,348 per annum within the primary care mental health pathway, with the understanding of the risks involved in Section 6.5;

4. new payment structure of the IAPT contract to be based on cost and volume with outcomes and treatment completion incentive payment; and

5. New contracting model to be lead provider contract, replacing current block contract and Any Qualified Provider (AQP) arrangements.

Recommendations 2 and 3 were introduced following a response from Commissioning Committee in January 2016 to place the IAPT vision in context of the whole mental health pathway.


Camden CCG continued investment in Improving Access to Psychological Therapies is consistent with the CCG’s strategic objective to:

Improve health outcomes, address inequalities and achieve parity of esteem and

Improve the quality and safety of commissioned service.

Integrating psychological therapies within Camden addresses the needs of residents with anxiety and depression, with the ultimate aim of providing people with:

increased choice and control over their care;

increased recovery capital;

improved quality of life and health and well-being; and

reduced need to use other NHS services.


The risk analysis and mitigating measures are at 6.5 The following risks have been identified.

NHSE targets may not be met and have implications for the CCG’s

assurance ratings;

Widening the scope could result in the service losing focus but a narrow scope presents risks around access targets and flexibility;

Duplication of services, especially around IAPT Step 4a and Team around the Practice; and

Delays to commencing the procurement process are likely to mean that new Public Contract Regulations 2015 will become effective from 18 April 2016 and there is a significant risk that the procurement will not be concluded in before current contracts expire.

1 Step 4a – this refers to a patient cohort who is likely to show clinical improvement in treatment but unlikely to recover (ie, will

not move from caseness to non-caseness following the IAPT intervention)

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There are no known conflicts of interest.


The paper seeks approval for the continued investment of £2.67 million per annum for psychological therapies in primary care. This funding is in line with the current IAPT contract(s) expenditure and the NHS England IAPT capacity and sustainability checker.

Engagement

Engagement activities include:

market engagement ‘Vision Event’ (see Appendix 7); consultation with iCope patient focus groups ongoing consultations with clinical leads and other colleagues.


The commissioning intentions do not result in any change to existing policies and procedures. An equality impact assessment is available and based on the proposals set out in this paper adjustments will be made as required.

Report History

March 2015 – paper approved by Commissioning Committee for contract extension of incumbent IAPT provider contracts until March 2017 to allow new services to embed before determining future commissioning intentions for people with common mental health needs.

January 2016 – Vision Paper proposing procurement of new contract and payment model, agreed by Commissioning Committee subject to following caveats: o Further clarity on the £468k core block funding and its

associated service provision o Placing the IAPT Vision in the context of the whole mental

health pathway including initiatives such as Team around the Practice and Big White Wall

o Revising the paper to focus more on Camden clinical outcomes as opposed to a purely nationally mandated, KPI approach

o Update the contract extensions and tender waivers already used (table in Appendix 3)

o Highlighting to the Governing Body the risk of a reduction in the CCG’s assurance rating in the event that IAPT metrics are not met.

February 2016 - IAPT Vision Paper was transferred to a business following guidance from PMO

Next Steps To proceed to the procurement phase

Appendices

Appendix 1 - Long Term Conditions/Medically Unexplained Symptoms Appendix 2 Benchmarking data with other London boroughs Appendix 3 – Contracting route – detailed description of possible models and contracting route appraisal Appendix 4 – Procurement routes Appendix 5 – IAPT Stakeholder Feedback events Appendix 6 - Service User Engagement Feedback [Extract]

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1. EXECUTIVE SUMMARY

Improving Access to Psychological Therapies (IAPT) is an NHS England (NHSE) mandated programme and is therefore a ‘must do’ for Camden CCG. There has been a significant expansion in access to psychological therapies since IAPT’s inception in 2008, including the introduction of a clear set of access, waiting times and recovery targets, closely monitored by NHSE.

For an individual experiencing mental health illness, psychological therapies are an important element of the package of care and for many people experiencing anxiety and depression an IAPT service may be the only type of mental healthcare they need.

NICE recommends the use of a stepped care approach in the commissioning and provision of psychological therapies, which demonstrates clearly defined pathways for the management of common mental health conditions.

The Department of Health (DoH) set the national ambition for IAPT services to achieve two targets by March 2015:

15 per cent per annum of those with anxiety and/or depression will be able to access psychological therapies; and

of those completing treatment it is expected that at least 50 per cent will recover (move from caseness to non-caseness.2)

Mental health access standards3 came into effect in April 2015, mandating CCGs to demonstrate improvements towards compliance by April 2016.

75 per cent of people referred to the IAPT programme will be treated within six weeks of referral, and

95 per cent will be treated within 18 weeks of referral.


block contract with (CIFT) for the iCope service, accountable for 9.79 per cent of the 15 per cent access target;

AQP framework delivered by seven providers delivering 5.21 per cent of the 15 per cent access target.

The iCope block contract, first commissioned in 2008, has been varied to include two additional service provisions to the basic IAPT offer. This includes the delivery of Step 4a4

services (iCope Plus) and the long-term conditions (LTC) medically unexplained symptoms (MUS) pilot (2013-16).

Historically, mental healthcare has been paid for using block contracts and data flows have been centred on activity. Monitor, as the sector regulator for health services is clear that there must be no more unaccountable block contracts for mental health going forward.

2 “Caseness" being the threshold at which it is appropriate to initiate treatment and is defined by a score of eight or more on

GAD7 and ten or more on PHQ-9. 3 NHS England February 2015 Guidance to support the introduction of access and waiting time standards for mental health

services in 2015/16 http://www.england.nhs.uk/resources/resources-for-ccgs/#times. 4 Step 4a – this refers to a patient cohort who is likely to show clinical improvement in treatment but les likely to recover (i.e.

move from caseness to non-caseness following the IAPT intervention)

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http://www.england.nhs.uk/resources/resources-for-ccgs/#times

The proposal in this business case is to change from the current block and Any Qualified Provider (AQP) arrangements to an outcomes-based contract. This contracting approach supports the stated aims of the Five Year Forward View (5YFV).

Performance in the current IAPT service continues to improve. However, we know there are some challenges in the system and we are clear where improvements need to be made. For example, access for under-represented groups, improved attrition rates and extending treatment sessions based on the patients’ complexity in line with NICE guidance for common mental health disorders. As well as the mandated standards set by NHSE, Commissioners propose to set a number of standards and outcomes that will benefit the needs of Camden patients.

The following outcome measures have been selected to reflect local priorities: These were identified following consultation with clinicians, patients and commissioners, and will be further developed to determine which ones will be attached to payment, how they will be measured and percentage weight distribution of the payment according to priority.

1. reduction in Employment Support Allowance for people with mental health conditions;

2. increased access to treatment for under-represented groups;

3. improvements in physical health;

4. data completeness;

5. recovery and clinical improvement;

6. waiting list target times;

7. patient satisfaction; and

8. course completion.

NELCSU are supporting Commissioners to specify the outcomes model in the contract and develop monitoring mechanisms.

A phased year on year implementation for meeting outcomes will be introduced, the outcome structure is proposed in the following increments:

Table 5: Example of proposed model of phased implementation of outcomes

Year 1 Year 2 Year 3 Year 4 Year 5 + 10% 20% 30% 40% 50%

The vision for future IAPT in Camden builds upon an understanding of the emerging drivers for change, including:

shift in the mental health landscape in Camden (including the Mental Health Mandate; initiatives such as Team Around the Practice, impact of personal health budgets, value based commissioning integrated practice units and federations);

awareness and understanding of local and national initiatives that are still in development/embedding;

move away from block contracting arrangements as per Monitor guidance;

ambition to widen the service’s reach beyond primary care, extending its presence into community and universal services;

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changing nature of referrals to psychological therapy services – a shift from predominately GP referrals (84 per cent in 2012/13 to 59 per cent in 20145/15) to a self-referral pathway (estimated eight per cent in 2012/13 to 27 per cent in 2014/15) particularly with the introduction of innovative treatment offers such as online therapy;

stakeholder/patient experience feedback of block and AQP provider and commissioning arrangements;

a need to review existing contract arrangements in order to address under-performance; most notably on national KPIs, drop-out and declined treatment rates;

low rate of access for under-represented groups experiencing anxiety and depression and as highlighted in the Camden Public Health: Depression and Anxiety profile;5

The new service will have a flexible approach to meet demands of Camden and support implementation of the new 5YFVMH including the expansion of IAPT services by 20/21. The contract will include levers to drive flexibility, including aligning with other primary care services moving towards seven-day access.

The mental health landscape is clearly changing; this business case for the re-commissioning of IAPT in Camden reflects those changes, ensuring the development of a flexible service model in order to achieve both NHSE and Camden specific key performance indicators and outcomes.

This business case outlines the new IAPT model from April 2017 and requests Camden CCG Governing Body to approve the following areas:



3. proposal to take out Step 4a6 from the current IAPT service configuration and recycle this activity and remaining £354,348 per annum within the primary care mental health pathway, with the understanding of the risks involved as outlined in Section 6.5;


5. New contracting model to be lead provider contract, replacing current block contract + Any Qualified Provider (AQP) arrangements.

5 Camden Profile Public Health intelligence. Mental Health: Depression and Anxiety; June 2014

https://opendata.camden.gov.uk/Health/Camden-Depression-And-Anxiety-Profile/pj45-ppfv 6 Step 4a – this refers to a patient cohort who is likely to show clinical improvement in treatment but unlikely to recover (ie, will

not move from caseness to non-caseness following the IAPT intervention)

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https://opendata.camden.gov.uk/Health/Camden-Depression-And-Anxiety-Profile/pj45-ppfv

2. CASE FOR CHANGE

2.1 Introduction

IAPT is an NHSE mandated programme and, therefore, is a ‘must do’ for Camden CCG.

There has been a significant expansion in access to psychological therapies since IAPT’s

inception in 2008, including the introduction of a clear set of access, waiting times and recovery targets closely monitored by NHSE. Currently Camden are mandated to reach 15 per cent of the adult population with common mental health needs and of those completing treatment 50 per cent are expected to recover, with 75 per cent of patients seen within six weeks and 95 per cent within 18 weeks of referral.

Performance in the current IAPT service continues to improve. However, we know there are some challenges in the system and are clear where improvements need to be made. For example, access for under-represented groups, improved attrition rates and extending treatment sessions based on the patients’ complexity/needs in line with NICE guidance for common mental health disorders.

The recently published 5YFVMH is clear that NHSE should increase access to evidence based psychological therapies to reach 25 per cent of need by 2020/21, with a focus on people living with long term physical conditions and supporting people into employment. There will be added investment from NHSE to increase access for people with psychosis, bipolar disorder and personality disorder, thus extending the offer above and beyond those with common mental health disorder. Through our current commissioning arrangements in IAPT, TAP and Value Based Commissioning (VBC) for psychosis, Camden CCG is already well-placed to meet this challenge.

Historically, mental healthcare has been paid for using block contracts and data flows have been centred on activity. This has not encouraged a detailed understanding of where and how service user needs are being met. Monitor, as the sector regulator for health services is clear that there must be no more unaccountable block contracts for mental health going forward. The proposal in this business case is to change from the current block and AQP arrangements to an outcomes-based contract, which will help coordinate services, leading to more closely integrated care from the service users’ perspective, generate system

efficiencies and improve the overall quality of care.

The mental health landscape is clearly changing; this business case for the recommissioning of IAPT in Camden reflects those changes, ensuring the development of a flexible service model/specification in order to achieve both NHSE and Camden-specific key performance indicators and outcomes.

This business case outlines the new IAPT model from April 2017 and requests Camden CCG Governing Body to approve the following areas:



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3. proposal to take out Step 4a7 from the current IAPT service configuration and recycle this activity and remaining £354,348 per annum within the primary care mental health pathway, with the understanding of the risks involved outlined in Section 6.5;


5. New contracting model to be lead provider contract, replacing current block contract + Any Qualified Provider (AQP) arrangements.

2.2 Current Provision


block contract with CIFT for the iCope service, accountable for 9.79 per cent of the 15 per cent of the access target; and

AQP framework delivered by seven providers delivering 5.21 per cent of the 15 per cent access target.

The iCope block contract, first commissioned in 2008, has been varied to include two additional service provisions to the basic IAPT offer. This includes the delivery of step 4a services (iCope Plus) and the long term conditions (LTC)/medically unexplained symptoms (MUS) pilot (2013-16).

The current contract configurations and related service provision of each provider within the IAPT pathway are presented in table 1 below:

Table 1: Camden IAPT Stepped Pathway Current Provision

Contract Type Contract provider Description of service provision

Annual Contract

Value (2015-16)

iCope Camden (CIFT) Block Contract

Step 2 Step 3 iCope Camden - CIFT (lead provider) with consortia partners: Camden

bereavement; Age UK; Nafsiyat; and Women & Health.

Step 2 – low intensity interventions and raising awareness of service. Step 3 – High Intensity Interventions.

£1.3m

7 Step 4a – this refers to a patient cohort who is likely to show clinical improvement in treatment but less likely to recover (ie,

move from caseness to non-caseness following the IAPT intervention)

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Contract Type Contract provider Description of service provision

Annual Contract

Value (2015-16)

LTC/MUS Business Case

iCope Camden - CIFT Increase numbers of people with LTC and MUS accessing IAPT services at all Steps.

Ensure psychological interventions are a routine part of integrated services for people with LTCs.

Develop and evaluate a model within primary care for the identification and management of MUS.

Increase competence and confidence of all IAPT staff in working with LTC and MUS.

£263,812

Step 4a iCope Camden - Camden & Islington NHS Foundation Trust

Step 4a locally defined patient group who present with more complex, often co-morbid problems and are more likely to show clinical improvement across the course of IAPT treatment than move to recovery.

£400,000

IAPT AQP Contracts

iCope Camden - Camden & Islington NHS Foundation Trust;

Age UK; Nafsiyat; Women & Health.

Step 2 and/or Step 3 Estimated £560,000

IESO Digital Health (formerly Psychology Online).

Step 2 and/or Step 3. Provides live, secure, one-to-one cognitive behavioural therapy online for people with anxiety, depression, stress and phobias. An accredited therapist chats with the patient via real-time text in a secure online meeting room.

Lea Vale Health Step 3

IAPT AQP Contracts Additional projected spend agreed Dec 15

Camden City, Islington and Westminster Bereavement Service.

Commissioners are going through the due diligence process with the provider.

£100,000

IAPTus CIFT host the IAPTUS platform under commercial terms.

IAPT minimum dataset software provider and care management tool.

Indicative £50,000

TOTAL £2,673,812

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2.3 Camden’s Vision for IAPT

The implementation of Camden’s Mental Health Mandate (February 2014) proposed transformation of mental health service provision in Camden, leading to significant service level changes. These shifts in the local mental health services landscape contributed to Commissioning Committee approval in March 2015 to extend incumbent IAPT provider contracts until March 2017. This was to allow new services to embed before determining future commissioning intentions for people with common mental health needs.

In January 2016, the Commissioning Committee approved the IAPT Vision Paper, proposing the CCG go to the market with a new contract model and service specification.

Following the success of the Long-Term Conditions/Medically Unexplained Symptoms pilot (see Appendix 1), Commissioning Committee also approved that this element be included in the new IAPT offer.

The vision for future IAPT in Camden builds upon an understanding of the emerging drivers for change, including:

shift in the mental health landscape in Camden (including the Mental Health Mandate; initiatives such as TAP, impact of personal health budgets, value based commissioning integrated practice units and federations);

awareness and understanding of local and national initiatives that are still in development/embedding;

move away from block contracting arrangements as per Monitor guidance;

ambition to widen the service’s reach beyond primary care, extending its presence into community and universal services;

changing nature of referrals to psychological therapy services – a shift from predominately GP referrals (84 per cent in 2012/13 to 59 per cent in 20145/15) to a self-referral pathway (estimated eight per cent in 2012/13 to 27 per cent in 2014/15) particularly with the introduction of innovative treatment offers such as online therapy;

stakeholder/patient experience feedback of block and AQP provider and commissioning arrangements;

a need to review existing contract arrangements in order to address underperformance; most notably on access, recovery, drop-out and declined treatment rates;

low rate of access for under-represented groups experiencing anxiety and depression and as highlighted in the Camden Mental Health: Depression and Anxiety profile.8

8 Camden Profile Public Health intelligence. Mental Health: Depression and Anxiety; June 2014

https://opendata.camden.gov.uk/Health/Camden-Depression-And-Anxiety-Profile/pj45-ppfv.

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https://opendata.camden.gov.uk/Health/Camden-Depression-And-Anxiety-Profile/pj45-ppfv

2.3.1 Progress of the IAPT programme, at national level

The IAPT programme is now well embedded and a good bank of research is beginning to emerge, Research of the IAPT programme at national level,9 identified services with higher recovery rates had the following attributes:

higher average number of sessions;

use of stepped care appropriately;

core of experienced staff;

NICE compliant treatment;

high problem-descriptor (ICD-10 code) completeness;

high paired outcome completeness rates;

low DNA rates; and

shorter waiting times.

Furthermore, HSCIC data indicates that providers who are more likely to focus on improving access may find it challenging to achieve recovery targets, Thus an important consideration for commissioners is the likely impact of access on recovery and vice versa.

2.3.2 Placing the IAPT Vision in the Context of the Mental Health Pathway

The graph below demonstrates how the future IAPT service fits into the mental health pathway, particularly in relation to other services such as Team around the Practice and other wrap around services in the community.

9 Lessons from Analysis of National Data (Gyani et al, 2013 & internal analyses).

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2.4 National Priorities

IAPT is an NHS initiative which commenced in 2008. Supported by the National Institute for Health and Care Excellence (NICE) guidance, the programme aims to make evidence-based psychological therapies for depression and anxiety disorders more widely available in the NHS. Its underlying objectives are to improve the mental health of the general population and reduce the impact of common mental health disorders.

For an individual experiencing mental health illness, psychological therapies are an important element of the package of care and for many people experiencing anxiety and depression an IAPT service may be the only type of mental healthcare they need.

NICE recommends the use of a stepped care approach in the commissioning and provision of psychological therapies, which demonstrates clearly defined pathways for the management of common mental health conditions. This ensures that patients receive the least burdensome, effective treatment, necessary for their recovery, determined by a mixture of need and past experience of treatment.

The Department of Health (DoH) set the national ambition for IAPT services to achieve two targets by March 2015:

15 per cent per annum of those with anxiety and/or depression will be able to access psychological therapies; and

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of those completing treatment it is expected that at least 50 per cent will recover (move from caseness to non-caseness.10)

Mental health access standards11 came into effect in April 2015, mandating CCGs to demonstrate improvements towards compliance by April 2016.

75 per cent of people referred to the IAPT programme will be treated within six weeks of referral, and

95 per cent will be treated within 18 weeks of referral.

The recently published 5YFVMH is clear that NHSE should increase access to evidence based psychological therapies to reach 25 per cent of need by 2020/21, with a focus on people living with long term physical conditions and supporting people into employment. There must also be added investment to increase access for people with psychosis, bipolar disorder and personality disorder. In view of the anticipated national changes to IAPT by 20/21 we will need to ensure there are sufficient break clauses and flexibility built into the contract to enable commissioners to make any necessary service changes.

2.5 Local Priorities

Mental health is a priority for Camden. It is a priority for both health and social care and features highly in the Health and Wellbeing Board strategy; tackling mental health requires a joined up response across all partners, including the third sector. There are a number of protective factors for good mental health, including safe and stable housing, employment and positive social relationships, which is why Camden is taking a bio-psychosocial approach to prevent and support those with a mental health need.

Camden has the seventh highest depression prevalence in London. There are 37,000 adults who have at one-time been diagnosed with depression, anxiety, or both12 (15 per cent of prevalence equates to 5,500 people). In Camden, 8,610 people receive employment support allowance and, of these, 55 per cent13 of claimants (4,736) have a mental health condition.14 Encouraging and supporting people back to education and/or work will be a key focus for the new IAPT service, ensuring that patients have access to the range of holistic care services available.

The CCG’s business plan sets out its ambition and makes it clear that Camden will improve mental health provision and achieve ‘parity of esteem’ for local residents who have a mental health need. This is evidenced through year-on-year increased investment in mental health services and the drive to embed provision where and when patients need it.

Camden CCG’s continued investment in IAPT is consistent with its strategic aims to:

reduce inequalities and meet identified needs;

ensure access to and the delivery of safe, effective and responsive services; and

ensure maximum positive health impact with the resources available.

10 “Caseness" being the threshold at which it is appropriate to initiate treatment and is defined by a score of eight or more on

GAD7 and ten or more on PHQ-9. 11 NHS England February 2015 Guidance to support the introduction of access and waiting time standards for mental health

services in 2015/16 http://www.england.nhs.uk/resources/resources-for-ccgs/#times. 12 Camden Mental Health plan, April 2012. 13 February 2014 data. 14 Camden economic development data, London Borough of Camden February 2014.

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http://www.england.nhs.uk/resources/resources-for-ccgs/#times

2.5.1 Camden IAPT Providers’ Current Performance

2.5.1.1 Data completeness

There are currently two sources of IAPT data:

local data from providers (submitted to commissioners); and

HSCIC data (published and preliminary).

The locally reported data in Camden and the HSCIC published data position is subject to variability. This is an ongoing national issue and the CCG continues to liaise with HSCIC to address disparities between the two data systems.

Section 2.3.1 demonstrated that IAPT providers with high levels of data completeness are more likely to achieve better outcomes for their service users. The procurement process will seek to improve congruence between locally reported data and HSCIC. As part of the offer, bidders will be asked to demonstrate how they propose to work with NHSE and HSCIC to achieve robust data quality and calculations mirror HSCIC formulas.

2.5.1.2 Current Performance

Based on locally reported data, Camden IAPT achieved the following performance levels in 2015/16 for the first 3 quarters.

Table 2: Camden IAPT Performance Quarters 1-3, 2015/16

Camden IAPT (All)

Target Indicator Q1 Q2 Q3

Access Target (3.75%) 3.70% 3.65% 3.98%

Recovery Target (50%) 43.33% 45.14% 46.58%

Percentage of people completing treatment within 6 weeks of referral (75%)

80% 75% 84%


98% 99% 98%

iCope

Target Indicator Q1 Q2 Q3

Access Target (2.45%) 3.38% 3.26% 3.58%

Recovery Target (50%) 43.81% 42.22% 44.82%


75% 73% 82%


97% 99% 98%

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Access Target (15 per cent)

Camden continues to show average performance amongst its neighbouring North Central London boroughs and London Central Cluster comparator boroughs when meeting the key performance indicators (as published by HSCIC – see Appendix 2, Table A).

Close working and robust performance monitoring and commissioning of additional capacity via AQP has improved activity performance. Given the population prevalence of anxiety and depression, Camden should be consistently achieving and exceeding the access into treatment targets. A more proactive approach is required from the provider and this will be a feature in the new service model.

Recovery (50 per cent)

The latest locally reported data on recovery rates demonstrates that Camden consistently improved for the first three quarters of 2015/16, with Q3 achieving 46.58 per cent recovery. HSCIC data for Q2 of this year showed the recovery rate for England as 45.7 per cent. The Camden locally reported rate in Q2 was 45.14 per cent.

Data from HSCIC shows in 2014-15, 27 per cent of CCGs in England achieved or exceeded the 50 per cent recovery rate. In the London region only 2 of the 64 CCG areas achieved 50 per cent recovery. However, one should observe caution here; the national recovery target was based on the basic stepped care IAPT model. The extended offer, which locally includes Step 4a, can impact on recovery rates, as this patient cohort (4a) are less likely to move from caseness to non-caseness, which is the metric used to monitor recovery, while still showing meaningful clinical improvement. This business case proposes removing step 4a from the new IAPT model.

2.5.2 Considerations for commissioning Camden’s new IAPT service

NHSE metrics present a number of conflicting priorities for commissioners. A key consideration for Camden CCG is the interrelation between access and recovery rates, as prioritising one area is likely to reduce performance in the other. Owing to Camden’s high

prevalence of common mental health, access and service acceptance rates are of high priority. Equally, underperformance of recovery rates is also of significant concern, which is the case across the majority of London CCGs.

Rates of access for under-represented groups experiencing anxiety and depression indicate that the current service configuration is not successfully meeting the needs of these people. A priority for the new service will be to take a proactive approach in extending its reach beyond GP practices into community and universal services. The service will also link with the Social Participation project, which has already identified target groups within BME communities in Camden who are currently under-represented in mental health services.

Feedback from our patients (see Appendix 6) tells us that choice, control and flexibility over their treatment is highly important to them. These qualities will continue to be an important feature of the new service. Greater flexibility over the number of sessions for complex patients will also be specified, in line with NICE guidance.15

15 In comparison with other psychotherapies, CBT is brief, highly structured, problem-orientated and prescriptive,

and individuals are active collaborators. The optimal length of therapy will vary among individuals. For mild

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Research of IAPT services in England has shown that services delivering an above-average number of sessions have achieved high levels of recovery. Commissioners will also need to be mindful that widening the range of interventions and increasing number of sessions may have an adverse effect on waiting list targets to see 75 per cent of people within six weeks and 95 per cent of people within 18 weeks.

The specification will be developed in close consultation with clinical leads and stakeholders to ensure that the future configuration of services meet the specific ambitions for Camden, as well as the achieving NHSE targets for access and recovery rates.

2.5.3 Key Interdependencies

Service Description Interrelation with IAPT

Planned Care Long Term Conditions

We know that people with long-term conditions are more likely to suffer poor mental health. As practices sign up to the new planned care LCS we would expect an increased number of referrals into the IAPT service, thus helping us to achieve our access targets.

Team around the Practice

TAP was commissioned in April 2015 for people with complex mental health needs who are too complex for IAPT and not complex enough for secondary care specialist mental health. The service delivers the following elements:

● Psychological interventions (eg, Evidence-based interventions aligned with NICE guidelines).

● Care Coordination to manage the holistic need of service users supporting them through the system to access the right support from the right person first time round.

● Non-medical interventions/social prescribing (eg, social care, voluntary sector services) to improve wellbeing and quality of life.

● Capacity and Capability Building in Primary Care.

There is currently overlap with some elements of IAPT Plus/Step 4a clients and TAP. Both services are geared to see a similar cohort of patients. Significant improvement is the most likely outcome for this group and, although this is measured, it is not a target mandated by NHSE.

Removing Step 4a provision from the IAPT offer should have an impact on IAPT recovery rates, as Step 2-3 patients are more likely to recover. However, may have an adverse effect on IAPT’s access targets. Within the new service the provider will have to work harder to improve access, for example, operating outside GP practices and extended hours in line with 7-day NHS services.

It is clear that the potential Step 4a element of IAPT and TAP present tensions that will be addressed as part of the recommissioning of IAPT and the evaluation of TAP. See risk analysis in Section 6.5.

Value-Based Commissioning Psychosis and Diabetes Integrated Practice Units

These may become relevant if the IAPT scope is widened to include people with psychosis

and moderate depression, brief CBT of six to eight sessions over ten to 12 weeks is usual. For moderate to severe depression, the duration is typically in the range of 16 to 20 sessions over six to nine months. For anxiety, the optimal range of duration of CBT is between seven and 14 hours. For people with OCD, in whom the degree of functional impairment is mild, up to 10 hours of CBT including exposure and response prevention (ERP) may be offered; for those with a higher degree of functional impairment more than ten hours of CBT that includes ERP should be offered. CBT-trained therapists can be from a number of disciplines and may include clinical psychologists, mental health nurse specialists and psychiatrists.

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Big White Wall

To become a pan-London peer support online service and will not be commissioned to provide psychological therapies.

This is a resource for all patients with a mental health need including IAPT; it is extremely helpful as a self-management tool post discharge from treatment.

2.8 Gaps Outstanding

People with bulimia and perinatal mental health conditions have been identified as two cohorts with very limited options available in the borough. The only services on offer have long waiting lists with capacity to meet a small number of people with high levels of need.

Consultation with commissioners and clinical leads suggest that some people whose conditions are not so far progressed might benefit from lower intensity interventions, such as those provided by IAPT.

There are examples of good practice where IAPT services have been shaped to meet the needs of more specialist groups specific to local areas. However, commissioners will be mindful that specialisation can stretch the core service. Furthermore, it will become difficult to achieve good quality data reporting, as IAPT is measured using PHQ9 and GAD7 scales, which may not be suitable for other conditions. A criticism of some commissioners and providers is that they over-commission by attempting to bolt on too many elements to the standard IAPT offer.

Our intention is to commission a more streamlined IAPT by removing Step 4a from the new model. This is because the CCG has recently commissioned the TAP, set up specifically to meet the gap for a more complex group of patients (clusters 4–8). This approach has some inherent risks, which are laid out, in section 6.5.

Public Health data also indicates a very high prevalence of mental health conditions amongst people receiving employment support allowance. This presents a need for improving links between IAPT and employment support services.

Commissioners suggest another area to consider for the new service is improving access for people in the borough who are deaf or hearing impaired. This has been added to the Equality Impact Assessment.

3. OBJECTIVES AND OUTCOMES

3.1 Project Description

The project is to procure an IAPT service, using an outcomes-based contract which will be specified to help co-ordinate services, leading to more closely integrated care from the service users’ perspective, generate system efficiencies and improve the overall quality of

care.

3.2 Scope

The service will be eligible for people over 18 years old with common mental health problems and who are registered with a Camden GP.

As a minimum standard, the commissioned IAPT service must deliver a range of NICE compliant therapeutic interventions in a stepped care pathway approach (See table 4).

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The service will integrate governance (clinical and corporate) and host the Information Technology (IT) platform to measure IAPT clinical and non-clinical wellbeing outcomes.

Table 4: Camden IAPT Stepped Pathway Elements

Provision of the Stepped Care Pathway element

Step 2 Step 2 – low intensity interventions

Step 3 Step 3 – High Intensity Interventions

Provision of cross cutting service elements

Awareness and training Raising awareness of service/supervision and contribution to multi-disciplinary meetings (where appropriate)

Training to support more non mental health workers to take a psychologically informed approach to their work

Workforce development within IAPT of LTC/MUS and within physical health settings of common mental health

Parity of esteem for LTC/MUS

Increase numbers of people with LTC and MUS accessing IAPT services at all Steps.

Delivery of psychological interventions as routine through integrated health service provision for people with LTCs

IT platform (hosted) IAPT minimum dataset and care management software platform

NICE guidance16 states that primary and secondary care clinicians, managers and commissioners should work together to design local care pathways that promote a stepped-care model of service delivery that:

provides the least intrusive, most effective intervention first;

has clear and explicit criteria for the thresholds determining access to and movement between the different levels of the pathway;

does not use single criteria such as symptom severity to determine movement between steps; and

monitors progress and outcomes to ensure the most effective interventions are delivered and the person moves to a higher step if needed.

The service will be expected to have a flexible approach to meet demands of Camden and to support implementation of the new 5YFVMH. This may mean working with people with different or more complex needs. The contract will include levers to drive flexibility, including aligning with other primary care services moving towards seven-day access.

The service will have a presence in GP practices and will extend to universal and other community-based services. It must support collaborative working and future integrated service approaches (including co-location and embedded delivery) between mental health acute, community, primary care and third sector mental health providers, to support the changing nature of referrals to psychological therapy services – predominately moving

16 http://www.nice.org.uk/guidance/cg123/chapter/1-Guidance

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toward self-referral pathways. The provider will work in collaboration with other initiatives in Camden, such as TAP, Federation mobilisation and VBC integrated practice units (IPUs).

The needs of those residents in Camden’s most deprived wards (Kentish Town; Gospel Oak; Kilburn and St Pancras and Somers Town) will continue to be a focus as people living in the most deprived areas have a higher diagnosed prevalence of depression and anxiety compared to the least deprived areas in Camden.

The specification may include elements of mental health and specific targeted training (LTC/MUS)/supervision to enable healthcare professionals give parity of esteem to mental health when treating people for physical health conditions

3.2.1 Step 4a/ IAPT Plus and Team around the Practice

Over 90 per cent of the patients assessed for TAP have been categorised within the severe to highly challenging range, which is essentially Step 4a plus. Currently the IAPT service also see patients under Step 4a which accounts for between seven to nine per cent of active open cases.

GPs, clinicians in both IAPT and TAP services, and commissioners identified the following principles:

the significant level of unmet need in this group, as evidenced by the Camden Mental Health Review and by early referral data for the TAP service;

the need for a clear guidance on appropriateness of referral to IAPT or TAP, where the client’s needs are apparent at the time of referral;

recognition that the complexity of a client’s needs may only become apparent at the

point of assessment by an IAPT service, or sometimes only during treatment sessions (for example the identification of features of personality disorder, or of particular risk);

the importance of avoiding multiple assessments where this is possible, and of continuity of therapist in the client’s recovery, where that therapist has the required skills;

the potential benefit in terms of recovery rate if such clients are identified and reported separately within the IAPT service; and

the need for collaborative working arrangements based on a client’s clinical need,

whether or not step 4a is in scope for IAPT service.

Commissioners propose to remove Step 4a from the new IAPT model in order to streamline the pathway and avoid service duplication. Provision will be made in the new IAPT model for a small number of patients in recognition that the complexity of a person’s needs may only become apparent during treatment sessions and where stepping up may disrupt the therapeutic effect.

3.3 Project Objectives

The overarching objective of this project is to procure an IAPT service that offers best value from the market which meets and/or exceeds the national targets set by NSHE and those local targets set by Camden CCG.

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Specific objectives will be to:

develop a new service specification that will improve outcomes for the needs of Camden residents, based on research, feedback and emerging good practice;

complete financial modelling, to cost the service and to include a payments by results scheme;

test the market through a competitive tendering process under OJEU regulations, with contract to be awarded in November 2016;

contract via a lead provider model to improve partnership working and collaboration across services;

successfully roll out mobilisation period (minimum 4 months), including TUPE if relevant, to contract start date in April 2017; and

continue to monitor and support the service’s success through robust contract

management as part of ‘business as usual’ arrangements.

3.4 Project Assumptions and Constraints

An assumption of this project is that the base costs are established within the CCG’s budget.

Monitor has stated that unaccountable block contract payments will not be allowed for mental healthcare services. In light of this, the project is constrained by the imperative to change the current block payment structure to a payment by results model.

Additionally, the current contracts’ expiry date of April 2017 constrains the schedule and Public Contract Regulations 2015 (effective from 18 April 2016) add further time pressures.17

There is an assumption that TUPE will apply to this procurement and, therefore, the timetable is restricted by a need to schedule sufficient provision for TUPE into the mobilisation period and contract award. Approval of the contract has been scheduled for the 9 November Governing Body meeting, which gives minimal time for mobilisation. Chair’s

Action may be requested if evaluation concludes sooner and TUPE is relevant.

3.5 Project Outcomes

IAPT deliverables are nationally mandated by NHSE, as set out in the Minimum Quality Standards.18 The 5YFVMH state that outcomes should be holistic and reward collaborative working across the system (eg, stable housing, employment, social and physical health outcomes). Payments will no longer be entirely based on providing a number of days of care within a particular setting, but instead be rewarded for delivering whole pathways of care with achievement of defined outcomes or meeting local population need, as appropriate.

A set of outcome measures have been selected to reflect local priorities:

1. reduction in Employment Support Allowance for people with mental health conditions;

2. increased access to treatment for under-represented groups;

3. improvements in physical health;

17 Public Contract Regulations 2015 changes include Prequalification Questionnaire (PQQ) and Invitation to Tender (ITT) to be published at the same time, along with finalised contract and specification 18 http://www.iapt.nhs.uk/silo/files/iapt-for-adults-minimum-quality-standards.pdf

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4. data completeness;

5. recovery and clinical improvement;

6. waiting list target times;

7. patient satisfaction; and

8. course completion.

These were identified following consultation with clinicians, patients and commissioners, and will be further developed to determine which ones will be attached to payment, how they will be measured and percentage weight distribution of the payment according to priority. NELCSU have been asked to support the CCG to specify the outcomes model in the contract and develop monitoring mechanisms.

A phased year on year implementation for meeting outcomes will be introduced. Further to a response from Commissioning Committee, the outcome structure is proposed in the following increments:

Table 5: Example of proposed model of phased implementation of outcomes

Year 1 Year 2 Year 3 Year 4 Year 5 + 10% 20% 30% 40% 50%

Subject to the contract length being approved, (3+2+2) there is potential for further increments beyond year five. NHSE guidance19 suggests where the contract is over five years, with careful modelling and consideration; the performance element could be increased up to 100 per cent of the contract payment.

However, a cautious approach with phased implementation of outcomes payments is recommended. This type of phased implementation attracts bidders and minimises the risk of setting the outcomes-based elements too high, which could adversely stifle market entry, as bidders may decide the risk is too high.

3.6 Potential QIPP contribution

Potential contribution to QIPP has been considered as part of this business case. IAPT is specifically geared for service users in primary care whose needs are not generally high enough for secondary care mental health services. However, it is expected that early intervention through IAPT may prevent common mental health conditions becoming more complex and getting to the stage where a secondary care service is required. Furthermore, as this business case seeks to increase volume this would increase the potential for savings.

The service also seeks to achieve efficiencies through better healthcare planning for people with long-term conditions.

The potential for QIPP contribution is being worked out by the CCG’s QIPP Analyst. Cost avoidance monitoring will be built into the service offer and any contributions to the QIPP budget will be planned prior to the contract.

19 Local Payment Examples: Improving Access to Psychological Therapies: a local payment case study. A

supporting document of “2015/16 National tariff Payment System: A consultation notice”. 26 November 2014 NHS England and Monitor Publication code: IRCP 15/14.

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4. OPTIONS APPRAISAL

4.1 Options Generation Process

The ‘Do Nothing’ option was not considered appropriate for this business case, as IAPT is a

nationally mandated programme and current contracts expire in April 2017. Furthermore, it is expected the NHSE will mandate that unaccountable block contracts will no longer be acceptable.

Two options appraisals were carried out:

1. financial modelling, to propose the financial cash envelope, contract payment structure and tariff; and

2. contracting route appraisal.

The full Financial Modelling Report for the Camden IAPT Service is available on request. Modelling was carried out by NELCSU and was based on historic costs, HSCIC data and Monitor guidance. Four contract options were appraised, including:

block;

cost plus volume;

cost and volume with outcomes payment; and

cost and volume with outcomes and treatment completion.

The appraisal of the contracting route was carried out by a subgroup of the IAPT Project Board, examining four contracting models:

Lead Contractor;

Lead Provider;

Any Qualified Provider; and

Alliance Contract.

Full details of the contracting route appraisal can be found in Appendix 4.

4.2 Financial Appraisal

4.2.1 Financial Envelope

The full investment is proposed at £18,690,000 (£2,670,000 per annum detailed in the financial modelling report, available on request).

It is proposed Camden’s IAPT service will be commissioned to provide steps 2 and 3 of the care pathway, as outlined in the scope (Section 3.2) and the financial envelope will be £16,209,564, (£2,315,652 per annum) for a seven-year (3+2+2) contract with appropriate break clauses.

The remaining £2,480,436 (£354,348 per annum) will be re-invested within the psychological therapies primary care offer.

The financial modelling was based on historic costs. The current provider was approached to verify the expenditure over the last three financial years. All figures have been verified except for a query of £468k.

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The provider claims that this relates to historic funding arrangements prior to IAPT, which continued under iCope. However, the funding still sits within the block contract and is not reported as part of the IAPT budget.

The issue for the CCG is that the TUPE envelope submitted by ICOPE currently exceeds the proposed financial envelope, which has been modelled on projected activity and the current IAPT budget. The CCG is currently liaising with the provider to clarify the TUPE envelope and to determine which posts relate to this funding.

At the time of circulating this report the query has not been completely clarified.

The likely two outcomes are:

additional cost pressure will be funded from the current block contract at no loss to the CCG but the IAPT contract will be overpriced;

this funding will not be allocated to IAPT but the TUPE envelope may make the contract unattractive to the market and the CCG would need to manage any risks of redundancy costs, for example, through a risk sharing agreement

4.2.2 Activity and outcomes payment structure

Four contract payment options were appraised. As the block contract model is not an option for this service, the CCG has the option to implement one of the other options. The appraisal of these options is summarised in table 6 below:

Table 6: IAPT Contract Payment Mechanism Proposals

Description Advantages Disadvantages Risk Mitigation

Cost and Volume with Outcomes Payment

Cost related to activity volumes

Eliminates risk of over-payment.

Visible link between activity and payment.

Incentive to ensure provider provides best service to patients as linked to outcomes payment.

Risk of overpayment.

No incentive to ensure provider completes treatment.

Robust activity and outcomes data after first year to enable review of data and price to ensure no over payment being made.

Robust reporting required to review and manage cost and volume and outcomes achievement.

Marginal rate payment for volume increases in excess of x % (eg, 5%).

Cost and Volume with Outcomes and Treatment Completion payment

Cost related to activity volumes.

Eliminates risk of over-payment.

Visible link between activity and payment.

Incentive to ensure provider provides

Risk of overpayment.

Robust activity and outcomes data after first year to enable review of data and price to ensure no over payment being made.

Robust reporting required to review and manage cost and volume and outcomes achievement.

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Description Advantages Disadvantages Risk Mitigation

best service to patients as linked to outcomes payment.

Incentive to provider to ensure patient completes treatment.

Marginal rate payment for volume increases in excess of x % (eg, 5%).

4.2.3 Financial Envelope and Payment Structure Recommendation

Governing Body is asked to note the options outlined in the financial modelling report (available on request) and approve the cash envelope of £18,690,000 (£2,670,000 per annum). The money is proposed to be allocated as follows:

IAPT Step 2-3, £16,209,564, (£2,315,652 per annum) commence from April 2017 for a contract period of 7 years (3+2+2) with appropriate break clauses.

Step 4a £2,480,436 (£354,348 per annum) to be available for Step 4a, reinvested into psycholigcal therapies in primary care until such time when commissioners need to consider the expansion of IAPT as per NHSE guidance

In addition, Governing Body is asked to approve that the third payment structure option Cost and Volume with Outcomes and Treatment Completion payment (with DNA enhancement removed) is approved to support improved treatment outcomes and reduce attrition rates.

4.3 Contracting route options

As outlined in Appendix 3, four contract model options were subjected to a qualitative assessment; financial and risk appraisal by members of the IAPT Project Board:

Lead Provider

Lead Contractor

Any Qualified Provider

Alliance contract models Appendix 3f details the final evaluation. Strengths of the 3 models are presented below.

Table 6: Advantages and Disadvantages of Contract Options

Advantages of lead provider model Disadvantages of lead provider model

Increased direct control over provision across a pathway

Demand risk shifts to provider(s)

Enables money to move within the pathway

Clear governance arrangements through contracts and sub-contracts

Possible provider monopoly

Perverse incentives – may limit patient choice and encourage cream-skimming

Provider organisation may not have sufficient skills in contracting, supply chain management and commissioning

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Advantages of AQP model Disadvantages of AQP model

Offers patient choice of provider

Provides treatment capacity within Camden

Payment by results / performance / fixed activity tariff

Market development and stimulation

AQP could possibly highlight unmet demand and put pressure on budgets

Requires collaborative working


Too many AQP providers/choice

No volume guarantees

Less flexibility to commission for outcomes

Financial risk

Advantages of alliance contract model Disadvantages of alliance contract model

Strong incentives to collaborate

Limits dominance of a single organisation

Strengthens relationship between commissioners and providers

Retains the active involvement of commissioners

Shared financial and clinical risk, reliant on the performance of other providers

More complex for commissioners to manage

Requires existing relationships founded on strong trust, which might not be present in all areas

Possibility of weak leadership and accountability unless appropriate governance arrangements are established

The evaluation resulted in the Alliance Contract route emerging as the top scoring model at 76 per cent followed closely by the lead provider model scoring 74 per cent. However, this was since discounted making use of the Alliance contract for the IAPT service as:

the CCG has the ability and intends to go out to the open market to tender a new IAPT service as opposed to integrating existing/incumbent provider services;

the lot requirement does not apply (see Section 5.5) therefore no overarching contract is required;

the level of complexity for providers (and CCGs) of utilising this alliance approach is only emerging within the NHS landscape;

the CCG takes on a level of risk sharing with the alliance;

the level of complexity and resource involved (from both commissioning and provider organisations) to developing an effective working partnership which is supported by a fair and transparent payment and governance system; and

limited benefits to the CCG (and lack of appetite) to develop alliance contract model for a service that the contracting appraisal (Appendix 3) has shown can be delivered through a lead provider model supported by effective and robust contract monitoring.

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4.3.1 Contracting Route Recommendation

The recommended contract route is Option 1. ‘Lead Provider model’.

5. SERVICE PROPOSED

5.1 Impact on activity

IAPT will impact with other projects, such as Value Based Commissioning projects for psychosis and diabetes, TAP and the social participation project. Impact on the wider health and social care system will form part of contract reviews and project evaluations, which IAPT will contribute to.

5.2 Resources required to deliver the project

Project resources have been built into current CCG budgets.

5.3 Timeline and key deliverables

The procurement timeline and key deliverables are set out below.

Activity Date

Approval of Business Case by CCG Governing Body 09-Mar-16

Issue/publish: PQQ, MOI, adverts (contract finder and pro-contract). 11-Apr-16

ITT Issued to shortlisted bidders – with TUPE information (if applicable).

12-Jul-16

Award approval by CCG Governing Body 09-Nov

Standstill Period (10 calendar days after the award notification. Last day of standstill must be a working day).

11 Nov to 21 Nov

Contract Award/Mobilisation Period Nov 16 to Mar 17

Predicted Service Commencement Date Apr-17

5.4 Procurement route

Further to the advice of NELCSU, the restricted (two stage) tender is proposed as the preferred procurement route. Procurement routes and their relative advantages and disadvantages are presented in Appendix 4.

The two-stage tender is subject to the contract being advertised no later than 15 April 2016.

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5.5 Contract approach

Due to this procurement project being covered by the “light touch regime” (Chapter 3,

Section 7) of the Public Contract Regulations, the requirements to consider breaking contracts into lots does not apply.

The contract model is detailed in the options appraisal in section 4.3, proposing a Lead Provider model. The contract term is recommended as 3 years with the option to extend for a further 2+2 years. The potential 7 year contract period will support market interest and provide the period of time for clinical and non-clinical outcomes to be evidenced.

5.6 Stakeholder/Patient Engagement and Communications

Camden IAPT already has established lines of communication with both the market and patients. The preparation of the IAPT Vision Paper preceding this business case was carried out following engagement with the market and service users. Feedback from the market at the IAPT vision event is presented in Appendix 5 and summarised in table 7 below:

Table 7: Summary of Stakeholder Feedback at Vision Event September 2015

Model strategically works well

Model is strategically satisfactory, but could

improve Model is strategically weak

IAPT workers integrated within primary care supporting GPs

Accessibility (co-location in wider settings) and flexibility in appointment times and location

Integration with health and social care services and emerging national and local mental health initiatives

Addresses parity of esteem (psychological support to people with long term physical health conditions and medically unexplained symptoms LTC/MUS)

Cultural awareness and competence of services to tackle inequalities

Integration with community and third sector service provision

Offers a range of choice of provider for patients including online digital therapy provision

Range of therapeutic interventions available

Any Qualified Provider competition prohibits capacity/resource sharing and/or partnership and collaborative working

Delivery of IAPT national key performance indicators, access standards and clinical outcomes

Delivers front end services which support mental health deterioration and improves patients recovery capital

Delivery of wider non-clinical quality of health and wellbeing outcomes

Patient experience is rated high across IAPT (including LTC/MUS)

Workforce development (current focus on LTC/MUS only)

Contribution to reducing discrimination and stigma

Two patient groups were also consulted, with findings presented in Appendix 6 and summarised below:

better promotion, raising awareness and communications;

improvements to online information;

better information, contact and support available prior and during to therapy;

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flexible therapy within the IAPT model that is focused on good relationships to address individual needs;

flexibility around arranging appointments;

better communication and choice about number of sessions available;

appointments outside of standard working hours to accommodate people in employment; and

help create a more welcoming environment by providing stigma awareness training for all staff.

Feedback will be used to shape the scope of the service specification. Engagement will continue to feature in the further development of commissioning. Contract Finder will continue to be the portal for initiating engagement with the market. Commissioners will use existing forums and mechanisms to engage with service users. Experts by experience and independent experts will be involved at all stages of the procurement and represented on the evaluation panel.

Commissioners will work with the CCG’s Communications Lead to ensure that the project there is an appropriate communication strategy in place to support the procurement.

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6. GOVERNANCE AND MONITORING

6.1 Summary of Proposed Governance Arrangements

IAPT Project Board

CSU contract management

Mental Health Programme Board

Commissioning Committee

6.2 Information Governance

There is senior level representation from Information Governance and Information Management & Technology on the IAPT Project Board and the Evaluation Panel, who will act lead on the development of relevant sections of the Service Specification, tender questions and evaluation process.

6.3 Quality and Safety Reporting

Head of Quality and Safeguarding will act in an advisory capacity on matters of quality and safety in relation to the development of the service specification and tender questions. We would suggest that issues relating to quality and safety are reported through the Clinical Quality Review Group (CQRG), although the appropriate group will be determined once the provider is known.

6.4 Proposed framework for project closure and post-project evaluation

This will continue to be managed within the commissioning team. The service will be evaluated through monitoring performance and evidence of outcomes.

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6.5 Risk analysis and mitigation measures

Area Risk Mitigation

Area 1

Access

If recovery targets are prioritised, there is a risk that access targets will not be met

Camden has considerable need. The commissioning process will seek a provider with skills to proactively widen the reach of IAPT, expanding its presence into universal/community services as well as primary care

Area 2

Scope

Whilst there are drivers to extend IAPT to people with more complex needs than common mental health, widening the scope of its basic offer could overly stress the service. As PHQ9 and GAD7 are the tools for measuring recovery in an IAPT service, data could become more difficult to collect and reporting less meaningful if conditions are not measurable using these scales

Place greater focus on what interventions are on offer rather than who is eligible for the service (eg, if a person can benefit from an IAPT intervention such as CBT, then they should be offered a service regardless of diagnosis)

Commissioning process will expect providers to develop a flexible and responsive service, without compromising the integrity of IAPT offer and data collection

Commission the IAPT offer at Step 2-3, removing Step 4a with savings being redirected outside of IAPT for other cohorts

Greater flexibility about intervention choices and number of sessions aligned to NICE guidance may impact on waiting times (which is a NHSE target KPI ) however, it could increase recovery targets

Test via the tendering process, with bidders describing how they will meet these conflicting challenges

Area 3

Targets

If Step 4a remains within the IAPT offer, there is a risk that recovery targets will not be met, as patients are less likely to move from caseness to non-caseness.

Step 4a patients currently contribute to the 15 per cent access target, therefore the removal of Step 4a is a risk that access targets will not be met.

If targets are not met, this will have implications for Camden CCG’s assurance ratings

Given the new contracting model we would expect the provider to be more proactive in its approach to achieving access targets by offering IAPT services in locations where patients require it i.e. community venues

Through contract negotiation with TAP in 2017/18, we would make the case to include TAP activity and outcomes in IAPT reporting

TAP has been commissioned to support patients who are too complex for standard IAPT services and not complex enough for secondary care, this includes patients who are

In order to streamline the pathway and avoid duplication of service we propose to remove Step 4a from the new IAPT model. However we will make provisions within the model for a small number of patients in recognition that the complexity of a client’s needs

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Area Risk Mitigation

classified as Step 4a. In the absence of TAP, IAPT was commissioned to provide the Step 4a service. Inclusion of Step 4a in the new IAPT contract would duplicate the service offer with TAP and add further confusion for general practice referrals.

Omitting Step 4a out of the new contract would reduce the financial envelope by approximately 360k. This may have redundancy implications for any incumbent provider, which may impact on the appetite from the market to submit a tender due to financial risks.

Removing Step 4a from IAPT will increase the referrals into TAP and create capacity issues creating extended waiting times

may only become apparent during treatment sessions (for example the identification of features of personality disorder, or of particular risk). This is a concern from our clinical colleagues in view that we would want to minimise disturbance of any therapeutic relationships that have built with a patient and psychologist.

The CCG could agree to enter into a risk sharing agreement with the incumbent provider – this will need to be clear in the tender documents.

We propose that the savings from IAPT are redirected to support capacity issues. This is likely to have TUPE implications, however this will negate any redundancy risks highlighted above. Further advice from CSU is required.

Area 4

Procurement

Public Contract Regulations 2015 will become effective from 18 April 2016. If approval to procure is delayed until after implementation of the regulations, all tender documents will need to be posted together, including finalised specification, contract model and all prequalifying and tender questions. The procurement timetable will need to be adjusted and there is a risk that there will be insufficient time to mobilise the service in line with incumbent providers’ contract end dates.

The procurement route could change from a 2-stage restricted tender to a 1-stage open tender. The subsequent risk is that there may be resource implications for the evaluation panel if a high number of bids are received without a prequalification stage. However, as the proposed model is a lead provider within a specialised market, it is expected that the response will be manageable.

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Appendix 1 - Long Term Conditions/Medically Unexplained Symptoms

A report presenting the findings of a review into the first two years and four months of the Improving outcomes for those with Long Term Conditions (LTC) and Medically Unexplained Symptoms project was presented to the LTC & Cancer Programme (LTC PIG) and Mental Health Programme Groups (MHPG).

Overview of the report findings:

1. the number of people with LTCs/MUS being assessed has increased to 391 in the last quarter (Q2 2015-16) from a baseline of 118 in Q1 2012/13, now making up 24 per cent of total IAPT activity;

2. There has been an increase in interest, knowledge and skills of all iCope staff in working with people who have LTCs/ MUS;

3. Patient experience for this group is positive, 83 assessment forms were returned since April 2015; 87 per cent said they were satisfied; 65 per cent reporting ‘completely satisfied’

and 22 per cent being ‘mostly satisfied’ with their assessment;

4. Following contact with IAPT services, on average patients have a reduced number of emergency admissions (11 per cent reduction) and attendances (23 per cent reduction);

5. 42.1 per cent of people show significant improvement or recovery on PHQ-9 (measure of low mood) and 46.2 per cent show significant improvement or recovery on GAD-7 (measure of anxiety); 56.7 per cent improved on Work and Social Adjustment Scale (measure of social functioning) by the end of treatment;

6. survey results and feedback suggest that MDT teams for diabetes, heart failure and COPD found it helpful to have iCope input at MDT meetings;

7. in the last year (up to July 2015), the following direct interventions were delivered: Mindfulness Based Stress Reduction Groups (53 people), psycho-educational sessions at pulmonary rehabilitation (222 people), Strategies for Relatives Intervention for relatives of people with dementia (29 referrals), stress and relaxation workshop for people with hypertension (1 workshop)

8. START Intervention for relatives of people with dementia (29 referrals last year) - initial audit in both Camden and Islington services suggested that 63 per cent of those who completed treatment showed statistically reliable change on one or both of the measures for depression and anxiety.

Evidence suggests that:

a third of all people with a Long Term Condition (LTC) have a co-morbid mental illness (usually depression or anxiety);

medically unexplained symptoms (MUS) is one of the most common health problems that clinicians see on a regular basis and accounts for one in five consultations in primary care;

these groups tend not to access psychological therapies services;

psychological interventions with these populations can have an impact on both physical and mental health outcomes; and

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psychological interventions can improve quality of life, functioning and reduce overall service utilisation costs;

The group recognised the following areas:

psychological support for LTC patients supports physical health improvements

continued support is required in the absence of other dedicated initiatives to provide LTC/MUS patients with psychological therapies;

acknowledgement of the work the service had invested in to build relationships with LTC clinicians/colleagues and the value that was placed on this partnership working by LTC clinicians/colleagues; and

the impact of IAPT on reducing Emergency Department (ED) attendances and emergency admissions was promising although not conclusive, however acknowledged more data was now available to be able to refresh the data to make a better judgement on impact.

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Appendix 2 Benchmarking data with other London boroughs

Table A: Camden percentage achievement of meeting 15 per cent prevalence into treatment 2014-15 (3.75 per cent per quarter) comparable with other London boroughs

Table B: Camden recovery rate achievement 2014-15 (50 per cent target) comparable with other London boroughs;

2015-16 Q1 Q2 Q3 Q4 year end total Q1

NHS Camden CCG 36,677 2.99 3.6 3.69 4.27 14.55 3.76NHS City and Hackney CCG 33,611 4.02 4.08 3.33 4.05 15.48 3.57NHS Haringey CCG 34,493 3.03 3.04 3.23 3.12 12.42 3.38NHS Islington CCG 31,031 3.71 4.64 3.67 4.03 16.05 4.19NHS Newham CCG 34,602 3.45 3.5 3.42 3.41 13.78 4.12NHS Tower Hamlets 31,205 4.68 3.61 3.7 5.27 17.26 3.94NHS Brent CCG 37,678 2.67 2.4 2.35 3.78 11.2 3.72NHS Ealing CCG 40,484 2.87 2.56 3.41 3.69 12.53 3.38NHS Hammersmith and Fulham CCG 27,803 3.47 3.67 3.85 4.19 15.18 3.92NHS West London CCG 35,429 1.81 3.43 3.43 3.7 12.37 3.82NHS Lambeth CCG 44,168 3.01 2.91 5.04 3.79 14.75 4.43NHS Lewisham CCG 37,757 2.4 3.23 3.46 4.11 13.2 3.93NHS Southwark CCG 41,928 3.64 3.36 3.97 4.36 15.33 4.03NHS Wandsworth CCG 44,100 1.97 1.83 1.86 3.93 9.59 3.56

London Centre IAPT Cluster boroughs

Percentage of met need (HSCIC Published data) 2014-15

Organisation Name

Number of people who have depression and/or anxiety disorders

(CCG submited prevalence)

2015-16

Q1 Q2 Q3 Q4 Q1*NHS Camden CCG 36,677 41.67% 38.46% 36.8 41.2NHS City and Hackney CCG 33,611 33.33% 40.00% 40.3 46.4NHS Haringey CCG 34,493 41.67% 44.52% 45.5 45.0NHS Islington CCG 31,031 38.71% 35.24% 43.5 43.7NHS Newham CCG 34,602 39.20% 40.56% 44.0 41.2NHS Tower Hamlets 31,205 30.43% 37.50% 40.7 45.7NHS Brent CCG 37,678 36.21% 37.50% 37.8 35.0NHS Ealing CCG 40,484 41.07% 45.10% 42.4 45.3NHS Hammersmith and Fulham CCG 27,803 37.04% 39.66% 45.6 47.1NHS West London CCG 35,429 38.46% 35.61% 30.2 35.1NHS Lambeth CCG 44,168 39.06% 43.51% 39.0 54.2NHS Lewisham CCG 37,757 37.62% 41.48% 36.8 43.1NHS Southwark CCG 41,928 36.36% 37.25% 36.8 38.4NHS Wandsworth CCG 44,100 32.73% 42.86% 42.4 42.2

London Centre IAPT Cluster boroughs* HSCIC published data for Q1 2015-16 not available

Organisation Name

Number of people who have depression and/or anxiety disorders (CCG submited

Recovery Rates (HSCIC Published data) 2014-15

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Appendix 3 – Contracting route – detailed description of possible models and contracting route appraisal

3a – Improving Access to Psychological Therapies (IAPT) recommissioning

Four possible contractual vehicles were considered by IAPT Project Board members to deliver IAPT services20; These frameworks are summarised below;

1. Lead contractor model

2. Lead provider model

3. AQP contract model

4. Alliance contract model

Lead contractor model:

In a lead contractor model, the CCG contracts with a single organisation (or consortium) which then sub-contracts individual providers to deliver care; The CCG retains overall accountability for the commissioned services, while the lead contractor holds each of the sub-contractors to account individually;

The lead contractor takes responsibility for designing a delivery model and patient pathway that will most effectively meet the terms of the contract; It uses the terms of the sub-contracts to stimulate and incentivise the necessary behaviours and performance it wishes to see across other providers.

Advantages of lead contractor model Disadvantages of lead contractor model

Simple for commissioners to manage

Enables pathway management

Shifts clinical accountability onto integrator and providers

High financial and relational risk for prime contractor

Concern over management of co-morbidities and other boundaries

Providers may not have sufficient skills in contracting, supply chain management and commissioning

Arms-length communication with providers

Lead provider model:

The lead provider model is a significant variation on the lead contractor model in which the contracted organisation also delivers care directly as part of the agreement; The lead provider could be a new or existing provider from within the local health economy, or a consortium of providers and ‘integrators’;

20 The overall structure of the IAPT contracting route options appraisal is consistent with the options appraisal used for the NCL Diabetes VBC and Camden CCG Mental Health VBC project(s). However, the IAPT qualitative appraisal has been tailored to address the specific project objectives and some of the questions differ. It should also be noted that, even where the qualitative appraisal questions are the same as those for the Mental Health qualitative assessment, the scoring may differ due to the different requirements, timescales and provider landscape of the IAPT project.

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http://www.kingsfund.org.uk/publications/commissioning-contracting-integrated-care/summary#alliance

http://www.kingsfund.org.uk/media_colorbox/12875/media_original/en

http://www.kingsfund.org.uk/media_colorbox/12875/media_original/en

Similar to the lead contractor model, a lead provider would typically receive a capitated budget to provide all care specified in the contract; The lead provider would also use this budget to ‘buy’ additional services (through sub-contracts) that it cannot deliver directly;

Advantages of lead provider model Disadvantages of lead provider model

Increased direct control over provision across a pathway

Demand risk shifts to provider(s)

Enables money to move within the pathway

Clear governance arrangements through contracts and sub-contracts


Perverse incentives – may limit patient choice and encourage cream-skimming

Provider organisation may not have sufficient skills in contracting, supply chain management and commissioning

AQP (Any Qualified Provider) contract model:

Any qualified provider model is an approach to commissioning under which any provider who is able to provide a specific service and meets the required minimum standards can be listed as a possible provider;

Patients choose which provider on the AQP list they wish to see.

No provider is guaranteed any volume or exclusivity.

Competition is based on quality and not price;

All providers will be paid the same price for a particular service;

Advantages of AQP model Disadvantages of AQP model

Offers patient choice of provider

Provides treatment capacity within Camden

Payment by results / performance / fixed activity tariff

Market development and stimulation

AQP could possibly highlight unmet demand and put pressure on budgets

Requires collaborative working


Too many AQP providers/choice

No volume guarantees

Less flexibility to commission for outcomes

Financial risk

Alliance contract model:

In an alliance contract model a set of providers enters into a single arrangement with a CCG to deliver services;

Commissioners and providers are legally bound together to deliver the specific contracted service, and to share risk and responsibility for meeting the agreed outcomes; As such, they

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should be incentivised to innovate and identify efficiencies across the system, rather than solely within their organisation;

The alliance is reliant on high levels of trust across its relationships;

Members collectively govern the alliance through a leadership board with an agreed term of reference.

Advantages of alliance contract model Disadvantages of alliance contract model

Strong incentives to collaborate

Limits dominance of a single organisation

Strengthens relationship between commissioners and providers

Retains the active involvement of commissioners

Shared financial and clinical risk, reliant on the performance of other providers

More complex for commissioners to manage

Requires existing relationships founded on strong trust, which might not be present in all areas

Possibility of weak leadership and accountability unless appropriate governance arrangements are established

3b – Contracting models appraisal – Shortlisting Qualification criteria:

IAPT project board members went on to shortlist these contracting models using qualification criteria:

1. The Contract model must support the key IAPT aims namely supports the delivery of a range of NICE compliant therapeutic interventions in a stepped care approach; integrated governance (clinical and corporate) and the ability to measure IAPT outcomes (clinical (including waiting times) and wellbeing outcomes);

2. The contract model must support collaborative working between acute, community, primary care and mental health providers;

3. The NHS must be able to support the contract model (from a legal perspective).

Qualification criteria questions

Option Q1 (Y/N)

Q2 (Y/N)

Q3 (Y/N)

Successful to shortlist?

Rationale

Lead Contractor Model

Y Y Y Y

Lead Provider Model

Y Y Y Y

AQP Contract model N N Y N AQP contracting does not support integrated governance; AQP model prohibits collaborative working and integrated approaches due to the market competition

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Alliance Contract model

Y Y Y Y There is no single agreed form of alliance arrangement in an NHS setting at present which fits with the NHS Contract, however in theory, from a legal perspective, the NHS can support the alliance contract model;

Option Q1 (Y/N)

Q2 (Y/N)

Q3 (Y/N)

Successful to shortlist?

Rationale

Current contract model (Lead provider and AQP)

N N Y N AQP contracting does not support integrated governance; AQP model prohibits collaborative working and integrated approaches due to the market competition

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3c – Contracting models appraisal - Qualitative Assessment

For each of the IAPT objectives (below) a number of qualitative assessment criteria were applied and formed a decision methodology for accessing each option; A weighting was applied to represent the importance of each criteria (see table below);

IAPT Objectives

1. Improve patient outcomes

2. Support improved patient experience

3. Support providers working together to achieve person centred integrated care

Commissioners added a fourth area for appraisal in line with the Mental Health VBC project:

4. Achievable in terms of implementation

Table showing assessment criteria questions and IAPT Project board member comments

lead contractor

model Notes

lead provider model

Notes Alliance Model Notes

Improve Patient Outcomes

Q1 - 1; Does the contract model incentivise providers to contribute to improved outcomes (clinical and wellbeing)?

y 1 Depends on strength of specification and contract; Lead contractor would need to be outcome focussed; Arguably the lead contractor is the middle man to the providing organisations; Providers may feel removed from the process;

y 2 lead provider is primarily responsible - accountability to the commissioner

y 2 All alliance members are responsible and have accountability

Q2 - 2; Does the contract model provide opportunities to integrate services to improve mental, physical and social care outcomes?

y 2 Lead contractor may access a wider supply chain - more creative to deliver a wider portfolio of interventions; The integration management may be a strength;

y 1 Lead provider may be more constrained - due to the sub contractor relationship; Primary focus is delivery of the psychological therapy rather than the wider integration;

y 1 Alliance model - Primary focus is delivery of the psychological therapy rather than the wider integration;

Q3 - 3; Does the contract model allow commissioners to address performance issues with providers?

y 1 Commissioners have limited access to providers;

y 2 Although commissioners do not discuss with sub-contractors - there is a more complete oversight of the process/delivery through the lead provider, who has

y 2 Alliance providers are around table;

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lead contractor

model Notes

lead provider model


responsibility and accountability;

Total 4 5 5

Average % 67% 83% 83%

Support Improved Patient experience

Q1 - 1; Does the contract model support cross provider/organisational focus on person centred care which addresses mental, physical and social care needs?

y 1 Lead contractor may facilitate referrals between sub-contracted providers; This will also depend on the strength of the specification and contract;

y 1 Primary focus is delivery of the psychological therapy rather than the wider integration/cross provider focus;

y 2

Q2 - 2; Does the contract model support an information focus on clinical governance and patient experience?

y 1 Lead contractor information focus is done at a different level as clinical governance/patient experience is at arm’s length;

y 2 y 2

Q3 - Does the contract model support continuous quality improvement across providers?

n 0 depends on the strength of the specification and contract with the lead contractor; Potentially the lead contractor may only be concerned about the numbers - not the quality being delivered;

y 1 y 2 Strongest model to support this;

Q4 - 4; Does the contract model support the delivery of psychological therapies through the use of appropriately qualified staff, future staff development and leadership across the stepped care pathway?

y 1 lead contactor may be at arm’s length from staff - will they be focussed on developing the staff

y 2 incentive to develop staff across pathways

y 2

Total 3 6 8

Average % 38% 75% 100%

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lead contractor

model Notes

lead provider model


Support Integrated care

Q1 - 1; Does the contract model sufficiently incentivise all providers to achieve integrated care across the stepped care pathway?

y 1 lead contactor should facilitate referrals - but how will the provider be incentivised to be integrated within the care pathway; (smooth movement for patients through the pathway/step up/step down); Lead contractor may be good at this function as they can review the client journey and see client in the appropriate treatment across pathway;

y 1 perverse incentive to keep patient at the higher step for more payment

y 2 Alliance model is strong on the integrated care across stepped care pathway;

Q2 - 2; Does the contract model support coordinated and aligned policies, rules and frameworks in the delivery of NICE compliant psychological therapies?

y 1 depends on the lead contractor's strength of contract with sub-contractors;

y 1 depends on the lead provider's strength of contract with sub-contractors;

y 2 These areas need to be thought out as part of the alliance framework,;

Q3 - 3; Does the contract model support shared values, culture and vision across organisations?

n 0 Arm’s length relationship y 1 y 2 Strongest model to support this;

Q4 - Does the contract model support coordinating structures, governance systems and relationships across organisations?

y 1 lead contractor umbrella organisation

y 1 y 2 Strongest model to support this;

Q5 - 5; Does the contract model support alignment of back office functions, budget and financial systems across the stepped care pathway providers?

y 2 lead contractor could provider these functions

1 1

Q6 - Does the contract model support coordination of information and services and integrating patient care within a single process?

y 2 Strongest model to support this; y 1 The single process may not be clear for other providers / sub-contractors;

y 2 As part of forming the alliance there would be an agreed single process;

Total 7 6 11

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lead contractor

model Notes

lead provider model


Average % 58% 50% 92%

Implementation Q1 - Is the provider landscape able to easily adopt this contract model?

n 0 Lead contractor would be a big shift especially for Camden where there is no precedent;

y 2 Camden could find lead providers - thinking about current landscape; This is the current provision;

y 1 Alliance may be a big shift as there is no precedent in Camden; There may need to be market shaping - and this might lead to alliance; Potential to build on the informal arrangements;

Q2 - Is the implementation timeframe acceptable?

y 2 y 2 y 2

Q3 - Is the contract model responsive to changing needs and demands?

y 1 Depends on how flexible the contract is to support emerging/changing needs and demands; Lead contractor can sub-contract within the lifetime of the contract - flexibility to meet emerging needs within the 5 year term (3 year +2)

y 1 y 1 Depending on the contractual leverages and the strength of the wording in contract;

Total 3 5 4

Average % 50% 83.3% 67%

SUMMARY TABLE

contract name lead contractor lead provider Alliance Weighting

Outcomes 67% 83% 83% 0;5

Patient experience

38% 75% 100% 0;2

Integrated care 58% 50% 92% 0;2

Implementation 50% 83% 67% 0;1

Weighted average score

58% 75% 87%

Non-weighted 53% 73% 85%

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3d - Contracting models appraisal – Risk Assessment

To support the contacting route qualitative appraisal a risk assessment for each shortlisted model was undertaken.

Table showing risk assessment categories and IAPT Project board member comments

Category Risk Lead Contractor (Integrator) Notes Lead Provider - Notes Alliance - Notes

Corporate governance

Failure to set up robust governance across providers and organisations

2 - The lead contractors organisation’s sole objective is to manage the contract; They have no vested interest in how the sub-contract payments are proportionally distributed; Therefore they can be very focused and targeted on providing more focused contract management as there is no distraction by service delivery pressures; - Providers are not individually incentivised to contribute to the whole; The management model may be based on a “stick” (penalty) model rather than a “carrot” (incentive) model, meaning providers could become disengaged and deliver the bare minimum;

2 - The lead provider would oversee all services; Commissioners would be able to hold one organisation to account for delivering agreed outcomes and performance across the entire stepped care pathway; - This model does provide a single leadership structure and clear accountability for integrated working; - The Commissioner remains accountable for the service, but is reliant on the lead provider to hold subcontracting providers to account; The lead provider is dependent on his sub-contracts to effectively flow the risks down to the supply chain and a failure to do this adequately can destabilise the contract and the providers

2 - Joint leadership is incentivised through an outcomes-based payments structure; - Generally decision making processes are more complex, as agreement is needed between all parties;

Wider public sector working

Cross-public sector working could create additional challenges to accommodate different ways of working, statutory responsibilities, priorities and financial challenges (eg, relationship with the local authority and the Health and Wellbeing Board)

1 - The lead contractors organisation’s sole objective is to manage the contract; - The other providers are solely focused on care delivery via sub-contract;

2 - no evidence to support higher or lower risk than existing arrangements

2 - no evidence to support higher or lower risk than existing arrangements

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Legislative change

Inability to cope with legislative change (changes to the national key performance indicators)

1;5 - Providers are not individually incentivised to contribute to the whole; The management model may be based on a “stick” (penalty) model rather than a “carrot” (incentive) model, meaning providers could become disengaged and deliver the bare minimum; - All of the stepped care providers will need to be engaged and to agree the terms of any legislative and performance changes– there is a risk of the lead contractor enforcing down a position to protect its position and margin; This could destabilise the provision - Use contract levers and contract breadth to ensure there is flexibility to allow for legislative and performance changes within the life of the contract;

2 - The lead provider would oversee all services; Commissioners would be able to hold one organisation to account for delivering agreed outcomes and performance across the entire care cycle; - The Commissioner remains accountable for the service, but is reliant on the lead provider to hold subcontracting providers to account; The lead provider is dependent on his sub-contracts to effectively flow the risks down to the sub-contractors and a failure to do this adequately can destabilise the contract and the providers; - Use contract levers and contract breadth to ensure there is flexibility to allow for legislative and performance changes within the life of the contract;

1;5 - Generally decision making processes are more complex, as agreement is needed between all parties; - Alliance contracting works better with a manageable number of partners; the greater the number, that greater the complexity and management issues - A further potential complexity is when a contract variation is required, which would normally require the written approval of all parties to the contract; Operation of ‘vetoes’ and/or protection of minority interests could be a particularly tricky area - Use contract levers and contract breadth to ensure there is flexibility to allow for legislative and performance changes within the life of the contract;

IM&T implementation

Delay in standardising and rationalising IM&T provision across provider organisations and commissioners leading to inefficient services;

2 - Potential for greater consistency in provision through more developed supply chain management across a broader spectrum of providers - The lead contractor organisation’s sole objective is to manage the contract; Therefore they can be very focused and targeted on providing more focused contract management as there is no distraction by service delivery pressures;

3 - The Lead Provider would normally directly employ a multi-disciplinary/multi-agency management team and provide the IT solution making information, data and governance issues easier - The lead provider would oversee all services; Commissioners would be able to hold one organisation to account for delivering agreed outcomes and performance across the entire stepped care pathway

2;5 - Joint leadership is incentivised through an outcomes-based payments structure; - A leadership forum would hold responsibility for ensuring all services are of consistently high quality and making changes where necessary; Project team: complicated by the range of organisations involved in this pathway; The IM&T developments within an alliance and a JV are likely to be limited to the extent of providers included in the alliance / JV, whereas with a lead provider, accountability for engaging the full range of organisations is clear;

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Information management

Failure to manage information adequately if problems of service continuity and data protection arise;

3 - Potential for greater consistency in provision through more developed information and data management across a broader spectrum of providers as this is one element of the lead contractors purpose; - The lead contractor organisation’s sole objective is to manage the contract; Therefore they can be very focused and targeted on providing more focused contract management as there is no distraction by service delivery pressures;

3 - The lead provider would normally directly employ a multidisciplinary/multi-agency management team and provide the IT solution and governance for all sub-contractors so should be able to deliver this objective;

2;5 - Generally decision making processes are more complex, as agreement is needed between all parties; - Alliance contracting works better with a manageable number of partners; the greater the number, that greater the complexity and management issues - Potentially a more collaborative and collegiate approach which seeks to create co-operative behaviours between providers and the Commissioner, around a pre-agreed set of objectives

Resilience/ stability

External factors are not effectively managed or responded to eg; changing demand, failure of another provider/supplier

2 - The lead contractor organisation’s sole objective is to manage the contract; They have no vested interest in how the sub-contract payments are proportionally distributed; Therefore they can be very focused and targeted on providing more focused contract management as there is no distraction by service delivery pressures; - Providers are not individually incentivised to contribute to the whole; The management model may be based on a “stick” (penalty) model rather than a “carrot” (incentive) model, meaning providers could become disengaged and deliver the bare minimum;

3 - Providers can directly work together, supported by the contracts between them, to ensure the stepped care pathway is as efficient and effective as possible; Incentives can be more effectively constructed to ensure all providers benefit from effective operation of the scheme (reducing perverse incentives and ensuring sharing of referrals to reduce waiting times) - This model does provide a single leadership structure and clear accountability for integrated working; The lead provider would be accountable for reviewing need for all services and planning resources accordingly, though this would need to be undertaken in conjunction with subcontracted providers and not imposed upon them; - The Commissioner remains accountable for the service, but is reliant on the lead provider to hold subcontracting providers to account; The lead provider is dependent on his sub-contracts to effectively flow the risks down to the supply chain and a failure to do this adequately can destabilise the contract and the providers;

3 - Joint leadership is incentivised through an outcomes-based payments structure; - A leadership forum would hold responsibility for ensuring all services are of consistently high quality and making changes where necessary; - Providers would need to agree roles between them, and sustain these when faced with challenges and there would need to be agreed ways to manage disputes between providers when these arise

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Legal Legal restrictions hinder full adoption of the model

1;5 - If a single contract approach is being adopted then the Commissioner would need to ensure that a single contract could cover all the relevant services within the stepped care pathway (likely to be either NHS Standard Contract) and that the lead contractor could hold the contract;

2 - If a single contract approach is being adopted then the Commissioner would need to ensure that a single contract could cover all the relevant services within the stepped care pathway (likely to be either NHS Standard Contract) and that the lead provider could hold the contract - Careful contractual arrangements would be required to set out clearly what is expected of the lead provider and subcontracted organisations;

1 - There is no single agreed form of alliance arrangement in an NHS setting at present; This would therefore be a complex approach where the time and cost required for legally compliant documentation and management should not be underestimated; - Technically, multiple providers are not able to enter into the same NHS Standard Contract for services and therefore the core alliance model is not compatible at this stage; Commissioners would need to look to introduce overarching alliance principles and mechanisms through a contract which is in addition to the providers service contracts;

Clinical governance

Failure to adopt robust clinical governance arrangements impacts patient safety

1;5 - The lead contractor as the only non-service deliverer, could become detached from how things work on the ground; This could cause tension between psychological therapy intervention delivery and contract management; - The lead contractor organisation’s sole objective is to manage the contract; They have no vested interest in how the sub-contract payments are proportionally distributed; Therefore they can be very focused and targeted on providing more focused contract management as there is no distraction by service delivery pressures; - the lead contractor may not account for interactions between the providers in the stepped care pathway and allow for flexibility in therapeutic dose based on clinical assessment; This could impact on wider service delivery, wider patient outcomes and could impact on patient safety;

3 - The lead provider would oversee all services; Commissioners would be able to hold one organisation to account for delivering agreed outcomes and performance across the entire stepped care pathway; - The Commissioner remains accountable for the service, but is reliant on the lead provider to hold subcontracting providers to account; The lead provider is dependent on his sub-contracts to effectively flow the risks down to the supply chain and a failure to do this adequately can destabilise the contract and the providers;

3 - Joint leadership is incentivised through an outcomes-based payments structure; This reduces the risk inherent in the lead provider model that the lead provider may be able to make changes not in line with Commissioners’ objectives, because the Commissioner remains the contract lead for all providers under the alliance elements - a leadership forum would hold responsibility for ensuring all services are of consistently high quality and making changes where necessary;

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Provider That there is insufficient provider appetite for the contract model

1;5 - Providers are not individually incentivised to contribute to the whole; The management model may be based on a “stick” (penalty) model rather than a “carrot” (incentive) model, meaning providers could become disengaged and deliver the bare minimum; - CCG would likely need to procure the lead contractor function; Defining the structure of the lead contractor procurement to allow for risk transfer and subcontracting with the providers is likely to be complex and time consuming; If a single contract approach is being adopted then the Commissioner would need to ensure that a single contract would cover all relevant services provided across the stepped care pathway

2;5 - Providers can directly work together, supported by the contracts between them, to ensure the pathway is as efficient and effective as possible; Incentives can be more effectively constructed to ensure all providers benefit from effective operation of the scheme; - Careful contractual arrangements would be required to set out clearly what is expected of the lead provider and subcontracted organisations;

2 - Typically providers are likely to be more amenable to this method of working but difficult in current NHS setting and competition / procurement concerns would need to be addressed - There is no single agreed form of alliance arrangement in an NHS setting at present; This would therefore be a complex approach where the time and cost required for legally compliant documentation and management should not be underestimated - unsure of the local appetite from providers for this type of contract model as it requires a greater degree of trust between providers as they are jointly accountable;

Political That the chosen contract model is politically unpopular and pressure is given to change the selected contract model

2 2 - Identifying one provider as the lead provider may disengage other providers who consider they may be more appropriate for that role; There is a risk that the lead provider could also enforce stricter contract terms or lower remuneration on the subcontractors to cover its management overhead for the structure

2 Project team: could be political concern if any one provider was seen to be excluded;

Procurement That provider/providers challenge the contract chosen model and the process to select it

1 - The CCG would be likely to need to procure the lead contractor function; Defining the structure of the procurement to allow for risk transfer and sub-contracting with the Providers is likely to be complex and time consuming - Providers are not individually incentivised to contribute to the whole; The management model may be based on a “stick” (penalty) model rather than a “carrot” (incentive) model, meaning providers could become disengaged and deliver the bare minimum

2 - Identifying one provider as the lead provider may disengage other providers who consider they may be more appropriate for that role; There is a risk that the lead provider could also enforce stricter contract terms or lower remuneration on the subcontractors to cover its management overhead for the structure

2 - Reliance on strong working relationships between providers

Summary Table

Total 19 26;5 23;5

Total % 43% 60% 53%

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3e – Contracting models appraisal – Financial Assessment

To support the contacting route qualitative appraisal a financial assessment of implementation and management costs was applied.

Table showing risk assessment categories and IAPT Project board member comments (scoring based on Mental Health VBC assessment)

Lead

contractor (Integrator)

Lead Provider Alliance Notes

Implementation cost 2 2 2

Set up costs are expected to be minimal and it is expected that such costs will be offset in year one through a CQUIN with providers

Management cost 2 2 2

Variance in management costs across the different contract models are expected to be minimal with savings anticipated over the duration of the contract

Total 4 4 4

Total % 100;0% 100;0% 100%

Scoring 2 The cost is equivalent to the standard project implementation cost and management costs

1 The cost is more expensive than the standard implementation and management costs

0 The implementation or management cost is prohibitive

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3f – Contracting models appraisal – Final Evaluation

The three elements described above were tabled in a final evaluation which showed Alliance Contract route was the preferred model scoring 76% followed closely by the lead provider model scoring 74%;

Table showing the final evaluation of the contract routes and percentage outcomes

lead contractor lead provider Alliance Weighting

Qualitative appraisal 58% 75% 87% 0.4 Significant evidence in place to carry out the appraisal

Risk appraisal 43% 60% 53% 0.4 Significant evidence in place to carry out the appraisal

Financial appraisal 100% 100.0% 100% 0.2 No significant difference in set up or management costs to commissioners

Weighted average 60% 74% 76%

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Appendix 4 – Procurement routes

There are a number of procurement options available to CCG commissioners; The NELCSU Clinical Procurement Team will provide technical advice on the most appropriate choice; this will depend on a number of factors, including contract value & CCG SFIs/Scheme of Delegation, the status of the provider market, geography, the needs of patients and patient choice; The following describes the procurement routes that could be used, with some of the advantages and disadvantages of each.

Please note that the table below sets out the maximum timescales that should be allowed for large scale, high profile clinical procurements; For smaller scale/value contracts these timescales can, in consultation with the CCG commissioning lead, be considerably contracted to be proportionate to the value of the contract to be awarded; These timescales are therefore discretionary but reflect cumulative experience of running tenders that have achieved the best outcomes with the minimum of delays and challenges, and that takes into account competing time demands on both bidders and commissioners/evaluation panel members; Whilst timescales can be reduced, there are associated risks which the CSU Clinical Procurement Team will set out and discuss with commissioners where a shorter timeframe is preferred.

However, the CSU Clinical Procurement Team will at all times work with CCG lead commissioners to develop an agreed timeline for each project on a case-by-case basis and which should be agreed up-front before the procurement begins.

Potential Procurement Route When it may be considered Advantages Disadvantages

Estimated Maximum Timescale (can be flexed down for smaller

procurements)

1;0 Open tender (Combined Response Document) [Formal tendering in which any interested provider may submit a tender]

Limited competition anticipated (ie, few suppliers in the market)

Niche requirement Patient/population need identified Specification, outcomes and

KPIs determined pre-procurement

Straightforward requirements Most commonly used for

purchase of goods or works

Open to all suppliers Doesn’t restrict small /

medium enterprises Contract currency

determined pre-procurement More competitive costs

submitted as more competition

Volume of responses may be high and all will require evaluation

Lower chance of winning due to “open to all” bidding, could result in limiting participation by ‘serious’ bidders;

6 months maximum (does not require PQQ stage; may require TUPE period before contract start)

2;0 Restricted tender [method used to pre-qualify bidders and narrow the number permitted to submit bids]

Large market available for competition

Patient/population need identified Specification, outcomes and

KPIs generally determined pre-procurement but can be refined during preliminary stages

Two-stage process that can minimise impact of resources by restricting the number competitors

Contract currency determined pre-procurement

EU Regulations sets minimum no of participants to be invited to ITT to 5;

Could limit the number of suitable bidders

6-9 months maximum (may require TUPE consultation period before contract start)

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procurements)

3;0 Competitive Dialogue Insufficient suitable suppliers available

Requires market development Can only be used in the following

exceptional circumstances: where Commissioner is unable to

define the technical means capable of satisfying their needs

where commissioner is unable to specify the legal/financial makeup of the project

Where the use of Open or Restricted procedure will not result in a contract award

Flexible approach to complicated procurements

Increases competition and encourages innovation

Specification and funding model are only developed during the process

EU recommendation – 3 minimum number of participants for dialogue;

Resource intensive to carry out dialogue phase

Innovative approaches may vary making it difficult to evaluate bids on a like for like basis

Dialogue, evaluation and feedback undertaken in successive stages;

A typical 3 stage dialogue will involve 3 sets of deliverables / solutions and assessments prior to closure;

Assessments of different solutions using the same criteria;

As bidding costs are high some bidders may deicide bid costs are not worth the risk or are unaffordable;

Could raise confidentiality issues – Confidentiality Policy recommended;

Higher risk of legal challenges since bids are often very close;

12 months

4;0 Negotiated Procedure [Can only be used in extremely limited circumstances]

where the contract is for genuinely unique solution where funding model is untested

No valid or suitable response received under Open or Restricted procedures

When only one supplier may provide the service for technical, artistic or intellectual property right reasons

Requirement is for research, experiment, study or development

Contract terms are negotiated upfront from a selection of potential suppliers

Assists in clearly defining the requirement and a selected number of bidders

Resources intensive to carry out negotiations

Less transparent procedure than the CD procedure as there is no final submission of offers, this affects the equal treatment principle;

Opportunity to suspend negotiations at any time and choose one bidder – may distort competition;

6 months maximum – but often follows an Open or Restricted process which has not identified a suitable provider

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procurements)

5;0 Framework Agreement Call-off

Where an existing framework has been implemented, that satisfies all service requirements

Reduces timescales – key terms have been agreed with suppliers appointed under the framework

Specification is fixed and cannot be varied once framework is implemented

9-12 months maximum to establish the framework, but once implemented, call-offs can take 1-3 months

6;0 AQP (Any Qualified Provider)

Community based activities where local tariff has been agreed

Where facilitating patient choice is a key local priority

Where payment for actual activity is preferred over block arrangements

For planned rather than emergency services as patients are in a position to exercise choice;

Designed to be a quicker process

Pre-qualifies potential providers, providing a ‘pool’ of potential supply

Supports Patient Choice as patients decide which qualified provider to use

Money follows patients

Initial accreditation may involve processing a large volume of applications

May not generate large/sufficient interest, as no volume guarantees are given

Does not encourage new providers as there is no guarantee of return on investment

May encourage increased activity as activity caps should not be used;

3-6 months maximum

7;0 Quotation Exercises When the whole life value of the proposed contract is below the EU/OJEU threshold for Part B public sector services of £172,514 (€200,000 at 1;1;14), the procurement requirement is reduced; This will be set out in the CCG’s Prime Financial Policies/SFIs Scheme of Delegation; Depending on the proposed contract value, the procurement requirement will range from verbal quotes to a minimum of 3 Competitive tenders;

Less intensive procurement process & documentation required

Preferred organisations can be directly approached and invited to submit a bid

Reduced timescales

Pre-identification of organisations invited to bid may not obtain best value for money or best quality as the market is not widely tested

More suppliers/contracts to manage

1-2 months

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ALTERNATIVES TO PROCUREMENT:

1.0 Contract Variation

When the value of a service development, re-design or expansion is within 10% of the existing contract value (or service line/s in an acute contract)

A relatively quick process where continuity is beneficial when a service or pathway would benefit from being delivered in a different way

Does not test the market for innovation or cost

Needs to be negotiated with the current provider to ensure it is acceptable to them

2.0 Contract Management

As set out in the DH “Procurement guide for Commissioners of NHS-funded services” (July 2010, clause 2.3), contract management can be used where an existing contract is in place in order to secure incremental improvements/changes to existing services, or to address under-performance, as an alternative to procurement

As above As above As above

3.0 Waivers When contract end dates need to be harmonised prior to a tender involving several services

When a service or contract would benefit from extension and the circumstances set out in the SFIs are met

Enables developing or remodelled services further time to become established

Continuity of service provider

Where a market is developing or developed, may be regarded by potential providers as anti-competitive

Does not test the market or demonstrate that VFM is being achieved

Waiver process needs to be followed, with senior management authorisation obtained. Timescale depends on robustness of supporting evidence.

4.0 Single Tender Action (NHS Procurement, Patient Choice & Competition) Regulations 2013)

Where it can be robustly demonstrated that only one provider is capable of providing a particular service, there is no requirement to put a contract out for competitive tender

Consideration of impact of procurement on pathway integration

A quick process that saves resources and time involved in running a tender

Does not test the market for innovation or cost

Contract will need to be negotiated with identified single provider

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Appendix 5 – IAPT Stakeholder Feedback events

May 2015

GROUP DISCUSSION QUESTION 1:

Camden would like to encourage and support collaborative working between providers within the IAPT landscape and promote working partnerships with external organisations, such as substance misuse services/employment support services/secondary care mental health teams/recovery college initiatives.

Suggest ways in which IAPT providers can work collaboratively and build partnerships?

Identifying gaps in service provision and targeting specific groups (eg, young male population)

Understanding of the range of external organisations and what they offer

Having a clear referral pathway

Addressing language (dialect) barriers and ensuring interpreters are easily accessible

Joint training and co locating wherever possible

Reducing the number of AQP’s to promote partnership working and avoid competition

Sustained/more collaborative working between GP’s and IAPT providers

How can partnership working with external organisations be promoted /used to deliver IAPT outcomes?

Changing the current structure which prohibits partnership working and developing a standardised access route where everyone is involved / developing a central point of referrals

Ensuring the right therapy is available

IAPT offering training and upskilling of staff to deliver services with a more psychological approach

How can commissioners of health and social care provision support / nurture collaborative working?

Commissioners will need to decide how many providers should be in the market

Encouraging co-location and creating of spaces with community providers premises for groups to be delivered alongside existing provision (eg, recovery café)


How improving access to psychological therapies might be facilitated (access, referral, location of services, choice of times, etc) and suggest ways of marketing therapies to potential clients? Are there any therapeutic interventions (NICE compliant) that are missing from the Camden IAPT services offer?

Home visits would increase the number of people accessing the service

Integrating all of Camden’s psychological therapies work streams

IAPT information is up to date and accessible via Camden’s website

Developing shared marketing strategies between providers

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Technology is changing the interface with healthcare; How can technology be used to support improving access to and delivery of psychological therapies (such as VOIP –voice-over internet phone/tele-healthcare approaches)? Are there good practice examples which you can share with the group and other stakeholders?

Introduction of a central hub to carry out assessments

Providers all have their own expertise, therefore formalisation of access and standards will deliver good outcomes and healthy competition

Hostel pathways and links with other secondary care needs to be seamless and integrated;


Prevention is a key policy focus. Discuss in your small groups and suggest what other/additional support would ideally be available following end of therapeutic sessions to prevent relapse?

Joint meetings between AQP and other providers

Utilisation of CQUIN funds


Numbers entering treatment targets for 2020 have been suggested at 25 per cent of prevalence entering treatment. This requires a fully trained workforce offering the maximum number of clinical sessions. Please can your group consider how Camden can meet the workforce requirement? Your group may wish to consider your responses to the previous questions.

Capacity sharing between providers

No issuers regarding recruitment eg providers reported 400 applicants for each post

June 2015


How could referring all Camden IAPT patients to a single point of access (SPOA) work?

The first point of contact should have a clinical background and knowledge of the service, in order to carry out the assessment without losing a personal touch

There could be a loss of direct contact for referrals through GP’s, therefore, referrals need to

be appropriately signposted

Steps in the process will need to be reduced to avoid another layer in the service as service users do not want to have to repeat themselves unnecessarily

Service users need multiple points of access in order to have choice and flexibility, many providers felt a SPOA may reduce patient choice

SPOA data should be up to date to avoid waiting times for treatment and be able to meet the language needs of BMER communities

High investment and resources would be required for a centralised referral/assessment system

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Many providers did not feel the SPOA was the best way forward


What other agencies can offer therapeutic services that differ from the ones suggested by Commissioning?

Financial Debt Services

BMER Communities

Service User Groups

Peer mentors

Mental Health Champions – Icope, White Wall

Employers

Housing Service and Community Safety (including Hostel providers)

Citizen Advice

Deaf and Blind accessible Counselling

Cancer care and McMillan

Multi-disciplinary Services and Statutory Emergency Services

Job Centre Plus

Substance misuse services


How can collaborative and partnership working be demonstrated in contract/performance monitoring?

Needs to be clearly specified in the contract/facilitated through the contract model

Where providers are referring or signposting service users to, in order to promote service user choice and demonstrate for example how diabetic clinics/IAPT services are all working towards the same outcome

Evidence of patient experience and outcomes (incl; IAPT patient experience questionnaires)

Tracking patients (using NHS numbers) to evidence how many health services are used during the year

Gathering evidence of how service take flexible approaches to facilitate access i;e home visits /outreach


What are the barriers for BMER communities to access psychological therapies?

Workforce needs to be upskilled by building upon language skills (ie, delivery of correct language/dialect to avoid creating waiting lists).

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Capturing services in the wider community (ie, outside of Camden and working cross borough to enable service users to use IAPT in another borough and improve service user choice);

Tackle and address the stigma attached to mental health (this may be hidden in families and communities) as service users may not trust ‘confidentiality’ of providers;

Sexual orientation;

Disabilities;

Culturally sensitive groups not mixed sets;

Staff having flexibility around work and commitments particularly when telling managers their going for counselling.


Are there examples of good practice engagement with BMER that might be useful to include in the Camden pathway/provision?

Engaging better with other services linking clinical and cultural services together

Training local cultural/religious leaders how to provide information to their communities

Training volunteers and champions to create awareness

Use ‘talking from the heart’ service


Are there other things the group can think of that might facilitate access to/break down perceptions of psychological therapies for BMER communities/individuals?

Flexibility of services and times

Branding ‘time to talk’ not IAPT

Talking more generally about wellbeing/ linking into physical health provision - parity of esteem

Developing volunteers, mental health champions and focus groups

GROUP DISCUSSION FINANCE:

How might Camden be able to meet extended targets (up to 25 per cent entering treatment by 2020) on a hypothetical £2M budget? And where should Camden be focussing the funding?

Focussing on outcomes including meaningful clinical improvement and wider non-clinical outcomes

Increasing access for older people (65+) BMER and young people

Reporting on service user feedback and experiences

Focussing on support: Using peer mentors to support people discharged from IAPT who have not recovered

Support in the system between referral from the GP to treatment and waiting times

Appropriate follow ups for customers at six and twelve months

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Ensuring there is evidence based interventions and therapies;

IAPT vision event feedback – Sept 2015

CONTRACT MODEL FEEDBACK:

What model might be perceived to be costly in terms of implementation (if any) and further advantages and disadvantages of each model

Lead Contractor:

- Additional cost not focussed on patient outcomes

+ An understanding of the contractors knowledge of the community, relationships and how they will capture outcomes

-/+ Less of a burden on a particular provider, but may be difficult to manage

+ Transparency and accountability of the provider

+ Increased flexibility for sub-contractors around delivery and choice

Lead Provider:

- Unable to increase sub-contractors throughout the lifetime of the contract

+ Further clarity on how providers will work with wider groups, how this will be marketed and the cost implications

+ Provision for organisations with expertise to input into service delivery, similar to the diabetes model

AQP:

- Historically contracts are not formed to align working together incentives with competitiveness affecting collaborative working and shared outcomes

-/+ The model offers choice, but can cause confusion for referrers and patients

- There needs to be resources available for providers to manage patients who access multiple therapies

+ Access targets can be easily achieved by individual providers

Alliance:

- Time and increased legal costs to form the alliance

+ Provider expertise and working towards shared targets

+ Allocating funds in a flexible way to providers depending on their size

PAYMENT STRUCTURE AND OUTCOMES FEEDBACK

Opportunities and risks of the structure:

Useful if all levels of information can be captured including community outreach activities

An increase in patient access to treatment

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Agreeing right, measureable and realistic outcomes and having the appropriate resources to analyse this data in a meaningful way

Supports cultural changes in the IAPT landscape – ie employment outcomes

The timeliness of collection of data aligned to payments would have an impact on smaller organisations

Additional cost in collecting data and resource implications for smaller organisations

The danger of perverse incentives where providers concentrate on areas of higher funding returns

QUESTIONS:

1. Can a lead provider bring in other organisations once the contract has been formed?

Similar to the current AQP model lead providers may be unable to include other organisations once the contract was formed. This will need to be discussed further with procurement colleagues if this option is considered.

2. Is it the responsibility of commissioners to form an alliance?

As part of the IAPT re-modelling and re-commissioning process, providers should already be having conversations regarding the future model. Within Camden there are a number of IAPT providers that have already form relationships therefore, the natural process would be for these conversations to continue with a view of working together and draw upon expertise where ever possible.

3. There is a general concern that it would be difficult to manage the NHS tracking suggested in the presentation

This information is currently being captured but would need to be improved through the use of a single IT system accessible to all organisations.

BMER Summit – Making the most of Psychological therapies in Camden – Oct 2015

Summary Feedback (full report available on request)

Integrated working with BMER community service providers: (children’s centres/culturally specific

centres/religious settings)

Culturally competent workforce: (Including language and dominant dialects)

Collaborative working to maximise referrals/treatment outcome: Collaborative working with CDW and social participation service – sharing patients feedback; good practice examples

Flexible service provision to meet changing needs and demand from BMER communities

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APPENDIX 6

Camden Improving Access to Psychological Therapies (IAPT) – Service User Engagement Feedback [Extract]

Shanta Joseph - Mental Health Commissioning Officer

25 January 2016

1. Feedback

Two focus groups were held in which it was explained that the current contract for the IAPT service would be coming to an end on the 31 March 2017 and as a result of this Camden CCG will be re-commissioning the service with the intention of starting on the 01 April 2017. As part of this process we were talking to people about their experiences to inform the re-commissioning process.

Service users were informed that Camden hoped to improve upon the current service by focusing on the following objectives.

Objectives:

reduce inequalities and meet identified needs;

ensure access to and the delivery of safe, effective and responsive services; and

ensure maximum positive health impact with the resources available;

Around 30 people attended the two sessions. A proportion of attendees had directly experienced IAPT and were able to speak about these experiences, whilst a larger proportion at times commented more widely on what they would expect or wider experiences of mental health services.

Feedback summary

Perception of IAPT services

At both focus groups the majority of people recognised IAPT through the names of iCope, talking therapies, etc, rather than IAPT directly.

Overall there were mixed views with regards to IAPT services. People who had experience using IAPT services felt that the service was flexible and responsive to their needs and goals. However a few individuals noted that they felt a lot of focus was placed on form filling and that this could restrict how the service responded to the individual’s situation.

One person felt the need to follow a sequence of steps was prescriptive, for another individual some of the service requirements in terms of sequencing one to one meetings significantly delayed attendance at group sessions, with no flexibility even though attending the group sessions was the individual’s stated preference.

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Experience of person that had accessed IAPT

He was referred to IAPT as he had a physical health problem that was thought to be the result of stress. He is a carer for his daughter who experiences severe mental ill health, does not sleep and becomes particularly distressed at night.

He felt the GP referral to IAPT was inappropriate and unhelpful. A referral for peer support/ carers’ group and a carer assessment would have been much more useful. He had to find out about this himself (and it took him some time). He felt that a wider “menu”

of services to refer to, with IAPT as one important option, would be better than a focus predominantly on IAPT.

In attending sessions he also felt that the process was quite rigid, for example, focusing on questionnaire completion at the start of sessions, rather than building rapport and not referencing the physical issue that had prompted the referral and was concerning him. In general he felt the process was quite formulaic and could have benefited from a more open conversation. He understood he was expected to find solutions for himself, but he didn’t feel guided in doing so.

What works within IAPT?

Despite the feedback above most people felt that once treatment was received it was beneficial. People were satisfied with therapy when they felt that therapists were able to respond to their individual needs and circumstances, although, some people felt that they received ‘text book’ therapy that did not adequately address their particular issues. Both the bereavement service and Age UK were highlighted as providing an outstanding service.

What does not work?

General Concerns

People felt that it would be helpful if services were available out of hours as not everyone is able to contact services during traditional working hours. It would be helpful if contact details could be given out as standard practice so people can leave messages out of hours. Other people felt that the offer could be strengthened for people that are housebound, either through physical or mental health needs.

One person was also referred to iCope, rather than secondary care, and then this referral was reversed, which made the person feel “passed around”.

There were also questions about whether CBT was on offer, and appropriate, for clients with more challenging needs, including those within secondary care.

Many people were concerned about the limited number of sessions. The time-limited nature of the therapy needs to be communicated to people to ensure that expectations are clear. It was felt that discussion and preparation for the end of therapy are equally important to avoid causing further anxiety.

In addition to the above points it was felt that peer support could be incorporated into IAPT.

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Waiting times

For some people it is clear that lengthy waiting times were distressing and that there could be more communication about timescales and information during long waits. Access to pre-start materials may also be an option to support people to begin thinking about addressing their challenges ahead of formal sessions.

It was noted that on occasions there was a long wait to be seen and in one case it was reported they were assessed and then not contacted and had to be re-referred by their GP.

Service users felt that there needs to be tighter performance management by commissioning on wait times, particularly around the small group of people that receive much longer waits to understand why this occurs.

DNAs (Did Not Attend.)

It was felt that the IAPT service had little tolerance for people not turning up and that it should be recognised that anxiety can make it difficult to attend appointments. A DNA can be an indicator of great need. It is not helpful when referrals are just closed. There was fear that this could lead to people with higher levels of need missing out on support. It was felt that some sort of follow up process on DNAs could be helpful.

Service coordination

It was felt there was a lack of coordination between services, a number of people stated it was obvious that mental health services have very little knowledge of other services and this is impacting on the help and assistance received. It was noted that on occasions two health appointments have been booked for the same time and people felt they needed to choose between health appointments.

Location

It was noted that venue, location and reception staff are crucial in establishing a relaxed and welcoming setting. Services need to be sensitive to the potential stigma for people when accessing mental health services.

Practical advice about accessing support needs to be given up front as if someone is referred to a service that is too far away from where they live, they will find it hard to access.

One person in the room noted their husband had an appointment with an IAPT provider, but felt that the location of the appointment was too far for them to travel.

The appropriateness of the locations from which services are delivered was queried. It was felt that more community locations should be used to deliver the service eg, hostels, day centres, and one stop shops. It was recognised that confidentiality should be taken into account no matter where the service is delivered from.

Public relations

Most people felt that the service could be much better publicised and wasn’t especially well

known even amongst regular users of health services. People were unsure if IAPT or even

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iCope were helpful names. Some people suggested that individuals should be encouraged to tell others as often word of mouth can be the best way to spread word about a service.

The group noted that the online information could be much clearer. The website asks for GP information without an explanation for why the data is being requested, this leaves people with the impression that referral is via GP only.

2. Recommendations

Based on the service user’s feedback, the following recommendations were offered for

delivering a person-centred IAPT service:

further promotion of the IAPT service to raise awareness among both public, GPs and partner organisations.

online information could be clearer and more user friendly.

more contact and information to be given in providing support while waiting to access the service.

accessible resources should be made available to patients prior to, and during therapy.

flexible therapy within the IAPT model that is focused on good relationships to address individual needs.

provide open communication for patients from the start and as far as possible accommodate personal circumstances and preferences.

more attention should be paid with regards to how the number of sessions available is communicated with service users.

more flexibility to be given when arranging appointments.

additional appointments outside of standard working hours are needed to accommodate those people who are in employment. and

stigma awareness training for all staff, including reception staff, would help to promote good practice and establish a welcoming environment.

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Report Title Business Case for Securing an Integrated And Accountable Musculoskeletal (MSK) Programme Of Care

Agenda Item 3.2 Date 01 March 2016

Lead Director Susan Achmatowicz

Chief Operating Officer Tel/ Email

[email protected]

Report Author Lyndsey Abercromby Tom Aslan Melody Woolcock (supported by McKinsey & Co team and Steven Laitner)

Tel/ Email

[email protected] [email protected] [email protected]


Dr Lance Saker Tel/ Email

[email protected]

Report Summary

This report provides a business case for the procurement of an integrated and accountable Musculoskeletal (MSK) programme of care. It provides options, for the Governing Body’s decision, on how to procure the desired service, as well as implications, risks and mitigations.


Information

Approval

To note Decision

Recommendation The Governing Body is asked to approve the clinical model as laid out in Section 3.1

The Governing Body is asked to approve the recommended contract parameters as laid out in Section 3.2

The Governing Body is asked to decide on whether to include a contractual requirement of interoperability as laid out in Section 3.2. point 4ii

The Governing Body is asked to decide on which implementation timetable option to take as laid out in Section 4

The Governing Body is asked to authorise the procurement of an integrated MSK service with fixed Global Sum of the value that should not exceed estimated actual spend on MSK services in scope in 2015-2016 contracting year (which will be verified before ITT is issued) by more than 5%

In light of these decisions the Governing Body is asked to approve this business case.


Improve health outcomes, address inequalities and achieve parity of esteem Integrate and enable local services to deliver the right care in the right setting at

the right time Maintain financial stability and ensure sustainability through robust planning and

commissioning of value-for- money services Identified Risks and Risk Management Actions

Risks and mitigations are fully detailed in Section 4.3


The lead provider will likely need to demonstrate their ability to deliver a service that ensures patients have appropriate and seamless access to local providers (acute hospitals). Local providers are also potential lead providers and should be discouraged from exerting their power and influence negatively on other bidders

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Additional resources will be needed to successfully procure the new service in both implementation timeline options. Details can be found in Section 4.2

Engagement

In producing this report, there has been engagement with patients & carers, providers, GPs and specialist clinicians. This includes patient interviews; patient surveys; GP interviews; a number of workshops with GPs; specialist consultant interviews.


The Equality Impact Assessment is provided separately.

Report History

This business case was considered at the February 2016 meeting of the Commissioning Committee.

Next Steps If the ambitious timeline is selected: the PQQ must be approved by the Procurement Committee by March

23rd and published by March 31st to stay on the timeline

Appendices

None

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Securing an integrated and accountable MSKprogramme of care

CAMDEN CCG

Business case

09 March 2016

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Executive Summary (1/3)

SummaryThis business case proposes that Camden CCG should proceed to commission a fully integrated MSK service and programme of care on the basis that

– This decision fits with the CCG’s strategic direction and the overall national context of commissioning

development– The solution will result in significant improvement of patient experience, patient outcomes and provider

experience and will deliver financial savings vs. the “do nothing” scenario

– It is possible to execute the procurement within a reasonable time and with medium1 levels of risk, provided there are sufficient resources allocated

Context▪ Commissioning an Integrated MSK Service has been a priority for the CCG over past 2 years but there

has been limited execution due to a lack of focus and resources, resulting in extension of the community-only contract alone

▪ Clinical integration is seen as a strategic direction by both Camden CCG and within national guidance, including the NHS Five Year Forward view and Department of Health’s MSK Service Framework

▪ There have been a number of Integrated MSK projects and procurements undertaken nationally, both successful and unsuccessful and the learning from these has been taken into account in this proposal

Case for change▪ Currently patients experience significant inconveniences across the MSK pathway, including long waiting

times, lack of information sharing between their clinicians, the need to obtain multiple referrals from GPs, and difficulty accessing support services

▪ The system is ineffective for providers, resulting in duplication of imaging procedures, a high share of consultant appointments not leading to procedures, and GPs taking on significant administrative burden

▪ Commissioners have difficulty understanding the overall programme value due to challenges in aggregating data from a variety of contracts and enforcing improvements across disjointed providers

1 Mitigated risk 162 of 443

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Clinical model▪ The proposed clinical model stipulates the creation of Camden Integrated MSK Service (CIMS), which

would be responsible for:– Providing a single point of access, triage, referral and case management for patients, carers and

referrers (including patient self-referral)– Providing a full range of clinically integrated MSK Services including specialist ambulatory care,

imaging and specialist inpatients services– Providing patient choice for specialist services and bearing the cost of such procedures should the

patient chose to go outside CIMS– Ensuring coordination, clinical education, and sharing of data with services related to the MSK

programme but not forming a part of CIMS (e.g. psychology support, lifestyle services, and general practice)

– Providing resources for patient self-management and education (including digital services)Contracting options▪ The proposed contracting choices are based on a set of principles, derived from academic findings,

national guidance and local priorities which have been used to generate criteria for evaluation of the choices

▪ Overall, the recommended contract would be with a single provider, for a fixed global sum over 5 years with 2 years extension. There would be a 20% outcome-based payment, starting initially at 0% and growing to 20% from Year 2

Implementation considerations▪ It is possible to procure and go live with the desired integrated MSK service by April 2017, though this will

require rapid programme mobilisation (Ambitious Option)– Pre-qualification questionnaire has to be issued before April 1st, 2016 with short-listing completed in

May– The ITT must be issued in June 2016 with selection confirmed by September 2016– Mobilisation will need to take place between October 2016 and March 2017

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Key risks in this Ambitious option are:– Lack of provider interest (mitigated by a recent market-testing exercise and a long period of current

provider engagement)– Providers not being able to lock the whole supply chain (mitigated by extensive provider engagement

over period of PQQ and ITT)– Lack of time required to confirm baseline spend on MSK services (mitigated by the work done to date

using HRG codes)– General time slippage (mitigated by the ability to carry out a short rolling extension of Connect’s

community service if the procurement is delayed for reasons beyond the CCG’s control)

▪ An alternative Moderate Option envisages launch in October 2017, with more time taken upfront to prepare all necessary documents and a longer provider selection process potentially through competitive dialogue. It has slightly lower level of risks, but requires a further 6 months extension to the Connect contract

▪ Both options would require external support to execute and personal accountability from a member of executive team and a Governing Body member

▪ The overall amount of financial resources required to run the project will be similar in both options, being spread more thinly in the Moderate Option

Financial considerations▪ In the “do nothing” scenario the costs of MSK services are projected to increase by ~2.5% PA

▪ In case the contract value is capped at £15m per annum1 it results in savings for the CCG of £4.2m over 5 years and an additional £2.3m in the next 2 years, should the extension option be exercised

▪ The recommendation is to procure an integrated MSK service with a fixed global sum of the value not exceeding an estimated actual spend on MSK services in the 2015-2016 contracting year (which will be verified before ITT is issued) by more than 5%1

Note: 2015-2016 MSK spend, calculated with final 3 months extrapolated based on actual spend in first 9 month, will need to be verified before the ITT is issued; financial savings could be higher if the global sum is lower or if providers payments are reduced due to missed outcomes1 The spend forecast and saving estimates (detailed in Section 5.1) assume a cap of £15m, which is 4% above the 2015-2016 spend

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Executive Summary – Summary of recommendations

Decisions required by the Governing Body

– The Governing Body is asked to approve the clinical model as laid out in Section 3.1– The Governing Body is asked to approve the recommended contract parameters as laid out in Section

3.2– The Governing Body is asked to decide on whether to include a contractual requirement of

interoperability as laid out in Section 3.2. point 4ii– The Governing Body is asked to decide on which implementation timetable option to take as laid out in

Section 4– The Governing Body is asked to authorise the procurement of an integrated MSK service with fixed

Global Sum of the value that should not exceed estimated actual spend on MSK services in scope in 2015-2016 contracting year (which will be verified before ITT is issued) by more than 5%1

In light of these decisions the Governing Body is asked to approve this business case.

1 The spend forecast and saving estimates (detailed in Section 5.1) assume a cap of £15m, which is 4% above the 2015-2016 spend165 of 443

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Contents

Context and scope

The case for change

Options and recommenda-tions for delivery

Implementa-tion of the recommended model

Financial implications

1.2 Learnings from other CCGs

1.1 Context

1.3 Project scope

2.2 Provider and commissioner experience

2.1 Patient experience

2.3 Potential root causes

3.1 Clinical model

3.2 Contracting options

4.2 Capabilities required

4.1 Implementation options

4.3 Risks and mitigations

5.1 Financial implications

▪ Overview of Camden CCG’s current situation, activity level for MSK & spend

▪ Overview of relevant national guidelines with respect to commissioning in general and MSK in particular

▪ Description of similar cases, both successful and failed, and key learnings

▪ Services, conditions, and patient demographics in scope

▪ Description of the current patient experience, including quotes, satisfaction ratings, patient outcomes, and activity statistics (e.g. waiting times)

▪ Description of the challenges and issues for GPs, specialist clinicians, as well as for the commissioners

▪ Root causes of issues experienced by patients and/or providers

▪ Graphical descriptions of the current model vs. the proposed model▪ Illustrative diagram of patient experience in current vs. proposed model

▪ Key principles for making decisions regarding potential contracting options▪ Outline of decisions to be made regarding end-state contracting arrangements▪ Analysis of options for each decision point and recommendation

▪ Options for implementing the desired end-state contracting arrangements, including description, implications for timeline and resources required

▪ Assessment of capabilities required to implement the programme

▪ Key risk areas, assessment of potential root causes and actions required to mitigate them

▪ Financial baseline (projections of spend in the “do nothing” scenario)

▪ Financial implications of implementation of the proposed business case (cost of services)▪ Financial resources required for implementation

1

2

3

4

5

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Contents

▪ Context and scope

▪ The case for change

▪ Options and recommendation for delivery

▪ Implementation of the recommended model

▪ Financial impact

▪ Appendix

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1.1. Local context

▪ Camden CCG have identified issues with the current MSK servicemodel, which are impacting patient care and experience

▪ Assessing activity-based performance only does not necessarily reflect patient-outcome based performance

▪ The lack of integration of care across service providers and lack of focus on patient outcomes are core to the problem

▪ In addition, there is increased financial pressure across the NHS, as well as pressure to improve patient experience and outcomes

▪ Camden CCG have been trying to commission an integrated service for 2+ years, but have been unsuccessful thus far, resulting in loss of knowledge, re-work, inconsistent messaging, and reputational impact

▪ There is pressure for Camden CCG to prioritise, commence, and complete this transformation now to improve MSK patient care and experience, increase value and address concerns about their ability to execute

▪ Camden CCG is looking to tackle the issue by moving to an integrated and accountable programme of care, using a value-based outcome models

▪ In January 2016, the Commissioning Committee– Approved a proposal to move to an integrated programme of care,

over continuing the existing fragmented model– Requested to see the full business case, for approval, at February's

Commissioning Committee meeting

What is the primary issue facing Camden CCG’s MSK

Services?

How is Camden CCG planning to address these issues?

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8|Source: MSK Baseline costs February 2016, including SUS, SLAM, Connect Health invoice data, InHealth invoice data, CNWL block contract data,

2014/15 Programme budgeting return, CCG and CSU

UCLH

0.4

2.63.7

Imp.Whitt. RNOH

0.2

Not broken down by provider

0

Other

0.3

2.2

0.6 5.2

CNWLIn-health

RFH

7.5

Comm-unity total

Acute total

CH High cost drugs and devices

2.4

0.90.8

Primaryprescri-bing

Total

0.2

14.4

5.1 Financial breakdown of current spend

Camden CCG spend for known or ratioed activities within key specialties1 at acute providers and community providers, and prescribing spend M9 2015/16 FOT2

£m

1 Trauma and Orthopaedics, Rheumatology, Pain management, Physiotherapy2 Actual spend to be verified with providers

PRELIMINARY

Spend includes:

▪ In-patient M9 2015/16 FOT: elective (IP EL) and day case (DC) spend by acute provider, using non-trauma HRGs for hip, knee, foot, shoulder, elbow, hand,spine (no lumbar segmentation). Excludes reconstruction

▪ Out-patient (OP) M9 2015/16 FOT by acute provider, calculated as 71% of total OP spend from key specialties. 71% = percentage of IP DC that is MSK, from T&O, Rheumatology and Pain management

▪ OP unbundled procedures M9 2015/16 FOT : MRI, ultrasound and DEXA, at InHealth ratios (see below)

▪ Connect Health M9 2015/16 FOT from invoice analysis

▪ InHealth M9 2015/16 FOT calculated using % of 2014/15 ultrasounds that are MSK by body part and % of MRI that are MSK by body part

▪ CNWL MSK portion of 2015/16 block contract

▪ Prescribing spend from 2014/15 CCG Programme budgeting return

Acute spend Community spend Prescribing spend

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1.1 National context

Source: DH "The Musculoskeletal Services Framework - A joint responsibility: doing it differently“, NHS “Five Year Forward View” (October 2014), Michael Porter’s “What Is Value in Health Care?” (December 2010), Michael Porter’s “Value-Based Health Care Delivery” (March 2012)

Department of Health’s Musculoskeletal Services Framework (MSF)

A framework that aims to provide patients with high-quality, effective, and timely advice, assessment, diagnosis, and treatment

• Recommends achieving this through “systematically planned services, based on the patient journey, and with integrated multidisciplinary working across the health economy”

• Is based on evidence from the European Bone and Joint Health Strategies Project (2005) showing that better integration of, and collaboration between, primary, secondary and social care can reduce hospitalisation and yet, crucially, provide better care and a better service to patients and carers alike

NHS’s Five Year Forward View

A set of recommendations for changes needed across the NHS to improve care in the near future, including:

• increased focus and investment in prevention and public health

• patients having greater control of their own care

• breaking down barriers in how care is provided – between family doctors and hospitals, between physical and mental health, and between health and social care

• better use of national resources to find the right balance between specialist and general care

• options for various integrated models of care

Value-based Commissioning (developed by Michael Porter)

A method for measuring performance aimed at achieving the best possible patient outcomes per £ spent

▪ Currently, financial success of the system is not aligned with patient success

▪ Value, i.e. patient health outcomes per £ spent, unites the interests of all system participants (patients and providers)

▪ Focus should be on better health, rather than treatment; better health is less expensive for the system than poor health

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1.2 CCGs that have started a similar procurement

Case study detail to follow

Source: Cobic’s “Lessons learnt from procurements of integrated MSK systems” (December 2015)

Health economy

Population size (‘000)

Annual budget (£m)

Procurement approach

Contract live from Prime contractor

Contract duration

Bexley224 17 Open market -

competitive dialogue

Apr-14 Kings College Hospital and partners

3 years + possible 2 year extension

Central Sussex

668 42 Open market -ITT

Jan-15 Sussex MSK Partnership

5 years

Coastal West Sussex

502 47 Open market -ITT

Halted BUPA/CHS – now withdrawn

n/a

East Sussex358 23 Open market -

competitive dialogue

Jan-15 Sussex MSK Partnership

5 years

Sheffield590 40 Work with local

providersApr-15 Sheffield

Teaching Hospital NHS Trust

5 years

Camden240 TBD TBDTBD TBD TBD

Bedfordshire450 26.5 Open market -

ITTApr-14 Circle

consortium5 years

North West Surrey

365 - Open marketHalted n/a n/a

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1.2 Case example: Bedfordshire

Bedfordshire integrated MSK contract (1 year later)

Description

▪ 1st April 2014

▪ 5-year contract with Circle - £26.5m pa

▪ Elective MSK for adults

Improvements (claimed by Circle)

▪ 100% of patients are triaged within 24 hours of referral

▪ 20% GPs referrals have been picked up as incorrect

▪ Wait times have reduced across the system; particularly dramatic in physio, where wait times halved and diagnostics reduced by a third)

▪ All patients are offered choice over secondary or community care

▪ Health-related quality of life (EQ-5D) is now captured at the start and end of each physio care bundle; never done before and can be tracked

Issues (claimed by local trust)

▪ Reduced volume of elective work at Bedford Hospital Trust▪ Delays in referrals to Bedford Hospital Trust and other specialist

consultants

Current Status ▪ Live


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1.2 Case example: North West Surrey

North West Surrey

Current Status ▪ On hold

Description

▪ Procurement started 2015

▪ 3 providers shortlisted post-PQQ

▪ All 3 providers withdrew their bid before ITT, resulting in halt

What went wrong

▪ ITT procurement route resulted in little opportunity to discuss specifications or raise concerns for resolution

▪ There were not enough levers to transform the system quickly enough

▪ The outcomes-based incentives were not well thought through


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Performance monitoring learnings

▪ Be transparent and clear on contract KPIs

▪ Monitor performance transparently and taking into account the lead provider’s ability and time required to establish baselines

Financial learnings

▪ Introduce financial contingencies for unexpected external impact, scope gaps, and start-up or running costs

▪ Ensure the programme budget is adequately and comprehensively modelled

▪ Be pragmatic in the financial model for the contract

Training learnings

▪ Train contract managers on how to manage lead providers in an integrated platform

Procurement learnings

▪ Implement an appropriate procurement model with sufficient provider engagement, e.g. aim to engage continuously from pre-procurement stage or use competitive dialogue if early engagement is low

▪ Require evidence from the lead provider demonstrating their ability to provide local access, in order to meet patient choice

▪ Sign the head contract only after the supply chain is fully in place and subcontracts signed

▪ Put emphasis on value, not money

1.2 Key learnings from similar CCG transformations


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1 Includes UCH, Imperial, RFH, and Whittington with services varying across the different hospitals2 Include services such as well-being programmes and exercise programmes 3 Includes Connect, CNWL, and InHealth4 Includes cost of high cost drugs and primary prescribing

1.3 Project scope – MSK services Out of scope,financially

In scope, financially

PRELIMINARY

Specialist ambulatory care Inpatient careSelf-care Entry points

Prevention

Patient self-care

Acute hospitals1

Re-ablement

Rheuma-tology

Frailty

Falls clinic

Rehab-ilitation

Ortho-paedic

Neuro-surgery

Domi-ciliary

services

Medication4

Lifestyle2

Falls clinic

Local authority & voluntary

BCOM

iCOPE

BMI

Osteopathy

Osteo-pathy

Various services

Various services

Various services

CIFT RNOH

Physio-therapy

Rheuma-tology

Podiatry

Sports medicine

Pain services

Community3

Domiciliary services

Orthotics Imaging

LTC Management Cancer NHSE Services

The financial scope

The clinical scope

▪ Only includes services that are directly commissioned by Camden CCG

▪ Excludes:– Primary care– A&E– Local authority and

voluntary services– Interdependent

services, such as mental health services, cancer treatments, LTC management, and NHSE services

▪ Includes all services relevant to the overall diagnosis and treatment of adult patients with non-acute trauma MSK conditions:– Primary care– A&E– Specialist

ambulatory care within acutes and community providers

– Hospital inpatient care

– Local authority, voluntary services, and other interdependent services

Imaging

GP

Non-MSK outpatients

Patient self-referral

A&E

GP medication4

Ortho-paedic Rheu-

matology

Neuro-surgery

Medication4

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Out of scope

1.3 Project scope – MSK conditions and patient demographics

MSK conditions including:

▪ All kinds of arthritis, including:– Osteoarthritis– Inflammatory Arthritis– Arthropathies

▪ Sports Injuries (non-acute)

▪ Low Back pain

▪ Shoulder Pain

▪ Upper Back/ Neck Pain

▪ Ankle pain

▪ Connective tissue disease / autoimmune disease

▪ Carpal Tunnel Syndrome

▪ Gout

▪ Trigger finger

▪ Dupuytren’s contracture

▪ Osteoporosis

▪ Foot pain and deformities

▪ Tenosynovitis

▪ Fibromyalgia

▪ Ganglion

▪ MSK related benign soft tissue lesions

▪ Emergency MSK Conditions

▪ Acute trauma

Patient demographic

▪ Adults

▪ Patients 16 years old and over, not already in Paediatric care

▪ Patients 16-25 years old previously in Paediatric MSK care

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Contents






▪ Appendix

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2.1 Camden CCG provider performance statistics

Source: Patient survey 2015 - Improving musculoskeletal services in Camden, Connect Physical Health – MSK Service Report (average for October 2015 – December 2015)

1 Average time from date of self or GP referral to first available PhysioLine appointment 1 Average time from referral acceptance to first available appointment 2 Connect’s Clinical Assessment and Treatment Service 3 Average time from slot booking to attendance

… others, particularly the community-provided services, are not

While some parts of the system are performing well…

▪ 53% rated their experience of the community management of condition “very poor” or “poor”

▪ 18 working days wait4 for Physiotherapy appointment

▪ 5 working days wait1 for first available PhysioLine appointment

▪ 13 working days wait2 for first available CATS3 appointment

▪ 15% of appointment not attended

▪ 60% “excellent” or “good” ratings for hospital based specialist services`

▪ Camden CCG acute spend per weighted population is better than average, compared to London peers

▪ 17 working days wait4 for Podiatry appointment

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2.1 Issues with the current service – patients and carers

Source: Patient survey 2015 - Improving musculoskeletal services in Camden

Patient sentiment StatisticsQuotes from patients and carers

I want timely and responsive service

~50% of patients want quicker access to appointments

▪ “It is also very, very slow to get ultrasound and steroid injections through the hospital, leaving me in pain and restricted mobility for weeks and months at end”

I want my care to be holistic, supportive, and personalised to my needs

~45% of patients want care that improves their quality of life

▪ “I was told 'I only look at feet‘”▪ “They make you leave and give you no

after-care except a routine visit so long after the op that complications… can cause

severe problems”

I want to be involved in my care

~45% wanted shared decision making on the options for their care

▪ “I explained that I had tried orthotics years

ago and that it had not worked. This was ignored and orthotics were recommended”

I want a coordi-nated, seamless experience

~55% of patients want improved coordination of care between professionals

▪ “I had to be re-referred by my GP to access another part of the MSK service, this is a waste of my time and GP’s time”

▪ “MSK services need to be joined up”179 of 443

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Diagram of a real-life patient journey over 3 years

Real-life patient journey over 3 yearsIn

patie

ntO

ut-

patie

ntE

ntry

poin

t

▪ Patient has:– torticollis1,

possible psychological elements, and autistic tendencies

– been bounced back and forth between specialist clinicians

– received conflicting messages from different clinicians

– had a significant amount of GP contact (107 times) as GP acts as their main point of advice and referrals

▪ After 3 years the patient:– experiences low

moods from expectations being heightened, then lowered

– still suffers from pain

A&EAcuteGP

Jan2013

Jan2016

Jun2013

Jan2014

Jun2014

Jan2015

Jun2015

Ap

po

intm

ent

typ

e

Date

Source: Working group workshop1 a condition in which the head becomes persistently turned to one side

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2.1 Case example: Bedfordshire CCG improvements of patient experience


Bedfordshire’s integrated MSK service is held by Circle and covers elective MSK care

for the whole adult population of Bedfordshire

Patient sentiment First year results

I want timely and responsive service

▪ 100% of patients are triaged within 24 hours of referral to the integrated MSK system

▪ Wait times have reduced, particularly in physio (50% reduction) and diagnostics (33% reduction)

I want my care to be holistic, supportive, and personalised to my needs

▪ Health-related quality of life (EQ-5D) is now captured at the start and end of each physio care bundle.

I want to be involved in my care

▪ All patients are offered choice over secondary or community care▪ Patients considering surgery with support of a dedicated shared

decision-making doctor

I want a coordinated, seamless experience

▪ 1 in 5 referrals from GPs have been identified as incorrect, i.e. without the MSK service, the patient would have been referred onto a suboptimal management pathway

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2.2 Issues with the current service – GPs and specialist clinicians

Issues Impact on GP Impact on specialist clinician

Lack of communication between providers and the patient

▪ Time spent consolidating and explaining varying messages from different providers

▪ Dissatisfied patients turn to GP for advice and to complain

▪ Unnecessary referral to specialists as:– Treatment is not holistic (e.g. lifestyle services

may be more appropriate)– Triage is done by GP alone– Patient’s preference for or against a specific

treatment is not always taken into account▪ Diagnosis and treatment is done in isolation; better

collaboration across providers and patients would yield better personalised results

GP is central point for administrative tasks (e.g. referrals), in absence of a dedicated coordinator

▪ Increased workload with time wasted administering referrals at every referral point

▪ Appointment times taken by patients who just need a referral

▪ GP is seen, by patients as the “expert”

▪ No dedicated team/person to own overall plan for the patient, throughout their course of treatment

▪ Referrals need to go back through the GP

Lack of specialist training for GP, who takes on an “expert” role

▪ GPs are put in a position where they are seen as “experts” without the required support

▪ Unclear about suite of available MSK services

▪ n/a

Limited access to “live”

advice

▪ GPs are put in a position where they are seen as “experts” without the required day-to-day support

▪ No central team or person to go to for advice on MSK services, in general

Non-integrated IT system makes sharing data difficult

▪ GPs receive complains from patients due to delays and need to do the same test multiple times

▪ Receiving and sending patient data is difficult, delaying service provided

Lack of image standardisation results in duplicative tests

▪ Tests need to be redone, at a cost to patient and providers and commissioners

▪ Poor data and imaging are received, which can’t be

used▪ Tests need to be redone, at a cost to patient and

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2.2 Issues with the current services – Camden CCG

Source: Interviews with GPs and specialist MSK clinicians

Providers do not provide patient-outcome based metrics

▪ Difficult to ensure patient outcomes are met and to assess the relative value of the different services provided

Providers send a large amount of varying performance metrics in different formats

▪ Difficult to pull out the key metrics needed to assess current and relative performance

▪ Unable to compare performance across providers, like-for-like▪ Difficult to verify accuracy of data provided

Data provided by providers is not always complete

▪ Lack of confidence in the quality of data provided▪ Unable to effectively make data-driven decisions▪ Lack of focus on population health/wellbeing

Issues Impact

Risk is wholly on commissioners and not providers

▪ No strong levers to push / encourage providers to achieve desired outcomes for patients

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2.3 Symptoms and root causes

Source: Stakeholder interviews at Camden CCG

Root causes

1 No clear ownership and accountability for the overall musculoskeletal health of patients

2 Diagnosis and treatments are silo’d,with no formal forum for a multi-disciplinary team to work together to manage patients

3 Patients are not fully informed of their choices and supported to make the right decision for their specific needs and preferences

4 Care is focused on an individual service for treatment and not holistically

5 Performance metrics are focused on activity, not patient outcomes, care, or experience

Symptoms

1 Long wait-times

2 Mis-diagnosis

Incorrect referrals3

Bouncing around clinicians

4

Poor outcomes and experience

5

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Contents






▪ Appendix

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1 Includes UCH, Imperial, RFH, and Whittington with services varying across the different hospitals2 Include services such as well-being programmes and exercise programmes 3 Includes Connect, CNWL, and InHealth4 Includes cost of high cost drugs and primary prescribing

3.1 Clinical model – current services Out of scope,financially


PRELIMINARY

▪ Referrals come primarily from GPs at each treatment stage

▪ There is little coordination between the various services and providers

▪ Patients are not fully informed of their options

Specialist ambulatory care Inpatient careSelf-care Entry points

Prevention

Patient self-care

LTC Management Cancer NHSE Services

Acute hospitals1

Re-ablement

Rheuma-tology

Frailty

Falls clinic

Rehab-ilitation

Ortho-paedic

Neuro-surgery

Domicili-ary

services

Medication4

Lifestyle2

Falls clinic

Local authority & voluntary

BCOM

iCOPE

BMI

Osteopathy

Osteopathy Various services

Various services

Various services

CIFT RNOH

Physio-therapy

Rheuma-tology

Podiatry

Sports medicine

Pain services

Community3


Orthotics Imaging

Imaging

GP

Non-MSK outpatients


A&E

GP medication4

Ortho-paedic Rheu-

matology

Neuro-surgery

Medication4

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3.1 Clinical model – future integrated service

1 Include services such as well-being programmes and exercise programmes2 MSK Services not commissioned by Camden CCG as part of the Integrated MSK Service, accessed by Camden patients (e.g., through patient choice)3 Includes cost of high cost drugs and primary prescribing

Specialist ambulatory care Inpatient careSelf-care & Prevention

Primary Care (and other entry points) ▪ CIMS

– manages patients’

cases throughout the lifetime of their condition

– acts as a single point of access for MSK-related services for patients and GPs

– completes triagesand referrals to coordinate patient care across MSK providers and services

– Coordinates with services adjacent to MSK (psychological support, lifestyle, etc.) to ensure data sharing and improved patient experience

▪ Patient choice is offered proactively at every referral point, including options closest to the patient’s

location; and in full compliance with national guidance

▪ Equality across demographics is maintained

Out of scope,financially


In scope for fullclinical integration

In scope for data sharing, patient signposting and clinician education

Single point of access, care coordination, case management and triage

Camden Integrated MSK Service (CIMS)

Prevention

Patient self-care

GP

A&E

Non-MSK outpatients


Ortho-paedic

inpatient

Rheu-matology inpatient

Neuro-surgery inpatient

Physio-therapy

Rheuma-tology

Podiatry

Sports medicine

Pain services

Orthopaedic outpatient

Rheuma-tology

outpatient

Neuro surgery outpatient

Frailty


Re-ablement

Rehab-ilitation

Lifestyle1Falls clinic

iCOPE

LTC Management

Cancer NHSE Services

Osteo-pathy

Other MSK Services2

Other MSK Services2

Imaging, Radiology

Camden Integrated MSK Service (CIMS)

111

Medication3

GP medication3

Medication3

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3.1 High level preliminary service specifications

Stage Provider is expected to:

Prevention, self-care, advice, self-referral

▪ Maintain patient facing resource for self-assessment, information & advice (incl. on local wellbeing resources, patient groups and networks, curated national resources, etc.)

▪ Ensure access to quick advice over phone or digitally▪ Provide easy ability for self-referral into the Camden Integrated MSK Service (CIMS) over phone or digitally

Primary care assessment, management, investigation and referral

▪ Work with practices to ensure timely assessment and management of MSK problems▪ Support GPs to use the new MSK system▪ Identify, isolate and re-engineer unwarranted variations in GP usage of MSK services▪ Equip GPs with skills and knowledge to deal with MSK problems▪ Provide easy access to specialist advice (electronically or over the phone) and promote its usage▪ Ensure an easy referral process into the CIMS for the GP▪ Ensure convenient data flows and IT interoperability between general practice and CIMS

Specialist ambulatory care

▪ Provide all necessary MSK care and support, until MSK needs have been resolved and can be supported by self-care or GP

▪ Ensure referred cases are triaged within 1 working day by a team of qualified professionals▪ Provide access to all diagnostic procedures ▪ Provide continuity of care for patients

Inpatient care

▪ Help patients make an informed decision about surgical procedures▪ Proactively offer patients a choice of providers with every referral, including hospital closest to their location;

this is compliant with national guidance▪ Undertake patient pre-procedural assessment ▪ Do forward planning for post-surgical needs (even before admission)▪ Ensure delivery of high-quality and safe inpatient care▪ Ensure convenient data sharing, including clinical data, with clinicians providing the service▪ Take every opportunity to shorten waiting times (including direct booking to surgery)

Stage-specific expectations

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3.1 High level preliminary service specificationsGeneral expectations

Area Provider is expected to

Patient empowerment

▪ Empower patients at every stage (e.g. provide information about condition and outcomes, empower to make decisions)

▪ Give information about potential route to complain and escalate

Clinical integration & MDT

▪ Ensure that clinicians across the integrated pathway work as one team (MDT), regardless of provider entity

▪ Enable convenient data sharing and IT interoperability between all members of MDT (incl. patient records)

Services outside CIMS

▪ Ensure appropriate utilisation by the patient of services outside CIMS (e.g. psychological support; lifestyle support, etc.); with seamless process where possible

▪ 2-way information flows with important outside providers (incl. provision of patient cases where appropriate and consented, integrating information on patient progress in patient case)

Quality and patient experience monitoring

▪ Ensure continuous robust collection of patient feedback and provision of patient satisfaction data▪ Ensure robust and detailed provision of data on complaints▪ Ensure timely provision of a set of process KPIs (e.g. waiting times, referral rates, etc.)▪ Ensure periodic clinical audits▪ Instil culture of continuous improvement and continuous learning

Seamless experience and case management

▪ Ensure patients have seamless experience (e.g. all providers have access to patient history; no unnecessary referrals)

▪ Organise a single point of contact, convenient for patients (through phone and online access)▪ Provide case management for all patients (with patient having access via phone or digital resources)

Outcomes ▪ Track, measure, analyse, report and actively manage patient outcomes

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3.1 Typical patient journey – current model

Assess-ment

Treat-ment

Diag-nosis

Service type

Weeks 1 & 2: Sue self-

manages her pain

Weeks 11-17:▪ Sue com-

pletes 6 physio-therapy sessions

3 weeks wait

Week 20: Sue has her

MRI scan Her results

are sent to her GP

2 weeks wait

Week 41: At neuro-

surgery, Sue has:− Another

MRI scan− Additional

tests Neuro-

surgery refers Sue back to her GP

4.5 months1

wait

Week 3: Sue visits

her GP Sue’s GP:

− Com-pletes assess-ment

− Write a pres-criptionfor pain

− Gives some leaflets

Week 8: Sue returns

to see her GP with continued pain

Sue’s GP

refers her for physio-therapy

Week 18: Sue returns

to her GPwith continued pain.

Sue’s GP

refers her for an MRI scan

Week 22: Sue returns

to see her GP for her MRI results

Sue’s GP

refers her to neuro-surgery

Week 45: Sue

returns to see her GP

Sue’s GP

refers her back for additional courses of physio-therapyand lifestyle services (iCOPE, Apples & Care, etc.)

2 3

1

5 7

6

4

8

9

10

Self-help information is not easily or readily available

Long referral wait times

Reliance on a single “expert” (GP) with no direct communication between providers results in an increased chance of incorrect referrals and unnecessary interventions

Patient issues

Multiple unsuccessful referrals from GP Only ~18% of time spent in treatment After almost one year in the system, the patient is still in pain and referred back to an early treatment

Patients get no direct advice from providers, resulting in less informed decision

Sue is experiencing back pains. She:▪ is 51

years old▪ is obese▪ does

minimum exercise

▪ has a sedentary desk job

▪ Experi-ences low moods

~10.5 months

1 Based on historic range between 3 and 6 months

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3.1 Typical patient journey – future integrated model (1/2)

Service improvements experienced

▪ Significantly shorter length of time – 3 months vs. 2 years – due to reduced waiting times▪ Majority of time (55%) spent in treatment▪ Unnecessary interventions avoided▪ Quicker recovery due to more holistic care (e.g. exercise)

Service type

Week 1: Sue completes a CIMS self-

assessment online She self-refers to CIMS

Week 3-9: Sue completes 6 physio sessions, as

well as iCOPE and weight management classes

Her care coordinator monitors her progress via the app

Treat-ment

2 weeks wait

1

…48 hours later (Week 1)CIMS contacts Sue to: Arrange her physio

appointment Discuss her personalised

treatment plan Set up her treatment

management app Signpost her to lifestyle

services (iCOPE and Apples & Care)

2

3

With the right information, Sue is able to identify a need to escalate to her GP sooner

A single integrated service has the right range of expertise to provide holistic, coordinated care

Week 11: Sue calls her appointed care

coordinator, still experiencing some pain

4

Assess-ment

Diag-nosis

…within 48 hours (Week 11):

Sue’s CIMS coordinator:

− Contacts her GP, physiotherapist, and a neurosurgeon to better understand her options and get their recommendations

− Contacts Sue to discuss her progress, options and expected outcome (e.g. success rates, wait-times, recovery time, etc.)

− Sue makes an informed decision to continue with physio and lifestyle services

5

Better informed, personalised decisions can be made with input from experts

3 months

Sue is experiencing back pains. She:▪ is 51 years

old▪ is obese▪ does

minimum exercise



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3.1 Typical patient journey – future integrated model (2/2)

Service improvements experienced

▪ Significantly shorter length of time – 4 months vs. 2 years – due to reduced waiting times▪ Patient is empowered to make an informed decision about the most appropriate treatment for them

Service type 4 months

Sue is experiencing back pains. She:▪ is 51 years

old▪ is obese▪ does

minimum exercise



Week 15: Sue

attends surgery

Week 16: Sue’s CIMS

coordinator− contacts

her with a person-alised recovery plan, post-surgery

− monitors herongoingprogress

10

Week 1: Sue completes a

CIMS self-assessment online

She self-refers to CIMS

Week 3-9: Sue completes 6 physio

sessions, as well as iCOPE and weight management classes

Her care coordinate monitors her progress via the app

2 weeks wait

1

…48 hours later (Week 1)CIMS contacts Sue to: Arrange her physio

appointment Discuss her

personalised treatment plan

Set up her treatment management app

Signpost her to lifestyle services (iCOPE and Apples & Care)

2

3

Week 11: Sue calls her appointed

care coordinator with continued pain

4

…within 48 hours

(Week 11): Sue’s CIMS coordinator:

− Contacts her GP, phy-siotherapist, & a neuro-surgeon to better under-stand her options & get their recommendations

− Contacts Sue to discuss her progress, options & expected outcome (e.g. success rates, wait-times, recovery time, etc.)

− Sue makes an informed decision, to have an MRI scan

5Week 12: Sue com-

pletes her MRI scan

Resultsare avail-able to her care coordina-tor

2 week wait

9

7

Waiting time is reduced as the integrated service has remit to triage and refer patients directly

Week 13: Sue’s CIMS coordinator:

− Contacts her GP and neurosurgeon to discuss her MRI results

− Contacts Sue to discuss their recommendation and her options with expected outcome (e.g. success rates, wait-times, recovery time, etc.)

− Sue makes an informed decision, to have neurosurgery

5

1 week wait

Treat-ment

Assess-ment

Diag-nosis

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3.1 Benefits of the new integrated model to acute providers and GPs

Benefit Detail

Reduced number of incorrect and unwanted referrals

▪ Multi-disciplinary CIMS team will have range of expertise resulting in improved triaging

▪ Patients will be empowered to make informed decisions about their care, resulting in fewer unwanted referrals

Improved patient data sharing across individual services providers

▪ Scalable automatic or semi-automatic data exchange mechanisms will ease of sharing and receiving patient data between patients, providers and GPs

Reduced number of duplicative tests done

▪ New model will promote imaging standardisation across services▪ Provider entity will be responsible for ensuring a seamless pathway

between providers, resulting in improved coordination between providers

Centralised, focused workforce development

▪ Provider entity will be responsible for workforce development, including– training specialists and GPs in MSK-related conditions– through collaborative experiential work

Reduced administrative work ▪ Administrative work, e.g. booking referrals and being the primary point of contact, will transfer from GPs to CIMS

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3.2 Criteria for decision-making on contracting options

These objectives will serve as the basis for assessment of various contracting options as presented in Appendix 2

Considerations Objectives for contracting

▪ Camden-specific considerations– Camden CCG Business Plan Priorities– Camden CCG financial position and

future outlook– Prior experience with value-based

commissioning (incl. Psychosis and Diabetes cases)

▪ National guidelines– NHS England Five Year Forward View– The Musculoskeletal Services

Framework (DoH 2006)▪ Academic frameworks for value-based

commissioning– Capsticks and Outcomes Based

Healthcare Value-Based Commissioning Paper

– M. Porter Redefining Health Care: Creating Value-Based Competition on Results

– Commissioning and contracting for integrated care (The King’s Fund 2014)

1. Improve patient experience and outcomes, including through single point of access, advice and support

2. Improve provider experience and effectiveness, including through single point of access for referrers, enablement of efficient MDT working, integrated scheduling systems and patient records, integrated governance

3. Provide long-term incentives to improve population health

4. Generate interest from a significant number of best-qualified providers

5. Create clear accountability for patient outcomes on the provider side

6. Shift the balance of financial risk between the commissioner and provider

7. Equip commissioners with levers to effectively manage the contract and associated risks with enough flexibility and shift to data-driven commissioning focused on population health and prevention

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3.2 Summary of contracting choices

1. Contracting structurei. One OR multiple contracts?

i. If One contract: do we specify the organisational form of providers OR let the market decide?2. Length of contract & alterations

i. Core contract length: ~3; OR ~5; OR ~7 yearsii. Extension length: ~1; OR ~2; OR ~3 yearsiii. Who has the right to extend: either party; OR only CCG; OR only provideriv. Phasing of implementation of service specifications: phased over 1-2 years OR no phasingv. Amendment to contract: generally allowed if both parties consent; OR allowed in restricted circumstances (e.g., change in legislation,

NHS guidance, honest mistake in specifications); OR not allowedvi. Break clause: possible in specified cases (e.g. significant deviation from agreed specifications; significant deterioration of patient

outcomes) OR not specified3. Payment structure

i. Core payment: capitation-type OR activity-based?i. If capitation-type, is it fixed global sum, OR capitation (fixed per head, based on GP registered list), OR capitation with adjustments

(e.g. age; MSK disease prevalence)ii. Magnitude of outcome-related payment: 10%; OR 20% ; OR 30%iii. Phasing of outcome-based payment: phased over 2 years (e.g. Y1- 0%; Y2- 10%; Y3-20%) OR phased over 1 year (e.g. Y1-0%; Y2-

20%) OR no phasingiv. Structure of outcome related payment: a risk for the portion of the core payment OR a on top of core paymentv. Freedom for CCG to use the money for not achieved outcomes: for the same purpose only OR for any purposevi. Basis for outcome metrics: e.g. 5-10 key outcomes1 OR 30-50 KPIs in a balanced scorecard

4. Constraints regarding local providers and patient choice i. For community services: require physical location in each locality OR in Camden OR no requirementii. Requirement for the provider to take all reasonable steps to ensure interoperability2 with respect to inpatient and some highly specialised

outpatient services with: All acute providers which provide 20% or more of MSK inpatient activities (of Camden residents) OR At least one acute provider which provides 20% or more of MSK inpatient activities (of Camden residents) OR Any acute provider / providers, so that all Camden residents can access the services within reasonable travel time OR Do not have any contractual requirements for interoperability

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3.2 Summarised rationale for contracting selection (1/2)

Choice

1.i Single or multiple contracts▪ Single contract ▪ Creates clear accountability for the provider

▪ Simpler and more flexible structure

1.ii Specify the organisational form of providers OR let the market decide

▪ Let the market decide ▪ Leaves significant choice to attract a wide variety of providers

2.i. Core contract length▪ 5 years ▪ Standard for national and local precedents (e.g.

Psychosis VBC)

2.ii Extension length▪ 2 years ▪ Standard for national precedents

2.iii Right to extend▪ Only for CCG ▪ Gives commissioners more flexibility

2.iv Phasing of implementation of service specifications

▪ None ▪ Simpler to manager and explain to providers

2.v Amendment to contract▪ Allowed in restricted

circumstances1▪ Creates enough flexibility while not invoking risk of

challenges from regulators

Preferred option Rationale

2.vi Break clause▪ Possible in specified cases2 ▪ Creates enough flexibility while not invoking risk of

challenges from regulators and remains attractive for a provider

Detailed option appraisal presented in Appendix 2

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3.2 Summarised rationale for contracting selection (2/2)

Choice

3.i Type of core payment▪ Capitation ▪ Creates clear accountability for the provider

▪ Simpler and more flexible structure

3.ii Calculation of capitation▪ Block sum ▪ Leaves significant choice to attract a wide variety of

providers

3.ii Magnitude of outcome payment▪ 20% ▪ Standard for national and local VBC precedents (e.g.

Psychosis VBC)

3.iii Phasing of outcome payment▪ Over 2 years (Y1- 0%; Y2- 10%;

Y3-20%)▪ Allow the provider to be adequately funded in the period of

service ramp-up

3.iv Structure of outcome payment▪ A risk for the portion of the core

payment ▪ Standard for national and local VBC precedents (e.g.

Psychosis VBC)

3.v Freedom for CCG to use savings from provider underachievement

▪ For any purpose ▪ Gives commissioners more flexibility

3.vi Basis for outcome metrics▪ 5-10 key outcomes ▪ Easier to measure and more directly linked to outcomes;

align with CCG strategic direction

4.i Physical location of community services

▪ In each locality ▪ Better patient convenience

Preferred option Rationale

Detailed option appraisal presented in Appendix 2

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3.2 General requirements with respect to interoperability (4.ii)

Interoperability1 between an inpatient service provider and CIMS makes the patient journey seamless and includes at the minimum

▪ Ability to list the patient directly to the inpatient procedure

▪ Access to stored patient health records and care plan, including scalable semi-automatic or automatic two-way data exchange (e.g. through an IT solution providing a “bridge” between different provider’s IT

systems)

▪ Support for the integrated MSK care plan

▪ Obligation to provide data (for Providers) and present the data (for the Integrated Service) about waiting times and outcomes for specific procedures, to enable more informed patient choice

Interoperability does not affect the patient choice:

▪ Patients will still be presented with a range of secondary care provider options, as per national guidelines, regardless of whether they are fully interoperable1 or not with the Integrated Service– as interoperability includes the ability to book patients directly, it is likely that waiting times will be

shorter and the booking process easier for patients choosing fully interoperable providers

Interoperability does not require the acute provider to formally be part of the provider entity

▪ A hospital can be interoperable with the service, yet not formally part of the provider entity

Any acute provider shall be able to request interoperability with the Service, and the Service should consider this request in good faith and not turn it down unreasonably

▪ The Service should make it as easy as possible for any provider to achieve interoperability (e.g. have universal standards for data exchange; have standardised procedures for direct listing, etc.)

The Service should be able to request interoperability from acute providers with significant volumes of Camden patients; these requests should be considered in good faith by the acute providers and not to be turned down unreasonably

1 Interoperability in this context means extended interoperability - to a certain degree all providers should be interoperable with CIMS

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3.2 Impact of provider interoperability on patient experience (4.ii)

▪ Regardless of patient choice CIMS will aim to offer a personalised, holistic, and coordinated service▪ However, patient experience may not meet the desired standards with non-interoperable providers

3 CIMS refersSam to his selected provider

CIMS

1 CIMS informsSam of his options, including choices of local and non-local providers, success rates, and wait times

2 Sam decides to proceed with a hip replacement and selects the most appropriate provider for him

Sam, thepatient, under-goes some tests via CIMS

If Sam selects a provider that is not interoperable

▪ CIMS may need to refer via Sam’s GP▪ CIMS will likely have to use “choose and book”,

causing longer wait times▪ Sam will need to have another outpatient

appointment before listing for surgery▪ Results may be sent in paper format back to Sam’s

GP, making it longer and less convenient▪ The provider may not be able to see or edit Sam’s

care plan – any updates to the care plan will have to be done by the GP or CIMS

If Sam selects a provider that is interoperable with CIMS

▪ CIMS can directly refer him, without GPinvolvement

▪ CIMS can directly list Sam in for a procedure, resulting in shorter wait times

▪ CIMS transfers patient records in a convenient way, ready to answer questions from the provider

▪ CIMS gets results back directly, enabling ease oftracking Sam’s progress, and seamlesscoordination without GP involvement

▪ The provider inputs in Sam’s care plan directly

4A

4B

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3.2 Options appraisal with respect to contractual requirement of interoperability (4.ii)

Recommended

1 Currently only UCH (47%) and Royal Free (36%)

▪ Interoperability requirement can be formulated in contract in a number of different ways.▪ The Provider Entity should be required to take all reasonable steps to ensure interoperability with:

– All acute providers which provide 20% or more of MSK inpatient activities (of Camden residents)– At least one acute provider which provides 20% or more of MSK inpatient activities (of Camden residents) – Any acute provider / providers, so that all Camden residents can access the services within reasonable travel time– Do not have any contractual requirements for interoperability

Pro’s Con’s

A. All acute providers which provide 20%1 or more of MSK inpatient activities

▪ Will ensure more convenient service for the majority of patients

▪ Less disruptive for current providers

▪ Potentially gives excessive bargaining power to existing large providers– Mitigated by obligation for acute

providers to consider in good faith requests for interoperability

B. At least one acute provider that provides 20%1 or more of MSK inpatient activities (of Camden residents)

▪ Will ensure convenience for some of the Camden residents

▪ May be more disruptive to one of providers and stimulate over competitiveness

C. Any acute provider / providers, so that all Camden residents can access the services within reasonable travel time

▪ Will ensure convenience for all patients

▪ Potential to attract wider variety of providers, stimulating patient choice and competition

▪ Potentially more disruptive for existing providers– Mitigated by obligation for the

Integrated Service to consider in good faith interoperability requests from providers

D. Do not have any contractual requirements for interoperability

▪ Maximum competition ▪ Potentially less convenient to patients and more costly for the commissioner if no provider is interoperable

Option

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Contents






▪ Appendix

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4.1 Implementation options

1 Option may not be in line with the January’s Commissioning Committee decision

2 Mitigated risk

Option

Ambitious1

Moderate2

Time to deliver (months)

13

19

Resources required

• Dedicated project team (13-15 months)

• CSU support• Medium-high

external support• Expert input

• Dedicated project team (20-22 months)

• CSU support• Light-medium

extended external support

• Expert input

Medium

Medium

Risk level2Description

▪ Procure fully integrated service by late 2016

▪ Go-live with the integrated service on April 1st, 2017

▪ The Connect contract is extended till April 1st, 2017 months (as planned through waiver)

▪ Acute contracts for 17-18 also need to change

▪ Procure fully integrated service by early 2017▪ Go-live with the integrated service on Oct 1st, 2017▪ The Connect contract will need to be further

extended until Oct 1st, 2017

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4.1 Considerations for informing timeline decision

Source: Bedfordshire CCG - Governing Body Paper MSK Procurement, Contract finder (online) – Camden Clinical Commissioning Group Community MSK Services, Camden CCG’s

Clinical Procurement Policy

1 Approved by Procurement Committee 2 Approved by Commissioning Committee 3 Approved by Governing Body 4 If the procurement process starts after March 31st 2016, all documents must be approved and published at the start of the procurement 5 Camden CCG tested the potential provider market for Integrated Community Musculoskeletal (MSK) Service

Des-cription

Go live

▪ Decommi-ssion existing services

▪ Start new service

Service mobilisation

▪ Execute TUPE▪ Initiate new

governance process▪ Prepare for go-live

Contract awarded

▪ Present selection report to Governing Body

▪ Notify unsuccessful bidders (with 10-day cooling off)

▪ Notify winning bidder▪ Finalise contract

Invitation to tender (ITT)/ competitive dialogue

▪ Publish ITT▪ Host Q&A session(s)▪ Accept and assess

submissions▪ Host presentation for

shortlisted bids▪ Evaluate and select

provider▪ Prepare report for

Governing Body

Pre-qualification questionnaire (PQQ)

▪ Publish PQQ▪ Accept and assess

submissions▪ Get approval for

PQQ shortlist▪ Notify bidders of

outcome▪ Finalise ITT▪ Get ITT approval

Pre-procurement preparation

▪ Public & provider engagement

▪ Business case approval

▪ Documentation prep

▪ Finalise PQQ▪ Get approval for

the procurement route & PQQ

Apr2017

Ambi-tious

1

Mar2016

2 months3.5 months(ITT)

5.5 months Service go-live1 month

1 month

Mode-rate

Oct2017

2 5 months 2.5 months4.5 months(competitive dialogue)

6 monthsService go-live

Mar2016

1 mo-nth

Bid selection approval(14 Sep 2016)3

PQQ shortlist approval2

(25 May 2016) ITT approval (1 Jun 2016)1

PQQ shortlist approval2

(28 Sep 2016)Bid selection approval(8 Mar 2017)3

Case example: Bedfordshire procurement plan

2 months 3 months (ITT) 4 months Service go-live1 month

Jan 2013 Jan 2014 (actual go-live Apr 2014)

4 engagement events over 1 year

Key considerations for decision

Availability and allocation of required resources

Amount of public engagement needed and wanted (for both the CCG and providers) –market testing on a smaller scope5 was done August 2015 with 14 EOIs responses

Progress so far on drafts of key documentation

Procurement route & PQQ approval(23 Mar 2016)1,4

Procurement route approval (23 Mar 2016)1,4

Procurement doc-ument approval (23 Jun 2016)1,4

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2016 2017

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2 months

3.5 months

1 month

5.5 months

1 month

Accept, assess and select top 3 bidders for presentation

Prepare PQQ document

24 Feb 2016

Finalise contract

1 Jun 2016

Activity

Execute Transfer of Undertakings Process (TUPE)

Begin drafting other key documents – ITT, specification, KPIs, etc.

Prepare for service delivery (mobilization, communication, etc.)

25 May 2016

ITT approval by Procurement Committee

Host Q&A sessions for bidders

23 Mar 2016

Confirm slot in March Procurement Committee meeting

9 Mar 2016

Send Alcatel letter to unsuccessful bidders (10-day cooling off period)

Prepare report of selected bid for Governing Body

Business case approved by Commissioning Committee

Establish procurement project team

Notify ITT bidders of outcome

Decommission the existing services

Send confirmation to winning bidder

Present selection report to Governing Body

Service go-live (+ initiate the new governance process)


Arrange presentation of finalist bidders

14 Sep 2016

Accept, assess, and shortlist PQQ submissions


PQQ shortlist approval by Commissioning Committee

Finalise ITT document

Notify PQQ bidders of outcome

Publish the ITT document

Market testing / engagement (PREVIOUSLY DONE)


Publish the PQQ with period for clarification

Business case approved by Governing Body

Get approval for procurement route from Procurement Committee

Evaluate finalists and select successful bid

Contract awarded

Invitation to tender (ITT)

4.1 Implementation timeline: Ambitious

To ensure success with such tight deadlines, Camden CCG must:▪ Be committed

to meet the planned deadline

▪ Allocate dedicated resources committed to deliver by the deadline

▪ Meet key milestones and escalate any delays immediately

▪ Meet planned committee meeting dates to avoid significant delay

▪ Be prepared to prioritise this work over other non-urgent procurements

▪ Be focused in engaging with the market

▪ Recognise the lack of contingency within this plan

PRELIMINARY

Commissioning Committee Meeting Governing Body MeetingProcurement Committee Meeting (adhoc)



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2016 2017

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

4.5 months

5 month

2.5 months

1 month

6 months

24 Feb 2016

23 Mar 2016

9 Mar 2016

Do additional market testing and engagement


PQQ shortlist approval by Commissioning Committee

Business case approved by Governing Body

27 Jun 2016

Confirm slot in March Procurement Committee meeting

Publish OJEU and all tender documents

25 May 2016 28 Sep 2016

Host Q&A sessions for bidders Release ITT documents to shortlisted bidders for completion

Prepare all tender documents – ITT, specification, KPIs, etc.

Execute Transfer of Undertakings Process (TUPE)

Activity


Business case approved by Commissioning Committee

Decommission the existing services

8 Mar 2017

Prepare for service delivery (mobilization, communication, etc.) Finalise contract

Contract awarded

Send confirmation to winning bidder

Notify ITT bidders of outcome Arrange presentation of finalist bidders

Accept and assess and ITT submissions

Evaluate finalists and select successful bid

Present selection report to Governing Body

Host ITT questions moderation meeting to shortlist bidders

Service go-live (+ initiate the new governance process)

Prepare report of selected bid for Governing Body

Get approval for all tender documents by Procurement Committee

Send Alcatel letter to unsuccessful bidders (10-day cooling off period)

Establish procurement project team

PQQ clarification period Accept and assess PQQ submissions

Bidder clarification period


Get approval for procurement route from Procurement Committee

Notify PQQ bidders of outcome

Host PQQ questions moderation meeting to shortlist bidders

Invitation to tender (ITT)

4.1 Implementation timeline: Moderate PRELIMINARY

Commissioning Committee Meeting Governing Body MeetingProcurement Committee Meeting (adhoc)



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4.1 Pros and cons of the implementation options

Ambitious

Pro’s Con’s

Moderate

Implementa-tion options

1

2

▪ Reduced reputational risk, as delivery meets Connect contract expiry date

▪ Flexibility to enhance/clarify tender documents, as submissions are not all required during preparation stage

▪ Acceleration of patient benefits as the new service will be introduced sooner

▪ Tight deadlines, with little room fordelays (internal or external)

▪ Less time for additional providerengagement

▪ Reduced time for providers to complete and enter their bids

▪ Greater time for procurement, particularly provider engagementand specification developmentduring preparation and ITT stages

▪ Room for contingencies in case ofdelays

▪ More time for providers to complete and enter their bids

▪ No opportunity to enhance/ clarifytender documents as all documents must be submitted at the preparation stage

▪ Increased reputational risk, with Connect contract requiring extension

▪ Delayed patient benefits

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4.2 Resources for integrated service procurement: Ambitious option LightMediumIntensive

Intensity of support required

Scenario B: Resourcing where project team is quickly mobilised with the required capabilities, thereby requiring less external support

Scenario A: Resourcing where intense external support is required early on, prior to recruiting an internal programme team

Timeline

▪ To success-fully deliver within this ambitious timeline, it isrecommendedthat the CCG:

– bring heavy external support early on

– ensure personal accountabil-ity of a Governing Body member and Executive Director

▪ Financial benefits can be gained by rapidly mobilising a capable, internal project team

Go liveService mobilisation

Contract awardedInvitation to tender (ITT)/ Competitive dialogue



Apr 2017Mar 2016

5.5 months2 months Service go-live3.5 months(ITT)

1 month

1 month

Clinical lead

1 – 2 sessions a week

Project team1 Full time (until Aug 2017)

CSU support

Procurement support

External support

Expert clinical reference group2

1 work-shop

1 work-shop

Clinical lead


Project team1 Full time (until Aug 2017)

CSU support

Procurement support

External support


1 work-shop

1 work-shop

1 Project team is made up of a full-time project manager with some analytical and administrative support; team can be built from existing CCG resource allocation or via recruitment 2 The expert clinical reference group is an independent source of expertise, made up of patient representatives and independent specialists from the private, public, and voluntary sectors

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4.2 Resources for integrated service procurement: Moderate option LightMediumIntensive

Intensity of support required

Timeline

Go liveService mobilisation

Contract awardedInvitation to tender (ITT)/ Competitive dialogue



Oct 2017Mar 2016

Scenario D: Resourcing where external support is required, particularly during PQQ and ITT assessment

Scenario C: Resourcing where intense external support is required to kick-off the programme, prior to recruiting the internal team ▪ To success-fully deliver this new service, it is recommend-ed that the CCG:

– bring in external support, as appropriate

– ensure personal accountabil-ity of a Governing Body member and Executive Director

▪ Financial benefits can be gained by rapidly mobilising a capable, internal project team

Clinical lead


Project team1

CSU support

External support


1 work-shop

1 work-shop

Clinical lead


Project team1 Full time (until Jan 2018)

CSU support

Procurement support

External support


1 work-shop

1 work-shop

Full time (until Jan 2018)

1 month

Service go-live

5 months 6 months4.5 months(competitive dialogue)

2.5 months

Procurement support


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4.2 Service procurement costs


Resources required

External consulting support (sub-total)

Total costs

Internal CCG team and reference group (sub-total)

Independent clinical reference group2

CCG clinical lead

Dedicated and skilled CCG project team1

External support

Heavy external support▪ Full time implementation consultant▪ Part-time experienced project manager support▪ Significant oversight from partner (or junior

partner)-level consultant▪ Significant input from external clinical advisor

Medium external support▪ Full time implementation consultant▪ Significant oversight from partner (or junior

partner)-level consultant▪ Moderate input from external clinical advisor

Light external support▪ Part-time implementation consultant▪ Light oversight from partner (or junior partner)-

level consultant▪ Light input from external clinical advisor

CSU procurement support

Upper range

10,000

1,500

10,000

130,000

75,000

35,000

2,000

Lower range

10,000

1,500

10,000

120,000

60,000

25,000

2,000

Monthly cost, £

2

13

15

315,000

518,500

203,500

1

2

3

7

BA

2

13

13

640,000

823,500

183,500

1

4

6

7

D

2

19

22

305,000

589,500

284,500

0

3

5

8

C

2

19

20

655,000

919,500

264,500

0

5

8

8

No. of months

Ambitious scenarios Moderate scenarios• Total programme

cost estimates range between:− ~£520k and

£825k for the Ambitious option; and

− ~£590k and £920k for the Moderate option

• Actual cost depends on:− how quickly

the dedicated project team can be secured and trained, if necessary

− fee of external support appointed

− when external support is required, e.g. only at specific strategic points)

− opportunities for sharing external support across other work

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4.3 Risk schedule: Ambitious option (1/2)High Medium Low

Current risk

Mitigated riskExisting mitigations Additional recommended mitigationsRisk

Camden CCG

Providers

▪ Engaged with market early via market testing1

▪ Engaged with current providers▪ Lack of responses from

capable providers5 ▪ Meet and start engaging with providers who

previously expressed interest asap (pre-PQQ)

▪ Compiled an initial list of patient outcome and activity KPIs to monitor

▪ Provider fails to deliver the desired outcomes

7 ▪ Compile a short list of focused, high impact KPIs with input from MSK commissioners and CSU, as well as learnings from other CCGs

▪ Engage with providers early and continuously to align on desired outcomes

▪ Contract payment with appropriate incentivised outcomes and plan alternate use for “savings”

to achieve similar objectives

▪ Providers fail to deliver the desired services

6 ▪ Produced a robust business case with detailed clinical model, contract options, and service requirements

▪ Identified potential issues with delivering desired service, e.g. lack of acute support

▪ Flexibility to iteratively enhance specification details at each stage (documents do not all have to be submitted simultaneously)

▪ Engage with providers early and continuously to align on service requirements

▪ Produce a detailed specification with risks▪ Request clear evidence of provider capabilities▪ Detail KPIs in contract, with payment

implications for poor service▪ Sign head contract only after supply chain is

fully in place and subcontracts signed▪ Allocated ample time for mobilisation

▪ Signed-off scope of services with multiple groups across CCCG (e.g. finance, CSU)

▪ Gaps in resulting MSK services contracted

3 ▪ Include a comprehensive list of services in the specification, signed-off by expert groups (e.g. current MSK commissioners, CSU)

▪ Include clause to alter contract, if needed


▪ Produced a robust business case, as a foundation for procurement documents

▪ Confirmed that a short rolling extension of the Connect contract is possible if the procurement takes longer than expected due to reasons beyond Camden CCG’s control

▪ Delays resulting ina. Further extension of

Connect contractb. missing planned

procurement delivery (1 April 2017)

1 ▪ Produce detailed plan with clear milestones▪ Rapidly mobilise team with sufficient capacity

and expertise to execute▪ Meet with key stakeholders (e.g. acutes) early

March to align on service request▪ Immediately begin preparing PQQ document▪ Syndicate procurement route prior to 23 Mar

▪ Signed-off financial envelop with finance▪ Built robust model, with clear assumptions,

forecasting anticipated activity and costs

▪ Service is under-funded or over-funded

4 ▪ Refine finance model, with provider input▪ Produce robust clinical, activity & financial

scope

▪ Poor resulting contract2 ▪ Identified key contracting options ▪ Build on other CCG learnings; test key contracting decision with external experts

▪ Get early and continuous input from current MSK commissioners and CSU

1 Camden CCG tested the potential provider market for Integrated Community Musculoskeletal (MSK) Service in August 2015, receiving 14 EOIs

Key Influen-cing party

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4.3 Risk schedule: Ambitious option (2/2)High Medium Low

Current risk


Other stake-holders

▪ Produced business case with GPs providing clinical leadership

▪ Engage early (March) and continuously with GPs across localities in refining specification

▪ Produce a communication plan for updating GPs on key milestones and impact

▪ Specify that providers arrange training for GPs

▪ GPs are unsupportive of the new model

8

▪ Produced a robust business case with detailed clinical model, contract options, and service requirements

▪ Proposed model avoids further extension of Connect contract

▪ Confirmed that a short rolling extension of the Connect contract is possible if the procurement takes longer than expected due to reasons beyond Camden CCG’s control

▪ Reputational risk from prior delays and inconsistent procurement message

11 ▪ Get final approval from Governing Body in March

▪ Develop a clear message and means of communication – what the service is, it’s

benefits, and the expected timelines – and actively communicate it to stakeholders including:– specialist providers (acutes & community)– GPs– patients– commissioners

▪ Immediately communicate any changes to the timeline

▪ Risk of NHSE blocking procurement for reasons such as concerns related to destabilising current major Camden providers

12 ▪ Specified need for provider to meet patient choice

▪ Engage with NHSE representative throughout the process to identify and address any concerns early

▪ Specify constraint that mitigates against provider destabilisation

▪ -▪ Legal challenge from the public (particularly relating to non-NHS bidders) or providers

10 ▪ Identify potential groups, based on previous similar challenges and address early

▪ Get legal advice on how best to proceed▪ Ensure patient-focused service with patient

representatives within reference group

▪ Main Camden hospitals unwilling to support other bids

9 ▪ Engaged with market early via market testing1 ▪ Meet with acute hospitals asap (early March) to re-iterate expectations


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4.3 Risk schedule: Moderate option (1/2)High Medium Low


Current risk


Camden CCG

Providers


▪ Allocated ample time for market engagement▪ Lack of responses from

capable providers5 ▪ Meet with providers who previously expressed

interest early in preparation stage

▪ Compiled an initial list of the type of KPIs to monitor

▪ Allocated ample time to produce detailed specifications and syndicate with experts

▪ Provider fails to deliver the desired outcomes

7 ▪ Compile a short list of focused, high impact KPIs with input from MSK commissioners and CSU, as well as learnings from other CCGs

▪ Engage with providers early and continuously to align on desired outcomes

▪ Contract payment with appropriate incentivised outcomes and plan alternate use for “savings”

to achieve similar objectives

▪ Providers fail to deliver the desired services

6 ▪ Produced a robust business case with detailed clinical model, contract options, and service requirements

▪ Identified potential issues with delivering desired service, e.g. lack of acute support

▪ Engage with providers early and continuously to align on service requirements

▪ Produce a detailed specification with risks▪ Request clear evidence of provider capabilities▪ Detail KPIs in contract, with payment

implications for poor service▪ Sign head contract only after supply chain is

fully in place and subcontracts signed

▪ Syndicated scope of services with multiple groups across CCCG (e.g. finance, CSU)

▪ Gaps in resulting MSK services contracted

3 ▪ Include a comprehensive list of services in the specification, signed-off by expert groups (e.g. current MSK commissioners, CSU)

▪ Include clause to alter contract, if needed

▪ Engaged with market early via market testing1▪ Produced a robust business case, as a

foundation for procurement documents▪ Allocated ample time for all stages, with some

buffer for missed milestones

▪ Delays resulting in missed delivery date (1 October 2017)

1B ▪ Produce detailed plan with clear milestones▪ Rapidly mobilise team with sufficient capacity

and expertise to execute▪ Meet with key stakeholders (e.g. acutes) to

align on service request▪ Poor resulting contract2 ▪ Identified key contracting options ▪ Build on other CCG learnings; test key

contracting decision with external experts▪ Get early and continuous input from current

MSK commissioners and CSU


▪ Syndicated financial envelop with finance▪ Built robust model, with clear assumptions,

forecasting anticipated activity and costs

▪ Service is under-funded or over-funded

4 ▪ Refine finance model, with input from providers

▪ None (extension will be required)Further extension of Connect contract

1A ▪ None (extension will be required)

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4.3 Risk schedule: Moderate option (2/2)High Medium Low


Current risk


Other stake-holders

▪ -▪ Legal challenge from the public (particularly relating to non-NHS bidders) or providers

10 ▪ Identify potential groups, based on previous similar challenges and address early

▪ Get legal advice on how best to proceed▪ Ensure patient-focused service with patient

representatives within reference group

▪ Produced a robust business case with detailed clinical model, contract options, and service requirements

▪ Reputational risk11 ▪ Get final approval from Governing Body in March

▪ Develop a clear message and means of communication – what the service is, it’s

benefits, and the expected timelines – and actively communicate it to stakeholders including:– specialist providers (acutes &

community)– GPs– patients– commissioners

▪ Immediately communicate any changes to the timeline

▪ Main Camden hospitals unwilling to support other bids

9 ▪ Engaged with market early via market testing1

▪ Allocated ample time for market engagement▪ Meet with acute hospitals asap (early March)

to re-iterate expectations


▪ Produced business case with GPs providing clinical leadership

▪ Allocated ample time for engagement, communication, and training GPs

▪ GPs are unsupportive of the new model

8 ▪ Engage early and continuously with GPs in refining specification

▪ Produce a communication plan for updating GPs on key milestones and impact

▪ Organise training for GPs

▪ Risk of NHSE blocking procurement for reasons such as concerns related to destabilising current major Camden providers

12 ▪ Specified need for provider to meet patient choice

▪ Engage with NHSE representative throughout the process to identify and address any concerns early

▪ Specify constraint that mitigates against provider destabilisation

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Contents






▪ Appendix

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54|Source: MSK Baseline costs February 2016, including SUS, SLAM, Connect Health invoice data, InHealth invoice data, CNWL block contract data,

2014/15 Programme budgeting return, CCG and CSU

UCLH

0.4

2.63.7

Imp.Whitt. RNOH

0.2

Not broken down by provider

0

Other

0.3

2.2

0.6 5.2

CNWLIn-health

RFH

7.5

Comm-unity total

Acute total

CH High cost drugs and devices

2.4

0.90.8

Primaryprescri-bing

Total

0.2

14.4

5.1 Financial breakdown of current spend

Camden CCG spend for known or ratioed activities within key specialties1 at acute providers and community providers, and prescribing spend M9 2015/16 FOT2

£m

1 Trauma and Orthopaedics, Rheumatology, Pain management, Physiotherapy2 Actual spend to be verified with providers

PRELIMINARY

Spend includes:

▪ In-patient M9 2015/16 FOT: elective (IP EL) and day case (DC) spend by acute provider, using non-trauma HRGs for hip, knee, foot, shoulder, elbow, hand,spine (no lumbar segmentation). Excludes reconstruction

▪ Out-patient (OP) M9 2015/16 FOT by acute provider, calculated as 71% of total OP spend from key specialties. 71% = percentage of IP DC that is MSK, from T&O, Rheumatology and Pain management

▪ OP unbundled procedures M9 2015/16 FOT : MRI, ultrasound and DEXA, at InHealth ratios (see below)

▪ Connect Health M9 2015/16 FOT from invoice analysis

▪ InHealth M9 2015/16 FOT calculated using % of 2014/15 ultrasounds that are MSK by body part and % of MRI that are MSK by body part

▪ CNWL MSK portion of 2015/16 block contract

▪ Prescribing spend from 2014/15 CCG Programme budgeting return

Acute spend Community spend Prescribing spend

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55|Source: MSK Baseline costs February 2016 including SUS, SLAM, Connect Health invoice data, InHealth invoice data, CNWL data, CCG and

CSU; planning assumptions within CCCG scenario planning, CCG

5.1 Projected costs – current model

2019/20 2020/21 2021/22

14.415.3

2017/18

15.6 15.9 16.2

+2.0% p.a.

2015/16 2016/17

14.916.2

2018/19

PRELIMINARY

Assumptions1:

▪ Net acute ETO deflator, net acute DTR deflator and net non-acute deflator applied for each year from 2016/17 to 2020/2021

▪ Demographic growth and non-demographic growth assumptions applied for each year from 2016/17 to 2020/2021

1 See appendix for annual values

Projected total Camden CCG spend on MSK services under ‘Do nothing’

scenario£m

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5.1 Projected costs – integrated model

3.0

2017/18Year 1

15.014.9

12.0

15.0

13.514.9

2016/17

0

2018/19Year 2

1.5

15.0

12.0

2022/23Year 6

15.0

12.012.0

3.0

2020/21Year 4

2021/22Year 5

15.0

12.0

3.0

2019/20Year 3

3.0

15.0

3.0

2023/24Year 7

15.00

15.0

Projected total Camden CCG spend on MSK services under ‘Integrated

MSK services’ scenario

£m

PRELIMINARY

Assumptions1:

▪ Total block contract value is capped at £15m (2015/16 MSK spend +4% approx.) from Y1 of implementation of the integrated service2,3

▪ Provider incentives begin in Y2 and are capped from Y3

Source: Interviews with key stakeholders

1 See appendix for annual values2 Chart assumes implementation at start of 2017/183 Actual block contract cap will not exceed actual baseline 2015/16 MSK spend +5%

Provider incentive Guaranteed spend Two year extension

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15.6

15.0

16.2

15.0

1.2

2021/22Year 5

16.2

15.0

2022/23Year 6

1.2 1.2

2020/21Year 4

16.2

15.0

2017/18Year 11

2018/19Year 2

0.315.314.9

2016/17

15.0

2023/24Year 7

16.21.2

15.0

2019/20Year 3

14.9

0

15.0

0.915.9

0.6

5.1 Projected potential savings

Projected Camden CCG maximum MSK spend in ‘Integrated MSK services’ scenario and savings vs. ‘Do nothing’ scenario2

£m

PRELIMINARY

5 years£4.2m (5.3%)

Source: Interviews with key stakeholders

1 Chart assumes implementation at start of 2017/182 Actual block contract cap will not exceed actual baseline 2015/16 MSK spend +5%

Total savings

7 years£6.5m (5.8%)

Savings Projected maximum MSK spend Two year extension

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£m

5.1 Comparison of total procurement and five-year forecasted service cost

90.73

79.92

10.8115.00

12.003.00

15.00

12.003.001.50

12.00

15.003.00

15.00

13.5015.0014.90

15.020.50 0.31

15.710.02

3.00

90.82

10.83

2019-20

79.99

15.00

12.0013.50 12.00

15.00

12.00

0.02

2017-18

0.1115.02

2016-17

15.520.39 3.003.00

15.000.22

15.0014.90

2018-19

1.500.18

Total2020-21 2021-22

15.29

Total estimated cost of ambitious option

Total estimated cost of moderate option

Total estimated cost of a “phased approach” 1, for comparison

1.60

2017-18

15.810.20

15.30

0.1816.02

2018-19

15.7015.10

2019-20

0.02

15.64

2016-17

16.00

0.39

14.90

16.00

89.833.20

Total2020-21

16.00

14.40

2021-22

94.63

12.80

Guaranteed service costProcurement cost (base cost) Total cost (base cost)

Procurement cost (upper range) Total (upper range)Provider incentivised service cost

1 “Phased approach” procuring community-only service in 2016, followed by integrated service from mid-2017 with delivery March 2019; estimates community procurement cost of ~£200k and integrated procurement cost of ~£590k (i.e. scenario D in Section 4.2); Block capped at £16m

▪ “Phased

approach”

costs more due to increasing baseline and cost of two procure-ments, (~£800k)

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Contents






▪ Appendix

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Key performance metrics to be measured across services

Source: The PCR Society Guide to Commissioning Musculoskeletal Services - Issue 2 (September 2011), A guide to PROMs methodology (hscic), Bedfordshire CCG MSK ITT Annex E

1 Metric is across 5 dimensions – mobility, self-care, usual activities, pain/discomfort, and anxiety/depression

PRELIMINARY

Measure performance metrics related to patient outcomes (tied to payment)

Monitor KPIs that assure quality and safety

1 2

▪ EQ5D1 measures:– % of patients who have seen condition

improve, worsen, or remain the same– % of patients self-reporting they have

returned to “normality”

– Average and range of time from first symptomatic attendance to patient reporting return to “normality”

▪ % of patients feeling supported to manage their conditions

▪ Proportion of people with rheumatoid arthritis who are diagnosed and treated within clinical recommended period

▪ % of joint replacements requiring reoperation within two years

▪ Complaints – both amount and nature

▪ Family and Friends score via immediate feedback

▪ Waiting times vs. national targets

▪ % of time spent in treatment vs. diagnosis

▪ Re-admission rates

3.1 CLINICAL MODEL

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Options appraisal (1/7)

1. Contracting structure

Improve provider experience and effectiveness, including single point of access for referrers, efficient working as an MDT

Provide long-term incentives to improve population health

Generate interest from a significant number of best-qualified providers

Create clear accountability on the provider side

Shift the balance of financial risk between the commissioner and provider

Improve patient experience and outcomes, including single point of access, advice and support for patients

1 2 3 4 5 6 7

Does the option support achievement of the following objectives

1.i The commissioner has options to tender:

1.ii For the single contract structure, the commissioner has options to:

2. Length of contract & alterations

2.i The commissioner has options to tender contract with length of:

▪ 3 years

▪ 5 years

▪ 7 years

N/A▪ Single contract

N/A▪ Multiple contracts

N/A▪ Specify the provider organisational form

N/A N/A N/A N/A

N/A▪ Not specify the provider organisational form

N/A N/A N/A N/A

Equip commissioners with levers to effectively manage the contract and associated risks with enough flexibility

Recommended option

Option strongly supports the objective

Option somewhat supports the objective

Option does not support the objective

Option is not relevant for the objectiveN/A

3.2 CONTRACTING OPTIONS

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1 2 3 4 5 6 7



2.ii The commissioner has options to tender contract with extension length of:

▪ 1 year

▪ 2 years

▪ 3 years

2. Length of contract & alterations (cont’d)

2.iii The commissioner has options to tender contract the right for extent for:

▪ CCG only N/A N/A N/A N/A N/A N/A

▪ Either provider or CCG N/A N/A N/A N/A N/A N/A

▪ Provider only N/A N/A N/A N/A N/A N/A

2.iv The commissioner has options to tender contract with the phasing of implementation:

▪ Not phased N/A N/A N/A N/A N/A

▪ Phased over 1 or 2 years N/A N/A N/A N/A N/A

Recommended option






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1 2 3 4 5 6 7



▪ Generally Allowed If Both Parties Consent

2. Length of contract & alterations (cont’d)

2.v The commissioner has options to tender contract to which amendments are:

N/A N/A N/A

▪ Allowed In Restricted Circumstances (E.G., Change In Legislation, NHS Guidance, Honest Mistake In Specifications)

N/A N/A N/A

▪ Not allowed N/A N/A N/A

▪ possible in specified cases (e.g. significant deviation from agreed specifications; significant deterioration of patient outcomes)

2.vi The commissioner has options to tender contract with the break clause:

N/A N/A N/A

▪ not specified N/A N/A N/A

Recommended option






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1 2 3 4 5 6 7



3.ii The commissioner has options to tender contract with outcome-related payment (as % of contract value) of:

3.i.i The commissioner has options to tender contract with the core payment which is:

▪ Capitation (Fixed Pay-ment Per Head, Based On GP Registered List)

N/AN/A N/A N/A

▪ 10% N/A N/A

▪ 30% N/A N/A

▪ 20% N/A N/A

3. Payment structure

3.i The commissioner has options to tender contract with the core payment:

▪ Capitation With Adjust-ments (E.G. Age; MSK Disease Prevalence)

N/AN/A N/A N/A

▪ Activity based

▪ Capitation based

▪ Fixed Global Sum N/AN/A N/A N/A

Recommended option






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1 2 3 4 5 6 7



3. Payment structure (cont’d)

3.iii The commissioner has options to tender contract with the phasing of outcome-related payment of:

▪ 2 years

▪ 1 year

▪ No phasing

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

3.iv The commissioner has options to tender contract with the outcome-related payment structured as:

▪ A risk for the portion of the core payment

N/A N/A

▪ A bonus on top of core payment

N/A

N/A

N/A N/A

N/A

N/A

N/A

N/A

3.v The commissioner has options to tender contract so that the CCG can use the money for not achieved outcomes:

▪ For the same purpose only

N/A N/A

▪ For any purpose N/A

N/A

N/A N/A

N/A

N/A

N/A

N/A

Recommended option






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1 2 3 4 5 6 7



3. Payment structure (cont’d)

3.vi The commissioner has options to tender contract with outcome-based payment tied to:

▪ 5-10 key outcomes

▪ 30-50 KPIs in a balanced scorecard

N/A

N/A

N/A

N/A

4. Constraints regarding local providers

4.i The commissioner has options to tender contract which requires provision of community MSK services:

▪ Within Camden N/A N/AN/A N/A N/A

▪ Within each locality N/A N/AN/A N/A N/A

▪ None N/A N/AN/A N/A N/A

Recommended option






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4. Constraints regarding local providers (cont’d)

4.ii The commissioner has options to tender contract which requires the provider to make all steps to reasonably ensure interoperability with:

▪ At least one acute provider which provide 20% or more of MSK inpatient activities (of Camden residents)

N/A N/AN/AN/A

▪ no requirements N/A N/AN/AN/A

▪ All acute providers1 which provide 20% or more of MSK inpatient activities

N/A N/AN/AN/A

▪ Any acute provider(s), so that all Camden residents can access the services within reasonable travel time)

N/A N/AN/AN/A

Recommended option











1 2 3 4 5 6 7




1.Currently UCH and Royal Free

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Risk schedule methodology detail

4.3 RISKS AND MITIGATIONS

Risk Schedule methodology

5

4

3

2

1

10

8

6

4

2

15

12

9

6

3

20

16

12

8

4

25

20

15

10

5

Lik

elih

oo

d

Impact

Ambitious option

Moderate option

Likelihood Impact Risk Likelihood Impact Risk

1 Late delivery, resulting in Connect extension 5 5 25 2 5 10

2 Poor resulting contract 3 5 15 1 5 5

3 Gaps in resulting MSK services contracted 3 3 9 1 3 3

4 Service is under-funded or over-funded 2 3 6 1 3 3

5 Lack of responses from capable providers 3 5 15 1 5 5

6 Providers fail to deliver the desired services 2 5 10 2 5 10

7 Provider fails to deliver the desired outcomes 3 4 12 2 4 8

8 GPs are unsupportive of the new model 1 3 3 1 3 3

9

Main Camden hospitals unwilling to support

other bids 3 3 9 2 3 6

10

Legal challenge from the public (particularly

relating to non-NHS bidders) or providers 2 5 10 1 5 5

11 Reputational risk 3 4 12 1 4 4

12 NHSE block 1 5 5 1 5 5

Current Post-mitigations

Likelihood Impact Risk Likelihood Impact Risk

1 Late delivery, resulting in Connect extension 3 5 15 1 5 5

2 Poor resulting contract 2 5 10 1 5 5

3 Gaps in resulting MSK services contracted 2 3 6 1 3 3

4 Service is under-funded or over-funded 2 3 6 1 3 3

5 Lack of responses from capable providers 1 5 5 1 5 5

6 Providers fail to deliver the desired services 2 5 10 2 5 10

7 Provider fails to deliver the desired outcomes 2 4 8 2 4 8

8 GPs are unsupportive of the new model 1 3 3 1 3 3

9

Main Camden hospitals unwilling to support

other bids 2 3 6 1 3 3

10

Legal challenge from the public (particularly

relating to non-NHS bidders) or providers 2 5 10 1 5 5

11 Reputational risk 4 4 16 3 4 12

12 NHSE block 1 5 5 1 5 5

Current Post-mitigations

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69|Source: MSK Baseline costs February 2016, SUS, CCG and CSU; Programme Budgeting Submission 2014/15, CCG

Comparison of estimated baseline MSK acute spend 2015/16 and MSK programme budgeting return 2014/15

Camden CCG spend for known or ratioed activities within key specialties1 at acute providers, M9 2015/16 FOT and CCG programme budgeting submission 2014/15£m

1 Excluding unscheduled care

PRELIMINARY

Inpatient EL and DC

4.8

3.7

Other secondary care1

Outpatient

1.2

2.72.6

0.1

Unbundled diagnostics

0

1.6

7.5

9.2

Total

Programme budgeting return

Baseline

5.1 FINANCIAL IMPACT

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70|

Assumptions: financial baseline

Source: CCG Analytics team, stakeholder interviews

PRELIMINARY

Assumptions for baseline spend

In-patient day case and elective MSK spend is the spend in specialties: T&O, rheumatology and pain management, spinal surgery1, associated with non-trauma, non-reconstruction HRGs for hip, knee, foot, shoulder, elbow, hand, spine

Out-patient non-procedure and procedure MSK spend is the spend on OP HRGs (new, follow-up, other), in specialties T&O, rheumatology and pain management. Percentage of spend on these specialties that is MSK is assumed to be 71%, i.e., based on the percentage of IP DC that is MSK, from T&O, Rheumatology and Pain management

1 Minimal spend; most spinal surgery is commissioned via NHSE specialised commissioning

Out-patient unbundled spend comprises spend on investigations MRI, ultrasound <20 minutes and DEXA. The percentage of spend on MSK activity is assumed to be comparable to that calculated from 2014/15 InHealth body part data (80% of MRI, 25% of ultrasound, 100% DEXA)

InHealth percentage of 2015/16 spend on MSK activity is assumed to be comparable to that calculated from 2014/15 InHealth body part data (80% of MRI, 25% of ultrasound, 100% DEXA)

CNWL MSK spend comprises 50% podiatry spend (50% MSK, 50% DM), 20% community rehabilitation spend (assumption from CNWL) and 8.7% domiciliary services spend (12.2% of all specialties that are the key specialties and 71% of the key specialties that is MSK, based on IP DC figure)


Prescribing spend sourced from spend allocated to MSK in the programme budget reviews

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71|

Assumptions: financial baseline forecast

2016/17 2017/18 2018/19 2019/20Financial assumptions 2020/21

Net acute ETO inflator 1.80% 0.00% 0.00% 0.00% 0.00%

Net acute DTR inflator 0.20% 0.00% 0.00% 0.00% 0.00%

Net non-acute inflator 1.10% 0.00% 0.00% 0.00% 0.00%

Demographic growth 1.50% 1.30% 1.20% 1.00% 1.00%

Non-demographic growth 1.36% 1.36% 0.96% 0.76% 0.56%

Source: CCG Finance team

PRELIMINARY

ValueAssumptions for integrated service

Actual block contract cap from Y1 to not exceed 2015/16 spend by 5%

Year 1 of implementation 2017/18

% of block contract comprising provider incentive:

Year 1 0%

Year 2 10%

Year 3 20%

Year 4 20%

Year 5 20%


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72|

PRELIMINARYHRG4 codes used to identify MSK inpatient spells

Hip, non-trauma

HB11A, HB11B, HB11C, HB12A, HB12B, HB12C, HB13Z, HB14B, HB14C, HB15D, HB15E, HB15F, HB15G, HB16B, HB16C

Knee, non-trauma

HB21A, HB21B, HB21C, HB22B, HB22C, HB23B, HB23C, HB24B, HB24C, HB25D, HB25E, HB25F, HB25G, HB25H, HB25J

Foot, non-trauma

HB31Z, HB32A, HB32B, HB33D, HB33E, HB33F, HB33G, HB34D, HB34E, HB34F, HB34G, HB35B, HB35C

Spine (no lumbar specificity)

HC01Z, HC02B, HC02C, HC03B, HC03C, HC04B, HC04C, HC05B, HC05C, HC06B, HC06C, HC07Z, HC08Z, HC09Z, HC10Z, HC11Z, HC12Z, HC20B, HC20C, HC21B, HC21C, HC26B, HC26C, HC27B, HC27C, HC28B, HC28C, HC29B, HC29C, HC30B, HC30C, HC31B, HC31C, HD23A, HD23B, HD23C

Shoulder, non-trauma

HB51Z, HB52B, HB52C, HB53Z, HB54B, HB54C, HB55B, HB55C, HB56B, HB56C

Elbow, non-trauma

HB61B, HB61C, HB62B, HB62C, HB63Z

Hand, non-trauma

HB71B, HB71C, HB72B, HB73Z


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Equality Analysis [Equality Impact Assessment] Form-May 2014 © Camden CCG Page 1

EQUALITY ANALYSIS (Equality Impact Assessment)

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http://www.camdenccg.nhs.uk/about


Name of policy/function Business case – Securing an integrated and accountable MSK programme of care

Is this a new or existing policy/function? [Please check appropriate box] New Existing

Please give a brief description of policy/function This business case proposes that Camden CCG should proceed to commission a fully integrated MSK service and programme of care on the basis that

This decision fits with the CCG’s strategic direction and the overall national context of commissioning development

The solution will result in significant improvement of patient experience, patient outcomes and provider experience and will deliver financial savings vs. the “do nothing” scenario

It is possible to execute the procurement within a reasonable time and with moderate levels

of risk, provided there are sufficient resources allocated

Scope of the Equality Analysis The project scope is as per MSK services provided today, i.e.:

MSK services provided across primary, specialist ambulatory, and inpatient care for

Camden residents

MSK conditions, such as arthritis, sports injuries, lower back pain, shoulder pain, upper

back/neck pain, ankle pain, and connective tissue diseases.

Adults and patients aged 16 – 25 not already in paediatric MSK care

The scope excludes:

Emergency MSK conditions

Acute trauma

Patients 16 – 25 years old, previously in paediatric MSK care

Consultation, engagement and contribution/outcomes [Please list who you have consulted with on this EA and what contribution they have made, if any. If the policy/function is customer facing then please mention which protected group from the potential beneficiary groups has been involved]

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Engagement has included key stakeholders across the system.

Patients and their carers

Primary consolation, engagement and contribution from:

− A patient’s real-life journey over 3 years within the MSK system (note: patient

consent was received)

− Patient survey – “Improving musculoskeletal services in Camden” (July – December

2015)

− MSK patient & carer focus group to “inform and shape the new integrated MSK

service” (November 2015)

− MSK patient & carer experience workshop – “The Case for Change / Redesigning

the Musculoskeletal Services” (September 2014)

Key themes include patient wanting:

− Involvement in their care

− Care that is holistic, supportive, and personalised to their needs

− A timely and responsive service

− A coordinated and seamless experience

GPs and specialist consultants (providers)


− Tom Aslan (GP / Clinical lead) & Steven Laitner (GP / Clinical advisor)

− Fares Haddad (Orthopaedic Surgeon)

− Paul Allan (Physiotherapist)

− Feedback session at all three locality meetings (July 2015)

Key themes include GPs and specialist consultants experiencing the following issues:

− Lack of communication between providers and the patient

− GP is central point for administrative tasks (e.g. referrals), in absence of a dedicated

coordinator

− Lack of specialist training for GP, who takes on an “expert” role

− Limited access to “live” advice

− Non-integrated IT system makes sharing data difficult

− Lack of image standardisation results in duplicative tests

Commissioners


− Camden CCG – Lyndsey Abercrombie, Melody Woolcock

− Learnings from other CCGs – Bedfordshire, North West Surrey, etc.

Key problem areas include:

− Not receiving patient-outcome based metrics

− Receiving a large amount of varying performance metrics in different formats

− Incomplete data

− Managing a model where risk is wholly on the CCG and not shared with the provider

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Impact assessment and actions Protected Group Relevance

YES/NO Evidence of impact Nature of

potential impact (positive/negative

/unknown)

Recommendations/ mitigating actions

Age

Yes

The elderly are more susceptible to experiencing both MSK and non-MSK related pain. Therefore, those requiring MSK services may also need interdependent services, such as falls clinics or frailty units. Providing a service that is coordinate and empowers patients to make informed choices that are right for them is important to ensuring a seamless and positive experience. This is a key requirement of this proposed integrated service.

Positive

Disability

Yes

There should be a positive impact to this group. The single integrated service will provide a holistic and personalised programme of care, thereby taking into account all facets of a patient’s needs in determining the best course of action. Core to this is ensuring the plan is personalised to the patient’s needs by empowering them with information and offering a holistic programme of care that will address interdependent conditions, which could include mental or

Positive

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physical disabilities, such as exercise and psychological services.

Race/ethnicity

Yes

The integrated MSK service will shift to monitor performance based on patient-outcomes, with a model focused on data-driven decision making. As a result, poor / relatively poorer care related to race/ethnicity will be more easily identified and tracked for improvement

Positive

Sex/gender

Yes

The integrated MSK service will shift to monitor performance based on patient-outcomes, with a model focused on data-driven decision making. As a result, poor / relatively poorer care related to sex/gender will be more easily identified and tracked for improvement

Positive

Gender reassignment No

N/A

N/A

N/A

Sexual orientation No

N/A

N/A

N/A

Religion/belief No

N/A

N/A

N/A

Maternity/pregnancy No

N/A

N/A

N/A

Civil partnership /marriage

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No

N/A

N/A

N/A

Human Rights No

N/A

N/A

N/A

Socio-economic group

Yes

The integrated MSK service will shift to monitoring performance based on patient-outcomes, with a model focused on data-driven decision making. This will support the identification of underserved socio-economic groups to drive initiatives for improvement

Positive

Social inclusion No

N/A

N/A

N/A

Community cohesion No

N/A

N/A

N/A

Final outcomes: [Please check appropriate box] A. Continue with the policy/proposal as it is B. Continue with the policy with adjustment or further analysis C. Stop/remove the policy/proposal D. Carry out a further analysis of new data

Signature of the SRO/Director:

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Date:

23 February 2016

Date of Next Review: [Statutory requirement at least 3 years unless there is any change in existing policy/function]

Further information: Please read the CSU guidance on ‘how to complete an equality analysis’ when completing an equality analysis. Please forward a copy of this EA report to the Equality and Diversity Team at the CSU at [email protected]

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Report Title Camden 2016/17 Operating Plan Agenda Item

3.3

Date 26/02/2016 Lead Director Ian Boyle

Chief Finance Officer Tel/Email [email protected]

Report Author Richard Young

Interim Strategy & Planning Manager



Dorothy Blundell, Chief Officer


Report Summary This paper gives a summary of the information submitted with regard to the

operating plan as part of the annual planning process. This covers the assumptions submitted within the operating plan submissions to date, a high level summary of the remaining requirements, and a description of the next steps.



Decision

Recommendation The Governing Body is asked to note the information and discuss the implications of these plans for their respective areas of work.


Commission the delivery of NHS constitutional rights and pledges


The trajectories are in line with national guidance and take into account the levels of existing performance and are built on existing service improvement plans. However there are notable risks associated with diagnostic waits, 62 day cancer waits and A&E performance.


The financial assumptions are detailed within the plan but consideration will be required regarding the financial position of the other NCL CCGs


The areas identified within the document have been identified as those that will deliver the greatest health benefits and tackle inequalities within the borough.

Report History This is a standalone report to inform the CCG Governing Body on progress in developing the 2016/17 Operating Plan to date. Previous reports on the process and progress have been reported to Finance and Performance Committee and regular reports are submitted to the Planning Oversight Group.

Next Steps Submit the second iteration of the Operating Plan (Activity Plans and Performance trajectories) via Unify by noon, 2nd March.

Continue to work with providers on issues of constitutional standards delivery (e.g. diagnostics, 62 day cancer waits)

Continue to work with NHSE Area Team and NCL CCGs to deliver an assured and compliant Operating plan for 2016/17.

Submission of final operating plan 11th April 2016

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1) Background This paper informs the CCG Governing Body on the progress that has been made with delivering NHS Camden CCG’s Operational Plan process for 2016/17.

Formal guidance was issued in late December 2015, however some crucial technical guidance and functioning templates were not issued until mid-late January 2016. For the forthcoming planning round, the 2016/17 process has been split into two distinct elements within a 3-stage process:

A five-year Sustainability and Transformation Plan (STP), and

A one year Operational Plan (OP).

For the Sustainability and Transformation Plans, each healthcare system will need to produce a sustainability and transformation plan for the local healthcare system outlining how local services will get from where they are now to where the FYFV requires them to be by 2020.

This report will concentrate on the OP in the first instance and it is suggested that a separate report will be required on the development of the STP.

The Operational Plan submissions for 16/17 will consist of several sets of templates (supported by the separate CCG Finance Plan). At this stage, a narrative document has not been required to support the 2016 / 17 Operating Plan. The latest version of the outline timetable is set out in table 1 below.

Table 1: 16/17 Planning Timetable

Timetable Date

Publish planning guidance 22 December 2015

Publish 2016/17 indicative prices By 22 December 2015

Issue commissioner allocations, and technical annexes to planning

guidance Early January 2016

Launch consultation on standard contract, announce CQUIN and Quality

Premium January 2016

Issue further process guidance on STPs January 2016

Localities to submit proposals for STP footprints and volunteers for

mental health and small DGHs trials By 29 January 2016

First submission of full draft 16/17 Operational Plans 8 February 2016

National Tariff S118 consultation January/February 2016

Camden CCG Operating Plan Stocktake with NHSE Area Team 25 February 2016

CCG Operating Plan – 2nd Submission 2 March 2016

Publish National Tariff March 2016

Boards of providers and commissioners approve budgets and final plans By 31 March 2016

National deadline for signing of contracts 31 March 2016

Submission of final 16/17 Operational Plans, aligned with contracts 11 April 2016

Submission of full STPs End June 2016

Assessment and Review of STPs End July 2016

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As in previous years, there is a strong expectation that provider and commissioner planning is aligned and a tripartite process has been developed to ensure that contracts can be signed by the 31st March 2016.

2) Main Requirements of the 2016/17 Operating Plan The plans are expected to cover the following areas:

Activity plans for contracted activity;

Planned performance trajectories for delivering NHS Constitution Standards;

Financial Plan covering planned expenditure for 2016/17 (and future years forecasts);

A revised Better Care Fund Plan;

A System Resilience Group-based Operational Resilience Plan (for Camden / UCLH);

Prov / Comm Analysis (activity analysis to triangulate and reconcile both commissioner and provider activity plans)

The national guidance and the NHS England KLOEs suggest that close attention will be given to four general themes:

Finance o Meet business rules or better o Plan for an underlying surplus and challenging level of QIPP o Work towards a balanced and stable financial position with realistic planning

assumptions o Detail how activity and finance data will be reconciled for the 2016/17 planning round o Be based on a position that has been agreed with providers

Activity o Use SUS as primary data source o Demonstrate a firm grip on demand and activity supported by reasonable planning

assumptions and robust capacity plans o Demonstrate detailed understanding of demand pressures and underlying growth o Contains realistic projections o Translate into contracts, containing agreed elective and non-elective positions

Performance o Set out ambitions to improve quality of outcomes, and where relevant ratings o Provide clear expectations and tolerance levels for delivery of constitution standards o Outline delivery of planning guidance measures i.e. core NHS constitution standards o Ensure delivery of mandate priorities

Alignment o With Better Care Fund, Provider Plans, Better Health for London and National

Priorities

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The priorities for 2016/17 are closely aligned to those of the Five Year Forward View: These are:

A radical upgrade in prevention and public health

A concerted effort to improve the quality of care

An unrelenting focus on getting finances back in balance

Plans will need to demonstrate how local health economies can rapidly accelerate their rate of transformation - taking them from where they are now, to the vision set out in the FYFV by 2020.

In previous years, there has been an expectation that CCG’s will work with Health & Well-being Boards (HWBs), and specific agreement is required in relation to specific areas (e.g. Better Care Fund and the Operational Plan should support delivery of the Health & Wellbeing Strategy).

3) Progress to Date The following progress has been made:

First submission of initial headline finance and activity data was submitted in accordance with the national guidance on 8th February 2016. This included:

• First-Cut Operating Plan to Unify (CCG activity and performance plans) • Operational Resilience Plan – 8th Feb • Finance Plan – 8th Feb • Contract Tracker – 9th Feb • Prov/Comm sheet – 11th Feb

Submission of the fortnightly contract tracker

Draft Key Lines of Enquiry (KLOEs) received and responded to from NHS England Area Team.

Camden CCG attended Operating Plan Stocktake meeting with NHSE Area Team (25/02/16)

• A verbal update will be given at the meeting.

Comparison of National growth assumptions compared with Camden CCG three-year actual growth levels completed. Activity plan to be revised with new growth assumptions.

08/02 Activity plan costed (at average 15/16 prices).

The 8th February Submission was based on the SUS SEM (TNR) data provided within the pre-populated functional spreadsheet as directed. The nationally provided IHAM model was used as a basis for growth assumptions.

Growth Forecast – assurances and rationalisation for the 2nd March Submission A detailed comparison of our local growth figures against the IHAM growth is underway to ensure that the right level of growth is being applied. Growth in specific population segments of children, adults & older people are being analysed.

Historic growth between years, looking back to 2012/13 is being completed. This is to confirm that the growth seen between 14/15 and 15/16 is ‘real’. Growth levels will then be adjusted accordingly.

Impact of recording shifts on each type of activity category are being calculated. • E.g. -Were increase in seen in 2015/16 due to shifts in activity?

• For example, during 2015/16 there was a shift in activity from inpatient to day case which resulted in increases in 2015/16

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• We are assessing whether we are expecting these increases to continue into 2016/17 or whether the transition was complete in 2015/16.

Additional activity will be required to be commissioned to meet constitutional targets.

4) Finance Plan and Affordability The first iteration of the CCG Finance plan was also submitted on 8th February.

This item is covered in detail in a separate report elsewhere on the agenda (Draft budget paper 2016/17),

5) Alignment with Provider Plans For 2016/17, there is a determined attempt by NHS England and Monitor/ TDA to ensure there is optimal alignment and full reconciliation between commissioner and provider activity and finance plans. To date, mostly because of the demanding submission deadlines, there has been limited engagement to align Camden CCG’s activity and finance plans with its main providers.

Since the initial submission on 8th February, there has been close working between the CCG and UCHL to align data and activity. After some initial difficulties, there is strong collaboration to work towards greater alignment for the next and final submissions.

6) Process to Develop the Final Operating Plan Submission A timetable / milestone tracker has been developed including the workstreams of Governance, Finance, Contracting and developing the Operating Plan Submission. Within the CCG, a Planning Oversight Group (POG) has been established, chaired by the Chief Finance Officer, which is driven and administered by the Interim Planning & Performance Manager and supported by the CCG Commissioning, Finance, Sustainable insights and the CSU teams. The CCG Finance Plan is also reported into the POG.

POG will report into the Executive Management Team as required but also produces a weekly Flash Report to keep members updated on progress / challenges. At times within the planning process, rapid turnaround of further information or supplementary submissions may be required. To respond to these information and clarification requests by NHS England, a small virtual sub-group of POG is in place that can be mobilised at very short notice to deal with such requests and provide material for Execs / AO to approve.

7) Next steps The following next steps will be undertaken:

Submit the second iteration of the Operating Plan (Activity Plans and Performance trajectories) via Unify by noon, 2nd March. For this Submission, Camden CCG will:

• Submit updated activity plans (using revised SUS SEM data). Including: • Apply adjusted growth figures using local intelligence to those activity plans • Apply activity & finance adjustments from our QIPP / transformational

programmes • Demand mitigations for areas such as A&E / 4 hour waits

Continue to work with providers on issues of constitutional standards delivery (e.g. diagnostics, 62 day cancer waits)

Continue to work with NHSE Area Team and NCL CCGs to deliver an assured and compliant Operating plan for 2016/17.

Submission of final operating plan 11th April 2016

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Report Title Procurement of Integrated Urgent Care Service: NHS111 and GP Out of Hours for North Central London


Lead Director Susan Achmatowicz


[email protected]

Report Author Ebun Eno-Amooquaye Project Manager, NHS111

Tel/ Email

[email protected]


Brigit Curtis Unscheduled Care Clinical Lead

Tel/ Email

[email protected]

Report Summary

Barnet, Camden, Enfield, Haringey and Islington CCGs (NCL CCGs) agreed to jointly commission a single, integrated NHS 111 and GP Out-of-Hours (111/OOH) service for their collective population. A tender process to select the new provider(s) started on 2 October 2015 and will finish in April 2016, allowing six months for mobilisation before the service starts in October 2016. The process has been led by Enfield CCG with support from the North East London Commissioning Support Unit (NELCSU) procurement team. The report in Appendix 1, summarises the procurement process and describes the many steps undertaken through the stages of this complex procurement. The five CCG Governing Bodies in North Central London will receive a separate report detailing the outcome of the procurement with a recommendation for approval of contract award. The separate report will be considered at the Part 2 (private) Governing Body meeting because the information it contains is commercially sensitive and the procurement process is not complete. All five CCGs need to approve the award of the contract during March 2016, after which the outcome of the procurement can be made public.

Purpose

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the content of the attached report at Appendix 1.


This procurement aims to support the following objectives: Improve health outcomes, address inequalities and achieve parity of esteem Integrate and enable local services to deliver the right care in the right setting

at the right time


Delayed release of the National Key Performance Indicators (KPI) We have been working closely with NHS England who have shared the

latest (draft) version of the Integrated Urgent Care KPIs with Commissioners as a guide. This has enabled us to compare against the local KPIs we are developing to rule out any duplication

It is anticipated that there will be low impact on the mobilisation of this service from a delayed release of the national KPIs.

Potential challenge on the procurement process Whilst we cannot predict whether a challenge will be made, we are confident that the service has been procured through a competitive, transparent and meaningful process in line with five NCL CCG Standing Financial Instructions / Prime Financial Policies, Public Contract Regulations and in addition to this:

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Our risk register was continually updated throughout the process; NHS England has reviewed and assured the procurement process through a formal checkpoint process prior to the procurement commencing. There are two further checkpoints which will run concurrently with the contract award decision and throughout the mobilisation period.

Our independent external chair (of the Procurement evaluation panel) has provided a report to the Lead Commissioner (Enfield CCG) to assure that robust processes were in place throughout.

Transparent records to explain the rationale behind the selection process and decision making have been maintained throughout the whole procurement process.

The unsuccessful Bidder(s) will be provided with detailed feedback on their ITT submission to assure them of the evaluation/selection process and final decision.

Delay to obtaining approval from all 5 CCGs

All five CCGs have fully invested in this procurement, have all signed up to Collaborative agreement and timelines have been clearly communicated

The five CCG Governing Body meeting dates have been built in to the project timeline.

The project team are available to deal with more detailed queries to expedite the decision making.


There are no conflicts of interest associated with this report.


The cost of the new service is expected to be higher than the current budget for NHS 111 and GP Out of Hours services. This was approved by Camden Governing Body on 25 March 2015.

Engagement

Significant public engagement has taken place on the proposal to develop an integrated NHS 111 and GP Out-of-Hours service across north central London. The draft specification was widely circulated for comment between 20th July and 19th August. The document was also available on the CCG public website, along with information about how to comment. There was also a patient and public reference group established to contribute to the development of the service specification. Seven members of the patient and public reference group contributed to the procurement process with three representatives as members on the evaluation panel. Four separate representatives were members of the assessing teams on the Objective Structured Clinical Examination scenario day, the detail of which is provided in the attached report.


An equality analysis was drafted in March 2015 by NCL 111/GP OOH programme team, no negative impacts were identified. The EQIA was update in August and September 2015, following public engagement.

Report History

The report in Appendix 1, was presented to Enfield Procurement Committee on 2 March 2016 for prior consideration.

Next Steps Following approval to award the 111/OOH contract by all five CCG Governing Bodies, the successful bidder will be notified of the award of contract and this will be followed by a 10-day standstill period which is anticipated to be completed by 5 April 2016. After completion of the 10-day standstill period, the decision on the successful bidder will be made public.

Appendices

Appendix 1: Procurement of Integrated Urgent Care Service: NHS111 and GP Out of Hours for North Central London Part 1 Report

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Appendix 1

Page 1 of 17

Part 1 Report

Title: Procurement of Integrated Urgent Care Service: NHS111 and GP Out of Hours for North Central London

Author:

Clare Kapoor, NCL Urgent Care Programme Manager

Marivie Papavassiliou, Senior Procurement Manager

Juan Carosio, Head of Procurement, NCL

Presented by: Juan Carosio and Clare Kapoor

Contact for further information:

Clare Kapoor NCL Urgent Care Programme Manager [email protected]

Marivie Papavassiliou, Senior Procurement Manager [email protected]

Juan Carosio, Head of Procurement, NCL [email protected]

Date paper finalised: 24th Feb 2016

Action requested: To note the steps undertaken during the procurement process

Executive summary:

This paper summarises the procurement process for the NCL Integrated Urgent Care NHS111 and GP Out of Hours (OOH) service. (Restricted Tender Procurement) that was undertaken in accordance with the North Central London CCGs Procurement policies. The paper outlines the background and complexity of the procurement process but does not include the outcome, which will be presented in Part 2 of Governing Body meetings. . It demonstrates that the service was procured through a competitive and meaningful process in line with the NCL CCG’s Standing Financial Instruction’s/ Prime Financial Policies (PFP).

How does this fit with NCL CCGs Strategy:

The need to redesign urgent and emergency care services in England and the new models of care proposed to support this are set out in the Five Year Forward View (5YFV). The Urgent and Emergency Care Review, led by Sir Bruce Keogh, proposes a fundamental shift in the way urgent and emergency care services are provided, improving out of hospital services so that we deliver more care closer to home and reduce hospital attendances and admissions. We need a system which is safe, sustainable and that provides consistently high quality. One of the key recommendations in the Emergency and Urgent Care review report is ensuring that people with urgent care needs are given the right advice in the right place, first time to ensure they then seek care in the setting most appropriate for their needs, rather than defaulting to Emergency Departments. An integrated urgent care system is a key step in the strategic plan for the NCL health economy.

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Appendix 1

Page 2 of 17

Provision of integrated urgent care services along with the extension of primary care access to 8am-8pm, 7 days a week, will help to ensure that Emergency Department resources is available to those who need it most.

The Business case was approved by the 5 NCL CCGs in March 2015: to commission an NCL-wide Integrated 1NHS 11/GP OOHs service through a lead provider contract for a period of five (5) years plus the option of a two (2) year extension through a competitive procurement process.

Where has the paper been already presented?

Enfield CCG Procurement Committee 2nd March 2016

Impact on risk:

All five CCGs within NCL supported the model and agreed to roll-on their existing contracts with the main providers within the scope of this procurement, namely London Central & West Unscheduled Care Collaborative (NHS111), Barndoc (OOH Barnet, Enfield and Haringey) and Care UK (OOH Camden and Islington). Over one year’s formal contract notice was given. A Risk register was developed and continually updated during the course of the programme and NHSE were assured through regular updates and formally through three checkpoint assurance reviews at key milestones of the project.

SUPPORTING PAPERS:

The following supporting papers are available on request.

Official Journal of the European Union / Contracts Finder advert Restricted Tender Pre-Qualification Questionnaire (PQQ) and Invitation To Tender (ITT)

documentations

Next Steps:

The purpose of this Part 1 paper is to note the steps taken during the procurement of the NCL Integrated Urgent Care Service: NHS 111 & GP Out of Hours. An additional paper detailing the outcomes of the procurement and final recommendation will be presented to Part 2 of all five NCL CCG Governing Bodies for approval.

If the Governing Body’s approve the recommendation, contract award letters will be sent to successful and unsuccessful bidders following this Governing Body meeting on 21st March 2016.

The 10 day standstill/Alcatel period will take effect as best practice, anticipated to be complete on 5th April 2016.

Contract signing will take place after the award of contract.

Service mobilisation will take place between April and September 2016.

Planned service commencement from 1st October 2016.

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1) Background – 2014/2015

In March 2014, the 5 North Central London Clinical Commissioning Groups (NCL CCGs) embarked on a review of unscheduled care services for the residents of NCL and agreed to commission an Integrated Urgent Care NHS 111 and GP Out of Hours Service. A comprehensive business case was produced, considered and approved by the Urgent Care Programme Board on 2nd March 2015 and by the CCGs [Governing Bodies] during March 2015. The decision was taken to agree the clinical model as set out within the business case for the commissioning of an NCL Integrated Urgent Care 111/OOH service through a lead provider contract for a period of five (5) years plus the option of a two (2) year extension through a competitive procurement process. The scope of services to be included in the tender process were for all residents and registered patients within Barnet, Enfield, Haringey, Camden and Islington boroughs. NCL Integrated NHS111/GPOOH service, namely NHS 111 and GP OOH services.

2) Procurement Process and Planning

In order to prepare for this complex procurement, an NHS111/OOHs steering group, a procurement sub-group and a clinical sub group comprising of key Clinicians and Commissioning Managers from each of the 5 CCGs was set up to manage the procurement. The project steering group reported regularly to the NCL Urgent Care Programme Board which comprised of the Urgent Care SRO (Enfield CCG Chief Officer), key Directors and senior managers from the 5 CCGs; public representatives and clinical leadership. As part of this process a procurement proposal was approved by the project steering group, in addition a Procurement Strategy was developed and approved (6th May 2015). The Procurement Strategy included details on the procurement options / route, considerations for collaborative arrangements, Subject Matter Experts / local provider requirements, overall evaluation criteria / weighting, payment mechanism and an agreed scoring range of 0 – 4. A programme manager was appointed to lead the project, and the procurement was undertaken as a project with a risks and issues register, communication (internal and external) strategy and lessons learnt report.

To comply with the required rules and regulations the contract for the integrated NHS111 and OOH service would need to be awarded through a competitive tender process to ensure that the provider would be selected following a fair and transparent process.

An options appraisal to justify the procurement approach was conducted and outlined in the Procurement Strategy document. The recommendation to use a ‘Restricted tender process’ was agreed upon for the following reasons:

• Significant work to define the clinical model, outcomes and financial model as well as extensive engagement with wider stakeholders gave the CCGs confidence that the needs / requirements had been identified and they would be able to clearly define the specification.

• Market research had identified a large number of potential providers in the market who would be interested in bidding for this service. A market information event held with organisations that provide NHS 111 and GP OOHs services in February 2015, generated much interest with over 13 providers in attendance.

The NHS111/OOHs service was considered to be a Part B Service under Public Contracts Regulations and therefore did not require the mandatory publication of an OJEU contract notice. The CCGs agreed to follow best practice and Monitor guidance and place a voluntary contract notice in OJEU.

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A ‘Restricted Tender process (Pre-Qualification Questionnaire [PQQ] and Invitation to Tender [ITT] requires interested parties to register their interest, submission of a PQQ for shortlisting, submission of an ITT and evaluation, presentation/interview and then contract award. Time is built into the process for clarifications during both the PQQ and ITT stages NHS England documentation was utilised as a base to develop the PQQ and ITT documentation. The steering group, procurement subgroup and key members of the evaluation panel tailored the documentation to the requirements of this procurement and developed the necessary evaluation criteria, scoring mechanisms and evaluation thresholds against which a fair and objective assessment could be made. As a further assurance process, an external independent review of the ITT documentation was undertaken. The PQQ stage itself focuses on the potential Bidders. It is about obtaining and interpreting general information about potential Bidders to test their capacity, capability, economic and financial standing, and eligibility to take part in the Procurement and for working with the NLC CCGs. The PQQ stage does not entail any detailed analysis of proposed solutions, nor how arrangement and interactions between potential Bidders and the NCL CCGs should work, or any information regarding pricing. Bidders provide this type of information at the ITT stage of the Procurement.

At PQQ stage, the focus is on evaluating potential Bidders in three main areas:

• Capacity and capability – Assessment of the resources and core competences available to the potential Bidder including, without limitation, clinical, workforce, infrastructure, local knowledge and ability to integrate with the local healthcare community;

• Economic and financial standing – Whether the potential Bidder is in a sound financial position to participate in the Procurement; and

• Eligibility – Whether the potential Bidder, or its Relevant Organisations, satisfy any of the conditions for which they may be deemed ineligible to be awarded a public contract as detailed in Regulation 23 of the Public Contracts Regulations 2006 (SI 2006 No 5).

The main objectives at this stage of the Procurement are to:

• Establish whether any potential Bidders should be excluded from further consideration because they fail to meet minimum criteria and standards;

• Create a list of realistic candidates who meet the threshold for participation and may be recommended to proceed to the next stage; and

• Identify any issues that need addressing prior to future stages of the Procurement.

The decision to shortlist up to five (5) potential bidders from the PQQ stage to the ITT stage was based on the requirements of the Public Contract Regulations (PCR), assessment of the market and the NCL CCGs own Prime Financial Policies (PFP). Under EU procurement rules, no less than five (5) potential bidders are to be invited to tender unless fewer suitable candidates have met the selection criteria and these are sufficient to ensure genuine competition. Although health contracts are usually classified as ‘Part B’ under the PCR and are not subject to all the EU procurement rules, five (5) is considered to be a reasonable number, and therefore a maximum of five (5) were to be shortlisted to the ITT stage At ITT stage it was proposed that an 80:20 Quality / Price weighted model would be used to evaluate tenders. This was based on OGC/Cabinet office guidance for complex specifications where failure of the service has an impact on the organisation, for long term contracts and where the provider is motivated to provide quality services.

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The ratio determines how much quality and price will influence the tender evaluation and should reflect the relative importance of either element to the CCG. To satisfy the service requirements, the shortlisted Bidders need to demonstrate satisfaction of the service requirements and are formally evaluated against the pre-defined criteria set out within the ITT documentation. These requirements represent the key issues that are important to NCL CCGs. To satisfy the commercial requirements, Bidders had to complete a Financial Modelling template. The design of the tender evaluation was to allow selection of a Bid that represented best Value for Money (VfM) rather than the lowest priced bid alone. The best VfM (most economically advantageous tender) would be that which was judged to offer the optimum combination of service, capability, quality (including clinical standards, safety, deliverability and other areas as detailed in the ITT) and Bid Price within the stated affordability parameters. To satisfy the legal requirements, Bidders had to be willing to contract on the terms and conditions set out in the NHS Standard Contract, and acceptance of any mandatory provisions issued with the ITT documents. All sections of the ITT would be formally evaluated in order to identify those Bidders to be invited to the final presentation stage. This final stage of the ITT was split into two assessment phases and 15% (from the overall 80% for quality) was adopted and split as follows:

10% for the Objective Structured Clinical Examination (OSCE) Scenarios. 5% for the formal presentation/interview.

The scores would be added to the ITT and finance score to result in an overall final score. Transparent records to explain the rationale behind the selection process and decision making would be maintained throughout the whole procurement process. Following completion of the ITT evaluation, a Part 2 Contract Award Recommendation report is finalised and co-ordinated by Enfield CCG as lead commissioner, is taken to the five (5) CCG Governing Bodies to obtain approval of the decisions recommended and hence approval to award the contract. 3) Communication and Engagement

Effective engagement with stakeholders is an essential requirement of all NHS Organisations and offers substantial benefits to the generation of outcome-based service specification. The five (5) CCGs engaged with their respective CCG Governing bodies, members, clinicians, service users, stakeholders, external agencies, local media and potential providers at appropriate times during the commissioning and procurement processes in accordance with the principles set out in the CCGs communication and engagement strategies.

Since January 2015, the 5 north central London (NCL) clinical commissioning groups have been engaging extensively with local service users and residents on our proposal to commission an integrated urgent care NHS 111 and GP out-of-hours service.

We engaged with hundreds of people, face to face or through our on-line survey, particularly those who would be most likely to use the proposed service or who we know face particular barriers to accessing services or are vulnerable.

We held a number of public meetings as well as arranging targeted events for specific user groups including people with learning disabilities, mental health users, young carers, people affected by HIV, older people and refugee and migrant communities.

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In parallel with the engagement programme we established a Patient and Public Reference Group (PPRG) including representatives from Healthwatch organisations across NCL. The PPRG had around 22 members with approximately 4 representatives from each borough. The PPRG met on a monthly basis and had the opportunity to discuss the service specification and make line-by-line comments.

Additionally, the draft specification was published on the websites of all five CCGs from 21st July to 19th August 2015, and circulated to stakeholders, inviting comments. We received 800 comments on the service specification and have reflected these comments within the service specification.

We presented an engagement report to the north central London Health and Wellbeing Boards and have attended a number of meetings of the Joint Health and Overview Scrutiny Committee.

Input from groups and associations across the five London boroughs, as well as the Patient and Public Reference Group, was used to ensure the views of patients were included in the service being commissioned.

4) Evaluation panel membership

An evaluation panel was established at the start of the process prior to the advertisement being issued with roles and responsibilities documented.

Evaluation demands a mix of expertise across a range of specialisms. The panel was organised into work streams for both the PQQ and ITT stages, with each stream headed by a suitably qualified / experienced Subject matter expert (SME) or Leads.

The evaluation panel comprised of an external Chair and a diverse range of representatives from across the five (5) NCL CCGs, NEL CSU and Patient Public reference group. In addition to this, there were non-scoring advisors/subject matter experts from NEL CSU and NHS England to provide additional support as and when required.

The work streams were as follows:

Chair Procurement Leads Clinical Leads Commissioning Leads Quality and Governance Leads HR Leads Contract Leads Patient Representative Leads Information Management & Technology Leads Information Governance / Risk Leads Estates Leads Finance Leads Independent subject matter experts (non-scoring)

Definition of roles

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Various roles are required to carry out the evaluation process at both the PQQ and ITT stages:

Procurement Lead – to oversee strategic and day-to-day management of the Procurement process ensuring quality and consistency of approach, and managing the moderation process;

Programme Manager – to oversee the evaluation process and ensure sufficient resources are available to conduct the evaluation;

Evaluator – to undertake evaluation activity as required and determined and coordinated by the Procurement Lead or Programme Manager;

It is the responsibility of each evaluator to ensure they are available to conduct the evaluation in the timescales required.

General Responsibilities

All members of the evaluation panel were asked to:

Ensure that they familiarise themselves with the context of the Procurement and have a full understanding of the relevant details at the PQQ and ITT stages;

Maintain high standards of confidentiality at all times; Undertake all activities in a manner consistent with fair competition; Declare to the Programme Manager / Procurement Lead any potential conflicts of interest

prior to joining an evaluation team; Notify the Procurement Lead of any element of any PQQ / ITT submission or dealing with

a Provider that gives rise to a suspicion of collusion between potential Bidders, or other practices not consistent with fair competition;

Not communicate with any potential Bidder other than through the formal process set down in this Plan; and

Notify the Procurement Lead of any attempt by any potential Bidder to communicate with them outside of the formal process.

All members received evaluation training, guidance and support throughout the process from the Procurement Leads and Programme manager.

5) Evaluation Methodology

The method of evaluation is designed to enable the identification of Potential Bidders / Bidders at each of the PQQ & ITT stages that:

Comply with the standards required by the Procurement Meet with the PQQ and ITT requirements specifically against the pre-defined criteria

Assessment of scored questions was carried out using the grading definitions in table 1 below. Half scores were not permitted.

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Table 1: Scoring scheme

GRADE LABEL GRADE DEFINITION OF GRADE

Unacceptable 0 The response has been omitted, or evaluator is confident that the potential Bidder has inadequate (or insufficient) capability / capacity to deliver the required services.

Compliant with shortcomings

1

The evaluator is confident that the potential Bidder has a level of capability and capacity to deliver the required services that is adequate for the purposes of the Procurement although contradictions in the submission are evident, or other doubts exist.

Compliant 2

The evaluator is confident that the potential Bidder has a level of capability and capacity to deliver the required services that is adequate for the purpose of the Procurement.

Compliant with superior capability

3

The evaluator is confident that the potential Bidder has a level of capability and capacity to deliver the required services that is adequate for the purposes of the Procurement (with significant capability evidenced).

Compliant with exceptional capability

4

The evaluator is confident that the potential Bidder has a level of capability and capacity to deliver the required services that is adequate for the purposes of the Procurement (with exceptional capability evidenced).

Assessment results were recorded in the score cards provided by the Procurement Lead with responses scored and comments appended (explaining the basis of this scoring). Evaluators reviewed and scored their relevant sections independently of each other.

6) Moderation

Moderation meetings were held during the PQQ and ITT stages, during which each evaluator was able to discuss their rational for the scores provided and to discuss any differences in views such as; split pass/fail decisions; variances of 2 or more in the scores allocated; any ‘fail’ or zero’ grades .

To ensure consistency of approach and grading, evaluators were given the opportunity to moderate their scores. It was agreed that where any difference in judgement within the panel occurred, the panel would take the average score to the nearest whole number. A final consensus score would be recorded at each moderation meeting with final agreement from the whole panel on the shortlisting of Potential Bidders / Bidders at each stage.

7) Governance arrangements Access to evaluation information (i.e.: Planning documents, Bid submissions, evaluation results etc.) were not granted until reasonable measures to ensure confidentiality and to secure against conflicts of interest were taken.

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Confidentiality and conflict of interest forms were signed by all members of the111/OOH project steering group, procurement sub groups and evaluation panel. In addition, at key points of the procurement process all members were reminded of the agreements signed to maintain such information as confidential and to guard against any Conflicts of interest. 8) Procurement timetable and further engagement The original plan to commence the procurement was scheduled for May 2015. It was agreed by the five (5) CCG chief officers to delay and revise the timetable to allow for a period of wider engagement with the public in July 2015. In addition, NHS England advised all CCGs that new commissioning standards for an Integrated Urgent Care NHS 111 and OOH service was in development and as such, commissioners were asked to suspend procurement of these services until the end of September 2015. This was already in line with the revised timeline of the NCL CCGs, with the planned procurement to commence on the 1st October 2015 following a further period of engagement and communication with each of the five CCGs local communities. A draft report on the additional engagement and communication conducted in July was published on the five (5) CCG websites in advance of the report going to September Governing Bodies. Furthermore, engagement on the draft service specification took place in early August with comments received sent to the drafting team. During September 2015 updates were provided to each Health and Wellbeing Board and NCL joint health overview and scrutiny committee. An update was also presented to both the Camden and Islington Health Overview Scrutiny Committees. In addition to the above, another Market Information sharing Event was held on the 5th August 2015, to re-engage the market by allowing potential bidders to learn more about this potential opportunity. There was a high level of interest in the event with over 35 attendees representing 20 organisations. An overview of the procurement timetable is outlined in table 2 below Table 2: Procurement timetable:

Activity Date

Pre-procurement planning and activities January to September 2015

NHS England Check point 1a 28th September 2015

Advert Placed on Official Journal of the European Union / Contracts Finder and Supplying2nhs.com

2nd October 2015

MOI, Information & Guidance and PQQ Published on Pro-contract

2nd October 2015

Deadline for PQQ clarification questions 23rd October 2015

Deadline for Expressions of Interest and PQQ submission

2nd November 2015

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PQQ Evaluations 3rd to 20th November 2015

NHS England Check point 1b 27th November 2015

ITT Issued to successful bidders 30th November 2015

Deadline for ITT clarifications 4th January 2016

Tender submission deadline 11th January 2016

Tender Evaluations 13th January to 1st February 2016

OSCE assessment & /Presentation/interview 11th and 12th February 2016

NSH England Check Point 2 29th February to 18th March 2016

Contract Award Approval by CCG Board 29th February to 18th March 2016

Successful and unsuccessful bidder notification 21st March 2016

Standstill Period expires 5th April 2016

Contract Signature From 6th April 2016

Commence mobilisation From 6th April 2016

9) NHSE Assurance Process

The NHSE NHS111 Procurement and Mobilisation Checkpoint Assurance Process consists of three checkpoints covering key phases from development of procurement strategy through to go live.

Checkpoint 1 Delivery strategy (Pre-tender up to publication of documents) Checkpoint 2 Investment decision (Post-evaluation and before contract award) Checkpoint 3 Operational review (Before go-live of the new service provision)

Checkpoint 1 takes place from the initial start of developing the local procurement strategy through to publication of tender documentation onto the appropriate procurement portal. The checkpoint sections are designed to enable assurance at critical planning stages before the formal procurement process begins:

Development and review of high-level strategy and options appraisal, including the geographical footprint of the service

Procurement specification development and sign-off

Development of procurement documentation and processes before formal process begins

The Checkpoint 1 assurance process was carried out in week commencing 23rd November 2016. NHS England’s recommendation for the “Checkpoint 1” (pre-ITT) gateway for Integrated Urgent Care procurement in NCL is that the CCGs should proceed and publish their tender as planned on 27th November 2015.

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NHS England was assured that the NCL CCG’s vision, specification and procurement

approach are closely aligned to the new commissioning standards for Integrated Urgent Care services.

The Checkpoint 2 assurance process will take place prior to contract award.

10) Pre-qualification stage Following approval by Enfield CCG on [16th Sep 2015] this restricted tender was advertised on the Official Journal of the European Union / Contracts Finder on the 2nd October 2015 to notify potential Bidders of this procurement and seek formal Expressions of Interest. The PQQ documentation was released on the 2nd October 2015 on the Pro-Contract e-procurement portals (www.supplying2nhs.com). This procurement process was carried out via the Pro-Contract e-procurement system and therefore the expressions of interest and PQQ submissions were received via this e-tendering suite. The deadline for expressions of interest and PQQ submission was at 1000hrs on 2nd November 2015. There were no late submissions. Potential Bidders were advised in the PQQ that their submissions would be; checked for compliance with the instructions given; checked that they agreed with the Commercial Terms set out; checked that they had signed the Declaration form; evaluated on the basis that they had to pass all Pass/Fail questions and score above a 50% threshold in order to qualify and be shortlisted to the ITT stage. The PQQ evaluation criteria and assigned weighting was as follows: Table 3: PQQ evaluation criteria

Section Contents and sub-criteria weighting Overall Weight / Criteria

A Details of Potential Bidder and its Business Structure

Pass/Fail & For information only

B Legal and Regulatory Pass/Fail

C Economic and Financial Standing Pass/Fail

D Business Continuity Planning 10%

E Workforce, Recruitment & Policy Pass/Fail

F Insurance Pass/Fail

G Technical and Professional Ability Pass/fail & scored 60%

H Equalities Pass/Fail

I Health and Safety Pass/Fail

J Quality Assurance Pass/Fail

K Environmental & Social Management Pass/fail & scored 10%

L Information Governance Pass/Fail

M Information Management & Technology Pass/Fail & scored 20%

N Applicant’s Declaration Pass/Fail / Compliance

Total 100%

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Following the PQQ submission deadline, the Procurement Lead accepted all on time submissions. The evaluation panel members were informed of who the Potential Bidders were and as an additional governance process were asked to confirm if there were any new Conflicts of Interest to Declare. None were raised. The PQQ evaluation consisted of two parts; an Initial evaluation and Detailed evaluation The initial evaluation was completed by the following work-streams; Procurement – compliance with the instructions and key commercial terms Finance - Economic and Financial standing Contracting - Eligibility and satisfaction of conditions to be awarded a public contract Following approval by all three work streams, the Potential Bidder submissions were then released to the wider panel for the Detailed Evaluation (assessment of remaining Pass/Fail questions and scored questions) Evaluators submitted their individual scores for the sections they reviewed to the Procurement Lead to collate ahead of the moderation meeting which was held on the 20th November 2015. During the moderation meeting each of the Potential Bidders responses were reviewed in full. Bidders who failed any of the Pass/Fail questions were excluded from the process and their scoring questions were not evaluated and moderated by the panel any further. For the Scored questions the panel reviewed each response and had the opportunity to discuss any variations of scores in order to reach a consensus score. Where there was a difference in judgment the panel agreed to take the average score to the nearest whole number. The Procurement leads kept a record of the final consensus scores and presented the results to the panel. At the end of the Moderation meeting, the Panel concluded by reviewing and confirming the following: Was the process compliant and in line with the Procurement Principles Were the evaluation criteria followed? Was everyone comfortable with the process followed and in agreement with the decisions

made? All panel members confirmed their agreement that the process was compliant, the criteria were followed and that all were comfortable with the decisions made. Following this stage, the Procurement Lead completed a PQQ evaluation report which summarised the conclusion of the PQQ evaluation process. This was to assure the NCL CCGs that the process for securing the necessary reassurance about the capacity, capability and eligibility of the applicants to satisfy the minimum requirements of the procurement process was robust. This was submitted to the Enfield Procurement Committee on the 23rd November 2015 and they were specially asked to consider and approve the following recommendations: To note the outcome of the PQQ process To approve the shortlist based on the outcome of the PQQ evaluations To approve issuing the ITT documentation to the shortlisted bidders. Enfield CCG Procurement Committee approved the recommendation on 25th Nov 2015

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11) Invitation To Tender stage Invitations to Tender were issued on [30th November 2015] to all shortlisted bidders. The deadline for submitting tenders was set as [1700hrs on the 11th January 2016] Tender responses were received as sealed bids through the Pro-contract e-procurement portal. There were no late submissions. Potential Bidders were advised in the ITT documentation that the award criteria weighting would be based on 80% quality and 20% price as follows: 65% Quality (ITT Bid response document – non financial) 20% Price (ITT Bid response document – financial) 15% Quality (OSCE/Presentation – non financial) Bidders were informed that in order to be shortlisted for the OSCE/Presentation stage, their submissions would be checked for compliance with the instructions given, they would have to pass all of the Pass/Fail Questions and also achieve the following minimum scores for Sections 1 to 7. Minimum of 60% for Section 1, 2 and 3 Minimum of 50% for Sections 4, 5, 6,& 7 The right was reserved to vary the minimum score threshold specified above if deemed necessary. An indication of the contract value was included in the OJEU and Pro-contract e-tendering portal advert and ITT documentation. The right was reserved to not appraise any bids that exceeded the maximum estimate of £50m based over the 5 year term. As was set out in the tender documentation tender submissions would be assessed on the following evaluation criteria and weights: Table 4: ITT Evaluation Criteria

Evaluation Criteria Overall Weight / Criteria

Bidder ITT Bid Response document

1 Service Delivery Pass/Fail & scored 15%

2 Demand & Workforce planning Pass/Fail & scored15%

3 Clinical Scored 15%

4 Mobilisation Scored 5%

5 Stakeholder Involvement and Feedback Scored 5%

6 Information & Reporting, IM&T / IG Scored7%

7 Premises and Equipment Pass/Fail & Scored 3%

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8 Cost Bid 20%

Bidder OSCE / Presentation

9 OSCE 10%

Presentation / Interview 5%

Procurement removed the seal, verified the submissions and then released them to the evaluators for scoring. There were two stages in the tender evaluation process Initial Evaluation - Verification / Pass/Fail stage Detailed Evaluation - Scoring stage Procurement verified the Bidder Submissions to confirm: Complete submissions were received (checked for any omissions) Bidders adhered to the instructions and word count limits set Bidders cost submissions were within the financial envelope set Bidders passed the Pass/Fail questions set. Following this Initial Evaluation score sheets were released to the wider evaluation panel to complete the Detailed Evaluation. As per the PQQ stage, evaluators submitted their individual scores for the sections they reviewed to the Procurement Lead to collate ahead of the moderation meeting which was held on 1st February 2016. The same process was followed in terms of reviewing each Bidders response in full and discussion and moderation of any scores where appropriate in order to reach a consensus score. Once the quality section of the moderation meeting had concluded, the Finance Leads presented their assessment of the Cost Bid section. The financial model contained within the ITT scoring mechanism, was constructed with one Pass/Fail Question and 4 scored questions where the highest weighting applied to the lowest 5 year contractual value. The Procurement Leads kept a record of the final consensus scores and presented the outcome to the panel members without revealing the actual scores. At the end of the Moderation meeting, the Panel concluded by reviewing and confirming the following: Was the process compliant and in line with the Procurement Principles Were the evaluation criteria followed? Was everyone comfortable with the process followed and in agreement with the decisions

made? All panel members confirmed their agreement that the process was compliant, the criteria were followed and that all were comfortable with the decisions made. Procurement notified the shortlisted bidders of their success in reaching the OSCE/Presentation stage of the ITT.

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12) OSCEs, BIDDER PRESENTATIONS AND INTERVIEWS Bidders were given advanced notice of the assessment process for the Objective Structured Clinical Examination Scenarios and Presentation stage, which was held over two consecutive days. OSCE The OSCE assessment was held on the 11th February 2016 , during which Bidders were given 10 clinical scenarios over the course of the day. The purpose of the day was to test Bidder responses to clinically based scenarios which covered a range of themes such as Safeguarding, Mental Health, pathways and clinical audit. There were 5 NCL teams responsible for assessing and scoring two clinical scenarios each. The teams were made up of three assessors (Clinical lead, Commissioning lead and Patient representatives) The ten clinical scenarios were weighted 1% each (total of 10%) and a numerical score of 0-4 was applied by the assessment panel. Bidders were allocated to a room, with the assessment panel teams rotating between rooms for each scenario accordingly. In addition other members of the evaluation panel and external observers were used to support the day as follows: Team roles and responsibilities Assessment Panel – There were five teams, made up of a panel which included a clinician, commissioner and patient representative. The assessment panel were responsible for assessing and scoring Bidders responses to two scenarios each. Facilitators – consisted of commissioner and/or CSU representatives. Each Bidder was assigned a facilitator who remained in the Bidder rooms and co-ordinated each OSCE Session. The facilitator was responsible for time management during the session, issuing the scenario questions, letting the panel members into the room to evaluate and collecting all materials from the Bidders at the end of the day. A separate facilitator also directed each assessment panel to the relevant Bidder rooms. Calibrators – consisted of Clinical, quality and CSU representatives. The calibrators were there to provide some support and test the reasoning behind the assessment panel’s evaluation & scoring. Calibrators were not told which Bidder the assessment panel had reviewed. Observers – consisted of external personnel from NHS England and the Chair. The Observers sat through 1 or 2 OSCE sessions to ensure uniformity in our process. Procurement – consisted of CSU representatives. The procurement leads collated all panel member scores and comments. Confidentiality The OSCE process was managed strictly in terms of confidentiality. All attendees (Bidders, evaluation members and observers) were asked at the start of the day to declare any conflicts of interest and were informed that all associated materials were to remain confidential due to

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the potential that this process would be replicated across other London Procurements. All documentation / materials (including any notes) was retained by the Project and Programme leads. 13) Presentation/Interview The final stage of the assessment was the presentation/interview. Bidders were advised in advance of the questions/themes in order to prepare their final presentation for a select key members of the evaluation panel. The presentation / interview stage was allocated the final 5% of the overall marks reserved for this ITT stage. Each Bidder was given 30 minutes to present followed by a 30minute Q&A session at the end. The Q&A question was used to clarify any points from the presentation and to ask each Bidders a series of unseen questions. The evaluation panel comprised of representatives from across the 5 NCL CCGs within the following workstreams: Clinical, Commissioning, Quality, Information Governance and Patient Representatives. The presentation was facilitated by the Chair, procurement leads, and programme manager and who did not take part in the scoring. There were two senior observers for quality assurance purposes. After each of the Bidder presentations, the panel members scored individually and then discussed scores as a wider group in order to reach a consensus score. The procurement leads subsequently recorded these scores to arrive at the final scores. The panel was not informed of the final scores and the Procurement leads will now complete a Contract Award Recommendation report which will be submitted to the five CCG governing boards for approval. 14) Integrated Urgent Care Service Contract and Contract Monitoring This contract will be offered on a block basis with the NCL CCGs developing local Key Performance Indictors (KPIs) that will sit alongside the suite of national KPIs. Some of the KPIs will pertain specifically to Quality and Performance and there will be financial sanctions attached to these KPIs for non-delivery. Payment will be monthly at 1/12th of the total contract value. 20% of the total contract value will be split across the aforementioned KPIs. Financial sanctions will be applied on a quarterly basis, following reconciliation where the provider has not achieved the KPI targets. This will be managed through the contract monitoring meetings and the clinical quality review group.

We are very keen to see patients and members of the public involved in monitoring the contract once it has been awarded. There will be an expression of interest exercise to recruit members of the public into this role following the contract award.

15) Conclusion

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This paper, presented to Part 1 of Governing Bodies, summarises the very complex procurement process for an Integrated NHS111 and GP OOH service to service the populations of the five NCL CCGs. Part 2 of Governing Bodies will receive a similar paper with the addition of the outcome of this process with a recommendation for one of the bidders to be awarded the contract. The Governing Bodies will also be asked to approve proceeding to contract discussions on successful completion of the standstill period and award the contract within the terms of the tender as outlined above.

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Report Title Camden CCG 2016/17 Draft Budget

Agenda Item 4.1

Date 25/02/2016

Lead Director Ian Boyle, Chief Finance Officer Tel/Email [email protected]

Report Author Ian Boyle, Chief Finance Officer Tel/Email [email protected]


Chief Officer Tel/Email

Report Summary This paper presents the draft Budget for 2016/17, following input from all budget holders, showing the planned income and expenditure, based on the officially notified NHS England Revenue Resource Limits for 2016/17 and planning assumptions, based on NHS England guidelines (‘Forward View’) and local health economy knowledge.

Purpose (tick one only) Information

Approval

To note Decision

Recommendation The Governing Body is requested to: - approve the main principles of the budget setting exercise for 2016/17, that is,

to deliver a 2% surplus based on the delivery of a 2.6% QIPP.

- note the first draft of the CCG 2016/17 budget and the assumptions and approach used to derive this draft

- note the next steps required in finalising the budget for 2016/17

- note the roadmap to full approval of the final budget in line with the Operational Planning timetable outlined by NHS England


Maintain financial stability and ensure sustainability through robust planning and commissioning of value for money services

Identified Risks & Risk Management Actions

Risk of failure to deliver commissioning intentions with the agreed financial resource budget, which will impact on the available resources that the CCG will have for future healthcare commissioning.


Not applicable for the purpose of this report.


Risk of not managing CCG resources over the next year, will impact on future resource allocations from NHS England.

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2



Report History The Governing Body approves the annual budget and receives regular progress reports throughout the year. The same is planned for 2016/17 financial year.

Next Steps As outlined above.

Appendices Appendix 1: Summary of 2016/17 draft budget.

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Camden CCG: Summary of 2016/17 Draft Budget

1. Introduction

This paper presents the first draft of the Camden CCG Operating Budget for 2016/17. The CCG is planning to deliver a 2% surplus subject to full delivery of a 2.6% QIPP.

The paper outlines the approach taken to derive the initial budget for the CCG for 2016/17 and outlines the next steps in respect of completing the planning and contracting round for 2016/17.

2. Historical Financial Position

The financial position of Camden CCG is robust, consistently delivering surpluses above the 1% NHS England Business Rules. The planned surplus for 2015/16 was £8 million, however this was increased at Month 9 to £11 million.

3. Five year allocations

The NHS England Board to decision to adopt an aggressive “pace of change” policy has significantly reduced in real terms the funding made available to the CCG. The table below reminds the committee of the growth the CCG will receive as a result of the Comprehensive Spending Review (CSR) from 2016/17 to 2020/21.

2015-16 2016-17 2017-18 2018-19 2019-20 2020-21 Allocation £k 349,812 354,671 355,250 355,453 355,519 360,786 Allocation per capita £ 1,344 1,329 1,314 1,301 1,308 Growth 1.4% 0.2% 0.1% 0.0% 1.5% £k change on previous year 4,859 579 203 66 5,267 Target £k 296,775 304,763 312,622 320,639 333,985 Opening DfT 24.1% 20.3% 17.4% 14.5% 11.6% Closing DfT 23.2% 19.5% 16.6% 13.7% 10.9% 8.0%

The impact of the allocation methodology means Camden will receive “minimal” growth for the next five financial years. The growth of £4.859 million for 2016/17 is fully committed to the required increase in national tariff to cover employers NI and pension changes.

To continue to invest, Camden CCG will therefore need to deliver sustained cash releasing QIPP savings as part of our medium term strategic financial planning.

4. 2016/17 Budget methodology

Two methodologies were utilised to derive the first draft of the 2016/17 CCG Budget. For Acute and Non Acute Contracts, the planning assumptions contained within the NHSE guidance have been applied. The table below sets out these assumptions. For Corporate and Overhead budgets, a bottom up exercise with CCG budget holders was undertaken to accurately cost all posts within the CCG at NHS pay rates. The table below identifies the planning assumption indices used in deriving the budget.

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2016-17 Planning Assumptions General Inflation 3.10% Tariff Efficiency -2.00% Acute ETO Tariff Efficiency -1.30% Acute DTR Tariff Efficiency -2.90% Net Acute ETO Inflator 1.80% Net Acute DTR Inflator 0.20% Net Non-Acute Inflator 1.10% Allocation Growth 1.39% CQUIN 2.50% Surplus 2.00% Non-Recurrent Headroom 1.00% Demographic Growth 1.50% Non-Demographic Growth 1.36% CCG Running Cost -1.67% Contingency 0.50% Continuing care Inflation 3.00% Prescribing Inflation 5.00% Primary Care Inflation 1.30% Better Care Fund 6.84% Pay inflation & change to employers NI & Pension costs 2.10% Employer PAYE 10.00%

Employer Pensions Contributions 14.00%

5. 2016/17 Better Care Fund Plan The total Better Care Fund planned is £18,049,000 funded by NHSE £5.975m. The guidance on

BCF for 2016/17 was published on 22nd February, and consequently the details of the planned expenditure within this envelope will be provided in the 2nd draft of the CCG budget for 2016/17.

6. QIPP

QIPP has increased from £7.6m in 2015/16 to £9.1m in 16/17, which is 2.6% of the CCG’s budget

and broadly in line with the London CCG average level of QIPP challenge. The table below identifies the QIPP plans for 2016/17 at a summary level. Given the allocations received and the budgetary requirements, all QIPP must be fully cash

releasing. The governance of the CCG’s QIPP arrangements is currently under review, and it is envisaged

that this will need to be reinforced to amalgamate QIPP delivery into CCG “business as usual.”

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Theme 2016/17 QIPP Scheme £000’s

Better Care Fund

Camden Community Rapid Care Service 980

Integrated Community Equipment Service 880

Assistive Technology 410

Occupational Therapy Led Projects 240

7 Day Working Week Within Social Care 110

Case Management Project 80

Reablement 50

Mental Health

Team Around the Practice 280

IPU for Patients with Psychosis 200

Mental Health Personal Health Budgets 120

SMI Planned Care LCS 50

Homeless Healthcare 50

Crisis Care and Crisis Prevention 50

Alcohol Assertive Outreach 50

Primary Care

Care Homes LCS 1,000

End of Life Care LCS / Coordinate My Care 1,000

Methotrexate LCS 240

LTC LCS Anticoagulation 180

Smoking Cessation 120

75+ Home Visiting Service 50

CNWL Community Services Nursing 50

Integrated Community Service LTC AF Project 50

ED Redirection 50

Primary Care Navigator 40

Long Term Conditions & Cancer

LTC LCS Chronic Obstructive Pulmonary Disease (COPD) 200

Early Diagnosis of Cancer Initiatives – Breast 70

Early Diagnosis of Cancer Initiatives - Lung 40

Early Diagnosis of Cancer Initiatives – Colorectal 40

LTC LCS Chronic Kidney Disease (CKD) 40

LTC LCS Diabetes Targeted Patient Finding 30

LTC LCS Heart Failure: Targeted patient finding, 20

Epilepsy 10

LTC LCS Hypertension: Targeted Patient Finding 10

Bowel Screening Calling Reminder Service 10

Prevention Work Through the ‘Love your lungs’ Campaign 10

Community Hypertension Service (Consultant Review) 10

Community Hypertension Service (Nurse Activity) 10

Frail & Elderly

Community Geriatrician Service 80

Complex Care LCS 50

Complex Care Case Managers 50

Care Navigators 50

Frailty Multidisciplinary Team Hub 40 Learning Disabilities Move People with Learning Disabilities Out of Hospital 50

Referral Management

Back Pain Referrals 50

Faecal Calprotectin / Gastro Referrals 20

Referral Management (General) TBC

Other OD & Corporate Overhead Efficiencies 1,000

Transactional QIPP 918

Grand Total 9,138

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7. Risks At the time of writing, all contracts are under negotiation. Any increase to the cash envelopes

determined via budget setting will impact on the CCG financial position

There is no contingency planned for any unforeseen Acute over performance, which historically has been £2.5m annually.

2015/16 overseas visitors costs are assumed fully funded by NHSE in 2016/17.

At the time of writing, the Better Care Fund plan, which has a key link into acute performance has not been finalised. The QIPP’s planned from BCF must therefore fully deliver in 2016/17.

The plan assumes drawdown of £3 million from the CCG’s cumulative surplus. At the time of writing, this has not been confirmed. If not made available to the CCG, then the subsequent draft of the budget will require detailed scrutiny in respect of the CCG’s Investment programs.

At the time of writing, there is a lack of clarity from NHS England in respect of the 1% non-recurrent

reserve, which the CCG has to make under business rules. The assumption was made that this would fund the NCL / risk share as per previous years, however emerging guidance suggest that this 1% must remain uncommitted at the start of the financial planning period. We await further guidance in this respect.

8. Next steps

Significant further work is required to finalise the planning and budgeting round for 2016/17. The

Finance & Performance Committee will receive monthly updates on the progress of the planning and budget.

The Governing Body will receive the second draft of the plan at the May public meeting. It is anticipated that this will be the final draft, however any material movements outside the parameters signed off by the Governing Body will be reported to the Finance & Performance Committee with Governing Body being updated in due course via the monthly CFO report.

9. Summary & Recommendations

Appendix 1 details the full summary of the first draft of the CCG budget for 2016/17.

At the time of writing the CCG is planning to deliver a surplus of c£7 million (2%) dependent on the

full delivery of a 2.6% cash releasing QIPP, or £9.1 million.

The Governing Body is requested to approve the parameters of the 2016/17 budget and note this draft of the report, and receive further updates at the next meeting in May, with regular updates via the Finance & Performance Committee.

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Camden CCG First Draft Budget 2016/17 Appendix 1

£000

Description 2016/17

from

Budget

Holders

2016/17

Budget

Proposed

Variance

Baseline Allocation 347,896 347,896 -

Non Recurrent Income - - -

Recurrent Income Better Care Fund 5,975 5,975 -

Return of prior year surplus/deficit 11,039 11,039 -

Running Cost Allocation 5,487 5,487 -

Revenue Resource Limit 370,397 370,397 -

Expenditure

Acute Contracts 151,305 151,305 -

Acute Non Contracted Activity & Re-admissions 7,643 7,643 -

London Ambulance Service 10,923 10,923 -

Acute Total 169,870 169,870 -

-

Mental Health 52,848 51,595 1,253

Learning Disabilities 5,220 5,220 -

Childrens Services 17,618 16,536 1,082

Continuing Care 12,717 12,717 -

End of Life Care 2,917 2,917 -

Better Care Fund 18,049 18,049 -

Community 21,233 21,233 -

Therapies / Connect Contract 2,083 2,083 -

Primary Care (LES, DES, NES & Out of hours) 4,495 4,500 (5)

Quality & Clinical Effectiveness 28,222 28,228 (6)

Older People, Physical Disabilities and Sexual Health 1,247 1,247 -

Non Acute Total 166,648 164,324 2,324

-

Primary Care Programmes 2,178 2,178 0

Mental Health Programmes 3,808 3,808 0

Frailty Programmes 894 894 (0)

CICS 1,585 1,585 -

Long Term Condition Programmes 1,564 1,564 0

Children Programmes 1,430 1,430 0

CIDR Programmes 1,515 1,515 0

Other Commissioning Programmes 2,920 2,920 0

Investment Programmes Total 15,894 15,893 0

-

Running Costs 8,230 5,462 2,769

General Overhead 5,642 7,756 (2,114)

Sustainable Insights/GP IT 3,914 3,844 70

SPG transitional investments - - -

Contingency 1,769 1,769 -

Contingency for Non Recurrent Expenditure (NHSE) 3,539 3,539 -

Total Other 23,094 22,369 725

Total Spend 375,506 372,457 3,049

Surplus/(Deficit) (5,110) (2,061) (3,049)

Surplus Target 7,077 7,077 -

QIPP Required to deliver 2% surplus 12,187 9,138 3,049

Reserves - - -

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Report Title Finance Report Agenda Item 4.2 Date 25/02/2016

Lead Director Ian Boyle,


Report Author Ian Boyle,


GB Sponsor(s) Dr Ammara Hughes Tel/Email [email protected]

Report Summary This paper confirms the month 10 financial position which was considered at the

Finance and Performance Committee on 2 March 2016.



Decision

Recommendation The Governing Body is asked to note the 2015/16 month 10 financial position.


Maintain financial stability and ensure sustainability through robust planning and commissioning of value for money services.


Any major financial risks are highlighted as part of this report.




None

Engagement Not applicable for the purpose of this report.


There are no equality impacts from this report.

Report History The Governing Body receives a Finance Report at each meeting.

Next Steps To be determined by the Governing Body as required.

Appendices None

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Finance Report Month 10 2015/16 January 2016

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Working with the people of Camden to achieve the best health for all 2

Contents

1. Business Headlines January 2016, Month 10. Page 3

2. Acute contract spend analysis Month 10 Page 4

3. Non Acute spend analysis Month 10 Page 5

4. Other CCG Expenditure Variances at Month 10 Page 6

5. QIPP Performance Month 10; YTD £0.2m adverse variance Page 7

6. Risks and Mitigations Page 7

7. Camden CCG Staffing Page 8

8. Summary Page 9

9. Appendices Pages 10-13

Appendix 1 Detailed Summary Appendix 2 Risks and Mitigations Appendix 3 RRL analysis Appendix 4 Detailed QIPP analysis

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1. Business Headlines January 2016, Month 10.

Table 1: Summary

Year to date Full year Forecast

Budget Actual Variance Budget Actual Variance

£000's £000's £000's £000's £000's £000's

Revenue Resource Limit 317,323 317,323 0 381,593 381,593 0

Total Income 317,323 317,323 0 381,593 381,593 0

Acute Spend 143,079 146,147 (3,068) 170,474 169,884 591

Non Acute Spend 133,076 131,795 1,281 159,881 158,035 1,846

Investment Spend 11,533 10,102 1,432 14,151 13,076 1,075

Running Costs 4,650 4,650 0 5,580 5,580 0

Overheads & Contingencies

18,708 18,353 355 23,467 23,978 (512)

Total Expenditure 311,046 311,046 (0) 373,553 370,554 3,000

Grand Totals 6,277 6,277 (0) 8,040 11,039 3,000

Camden CCG has delivered a £6.3 million surplus to Month 10 which is in line with the plan. The year-end forecast surplus has been increased to £11 million. QIPP is now forecasting to deliver fully at year end. NHS England (London Region), have confirmed that this additional £3 million surplus can be drawn down in 2016/17 to fund non-recurrent projects in 2016/17. Business cases have been submitted on this basis.

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2. Acute contract spend analysis Month 10

Table 2: Acute Expenditure

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Provider Plan YTD Spend YTD Variance YTD Plan Full Year Forecast Full Year Variance to Full

Year Forecast Headlines

£000 £000 £000 £000 £000 £000

UCLH 49,689 49,959 (270) 59,495 60,024 (529)

The full year over spend is primarily driven by over spends in Elective £1.2m, Drugs and Devices £0.3m, Diagnostics £0.1m and Maternity £0.01k. This is partially offset by underspend in Critical Care £1.1m and A&E £0.1m. There is a favourable movement of £0.2m since last month as a result of decrease in activity within Elective, Maternity, Diagnostic Imaging and Outpatients.

ROYAL Free 47,579 45,515 2,064 56,968 54,471 2,497

The 2015/16 contract was agreed at £2.5m lower than the budget. The contract value was reduced due to non-payment of CQUINN, £0.8m, Better Care fun £0.7m, change in readmissions £0.4m and QIPP £0.4m.

Barts 1,038 2,202 (1,164) 1,243 2,642 (1,399)

The majority of the over spend relates to additional Cardiac expenditure, transferred from UCLH which is not included in the original budget. This is offset partially by under spends in Critical Care, £1.1m and A&E

Contigency 735 4,975 (4,240) 1,544 147 1,397The contingency was £4.2m overspent YTD. All reserves are expected to be released at year end.

Other 44,773 48,472 (3,699) 52,769 52,747 21

Non-exempt overseas visitors’ costs were forecast to be

£1.0m over spent (UCLH £0.8m and Royal Free £0.2m). NHSE has agreed to pay Camden £7.5m in January 2016 for the prior year, which is lower than the expected £8.5m.

Total 143,079 146,147 (3,068) 170,474 169,884 590

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3. Non Acute spend analysis Month 10

Table 3: Non-Acute Expenditure

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Service Plan YTD Spend YTD Variance YTD Plan Full Year Forecast Full Year Variance to Full

Year Forecast Headlines

£000 £000 £000 £000 £000 £000

Mental Health 42,119 41,783 336 50,543 50,262 280

This is mainly due to the CNWL contract which was negotiated lower than the 14-15 contract value. Additionally there was lower than expected non-contracted activities.

Children's Services 13,755 13,562 193 16,844 16,636 208

Underspend due to lower complex needs and reduced activity in child care packages. In addition the ‘All Together Better’

project was below budget due to a delayed start in the project. Expenditure is expected to increase in the last quarter of the year.

Continuing Care 10,456 10,289 167 12,548 12,348 200Marginal variance offsetting the CNWL SLA overspend in Community.

End of life 2,417 2,273 143 2,900 2,750 150

This was mainly due to delays in the implementation of the Out of Hours Service for Marie Curie and recruitment of nurses.

Better Care Fund 15,142 14,307 834 18,170 16,893 1,277

The Better Care Fund target to reduce non-elective admissions has not been achieved to date resulting in the release of £0.8m YTD performance related payment.

Community 16,549 17,446 (898) 19,858 20,935 (1,077)

CNWL contract was agreed at a higher cost £0.6m and overspends in areas of NCA £0.2m, UCLH Social Workers £0.1m, CLCH £0.05m and Whittington £0.08m. There was an additional YTD cost of £0.3m for an invoice for Community Health Partnership which is under investigation. Adverse movement £0.1m in the forecast due to increased levels of Interpreting and CNWL contract variation for Telehealth.

Therapies / Connect Contract 1,828 1,730 99 2,194 2,030 164The underspend was a result of lower activity in the variable element of the MSK contract with Connect Physical Health.

Quality & Clinical Effectiveness 22,705 22,095 610 27,099 26,186 912

The majority of the underspend was a result of a slower uptake of the drug NOACS, additionally there continues to be an underspend in staffing and training expenditure.

Other 8,105 8,309 (204) 9,726 9,995 (269)

Year to date overspend from Marie Stopes increased activity £0.07m. Additionally there is an overspend YTD £0.1m, on the Out of Hours contract with Care Uk and Audiology AQP.

Total 133,076 131,795 1,281 159,881 158,035 1,846

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4. Other CCG Expenditure Variances at Month 10.

Investment Programmes expenditure YTD £1.4m favourable variance

Primary Care underspent by £0.4m YTD; this is due to a delay in the start of the delivery of the Primary Care mandate, including setting up the GP Federation. Mental Health underspent by £0.6m YTD; this is due to delayed commencement of several investment schemes. Expenditure is expected to increase in the last quarter of the year. CIDR YTD £0.1m underspent: again there is a delay to the project, expenditure is expected in the last quarter of the year. Other investments are £0.2m YTD underspent. The budget covers Homeless Healthcare with St Mungo’s and Lymphedema. Lymphedema services are covered within the St John’s contract within EOLC. In addition the Long Term Conditions programme is underspent by YTD £132k. Again this is due to delays in the commencement of Hypertension and Population Awareness programs.

General Overhead expenditure £0.7m adverse variance

The YTD £0.7m overspend is mainly due to unbudgeted spend on consultancy relating to business case plans and the review of Operational Performance earlier in the year. The full year forecast has been adjusted to reflect a further £0.4m, for projects in respect of Commissioning, MSK pathway Business Case and Out of Hospital PMO support.

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Sustainable Insights expenditure £0.4m favourable variance

The current YTD underspend of £0.4m is due to timing difference in the purchase of hardware and software. This expenditure is expected in the last quarter of the year.

SPG Transitional Investment Variance Nil

The original budget is forecast to be spent in full. £5.6m has been transferred to Barnet CCG in July for BEH/ Royal Free Clinical Strategy. £0.5m has been transferred to Islington CCG in June for the London Transformation Fund. Additionally in October £0.9m was transferred to Enfield CCG for BEHMHT contract. These were in line with the risk share as agreed by the Collaboration Board. The £4.8m is the YTD charge for the remaining £8.5m which is the full year cost.

Contingencies - YTD £0.5m favourable variance

The full year budget is £5.3m with £4.4m committed as the agreed funding for the NCL Risk and Transition Fund.

5. QIPP Performance Month 10; YTD £0.1m adverse variance.

QIPP delivery is marginally behind budget YTD; this is due to the slippage on the MSK business case. The full year forecast is projected to be in line with budget, this is because of increased initiatives in Referral Management, and contractual gains from the negotiation of the Royal Free contract. Detailed QIPP performance is detailed at Appendix 4.

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6. Risks and Mitigations

A detailed analysis of Risks and Mitigations for Month 10 are reported at Appendix 2. All financial risks currently identified are fully mitigated.

7. Camden CCG Staffing

The staff budget is YTD overspent by £0.1m; the budget is expected to be £0.8m overspent by the end of the year. The CCG is forecasting compliance with the running cost allocation.

0

200

400

600

800

1,000

1,200

1,400

Apr May Jun Jul Aug Sep Oct Nov Dec Jan

£000

s

Month

M10 2015/16 YTD Payroll and Contractor Budget vs Actuals

Payroll Budget

Payroll Actual

Contractor & Agency Budget

Contractor & Agency Actual

Total Salary Budget

Total Salary Actual

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8. Summary

Camden CCG is forecasting full delivery of our financial plans for 2015/16. The forecast surplus has increased to £11 million, following the issue on Royal Free reporting previously reported at Month 8. Whilst QIPP is marginally behind plan, the forecast for the year end sees delivery of the full target as per our original plans. The CCG is forecasting full compliance with the running cost allocation.

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Camden CCG Summary Report Between 0-3% Page 10

January 16 Month End Between 3-10%

>10%

Resource Limit Budget Actual Variance Var Rating Budget Actual Variance Var Rating Budget Forecast Variance Var Rating£000 £000 £000 % £000 £000 £000 % £000 £000 £000 %

Baseline Allocation 9,310 9,310 - - G 287,386 287,386 - - G 346,778 346,778 - - G

Non Recurrent Income 0 0 - - G 0 0 - - G 0 0 - - G

Recurrent Income Better Care Fund 5,836 5,836 - - G 5,836 5,836 - - G 5,893 5,893 - - G

Return of prior year surplus/deficit 19,452 19,452 - - G 19,452 19,452 - - G 23,342 23,342 - - G

Running Cost Allocation 4,650 4,650 - - G 4,650 4,650 - - G 5,580 5,580 - - G

Revenue Resource Limit 39,247 39,247 - - G 317,323 317,323 - - G 381,593 381,593 - - G

Expenditure

Acute Contracts 19,586 18,844 742 4% A 127,470 126,516 954 1% G 151,134 151,904 (770) (1%) G

Contingency for Acute Over-performance 26 1,478 (1,452) (5,672%) R 735 4,975 (4,240) (577%) R 1,544 147 1,397 91% R

Acute Non Contracted Activity & Re-admissions 612 1,132 (520) (85%) R 6,157 6,792 (635) (10%) R 7,360 7,396 (36) (0%) G

London Ambulance Service 875 22 853 98% R 8,717 7,864 853 10% A 10,437 10,437 0 0% G

Acute Total 21,098 21,476 (377) (2%) G 143,079 146,147 (3,068) (2%) G 170,474 169,884 591 0% G

G G G

Mental Health 4,212 4,230 (18) (0%) G 42,119 41,783 336 1% G 50,543 50,262 280 1% G

Learning Disabilities 394 393 0 0% G 3,939 3,944 (5) (0%) G 4,727 4,746 (19) (0%) G

Childrens Services 1,401 1,445 (44) (3%) A 13,755 13,562 193 1% G 16,844 16,636 208 1% G

Continuing Care 1,046 1,029 17 2% G 10,456 10,289 167 2% G 12,548 12,348 200 2% G

End of Life Care 242 268 (26) (11%) R 2,417 2,273 143 6% A 2,900 2,750 150 5% A

Better Care Fund 1,514 1,628 (114) (8%) A 15,142 14,307 834 6% A 18,170 16,893 1,277 7% A

Community 1,655 1,719 (64) (4%) A 16,549 17,446 (898) (5%) A 19,858 20,935 (1,077) (5%) A

Therapies / Connect Contract 183 174 8 5% A 1,828 1,730 99 5% A 2,194 2,030 164 7% A

Primary Care (LES, DES, NES & Out of hours) 321 337 (15) (5%) A 3,213 3,334 (121) (4%) A 3,856 4,038 (183) (5%) A

Quality & Clinical Effectiveness 2,273 2,143 131 6% A 22,705 22,095 610 3% G 27,099 26,186 912 3% A

Older People, Physical Disabilities and Sexual Health 95 109 (13) (14%) R 953 1,030 (78) (8%) A 1,143 1,210 (67) (6%) A

Non Acute Total 13,336 13,474 (138) (1%) G 133,076 131,795 1,281 1% G 159,881 158,035 1,846 1% G

Primary Care Programmes 208 164 45 22% R 2,083 1,661 422 20% R 2,500 2,178 322 13% R

Mental Health Programmes 285 300 (15) (5%) A 2,644 2,051 592 22% R 3,214 2,706 509 16% R

Frailty Programmes 97 40 56 58% R 839 783 56 7% A 1,102 1,117 (15) (1%) G

CICS 126 126 (0) 0% G 1,258 1,321 (63) (5%) A 1,510 1,614 (104) (7%) A

Long Term Condition Programmes 205 156 49 24% R 1,920 1,788 132 7% A 2,478 2,440 38 2% G

Children Programmes 94 93 1 1% G 943 963 (20) (2%) G 1,131 1,159 (28) (2%) G

CIDR Programmes 126 172 (46) (36%) R 1,263 1,186 76 6% A 1,515 1,443 72 5% A

Other Commissioning Programmes 58 35 24 40% R 584 348 235 40% R 700 418 282 40% R

Investment Programmes Total 1,200 1,086 115 10% A 11,533 10,102 1,432 12% R 14,151 13,076 1,075 8% A

Running Costs 465 465 0 0% G 4,650 4,650 0 0% G 5,580 5,580 0 0% G

General Overhead 444 325 119 27% R 4,686 5,395 (709) (15%) R 5,580 6,913 (1,333) (24%) R

Sustainable Insights/GP IT 341 216 125 37% R 3,411 2,977 435 13% R 4,094 4,216 (123) (3%) G

SPG Transitional Investments 1,339 1,339 0 0% G 6,181 6,181 0 0% G 8,477 8,477 0 0% G

Contingency 157 157 0 0% G 1,573 944 629 40% R 1,888 944 944 50% R

Contingency for Non Recurrent Expenditure (NHSE) 286 128 157 55% R 2,856 2,856 0 0% G 3,428 3,428 0 0% G

Total Spend 38,667 38,667 0 0% G 311,046 311,046 0 0% G 373,553 370,553 3,000 1% G

Surplus/(Deficit) 580 580 0 0% G 6,277 6,277 (0) (0%) G 8,039 11,039 3,000 37% R

Month YTD Full Year

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Report Title Performance Report

Agenda Item

4.3

Date 22 February 2016

Lead Director Charlotte Mullins, Director

Sustainable Insights

Tel/ Email

[email protected]

Report author Richard Cartwright Head of Performance Carla Viana Performance and Contract Manager

Tel/ Email

[email protected] [email protected]


Dr Ammara Hughes Tel/ Email

[email protected]

Report summary This paper reports on provider performance against the constitutional targets

and highlights the key issues for the Governing Body’s consideration.



Decision



Commission the delivery of NHS Constitutional rights and pledges Improve the quality and safety of commissioned services


These are identified within the report.


There are no direct implications

Engagement



There are none arising from this report.

Report History This report is a standing item on the Governing Body agenda.

Next Steps None

Appendices None

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• The report includes the latest nationally verified data available.

Monthly Performance Report

Updated and released in February 2016

290 of 443

2

ContentsDescription Page

Executive Summary…………………………………….. .. 3

Executive dashboard YTD and latest month……………………………………. .

4-5

18 weeks RTT incomplete Pathways summary………... 6

Diagnostics summary ……………………………………. 7

Cancer overall Actions and progress…………………… 8

2 weeks Cancer waits summary……...………………… 9

31 day Cancer waits summary……...…………………. 10

62 day Cancer waits summary……...…………………. 11

A&E summary……………………………………………... 12-13

LAS summary ……………………………………………. 14

Quality ……………………………………………………... 15-16

IAPT summary……………………………… 17

Appendix 1…………………………………………………. 18

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Report release & latest update

• This monthly report is released in February 2016.• The report was last updated on 22 February 2016, all available intelligence (published and or provisional) known up until this date was included in this report for insight and planning purposes.

Audience • Camden CCG Finance and Performance Committee• Camden CCG Governing Body

Update from the previous report

• There is no significant improvement or change from the previous report in the CCG performance position, the areas of good and challenging performance remain the same as reported last month.

Areas of Good PerformanceNo current concerns with the monthly and/or the Year to date position

• 18 weeks RTT Incomplete pathway (See page 5).• 31 day Cancer wait subsequent treatment Chemotherapy and Radiotherapy (See page 10).• 31 day Cancer wait 1st definitive treatment and Subsequent treatment Surgery (See page 10).

Areas of Challenging PerformanceMonthly and/or year to date performance below standard

• 6 weeks Diagnostics waits (See page 7).• Cancer Performance (2 weeks Cancer waits and Breast symptoms; 62 Cancer wait GP referral and Screening). (See pages 9-11)• A&E Performance (See page 12-13).• LAS performance (See page 14).• IAPT performance (See page 17).• Dementia diagnosis (See page 24).

Quality • No patient safety concerns at this stage.(See page 15-16).

Central and North West London Community Services

• CNWL is meeting the majority of KPI's set by Camden CCG in December 2015 (See appendix 1, page 31).

CCG Performanceteam update

• Richard Cartwright was appointed as Camden CCG Head of Performance. • Camden Operational Performance group (CPOP) continues to meet weekly to discuss latest performance issues that affect Camden CCG.• Weekly briefings prepared for executive team to support phone call with NHSE regarding cancer performance. • Attendance of UCLH weekly RTT/Diagnostics and monthly Cancer quality/performance meetings. • The team prepared papers to support the executive team in the quarterly assurance meeting with NHSE on 17 th February.

Data Sources • The main data sources used in this report are Month 10 2015/16 Integrated Contract Monitoring Report (CSU) and additional intelligence by Camden CCG. See appendix 1 for detailed data sources and data availability.

• The following data is always provisional for the CCG and subject to change, due to the data source timetable: RTT incomplete 18 weeks, 6 weeks diagnostic waits and over 52 weeks incomplete waits. Provisional data will be updated with published data in next month’s report.

• A&E performance for Provider is provisional for the latest available month, since this is the based on provider submitted reports. Provisional data will be updated with published data in next month’s

report.

3

Camden CCG – Executive Summary Performance, February 2016

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Camden CCG Performance and Quality Dashboard YTD

• This scorecard contains Camden CCG monthlyperformance from May 2014 to the latest monthwhere published data is available. The scorecardalso includes 14/15 year end and 15/16 year to dateposition.

• The A&E CCG Performance shown above is basedon the AE Quality Premium calculation, which isderived from data mapping (HES figures) providedby NHS England. This calculates what proportion ofeach provider’s activity can be attributed to a givenCCG. Any activity under 1% is ignored. The totalnumber of attendances is divided by the total numberof 4 hour breaches over a 52 week period is used tocalculate an overall percentage for the year.

4

A&E A&E All Types Performance 95.6% 96.2% 95.8% 95.5% 95.5% 94.96% 95.4% 93.2% 92.7% 95.9% 95.8% 95.1% 96.8% 97.1% 97.5% 96.3% 95.9% 94.9% 94.4% 92.2% 95.7% 95%

18 Weeks RTT Admitted 89.1% 87.3% 87.8% 88.5% 84.7% 86.5% 87.9% 87.7% 86.4% 87.6% 88.0% 87.3% 87.9% 86.8% 89.0% 88.9% 91.1% 83.7% 81.7% 84.4% 87.26% 86.4%Previously

90%

18 Weeks RTT Non-Admitted 95.7% 95.4% 96.3% 95.1% 94.7% 94.0% 94.7% 94.8% 95.1% 96.1% 95.9% 95.3% 96.7% 94.8% 95.3% 95.4% 95.0% 94.5% 94.7% 94.0% 95.08% 94.98%Previously

95%

18 Weeks RTT Incomplete Pathways 91.1% 89.9% 90.0% 90.6% 91.0% 90.1% 91.6% 91.5% 93.1% 93.6% 93.8% 91.4% 94.7% 92.4% 92.9% 92.7% 92.1% 92.5% 92.8% 92.2% 91.00% 92.6% 92%

6 Weeks Diagnostic Waits 97.2% 97.7% 97.5% 96.3% 97.1% 98.1% 98.2% 97.0% 95.0% 96.4% 97.1% 97.0% 97.5% 97.1% 97.4% 97.0% 96.2% 97.5% 97.3% 96.7% 96.84% 97.08% 99%

2 Week Cancer Wait 95.7% 93.6% 96.1% 94.7% 95.4% 96.6% 96.0% 97.5% 96.1% 98.0% 96.5% 96.0% 93.3% 95.6% 93.9% 95.5% 94.4% 93.2% 92.2% 92.4% 93.83% 93%

2 Week Cancer Wait:Breast Symptoms

95.1% 96.8% 96.9% 95.5% 94.5% 96.3% 89.0% 88.1% 95.8% 95.9% 97.6% 94.8% 97.3% 99.0% 96.3% 96.8% 96.1% 90.1% 70.1% 64.2% 89.35% 93%

31 day Cancer Wait:1st definitive treatment

100.0% 98.1% 95.5% 100.0% 100.0% 98.0% 97.5% 98.0% 100.0% 96.0% 98.1% 98.4% 97.2% 92.9% 96.2% 98.6% 94.8% 93.8% 100.0% 98.2% 96.44% 96%

31 Day Cancer Wait: Subsequent treatment (Surgery)

83.3% 90.9% 100.0% 100.0% 80.0% 100.0% 100.0% 66.7% 100.0% 100.0% 100.0% 95.8% 87.5% 87.5% 90.0% 90.0% 100.0% 100.0% 92.3% 100.0% 93.42% 94%

31 Day Cancer Wait: Subsequent treatment (Chemotherapy)

100.0% 100.0% 100.0% 100.0% 100.0% 96.2% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00% 98%

31 Day Cancer Wait: Subsequent treatment (Radiotherapy)

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 90.9% 100.0% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0% 100.0% 94.4% 100.0% 100.0% 99.35% 94%

62 Day Cancer Wait: GP Referral

77.4% 95.5% 81.8% 75.0% 76.2% 75.9% 91.3% 81.3% 83.3% 82.6% 82.1% 81.3% 75.0% 85.1% 88.5% 84.9% 72.7% 79.1% 76.9% 77.4% 80.00% 85%

62 Day Cancer Wait: Screening service

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 66.7% 100.0% 100.0% 100.0% 100.0% 100.0% 96.30% 90%

62 Day Cancer Wait: Consultant Upgrade

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 92.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00%No

Threshold

MRSA reported infections 0 0 0 0 0 3 0 0 0 0 0 3 0 0 0 1 1 0 0 0 2 0

C. difficile reported infections 6 6 9 11 10 6 13 8 15 12 2 105 15 11 3 5 10 8 5 6 63 0

Mixed Sex Accommodation (MSA) (Number of breaches)

2 3 1 4 2 8 3 5 2 6 2 38 1 2 2 1 1 0 6 2 4 19 0

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2014-15YTD

2015-16 Target

Jul-14 Aug-14 Sep-14 Oct-14May-14 Jun-14Theme KPI / Measure Feb-15 Mar-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15Dec-14Nov-14 Jan-15 Apr-152015-16

YTDMay-15 Jun-15

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Camden CCG Performance and Quality Dashboard – Latest Month

5

Key:

Performance

Performance is above Target

Performance is below Target

Target does not apply to CCG ORProvider.

Arrows indicate

improvement or

deteriorating performance

on the previous month

CCG Performance is achieved(green rag rating for the period ifthe value attained for that period isabove target) or in some caseswhere there is zero tolerance (i.e.MSA, C.difficile) if the CCG doesnot exceed the agreed threshold.

Performance Trend Performance Trend

RTT Incomplete < 18 Weeks Dec-15 91.00% Dec-15 93.46% 86.67%

Diagnostic Tests < 6 Weeks Dec-15 96.84% Dec-15 93.60% 96.56%

> 52 Weeks waits Incomplete Dec-15 1 Dec-15 0 12

2 Week Cancer Wait Dec-15 92.90% Dec-15 84.70% 96.10%

2 Week Cancer Wait:Breast Symptoms

Dec-15 74.00% Dec-15 11.90% 93.70%

31 day Cancer Wait:1st definitive treatment

Dec-15 100.00% Dec-15 97.00% 98.10%

31 Day Cancer Wait: Subsequent treatment (Surgery)

Dec-15 100.00% Dec-15 96.20% 100.00%

31 Day Cancer Wait: Subsequent treatment (Chemotherapy)

Dec-15 100.00% Dec-15 100.00% 100.00%

31 Day Cancer Wait: Subsequent treatment(Radiotherapy)

Dec-15 100.00% Dec-15 100.00% 100.00%

62 Day Cancer Wait: GP Referral

Dec-15 81.80% Dec-15 67.40% 75.00%

62 Day Cancer Wait: Screening service

Dec-15 75.00% Dec-15 50.00% 98.00%

62 Day Cancer Wait: Consultant Upgrade

Dec-15 100.00% Dec-15 85.0% 70.6%

A&E 4 Hour Waits Nov-15 92.17% Jan-16 (unvalidated)

88.39% 89.89%

CAT A Ambulance 8 mins (London Wide LAS) - Red 1 Dec-15 72.80% 75%

CAT A Ambulance 8 mins (London Wide LAS) - Red 2 Dec-15 65.90% 75%

Ambulance Handover 15 Mins Dec-15 37.40% 26.90%

Dec-15 91.40% 87.30%

UCLH Royal Free

C.Diff Dec-15 5 Dec-15 5 4 zero

tolerance97 66

MRSA Dec-15 0 Dec-15 0 0

VTE Assessments Sep-15 94.48% 96.37%

Mixed Sex Accommodation Dec-15 4 Dec-15 12 12

IAPT (Access to Service) Q3 15/16 3.98% Q3 15/16 3.58% 3.75%

IAPT (Moving to Recovery) Q3 15/16 46.58% Q3 15/16 44.82%

UCLH

Reporting Month

Camden CCG TrendReporting

Month

Reporting Month

UCLH

50%

Reporting Month

93%

Camden CCG Performance Main Providers Performance

Reporting Month

UCLH

Royal FreeCamden CCG Trend Trend

Trend

UCLH Royal Free

Camden CCG Trend

Ambulance Calls and HandoverReporting

MonthCamden CCG Trend

Area/ KPI

Royal Free CCG

CCG

IAPTReporting

MonthCamden CCG Trend

Reporting Month

CIFT (iCOPE) CCG

Cancer WaitsReporting

Month

98%

94%

18 weeks Referral To Treatment and Diagnostics CCG Provider

Target

92%

zero tolerance

99%

zero tolerance

zero tolerance

95%

85%

90%

93%

96%

94%

CCG

Area/ KPI Camden CCG Performance Target

Trend

Trend

Trend Trend

Main Providers Performance

Provider

Provider

Provider UCLH Royal Free

A&E Reporting

Month

Provider Annual threshold

95%

CCG Quality Reporting

MonthCamden CCG

TotalTrend

Reporting Month

Trend Royal Free Trend

Provider

2.45%

Trend

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KPI Latest Position Key Issues Key Actions Progress

RTTIncomplete pathways

Monthly positionDecember (91%)

Rating: RED

Year to date YTD

position(92.6%)

Rating: GREEN

Target 92%

RTT incomplete Pathways• The CCG position has been

consistently above the standard in15/16 however In December 2015the CCG did not achievecompliance of the incompletestandard driven by the Royal Freeperformance.

• UCLH maintained performanceabove the standard throughout thisyear including the month ofDecember 2015 however the RoyalFree has failed the incompletestandard continuously since May2015 to date.

• Royal Free resumed nationalreporting in May 2015 following asystem review and PTL validation.The trust are managing the backlogthrough extra internal capacity andoutsourcing.

Over 52 weeks waits Incomplete• In December, Camden CCG had 1

over 52 week waiter at the RoyalFree. Camden CCG is awaitingresponse from the Royal Free toconfirm if this patient has now beentreated.

At UCLHUCLH is achieving against the incomplete standard.

The trust has reported a non-admitted backlogabove sustainable levels, although this is still withinthe incomplete tolerance.

The specialties of concern are:

• Restorative dentistry – the backlog build up isrelated to an increase in referrals due to changesin services within the sector and patient choice.

• Queens Square – this related to an increase inspinal referrals. The Trust’s performance team islooking at this in a lot more detail.

• Urology – There has been a small increase inwaiters on the non-admitted side, which is mainlyaround a sub-specialty pathway. There were alsosome data quality validation issues overDecember that has increased the number ofwaiters.

At Royal Free

• Royal Free waiting list increased by 1,104pathways in Nov 2015 as a result of PAS/CernerMerger

• In Nov 2015 performance was below trajectoryin Gastroenterology, Dermatology, GeneralMedicine, Gynaecology, Neurology and Oralsurgery.

• The impact of long waits on clinical harm isreviewed as part of the CQRG process includingRoot Cause Analysis.

At UCLH• Restorative Dentistry – UCLH is in

conversations with NHS England to establish asystem resilience group, to help manage theextra demand for acute dental work.

• UCLH choose and book team is meeting withCamden CAS team, this month to review ENTat the end of January and then Urology inFebruary. Neurology, ENT and T&O are stillchallenged in terms of slot issues.

• Camden CCG has requested for the Trust tolook into how it could best notify patients oftheir constitutional rights to be seen within 18weeks and what they are entitled to do ifwaiting over 18 weeks. UCLH is looking atalternative methods of informing patients otherthan in letters, which were recently redesigned.

At Royal Free• Barnet CCG issued a Contract Performance

Notice on 31st July 2015 requesting a Demand& Capacity Plan and specialty levelperformance trajectories.

• Royal Free produce a monthly report includingperformance detail by specialty and CCG andincludes outsourcing activity that underpins thetrajectory. Barnet CCG review and share thisreport with Associate CCGs.

• The RTT contract variation is complete.

• Barnet CCG Task & Finish Group to reform tomonitor the action plan and trajectories. Termsof Reference and membership have beendrafted, meeting to commence in Feb 2016.

At UCLH• UCLH is meeting the incomplete standard

• A Contract Query Notice that was issued on 3rd July2014 is closed. UCLH has successfully met theincomplete target, since Nov 2014 and the RTTdashboard has now been agreed and is populatedweekly.

At Royal Free• RTT performance was below trajectory by 1.28% in

Nov 2015 due to PAS/Cerner Merger, backlogincreased due to duplicate pathway amalgamation.

• The Trust increased capacity through Waiting ListInitiatives, insourcing and outsourcing to reducebacklog as a result of PAS/Cerner merger.

• The Derm IS tariff has been renegotiated and anincrease in outsourcing is expected in Jan 2016.

• Outsourcing referrals have decreased in Dec 2015that may impact on activity levels for Jan/Feb 2016.This will be raised at the Task & Finish Groupmeeting.

Over 52 weeks waits

Incomplete

Year to date YTD

December (1)Rating: RED

Target: Zero tolerance

6

Camden CCG 18 weeks RTT incomplete Pathways

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KPI Latest Position Key Issues Key Actions Key Camden CCG actions Progress

DiagnosticsTests under 6

weeks

Monthly positionDecember(96.84%)

Rating: RED

Year to date YTD

position(97.1%)

Rating: RED

Target 99%

• Camden CCG continues to fail thisstandard in December, monthlycompliance has not yet beenachieved in 2015/16. The CCGperformance is driven byperformance at UCLH and theRoyal Free trusts (both providershave failed the diagnosticsstandard in the last 12consecutives months, up toDecember).

• On the 5 February, UCLHconfirmed to Camden CCG that anadditional backlog of 577endoscopy patients had beendiscovered by the Trust and asconsequence compliance can onlybe achieved in June 2016.

• UCLH submitted a revisedtrajectory (recovery by June 2016)on the 19 February however thisas not been accepted by CamdenCCG. Ongoing weekly meetingsare in place.

• Royal Free continues to bemonitored against a recoverytrajectory. Compliance will not beachieved until January 2016.

Due to the normal reporting timetable, December’s

detailed analysis was not available at the time thisreport was produced, only the overall position. Theissues reported here relate to November's position.At UCLH

The Trust is not meeting the diagnostics target.

• Endoscopy: UCLH has specified that the mainreasons for the endoscopy backlog (additional577 patients) were:

o High demando lack of trained endoscopy nurses;o staffing feeling over worked (a lot of

weekend lists)o delays in outsourcing to Whittington

and delay in the movement ofcystoscopy suite to WestmorlandStreet (which will release 4 lists perweek).

• Endoscopy compliance was behind plan inNovember because the move of cystoscopy toWestmoreland street has been delayed to theend of January, due to equipment that need to beordered. The move will free up internal capacityfor 3 additional lists in endoscopy.

• MRI: UCLH has flagged up an issue with theQueen’s Square MRI scanner, which was givento the Neurosciences division via a research bid.It has to be serviced in the next few weeks andthe work will take 6 weeks. This cannot bepostponed as it has to be completed by year end.

• Echocardiography –The service is workingthrough the small backlog within this area

At Royal Free• Performance remains below standard in

November 2015 (and December). Performancewas 0.87% below agreed diagnostic trajectory.

• Ultrasound scan waiting list increased to 2.9% inNovember from 0.3% in October 2015. Theincrease in Ultrasound is due to inappropriatereferrals from GPs.

• All endoscopic modalities performance improvedexcept for Flexi Sigmoidoscopy.

• The Trust needs to make significant strategicinvestment to deliver in JAG (Joint AdvisoryGroup) standards for Bowel Screening.

At UCLHMRI - Trust plans to mitigate the servicing of the MRIthrough:

• Use of UCH Tower scanner - Some of theQS work is transferable, however thereporting is non-transferable and Trust mayhave to pay consultants for extra sessions.

• There is the option of using another MRIscanner in QRIC sports institute onTottenham court road.

• The Trust plans to clear the MRI backlog by end ofJanuary, with 48 additional slots per week. There isconfidence in clearing the backlog, but Trust is aware ofthe risk of having a scanner down.

• Endoscopies – It has been confirmed that theCystoscopy move is going ahead at the end of thismonth. This will provide an additional 4 sessions perweek, which were originally meant to be in January butnow will be available in February.

• Echocardiography – UCLH has sufficient internalcapacity to treat any backlog by end of January.

• Sleep studies – The Trust is doing further serviceimprovement work to reduce the backlog number withinthe inpatient part of the service. However the backlognumbers in the service are so small that they will havelittle to no impact on the total Trust diagnosticsperformance.

At Royal Free• Recovery actions form part of the Royal Free Cancer

CQN (Dec 2014) and Exception letters. The trajectory recompliance has been re-agreed following Royal Free andNHS IMAS modelling to Jan 2016.

• Royal Free recovery is un progress with insourcing,outsourcing and increased service provision to managethe backlog and deliver sustainability.

• NHS E held a workshop in Dec 2015 and January 2016for all provider to take part in London Demand andCapacity Review Project

• Causes of the increase in waiting list for ultra sound wasdiscussed at the PRG meeting in Jan 2016. Membershiphas been agreed to form a Task and Finish group tofocus on demand management. First meeting date to beconfirmed in February 2016.

At UCLH• CQN issued 12.02.2015.• February 2015 recovery action plan with agreed

improvement for April 2015 and a trajectory wassubmitted by UCLH.

• Ongoing RTT and Diagnostics bi-weeklyperformance meetings have been in place sinceMarch 2015 (UCLH, CCG and CSU).

• On 11th January 2016 further slippage on recoverywas communicated by the Trust and recovery is nowexpected in February 2016. In response to thechange in the timescale for regaining complianceCamden CCG has sent an Exception Letter to theTrust on the 8 February 16. The following additionalactions are expected to be completed, inline with theProvider Performance Framework:

o Revised Diagnostic Recovery Action Plan– CCG will monitor against this on aweekly basis.

o Revised endoscopy recovery trajectory –

CCG will monitor against this on a weeklybasis.

o Enhanced performance monitoringo Weekly monitoring meetings until

compliance – CCG lead meeting withTrust performance team and divisionalleads for failing modalities.

o Clinical discussion with key specialitieso Feedback to other for a – (e.g. CRG,

CQRG)

• Following UCLH communication on the 5 February,where the Trust confirmed that an additional backlogof 577 endoscopy patients had been discovered bythe Trust and as a consequence compliance can onlybe achieved in June 2016.

o Camden CCG raised a Serious Incidentnote including request for cause analysisand any clinical harm that has arisen fromthis.

o At the quarterly assurance meeting withNHSE on 17 February 2016 CamdenCCG as formally requested support fromthe tripartite (Monitor) to tackle theongoing performance issues at UCLH.

At UCLH• On the 5th Feb the Trust informed the CCG

of further delays on achieving Trust levelcompliance, due to issues in endoscopies.The revised compliance date is 13 June2016.

• CQN was issued on 12 Feb 2015.

• Action plan is reviewed as part of the jointRTT and diagnostics meeting with the Trust.

• The CCG, sent an exception letter has beensent to the Trust on the 8th February.

At Royal Free• MRI, Peripheral Neurophysiology, Dexa Scan

and audiology recovered to 100% inNovember 2015 but waiting list increased inFlexi sigmoidoscopy and Ultrasound.

• An extended RF(L) consultation process for 3sessions days and weekend working isimpacting on progress. Consultant job plansare still under review. Patient choice andshortages of staff are also quoted ascontributing to underperformance. Thesetogether will impact on delivery of complianceby Jan 2016

• Cystoscopy capacity increased to 30 slots perweek since November 2015

• The Trust has planned to increase endoscopycapacity to provide an additional 168 slots perweek. 114 slots per week have already beendelivered through insourcing and outsourcingin Jan 2016

• Barnet CCG, NELCSU and RF attended twoworkshops held by NHSE in December 2015and January 2016 on Demand and capacityanalysis .

• Royal Free will complete demand andcapacity analysis and will submit to NHSE tosupport London Demand and Capacity reviewproject.

7

Camden CCG Diagnostics waits under 6 weeks

296 of 443

KPI Key Actions Key Camden CCG actions Progress

CancerOverall

PerformanceDecember

At UCLH• Breast symptomatic 2 week wait capacity – the Trust

confirmed that the 2 members of staff who were on sick leavewill return to work in January 2016 and therefore thedepartment returns to full capacity. The backlog will becleared by March 2016.

• RCAs – are being sent directly to CSU lead and CCG clinicalcancer lead prior to the monthly meeting to enable him topre-review them.

• 62 day capacity – UCLH has outsourcing arrangements inplace for a few of the Tumour groups that are meeting the 62day standards.

• 31 day (1st Treatment) – The Trust has highlighted apotential risk of compliance to this target due to HIFUtreatment pathway. However the risk is mitigated with alocum consultant covering whilst a substantive consultant isbeing recruited.

At Royal Free• A CQN was issued in Dec 2014 and subsequent exception

letters requiring additional assurance were sent. 10 % of thecontract value was initially withheld. The CQN will remainopen until the standard is met.

• Under activity and PAS/Cerner merger and data validationissues mean that it is now likely that delivery of trajectory willbe re-set to March 2016.

• Barnet CCG requested further assurance in December 2015on Cancer and RTT, Royal Free was ask to providebreakdown of PTL by CCG, long waiters next planned eventand reason for long delays by Practice and by CCG.

• Extensive data validation exercise is underway. RF(L) areexpected to upgrade their data warehouse by the end of Jan16. Improvement in data quality will be seen from Feb 2016.

• 62 day Screening target failed due to 3.5 breaches whichoccurred in the Breast screening pathway referred fromEdgware screening services. The main reasons for breacheswere complex pathways, inter referrals delays and patientchoice. RF(L) are proactively managing the pathway andremain confident to meet Q3

At UCLH• CQN issued 22.12.2014 for 62 day performance breach

• Ongoing monthly Cancer Quality Requirements meeting with UCLH, CSU and CamdenCCG since December 2014

• 1st Exception letter 17.07.2015 issued to the Trust to address 62 day performance with anadditional concern for 31 day performance breaches, and flagging 2week wait risks.

• 2nd Exception letter 25.11.2015 issued to the Trust, formalising the 2 week wait issues.

• Camden CCG has set up an internal performance operational group in January 16. Thisgroup discusses CCG acute performance management issues, decisions and actions on aweekly basis led by the CCG Chief Financial Officer.

• Camden CCG has completed a detailed review of the UCLH Cancer recovery plan in thefirst week of February 16 and some improvements have been identified which areapplicable to all cancer standards. The CCG will discuss with UCLH and request for these tobe amended as soon as possible.

• UCLH breast service was requested by CQRG in February 16 to provide businesscontinuity plans, this is expected to be delivered to CQRG in May 16.

• Camden GP practices were informed in February 16 (and previously in November15) of theissues within UCLH breast service and were advised that due to the longer waits, if thepatient preferred they could be referred to alternative providers.

Next StepsIf UCLH performance does not improve as per the agreed trajectory and due to sustained poorperformance Camden CCG will consider taking the following actions (applicable to 2 weeks,2weeks breast symptomatic, 31day 1st treatments and 62day GP referral cancer standards):• Clinician to clinician discussion or CCG Board challenge session with provider• Ascertain bespoke governance arrangements e.g. peer to peer review with clinical leads

and/or facilitate Chair to Chair meetings• Apply contract levers including withholding of funds• Monitor progress against the Trust’s remedial action plans and trajectories, including setting

key milestones for recovery• Risks to recovery/mitigations in place• Lack of resilience and continuity planning in tumour site services with a high impact on

standard performance. UCLH have been asked to produce continuity plans In FebruaryCQRG, this should be delivered by May 2016.

• Existing breast service backlog, the Trust continues to work to clear this through extraclinics that have been put in place.

At UCLH• Cancer 2ww and Breast Symptomatic – Recovery planned for March 2016.

• Cancer 31 day - UCLH has confirmed compliance with these standards byJanuary 2016.

• Cancer 62 day – Trust confirmed an internal compliance to the target byMarch 2016.

• Quarter 4 compliance for Total Trust is related to Royal Free London, Bartsand Barking Havering and Redbridge Trust, being compliant with their targetsand sending inter trust transfers prior to day 42.

• UCLH has been sent a CQN (December 2014) and two exception letters(Aug 15 and November 15), relating the poor cancer performance across the8 standards. In response to this correspondence the Trust sends a weeklyCancer PTL tracker, listing all patients with open pathways, with anonymisedtracking notes. A CCG clinical representative will also attend a weekly Trustcancer PTL meeting to raise queries.

• Progress with the action plan is reviewed in a monthly meeting with the Trust,by NEL CSU, CCG and NHS E. (See Contractual Notices/ Queries Sectionfor more detail)

At Royal Free• Royal Free performance in Nov 2015 linked to under activity (41 pathways

lower than planned). It is expected that the performance will further dip inDecember 2015 as RF(L) due to catch up with the activity lost in Nov 2015.

• RF(L) has put plans in place to rectify data quality issues, meeting withoperational leads are being held. Backlog clearance model and monitoringtool has been develop to review weekly progress.

• Regular monthly meeting held between RF(L) and BCCG to review progressagainst Cancer RAP and any operational issues.

• Regular weekly detailed PTL including performance data and 100 dayreports are being received from Royal Free now broken down by CCGincluding TCI, these are reviewed by BCCG and shared with AssociateCCGs with update analysis by NEL CSU.

• Barnet CCG attended assurance meeting on the 7 January 2016 to discussperformance issues with NHSE

Camden CCG Overall Cancer Performance - Actions and progress

8297 of 443

KPI Latest Position Key Issues

2 weeks GP referral

Monthly positionDecember (92.90%)

Rating: RED

Year to date YTD

position(93.72%)

Rating: GREEN

Target 93%

• Camden CCG has not achieved both 2 week waits standards inDecember driven by the poor performance seen in UCLH,particularly for breast symptoms.

• Royal Free achieved both 2 weeks standards in the last 3consecutive months (October to December 2015).

• The CCG is currently investigating ways in which waiting times canbe conveyed directly to GPs so that patients can make an informedchoice about where they would like to be referred.

At UCLH

2 week (urgent GP referral)• The threshold was 64 breaches this month and the trust failed this standard by a margin of 77 breaches. The

greatest volume and majority of these were in the breast tumour site (the standard would have been failed onbreast breaches alone).

• Breach reasons were submitted as follows:Patient Choice - 47Patient Unfit - 1Capacity - 83Admin Issue - 10

• Breast capacity clearly impacted performance this month and the trust would not have exceeded the thresholdthrough all other tumour site performance.

2 week breast symptomatic• The trust failed this standard by a significant margin, exclusively due to capacity (74 breaches due to capacity).

2 weeks Breast Symptoms waits


Rating: RED

Year to date YTD

position(89.4%)

Rating: RED

Target 93%

Camden CCG Cancer Performance – 2 weeks Cancer waits

9

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KPI Latest Position Key Issues

1st Definitive treatment


Rating: GREEN

Year to date YTD

position(96.88%)

Rating: GREEN

Target 96%

31 day 1st definitive treatment• In December 2015, Camden CCG achieved this standard driven by

performance at both UCLH and the Royal Free.

31 day subsequent treatment (Surgery)• This standard was achieved by the CCG in December and the YTD

performance is now also compliant due to the royal Free and UCLHrecovery between October and December.

31 day subsequent treatment (Chemotherapy; Radiotherapy )• Both standards have been consistently achieved by Camden CCG

and by our main providers.

At UCLH31 day (1st treatment)• The trust recovered this standard for the month but narrowly failed the

quarter due to October and November performance.

31 day subsequent treatment (surgery)• Trust was compliant in October and November. Breaches were

exclusively due to capacity reasons and the trust reports they are in theurology tumour site. The trust reports capacity issues with the urologytumour site, robotic capacity have now been resolved can treat patientswithin 31 days.

At Royal Free• All three 31 day standards have been achieved by the trust throughput

15/16.

Subsequent treatment (Surgery)


Rating: GREEN

Year to date YTD

position(94.32%)

Rating: GREEN

Target 94%

Subsequent treatment (Chemotherapy; Radiotherapy)


Rating: GREEN

Year to date YTD

position(100%)

Rating: GREEN

Target 94%

Camden CCG Cancer Performance – 31 day Cancer Waits

10

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KPILatest Position

Key Issues

GP Referral


Rating: RED

Year to date YTD

position(80.0%)

Rating: RED

Target 85%

62 day GP referral• Camden CCG position remains below standard in December

2015 driven by the challenges at both main providers, UCLHand the Royal Free.

• This standard has been challenging for the last 12 months andit was not achieved in any month by UCLH or the Royal Free.

• UCLH has shared 2 trajectory scenarios on the 2 February withNHSE and Camden CCG

o Scenario 1 - Overall Performance by the end of March85.84%, this is a less likely scenario since it assumesa reduction in late referrals not yet verified.

o Scenario 2 - Overall performance by the end of Marchwill be at 62.5% and UCLH internal 85%. This is amore likely scenario since it assumes the current rateof referrals received late in the pathway does notreduce.

• Royal Free expects to recover this standard by the end ofMarch 2016.

62 day Screening Service• Camden CCG failed this standard for the first month in

December driven by UCLH poor performance.

At UCLH62 day (urgent GP referral) standards• This exception continues to occur due to a large number of breaches in the urology, lung, sarcoma, upper GI, breast

and head and neck tumour sites. The operational threshold was 9.5 breaches and the trust failed this by a margin of10.5.Breach reasons are recorded as follows:

o Patient Choice - 1.5o Exceptionally Complex Diagnostic Pathway - 4.5o Capacity - 2.0o Delay in work up - 2.5o Admin Issue - 2.5o Intertrust with no Information - 8.0

• There continues to be a large number of late intertrust transfers with no additional data. However there are asmany other breach reasons combined (this standard would not have been failed for ‘unavoidable reasons’ such aspatient choice).

62 day Screening• This standard was failed due to three breaches in both the breast and lower GI screening pathways, 2 complex

diagnostics, 1 capacity.• This locally agreed threshold was failed for the quarter due to small numbers. In December the threshold

was failed by a single shared breach.

At Royal Free62 day (urgent GP referral) standards• The trust failed this standard by a margin of 10 breaches. This exception is caused by a number of breaches of the

standard in the urology tumour site(one third of all breaches), skin tumour site and a mixture of other sites. Thebreach reasons are as follows:

o Patient Choice – 5.0o Exceptionally Complex Diagnostic Pathway - 5.0o Capacity - 2.0o Delay in work up - 7.5o Admin Issue - 0.5o Intertrust with no Information - 6.5

.

Screening Service


Rating: RED

Year to date YTD

position(96.3%)

Rating: GREEN

Target 90%

Consultant Upgrade


Year to date YTD

position(100%)

Target No target for 15/16

Camden CCG Cancer Performance – 62 day Cancer Waits

11300 of 443

Camden CCG - A&E Performance summary

KPI Latest position Key Issues Key Actions Progress

A&E 4 hours wait

Monthly position

December (92.10%)

Rating: RED

Year to date YTD

position(95.27%)

Rating: GREEN

Target 95%

• Camden CCG has failed the A&Estandard for the last 4 consecutivemonths. Many local trusts andothers providers across Londonhave also been unable to meet theA&E target.

• Camden CCG current YTDperformance remains abovestandard, 95.2% however the poorperformance seen in UCLH andmore recently in the Royal Freecould potentially affect the overallCCG performance at year end.

• UCLH current trajectory is forrecovery by 15 February 2016,however the new Ambulatory Unitopening was delayed until Monday21 February 2016. The Trustupdated the recovery plans toincorporate this potential delaysince January 2016.

• Unvalidated performance forDecember 15 and January 16 atUCLH and the Royal Free does notshow improvement in performance

At UCLH• UCLH has not achieved compliance against

the 4hr standard for the fourth consecutivemonth (up to November). Unvalidatedperformance indicates that the Trustcontinued to fail into December (90.96%) andJanuary (88.39%).

• UCLH failures are related to:o High “walk in” attendances (of over 450 on

some days)o High acuity of patients in A&E, therefore a

busy resus departmento Bed capacity – which causes blockages

out of the department and patients have toremain in cubicles until they can beadmitted to a bed.

o Specialty delays – due to waiting forspecialty teams to attend A&E toreviewing patients, as well as delays inmaking decisions.

At Royal Free• The Trust did not meet the standard in

November 15. Performance wascompromised due to surges in ambulanceactivity at both sites, a lack of bed capacityand an increase in volume of DToC.Unpublished data suggests further potentialfailure in December and January.

• Bed Management, A&E Triage and delay dueto wait for the specialist team including Mentalhealth were the key reasons for breaches inNovember 2015. Exception reports inDecember 2015 also highlighted somestaffing shortages.

• Surge Team raised concerns around a lack ofweekend assurance and clinical leadership toaid performance along with negative bedbalance.

At UCLH• UCLH has submitted a ED action plan and trajectory to

recover performance by 15 Feb 2016. The key elementin the recovery of performance is the implementation ofphase 1 of the AMU new model of care.

• Phase 1 of the AMU new model of care will deliveradditional space for an Ambulatory Care Unit and anEmergency Assessment unit, adjacent to the ED. This inturn will reduce the demand for A&E and hence reducethe pressure on the department.

• The CSU/ CCG is monitoring the Trust’s recoveryagainst the trajectory, which is currently not being met.The trajectory provided is broken down by breach reason(i.e. ED delays, bed delays).

At Royal Free• On 27 January 2016 Barnet CCG emailed the Chief

Operating Officer at Royal Free and requested anoperational plan to be shared with the CCG. Seniorexecutive discussions on the issues and actions havetaken place.

• Barnet CCG escalated to Herts via SRG to Herts ValleyCCG for social care capacity issues which are affectingdelays in discharges at Royal Free.

• Increased GP Out of Hours Service, covering theweekend operational since 11 December 2015.additional capacity is being considered by Barnet CCG totest various model i.e. GP based in acute site/ vicinity ofA&E GP Practice, St. Thomas Model, slots bookabledirectly from ED etc.

• Contract Variations agreement for Resilience schemeare in progress.

• A Weekly Action Group with system representation hasbeen set up to review progress on admission avoidance,delays discharges and unplanned admissions.

• Surge calls for bed predictions and actions continuedwith Trusts and CCGs and NHS E hosted by NEL CSUSurge Team.

At UCLH• The CCG/CSU has requested to attend the Trust’s

internal Urgent Care Transformation group, to betterunderstand the issues and the actions to recoverperformance.

At Royal Free• Weekly progress report on key actions is shared with

NHSE.

• East of England Ambulance Trust now have a formaldivert in place as a result of Barnet CCG escalation viaSRG. Royal Free are now cited on AmbulanceConveyances.

• 4 calls in place a day between LAS and the Trust tomanage ambulance flow.

• Escalation and capacity framework to support earlydischarges have been completed and due to be signedoff at the SRG in February 2016.

• 10 additional Care Home beds for non-weight bearing,rehab and enablement are now operationalcommissioned by Barnet CCG

• Enhanced Rapid Response team 7 days a week is inplaced since November 2015 to assist with unplannedadmissions.

• An update on Contract Variation progress was tabled atthe SRG Meeting in January 2016, 3 of the 6 recurrentschemes are signed off. This includes opening 25enablement beds at Royal Free and employment of thedischarge coordinator.

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Camden CCG - A&E Performance summary

KPI Camden CCG actions

A&E 4 hours wait


Rating: RED

Year to date YTD

position(95.27%)

Rating: GREEN

Target 95%

At UCLH• Current trajectory is for recovery by 15 February 2016. However the new Ambulatory Unit opening was delayed until Monday 21 February 2016. The Trust updated the recovery plans to

incorporate this potential delay since January 2016.

• UCLH A&E recovery plan is managed through SRG and the plan was last reviewed on 20th January.

• Camden CCG SRG Chair, Matthew Clark met with the UCLH Divisional Clinical Director for Emergency Services on 3 February 2016 regarding the redesigning of UCLH emergencydepartment and pathways to cope with the pressure the Trust are under.

• Camden CCG are reasonably assured with UCLH recovery plans. The plans are operational and system focused, rather than focusing on expensive specialist care, there is a clearrecognition that most of the patients are low acuity and need to be managed accordingly.

• UCLH commitment to redirect patients to self-care/primary care and embedding ambulatory care within the emergency department fit particularly well with the CCG's ambition to moveactivity out of acute providers, providing better and cheaper care. It is our expectation that the new models of care will allow UCLH to recover and achieve the 4 hour target.

• Following the review of the A&E deep dive (completed by the CSU) two main actions will be followed by Camden CCG:• Scheduling of the A&E clinical audit at UCLH (last audit took place in August 2015)• Analysis of Camden GP practices that have a higher than average proportion of A&E attendances.

Primary Care update• Camden CCG have commissioned a Saturday service from the GP Federation. The Federation is delivering services in a phased manner to ensure that patients experience safe, high

quality care. Service delivery started at the beginning of February with routine appointments for patients living in the South of the borough. It is expected Saturday services will be availablein the North and West of the borough by June/July 2016.

• From August 2016 the Federation will also provide services from 4pm till 8pm. This service will also provide same day access for patients appropriately redirected from the EmergencyDepartment (ED). The CCG is currently planning the logistics of this service with the ED team in UCLH. Future conversations will include redirection from the Royal Free hospital as well.

• In December the CCG approved the investment of £250,000 in general practice. This investment was to give practices the opportunity to access extra capacity (the equivalent of 14,000extra appointments) between December and March in order to address the issue of winter pressure on GPs. There is an expectation that the extra capacity will have an impact on A&Eattendances, however we have not had access to A&E data to corroborate this as yet

Next Steps

UCLH A&E monthly performance has not been met since August 2015 to date. Camden CCG will consider the following contractual steps if performance is not achieved by the agreed date,including the issue of a contract performance notice and the application of contractual levers including withholding of funds.

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Camden CCG LAS Performance

14

KPI Latest position Key Issues Key Actions Progress

Category Red 1(8 minutes)


Rating: RED

Year to date YTD

position(67%)

Rating: RED

Target 75%

• Camden CCG performance remainsbelow the standard in December 15.LAS poor performance is an issue thataffects the majority of CCGs and acuteproviders across London.

• NCL is taking a much more ‘hands on’

approach to the LAS contract, managedby Brent CCG. Internal CSU/Commissioner meetings now take placemonthly and we are working on providingmuch more robust direction to BrentCCG as lead commissioner for LAS..

• There were 1,803 conveyances to anEmergency Department in December.868 conveyances within Camden went toUCLH and 695 to Royal Free. Thisequates to 86% of all ambulanceconveyances from Camden to anEmergency Department Care Pathwaylocation.

At UCLH• Handover Overrides (activated when the

Emergency Department has not receivedthe pin number regarding agreed handovertime from LAS) at UCLH were 22.9%,marginally above the London average of21.2% in December 2015.

At Royal Free• LAS handover performance has improved

in-month but is still not achieving therequired standards.

• In Dec 2015 there were 143 (+7 fromprevious month) 30min LAS handoverbreaches and 27 (+13 from previousmonth) 60mins breaches at Hampsteadsite. There were 238 (+53) 30minsbreaches confirmed 124 (+58 fromprevious month) 60minutes breaches atBarnet Hospital.

• The 30 and 60 min handover breachesincreased in Dec 2015, particularly atBarnet site.

• At the Royal Free site there are issuesrelating to physical design of thedepartment which contribute to handoverdelays this will be improved when the newbuild is complete due in Autumn 2016.

At UCLH

• LAS Handover within 15 mins: over the 4 months, UCLHhas been using an iPAD at RATing. With this technology,UCLH is still seeing improvements - of over 22% and acontinuing higher percentage of handovers completed in 15mins.

• For December 2015 handovers, the Trust challenged 52 outof 177 Thirty Minute handover breaches - a significantreduction from April 2015, which had no challenges of atotal of 101 Thirty Minute breaches. There were fifteen 60minute breaches in December r 2015 at UCLH, and fourwere challenged by the Trust.

At Royal Free

• Performance issues and a request for an operationalrecovery plan to improve LAS handovers was requested aspart of A&E performance improvement.

• Intelligent Conveyancing (IC) continues to be in place forLAS aiming to avoid ambulance queuing that impacts onhandover performance and A&E performance.

• At Royal Free site, work is in progress for majorredevelopment in A&E which will improve physical designand thus will reduce the handover delays.

At UCLH• Continuation of LAS action plan to

recruit staff, and hence improveservice performance.

At Royal Free

• CEO at Royal Free has discussed theneed for the recovery plan with JointCOO at BCCG.

• Surge Management in place to assistwith demand and capacity and liaisewith ambulance services.

• Partners including LAS continue towork on reduction of 111 callsconverting to 999 and work withBCCG SRG/ UCB (Enfield CCG) tounderstand and review demand.

Category Red 2(8 minutes)


Rating: RED

Year to date YTD

position(65%)

Rating: RED

Target 75%

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Area Latest position Key Issues Key Actions Progress

MRSA Monthly position

December (0)Rating: GREEN

Year to date YTD

position(2)

Rating: RED

Target Zero tolerance

• Camden CCG had no new cases ofMRSA in December.

• The CCG had 5 cases of C.difficilein December, this is animprovement from the previousmonth (6 cases in November).

• Although performance is belowstandard there are no patient safetyconcerns at this stage.

• These indicators (MRSA, C.difficileand MSA) are closely monitored bythe monthly CQRG and any patientsafety concerns are also dealt bywithin this group.

Due to the normal reporting timetable,December’s detailed analysis was notavailable at the time this report was produced,only the overall position. The issues reportedhere relate to November’s position.

At UCLHMRSA• 0 cases of MRSA bacteraemia reported in

December 2015.• The current Trust position still remains as

two cases being reported for 2015/16.

C.difficile• UCLH’s latest validated position reports

eight C.difficile cases in November 2015,bringing the current total year to dateposition of 67 cases, against a trajectory of97.

• The latest data presented by the Trust at theJanuary 2016 CQRG showed reporting of 59cases of C.difficile as at the end of October2015. 16 of these cases have beenidentified as not being a lapse in care. 15cases of C.difficile have found to be a lapsein care by the Trust. 28 cases are still underreview.

At Royal FreeMRSA• Zero cases of MRSA bacteraemia reported

in October 2015.C.difficile• The threshold for Royal Free for 15/16 is set

by Public Health England at 66.• 6 cases attributed to Royal Free in

November 2015 and 4 in December 2015. toend of Q3 Royal Free reported 53 cases thatwere attributable to the Trust.

• Provisional data indicates that 12 lapses incare have been reported by the Trust to theend of November 2015.

At UCLH• The Trust have presented their C.difficile reduction plan

to the CQRG and will report further progress againstactions at the February 2016 CQRG.

At Royal FreeMRSA• Cases carry a minimum penalty of £10,000.

C.difficile• Royal Free HCAI reduction plan and actions taken to

improve the prevention of HCAIs to be regularlymonitored at the CQRG and by the CSU infectioncontrol lead.

• Financial penalties for 2014/15 to be applied followingcommissioner approval.

• NEL CSU lead to continue to attend the fortnightlyC.Diff action groups across all sites and will continue tomonitor Royal Free implementation of this improvementwork at this level with reports back to CCG colleagues.

At UCLH• The CCG Quality and Safety Manager and CSU Infection

Control Specialist review all UCLH submitted C.difficileRoot Cause Analysis (RCAs) to assess quality of reportand whether a lapse in care has occurred.

• The CCG Quality and Safety Manager and CSU InfectionControl Specialist regularly undertake C. difficile Reviewmeetings with the Trust where formal outcome of theRCA is agreed.

• Learning and themes from RCAs form part of the TrustC.difficile reduction plan.

• There is a clear Trust wide communication strategy withweekly publications to staff

At Royal FreeMRSA• 3 cases assigned to Trust in period 01.04.2015 –

31.12.2015.• The number of cases attributed has increased over the last

2 years and the Trust is currently above the trajectory.• An improvement plan is in place

C-Difficile• Monitor monitors lapses of care rather than total attribution.• The Trust is slightly above their assignment of cases

trajectory, having reported less than expected cases in Q3.• An improvement plan is in place

C.difficile Monthly position

December (5)Rating: GREEN

Year to date YTD

position(63)

Rating: RED


Camden CCG Quality Performance

15304 of 443

16

Area Latest position Key Issues Key Actions Progress

Mixed Sex Accommodation (MSA)

Monthly position

December (4)Rating: RED

Year to date YTD

position(19)

Rating: RED


• Camden CCG had 4 MSAbreaches reported inDecember 2015.

• This is an increase incomparison to the previousmonth when there were 2breaches.

At UCLH• The Trust have reported 12 MSA

breaches in December 2015, this is asimilar number reported in comparison tolast month, when 15 breaches werereported.

• One of these breaches was reported atWestmoreland Street and the remaining11 were reported under the UniversityCollege Hospital Site.

At Royal Free• 12 breaches in December 2015

o 6 Royal Free Hampstead siteo 6 Barnet Hospital site.

• Concern raised regarding the additionalpressure of winter as it is recognisedmixed sex breaches are theconsequence of demand and flow issues

At UCLH• The Trust provide monthly reports against MSA breaches

to CQRG. Assurance discussions will take place betweencommissioners and the Trust at CQRG.

At Royal Free• MSA breaches to remain on CQRG agenda as an

indicator for patient experience and update reports onbreaches delivered.

At UCLH• The previous actions and discussions at CQRG still remain

unchanged. Previously the Trust advised at the DecemberCQRG, the reasons for the breaches remain the same interms of capacity within the UCH tower is full resulting inpatients not being moved on from critical care/ITU beds.Patient safety is a priority within the Trust in ensuringpatients are receiving safe care and treatment within theright area and the Trust have not received any complaintsor concerns from patients in relation to MSA breaches. Inaddition Daily site management meetings take place, inwhich capacity and demand is discussed together with theITU discharges and staffing overall.

At Royal Free• Trust has given an in depth presentation at the November

2016 CQRG.• The trust’s chief operating officer is leading a programme

consisting of a number of work streams all with the aim ofimproving the flow of patients. These include:

1) Front end redesign program2) Provision of additional enablement beds on theRoyal Free hospital site3) Reviewing the configuration and leadership ofthe short stay wards to improve flow from theemergency department.4) Focus on reducing DToC and medically fitpatients occupying hospital beds in partnership withthe System Resilience Group.

Camden CCG Quality Performance

305 of 443

KPILatest Position

Key Issues Key ActionsKey Camden CCG actions

Progress

IAPTAccess to service

Q3 position: 1461 (3.98%)

Rating: Green

(Target 1375 or 3.75%)

• Camden CCG position in Q3was 3.98% with 1461 enteringtreatment showing a 9%increase in performance fromthe previous quarter.

• Camden and Islington FT iCOPE(main provider) position showeda small increase in actualnumbers entering treatment witha 10% increase from 1197 to1313 and a 2% increase inrecovery to 44.82%.

• Discrepancies between localdata and the HSCIC publisheddata.

• Service needs to be streamlinedto reflect a predictive and pre-emptive approach to the systemrather than reactive delivery ofservice. This is reflected in thepeaks and troughs seen inreferral numbers and accessrates.

• Service Development Implementation Plans(SDIP) for the three providers delivering IAPTservices within Camden:

o Camden & Islington NHS FoundationTrust, CIFT (main provider)

o Lea Vale Health (AQP Provider)o IESO Digital Health Ltd (AQP

Provider)

• These plans were also submitted in theCamden CCG operating plan.

• CIFT have taken actions as outlined in theirSDIP, to mitigate the seasonal variation thatoccurs during Q2 in Camden. This ispredominately caused by the change inpsychological wellbeing practitioner (PWP)trainee cohort and annual leave taken over thesummer which reduces capacity. Thenumbers entering treatment between Q1 andQ2 for our main provider shows a variance of -51 people entering treatment between Q1 toQ2, whereas in the past (2014-15) this variancewas over 250 people between Q1 andQ2. Below is a sample of the actions taken:

o PWPs are working at highercaseloads to accommodate thereduction in capacity

o Active management of waiting listswithin clusters by ClinicalCoordinators

o Using data to predict problems earlyand take immediate action (e.g.monitoring increase in referrals/ staffshortages)

o Maximizing clinical time availablethrough ensuring best use is made ofadmin resource

• Work with providers toresolve the differencesbetween the local data andthe nationally publishedHSCIC data.

• CCCG is also Monitoring theperformance via the AQPmonthly meetings as well asthe directly with the AQPs

• Local data and the HSCIC publisheddata position is subject to variabilityacross all providers and as you areaware this is an ongoing nationalissue. Locally discrepancies betweenlocal reports and the HSCIC data arecontinually being addressed via ITdepartments across providers and allhave been working hard toensure/reconcile data quality on amonthly basis (following availability ofreports from HSCIC). The datarefresh period will also meanunpublished figures are indicative andthere will be variance in the finalpublished figures. Camden’s mainprovider, C&I is also working closelywith the software provider to ensurereports mirror the HSCIC algorithms forconsistent calculation of the IAPTtargets at local level

• Although the recovery standards arenot being met, there is on going workto review the measurement criteriaespecially from HSCIC to begin tounderstand the difference between theclinical and data issues.

• IAPT performance position usuallyimproves towards the year end andthis is likely to be reflected in Q3 andQ4 positions.

Waiting times6 Weeks & 18 Weeks

Q3 position: 6weeks 84%

Rating: GREEN

Q3 position: 18weeks 98%

Rating: GREEN

(Targets:6 Weeks: 75%;

18 Weeks: 95%)

• Camden CCG continues abovethe standard in Q3 for both the 6and the 18 weeks waits.

Moving to recovery

Q3 position: 46.58%Rating: RED

(Target: 50%)

• Camden CCG improved in Q3 although still below target.

• Camden and Islington FT iCOPE performance increased slightly in Q3 to 44.82% from 42.22%

17

Camden CCG IAPT Performance

306 of 443

Appendix 1

• Report data sources and availability month 9 report • Camden CCG activity by provider and by type• Camden CCG NHS 111 and GP Out of Hours summary• Camden CCG IAPT• Camden CCG Dementia Diagnosis update• UCLH Accident & Emergency weekly trend• Royal Free Accident & Emergency weekly trend• UCLH and Royal Free - Referral to Treatment trend• UCLH and Royal Free - Diagnostics trend• UCLH and Royal Free - Cancer Performance trend • Camden & Islington FT (Mental Health update)• Central and North West London NHS FT (Community Care update)

18307 of 443

Report data sources and availability month 9 report

19

Indicator Data SourceFrequency of Update

Data typeMonth to be

reportedData Type Expected data extraction Comments

MRSA and C.difficile Public Health England MonthlyOverall Provider Commissioner based

Dec-15 Published 12/02/2016

Mixed Sex Accommodation

Unify2 MonthlyOverall Provider Commissioner based

Dec-15 Published12/02/2016

RTT Unify2 MonthlyOverall Provider Dec-15 Published

12/02/2016

Commissioner based

Jan-16 Provisional 24/02/2015Provisional Commissioner data subject to change.

Monthly Ambulance Quality Indicators -Category A calls

LAS MonthlyCommissioner

basedDec-15 Published 25/01/2015

A&E

From Trust internal data

MonthlyOverall Provider Dec-15 Provisional 04/02/2016

06/02/2015Provisional Provider data subject to change.

Unify2 (monthly data)Commissioner

basedNov-15 Published

Diagnostics Unify2 MonthlyOverall Provider Dec-15 Provisional 12/022016

Provisional Provider data subject to change.

Commissioner based Jan-16

Provisional 22/12/2015Provisional Commissioner dataset subject to change.

Cancer Waiting Times (CWT)

OpenExeter MonthlyOverall Provider Commissioner based

Jan-16Published 18/02/2016

Ambulance Handover HAS portal Daily Overall Provider Dec-15 Published 04/02/2016

VTE Risk Assessment Unify2 Monthly Overall Provider 2015-16 Q2 Published 04/12/2015

IAPTProvider returns

/Camden CCGQuarterly

Overall Provider Commissioner based

2015-16 Q3 Provisional 14/01/2016Provisional Commissioner dataset subject to change.

NHS111 Provider return (LCW) Monthly Commissioner based

Dec-15 Published 15/02/2015

GP Out of Hours Provider return (Care UK)

Monthly Commissioner based

Dec-15 Published15/02/2015308 of 443

20

Camden CCG Activity by provider

Camden CCG ActivityAnalysis - YTD vs Plan

• Over performance againstplan in Red. Figures basedon M9 submission.

• Data source is M8 YTDSLAM data for all Trusts

• Adjustments have beenmade to remove activityfrom plan and actualswhere this related toDrugs; Devices; PatientTransport; or non-chargeable activity.

• Where contract plans arenot in place for the CCG'stwo main providers (UCLHand Royal Free) theactivity has beencompared to 2014/15activity levels with theappropriate phasingapplied

Provider YTD Plan YTD Actual Variance % Commentary M8 Movement

Imperial College Healthcare NHS Trust 20,965 20,906 -59 0%

Activity remains in line with the plan submitted. Diagnostic imaging, Drugs and Devices and A&E attendances are the main areas of activity above plan. A&E activity above plan relates to a higher than planned case mix with the majority of activity above plan being in the higher end of A&E attendances.

These areas are offset by below plan outpatients, critical care and non-elective.0% -1%

University College London Hospitals NHS Foundation Trust

130,826 135,766 4,940 4%

Activity has decreased to 4% in M9 YTD. Over performance is related to elective where RTT (range of specialties) and Diagnostic Waits (Gastroenterology) impact is seen in 2015/16, alongside growth in Dermatology and Clinical Haematology. Dermatology growth is under investigation with the Trust as a counting and coding change.

The other significant activity growth is within Diagnostics, driven by MRI Ultrasounds. The Trust is continuing its recovery plan to regain compliance with the 99% waiting time standard and therefore increased activity compared to last year can be expected. Additional capacity has been created for the coming month with an option to extend to the end of the year if required to achieve compliance.

Non-elective over performance is driven by CDU and Ambulatory Care services. Outpatients over performance is driven by increased GP referrals, especially within Gynaecology.

A&E and Critical Care activity are partially offsetting the over performance.

7% -3%

The Whittington Hospital NHS Trust 19,298 22,761 3,462 18%

The main service areas where activity is above planned levels are A&E, Critical Care, Direct Access (Pathology), Outpatients, and Occupational Therapy. Maternity activity is also above planned levels YTD.

The financial risk associated with activity over performance is partially mitigated by the +/- 2.5% cap on over and under performance for acute activity in 2015/16.

17% 1%

Royal Free London NHS Foundation Trust 145,351 156,448 11,097 8%

The over performance has stablised in M9 YTD, but significant over performance is identified in Diagnostic Imaging, specifically Direct Access. This may be related to how the Trust records Direct Access in the actuals and is not high cost actiivty, whcih is why the activity position does not correlate with the financial underperformance.

The M9 YTD activity position for the Trust shows significant activity over performance in Diagnostic Imaging (especially Direct Access, which is due to no plan being submitted because of data quality issues identified at RFH), Community, and Outpatient attendances. These are being partially offset by lower than planned admitted patient care (elective and non-elective, and maternity).

8% 0%

Other Acute Providers 27,741 31,444 3,703 13% 14%

Camden CCG Total 344,181 367,324 23,143 7%

UCLH and the Whittington are driving the overall overperformance against the plan with Diagnostic Imaging and Elective activity at UCLH and Outpatients activity at the Whittington the main over performing areas.

The Royal Free is over performing now, despite activity for Direct Access activity having been adjusted for previously, however due to the high volume, low cost of the overperforming services this is not resulting in a financial overperformance. Due to the merger of the Cerner PAS migration at RFL on the 31 October there are a number of issues identified within the M8 data submission resulting in the submission being formally rejected and an information breach notice letter has been drafted to support the rejection, therefore the position remains unchanged from last month.

8%

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21

Camden CCG Activity by type

Camden CCG ActivityAnalysis - YTD vs Plan

• Over performanceagainst plan in Red.Figures based onM8 submission.

• Data source is M8YTD SLAM data forall Trusts

• Adjustments havebeen made toremove activityfrom plan andactuals where thisrelated to Drugs;Devices; PatientTransport; or non-chargeable activity.

• Where contractplans are not inplace for the CCG'stwo main providers(UCLH and RoyalFree) the activityhas been comparedto 2014/15 activitylevels with theappropriate phasingapplied.

Provider YTD PlanYTD

ActualVariance Activity

% Variance

Commentary M8 Movement

Accident and Emergency

69,165 70,580 1,415 2.05%

Although there are over and under performances at an individual provider level the overall level of A&E activity is in line with planned values and below demographic growth percentages.The main shift in activity is seen at Barts, Barnet, Imperial, UCLH and the Whittington where more attendances than planned have been seen, however activity levels are lower than planned at RFH.

1.97% 0.08%

Diagnostic Imaging 40,769 55,482 14,714 36.09%

The over performance has increased from M8 YTD, despite an adjustment to the Royal Free Direct Access activity, where a large over performance had been reported. Clarification is being sought with the RFH team for future months. Actual outpatient diagnostic imaging at the Trust is in line with planned levels.UCLH continues to report an over performance in MRI and CT scanning due to their ongoing clearance of the Trust's backlog. The Trust recently regained compliance at UCH however there remains backlog clearance to be completed at the Queens Square site. The Whittington is also reporting an over performance however this is within Direct Access Pathology, which is high volume and very low cost.

36.73% -0.64%

Elective 15,518 16,179 661 4.26%

Over performance is driven by the RTT position at UCLH; increased Dermatology activity in 15/16 at UCLH which has been queried with the Trust; and Cancer activity. The increase in Dermatology activity appears to be a change in counting and coding from outpatient procedures to Day Case which has been challenged with the Trust. The Trust has yet to respond to the challenge. UCLH is reported against the 14/15 activity profile in the absence of an agreed plan, however this will change in future months as the 2015/16 contract has been signed now. As additional RTT activity is built in to the current contract offer to UCLH this may mitigate some of the over performance once the contract is agreed.Imperial and Moorfields are over performing to a lesser extent. The position is partially offset by below plan activity for the RFH and RNOH.

6.94% -2.68%

Non-Elective 18,169 15,317 -2,852 -15.70%

The position is partially driven by a lower count of excess bed days reported at Royal Free compared to last year. The level of over performance has reduced by 17% in M9 YTD and the CCG is now under plan overall. Within this position reduced emergency admissions compared to plan for RFH and the Whittington.Activity at UCLH has decreased this month, due to reduced emergency admissions.The remaining Trusts in the CCG position are showing a net activity performance of below plan. At Barts, the activity above plan is partially related to the Cardiac transfer from UCLH not being reflected in the Trust's plan and also genuine higher activity than planned across a range of specialties, however this is offset by Guys and Imperial.

-10.99% -4.71%

Other 20,037 18,320 -1,717 -8.57% No major variances, with the majority of over and under performance related to SLAM mapping issues with Imperial. -7.05% -1.53%

Outpatients 166,318 176,244 9,925 5.97%

The level of over performance in terms of activity against plan increased in M9 YTD. The Trusts driving the overall performance against planned activity levels continue to be RFH; Whittington; Barts and Moorfields. The majority of the activity over performance at the RFH is due to the transfer of Ophthalmology services from UCLH, which have not been reflected in the plan currently reported against. The same is true for Barts Cardiac activity. These over performances are partially offset by underperformance in the UCLH position.Overall UCLH activity is below (-1%) 2014/15 levels however within the overall UCLH outpatient position activity over performance in Urology and ENT (RTT related) and Gynaecology and Physiotherapy has increased the overall position. Gynaecology appears to be demand driven, with the Trust reporting increased community screening as driving activity. UCLH proposed significant Physiotherapy growth resulting from an increase in emergency activity in 15/16. Further information and discussion with commissioners on service pathways is required for physio activity.The Whittington activity is an increase in outpatient first and follow ups and appears to be driven by GP referrals. It is also partially related to Ambulatory Care activity which has taken place but has no 15/16 plan.

6.51% -0.54%

Camden CCG Total 329,976 352,122 22,146 6.71%

The overall activity against plan position is driven by Outpatient attendances and Diagnostic and Elective activity. There is a 36% over performance in Diagnostic activity driven by Direct Access and recording issues at RFH. 8% over performance can be seen in Elective activity, driven by RTT and Dermatology issues at UCLH, with other Trusts performing to the planned elective demand when looking across all providers.Overall non-elective activity is below plan, driven by emergency admissions at UCLH.

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Camden CCG NHS 111 and GP Out of Hours summary

22

Published performance

• NHS111: London Central & West (LCW) triaged 23,158 callsin November 2015 (an decrease of 229 calls fromNovember) across NCL, of which 13% were referred to LASfor an ambulance dispatch and 10% required emergencytreatment. 57% (including GP OOH) of referrals via NHS 111ended up in primary care or were closed with homemanagement advice. 5% were recommended to attend‘Other Services’ and 15% were not recommended to contactanother service – Self Care/Home Care/Non clinicalservice/No further action required.

• GP OOHs: The CSU have successfully agreed a contractextension with Care UK for six months from the period 1stApril 2016 – 30th September 2016. this is to cover themobilisation period of the new integrated NCL111/GP OOHsservice, scheduled for October 1st 2016.

• Care UK Activity: There was an increase of 335 OOHscontacts across Camden in October, compared toSeptember with an increase of 206 F2F base visits

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Camden CCG IAPT update

23

6 Weeks and 18 Weeks waits Q1 Q2 Q3 Q4The number of ended patient referrals that finish

a course of treatment in the reporting period

who received their first treatment appointment

within 6 weeks of referral

593 719

The number of ended patient referrals that finish

a course of treatment in the reporting period

who received their first treatment appointment

within 18 weeks of referral

726 948

The number of ended patient referrals that finish

a course of treatment in the reporting period743 960

The percentage of patient referrals that finish a

course of treatment in the reporting period who

received their first treatment appointment within

6 weeks of referral (75%)

80% 75%

The percentage of patient referrals that finish a

course of treatment in the reporting period who

received their first treatment appointment within

18 weeks of referral (95%)

98% 99%

Access standards Q1 Q2 Q3 Q4Access (Target 3.75%) 3.70% 3.65%

Recovery Q1 Q2 Q3 Q4Recovery Rate (Target 50%) 43.33% 45.14%

98%

574

583

84%

489

3.98%

46.58%

Provisional performance

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24

Camden CCG Dementia Diagnosis update

The 2015/16 planning guidance states that an increase in the dementia diagnosis rate to 66.7% should be achieved by March 2015, and sustainedthrough 2015/16

Camden CCG dementia diagnosis rate is reported on monthly by NHSE. The CCG position improved in January 2015 to 67.30% from in December 2015 is66.5%. The change in diagnosis rate is due to an adjustment made by NHSE regarding the estimated number of people living with dementia in Camden – theestimated prevalence rose from 1600 to 1688. This has bucked the national and local trend, where estimated dementia prevalence has decreased. Dementiaprevalence is calculated by looking at the over 65 population and calculating an expected prevalence amongst this age group. The figure used to be 7.1%(685,000 nationally) but this was reduced to 6.5% (617,000 nationally). Camden has the fastest growing over 65 population in London. If NHSE updated thepopulation figures of over 65’s in each area at the same time as changing the prevalence figures, it would explain why the CCG got an increase in expectedprevalence. The CCG is currently challenging NHSE to find out why the expected prevalence has increased so significantly.

In order to increase our diagnosis rate the CCG has completed a risk stratification exercise to determine which practices have low levels of referrals to thememory service. The clinical lead for dementia and practitioners from the memory service will continue to work with these practices to increase referrals. TheCCG is also undertaking a further Read code cleaning exercise to make sure all dementia diagnoses are properly recorded in line with the recommendationsfrom the Dementia quality toolkit

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-15

Dementia Register 1124 1064 1149 1148 1087 1149 1146 1142 1145 1159

Under 65 years (0-64) 22 23 24 26 21 22 23 21 23 23

65 years plus (65+) 1102 1041 1125 1122 1066 1127 1123 1121 1122 1136

Estimated prevalence for the CCG calculated from the ONS population estimates multiplied by dementia prevalence rates from the second cohort Cognitive Function and Ageing Study (CFAS II)

1688 1688 1688 1688 1688 1688 1688 1688 1688 1688

Estimated Diagnosis rate (%) 65.28% 61.67% 66.65% 66.47% 63.15% 66.77% 66.53% 66.41% 66.47% 67.30%

RAG RATING

Estimated Diagnosis rate (%)Greater than or equal to 66.7%

Less than 66.7%


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UCLH Accident & Emergency trend

25

• UCLH A&E performance was not achieved in January 2016 at 88.39% (unvalidated data).

• UCLH did not meet the A&E target for any week in January 2016 (unvalidated data).

• Latest performance (week ending 14th February 2016) shows that UCLH did not meet the A&E standard for the first two weeks of February 2016.

KPI / Measure Provider Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-152015-16

YTD2015-16 Target

A&E All Types Performance

UCLH 94.64% 94.89% 95.15% 94.21% 95.78% 97.63% 98.13% 97.51% 97.31% 94.54% 92.98% 90.97% 89.70% 94.42% 95%


Breach report for week ending 7th

February 2016

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Royal Free Accident & Emergency weekly trend

• Royal Free (Hampstead) site A&E performance wasnot achieved for January 2016 at 89.89%(unvalidated data.)

• Royal Free did not meet the A&E target for any weekin January 2016 (unvalidated data).

• For the first two weeks of February 2016 the RoyalFree continues to experience poor performance forat both Barnet/Royal Free sites.

KPI / Measure Provider Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-152015-16

YTD2015-16 Target

A&E All Types Performance Royal Free London FT 95.61% 92.25% 91.01% 96.45% 95.71% 96.70% 97.07% 97.57% 95.89% 96.15% 95.42% 95.52% 92.53% 95.42% 95%


Breach report for week ending 7th February 2016

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UCLH and Royal Free - Referral to Treatment trend

27

Measure Target December 2015 Published data

18 weeks RTT adjusted admitted 90% (Discontinued) 91.71%

18 weeks RTT non-admitted 95% (Discontinued) 96.77%

18 weeks RTT incomplete 92% 93.46%

Camden patients waiting >52 weeks Adm = 0; Non-adm= 0; Incomplete = 0

UCLH• Achieved the incomplete target in November 2015.• The focus for the Trust is to continue with the clearance of the backlog. Non-

admitted back log has continued to decrease gradually through September toNovember.

Measure Target December 2015Published data

18 weeks RTT adjusted admitted

90% (Discontinued) 79.56%

18 weeks RTT non-admitted

95% (Discontinued) 92.59%

18 weeks RTT incomplete

92% 86.67%

Camden patients waiting > 52 weeks

Adm = 1; Non-adm= 7; Incomplete = 1

The Royal Free• Started reporting performance across the whole site from May.• As expected there are significant patient back logs, and the trust did not meet

any of the RTT targets in November.

KPI / Measure Provider Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-152015-

16YTD

2015-16 Target

18 Weeks RTT Incomplete Pathways

Royal Free London FT 92.61% 92.25% 92.17% 92.07% 92.13% 92.29% 88.11% 88.35% 87.82% 87.68% 88.66% 89.46% 87.49% 86.67%88.73%92%

UCLH 92.17% 92.05% 93.11% 93.42% 93.40% 95.11% 94.28% 94.84% 94.53% 93.81% 93.71% 94.12% 94.04% 93.46%94.31%


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UCLH and Royal Free - Diagnostics trend

28

KPI / Measure Provider Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-152015-

16YTD

2015-16 Target

Diagnostics over 6 weeks

Royal Free London FT 1.68% 3.71% 4.40% 4.10% 4.47% 6.40% 7.00% 7.58% 6.80% 7.25% 5.11% 3.90% 4.15% 3.44% 6.07%1%

UCLH 3.80% 6.02% 11.42% 8.38% 7.68% 5.15% 4.75% 3.66% 2.99% 2.88% 2.81% 4.61% 6.64% 6.40% 4.19%


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C:/Users/vianaca/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.Outlook/ST1SD9VL/6 wks Diagnostics

UCLH and Royal Free - Cancer Performance trend

UCLH

29

Royal Free


Threshold Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 YTD Dec-15

2 Week - GP Referral 93% 92.59% 98.08% 93.62% 92.39% 93.76% 92.09% 92.78% 92.34% 87.77% 82.70% 84.14% 84.71% 89.17%

2 Week - Breast Symptomatic 93% 93.79% 95.93% 95.12% 96.10% 96.43% 94.74% 91.18% 92.42% 75.49% 25.00% 12.82% 11.90% 70.88%

31 Day - 1st Treatment 96% 90.83% 93.30% 92.13% 92.40% 88.52% 90.00% 91.09% 88.26% 89.64% 94.62% 95.56% 96.98% 91.88%

31 Day - 2nd/Subs Surgery 94% 91.46% 92.06% 100.00% 87.04% 87.34% 87.23% 94.29% 91.23% 87.88% 97.30% 96.61% 96.25% 91.98%

31 Day - 2nd/Subs Chemo 98% 100.00% 99.60% 100.00% 99.58% 99.62% 100.00% 100.00% 100.00% 99.18% 100.00% 99.53% 100.00% 99.78%

31 Day - 2nd/Subs Radiotherapy 94% 100.00% 98.98% 100.00% 100.00% 99.08% 97.83% 100.00% 100.00% 96.18% 99.21% 100.00% 100.00% 99.13%

62 Day - GP Referral 85% 70.40% 63.64% 71.93% 70.94% 77.23% 69.23% 63.56% 68.00% 70.63% 55.45% 70.59% 67.44% 68.22%

62 Day - Screening 90% 100.00% 75.00% 71.43% 58.82% 87.50% 100.00% 100.00% 75.00% 84.62% 80.00% 50.00% 78.38%

62 Day - Upgrade 86.36% 96.15% 100.00% 100.00% 96.88% 80.65% 91.43% 75.00% 82.61% 83.33% 87.10% 85.00% 86.44%

Threshold Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 YTD Dec-15

2 Week - GP Referral 93% 95.42% 96.33% 94.99% 94.42% 95.25% 95.10% 95.90% 94.46% 93.62% 96.92% 95.64% 96.12% 95.32%

2 Week - Breast Symptomatic 93% 91.13% 94.71% 95.79% 98.95% 98.81% 98.35% 96.86% 96.06% 92.61% 98.42% 96.61% 93.68% 96.82%

31 Day - 1st Treatment 96% 100.00% 100.00% 99.45% 98.62% 99.46% 100.00% 99.60% 98.35% 98.18% 99.61% 99.56% 98.10% 99.10%

31 Day - 2nd/Subs Surgery 94% 98.04% 100.00% 100.00% 100.00% 100.00% 97.37% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 99.59%

31 Day - 2nd/Subs Chemo 98% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

31 Day - 2nd/Subs Radiotherapy 94% 97.62% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

62 Day - GP Referral 85% 72.19% 76.30% 70.55% 82.14% 78.74% 72.30% 72.02% 67.30% 64.92% 66.07% 77.37% 75.93% 72.63%

62 Day - Screening 90% 100.00% 89.29% 100.00% 87.10% 88.64% 92.00% 98.15% 94.12% 90.57% 97.78% 85.71% 97.96% 92.67%

62 Day - Upgrade 90.57% 91.30% 86.21% 100.00% 100.00% 93.48% 92.68% 64.71% 77.78% 97.78% 81.08% 70.59% 87.77%

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Camden & Islington FT (Mental Health update)

30

Provisional performance

Camden and islington FT data is retrieved from theTrust’s quarterly performance report. Updated positionwill be available in the next report.

Whilst there has been an improvement in the acutebed occupancy rates bringing the trust close to the 90-95% from it’s excesses of 100% plus in 2014/15, it stillremains slightly above target at 96%.

A recent recruitment program for nursing vacancieswithin Camden and Islington FT has been successfuland the Trust is confident reliance on Bank andAgency staff will decrease substantially in quarter 3.

Camden and Islington FT performed well against thestandard for Emergency psychiatric admissions with 28days of discharge with 4% of patients being re-admitted against a target of 6.2%.

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Central and North West London NHS FT (Community Care update)

31

Local KPIs performanceCNWL is meeting the majority of KPI's set byCamden CCG in November.

Following the migration of clinical systems fromRiO to SystemOne in October there were anumber of KPI's that were impacted by dataquality issues. The majority of these have nowbeen resolved and performance has increased inline with targets. The proportion of patients withfirst language recorded has increased from 69% to73%, just behind the target of 74%. FurthermoreRapid Response avoided admissions and Podiatrywaiting times are now above target. Performanceof Palliative Care patients with a recorded religionremains below the 85% target at 75%. Furthersupport through targeted training and referenceguides will be provided to Palliative Care staff toensure they record religion for all patients.

Bed occupancy at St Pancras continues toincrease with occupancy at 96% in November, upfrom 90% in October and the highest level sinceMarch 2014. Camden occupancy has increasedfrom 67% in October to 81% in Novemberwhereas Islington has dropped from 132% inOctober to 118% in November. Part of the reasonfor Islington high bed occupancy is patients with adelayed transfer of care arising from delays inSocial Care assessments. This has been raiseddirectly with Islington commissioners to see ifthese issues can be resolved before winterpressures impacts on the whole system.

Area KPI Target per month Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

AccessDistrict Nursing % of referrals to the service acknowledged

within 1 day for DNS ≥ 80% 89% 91% 87% 93% 98% 100% 86% 100% 100% 100% 100% 100% 100% 100% 99% 100% 100% 100% 100% 100% 100%

Integrated Primary Care

% of referrals seen within priority timescale ≥ 88% 89% 89% 88% 93% 88% 89% 90% 89% 88% 89% 90% 89% 91% 90% 93% 92% 92% 83% 95% 95% 94%

Podiatry % of 1st attendances seen within 8 weeks of referral - commissioned target > 80% 81% 78% 88% 81% 97% 99% 98% 98% 99% 96% 98% 97% 97% 97% 96% 97% 95% 97% 75% 95% 80%

Heart Failure % of Heart Failure patients seen within two weeks of referral being received > 85% 36% 50% 22% 67% 69% 100% 95% 89% 100% 89% 77% 94% 88% 93% 88% 80% 100% 100% 100% 75% 100%

Palliative Care % of non-urgent referrals responded to within 48 hours > 89% 81% 78% 88% 81% 97% 99% 98% 98% 99% 96% 98% 97% 97% 97% 97% 99% 95% 100% 97% 99% 100%

Palliative Care % of urgent referrals responded to within 24 hours 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Wheelchair Average waiting time from referral to assessment (days) N/a 38 19 27 13 40 40

Occupancy & ActivityInpatients Bed occupancy at South Wing - Camden

patients > 95% 99% 103% 90% 62% 81% 97% 69% 75% 92% 84% 76% 77% 68% 79% 80% 88% 78% 77% 67% 81% 78%

Inpatients Number of FCE's - Camden patients26 25 26 32 30 21 27 31 27 28 26 17 34 24 23 26 35 23 20 30 16 29

Inpatients Average Length of Stay< 42 29 35 39 31 27 37 31 25 29 30 33 32 28 34 26 28 28 34 29 32 28

BCF Case Management

No. of patients provided with in depth case management in the community for up to 12 weeks > 175 35 73 105 131 168 203 242 262 297 359 399 440 33 88 113 140 160 183 209 241 278

Wheelchairs First fixed rate> 80% 84% 81% 82% 89% 91% 87% 79% 78% 78% 77% 70% 60% 72% 88% 85% 85% 83%

Continuing Care % of CHC patients with a review at three months after their initial decision of eligibility > 90% 0% 9% 18% 89% 71% 67% 75% 80% 100% 60% 100% 50% 25% 0% 0% 17% 71% 100% 100% 100% 100%

Continuing Care % of all CHC patients reviewed annually, for those eligible after 3 month assessment > 90% 33% 50% 25% 100% 0% 100% 100% 100% 100% 100% 100% 67% 0% 0% 0% 100% 75% 100% 100% 100% 100%

DischargeInpatients % of patients discharged to usual place of

residence - South Wing > 64% 65% 51% 78% 73% 67% 72% 46% 65% 71% 83% 66% 71% 88% 67% 60% 80% 68% 83% 88% 60% 54%

OutcomesCommunity Rehab % of CRT patients with all goals achieved

> 74% 82.0% 92.0% 89.0% 75.0% 81.0% 85.0% 100.0% 100.0% 100.0% 67.0% 71.0% 75.0% 82.0% 88.0% 75.0% 79.0% n/a n/a n/a n/a n/a

Community Rehab % of CRT patients with a positive change in their EQ-5D-5L scores N/a tbc 86% 60% 100% 100% n/a n/a

Rapids Rapids - Number of admissions avoided> 83 32 35 25 28 31 31 42 50 44 43 23 25 70 63 85 97 94 115 98 85 100

REDs % of REDS patients with reduced or no packages of care > 49 64% 75% 67% 67% 100% 86% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 88% 67% 57% 87% 70%

Inpatients Number of patients with demonstrated improvement against Barthel therapy measures > 85% 83% 100% 87% 89% 82% 75% 91% 88% 83% 91% 83% 71% 100% 97% 63% 91% 84% 100% 91% 96% 83%

Wheelchair % of clients that report improved mobility, measured 3 months after issue of equipment. ≥ 90% 80% 91% 89% 100% 100% tbc 67%

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Report Title Business Plan Report Agenda Item 4.4

Date 24/02/16 Lead Director Ian Porter, Assistant Director

Corporate Services Tel/ Email

[email protected]

Report Author Debbie Hawkins, Head of PMO

Tel/ Email

[email protected]


Dorothy Blundell, Chief Officer

Tel/ Email

[email protected]

Report Summary

This report provides a progress update on the Business Plan, highlighting key achievements, issues and risks. This is primarily an exception report focusing on those initiatives which have a RAG status of either red or amber. Overall progress

Progress is being made across all eight objectives with a positive direction of travel overall. Of the 52 live initiatives, 31 are reporting a RAG status of Green, with eight initiatives having changed from Amber to Green since the January update. 14 initiatives are already complete with a further eight scheduled for completion by the end of this financial year.

The remaining 21 initiatives have a status of Amber, with issues or risks being actively managed. Three initiatives have changed from Green to Amber, reflecting that progress is being closely monitored to ensure reporting of the latest position (see Appendix 1 for details). Updates for all amber initiatives are included in Appendix 1.

The Business plan reporting cycle is now fully established with collective input from across the organisation and good ownership of initiatives.

Key updates

Updates for each Objective are included in Appendix 1 with highlights set out below

• The Team Around the Practice (TAP) is doing well with 428 referrals in the first two quarters. This new service was formally launched in November and aims to optimise the care of people with mental health issues in primary care.

• As part of ‘Improving access to Primary Care - Enhanced access 8-8’, the Saturday service in South Camden Centre went live in February. Work is ongoing to ensure that the service is embedding and this will be closely monitored.

• The Frailty Register has reached 1499 as of November 2015 (last available refresh), a 75% increase on 855 in December 2014. This is a means of supporting GPs to identify frail patients as part of a care planned model that supports proactive, coordinated and high quality care for frail and elderly patients.

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• Very positive feedback was received following Care Quality Commission’s (CQC) visit to Camden, as part of a thematic review of Older People and Integrated Care. Inspectors have asked to return to the Frailty MDT so that they can use it as an example of best practice. The MDT brings together a range of clinicians and practitioners who present on individual cases that are highly complex.

• Alcohol Management training in primary care - the training package has been developed, and 51 clinicians have taken part in the course so far with excellent feedback. This is part of an ongoing programme to improve awareness and skills in dealing with alcohol issues.

• The Children’s and Adolescence Mental Health Services (CAMHS) transformation plan, looks at reshaping the way services for children and young people with mental health needs are commissioned and delivered across all agencies over the next 5 years. The implementation plan was assured by NHSE in December 2015 and is well underway to deliver the 11 local priorities.

• The GP website has been re-launched with a new user-friendly interface including an optimised search bar. The GP website has proved to be an invaluable resource for our GPs.

• Camden Integrated Digital Record (CIDR) website is now live and actively in use at the 35 GP Practices across Camden. CIDR is an electronic record linking health and social care information from primary, secondary and adult social care services within Camden. This helps to provide Camden residents with a higher quality of care, improved safety of care, improved care experience and increased data accuracy.

• A Membership Summit was held in January 2016 with attendance by 62 members and representation from over 70% of practices. Delegate feedback showed 88% felt presentations were ‘useful/very useful’ and over 80% felt the balance between presentation and discussion was correct.

• As part of the NHS England assessment, Camden CCG was ‘assured as good’ on our individual and collective statutory duties related to patient and public involvement activity.

• A ‘You Said, We Did’ action plan has been developed to continue to improve engagement with member practices based on feedback from practices. A working group with Governing Body representation is in place to oversee this.

Key issues / risks

Issues and risks for each objective are included in the main report, with key points summarised below:

• Dependency on Federation: Three primary care initiatives are rated amber due to a dependency on the Federation to put in place the necessary policies, staffing and ways of working. These initiatives are: Complex Care LCS Over 75 Home Visiting pilot; Improving access to Primary Care - Enhanced access 8-8; Enabling IT infrastructure set up. Camden CCG is working with the Federation to ensure delivery against key milestones. Assurance is provided through the Commissioning Committee.

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Other points to note: Two initiatives will no longer be reported as separate initiatives within the Business Plan

D3.15 Development of Community Hub model to coordinate primary and community services – this has been superseded by the Out-of-Hospital strategy which means it will no longer be reported as a separate initiative.

C3.5 Project to address value for money of cancer services to be identified and scoped – this work is now being taken forward as part of the NCL programme, with assurance and reporting provided through the NCL Collaboration Board.


Information

Approval

To note

Decision



The Business Plan makes a contribution to all of the CCG Strategic Objectives. The majority of the initiatives are in objectives C and D which are:

Objective C: Improve health outcomes, address inequalities and achieve parity of esteem.

Objective D: Integrate and enable local services to deliver the right care in the right setting at the right time.


Issues and risks for each objective are included in the main report and the key risks are noted above in the report summary. Risks which may relate to the Business Plan initiatives are monitored through the Board Assurance Framework, Corporate Risk Register and the relevant Committee Risk Registers.


Where conflicts of interest arise in relation to specific Business Plan initiatives, these will be addressed accordingly.


Resource implications of the Business Plan are being addressed as part of the implementation planning and mobilisation.

Engagement

This report has been prepared with the involvement of the CCG Executive Team and senior managers involved in delivering the Business Plan.


There are no equality issues arising from this report.

Report History

The Business Plan was agreed by Governing Body in July 2015. Previous updates have been presented to Governing Body in September 2015 and January 2016.

Next Steps The CCG will continue to prioritise the implementation of the Business Plan and provide regular updates to Governing Body.

Appendices Appendix 1: Business Plan Report

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Governing Body – 9th March 2016

Appendix 1

Business Plan Update Report (15/16 – 17/18)

(Information accurate as of 24/02/16 )

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Table of Contents

Title Slide No.

Business Plan Objectives 3

Overview of Business Plan Initiatives 4 - 6

Objective A: Commission the delivery of NHS constitutional rights and pledges 7 – 8

Objective B: Improve the quality and safety of commissioned services 9 – 10

Objective C: Improve health outcomes, address inequalities and achieve parity of esteem

11 – 13

Objective D: Integrate and enable local services to deliver the right care in the right setting at the right time

14 – 18

Objective E: Work jointly with the people and patients of Camden to shape the services we commission

19

Objective F: Involve member practices and commissioning partners in key commissioning decisions

20-22

Objective G: Maintain financial stability and sustainability through robust planning and commissioning of value-for-money service

23-24

Objective H: Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce

25-26

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Improve the quality and safety of commissioned servicesB

Improve health outcomes, address inequalities and achieve parity of esteem

C

Commission the delivery of NHS constitutional rights and pledgesA

Integrate and enable local services to deliver the right care in the right setting at the right time

D

Involve member practices and commissioning partners in key commissioning decisions

F

Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for-money services

G

Work jointly with the people and patients of Camden to shape the services we commission

E

Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce

H

Enablers

Population segment addressed

Eight objectives in the Business Plan

Children Adults Older people


Objectives

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Overview of Business Plan Initiatives

Key Points

There are now 66 initiatives across the lifetime of the plan. There were 68 initiatives in the January 2016 report, the following initiatives will no longer be reported separately:• ‘Development of Community Hub model to coordinate primary and community services’ has been superseded by the Out-of-Hospital strategy• ‘Project to address value for money of cancer services to be identified and scoped’ is now being taken forward as part of the NCL programme

In this financial year (15/16):• 66 initiatives in total • 14 initiatives have already been completed• 52 initiatives are being progressed - by the end of 15/16, 8 of these initiatives are scheduled to finish, with a further 44 initiatives underway. The number to be

finished in 15/16 has changed from 9 in the January update as the initiative ‘C3.5: Project to address value for money of cancer services to be identified and scoped’ has been superseded and will no longer be reported separately

• Of these 52 initiatives, 31 are progressing to plan (RAG status - green) and 21 have some risks and issues which require action (RAG status - amber).• The changes in the RAG status since the January Governing Body report are shown on the next slide.

The subsequent slides focus primarily on the status of the ‘amber’ initiatives, whilst also highlighting key achievements.

KeyBlue – Initiatives which have been completedRed – Significant risks/issues have arisen that require action immediatelyAmber – There are risks/issues that require action in the near futureGreen – No Issues, progressing according to plan

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Governing Body - Mar '16Initiative Status by Financial Year-end

Completed Underway To be finished

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Governing Body - Mar '16Summary of RAG Status (15/16)

Blue Red Amber Green

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Initiative RAG status Reason for change in RAG status

Jan’16 Mar’16

A2 & A4: Develop and negotiate into the acute provider contracts a specific set of performance incentives. Develop models of joint working with Monitor, NHSE (National Health Service England) and CQC (Care Quality Commission)

This initiative is now on track with the framework having been approved by Finance and Performance Committee in January

C5.26: Pain management – UCLH This initiative is now on track and the service is now live

C2.3: Placement for Children and Young People with Complex Needs, Health, Education and Social Care

This initiative is now on track with the strategy and action plan due to be signed off in February

D3.41: Investing in GP and Practice Education• GP education to enable early Diagnosis of

Cancer

This initiative is now on track and work on next year’s

education programme has commenced

D3.26: NCL Primary Care Pathways (previously 'Royal Free pathways redesign to reduce secondary care in a selected group of specialties')

This initiative is now on track. Camden CCG is developing new pathways, on behalf of the NCL.

D3.4: Joint co-commissioning of primary care This risks are now reduced as the potential impact of joint co-commissioning on the CCG’s resources and ways of working

is now clearer and manageable.

C5.27: Enhancing Primary Care through Locally Commissioned Services (LCS)• Improving physical & psychosocial outcomes

for patients with mental health needs

This initiative is now on track. This initiative is part of the Planned Care LCS which will go live in April 2016.

F3: Develop a communication strategy for Primary Care

The Primary Care communications strategy will now form part of the 2016/17 Communications, Engagement and Member Relations (CEMR) strategic plan instead of a separate plan, to allow for a consistent communications approach.

D3.25: Production of local Quality Scorecard for Primary Care

This initiative has been rated amber as the pilot scorecard is still in development

D3.9: Camden Integrated Digital Record (CIDR) Whilst CIDR has recently been successfully relaunched, this initiative is amber due to an issue with UCLH sending data through to CIDR.

C5.28: Review of Mental Health Secondary Care• Crisis Care and Prevention

This is rated amber due to the dependency on the decision around NCL mental health workstreams to see if there is scope to commission Psychiatric Liaison collaboratively.

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Governing Body – Jan ‘16Summary of RAG Status (15/16)


Overview of Business Plan Initiatives

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Governing Body - Mar '16Summary of RAG Status (15/16)


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Overview of Business Plan Initiatives (cont’d)


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Obj A Obj B Obj C Obj D Obj E Obj F Obj G Obj H

RAG Status of Initiatives by Objective


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Objective A: Commission the delivery of NHS constitutional rights and pledges

PrioritiesPA1. Consistently achieve the NHS Constitution targets for all our patients for the next 3 yearsPA2. Resolve the cancer, RTT, and A&E waiting time problems at the main acute providers for Camden residentsPA3. Implement nationally mandated programmes (e.g. 8-8 GP access)

Accountable:Director of Sustainable InsightsChief Operating OfficerChief of Staff

Key Updates

• New performance incentives framework approved by Finance & Performance Committee in January 2016• In relation to the initiative ‘Investing Strategically to Improve Acute Provider Performance’, following a demand and capacity analysis, a report is going to March

Commissioning Committee to consider the recommendations to address the level of demand for diagnostic, elective and cancer care pathways within Camden

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Objective A (Graph 1) - Initiatives Scheduling(by year)

Underway To be finished


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Objective A (Graph 2) - Initiatives by RAG Status (15/16)


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Objective A (cont’d): Commission the delivery of NHS constitutional rights and pledges

Initiative Reason for Amber and Red Status Red or Amber

Key Actions being taken (and by when) Accountable

A11 (A5-A10): Enhancing organisational capabilities for managing acute performance

This initiative includes a range of activities: realigning a CCG/CSU performance management team with responsibility for provider performance; ensuring staff have the required knowledge and capabilities to manage provider performance; incorporating measures of provider performance in appraising staff; increasing the effectiveness of Governing Body with respect to influencing provider performance; addressing the mindset of limited influence over major acute providers and the tendency to focus on new investment rather than performance of existing services; and clarifying the roles of Quality, Finance, and performance teams with respect to performance and increasing effectiveness of current meetings.

A range of activities are underway to deliver this initiative, many of which are ongoing and will take time to embed. Strengthened monitoring of acute performance will help assess impact.

As per the last update in January, organisational focus on acute provider performance continues to be strengthened.

Work is ongoing to understand and consolidate existing performance reporting to provide assurance and support providers to achieve targets. A weekly performance review meeting is taking place, between CCG and CSU senior officers, to facilitate this workstream.

Roles and responsibilities in relation to performance have been clarified and strengthened, with the performance function now being led by Sustainable Insights.

A ‘training needs assessment’ will be undertaken

to identify development needs to strengthen capabilities to manage provider performance. This will link into the HR and organisational development strategy.

Director of Sustainable Insights

Chief Operating Officer

Chief of Staff

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Objective B: Improve the quality and safety of commissioned services

PrioritiesPB1. Ensure that all commissioned services have a quality schedule in place and regular quality reviewsPB2. Work jointly with Performance Management and Finance to improve the RTT, cancer, and diagnostics issues at UCLH by focusing on the safety and quality aspects of operational standardsPB3. Expand and improve the intelligence and measures available about the quality, safety and patient experience in community and mental health servicesPB4. Ensure that quality is everyone’s responsibility

PB5. Develop the whole systems quality strategy and commission strategically to support the strategyPB6. Successfully implement the new requirements with respect to safeguarding

Accountable:Director of Quality & Clinical Effectiveness


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Objective B (Graph 4) - Initiatives by RAG Status (15/16)


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Objective B (Graph 3) - Initiatives Scheduling (by year)


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Objective B (cont’d): Improve the quality and safety of commissioned services



B2: Research community and mental health quality measures and incorporate the most valuable into routine quality monitoring

Currently, there are no national metrics which is a recognised issue by NHSE.

In the absence of national metrics, the CCG is monitoring community and mental health quality by: inputting into the London Mental Health dashboard; and monitoring by the Quality & Safety committee via the ‘Complaints’ and

‘Safeguarding’ dashboards.

Local metrics are being incorporated in mentalhealth investment programmes.Work is planned to incorporate quality monitoring into all community and mental health contracts as appropriate.

Director of Quality and Clinical Effectiveness

Key Updates

Upcoming milestones:• Whole systems quality strategy to be presented to the Governing Body in March 2016

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Objective C: Improve health outcomes, address inequalities and achieve parity of esteem

Children and Maternity• Early intervention (first 1,001 days)• Value for money of mental health

services commissioned• Obesity• Asthma

Adults• Preventing ill health via lifestyle changes: alcohol, smoking• Achieving early diagnosis, and better outcomes and value for money

of LTC management• Value for money of mental health services commissioned, ensure

services meet the needs of the whole population, achieve parity of esteem

• Early diagnosis of cancer• Value for money of cancer services commissioned

Older people• Outcomes and Value for money

of LTC management• Early diagnosis of dementia• Support for independent living

Priorities Accountable:Chief Operating OfficerDirector of Sustainable InsightsTransformation Programme Director


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Objective C (Graph 5) - Initiatives Scheduling(by year)


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Objective C (Graph 6) - Initiatives by RAG Status (15/16)


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Key Updates

• The Children’s and Adolescence Mental Health Services (CAMHS) transformation plan, looks at reshaping the way services for children and young people with mental health needs are commissioned and delivered across all agencies over the next 5 years. The implementation plan was assured by NHSE in December 2015 and is well underway to deliver the 11 local priorities. The first assurance tracker for Q3 has been submitted to NHSE with all KPIs on track

• The Autism Spectrum Disorder strategy and action plan has been developed. These will be submitted to the Complex & Additional Needs Outcomes Based Commissioning Group for agreement on the 29th February, in advance of final stakeholder input and sign-off off by the end of March 2016

• The All Together Better project (the system-wide review of how we promote and maintain the health and wellbeing of children and young people in Camden) has developed an implementation plan, which was presented to the February Commissioning Committee

• The Team Around the Practice (TAP) is doing well with 428 referrals in the first two quarters. This new service was formally launched in November and aims to optimise the care of people with mental health issues in primary care

• All initiatives in Children’s and Long Term conditions areas are reporting ‘Green’ RAG status

Objective C (cont’d): Improve health outcomes, address inequalities and achieve parity of esteem

Population Segment

Reason for Amber and Red Status Red or Amber


Adults C3.9 Prevention Work Programme (secondary prevention strategy for adults with long-term conditions): This workstream relates to provisions within the Care Act 2014, for staying independent for longer. A preventative strategy is being developed in collaboration with Public Health. This workstream will identify any additional services to be commissioned to fulfil the relevant provisions within the Act and the strategy once finalised. This workstream is fully funded by the local authority.This continues to be rated as amber as the preventativestrategy is not yet in place.

Discussions are taking place on the role of the steering group and future direction of this work. In the meantime work continues to be undertaken in many areas of prevention e.g. study into reasons for those who have frequent falls to enable staff to put preventative measures in place; increasing the uses of telecare and telehealth services. Much of the work has been absorbed into business as usual.


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Population Segment



All Population

C5.7 Transforming Care: This forms part of the Big 8 agenda which relates to facilitating the effective discharge of adults with learning disabilities and/or autism who are in mental health hospitals. The programme aims to enhance community based and preventative services in order to prevent a hospital admission or to expedite a timely discharge when an admission is unavoidable.The status is amber due to challenges in ensuring safe and effective care of individuals, who have been in long-term care, to live in the community.

Each case, of those who have been in long-term care, is being addressed with relevant services to ensure co-ordinated care can be achieved.In addition, there is a new NHSE requirement (through the planning guidance) that Camden CCG works with commissioning leads across NCL and that a sector wide Senior Responsible Officer has been appointed (Enfield CO) to oversee the programme. Work is underway across NCL to draft a NCL wide Transforming Care Plan. The final plan needs to be submitted to NHSE in September, with the first draft submitted in February. The plan includes reviewing existing services within Children's Services and aligning with wider programmes of work such as the Mental Health Crisis Concordat and Camden’s

Children's Transformation plan.


C5.27 Enhancing Primary Care through Locally Commissioned ServicesThere are 7 streams of work, 1 is complete, 4 are green and 2 are amber as reported below. The overall status is amber.

• Complex Care LCS Over 75 Home Visiting pilot (PC IP) All milestones are on target at present but the project has been rated amber due to the dependency on a third party (the Federation) to put in place the necessary policies, staffing and ways of working to deliver the service. The service started with a soft launch on 17th

February 2016, in preparation for the full launch in March.

• Anticoagulation LCS (Atrial Fibrillation) (PC) This has been rated amber because progress is behind schedule. Pathway is being further developed after review by Clinical Cabinet. Final pathway and timing of business case may be impacted by approval of NCL guideline on DOAC (Direct Oral Anti-coagulation)

• Complex Care LCS: Close working with the Federation will continue to ensure delivery against key milestones. A delivery plan is being developed.

• Anti-coagulation LCS: Pathway and business case to be discussed at April Clinical Cabinet.


TransformationProgramme Director


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Population Segment



All Population

C5.28 Review of MH Secondary CareThere are 5 streams of work, 1 is complete, 1 has not started, 2 are green and 1 is amber as reported below and the overall status is amber.

• Crisis Care and Prevention: This is rated amber due to the dependency on the decision around NCL mental health workstreams to see if there is scope to commission psychiatric liaison collaboratively.

Work with NCL is ongoing to agree the best way forward. The business case being developed for the April Commissioning Committee will include psychiatric liaison, but the decision to deliver this collaboratively across NCL will develop as the NCL Mental Health Board evolves.



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Objective D: Integrate and enable local services to deliver the right care in the right setting at the right time

PrioritiesPD1. - Develop a single high quality, completely integrated out-of-hospital service

- Coherent seamless care pathways for care in and out of hospital settings- Consistent high quality delivery of these pathways

PD2. Facilitate further integration with acute care and specialist Mental Health- Simpler – fewer organisational boundaries: integration between two services vs >40- More balanced – role of community/primary care valued- More ability for the enhanced out of hospital service to set the framework for integration vs being dominated by acute/specialist providers’ agenda

PD3. - Develop the planning, financial, and contracting architecture to support the completely integrated service

Accountable:Chief Operating OfficerDirector of Sustainable InsightsChief Finance OfficerTransformation Programme Director


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Objective D (Graph 8) - Initiatives by RAG Status (15/16)

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Objective D (Graph 7) - Initiatives Scheduling(by year)


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Key Updates

Achievements:• Primary Care

o As part of ‘Improving access to Primary Care - Enhanced access 8-8’,the Saturday service in the South Camden Centre went live in February. Work is ongoing to ensure the service is embedding and the service will be closely monitored

o 60% of Health Care Assistants (HCA) in Camden will be attending Care Certificate training, which will set a core standard of care by all Camden HCAso Three locality nurses have been appointed to provide support and upskill practice nurses

• Frail and elderlyo From 1st February, the GP Federation is supporting the development of key service initiatives for the Frail and Elderly cohort (locality Multi Disciplinary

Team’s (MDT), Single Point of Access and Integrated Admissions Avoidance), that are phased for delivery by several providers over 2016/17o GPs are being supported to identify frail patients who are then added to the Frailty Register. This is part of a care planned model that supports proactive,

coordinated and high quality care for frail and elderly patients. The Frailty Register has reached 1499 as of November 2015 (last available refresh), a 75% increase on 855 in December 2014

o 74% of patients have spent either the same amount of, or more days at home since being added to the borough wide MDT caseload. (299 patients measured since the Q2 refresh)

o Very positive feedback was received following CQC’s visit to Camden, as part of a thematic review of Older People and Integrated Care. Inspectors have asked to return to the MDT so that they can use it as an example of best practice

• The 10 step down beds at Rochester West are operational since February which is helping to reduce pressure on the Delayed Transfer Of Care

• Alcohol Management training in primary care -- The training package has been developed, and 51 clinicians have taken part in the course so far and the feedback has been excellent. This is part of the ongoing programme to improve awareness and skills in dealing with alcohol issues.

• Digitalo GP website, which has proved to be an invaluable resource for our GPs, has been re-launched with a new user-friendly interface including an optimised

search bar. It helps to promote services and bring it to the attention of local GPso CIDR website is now live and actively in-use at the 35 GP Practices across Camden. CIDR is an electronic record linking health and social care information

from primary, secondary and adult social care services within Camden. This helps to provide Camden residents with a higher quality of care, improved safety of care, improved care experience and increased data accuracy

Upcoming milestones:• Community Education Provider Network (CEPN) website launch April 2016. This will coordinate education and training for the workforce across health and social

care through an integrated approach• A new mental health website which provides information on the various mental health services within Camden -- Launch April 2016

Objective D (cont’d): Integrate and enable local services to deliver the right care in the right setting at the right time

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D3.3 Improving access to Primary Care -Enhanced access 8-8

All milestones are on target at present but the project has been rated amber due to the dependency on a third party (the Federation) to put in place the necessary policies, staffing and ways of working to deliver the service.

Close working with the Federation will continue to ensure delivery against key milestones. A delivery plan has been developed, which outlines the activities required to deliver the subsequent phases of the project.


D3.6 Reablement and Step-down

A Joint Health and Care Reablement Strategy has been developed to look at preventing admissions / readmissions through early interventions and maximisation of step-down facilities.This project remains at amber due to the complexities of co-ordinating all reablement services into one single pathway.

A further paper on the single pathway (an element of the strategy), is due to be presented to the Commissioning Committee on 27th April 2016. The Rochester West and Roseberry Mansion step down beds and flats are being fully utilised and are helping to reduce pressure on Delayed Transfers ofCare (DTOC).


D3.16 Development of a Premises Strategy to enable increase in capacity in primary care

This initiative remains at amber until the next draft of the strategy has been approved.

Initial draft completed and submitted to NHSE in line with the deadline. Draft presented to Governing Body and Membership Summit in January. Subsequent draft to be completed by March 2016, taking account of appropriate stakeholder feedback. Going forwards the Business Plan refresh for 2016/17 and beyond will need to capture the iterative nature of the estates strategy as the Transformation agenda accelerates.


D3.23 Musculoskeletal Services redesign (MSK)

Timescales for the new service are delayed as further work is required on the Business Case to ensure it clearly articulates the clinical pathway change.

In September an action plan detailing next steps was submitted to Commissioning Committee. A task and finish group with associated workstreams started in October 2015 expected to be completed within 6 months. The scope of the Business case was confirmed at January Commissioning Committee to focus on integrated MSK service. The Business Case was presented at the Commissioning Committee in February and will be presented at the Governing Body in March 2016.


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D3.25 Production of local Quality Scorecard for Primary Care

This initiative has been rated amber as the pilot scorecard is still in development.

The proposed pilot scorecard will be finalised and presented to the Primary Care Programme Implementation Group in March 2016.


D3.42 Frailty IPU Core Enablers

There are 8 streams of work, 7 are green and 1 is amber as reported below. The overall status is amber.• Care Navigators to support patients

requiring access to any non-clinical services (includes pilot evaluation) The provider is not meeting activity targets for number of referrals (the provider is responsible for promoting this service)

A comprehensive recovery plan is in place to actively address this issue. Weekly contact with the provider is scheduled up until 31st March 2016 and formal review end Q4 to escalate/ de-escalate. Additional actions with clinical leads/ practices on further embedding the service is underway.


D3.44 Long Term Conditions –CICS

There are 3 streams of work, 2 are green and 1 is amber as reported below. The overall status is amber.• Camden Integrated Care Services (CICS): CICS underpins a new approach to patient-focused delivery of care in the local community. The service includes specialist support for patients with: heart failure, COPD, CKD, Memory loss, Frailty and COPD MDTs. The amber status is because a recent review indicated a number of areas for improvement.

Following the recent initial review of the service which highlighted a number of areas of improvement, the programme group has decided to undertake a full clinical review of the service.

Transformation Programme Director

D3.21 – Frailty Integrated Practice Unit (IPU)

IPU amber due to the complexity of timescales and multiple inputs needed for the business case.

Development Partnership meetings with providers have been established, as have Commissioning group meetings internal to the CCG. NELCSU is supporting with the development of the business case and providing procurement, contracting and strategic advice to the project.


D3.9 – Camden Integrated Digital Record (CIDR)

Whilst CIDR has recently been successfully relaunched, this initiative is amber due to an issue with UCLH sending data through to CIDR.

The procurement of additional IT functionality will be considered to resolve this issue. This currently sits outside the scope of the project.


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Objective E: Work jointly with the people and patients of Camden to shape the services we commission

PrioritiesPE1. Develop a standard approach to patient involvement across all programmes in service design, decision making and evaluationPE2. Creatively and systematically capture views of patients and from a range of sources and embed patient feedback in all stages

of commissioning and contract monitoringPE3. Improve the two-way flow of information from patient reps to the wider CPPEG group, and to the PPGs to increase the patient

voice in decision making

Accountable:Assistant Director Corporate ServicesChief Operating Officer

Key Updates

The ‘Green’ initiative is ‘Develop and maintain a standard approach to patient involvement in service design, decision making and evaluation’ – all activity is progressing to plan with no reported issues. NOTE: More information on this objective is available in the Patient Voice report

Achievements:• NHSE assessment; ‘assured as good’ on our individual and collective statutory duties related to patient and public involvement activity (January 2016)• Camden CCG Twitter account launched reflecting feedback from PPG (Patient Public Group) survey (January 2016)• Bi-annual Pan-Camden PPG events scheduled (9th May & 12th September 2016), with ‘You said, We did’ action reporting planned

Upcoming milestones:• Healthwatch Camden meeting to agree an approach to collaborative working on PPI (Public Patient Involvement) - February 2016• Additional social media channel (Facebook) scheduled to launch - March 2016• Online registration & reporting form launching - to track PPI impact on CCG commissioning, services, procurement and strategy development - March 2016

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Objective E (Graph 10) - Initiatives by RAG Status (15/16)

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Objective E (Graph 9 - Initiatives Scheduling(by year)



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Objective F: Involve member practices and commissioning partners in key commissioning decisions

PrioritiesPF1. Make member practice involvement an accepted part of key decision making processesPF2. Deliver the national requirement to achieve better outcomes through work with the Local Authority on Better Care Fund

(BCF) and Health and Wellbeing board (HWBB) Deliver the requirement to plan at SPG level from NHSEPF3. Work jointly with specialised commissioning to develop a long-term strategy for services from UCLH

Accountable:Chief OfficerAssistant Director Corporate ServicesChief Operating Officer

Key Updates

Member Practice engagement: • Member Relations Team created• 21 January 2016 Membership Summit - 62 members attended with representation from over 70% of practices. Delegate feedback showed 88% felt presentations

were ‘ useful/very useful’ and over 80% felt the balance between presentation and discussion was correct.

• Working group with Governing Body representation established to oversee/deliver the ‘You Said, We Did’ action plan

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Objective F (Graph 11) - Initiatives Scheduling(by year)



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Objective F (Graph 12) - Initiatives by RAG Status(15/16)


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Objective F (cont’d): Involve member practices and commissioning partners in key commissioning decisions



F1: Involve member practices and local stakeholders in commissioning decisions

Good progress is being made, however, this initiative is rated amber as work is ongoing to improve engagement with member practices.

Creation of a Member Relations Team (completed).

Responsibility for Locality Meetings and Summits has now transitioned to the Member Relations team (from Primary Care and Governance, respectively). Member Relations will now manage agenda-setting, content development and effective member involvement.

Established a working group (with Locality Leads) to oversee the You Said, We Did action plan (first meeting took place in January 2016).

Primary care partners meeting to ensure a co-ordinated strategy and shared understanding/goals (February 2016).

Creation of a forward planner in partnership with PMO to support engagement with member practices about key agendas (March 2016).

Localities report to Governing Body to be adjusted to reflect the widening scope and importance of member relations work (March 2016).

AD Corporate Services

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Objective F (cont’d): Involve member practices and commissioning partners in key commissioning decisions



F2: Work jointly with the local authority and across NCL & NHSE re Better Care Fund, Joint Health & Wellbeing Strategy, NCL programme and NHSE pan-London programmes

The amber status reflects the ongoing nature of this work which will develop over time. NCL joint governance arrangements are still beingestablished including the delivery of the Sustainability and Transformation Plan.

Joint working between Camden CCG and the local authority continues to be strengthened, including: ongoing joint commissioning arrangements; the development of the 2016/17 Better Care Fund (BCF) plan; joint development of the work plan for the Council’s Health and

Adult Social Care Scrutiny.Camden CCG is also working closely with partners on the development of the Out of Hospital strategy, under a governance board with key local partners.There is close partnership working with the Health and Wellbeing Board. Work with NCL continues in a number of areas including: mental health, urgent and emergency care work; cancer; Transforming Care plan; the Sustainability and Transformation Plan; joint procurements (e.g. 111/OOH).

Chief Officer

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Objective G: Maintain financial stability and sustainability through robust planning and commissioning of value-for-money service

PrioritiesPG1. Effectively plan the services to be commissioned to maximise patient valuePG2. Encourage deeper partnerships between finance and other functionsPG3. Develop effective financial governance through an aligned organisational development strategy

Accountable:Chief Finance OfficerDirector of Sustainable Insights

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Objective G (Graph 13) - Initiatives Scheduling(by year)


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Objective G (Graph 14) - Initiatives by RAG Status (15/16)



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Objective G (cont’d): Maintain financial stability and sustainability through robust planning and commissioning of value-for-money service



G3 Increase the clarity and effectiveness of financial governance across the CCG and commissioning with partners

This initiative continues to be amber until the financial review has been completed.

Chief Finance Officer is now substantively appointed. Budget holder training has been conducted with positive feedback. Governing Body seminar on financial allocations and long term strategic financial planning has been completed. Independent baseline financial review is being undertaken and will make recommendations on financial governance and QIPP governance. A review of governance meeting schedules is underway to ensure that the latest finance and performance information is presented to Governing Body.


24347 of 443

Objective H: Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce

PrioritiesPH1. Develop an HR strategy that aligns the organisation with the Camden business planPH2. Ensure that fair and consistent recruitment processes are undertaken to recruit high calibre staff to help the CCG deliver service excellencePH3. Implement a robust appraisal system and performance management frameworkPH4: Improve staff wellbeing to develop an engaged workforce that feels supported and valued

Accountable:Chief of StaffChief Finance Officer


Key Updates

• Staff representative forum launch due in February 2016• A range of HR policies were updated and approved by Executive Team in January 2016• Updates to HR processes, to reflect current business requirements, will be proposed to the Executive Team for approval in March

3

1

Objective H (Graph 16) - Initiatives by RAG Status (15/16)


4

2

2

2

0

1

2

3

4

5

15/16 16/17 17/18

Objective H (Graph 15) - Initiatives Scheduling(by year)


25348 of 443

Objective H (cont’d): Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce



H2 Review of CSU contracted services, including effectiveness and capacity of currently outsourced functions

Arrangements for robust contract monitoring are in place. However, this initiative continues to be amber whilst the CCG continues to work with the CSU to improve effectiveness and capacity.

The Chief Finance Officer (CFO) meets with local managers and senior CSU leadership on a monthly basis. The CFO has agreed a framework for internal service review, with the CSU. This review will link into the CCG’s HR and

organisational development strategy to optimise services.


H3 Develop robust HR processes, policies and controls including recruitment policies and management standards

Work is ongoing on remaining policies. The internal resource to lead on this initiative is now in place.

A range of HR policies were updated and approved by Executive Team in January 2016. These will be effective from 1st March 2016.

Recruitment policy/best practice will be reviewed and a streamlined process implemented by June 2016.

Process for the approval of workforce requests (establishment control) will be proposed to the Executive Team in March 2016.

Chief of Staff

H4 Write the organisational development strategy,which should cover development programmes for CCG staff, skills training, and performance management appraisals.

Organisational Development (OD) strategy developed and signed off in September 2015 as per the plan. An implementation schedule has been developed and started, by the new Head of HR and OD, but is in its early stages.

The revised appraisal policy linking to competency framework will be implemented by May 2016.

Staff representative group launched (February 2016).

Work is underway to integrate the HR and OD strategies and is due to be completed by May 2016.

Chief of Staff

26349 of 443

350 of 443


Report Title Localities Report

Agenda Item 5.1 Date

26/02/16

Lead Director Ian Porter, Assistant

Director, Corporate Services


Report Author Francesca McNeil, Head of Communications Wayne Rabin, Member Relations Manager

Tel/Email [email protected] [email protected]

GB Sponsor(s) Dr Martin Abbas Dr Burgit Curtis Dr Jonathan Levy

Tel/Email

Report Summary

This paper is a summary report of the Locality meetings held in January 2016.


Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of this paper.


Involve Member Practices and commissioning partners in key commissioning decisions.


There are no risks associated with this report.


None


None

Engagement




Report History A Locality Report is presented at every Governing Body meeting.

Next Steps

None

Appendices None

351 of 443




Summary Report from the Camden CCG Locality Committees

Introduction Since the last meeting of the Governing Body, the North, West and South Locality Committees have met once, in January 2016. The February Committees were replaced by a primary care planning meeting with Camden practices, coordinated with the Camden Local Medical Committee and Camden Federation. A separate report on this meeting will be available. Topics Covered The following agenda items were considered at January Locality Committees:-

Community Nursing Project

An update on the Community Nursing project was given - developed following a Central North West London NHS Foundation Trust (CNWL) community services review that found Camden is under-resourced in terms of district nurses (DNs), compared to London and national benchmarks. A number of district nursing model options, all of which include additional investment, have been developed. Locality attendees were asked for feedback and a number of points were raised, including: - The need to clearly specify the issues this project is trying to address, such as improving

continuity of care, in the CCG business case - The need for baseline data re: referrals to DN and practice nurses (PNs), and any cross-over,

to establish whether DNs have a skill set that enables them to ‘step into’ a PN role - Whether recruiting additional PNs (rather than DNs) was being considered, if transition funding

is available for additional staff.

PMS Review – Commissioning Intentions

The Head of Primary Care provided an update on the PMS Contract review. This included details of the new service requirements for PMS practices published by NHS England in December. Practices asked for clarity on the transition timeframe and noted that, at the time of the January Committees, PMS practices in Camden had not yet received their baseline figures from NHS England. The CCG committed to coming back to practices with further information.

CCG Operating Plan 2016/17

The Localities were informed that, in addition to the Camden CCG one year Operational Plan for 2016/17, the CCG was required to develop a five year Sustainability and Transformation Plan with the other four North Central London CCGs, and that the Operational Plan would be regarded as year one of the Five Year STP, with a submission date to NHSE of 11th April. The CCG committed to bringing updates on development of the NCL STP to future meetings.

RAPIDS

The South Locality Committee received RAPIDS activity data by GP surgery which showed significantly lower usage of the service in the South locality compared to the North. RAPIDS had indicated that they had the capacity to take further referrals from the South locality. In discussion, difficulties in terms of RAPIDS accepting referrals were highlighted. The CCG committed to clarifying the RAPIDS referral criteria.

352 of 443

Children’s Services

South Locality received an update on Camden Sure Start Children’s Service and Camden’s Integrated Child Health Project, which had been discussed at the December North and West Locality meetings.

Female Genital Mutilation (FGM)

The Localities noted new mandatory reporting requirements in relation to FGM. With effect from 1st October 2015, all GP practices are required to have introduced an FGM Enhanced Dataset and to have developed a method to capture and submit this information on a monthly basis.

New Member Relations Function In January, the CCG established two new posts within the Communications and Engagement team – a Member Relations Manager and Membership Secretary. With effect from February, Locality Committee and Membership Summit organisation transferred to the Member Relations team. The process for agenda setting is being revised and guidance with regard to proposing topics, submitting content and presenting at Committees and Summits introduced. The goal is to ensure Committees and Summits reflect the priorities of, and topics of most interest to, our members. The revised process will ensure events provide a greater opportunity for members to understand, review, discuss and make informed decisions on CCG commissioning plans and services. The Member Relations team is updating the Terms of Reference for the Locality Committees to align with the work being undertaken by the Governance team on the CCG Constitution. The Member Relations team also coordinated the first Member Relations Working Group meeting in February, which focused on delivering the Member Relations Action Plan approved by the CCG Chair and Chief Officer in January 2016.

353 of 443

354 of 443


Report Title Board Assurance Framework

Agenda Item 5.2

Date 2nd March 2016

Lead Director Ian Porter, Assistant Director

Corporate Services

Tel/ Email

[email protected]

Report Author Andrew Spicer, Governance Lead

Tel/ Email

[email protected]


Ellen Schroder, Lay Member Governance and Audit

Tel/ Email

[email protected]

Report Summary The Board Assurance Framework (‘BAF’) captures the main risks identified as

threatening the achievement of the CCG’s eight business plan objectives. The BAF was last reviewed by the Executive Team on 29th February 2016, Audit Committee on 27th January 2016 and by the Governing Body on 11th November 2016. Number of risks There are 19 risks on the BAF. One is a new risk and two are recommended for removal. Key Risks The key risks to bring to the attention of the Governing Body in relation to finance and performance are:

323: This is a new risk. 1. The aggressive pace of change policy adopted by NHS England has drastically reduced the funds available to the CCG for the 5 year period 2016/17 to 2020/21. Material cost reductions are required to maintain compliance with NHS England business rules. 2. There is a risk that Camden CCG does not make the necessary cost reductions. 3. This may result in Camden CCG going into financial deficit;

242: 1. If there is poor performance against contractual standards by Camden CCG providers. 2. There is a risk that the CCG does not achieve NHS constitutional targets. 3. This may result in the CCG not demonstrating that we are commissioning for delivery of NHS constitutional rights and pledges.

Risks proposed for removal There are two risks on the BAF that are recommended for removal:

Risk 3: 1. Barnet and Chase Farm Hospital's integration with the Royal Free London Hospital is in its early stages and continues to face organisational and financial challenges. 2. The risk is that attention and energies may be diverted from RF delivery. 3. This may result in poorer services for Camden residents. This risk is covered by other risks on the Board Assurance Framework and Corporate Risk Register;

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Risk 10: If budget holders fail to actively engage in monitoring budgets and programmes with local managers and CSU. 2. The CCG may not receive timely reporting and forecasting. 3. This would mean the CCG would be unable to identify and/or understand the adverse or favourable performance against financial targets and the need for mitigating actions to achieve those financial targets.

This risk has been reassessed to ensure the risk is addressed from a strategic planning level and has been replaced with a new risk number 323.

Risks owned by Acting Director of Commissioning and Chief of Staff All risks previously owned by the Acting Director of Commissioning and by the Chief of Staff have been reassigned to the appropriate directors.



Decision

Recommendation The Governing Body is asked to review the risks and feedback on the updated BAF.


The BAF focuses on risks relating to the strategic areas from the mission statement as set out in the Business Plan, which are:

A. Commission the delivery of NHS constitutional rights and pledges B. Improve the quality and safety of commissioned services C. Improve health outcomes, address inequalities and achieve parity of esteem D. Integrate and enable local services to deliver the right care in the right

setting at the right time E. Work jointly with the people and patients of Camden to shape the services

we commission F. Involve member practices and commissioning partners in key

commissioning decisions G. Maintain financial stability and ensure sustainability through robust planning

and commissioning of value-for- money services H. Build a high performing organisation that attracts, develops and retains a

skilled and motivated workforce.


The BAF is a risk management document.

The BAF is presented at public meetings of the Governing Body at every other Governing Body meeting (every four months) and is available to members of the public on the CCG’s website.


There are no conflicts of interest arising from this paper.


Updating of the BAF is the responsibility of each risk owner and their respective directorates. The Governance Team helps to support this by providing monitoring, guidance and advice.

Engagement



This report was written in accordance with the provisions of the Equality Act 2010.

Report History The BAF was last reviewed by the Executive Team on 29th February 2016, Audit Committee on 27th January 2016 and by the Governing Body on 11th November 2016.

Next Steps To continue to manage risk across the organisation in a robust way.

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Item 5.2 Appendix 1

STRATEGIC RISK SUMMARY

STRATEGIC OBJECTIVES:A Commission the delivery of NHS constitutional rights and pledgesB Improve the quality and safety of commissioned servicesC Improve health outcomes, address inequalities and achieve parity of esteemD Integrate and enable local services to deliver the right care in the right setting at the right timeE Work jointly with the people and patients of Camden to shape the services we commissionF Involve member practices and commissioning partners in key commissioning decisions

G Maintain financial stability and ensure sustainability through robust planning and commissioning ofvalue-for- money services

H Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce

Ref Risk

Clin

ical

Finan

cial

Rep

utatio

nal

Pre-m

itigation

risk rating

Po

st-mitigatio

n

risk rating Key changes since last review

8

1. Insufficient clarity with regards to our partner organisation priorities and stakeholder interests. 2. This could lead to divergent priorities, failure to work with partner agencies, creating ineffective partnership culture and behaviours, to lead the healthcare system 3. This could result in an adverse effect on achievement of the corporate objectives.

a a a

12 9

1. NCL Transformation Board established and first meeting was held on 24.2.16.

11

1. Structural changes in CSU and contracting arrangements.2. Could result in a failure to establish timely and high quality of reporting.3. With the consequence the CCG is not able to monitor contracts, service change trajectories and delivery.

a a

6 6

1. Quarterly review of information is in progress and a full review of all service lines purchased from NEL CSU is to be undertaken in 2016-17.

12

1. Failure to follow governance arrangements.2. Could result in financial penalties for not discharging our statutory responsibilities correctly, significantly compromised reputation and flawed clinical solutions that 3. Diminish the quality of services.

a a a

16 6

1. NCL Conflicts of Interest Policy was agreed.2. Head of Primary Care recruited.3. Procurement Committee considered report of Haverstock Healthcare Limited shareholders.4. Risk Audit was undertaken by internal auditors and actions agreed.

13

1. If the CCG was not to maintain its accredited safe haven status, 2. The CCG could lose its ability to manage its own data flows3. This would mean the CCG would have to rely on the Health and Social Care Information Centre's more limited data set resulting in an inability to accurately report.

a a

12 2

1. Risk descriptor amended;2. Initial risk rating regraded from 9 to 12;3. Current risk rating regraded from 3 to 2;4. Internal audit on Accredited Safe Haven status complete and being presented to Audit committee in March 2016.

14

1. Not meeting our public sector and statutory equalities and diversity duties consistently.2. Could lead to seldom heard communities experiencing unequal health outcomes, legal challenge.3. Lost confidence in the CCG to meet the needs of all the community.

a a

12 9

1. Governing Body Seminar on Equalities arranged for March 2016;2. Developing the Equality and Diversity strategy 2016-20.

15

1. CCG does not have adequate systems in place to measure how cost effective services are. 2. Lack of baseline assessment makes it difficult to measure impact of changes.3. This results in the CCG not being able to determine whether investment delivering improvement to objective.

a

16 9

1. QIPP planning for 2016-17 has been completed.2. NCL Sustainability and Transformation Plan under development.

16

1. If the CCG does not seek, listen to and appropriately respond to feedback from Camden residents, patients and leaders.2. There is a risk that Camden patients and/or other key stakeholders disengage from Camden CCG's work.3. Resulting in reputational damage to the CCG and hindering our ability to commission services that take our patients' needs into account.

a

12 9

1. Risk descriptor amended to reflect risk.2. Head of Communications and Engagement recruited.3. Increased social media monitoring.

20

1. Not sufficiently shifting preventative care and finances away from the acute setting2. Leading to increased expenditure, poor clinical outcomes 3. Unnecessary ill-health a a

16 121. Out of Hospitals Strategy being developed.

21

1. Significant CCG resource requirements to provide NHS England with assurance and assist in NCL collaborative working.2. Impacts on the resources available to deliver the CCG’s corporate objectives.

3. Resulting in the risk of not fully meeting corporate objectives.

a a

16 12

1. Head of Performance in place;2. Interim Head of Assurance in place;3. A standardised approach to updating systems to provided consistent information to addressing changing priorities is under development.

51

1. The CCGs financial position.2. Could lead to focussing on issues of affordability rather than cost effectiveness and quality.3. The CCG does not deliver cost-effective and quality based service change.

a a a

9 9

1. Procurement Policy has been updated and is being finalised;2. Case training made available to budget holders.

Item 5.2 Appendix 1 357 of 443

Item 5.2 Appendix 1

52

1. CCG may not be fully utilising the Joint Strategic Needs Assessment (JSNA) to inform commissioning intentions2. Risks inappropriate commissioning intentions3. That result in the CCG's corporate objectives not being met in respect of meeting patient needs a a

12 9

1. Business Plan approved;2. Operating Plan approved.

72

1. NHS England Sis- Processes not in place to share information relating to patients in NHS England commissioned services. 2. Without formal processes in place for NHS England to share relevant SI information with Camden CCG the CCG will not be aware of relevant safety events. 3. This could impact on the CCG's responsibility to assure and improve delivery of safe, effective and responsive services.

a a

15 9

1. Camden CCG has contacted NHS England to raise issues;2. NHS England to establish a systematic process for dissemination of Sis relevant to CCGs from NHS England specialist commissioned services.

240

1. Inability to establish a baseline for current service costs.2. Prevents the CCG from effectively evaluating the impact of change.3. This could result in investment in services which do not deliver the required outcomes.

a a

16 9

1. No key changes.

241

1. The contractual and payment models do not support the clinical service transformation we are trying to achieve.2. This prevents us from delivering the transformation.3. Resulting in the CCG not delivering the required integration of services. a

16 9

1. Work progressing on new contractual models.

242

1. If there is poor performance against contractual standards by Camden CCG providers.2. There is a risk that the CCG does not achieve NHS constitutional targets.3. This may result in the CCG not demonstrating that we are commissioning for delivery of NHS constitutional rights and pledges. a a

20 16

1. New Head of Performance in post;2. Interim Head of Assurance in post.

243

1. Current contracting models do not incentivise providers to remove costs as part of the implementation of projects and programmes. 2. The CCG may not realise the savings forecasted within each project and programme.3. This may not support the development of services in primary care and community. a a

16 8

1. Productivity metrics monitored through QIPP programme.

323

1. The aggressive pace of change policy adopted by NHS England has drastically reduced the funds available to the CCG for the 5 year period 2016/17 to 2020/21. Material cost reductions are required to maintain compliance with NHS England business rules.2. There is a risk that Camden CCG does not make the necessary cost reductions.3. This may result in Camden CCG going into financial deficit.

a a a

20 16

New risk

3

1. Barnet and Chase Farm Hospital's integration with the Royal Free London Hospital is in its early stages and continues to face organisational and financial challenges. 2. The risk is that attention and energies may be diverted from RF delivery, 3. This may result in poorer services for Camden residents. a a a

12 8

1. Risk to CCG covered by other risks. Recommended for removed from BAF.

10

1. If budget holders fail to actively engage in monitoring budgets and programmes with local managers and CSU2. The CCG may not receive timely reporting and forecasting3. This would mean the CCG would be unable to identify and/or understand the adverse or favourable performance against financial targets and the need for mitigating actions to achieve those financial targets a

6 6

1. Risk replaced with risk 323. Recommended for removal from BAF;2. Two new senior management accountants appointed.

Item 5.2 Appendix 1 358 of 443

BAF Risk Heat Map

2 3 4 5

3

4

5

Consequence

Likelihood

2

1

1

21

240

10 11

Item

5.2

Ap

pe

nd

ix 2

20

10

3

51

242

242

11

20

16

241

Pre mitigation: Post mitigation:x x

16

21

51

12

1213

13

240 241

243243

52

52

3

72

72

14

14

8

8

15

15

323

323

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Updated Board Assurance Framework - March 2016

ID Director Principal objectives DescriptionConsequence

(initial)Likelihood

(initial)Rating (initial)

Risk level (initial) Controls in place Gaps in controls Assurances Gaps in AssuranceConsequence

(current)Likelihood (current)

Rating (current)

Risk level (current)

DescriptionReporting/Monitoring

requirementsDate of last review

(dd/mm/yyyy)

8Susan Achmatowicz - Chief Operating Officer

Commission the delivery of NHS Constitutional rights and pledges, Improve health outcomes, address inequalities and achieve parity of esteem, Involve member practices and commissioning partners in key commissioning decisions

1. Insufficient clarity with regards to our partner organisation priorities and stakeholder interests. 2. This could lead to divergent priorities, failure to work with partner agencies, creating ineffective partnership culture and behaviours, to lead the healthcare system.3. This could result in an adverse effect on achievement of the corporate objectives.

4 3 12 Moderate

1. CCG Business Plan in place. This involves stakeholder and partner engagement, with the CCG Operating Planning process engaging partner agencies;2. Business Plan describes the priorities;3. Joint work with stakeholders and partners to engage them in the development phase of any joint working arrangements;4. Review of Commissioning Intentions at the Health and Wellbeing Board. Commissioning intentions letters are then sent to inform providers;5. Operating Plan as per NHS England requirements;6. CCG Communications Plan;7. Business Plan for 2015/16 agrees priorities;8. Annual 360 stakeholder feedback;9. Head of Communications and Engagement recruited;10. NCL Transformation Board Established.

1. Do not currently have an agreed 5 year plan across Strategic Planning Group as per NHSE requirements.

1. Engagement with providers; Joint planning work with partners; Feedback from partners; Partner strategic plans; Joint planning meetings;2. The feedback on the authorisation 360 degree survey strongly indicated that partners understood our priorities; the planning meetings with other CCGs and the CSU team indicate that we are working effectively and with sufficient clarity; 3. The Health and Wellbeing Board is now formally in place and supports the development of partnership working;4. We have completed our operating plan; 5. GB lead for Communications & Engagement;6. First meeting of NCL Transformation Board took place on 24.2.16.

No gaps 3 3 9 Moderate

A1. Aiming to establish an NCL wide communications and engagement group;A2. Sustainability and Transformation Plan to be developed.

A1. In progress;A2. Plan is under development as is on target to submit the first draft by the deadline of 31.3.16.

29/02/2016

11Ian Boyle - Chief Finance Officer


1. Structural changes in CSU and contracting arrangements.2. Could result in a failure to establish timely and high quality of reporting.3. With the consequence the CCG is not able to monitor contracts, service change trajectories and delivery.

3 2 6 Low

1. Project plan and assurance framework for CSU;2. Close involvement around minimum requirements and reporting;3. Monthly information reports;4. CSU Improvement Group formed in July 2014 to address key CCG concerns;5. Measurement of KPIs agreed with CCGs from November 2014;6. Quarterly reviews of information.

1. MDT Lead (senior liaison officer at the CSU) agreed;2. CSU Improvement Group action log.

3 2 6 Low

A1.Undertake quarterly review of information;A2. Framework for keeping information provision up to date;A3. Full review of all service lines purchased from CSU to be undertaken in 2016/17.

A1. In progress;

A2. Residual risk has been raised to reflect ongoing challenges.

29/02/2016

12Ian Porter - Associate Director of Corporate Services.


1. Failure to follow governance arrangements.2. Could result in financial penalties for not discharging our statutory responsibilities correctly, significantly compromised reputation and flawed clinical solutions that 3. Diminish the quality of services.

4 4 16 High

1. Committee oversight, particularly Audit Ctte;2. Internal and external audit;3. BAF and Corporate Risk Register;4. Programme Management Office in place and supporting all projects and programmes;5. Budget controls, including standing financial instructions;6. Whistle-blowing policy;7. Identified leads for key governance roles: Caldecott Guardian; SIRO etc;8. NHS England Assurance process;9. Dedicated governance day in Induction programme for Governing Body;10. Relevant reports considered by the Procurement Committee;11. Joint NCL CCG conflict of interest policy agreed;12. Clincial Lead induction completed;13. Governance strengthened in Constitution.

1. Risk management strategy and process needs to be amended following internal auditor's report.

1. Auditor's governance report;2. Analysis of risk registers;3. Reports and attendance at committees;4. IPSOS stakeholders survey;5. Staff surveys;6. Media reporting;7. NHS England assurance feedback;8. NCL CCG Governance Leads Group established;9. New Executive Team in place;10. Head of Primary Care in place;11. Governance Lead in place;12. Procurement Committee considered paper on Haverstock shareholders.

3 2 6 Low A1. Implement the planned action on risk management contained in the Internal Auditor's Report on BAF and Risk Management

A1. Actions have been agreed with the internal auditors.

27/02/2016

13Charlotte Mullins - Director of Sustainable Insights

Improve the quality and safety of commissioned services

1. If the CCG was not to maintain its accredited safe haven status, 2. The CCG could lose its ability to manage its own dataflows3. This would mean the CCG would have to rely on the Health and Social Care Information Centre's more limited data set resulting in an inability to accurately report.

4 3 12 Moderate

1. Annual assurance statement provided via Information Governance review;2. Data sharing agreements between HSCIC and CCG in place;3. Internal audit review of Accredited Safe Havens process.

1. Potential national plan to close Accredited Safe Havens and move to central body provided by HSCIC. We are awaiting the outcome of the Caldicott 3 review.

1. Information Governance Toolkit;2. Audit of Action Plan to achieve ASH status requirements;3. Audit committee minutes and report.

1. IG toolkit has limitations in data flow mapping (not all historical data flows have been mapped).

2 1 2 Very low

A1. System process and policy documentation to be developed;A2. Ensure compliance with IG toolkit level 2;A3. Internal audit review of Accredited Safe Haven status.

A1. In progress;A2. In progress- estimated score 76% (Satisfactory); A3. In progress. The audit is complete with review to be presented to Audit Committee on 16.03.16.

29/02/2016

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(initial)Likelihood




Rating (current)




(dd/mm/yyyy)


Improve health outcomes, address inequalities and achieve parity of esteem

1. Not meeting our public sector and statutory equalities and diversity duties consistently.2. Could lead to seldom heard communities experiencing unequal health outcomes, legal challenge.3. Lost confidence in the CCG to meet the needs of all the community.

3 4 12 Moderate

1. Equalities Plan;2. Governing Body sponsor;3. Commissioning Plan adopting an equalities-based methodology;4. Community Ownership Plan;5. Equality Impact Assessments (template simplified);6. Coversheets requiring Equalities analysis;7. Camden Patient and Public Engagement Group (CPPEG);8. CSU Equalities expert support;9. Internal officer identified to lead on equalities;10. CET quarterly EDS2 progress Report introduced (part of integrated reporting);11. Equalities part of Governing Body members' induction in February 2016;12. Equality information report was presented at the January 2016 Governing Body meeting;13. EDS2 progess is being monitored and tracked.

1. Plan on a page;2. Analysis of equalities work plan;3. Analysis of Communications and Engagement Plan 2016-17;4. Equalities Information Update;5. Updates to Governing Body and Borough Executive Team;6. EDS2 Equalities Group chaired by Lay Member Equalities Lead;7. CET action log;8. Equalities report to governing body;9. Internal audit green rating on equality & diversity August 2015;10. EDS2 progress tracker.

3 3 9 Moderate

A1. The EDS2 workplan to be finalised and actioned;A2. Progress reports will be provided to CET quarterly and to Governing Body annually;A3. Director to be invited to ED2 group (chaired by Lay Member) to discuss progress against actions;A4. Arrange a Governing Body seminar on equalities;A5. Develop the Equality and Diversity strategy 2016-20.

A1. In progress;A2. In progress;A3. In progress;A4. Seminar has been arranged for March 2016;A5. Under development.

29/02/2016


Improve health outcomes, address inequalities and achieve parity of esteem, Integrate and enable local services to deliver the right care in the right setting at the right time

1. CCG does not have adequate systems in place to measure how cost effective services are. 2. Lack of baseline assessment makes it difficult to measure impact of changes.3. This results in the CCG not being able to determine whether investment delivering improvement to objective.

4 4 16 High

1. Using local and national benchmarking to assess spend, supported by the Sustainable Insights Team.

1. Changes to benchmarking;2. Outcome reviews.

3 3 9 Moderate

A1. Budgetary review of value for all acute and community spend

A1. As part of the QIPP Planning for 2016/17 this has been completed. During 2016/17 and underpinning the STP the CCG must clealry linbk external benchmarking, Right Care, Anytown CCG and Sustainable Insights data to formulate longer term systemic QIPP plans to drive quality for patients.

29/02/2016


Improve health outcomes, address inequalities and achieve parity of esteem, Integrate and enable local services to deliver the right care in the right setting at the right time

1. If the CCG does not seek, listen to and appropriately respond to feedback from Camden residents, patients and leaders.2. There is a risk that Camden patients and/or other key stakeholders disengage from Camden CCG's work.3. Resulting in reputational damage to the CCG and hindering our ability to commission services that take our patients' needs into account.

3 4 12 Moderate

1. CCG Communications & Engagement Plan delivery;2. CSU media handling and CCG media management protocols:* CCG Communications and Engagement support for SI management;* CCG Communications and Engagement support for HOSC and JHOSC;3. NCL CCG Communications Leads Group - Camden CCG attendance;*Camden & Islington Stakeholder Engaement Network - Camden CCG attendance;4. Communications & engagement updates to SMT and GB;5. Proactive horizon-acanning to identify potential issues;6. Use of outomes measures;7. Head of Communications and Engagement Recruited.

1. CPPEG;2. IPSOS survey;3. Media & FOI monitoring reports;4. Question Time with the Chair;5. Committee Chairs meeting;6. NHSE Governance assurance process;7. Media monitoring;8. Social media channels.

3 3 9 Moderate

A1. Recruit Head of Comms & EngagementA2. Establish regular media monitoring protocol with NEL CSUA3. Continued reporting to Executive Team and the Governing Body through usual chanels

A1. Action completed. Head of Comms and Engagement in place;A2. In progress;A3. In progress.

29/02/2016



1. Not sufficiently shifting preventative care and finances away from the acute setting.2. Leading to increased expenditure, poor clinical outcomes.3. Unnecessary ill-health.

4 4 16 High

1. Primary Care Programme;2. Review of expenditure and financial controls;3. Contracting process;4. Clear strategic plans to allow shift to occur;5. Out of Hospital Programme initiated, engaging local stakeholders in agenda;6. Joint Health and Wellbeing strategy;7. Business plan agreed;8. GP Practices have federated.

1. Out of Hospital strategy to be developed;2. Long term plan to manage acute activity growth to be developed.

1. Activity shift arising from the plan;2. Acute expenditure;3. Number of services consistently within primary care

1. No out of hospital strategy.

4 3 12 ModerateA1. GP Practices federating;A2. Develop Out of Hospital Strategy;A3. New models of care.

A1. GP Practices have federated and work is ongoing;A2. Work is progressing on the Out of Hospital Strategy;A3. Camden is one of the few CCG areas to see A&E attendance drop that has received national attention and praise

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(initial)Likelihood




Rating (current)




(dd/mm/yyyy)

21Dorothy Blundell - Chief Officer

Commission the delivery of NHS Constitutional rights and pledges, Improve health outcomes, address inequalities and achieve parity of esteem, Improve the quality and safety of commissioned services

1. Significant CCG resource requirements to provide NHS England with assurance and assist in NCL collaborative working.2. Impacts on the resources available to deliver the CCG’s

corporate objectives.3. Resulting in the risk of not fully meeting corporate objectives.

4 4 16 High

1. Sructured assurance meetings with NHSE to provide assurance and receive NHSE feedback;2. NCL specifice Programme Managemnent Office (PMO)established for the NCL Collaboration Board with dedicated resource (the TSDO);3. Dedicated assurance resource in place within the CCG;4. Head of Performance in place;5. Interim Head of Assurance in place.

1. Record of assurance meetings;2. Minutes of the NCL Collaboration Board;3. The CCG is closely monitoring progress in meeting NHS England requests;4. A weekly assurance briefing is circulated to the Executive Team with a summary also provided in Governing Body briefings.

4 3 12 Moderate

A1. Recruit substantive Head of Assurance;A2. Developing standardised approach to updating systems to provide consistent information to address changing priorities.

A1. Substantive recruitment is on-going;A2. In progress. 29/02/2016



1. The CCG's financial position.2. Could lead to focussing on issues of affordability rather than cost effectiveness and quality.3. The CCG does not deliver cost-effective and quality based service change.

3 3 9 Moderate

1. Clear guidance around driving cost-effectiveness and value;2. Planning to identify QIPP and areas for service change;3. Decision criteria/thresholds for business cases;4. Training and awareness raising;5. Greater engagement with the Finance and Quality & Safety teams.

1. Robust business cases for service change;2. Monitoring in year;3. Business Cases positions being reported monthly to Commissioning Committee.

3 3 9 Moderate

A1. Revise, communicate and train on business case development and substance;A2. Update Procurement Policy.

A1. Case training made available to budget holder via pipeline planning process;A2. Policy has been updated and required finalising.

29/02/2016


Improve health outcomes, address inequalities and achieve parity of esteem, Integrate and enable local services to deliver the right care in the right setting at the right time, Involve member practices and commissioning partners in key commissioning decisions, Work jointly with the people and patients of Camden to shape the services we commission

1. CCG may not be fully utilising the Joint Strategic Needs Assessment (JSNA) to inform commissioning intentions.2. Risks inappropriate commissioning intentions.3. That result in the CCG's corporate objectives not being met in respect of meeting patient needs.

3 4 12 Moderate

1. Forward Planning for Governing BodyGB sign off of JSNA;2. CCG involvement of development of JSNA;3. Annual srategic planning process;4. Business case process;5. JSNA development workshop.

1. Forward Plan for Governing Body;2. Business case;3. Meeting minutes;4. JSNA strategic plans;5. IPSOS Mori;6. Feedback on the Business Plan from Partners.

1. No gaps 3 3 9 Moderate

A1. IPSOS findings feeding into acute plan;A2. Sustainable Insights Team working with Public Health on segmentation of populations data.

A1. Work on-going;A2. Work on-going.

29/02/2016

72Neeshma Shah - Director of Quality and Clinical Effectiveness

Improve the quality and safety of commissioned services

1. NHS England SIs - Processes not in place to share SI Information relating to patients in NHS England commissioned services. 2. Without formal processes in place for NHS England to share relevant SI information with Camden CCG, the CCG will not be aware of relevant safety events. 3.This could impact on the CCG's responsibility to assure and improve delivery of safe, effective and responsive services.

3 5 15 High

1. Contact made with relevant leads at NHS England to raise this issue;2. Quality Surveillance Groups are set up which bring together different commissioners and regulators;3. NHSE have now established a serious incident (SI) reporting system for primary care.

1. Future actions are largely out of the CCG control. Requirement is for NHS England to set up systematic processes, especially for dissemination of SIs relevant to CCGs. The implication is that the CCG is not cited on matters for which it has responsibility; 2. CCG is still not receiving any quality and safety updates for GOSH and primary care, and this has been raised with NHSE at assurance meeting on 17th October 2013. CCG is still not receiving any quality and safety updates for GOSH and primary care.

1. Contact made with relevant leads at NHS England to raise this issue; 2. NHS E confirmed in May 2014 that they are considering a methodology for sharing information about service providers that are commissioned directly by them.

1. Future actions are largely out of the CCG control. Requirement is for NHS England to set up systematic processes, especially for dissemination of SIs relevant to CCGs. The implication is that the CCG is not cited on matters for which it has responsibility;2. CCG is still not receiving any quality and safety updates for GOSH and primary care, and this has been raised with NHSE at assurance meeting on 17th October 2013.

3 3 9 Moderate

A1. Contact made with relevant leads at NHS England to raise issue;A2. NHS England to set up systematic processes for dissemination of SIs relevant to CCGs from NHS England specialist commissioned services.

A1. Contact made- At present still no receipt of formal reports from NHSE. 29/02/2016



1. Inability to establish a baseline for current service costs.2. Prevents the CCG from effectively evaluating the impact of change.3. This could result in investment in services which do not deliver the required outcomes.

4 4 16 High

1. Service specifications detailing expected outcomes from services;2. Contract reviews against budgeted baselines;3. Acute and Community Performance reviews;4. Monthyl finance review meeting with CSU;5. Reprocurement and review work planned in both Community Services and Mental Health.

1. Information from Performance Reviews report to the Finance and Performance Committee;2. Data validation and assurance checks;3. Quarterly budget updates;4. Annual Outcome review.

3 3 9 Moderate

A1. Budgetary review of value for all acute and community spend- subject to gaining access to the data;A2. Details of the impact of the changes are identified in the Business Case;A3. Review of impact to be conducted after 12 months subject to access to data;A4. Taks and Finish Group to be established.

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1. The contractual and payment models do not support the clinical service transformation we are trying to achieve.2. This prevents us from delivering the transformation.3. Resulting in the CCG not delivering the required integration of services.

4 4 16 High

1. Contracting process development of commissioning;2. Value based commissioning work;3. Development of different contracting models;4. Publish commissioning intentions;5. New types of contract in place and working.

1. Finance and Performance Committee oversight;2. Commissioning Committee oversight.

3 3 9 Moderate

A1. Intentions reflecting Value Based Commissioning work;A2. Work with UCLH, RFL and other providers;A3. Implement examples e.g. Mosaic, diabetes;A4. Task and Finish Group to be established.

A1. Action completed. The Diabetes VBC contract signed on 6/07/2015. The Mental Health VBC Business Case due in September 2015;A2. Action complete. There has been good engagement with a range of trusts. There is some concerns regarding Royal Free London as the lead provider.Action is complete and examples are in place.

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Commission the delivery of NHS Constitutional rights and pledges

1. If there is poor performance against contractual standards by Camden CCG providers.2. There is a risk that the CCG does not achieve NHS constitutional targets.3. This may result in the CCG not demonstrating that we are commissioning for delivery of NHS constitutional rights and pledges.

4 5 20 High

1. Performance monitoring.2. Conteract Query Notices.3. Contract meetings.4. Balanced scorecard for the Governing Body.5. Tri-partite panel in place.6. RTT recovery plan in place.7. Reporting systems in place.8. Systems Resilience Group.9. Business Plan.

4 4 16 High

A1. Continued reporting;A2. Review of progress against improvement plans;A3. Implement McKinsey review and performance;A4. Business Plan objective;A5. Performance Report to September 2015 Governing Body meeting.

The CCG is using a performance trajectory plan approach to manage the areas of concern. Plans are derived through Contract Query Notices. Risks in the areas remain high. This risk was also discussed at the February 2015 Governing Body seminar.A3. Implementation work is on-going.A4. Action complete.A5. Action completed.

27/10/2015



1. Current contracting models do not incentivise providers to remove costs as part of the implementation of projects and programmes. 2. The CCG may not realise the savings forecasted within each project and programme.3. This may not support the development of services in primary care and community.

4 4 16 High

1. The Camden Integrated Care Steering Group monitor both activity in the new community services in relation to activity going through acute outpatients/A&E/Admissions;2. Performance management structures in place. Monthly meeting with providers. Projects aimed at reducing referrals and admissions;3. Escalation as necessary to the Finance and Performance Committee;4. Specific work taking place with UCLH on Productive Outpatients and the RFL with regards to the acquisition of Barnet and Chase Farm;5. Productivity metrics in RF & UCLH contracts have been agreed in 2014-15 contracts;6. Commissioning intentions;7. PMO/Sustainable Insights agreed methods of monitoring financial impact;8. Role of QIPP improved.

1. To develop new innovative contractual and payment models to disincentivise 'auto-fill' within acutes. For example, by negotiating a cap and collar arrangement for LTC OP to ensure that the step down trajectory is achieved;2.Change contracting approach to reward outcomes achieved rather than activity performed;3. Joint performance management structures following Barnet and Chase Farm acquisition.

4 2 8 Moderate

A1. Reviewing effectiveness of newly agreed productivity metrics in Royal Free & UCLH Contracts;A2. Improve role of QIPP in articulating and delivering cost reductions;A3. PMO/Sustainable Insights to agree methods of monitoring financial impact;A4. Task and Finish Group to be established.

A1. Productivity metrics monitored through QIPP programme;A2. Action completed;A3. Action completed;A4. Action completed.

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1. The aggressive pace of change policy adopted by NHS England has drastically reduced the funds available to the CCG for the 5 year period 2016/17 to 2020/21. Material cost reductions are required to maintain compliance with NHS England business rules.2. There is a risk that Camden CCG does not make the necessary cost reductions.3. This may result in Camden CCG going into financial deficit.

4 5 20 High

1. Annual Budget Setting exercise;2. QIPP Planning and PMO support for delivery of QIPP, with clear Executive and Clinical sponsorship;3. Clear pipeline process for all future investments;4. Implementation of establishment control framework;5. Monthly Finance and QIPP reporting to Finance and Performance Committee;6. Quarterly Strategic Financial Planning monitoring via F&P Committee;7. Regular item presented to Governing Body seminars.

1. In year monitoring via Finance & Performance Committee;2. Pipeline process approved by Commissioning Committee;3. Governing Body regularly briefed on Strategic Financial Planning by CFO.

4 4 16 High

A1. 5 year plan to Governing Body;A2. Review QIPP performance;A3. Drive organisational buy into QIPP delivery by assigning Governing Body and Clinical leads;A4. Assess organisation with a view to future reductions in running costs;A5. Monitor performance at the Finance and Performance Committee.

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3Susan Achmatowicz, Chief Operating Officer


1. Barnet and Chase Farm Hospital's integration with the Royal Free London Hospital is in its early stages and continues to face organisational and financial challenges. 2. The risk is that attention and energies may be diverted from RF delivery, 3. This may result in poorer services for Camden residents.

4 3 12 Moderate

1. CCG membership on the Transformation Board;2. Regular updates for the Govering Body;3. GB Lead identified;4. Executive Lead identified.

1. The CCG has comprehensive engagement in performance management system with clinical leadership.

4 2 8 Moderate

A1. Monthly performance report to the Finance and Performance Committee;A2. Engagement in Systems Resilience Group.

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1. If budget holders fail to actively engage in monitoring budgets and programmes with local managers and CSU.2. The CCG may not receive timely reporting and forecasting.3. This would mean the CCG would be unable to identify and/or understand the adverse or favourable performance against financial targets and the need for mitigating actions to achieve those financial targets.

3 2 6 Low

1. Standard Operating Procedures for managers about importance of setting an accurate budget and method of monthly reporting and accurate forecasting;2. Development of Acute Performance Reviews (APR), MH PR, Community PR and clarity around content, format and presentation of monthly reports;3. Ditto for FAPS;4. SLA and user groups for CSU; close involvement with engagement manager;5. Operational and administrative budgets completed and signed off by Directors and Budget Holders;6. Finance Team ran workshops for budget holders on monthly reporting and the forecasting process in July 2015.

Fianance Team ran two workshops in July 2015 for budget holders on monthly reporting and the forecasting process

1. Nature of presentations to APR etc; monthly management of accounts,nature of issues raised;2. Month end review of accounts;3. In year monthly monitoring and in-year review and calibration;4. Delivery on target at end of year to meet stakeholder (Governing Body and NHS England) expectations.

3 2 6 Low

A1. Risk reassessed to ensure the risk is addressed from a strategic planning level;A2. Appoint senior management accountants.

A1. New risk 323 added;A2. Two new senior management accountants appointed and in place.

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Report Title Information Governance Assurance Report

Agenda Item 5.3 Date 09/03/2016

Lead Director Charlotte Mullins Tel/Email [email protected] Report Author Nicholas Murphy-O’Kane Tel/Email [email protected] GB Sponsor(s) (where applicable)

Ellen Schroder Tel/Email [email protected]

Report Summary

This is the final report for the 2015/16 Information Governance (IG) Assurance Framework and internal review of compliance. The purpose of the report is to provide the Governing Body with the details of the CCG’s IG assurance compliance for 2015/16.


Information

Approval

To note

Decision

Recommendation The Governing Body is asked to note the report and accept the final scores for the CCG assurance.




IG Assurance Framework compliance IG Assurance framework completed each year. IG Group provide internal periodic assurance, with reports to the

Executive Management Team, Audit Committee and GB periodically. Annual Internal Audit review of IGT assessment.


None


None

Engagement

Engagement across the CCG including IG Briefing for GB members (voting) and the Camden IG Group representing the CCG operational services. Briefing for the SIRO and Caldicott Guardian for acceptance of position and scores


None

Report History

Audit Committee – January 2016 Audit Committee – September 2015

Next Steps This report identifies that IG constantly continues to have a level of further development and improvement each year based on current and potential new standards introduced by Department of Health, NHS England and HSC IC. Compliance against the recommendations will be monitored via the Camden IG Group, reporting to the Executive Management team and Audit Committee (including updates to the GB as part of overall assurance).

Appendices None

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Information Governance Assurance Report

The following report provides the Governing Body with the key final position for the CCG in regards to the IG assurance compliance for 2015/16.

IG Implementation

Camden CCG continues to strengthen its approach to Information Governance across the organisation through its internal IG Group that was revised in October 2015 following the recruitment of a permanent IG Manager. Membership of the group includes representation from across the CCG and key stakeholders from the Camden LMC (Chair), London Borough of Camden (Adult Social Care – Caldicott Guardian) and NEL CSU (IG representation). The IG Group reports through to the Executive Management team for operational matters and provides regular assurance reports to the Audit Committee. The SIRO (Dorothy Blundell) and Caldicott Guardian (Dr Caroline Sayer) are provided with minutes of all meetings for their information and awareness.

IG Assurance The table below provides the level of assurance that has been identified in the CCG for this year’s return. This gives the CCG an overall score of 76% which is an increase of 10% based on our previous return.

Internal Audit As part of the annual assurance, the CCG commissioned its internal auditors to review its IG compliance, including a key focus on the Accredited Safe Haven (ASH). The final report (to be presented to the Audit Committee in March 2016) provided the CCG with a reasonable level of assurance that the work that has been undertaken. The report did highlight the need to have evidence ready over the year, but accepted that the CCG’s procedures for managing its IG

Toolkit improvement plans, including monitoring and reporting were found to be robust and reduce the risk of failure or delay in implementing improvements.

In regards to the ASH controls, the audit has highlighted that the CCG can take substantial assurance that the ASH processes are suitably designed, consistently applied and operating effectively.

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Secondary Assurance The IG Toolkit standards and scores submitted this year also provide the relevant assurance to the Department of Health and HSC IC around two other key areas of IG compliance for the CCG:

- IG Statement of Compliance (IG SoC) – covering the required assurance statements of safe and secure process and procedures for the use of NHS IT services such as the N3 network and other national systems (e.g. Registration Authority).

- Accredited Safe Haven (ASH) – these scores are a key measure of compliance used by HSC IC as part of our original and on-going Level 1 Accredited service.

In both cases, the scores and level of assurance provided are above sufficient levels to provide the assurance required.

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IG Training The CCG undertook a challenge in October 2015 to ensure that all its employees, including those on agency and temporary contracts had received a core set of training covering Information Governance, Confidentiality (Caldicott), Information Security and Information risk management. This approach has established a far greater level of awareness and training than previous years across the CCG. The 4 modules now represent the minimum standard for ALL new CCG employees moving forward.

The table overleaf provides the Governing Body a report of the achievement of this standard, where for the first time, the CCG can confirm that 99% of everyone working on for the CCGs (Until a cut-off date of 1st February) has a minimal level of IG training, and additionally with over 93% of staff have received appropriate training in Information Security, Information Risk and Confidentiality

For those staff that have yet to complete the training, this will be addressed in between April and June 2016.

It should be highlighted, that during this time the CCG have worked with closely with colleagues in the London Borough of Camden to support those staff working within the Joint Commissioning area, and in agreement for these groups to also complete the same standard of training.

In addition, the Governing Body (voting members) also received “face to face” training following

its last formal meeting. The training was well received with positive comments made by various members.

Module / ServiceIG - The Beginner's

Guide

Information

Security

Guideliens

NHS

Information

Risk

Management -

Introductory

Secure Handling of

Confidential

Information

Service

Total

6 6 6 6

100% 100% 100% 100% 100%

20 18 17 17

105% 95% 89% 89% 95%

27 27 27 27

100% 100% 100% 100% 100%

37 35 35 35

97% 92% 92% 92% 93%

12 11 12 12

100% 92% 100% 100% 98%

5 5 5 5

100% 100% 100% 100% 100%

15 15 15 15

100% 100% 100% 100% 100%

59 52 52 53

100% 88% 88% 90% 92%

Module Total 100% 93% 93% 94%

Joint Commissioning

(Susan Achmatowicz)

Sustainable Insight

(Charlotte Mullins)

Directors

(Dorothy Blundell)

Corporate Services

(Ian Porter)

Commissioning

(Susan Achmatowicz)

Primary Care

(Susan Achmatowicz)

Finance

(Ian Boyle)

Quality

(Neeshma Shah)

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Report Title Quality and Safety Committee Terms of Reference


Lead Director Neeshma Shah, Quality and

Clinical Effectiveness Tel/Email [email protected]

Report Author Andrew Tillbrook,

Deputy Board Secretary Tel/Email [email protected]


Jo Wickens Tel/Email [email protected]

Report Summary

The Quality and Safety Committee considered its terms of reference at a meeting held on 20 January 2016 as part of the annual review. The Head of Adult Safeguarding was added to the committee’s membership.


Information

Approval

To note Decision

Recommendation The Governing Body is asked to approve the revised terms of reference for the Quality and Safety Committee.


Improve the quality and safety of commissioned services.


Inappropriate committee terms of reference may result in ineffective decision making, duplication or omission of work due to unclear duties and responsibilities.


There are no conflicts of interest arising from the current and proposed version.


None.

Engagement

With members of the Quality and Safety Committee.



Report History

The Quality and Safety Committee reports to the Governing Body at regular intervals. The Terms of Reference is considered by the Committee annually and recommendations made to the Governing Body accordingly.

Next Steps None

Appendices

None

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1

Quality & Safety Committee Terms of Reference

1. Introduction The Quality and Safety Committee (the Committee) is established in accordance with Camden Clinical Commissioning Group’s constitution, standing orders and scheme of delegation. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the clinical commissioning group’s constitution and standing orders.

The Committee is established by resolution of the Camden Clinical Commissioning Group. It is an executive committee of the CCCG with the decision-making powers specified in these Terms of Reference, to provide assurance that it is sighted on the quality and safety of its commissioned services and patient safety.

2. Membership The membership and quorum of the Committee is as follows:

Chair (Clinical Lead on Quality and Safety on Governing Body for the CCCG) Camden CCG GB Non Executive (Vice Chair nomination) Camden CCG GB Secondary Care Nurse Representative Camden CCG GB Clinician(s) (GPs) Director of Quality and Clinical Effectiveness, Camden CCG Designated Nurse for Safeguarding Children, Camden CCG

Local Authority Representative, Camden Council Patient Representative, CPPEG Lay Member, Camden CCG CSU Quality and Safety Representative Clinical Director, Camden CCG

Head of Quality and Safeguarding, Camden CCG

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2

Also in attendance:

Quality and Clinical Effectiveness staff as required Invited persons relevant to the agenda

3. Secretary

Secretariat support for the committee will be provided by a CCG member of staff. 4. Quorum

At least four members of which there should always be:

The Chair or Vice Chair One GP One patient or lay member representation One CCG Executive Member (This would usually be the Director of Quality &

Effectiveness. In their absence, a Camden Executive Team to be nominated to cover this role by either the Director of Quality and Clinical Effectiveness or Clinical Director).

5. Frequency and notice of meetings The frequency of the Sub-Committee will be defined, in part, by the frequency of the Quality and Safety reports. The Committee will meet at least six times a year. The Chair of the Committee may call additional meetings as necessary. Meetings cannot be called at less than five working days’ notice

6. Remit and responsibilities of the committee

The overall purpose of the Committee is to ensure:

the quality and safety of commissioned services, by keeping under review providers’ compliance with terms and conditions of contracts relating to

clinical quality, and taking account of patient experience that patients have effective and safe care with a positive experience of

services.

Its specific duties are:

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3

Effectiveness

a) Provide Camden CCG with a clear, comprehensive summary on the effectiveness, safety and user view of services commissioned.

b) Provide assurance that commissioned services are being delivered to a high quality and safe manner, ensuring that quality is core to everything the CCG does. This could be extended to include jointly commissioned services.

c) To review remedial action taken by providers in relation to breaches in quality standards.

d) Oversee and be assured that effective management of risk is in place to manage and address clinical governance issues.

e) To review any notification, advice or instruction issued by Monitor /TDA or any other regulator.

f) To review reports from Trusts on progress against existing Quality Account workplans, and to review new workplans.

g) To receive assurances from within the organisation and providers that areas relating to clinical governance & quality assurance are implemented.

h) Seek assurance on the performance of NHS organisations in terms of the Care Quality Commission, Monitor / TDA and any other relevant regulatory bodies.

i) To ensure that the quality agenda leads to improvements in productivity and prevention through innovation and to develop a robust process for ensuring patient safety is paramount in commissioning decisions.

j) To engage with Healthwatch, other patient groups, wider stakeholder groups and partners.

Safety

a) Advise Camden CCG on actions required following national enquiries; and national and local reviews undertaken by external agencies (e.g. Care Quality Commission, NHS Litigation Authority) in relation to commissioned services and monitor the implementation of actions.

b) To receive quarterly and annual reports relating to Healthcare Associated Infections to providing the Committee with assurance that all commissioned services are compliant with the requirements set out in the Regulations made under the Health and Social Care Act 2008.

c) Have oversight of the process and compliance issues concerning serious incidents requiring investigation (SIRIs); being informed of all Never Events and informing the governing body of any escalation or sensitive issues in good time.

d) To receive quarterly patient safety incident and Serious Incidents reports relating to NHS and service providers that identify themes and trends and recommend areas for change in practice through the commissioning process.

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4

Review exception reports in respect of clinical risks including serious incidents and investigations of poor quality care/patient safety issues where appropriate to identify organisational learning.

e) To review quality and service development reports about maternity services f) To review reports about services that are managed by Camden Council and

funded (whole or in part) by Camden CCG g) To review the high level risks on the Camden CCG Risk Register that relate to

patient safety and recommend appropriate actions. h) To receive reports in relation to safeguarding adults and children which

identify areas of compliance, themes and trends and recommend appropriate actions.

i) Approve arrangements, including supporting initial Camden CCG priorities to minimise clinical risk, maximise patient safety and to secure continuous improvement in quality and patient outcomes.

Patient Experience

a) To receive patient experience reports (both qualitative and quantitative) on a quarterly basis, including Patient Advice and Liaison (PALs) reports and complaints reports, that identify themes and trends and recommend areas for change in practice through the commissioning process.

b) Receive and scrutinise independent investigation reports relating to patient safety issues and agree publication plans.

c) Ensure a clear escalation process, including appropriate trigger points, is in place to enable appropriate engagement of external bodies on areas of concern.

d) To review trends in complaints received in relation to services. e) To monitor the performance of Trusts against agreed CQUINs and to support

the development of future CQUINs. f) To review a year plan setting out the priorities for audits of patient experience

in all commissioned services, and summarised results of audits previously undertaken.

Reporting Line

a) To receive and consider reports and minutes from Camden CCG’s Medicines

Management Committee b) To call upon Clinical Quality Review Groups (CQRGs) relevant to Providers

commissioned by Camden CCG to consider and embed recommendations from this Committee

7. Relationship with the Governing Body

The Committee is a committee of the Governing Body, (see structure below). The Committee will report to Camden CCG after each meeting. The report will set out the main matters discussed and any decisions taken.

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5

It will also draw the attention of Camden CCG to any matters requiring disclosure to them, or requiring their approval.

8. Conduct of the committee

Meetings will be conducted in line with the relevant Standing Orders and Standing Financial Instructions, and having regard to the:

Nolan principles, Standard of conduct for NHS managers Principles and Rules for co-operation and competition NHS constitution

Particular attention will be paid to declarations of conflict of interest. All declarations of interest will be recorded at each meeting.

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6

As a matter of principle the Committee is committed to working with other Camden CCG committees to fulfil its duties and oversight responsibilities. The Committee will therefore refer matters to other committees where consultation or expertise is required. For example, the Quality and Safety Committee may advise on any quality issues that arise in the commissioning of healthcare. Equally, the Committee may defer to the advice, guidance or decisions from other committees where their remit covers the area of expertise in question.

9. Review date

January 2017 or earlier in line with any legislative changes or CCG requirement

January 2016

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Report Title Out of Hospital Strategic Board – Terms of Reference

Agenda Item 5.5 Date 24th February 2016

Lead Director Sally MacKinnon Tel/Email [email protected] Report Author Sophie Whitehead Tel/Email [email protected] GB Sponsor(s) (where applicable)

Dr Lance Saker Tel/Email [email protected]

Report Summary

The report brings the proposed Terms of Reference for the Out of Hospital Strategic Board to the Governing Body for approval. The Camden Out of Hospital Strategy will set out how the local health and care partnership aim to work differently together to address the key challenges of:

The Care Gap – reducing the variability of care and health outcomes The Health and Well Being Gap – increase the action on prevention of

health and care needs The Financial Gap – reduce the cost of health and care services to

match the diminishing resources available

The strategy will provide a summary of: Why we are proposing the strategy – the case for changing the way we

work in health and social care The model of care – how we think the whole health and care system will

change and work differently to address the gaps above The approach to implementing the new model of care – how we will

implement our aim to work differently together over the next 5 years and the enablers that will support this work e.g. workforce, IT, estates

First year action plan – what actions we will take in the first year to take us towards the new model of care

The Strategic Board brings together representatives from across the local health and care economy, to oversee the development of the strategy. The board will report directly into the CCG Governing Body.

Purpose Information

Approval

To note Decision

Recommendation The Governing Body is asked to approve the Terms of Reference for the Out of Hospital Strategic Board.


C. Improve health outcomes, address inequalities and achieve parity of esteem D. Integrate and enable local services to deliver the right care in the right setting at the right



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Some administrative support will be needed to support the board

Engagement

The Terms of Reference have been reviewed at both the operational and strategic board, where they were agreed. The boards include representatives of all stakeholder organisations (providers and commissioners) as well as patient representatives.



Report History

This is the first time the Out of Hospital Strategic Board Terms of Reference have been presented to the Governing Body.

Next Steps The terms of reference will be reviewed annually and any significant changes will be brought back to Governing Body for approval

Appendices

None

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1 V3.1 2nd December 2015

Out of Hospital Strategic Board Terms of Reference

1. Introduction

These Terms of Reference set out the membership, remit and responsibilities of the Camden Out of Hospital Strategic Board.

2. Purpose

The Out of Hospital Strategic Board (“Strategic Board”) brings together representatives from across the health and care economy in Camden, to oversee the development and delivery of the Out of Hospital Strategy.

The Strategic Board has no constitutional status but is authorised by the Governing Body to provide a steer and make appropriate decisions with regard to the development and operationalisation of the Camden Out of Hospital Strategy. The Strategic Board will defer to the relevant CCG committee for decisions in relation to finance, quality and business cases.

3. Membership

A list of members is shown at Appendix 1. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend these Terms of Reference. The Strategic Board may co-opt additional members on a case by case basis where this is required at the absolute discretion of the Chair.

The Strategic Board may invite or allow non-voting attendees to attend meetings. People in attendance may present at meetings and contribute to relevant discussions but are not allowed to participate in any formal vote.

The Strategic Board may invite or allow non-members to attend meetings as observers. Observers may not present at meetings, contribute to any discussion or participate in any formal vote.

4. Chair The Chair will be the Chair of Camden CCG.

5. Secretary

The Strategic Board will be supported by a secretary to take minutes and distribute papers.

6. Quorum

The Board must be representative of the local health and care sector and will therefore include:

- 3 CCG members including at least 1 of Chair; Accountable officer or GB Lead for Out of Hospital.

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- 2 Local Authority members - 2 provider representatives - 1 representative from patient and voluntary sector representatives

7. Frequency of Group Meetings

Meetings will be held every 2 months, in the 2 weeks following the Operational Board

8. Notice of Meetings Meetings of the Strategic Board may be called by the Chair. Unless otherwise agreed,

notice of each meeting together with an agenda of items to be discussed and supporting papers will be sent to each member no less than seven days before the date of the meeting. The notice shall confirm the time, date and place of the meeting.

9. Minutes of Meetings Each meeting shall have formal minutes which will serve as a record of the meeting. 10. Duties

1. To oversee the development of the strategy, providing strategic direction and decision making

2. To oversee the development of a plan to deliver the vision & aims set out in the strategy

3. To oversee the implementation of the plan, via a programme of work which will be managed by the programme team working to the Operational Board.

4. To report on progress to Governing Body of Camden CCG and Cabinet of the Local Authority.

11. Authority

The Strategic Board is accountable the Governing Body of Camden Clinical Commissioning Group and Camden Council (Cabinet).

12. Conflicts of Interest The Chair shall manage actual and potential conflicts of interest to ensure that decisions

are made and are seen to be made in an open and transparent way in the best interests of the organisation and the public. Decisions must be taken and seen to be taken with integrity and without being unduly influenced by private interests.

Any conflicts of interest shall be dealt with in accordance with Camden CCG’s Conflict of

Interest Policy. 13. Review These Terms of Reference shall be reviewed annually.

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Appendix 1

List of Members of the Strategic Board

Role Name CCG representatives CCG Chair Caz Sayer (Chair) Transformation Programme Director Sally MacKinnon Accountable Officer Dorothy Blundell Chief Operating Officer Susan Achmatowicz Director of Commissioning Lyndsey Abercromby Programme Manager Sophie Whitehead Governing Body representatives CCG Governing Body GP Member Lance Saker (Vice Chair) CCG Governing Body Secondary Care Clinician Matthew Clark GP Governing Body GP Member Neel Gupta CCG Governing Body GP Member Jonathan Levy CCG Governing Body GP Member Martin Abbas Provider representatives Haverstock Health – Chief Executive Mike Smith Royal Free Medical Director Stephen Powis Royal Free Director of Integration Katie Fisher UCLH Associate Medical Director Charles House UCLH Clinical Director, Integrated care Helen Taylor CIFT Medical Director Vincent Kirchner CNWL Borough Director for Camden Graham Caul CNWL Divisional Medical Director Pramod Prabhakaran LMC representative Farah Jameel Patient and voluntary sector representatives CPPEG rep Saloni Thakrar Representative from Voluntary Action Camden Simone Hensby Healthwatch representative Frances Hasler Local Authority Director of Adult Social Care Rosemary Westbrook Camden & Islington Director Public Health Julie Billett Assistant Director, ASC and Joint Commissioning

Tim Bishop

Director of Children’s Services Martin Pratt Head of Adult Social Care and Safeguarding Vivienne Broadhurst

Head of Integrated Commissioning Gillian Dent (joint post LA/CCG)

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Report Title Report of the Audit Committee


Lead Director Ian Boyle,


Report Author Andrew Tillbrook,

Deputy Board Secretary Tel/Email [email protected]


Ellen Schroder, Lay Member


Report Summary

This report provides a summary of the key topics discussed at the 27 January 2016 Audit Committee meeting.


Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the Audit Committee Report.


Commission the delivery of NHS constitutional rights and pledges Maintain financial stability and ensure sustainability though robust planning

and commissioning of value for money services Identified Risks and Risk Management Actions

Audit Committees have a crucial role to play in the governance of NHS organisations. They report on the relevance and rigour of underlying structures and processes and on the assurances that the Governing Body receive.




None identified.

Engagement




Report History

The Audit Committee reports to the Governing Body at regular intervals.

Next Steps None

Appendices

Appendix 1, summary of the meeting of the Audit Committee, 27 January 2016.

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Appendix 1 This report provides a summary of the items considered by the Audit Committee on 27 January 2016. Internal Audit The Committee considered the Internal Audit Progress Reports; of which there were four final reports:

Equality and Diversity – green rating Procurement and Conflicts of Interest Review - amber / green rating, from which the auditor’s

recommendations were accepted which included a review of the policy as well as formalising a contracts register and a register of procurement decisions.

GP Federation Review - amber/red rating, from which the committee sought clarity as to this grading. It was noted that much of the review had been conducted at a time when the Federation was being formed. Most concerns had been subsequently addressed and it was likely that a higher rating would be awarded if the review was being conducted in late 2015.

Clinical Governance and Quality – green rating. The review had focussed on how the CCG managed and retained oversight of clinical quality of a major provider.

CSU Internal Audit Report – three reports had been completed:

Business Continuity / Disaster Recovery Plans – awarded an amber / green rating IT General Controls – awarded an amber / green rating Continuing Health Care / Personal Health Budgets and retrospective claims – awarded an amber

/ green rating. Local Counter Fraud Service Progress Report – the committee noted:

the CCG’s Medicines Management Committee had received fraud awareness training the first phase of a counter fraud exercise of the continuing healthcare function had been

conducted the internal auditor would initiate training for counter fraud in GP Practices.

The draft Internal Audit Plan 2016/17 was considered in depth; noting that it was a solid draft. It was agreed that further refinement was required. Given the timescales, it was agreed for the Plan to be developed further and represent to an additional Audit Committee meeting scheduled for 16 March 2016. External Audit External Audit Plan 2015/16 The Plan was considered and approved; members were reminded of the tight schedule for preparing and approving the accounts for 2015/16, in accordance with the NHS England timeframe. Conflicts of Interest – update Members noted the progress in developing a conflicts of interest strategy which included the development of contracts and procurement registers. The management of declarations of interest were also noted; in line with NHS England guidance, all CCG staff had been asked to submit a declaration return.

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Committee Effectiveness Review A light touch – (on-line) survey committees was due to take place in February 2016. A more formal and in depth approach to review committee working was scheduled to take place in 2017. NHS 111 / OOH Declarations of Interest – Assurance Statement The Committee noted and approved the response to the NCL Urgent Care Programme as regards minimising and taking reasonable steps to ensure that appropriate arrangements were in place. Business Continuity and Emergency Preparedness The report and its contents were broadly accepted; this report is included in the Governing Body papers for approval at item 5.4. Establishment of an Audit Panel Members noted that due to legislative changes, CCGs would need to appoint their external auditors directly rather than via the National Audit Office which was the current situation. The changes would be effective for 2016/17. The Committee agreed to note the draft Terms of Reference for an Audit Panel, whilst there would be more discussion between the CFOs and the Audit Panel in the NCL area as to whether to set up a joint Audit panel across the NCL area (5 CCGs) or to establish the Panel just for Camden. Information Governance Report Was considered and accepted; this report is included in the Governing Body papers for note at item 5.3. IG Policies The committee considered and approved six related IG policies

Information Management (revised) Registration Authority (revised) Information Security (revised) Subject Access (new) Information Risk Management (new) NHS Number Strategy (new).

The Audit Committee is next due to meet on 16 March 2016

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Report Title Commissioning Committee Report

Agenda Item 6.2

Date 25/02/2016 Lead Director Susan Achmatowicz


[email protected]

Report Author Andrew Tillbrook Deputy Board Secretary

Tel/ Email

[email protected]


Dr Neel Gupta Tel/ Email

[email protected]

Report Summary This paper presents a summary of the Commissioning Committee

meeting held on 24 February 2015. The approved minutes of previous meetings may be found at part B of the agenda.

Purpose


Decision

Recommendation The Governing Body is asked to note the summary report.


Commission the delivery of NHS constitutional rights and pledges Improve health outcomes, address inequalities and achieve parity of

esteem Integrate and enable local services to deliver the right care in the right

setting


Any major risks are highlighted as part of this report.




None

Engagement

This summary report is shared with the Camden Public and Patient Engagement Group.



Report History The Commissioning Committee reports to each Governing Body meeting.

Next Steps None

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Report of the Commissioning Committee Summary of the meeting held on 24 February 2016 Items of Business

Community Nursing Investment and Interoperability Musculoskeletal Services Tier 3 Adult Weight Management Services Domestic Violence Support Marie Stopes International and British Pregnancy Advisory Service CAMHS Tier 4 Draft Co-commissioning proposal All Together Better Action Plan CCG Contracts

Decisions Made

1. The Committee considered a paper on Community Nursing Investment and Interoperability. Following discussion further clarity was sought on:

Confirmation as to how the service would be funded, immediate and longer term An assurance that the service would include an agreed level of interoperability, as

this was a crucial element of the proposal A financial plan and any effect of funding from the Better Care Fund (and effect on

the Better Care Fund commitments) Clarification of what the CCG’s current contractual obligations were if the whole service

was to be reproduced. An updated business case will be presented to the March Commissioning Committee for consideration, with a view to its endorsement, before being presented to the Governing Body in May for approval.

2. The Committee considered a paper on Musculoskeletal Services which was a proposal for a fully integrated service. The Committee discussed the level of the proposed service and level of integration of working with other patients. Consideration was given about the level of complexity and what the possible options were to the current proposal. There was a view to have complete interoperability between providers so that referral processes would be more efficient and beneficial for the patient. Other issues raised included:

the need to maintain stability of the service across the Borough, whether all providers invited to bid could provide interoperability

It was noted that the CCG had made some provision but there were other demands on a finite resource. The proposed model meant that the Commissioner would be able to manage the risk, noting the projection for the demand on MSK services and cost to increase in the future. However, consideration was given to see what the comparative costs for the Community alone service would be.

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The timetable for re-procurement was considered; noting that the procurement rules were due to change in April 2016 Overall, the view was to support the principle of the clinical model and to provide an updated report to the Governing Body to highlight:

The comparative costs of a community only service to a fully integrated service, To support the proposed timetable outlined in section 4 as well as including what

the risks are The issues of interoperability showing the pros and cons of each type of service To note the proposal of an integrated MSK service with a fixed Global Sum of the

value that should not exceed an estimated actual spend on MSK services in scope in 2015/2016 contracting year (which will be verified before the invitation to tender is issued) by more than 3% and not to exceed £13m per annum.

3. The Committee considered a paper on Tier 3 Adult Weight Management Services from

which there was a view to review Tiers 1 to 4 as a complete pathway and the cost of supporting Tier 4 services, with a view to focus on preventative programmes, so reducing the need for patients needing to access Tier 4 services. An updated report was asked to be brought back to a future meeting to include:

More clarity about the level of QIPP savings and analysis of funding To develop an integrate pathway of Tiers 1 to 4, emphasising work at Tier 1 and

2 , focusing on preventing obesity and promoting good health, with the objective of minimising the need for patients to access services at Tiers 3 and 4

4. A Domestic Violence Support business case was considered; being a three year funded

project, extending the work that the Local Authority had already achieved. Whilst there was broad, in principle support, further work was requested with regard to funding and investment priorities.

5. The Committee agreed a business case in support of the Marie Stopes International and

British Pregnancy Advisory Service.

6. The CAMHS Tier 4 Draft co-commissioning proposal was considered. The Committee noted the mental health stocktake that had taken place in November 2015 which had led to the proposal to co-commission with Islington CCG to secure provision of services at Simmons House (Haringey) for young people with mental health conditions. This route was preferred to minimise the possibility for adolescents being placed out London and losing connection and support from family and friends.

7. All Together Better Action Plan was noted and the significant progress made since this

project was last discussed at the November 2015 Committee. The Committee noted the developed governance structure to deliver the programme, pilot schemes including asthma management, working with the 111 service development and setting up a Patient Advisory Group.

8. Camden CCG Contract Database – The Committee endorsed the work that had been

completed and the proposal to maintain the list in three groups:

Commissioned Services Annual Clinical Contracts Corporate Services

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Report Title Report of the Finance and Performance Committee

Agenda Item 6.3

Date 23/02/2016 Lead Director Ian Boyle,

Chief Finance Officer Tel/ Email

[email protected]

Report Author Andrew Spicer, Governance Lead

Tel/ Email

[email protected]


Dr Ammara Hughes Tel/ Email

[email protected]

Report Summary This report sets out a summary of the items discussed at the Finance and

Performance Committee meeting held on 3rFebruary 2016



Decision

Recommendation The Governing Body is asked note the report.


This paper links with the following strategic objectives:

Commission the delivery of NHS constitutional rights and pledges Maintain financial stability and ensure sustainability through robust planning

and commissioning of value-for- money services; Integrate and enable local services to deliver the right care in the right

setting at the right time.


The Finance and Performance Committee reviews the Finance Risk Register each month.

Resource implications

None.

Engagement




Report History The Governing Body receives regular reports and minutes from the Finance and

Performance Committee.

Next Steps None.

Appendices None

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Report of the Finance and Performance Summary of the Meeting Held on 3 February 2016

Items of Business Finance Report: Month 8 It was reported that Camden CCG has delivered a £5.1m surplus to Month 9 which is in line with plan. Following NHS England’s offer the planned budget surplus has been increased from £8m to £11m and the CCG is on track to deliver this. NHS England has confirmed that the additional £3m can be drawn down in 2016/17 to fund non-recurrent projects in 2016/17. It was reported that an additional £1m on the forecast year end out turn has been identified at Month 9 and that the money has been made available to the North Central London (‘NCL’) risk share to cover Critical Care pressures. The £1m will however, accrue back to Camden CCG over a twenty-four month period through projects funded through the risk share. QIPP performance at Month 9 was reported. There was a Year to Date adverse variance of £0.2m due to an underspend in the transformation programmes. The full year forecast is expected to be in line with budget due to increased initiatives in referral management and contractual gains from the negotiation of the Royal Free London NHS Foundation Trust Hospital (‘Royal Free London’) contract. Regarding risks and opportunities it was reported that the main risk on Overseas Visitors’ costs was no longer a risk as NHS England had confirmed that it will refund £7.5m to Camden CCG. It was noted that it is £1m lower than accounted for so the risks and opportunities now balance. Finance Risk Register The Committee reviewed the Finance Risk Register and identified three additional risks:

A risk on failure to pass Year End financial audit;

A risk on technical accounting on the Better Care Fund;

A risk on failure to meet QIPP targets in the future. Financial Planning and Stocktake It was reported that NHS England had released the funding allocations for the following five years. It was noted that as Camden CCG previously received funding significantly above the national ‘Fair Share’ target it would only receive 1.39% growth in 2016/17. However, this will not result in additional investment funds as these have already been allocated against national policy changes which see costs increases in pensions, national insurance contributions, Child and Adolescent Mental Health Services (‘CAMHS’) and GP IT. The Committee noted that Camden CCG needed to implement an effective QIPP programme to avoid the risk of deficit by 2020/21. If the CCG implements a 2.5% QIPP saving, a £3.6m surplus is forecast in in 2020/21. It was noted that the financial forecasts are based on the current Governing Body mandates but that in 2020 the mandates are due to end. Therefore, the forecasting may change with the introduction of the new mandates. It was also noted that the minimum mandated QIPP saving is 2% with the 2.5% QIPP target being the average for London. If the QIPP target is too low it would be challenged by NHS England. The Committee discussed the importance of delivering QIPP and ensuring that the Out of Hospitals Strategy is successful to ensure that there is money to invest in the future. The Committee also discussed the need to ensure that core commissioning also delivers in relation to QIPP.

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Performance Report It was reported that University College London NHS Foundation Trust Hospital (‘UCLH’) failed five of the eight cancer targets and that Camden CCG is considering issuing a Contract Query Notice (‘CQN’). It was also reported that there are challenges at Royal Free London particularly on the 62 day standard for neurology. Barnet CCG as the lead commissioner for the Royal Free London contract is withholding £5m of funding until the targets are delivered. Camden CCG has failed the Accident and Emergency (‘A&E’) targets for the previous two consecutive months as a consequence of the poor A&E performance at UCLH and Royal Free. It was noted that to try to improve A&E performance UCLH is implementing a key element of its recovery plan which is phase one of the Acute Medical Unit new model of care. Camden CCG is also reviewing a deep dive report into A&E at UCLH. Once Camden CCG has analysed the results of the deep dive and the effect of the new Acute Medical Unit it will consider whether to issue a CQN. Regarding Diagnostics neither UCLH nor Royal Free London have met the standard in the previous 12 months to November 2015 with the key actions and progress being reported. The Committee discussed the issue of cancer performance at UCLH. It noted that cancer performance at UCLH has not improved despite many assurances from the Provider. The Committee discussed the Provider’s resilience planning and having the right systems and processes in place to drive and sustain change. The Committee considered methods of supporting UCLH to bring about change. It considered that an effective method would be to undertake a peer review undertaken by a team from an industry leader such as the Christie Hospital. It was agreed that a peer review would be arranged.

Prescribing Budget The Committee considered a paper on the expected financial pressures on Camden CCG’s prescribing budget. The Committee agreed that it would only approve significant expenditure with due consideration to Camden CCG’s overall budget. The prescribing budget will be reviewed at the March 2016 Committee against the CCG’s overall budget. Forward Planner The overall strategic approach to agenda items and papers is being reviewed. Once this is completed the Forward Planner will be presented to the Committee for its approval.

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Report Title Camden Health and Wellbeing Board Report


Lead Director Julie Billett,

Director of Public Health Tel/Email [email protected]

Report Author Baljinder Heer-Matiana, Senior Public Health Strategist



Julie Billett, Director of Public Health

Tel/Email

Report Summary

This report provides a summary of the January 2016 meeting of Camden’s Health and Wellbeing Board.


Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of the report.


This paper links to the following strategic objectives:- • Improve health outcomes, address inequalities and achieve parity of esteem • Work jointly with the people of Camden to shape the services they receive




There are no conflicts of interest.



Engagement



No equality impact assessment is required for this report.

Report History

This is the first report to the Governing Body, providing members with an overview of the Camden Health and Wellbeing Board’s agenda, discussions

and decisions. The intention is to provide these reports to the Governing Body four times a year, aligned to the Health and Wellbeing Board’s schedule of

quarterly meetings. Next Steps None

Appendices

None

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Summary Report of Camden’s Health and Wellbeing Board Meeting on 21 January 2016

1. Background 1.1. The purpose of this report is to provide the Governing Body with a brief summary of the business

of Camden’s Health and Wellbeing Board (HWBB). The Board, which meets four times a year, is a statutory committee where key leaders from the health and wellbeing system in Camden work together to improve health outcomes and reduce inequalities for our local population. Camden’s Board, chaired by the Leader of Camden Council, includes membership from Camden CCG, HealthWatch Camden, a representative of the voluntary and community sector and elected member and senior officer representatives from Camden Council.

1.2. Camden CCG representatives on the HWBB are Dr Caz Sayer, Chair, Judith Hunt, Lay Member,

Dr Martin Abbas, Elected GP and Dorothy Blundell, Chief Officer. 1.3. The Board meets four times a year.

2. Key items discussed

2.1. Safeguarding Children and Adults in Camden and alignment with the Health and

Wellbeing Board's Priorities

Safeguarding of both vulnerable adults and children is critical to the wellbeing of Camden residents. The independent Chairs of the Camden Safeguarding Children Board and Camden Safeguarding Adults Partnership Board presented their annual reports to the Health and Wellbeing Board, highlighting key priorities in relation to safeguarding adults and children, and focusing on the importance of and further opportunities to strengthen links between all three Boards in order to champion and support action across the system.

The independent Chairs highlighted key safeguarding issues for children and adults and the challenges and risks around new areas of responsibility. The Chairs identified six cross cutting issues of common interest between the three Boards, namely: Multi agency safeguarding hubs, female genital mutilation, complex families, domestic violence and abuse, sexual exploitation of adults at risk and children, and the links between mental health, substance misuse and the risk of abuse and neglect.

The Health and Wellbeing Board discussed how it could add value to the joint agenda of work that was already being developed, particularly through implementation and delivery of the new Health and Wellbeing Strategy. The Board asked the independent Chairs to bring a report back to a future HWBB meeting, scoping out these shared priorities and cross cutting issues in further detail, and setting out the specific contribution that the Health and Wellbeing Board could make.

2.2. Camden's Joint Health And Wellbeing Strategy (JHWS) 2016-18: Living Well, Working

Together

The Board approved and formally adopted Camden’s new Joint Health and Wellbeing Strategy for the period 2016-2018. This strategy sets out the Board’s continued commitment and approach to tackling health inequalities and promoting health and wellbeing for the population of Camden, with a focus on action under five priority areas: healthy weight, healthy lives; reducing alcohol-related harm; resilient families; the first 1001 days; and ensuring good mental health for all.

The Board also considered and agreed the key actions and programmes of work to be taken forward under each priority area over the next three to six months, including the development of more detailed delivery plans. The delivery plans for each priority will be considered at the next Health and Wellbeing Board meeting on 5th April 5th 2016.

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2.3. Strategic Developments in Primary Care in Camden

The Board considered a report of the Chief Officer of Camden Clinical Commissioning Group, which provided a strategic overview of key developments in primary care commissioning and provision across Camden. Specifically this report provided the Board with updates on progress in relation to three specific areas:- primary care co-commissioning, development of the Camden GP Federation and the local primary care estates strategy.

The Board discussed the linkages between this local estates strategy and the North Central London devolution pilot on estates, and noted the importance of having the right estate available locally to support the provision of accessible, quality primary care in Camden, as well as facilities that will support future models of integrated health and care. Some of the key challenges relating to the cost and availability of premises in Camden were also discussed.

The Board welcomed the opportunity to focus on strategic developments in primary care, and the opportunities afforded by these developments to further strengthen primary care in Camden and tackle variation, given its importance to residents, to health outcomes and to future models of care.

2.4. Camden's Better Care Fund Programme

Camden’s five year Better Care Fund (BCF) Programme was agreed by the Health and Wellbeing Board in 2014 and approved by ministers in November 2014. Funding for the BCF in 2016/17 was confirmed as part of the Comprehensive Spending Review (announced in November 2015). A progress report and refreshed plans for 2016/17 were presented, and a final plan for 2016/17 will need to be signed off by the Board at its April meeting.

The Board discussed the limited national performance metrics that are being used to monitor the impact of the BCF, as well as the importance of local evaluation and the use of a broader range of measures to assess the impact and value of this pooled fund and the range of programmes and services being delivered through the BCF. Economic evaluation and patient/user experience were also noted as key aspects of this local evaluation.

2.5. Halve it: Reducing Undiagnosed HIV Infections and Reducing Late Diagnoses of HIV in

Camden

Camden Council is a signatory to the Halve It Coalition, which aims to: o Halve the proportion of people diagnosed late with HIV o Halve the proportion of people living with undiagnosed HIV.

This report from the Director of Public Health provided an overview of the key HIV prevention and testing services currently provided in Camden, as well as identifying what more needs to be done locally in the commissioning and provision of services to achieve the Halve it goals locally by 2020.

The Board supported the establishment of time-limited Task and Finish group to develop an action plan focused on delivery of the Halve It objectives. The Board also agreed that this group should report on future progress to Camden Council’s Health and Adult Social Care Scrutiny Committee.

2.6. Health and Care Devolution

The Board considered a report on health and care devolution developments in London, and noted the establishment of five devolution pilots to test the viability of health and care devolution in the London system, including a pilot focused around health and care estates in North Central London. Whilst it was acknowledged that these developments could pose certain challenges and risk to Camden’s local health and care integration agenda, the Board also noted potential opportunities to help drive further progress locally towards integrated health and care and improved outcomes.

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Locally it was agreed that the focus should be on identifying those new levers, powers or enablers that would help to accelerate our well-established health and care integration agenda and improve population health outcomes for Camden residents.

The Board agreed to convene a seminar in late February/March involving Board members and key providers as a useful next step towards identifying those ‘devolution’ opportunities of most relevance and benefit to Camden, and developing an approach to taking this forward.

3. Date of Next Meeting The next meeting of the Board is on 5th April 2016 at Camden Town Hall from 4pm to 6pm. The agenda for the meeting will be published here: http://democracy.camden.gov.uk/ieListMeetings.aspx?CId=598&Year=0

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http://democracy.camden.gov.uk/ieListMeetings.aspx?CId=598&Year=0


Report Title Report of the Procurement Committee

Agenda Item 6.5 Date 25 Feb 2016

Lead Director Ian Boyle

Chief Finance Officer Tel/ Email

[email protected]

Report Author Andrew Tillbrook Deputy Board Secretary

Tel/ Email

[email protected]


Ellen Schroder, Lay Member Tel/ Email

[email protected]

Report Summary

This report provides a summary of the issues considered by the Procurement Committee at a meeting held on 17 February 2015.


Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the content of this report.




There are no identified risks arising from this report.


The Procurement Committee’s role is to: Ensure conflicts of interest are managed; and Preserve the integrity of the CCG’s decision making processes; Ensure that the CCG’s decision making is not open to legal challenge.


None.

Engagement




Report History

The Governing Body receives regular reports and minutes from the Procurement Committee.

Next Steps None

Appendices

None

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Procurement Committee Report Summary of the Meeting Held on 17 February 2015

The Procurement Committee (‘Committee’) considered two items of business which concerned the

Primary Medical Services (PMS) contract review and Local Performance Indicators for the North Central London Integrated NHS 111 and GP

Out of Hours (OOH) Service The Committee noted that the PMS Review which set out the commissioning intentions were required by NHS England as part of a London wide review. They set out the expectations for PMS Practices over the next contract period for 2016/17. The Committee noted that:

There had been patient consultation via CPPEG The full service specification would not be implemented as there were already plans to deliver

improved access via the GP Federation which included plans for weekend service provision There was a considered debate about what services the CCG were intending to commission from Practices, noting how current funding for services were apportioned and, in the longer term, re-specifying the service, to be completed over the next four years. The review would provide an opportunity to understand how PMS Practices spent their premium monies. Concern regarding the potential financial pressures on some Practices and potential impact on patient care was acknowledged; noting that the transitional arrangements of four years (rather than two) was recommended to provide sufficient time to look at the commissioning arrangements for the affected Practices The Committee considered the performance indicators for the NHS 111 and OOH service, which were Camden specific, devised to ensure that local variations were taken into account. Members recommended some fine-tuning of some wording of the key performance indicators to include an indicator around the percentage of callers referred to a pharmacy. It was noted that the impact of Saturday and evening opening of surgeries in the future and the corresponding demand on the 111 and OOH service was still to be addressed across the whole of North Central London. The Committee supported the progress to date and noted that a report for the contract award would be brought to the Governing Body in March 2016.

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Meeting in Public of the Camden Clinical Commissioning Group Governing Body Wednesday 11 May 2016, 13:00hr The Wesley Hotel 81-103 Euston Street London NW1 2EZ

PART I AGENDA

Item Title Sponsor Action Paper Time Page

1. Introduction 1.1 Apologies for Absence Chair Note Verbal 13:00 -

1.2 Declarations of Interest Chair Note 1.2

1.3 Minutes of the Previous Meeting Chair Approve 1.3

1.4 Action Log Chair Note 1.4

2. Chair, Chief Officer, Patient and Quality Reports 2.1 Chair’s Report Chair Note 2.1

2.2 Chief Officer’s Report Chief Officer Note 2.2

2.3 The Patient Voice Report Kathy Elliott Note 2.3

2.4 Quality and Safety Report Jo Wickens Note 2.4

3. Strategy 3.1 The Camden Story and Investment

Programmes End of Year Report Dr Lance Saker Note 3.1

3.2 Community Nursing Services Dr Lance Saker Approve 3.2

3.3 Primary Care Commissioning Intentions

Dr Neel Gupta Approve 3.3 -

3.4 Public and Patient Engagement Plan Kathy Elliott Approve 3.4

3.5 Camden 2016/17 Operating Plan Chief Finance Officer

Note 3.5

3.6 Camden and Islington Annual Public Health Report

Director of Public Health

Note 3.6

4. Finance and Performance

4.1 Final 2016/17 Budget Chief Finance Officer

Approve 4.1

4.2 NCL Risk Share and Transitional Investment Fund


Approve 4.2

4.3 Finance Report Chief Finance Officer

Note 4.3

4.4 Performance Report Chief Finance Officer

Note 4.4

4.5 Business Plan Report

Chief Officer Note 4.5

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5. Governance

5.1 Camden CCG 2015/16 a) Draft Annual Report and b) Draft Annual Accounts

Chief Officer/ Chief Finance Officer

Approve 5.1

5.2 Localities Report Locality Leads Note 5.2

5.3 Corporate Risk Register Judith Hunt Review 5.3

5.4 Risk Management Strategy Judith Hunt Approve 5.4

5.5 Emergency Preparedness and Business Continuity Annual Report

Judith Hunt Note 5.5

6. Committee Reports

6.1 Audit Committee Judith Hunt Note 6.1

6.2 Commissioning Committee Dr Neel Gupta Note 6.2

6.3 Finance and Performance Committee Dr Ammara Hughes

Note 6.3

6.4 North Central London Collaboration Board

Chair Note 6.4

6.5 Procurement Committee

Ellen Schroder Note 6.5

7. Any other Business

7.1 Draft Agenda July 2016 meeting Chair Note 7.1

8. Questions from the Public Chair Verbal -

NB: Members of the public are now given the opportunity to ask questions. These must relate to items that are on the agenda for this meeting and should not take longer than three minutes per person.

9. Date of Future Meetings

14 September 2016 1:00pm – 4:00pm

REGISTER OF INTERESTS A register of members’ interests is available on the Camden CCG website


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1

AUDIT COMMITTEE (the “Committee”)

Minutes of a Meeting of the Committee Held on Tuesday 30 September 2015

Room 4LM1, Stephenson House, 75 Hampstead Road London NW1 2PL

Members: Ellen Schroder(Chair) ES Governing Body Lay Member, CCCG Judith Hunt OBE JH Governing Body Lay Member, CCCG Dr Neel Gupta NG Governing Bod, GP Member, CCCG In Attendance: Susan Achmatowitz SA Director of Primary Care, CCCG Nick Atkinson NA Partner, Internal Audit, Baker Tilly Risk Advisory Services Andrew Chappell AC Audit Manager, External Audit, KPMG Stuart Dalton SD Assistant Director of Corporate Services, CCCG Tim Halford TH Chief Financial Officer, CCCG (item 1.1 to 2.2.3 and 4.3) Nicholas Murphy- O’Kane

NMOK Information Governance Manager, CCCG

Fleur Nieboer FN Director External Audit, KPMG, Tony Uttley TU Financial Accounts and Governance Director, NELCSU Minutes: Andrew Tillbrook AT Deputy Board Secretary, CCCG Apologies: Dr Martin Abbas MA Governing Body Member, GP Representative, CCCG Gemma Higginson GM Managing Consultant, Counter Fraud, Internal Audit, Baker Tilly Risk

Advisory Services Clive Makombera CM Risk Advisory Director, Internal Audit, Baker Tilly Risk Advisory

Services Charlotte Mullins CM Acting Director, Sustainable Insights, CCCG

1. Introduction 1.1 Welcome and Apologies

The Chair welcomed all present to the meeting. Apologies were recorded as above. A quorum being present the Chair declared the meeting open.

1.2 Declarations of Interest

The members considered the Register of Interests. There were no new interests declared nor amendments made.

1.3 Minutes of the Previous Meetings, 21 April 2015 and 27 May 2015 1.3.1

The Chair drew the Committee’s attention to the April Minutes which had been amended and tabled for consideration. In particular, discussion focused on Internal Audit reports and their

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ratings. Although it was noted that this review was retrospective, the Chair expressed the opinion that some of the ratings had not been in line with the CCG’s expectations. For example the report on Budgetary Control and Transformation Programmes had been given a green rating by BT but it was felt that the CCG’s record of spending the funds budgeted for projects in year was poor and could have been given a lower rating. Whilst there was no suggestion of revisiting the ratings, consideration was given as to how Baker Tilly and the CCG could learn from the exercise, leading to the consensus that the scoping of future internal audit reports should be better focussed; i.e. the CCG needed to provide an improved specification for each area of work in order for Baker Tilly to review and give the appropriate level of assurance.

1.3.2 The April minutes were considered following the above discussion and, acknowledging that appropriate concerns had been raised and recorded, members agreed that they were a true and fair record of the meeting.

1.3.3 The Chair invited members to consider the May Minutes from which the following comments

were made: Para 2.3 to add a sentence at the end of this item to re-inforce the CCG’s concern. ‘It

was agreed that there should be greater focus on Counter Fraud work undertaken in the CSU to complement the work that had already been done in the CCG.’

Para 2.4.1 to add reference in the last sentence: The list of reviews for the forthcoming year were noted and it was suggested that budgetary control should also include QIPP and non-acute expenditure, and that the IG Toolkit / ASH status review should be deferred from October 2015 to January 2016.

1.3.4 With the additional wording provided above, members agreed that they were a true and fair

record of the meeting. AGREED: The minutes of meetings dated 21 April 2015 and 27 May 2015 were agreed

subject to the amendments recorded above. 1.4 Action Log The Action Log was considered:

27 May 2015 Action 1: consideration was given about the cross representation

between the key committees, confirming that there is representation from the Commissioning, Finance & Performance and Quality & Safety Committees on Audit Committee. However, links between the Commissioning and Quality & Safety committees could be strengthened, a point which would be fed into the Organisation Redesign work that the CCG was undertaking. The Chair confirmed that the role of the Audit Committee was to be an assurance and risk function for the CCG, endorsed by NA, supporting the suggestion that it was more important to have appropriate membership than representation across other CCG committees. It was agreed that the cross membership of this and other Committees should continue to be monitored

21 April 2015 Action 14: NA advised that there remained an on-going concern about counter fraud prevention within the CSU and other services in NHS England. The view was expressed that NHSE should be focusing greater attention on areas such as primary care, dentists, pharmacists and opticians. Following further discussion, it was agreed that the Baker Tilly 2015/16 plans for up to 21 days on counter fraud and 77 days on internal audit work were agreed, subject to flexibility to redirect some resource if appropriate (e.g. using counter fraud days to review controls on continuing health care spend),

21 April 2015 Action 15: the Committee noted that positive progress had been made with regard to the evaluation of the OOH /111 contract risk, with all CCG’s in North Central London having sought legal advice. Agreed to close this Action

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21 April 2015 Action 16: the Committee noted that the frequency of reviewing smart card had been taken adequately addressed. Agreed to close this Action

21 April 2015 Action 17: the Committee noted this was an agenda item at this meeting. Agreed to close this Action

28 January 2015 Action 8: the Committee noted the extension of contract with the CSU to March 2016 and that work continued on possible ways to retender these services. Agreed to close this Action

29 January 2014 Action 5: Commissioning and Contract Management – would be considered at the January 2016 meeting.

29 January 2014 Action 6: Audit Committee membership – noted that guidance on membership of both Audit Committees and Auditor Panels was still due. , Agreed to Keep in View. [Later note: Audit Panel Guidance received from Baker Tilly on 5 October 2015 for review]

The members agreed to note the action log and the updates provided.

2. Internal Audit 2.1. Internal Auditor Progress Report 2.1.1 NA introduced the report from which members noted that the Work plan was now underway,

with particular attention drawn to: the Equality and Diversity Review, which had been rated green the good progress being made regarding contract monitoring at the CSU and the risk

assessment framework the draft report on GP provider networks had been issued but needed more work.

Consideration was given whether this report and its recommendations should be reviewed by the Procurement Committee, given its importance to working with the GP federation and the future of co-commissioning. This report was now due to be completed by the end of October 2015

review of the Better Care Fund would be scheduled for April 2016. 2.1.2 The Committee considered the Equality and Diversity report from which the following,

additional work was recommended: to implement additional training and ensure that there was parity between what

happened at a strategic level as well as at the day to day working level more work was needed to embed the spirit of equality and diversity within the CCG as

well as taking account of meeting the needs of the existing diverse populations in Camden. It was noted that some of this work could be supported by the Sustainable Insights team to provide supporting evidence on population groups to ensure that services were commissioned in the most equitable way.

2.1.3 It was agreed:

To note the report That an upcoming governing body seminar should address equality and

diversity with regard to the delivery of healthcare across the Borough, in conjunction with Public Health (Action 1: SD).

2.2 NEL CSU Assurance Committee Reports and Updates 2.2.1 NA referred to the above report, highlighting that the:

Business Continuity and Disaster Recovery Plans had been tested and rated as Amber Green. Recommendations include strengthening back-up plans and ensuring that any plans dovetail with NHS England’s expectations

The CSU has significantly improved its implementation of the recommendations

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arising from internal audit work Deloittes have focused on the scope and timeliness of the Service Auditor Report and

will consider ways to make the report more useful to CCGs ahead of the year end. Baker Tiily has made some suggestions to the CSU which will be discussed further with Deloittes and NHS England. The NELCSU Assurance Plan is now well underway and Clive Makombera gave a full progress report to the Audit Chairs Group on 29 September 2015.

2.2.2 The NCL and NEL Audit Chairs had expressed concern that attendance by the CCG Finance

Directors at the CSU Assurance meetings had been falling. It was acknowledged these meetings presented additional time pressures and geographical constraints for to all to attend; it was suggested that at least one Finance Director from each of NCL and NEL should attend and find a way of rotating the representation. Representation should also include the relevant staff to address specific concerns as and when they arose. Action 2: TH to discuss with his counterparts for the best way to ensure adequate attendance at the CSU Assurance meetings.

AGREED: to note the report. 2.3 LCFS Counter Fraud Annual Progress and Updates 2.3.1 NA referred the Committee to the above report from which it was noted:

The induction pack had been updated, details of which would be forwarded to SD Three National Fraud Initiative 2014/15 non-creditor matches had been looked at.

One did not need further investigation and was processed, the other two required more information from the matching body and were then processed.

Pharmacies with excessive out of pocket spend have been identified and investigated by NHS England and participating CCGs. The reasons seem to be cultural and related to inefficient ordering rather than any dishonesty. Fraud awareness training will be given to the CCG’s Medicine’s Management Committee in October,

The investigation following press coverage about drug company sponsorship of some pharmacies had queried whether there was any connection to the way the CCG commissioned medicine expenditure. The Committee noted that the CCG had a Gifts and Hospitality Register and a Conflicts of Interest Policy in place - both of which were well understood by the CCG’s Medicines Management Team. Following further discussion, it was agreed that all offers of hospitality, irrespective of whether they were accepted, should be recorded.

2.3.2 The Committee discussed how GP Practices managed counter fraud and suggested that

fraud awareness training could be offered to the practices by Baker Tilly. Action 3 SD to check with Pat Elliott, Practice Manager representative of the Governing Body, as to whether there was an appetite to pursue this matter.

2.3.3 Counter fraud training for other areas of the health sector such as pharmacists, opticians and

dentists was discussed but it was agreed this remains outside the CCG’s authority until the co-commissioning of these services was established.

2.3.4 NA assured the Committee that under the CSU Assurance Plan, counter fraud would be

adequately addressed, in addition to the work that CSU’s Auditors may cover. 2.3.5 NG raised a concern regarding fraud connected to personal health budgets. It was agreed

that Baker Tilly would evaluate any risk when these systems were established. AGREED: to note and endorse the report.

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3. External Audit 3.1 Annual External Progress Report 3.1.1

FN introduced the above report, confirming that all the work on the 2014/15 financials had been completed and KPMG’s opinion on the accounts and consistency statements had been issued. KPMG’s proposed 2015/16 Audit Plan would be presented at the January 2016 Committee. It was also noted:

The engagement on national tariff proposals The reporting arrangements for the Better Care Fund.

AGREED: to note the report. 3.2

External Audit 2014/15 Annual Audit Letter

3.2.1 Members noted the Annual Audit Letter which confirmed completion of the work carried out for Camden CCG.

AGREED: to note the Annual Audit Letter.

4. Financial Reporting 4.1 Annual Report Planning for 2015/16 4.1.1

TH and SD provided a verbal update: the planning process was still at early stages, with more substantive discussions

taking place in early 2016 at which any statutory changes would also be taken into account.

Communications Manager had been appointed on a substantive basis; the text of the Annual Report would be part of her responsibilities.

AGREED: to note the verbal update and assurance. 4.2 Financial Control Environment Assessment 4.2.1

TH introduced the above report, which required Camden to undertake a financial control assessment at NHS England’s request. Members were invited to review and approve the report which laid out a number of areas of financial control which we had assessed in a range of ‘Improvement needed’ to ‘Excellent’.

4.2.2 Attention was drawn to the summary on page 73,which showed the majority of areas

assessed as Good, some as Moderate and one, , the ‘alignment with activity and provider contracts’ assessed as ‘Improvement Needed’. This reflected the fact that two of our major provider contracts with UCLH and the Royal Free for 2015/16 had yet to be agreed and signed. One area had been assessed as Excellent, the ‘consistency of reporting with ledgers and NHSE submissions.

4.2.3 Members noted that the Assessment was likely to help provide NHSE with early indications of

the level of financial stability of each CCG in advance of year end. Consideration was given as to how the Assessment would be monitored; noting that it was likely to reviewed annually at NHSE’s request with additional oversight provided by Internal Audit, if it was felt appropriate.

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AGREED: the Committee approved the Financial Control Environment Assessment and recommends its submission to the Governing Body for consideration and approval.

5. Governance, Risk Management and Internal Control 5.1 Directorate Risk Update, Primary Care 5.1.1 SA was welcomed to the meeting to present the Primary Care Directorate Risks. SD advise

members that the Risk Register had been developed on the new DATIX system which had led to increased engagement with senior staff and front line teams from all directorates since its roll out in June 2015. Whilst some modifications to the DATIX system had been identified, significant progress had been made.

5.1.2 SA drew attention to the following risks:

Member engagement Development of the Federation Estates Strategy, for which it was agreed to raise the initial risk from yellow to red.

Members noted that the CCG had been asked by NHSE to develop an Estates Strategy by end of December 2015. However, we need to develop the Out of Hospital Strategy as well because of its impact on our estates requirement. The first meeting to discuss this strategy is due to take place on 5 November 2015.

NHSE is undertaking a nationwide review of GP practices which hold PMS Contracts. 16 Camden practices have PMS contracts and the review is expected to be disruptive and destabilizing. Timelines are also very tight. Members agreed that it was important to review this sensitive piece of work, ensuring adequate engagement with the PMS GP Practices. It was agreed to amend the mitigation risk colour from yellow to red

Conflicts of Interest, whilst it had been considered at great length, remain a significant risk as the CCG progresses to co-commissioning the core GP contracts jointly with the other NCL CCGs and NHSE.

Member relations, which currently came under Primary Care’s jurisdiction, was expected to be transferred to the Governance Team as part of the CCG’s current Organisational Re-Design.

The lack of capacity available in the CCG to support joint co-commissioning of primary care, not least on strategic planning and financial modelling. This could be supported by the Healthy London Partnership. The Committee expressed its support for this proposal.

5.1.3 It was agreed that reports on Conflicts of Interest and the GP Federation should be presented

to the Procurement Committee, once finalized. 5.1.4 TH proposed that each Directorate Risk Register should have its own finance risk (i.e. the risk

of underspend or overspend). AGREED: to note the Directorate Risk Register for Primary Care. 5.2a Board Assurance Framework 5.2.1

SD presented the BAF and the Strategic Risk Register which was taken as read, noting that primary care is an emerging risk and that the signing of the UCLH contract remained high at ‘16’. AGREED: to review and note the Board Assurance Framework.

5.2b Corporate Risk Register 5.2.2 SD presented the Corporate Risk Register which was taken as read. The three new risks

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added and the seven risks to be removed were discussed and agreed. AGREED: to review and note the Corporate Risk Register.

5.3 Tender Waiver Register 5.3.1 The Committee noted the Waiver relating to the provision of HR services by Camden Council.

However the reason for the waiver was queried. It was agreed that the reason was not our combined geography but rather the strong corporate relationship and history of joint working with the Local Authority.

AGREED to note the Tender Waiver Register. 5.4 Committee Effectiveness Review 5.4.1

SD advised that the questionnaire for the review been prepared and would be issued later in 2015, after the 360 degree Governing Body member exercise had been completed.

AGREED: to note the update. 5.5 Information Governance Report 5.5.1

Nicholas Murphy-O’Kane, the CCG’s Information Governance Manager was welcomed to the meeting. He advised that the CCG had increased its capacity on IG by NMOK’s appointment. The Committee noted that :

The CCG maintained its IG Level 2 IG and its accreditation for ASH The aim for this year is to achieve Level 3 for the majority of requirements as

required, revised data sharing agreements have been submitted to HSC IC and the CCG is working to resolve the issues raised.

Data flow mapping has identified a limited number of flows of personal confidential data within the CCG. These will need to be mapped and risk assessed against current standards.

Policy review, which had initially been considered in January 2015, would be subject to further assessment and will be brought back to this Committee for review.

AGREED: to note the report and initial progress made; and to receive a progress report

in January 2016. 5.6 Information Governance Strategy and Framework 5.6.1

Nicholas Murphy-O’Kane introduced the above report and drew attention to the progress being made on IG training; noting that there was a target to train 95% of all CCG staff. He suggested that this should be a mandatory requirement for all staff and new staff would need to complete the training during their probationary period. This proposal will be discussed at the Camden Executive Team meeting.

AGREED: to note the IG Framework. 5.7 Conflicts of Interest 5.7.1 SD referred the Committee to the NAO report on managing conflicts of interest and the CCG

Action Plan. It was noted that a list of all the CCG’s contracts and a Register of Procurement Decisions needs to be published on the CCG’s website The target date for publication is January 2016. Members asked to be kept up to date with this process.

AGREED: to note the current position with regard to the implementation of the NHS

England statutory guidance on managing conflicts of interest.

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5.8 NELCSU update on Governance and Assurance Methods and Slide Report – Service Auditor

Reporting at the CSU 5.8.1

Tony Uttley, the Financial Accounts and Governance Director, NELCSU, was welcomed to the meeting. Tony explained the structural background of the relationship between the CSUs and the CCGs. Discussion focused on Service Auditor Reporting, noting the opportunity and assurance that the CCG’s Internal Auditors could have when reviewing aspects of the CSU’s work on behalf of the CCG. It was noted that CSU was keen to work with all CCGs via the CSU Assurance Group and ensure that there was a clear understanding of the expectations of all the parties concerned, reiterating the importance of relevant representation to ensure its effectiveness.

5.8.2 The Chair suggested that counter fraud was likely to be included as part of the assurance plan.

AGREED: to note the presentation.

6. Any Other Business 6.1 Forward Planner 6.1 The members noted the contents of the updated forward planner. It was noted that the

deadline for submitting draft accounts and final accounts to NHSE was 22 April and 27 May so April and May meeting dates needed to take account of these deadlines.

6.2 There was no further business; the meeting closed at 12:25. 7.0 Date of Next Meeting: 27 January 2016.

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CAMDEN CLINICAL COMMISSIONING GROUP

Minutes of the Commissioning Committee

held on Wednesday, 16 December 2015, Room 6LM1, Stephenson House,

75 Hampstead Road, London, NW1 2PL

Members: Dr Neel Gupta (Chair) Elected GP Representative, CCCG Governing Body Member Lyndsey Abercromby Acting Director of Commissioning, CCCG Charlotte Ashton Public Health Consultant, Camden and Islington (until11:30am) Tim Bishop Assistant Director Adult Social Care and Joint Commissioning, LBC Dorothy Blundell Chief Officer, CCCG Ian Boyle Interim Chief Financial Officer, CCCG Dr Matthew Clark Secondary Care Doctor, CCCG Governing Body Member Dr Ammara Hughes Elected GP Representative, CCCG Governing Body Member Judith Hunt OBE Lay Member, Camden CCG Dr Jonathan Levy Elected GP Representative, CCCG Governing Body Member Richard Lewin Assistant Director Strategy & Resources, Children Schools and Families, LBC Charlotte Mullins Acting Director of Sustainable Insights, CCCG David Richards Patient Representative, CCCG Dr Lance Saker Elected GP Representative, CCCG Governing Body Member In Attendance Chris Clark Project Manager, NELCSU Gillian Dent Head of Integrated Commissioning, LBC Jenni Frost Deputy Director, NCL POD Debbie Hawkins Head of PMO, CCCG Gordon Houliston Head of Primary Care, CCCG (Observer) Dr Tom Huitson Darzi Fellow, Primary Care Team, CCCG Chris Orton Property Consultant (item 2.2) Dr Alex Warner Mental Health Clinical Lead, CCCG Minutes: Tyrieana Long Board Secretary, CCCG Apologies: Tim Bishop Assistant Director Adult Social Care and Joint Commissioning, LBC Ian Boyle Interim Chief Financial Officer, CCCG

1. Introduction

1.1 Welcome and Apologies for Absence The Chair opened the meeting and welcomed new committee members and those attending

the meeting for the first time. 1.2 Declaration of Interests The Register of Interests was considered. There were no new declarations of interest. 1.3 Minutes of the previous meeting

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1.3.1 The minutes of the meeting held on 25 November 2015 were considered. Two amendments were requested:

1. At 2.1.6 – To assign the action point to Charlotte Mullins instead of Lyndsey Abercromby

2. Page 1 – to remove the reference to video conference in respect of the Chief Officer 1.3.2 Subject to the above amendments the minutes of the meeting held on 25 November

2015 were approved as an accurate record. 1.4 Actions Log Members reviewed the Action Log and noted the updates that had been provided. 1.4.1 Action 1: Dorothy Blundell confirmed that the Chief Finance Officer was working on the

CCG’s financial and QIPP position and an update would be presented at the January 2016 meeting.

1.4.2 Action 2: Gillian Dent confirmed that she was now in receipt of the delayed transfers of care

(DTOC) data for non-Camden residents. Dr Clark advised that the SRG would look at the DTOC data that had been supplied. In response to a question from Dr Hughes, Gillian Dent also confirmed that the Better Care Fund investment did not include addressing DTOC’s for non-Camden residents.

1.4.3 Action 3: Richard Lewin advised that the executive summary report that had been circulated

had been commissioned by the Minding the Gap group to look at the extent of mental health issues in the 16-24 population group in Camden. A full report was expected in due course which would be subject to oversight within the Council and CCG.

1.4.4 Action 5: Dorothy Blundell confirmed the action in respect of the update on Resilient Families

to demonstrate the Council’s commitment to the wider work of the Children’s Team. 1.4.5 Action 7: Lyndsey Abercromby confirmed that an update on the patient choice aspect for the

Fertility Policy would be brought to the January 2016 meeting. . 1.4.6 Action 13: It was agreed that the action point in respect of the CSU’s procurement support

could be closed because it had been transferred to the Committee’s risk register. 1.4.7 The Committee agreed to note the Action Log updates.

2 Business Cases and Commissioning Items

2.1 Mental Health Value Based Commissioning (VBC) 2.1.1 The Committee received a paper on the Provider Assurance Process for VBC for people

living with psychosis and an update on the additional work that had been completed to establish an incentives framework.

2.1.2 The Committee was asked to note the work that had been undertaken on contract terms in

preparation for contract negotiations with Camden and Islington Foundation Trust (CIFT) as the preferred Lead Provider for the VBC model. In addition, in response to a request at the September Governing Body meeting the Committee was asked to consider options to monitor admissions to acute care.

2.1.3 The Committee discussed the measures that had been identified to monitor mental health

acute care admissions. Members discussed:

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a) The very strong steer from the Governing Body to include some measure of admissions or ideally “time spent at home” in the outcomes framework.

b) The need to focus on the whole pathway and not just at the acute end c) Whether admissions could be classified as outcome measures d) The importance of measuring time at home as well as in hospital e) That some of the measures that had been identified were proxy outcome measures

rather than simply process measures f) The possibility of perverse incentives if providers attempted to avoid a hospital

admission. The role of other regulators was raised to counter such behaviour. g) The complexity of the Camden mental health issues and the need for caution around

the admission measures h) The positive benefits of a focus on admissions to understand the pathway as

demonstrated with hip replacements in the frail and elderly patient group i) The absence of a measure for patients detained under the Mental Health Act when

such a measure could indicate a lack of early intervention j) The value of monitoring admissions to acute care to prevent further bed closures k) The possibility of closely monitoring admissions but not linking these directly to

financial incentives 2.1.4 The Committee agreed that additional work was needed on the outcome measures

around admissions and any possible link to financial incentives. Dr Ammara Hughes and Charlotte Mullins agreed to meet and discuss in more detail with the mental health team. Dorothy Blundell requested that the learning from the diabetes and frail elderly VBC work was considered as part of the discussions.

2.1.5 The Committee turned its attention to the Provider Assurance Process and the

recommendation to initiate negotiations with Camden and Islington Foundation Trust as the preferred lead provider for the VBC model for people living with psychosis.

2.1.6 The Committee considered the outcome of the lead provider assurance process and the

contract terms that had been discussed. The Committee:

a) Noted that CIFT had achieved the required standard as a result of the lead provider assurance process and had demonstrated a commitment to deliver the VBC

b) Acknowledged that the largely qualitative assurance process was subjective, with some shortfalls in the questions relating to whole system working, integration and improvements over the five year contract

c) Acknowledged the relationship with Islington CCG and the need to maintain the momentum and direction of travel

d) Requested greater assurance through formal gateways before contract signature and with clear expectations on outcomes articulated to the provider at the outset

e) Requested annual reviews of the contract to be assured on progress against outcome measures

f) Noted that NHS England was taking an interest in the contract to bring about major transformation for patients.

2.1.7 The Committee agreed that further work was needed to increase the robustness of the

contract and to provide sufficient assurance to the Governing Body relating to CIFT’s suitability as Lead Provider. This includes establishing a gateway assurance framework prior to contract signature. Dr Ammara Hughes, Dr Alex Warner and Dr Jonathan Levy agreed to discuss further prior to the start of contract negotiations.

2.1.8 The Committee agreed that Governing Body approval of the recommendations was

best sought when further work was completed on: 1. Outcome measures and the link to financial incentives as highlighted above 2. Provider assurance and contract review.

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2.2 Belsize Priory Health Centre Outline Business Case 2.2.1 Further to a report received at the July 2015 meeting, the Committee received an outline

business case for the development of a new Belsize Priory Health Centre to replace the existing facility, to be developed by the London Borough of Camden as part of a wider generation of the area.

2.2.2 Chris Orton advised that the existing premises were operating at capacity and did not meet

CQC premises standards. The proposed development had been designed to provide a new modern facility, with high quality flexible accommodation to meet current and future health needs.

2.2.3 It was anticipated that the development would lead to a significant increase in rental costs.

However, a review of local estate options had revealed that there were no alternative site options. Moving services to separate sites or dispersing the existing practice list was not thought to be a viable option because of the disruptive impact on patients and increased costs for new accommodation.

2.2.4 The Committee noted:

a) That the new facility had been designed in accordance with NHS England regulations b) Only two new consulting rooms would be provided in the new health centre but with

improved design and the provision of new office space the overall increase in available space for clinical work would be more significant

c) The 60% increase in space which was needed for increasing demand and anticipated population growth

d) A number of financial models had been considered, including funding from NHSE via the Primary Care Transformation Fund which was likely to be restricted to the GP element of the service; it would need to be clarified if NHSE were willing to fund the non-GP elements of the development and the figures presented were based on a “worst case” of no additional funding.

e) The projected costs from 2018/19 f) That the Council and NHS property services had not reached an agreement on the

rental terms. 2.2.5 In discussion the Committee agreed that:

a) The Council had a duty to provide healthcare for the local population if they planned to demolish existing healthcare facilities

b) The role of the CCG was to commission services. It was not an estate holder. c) There were cost pressures on contracts with providers when rental costs were

increased d) The CCG could ask the service provider to absorb the additional costs, although this

may have an adverse impact on quality e) The provision of new GP premises was in line with the CCG’s strategic objectives f) The CCG would not pay rent for commissioned services as that would significantly

impact on the CCG’s commissioning budget g) The full business case would need to include demographic details for the ward to

understand the health care needs of the population 2.2.6 The Committee noted that the Belsize Priory development was part of the CCG’s wider

estates strategy which was due to be considered at the January 2016 Governing Body meeting.

2.2.7 The Committee agreed to the submission of the outline business case for the Belsize

Priory Care Health Centre to NHS England for approval and the drafting of the full business case, subject to further negotiations with the Council and NHS Property Services relating to the rental terms, clarification of the funding available from NHSE

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via the Primary Care Transformation Fund and clarification of the CCG’s role and responsibilities in relation to the recurrent and non-recurrent costs.

2.3 Investing Strategically to Improve Acute Provider Performance for Camden Patients 2.3.1 The Committee received a report which summarised the outcomes and findings of an

independent demand and capacity analysis which was completed as part of the above named project initiative (Initiative A3 from the Business Plan).

2.3.2 The report explained the work that had been undertaken and the methodology used to

identify where there may be capacity gaps within hospital services in Camden either now or in the future.

2.3.3 The Committee considered the report’s recommendations, including where specific

commissioning of additional capacity may be needed for some services in 2016-17, and also wider commissioning strategies to address the level of demand for diagnostic, elective and cancer care pathways within Camden.

2.3.4 The Committee:

a) Noted the potential outsourcing of private provider options to address the capacity

shortfall and questioned whether the CCG could provide additional non NHS services to increase capacity

b) Noted that the use of private providers to boost capacity was not unique to UCLH and Royal Free

c) Acknowledged that outsourcing of additional capacity outside of Camden was not ideal for patients

d) Agreed that the ideal approach would be to support additional NHS capacity within Camden e.g. through supporting 6 or 7 day working within local acute trusts.

e) Recommended that the project seek the audit data on provider referrals to fully identify the level of referral activity

f) Noted that the IMAS tool had been used to do the work and that it would be compatible with the NHS England national tool that would be used as part of the assurance process

g) Recommended an analysis of the appropriate use of CCAS Action 1: Lyndsey Abercromby agreed to bring an overview of the CCAS referral data to the February 2016 meeting h) Requested more detail about the timelines associated with the recommended work

and the link to the national developments and strategic work on demand and capacity analysis.

2.3.5 The Committee agreed to consider the recommendations again at the January 2016

meeting. 2.4 Camden CCG List of Contracts 2.4.1 The Committee received a list of CCG’s contract for information and review. The Chair

confirmed that the contracts list would be a standing agenda item for future meetings. 2.4.2 The Committee:

a) Requested more detail on the UCL Partners contract (CM042) which was due to expire on 31 March 2016. Action 2: Lyndsey Abercromby

b) Agreed to receive a detailed update on LAS at the January 2016 meeting. Action 3: Lyndsey Abercromby c) Noted that there would be pressure on resources at certain points and agreed to

consider the resourcing plan at the next meeting d) Noted that the contracts list was to be considered at the January 2016 Finance and

Performance Committee

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2.4.3 The Committee agreed to note the contract list and consider in more detail at the next

meeting. 2.5 Long Term Conditions and Cancer Programme 2.5.1 The Committee received a request to revise to the Long Term Conditions and Cancer

Programme Mandate, to take forward a number of projects in 2016/17 within the original mandate funding allocation. The additional areas were an initiative for an Integrated Neurology Service and a continuation of the Early Diagnosis of Cancer initiative.

2.5.2 The Committee agreed to approve the revision to the Long Term Conditions and

Cancer Programme Mandate and the projects proposed in 2016/17 and 2017/18.

3. Governance

3.1 MSK Provider Performance Improvement Plan 3.1.1

Further to a request by the Governing Body, the Committee received the MSK Provider Performance Improvement Plan to provide assurance on the quality of MSK services delivered by Connect.


a) Noted that there had been no change in the quality improvement RAG status b) Noted that the lack of capacity and backlog of patients were continuing issues c) Requested the inclusion of patient experience data d) Agreed that there was a lack of assurance from the provider and that the current

contract management approach with the community MSK provider was not providing the required level of assurance around MSK services locally

e) Acknowledged the CCG’s responsibility to patients and the need to explore alternative approaches for MSK service improvement

3.1.3 Dorothy Blundell advised that she would speak to the Commissioning team about the next

course of action. The Committee agreed to consider MSK provider performance again at the January 2016 meeting.

3.2 Commissioning Committee Risk Report 3.2.1 The Committee considered the second presentation of the Commissioning Risk Register. 3.2.2 Dr Ammara Hughes suggested that performance risks, to include the two Better Care Fund

risks were transferred to the Finance and Performance Risk Register. 3.2.3 A request was made for the MSK risk to be reframed to fully capture the entirety of the risk

and also to add the risks around the Mental Health VBC. Action 4: PMO/Lance Saker 3.2.4 The Committee agreed to note the Commissioning Committee Risk Register and keep under

review as a standing agenda item. 3.3 Commissioning Committee Terms of Reference 3.3.1 The Committee considered a revision to the terms of reference to reflect the establishment of

the Clinical Cabinet and the Committee’s oversight role for clinical pathways. 3.3.2 The Committee also discussed adding the Director of Quality and Clinical Effectiveness to the

Committee’s membership.

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3.3.3 The Committee agreed to the proposed amendment to the terms of reference and to invite the Director of Quality and Clinical Effectiveness as a new committee member to strengthen integrated working between the committees.

4. AOB

5.1 January 2016 Agenda 5.1.1 The Committee noted the contents of the January 2016 meeting agenda. 5.1.2 There was no further business. The meeting closed at 11:55am.

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CAMDEN CLINICAL COMMISSIONING GROUP

Minutes of the Commissioning Committee

held on Wednesday, 27 January 2016, Room 4LM1, Stephenson House,

75 Hampstead Road, London, NW1 2PL

Members: Dr Neel Gupta (Chair) Elected GP Representative, CCCG Governing Body Member Lyndsey Abercromby Acting Director of Commissioning, CCCG Charlotte Ashton Public Health Consultant, Camden and Islington (until11:30am) Tim Bishop Assistant Director Adult Social Care and Joint Commissioning, LBC Dorothy Blundell Chief Officer, CCCG Ian Boyle Interim Chief Financial Officer, CCCG Dr Matthew Clark Secondary Care Doctor, CCCG Governing Body Member Dr Ammara Hughes Elected GP Representative, CCCG Governing Body Member Judith Hunt OBE Lay Member, Camden CCG Dr Jonathan Levy Elected GP Representative, CCCG Governing Body Member Richard Lewin Assistant Director Strategy & Resources, Children Schools and Families, LBC Charlotte Mullins Acting Director of Sustainable Insights, CCCG David Richards Patient Representative, CCCG Dr Lance Saker Elected GP Representative, CCCG Governing Body Member Neeshma Shah Director of Quality and Clinical Effectiveness, CCCG In Attendance Dr Tom Aslan Clinical Lead MSK, (item 3.6) Liz Crisp IAPT Project Manager, LBC (items 3.1 and 3.2) Gillian Dent Head of Integrated Commissioning, LBC Anna Hall Shared Care Co-ordinator, LBC (items 3.1 and 3.2) Debbie Hawkins Head of PMO, CCCG Dr Steven Laitner Consultant, (item 3.6) Fiona Mortlock Head of Integrated Commissioning – Community, LBC (item 3.3) Doreen Murray MSK Project Lead, CCCG (item 3.60 Helen Saunders Project Manager, CCCG (item 3.4) Minutes: Tyrieana Long Board Secretary, CCCG Apologies: Tim Bishop Assistant Director Adult Social Care and Joint Commissioning, LBC Dr Ammara Hughes Elected GP Representative, CCCG Governing Body Member Charlotte Mullins Acting Director of Sustainable Insights, CCCG Neeshma Shah Director of Quality and Clinical Effectiveness, CCCG

1. Introduction

1.1 Welcome and Apologies for Absence The Chair opened the meeting and noted the apologies as recorded above. 1.2 Declaration of Interests The Register of Interests was considered. There were no new declarations of interest.

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1.3 Minutes of the previous meeting 1.3.1 The minutes of the meeting held on 16 December 2015 were considered and approved

as an accurate record. 1.4 Actions Log Members reviewed the Action Log and noted the updates that had been provided. 1.4.1 Action 2: The Committee noted the update with regard to the UCL Partners contract. The full

list of CCG contracts will come back to the February 2016 meeting for committee review. 1.4.2 Action 7: Lyndsey Abercromby advised that there was a requirement to review the Fertility

Policy in relation to Patient Choice obligations, adherence to NICE guidelines and value for money as set out in the Pipeline Report. It was confirmed that Patient Choice obligations only applied to secondary care services, not community services including community MSK services.

1.4.3 The Committee agreed to note the Action Log updates.

2 Commissioning and Programme Performance

2.1 PMO Report, Pipeline Report and Business Case Schedule 2.1.1 Debbie Hawkins introduced the PMO Report and highlighted the further development work on

the Commissioning Dashboards to present the complete budgetary picture and also the QIPP summary which was expected to gain prominence as the QIPP profile was raised.

2.1.2 The Committee noted the business cases that were expected to come to the February 2016

meeting and the work that had been carried out to refine the pipeline process for in year project proposals. The Committee:

a) Noted the governance process for corporate services proposals and clinical services proposals

b) Noted the requirement for the proposal to align with Business Plan strategic objectives and priorities

c) Welcomed the ‘from ideas to action’ methodology d) Requested the insertion of a reference to patients and patient groups in ‘Ideas

Formed’ e) Requested specific mention of Equality Impact Analysis in the proposals criteria to

ensure that the equality duty was thought about at the right time early in the process. It was acknowledged that this may be through the Business Case rather than the Pipeline proposal.

f) Noted that having effective evidence as part of a proposal was important but may apply more to the Business Case stage. The most important aspect was to define the problem that needed to be addressed.

g) Recognised that the Project Pipeline was a key mechanism for sharing information within the organisation and that some projects were part of wider pieces of work.

h) Endorsed the Pipeline Process as the process to be followed for CCG business proposals

2.1.3 Pipeline Projects

The Committee considered three Pipeline Projects for decision: 1. Personal Health Budgets (PHBs) – The Committee supported the principle of PHBs,

noting that this was a national requirement. However, members were mindful that there were other potential innovative schemes that the CCG could consider and progress.

The Committee agreed to:

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a) Receive a concise paper (no more than 10 pages in length) to include a detailed assessment of personal health budgets and evaluation data, with options for taking these forward beyond the national mandate remit.

2.1.4 2. Street/Mental Health Triage Pilot

The Committee noted that the project proposal was part of the wider Mental Health Mandate and agreed to consider the proposal again in preference to considering the proposal in isolation. The Committee agreed to support the Pilot in principle and to receive an integrated paper in order to consider the proposal as part of the overall Crisis Care Plan.

2.1.5 3. Fertility Policy

The Committee noted the requirement to undertake a review of the Fertility Policy and practices relating to the policy to ensure compliance with NICE guidelines, Patient Choice regulations and value for money. The Committee approved the recommendation to review at a future time due to other competing priorities.

2.1.6 Ian Boyle confirmed that there was a forecast underspend in the Investment Programmes

and that the Finance and Performance Committee would take decisions regarding the overall budget position.

2.1.7 The Committee noted the contents of the business case schedule. 2.1.8 The Committee agreed to note the PMO Report, Pipeline Report and Business Case

Schedule. 2.2 Commissioning Dashboards 2.2.1 Children’s

Richard Lewin confirmed that the Paediatric Diabetes work had come to an end with the approval of the Children’s sponsor as the concept business case was not strong enough to bring to the Commissioning Committee. The also advised the CAMHS Transformation Plan had been approved by NHS England and funding allocated for 2015/16 to be used for one off or short term activities to support the delivery of the plan and the capacity to deliver it.

2.2.2 Mental Health The Committee noted that the VBC Psychosis business case had been approved by the

Governing Body. They agreed not to attach financial incentives to some of the admissions outcome measures.

2.2.3 Adult Community

The Committee noted the main focus was the annual contracting round and re-negotiation of the main community health contract with CNWL. A community healthcare paper is due to come to the February 2016 meeting together with a paper on Whittington Health community services provision.

2.2.4 The Chair updated the Committee on the integration of IT systems in relation to community

services. A single IT system had been identified as the only viable option and the existing provider had requested a substantial investment from Camden CCG to fund a new IT system. Piloting an EMIS based system similar to the one used by the Camden Integrated Care Service (CICS) for community services had been put forward as an alternative option.

2.2.5 Core Commissioning

Lyndsey Abercromby highlighted that the UCLH Pain Management Service was now live and the Dermatology project was progressing according to schedule.

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2.2.6 Better Care Fund Gillian Dent confirmed that the Better Care Fund would continue in 2016/17 and that the overall budget was at a similar level to year 1; around £18m. Ian Boyle advised that the Governing Body would be required to formally approve the Better Care Fund allocation at the March 2016 meeting.

2.2.7 The Pay-for-Performance element of the Fund had been removed for 2016/17, although there

was an expectation that local areas agree how to fund services to avoid unplanned emergency admissions. Once the national guidance is received in February 2016, the Better Care Plan will be refreshed and submitted to the Health and Wellbeing Board for approval.

2.2.8 In terms of evaluation, Gillian Dent advised that the Better Care Fund broadly consisted of

existing projects, mainly community services and with some new projects. There had been a six month evaluation of individual projects and an annual evaluation of the whole programme was planned. The Chair requested that the Committee see the outcome of the Better Care Fund evaluation exercise at the next meeting. Action1: Gillian Dent

2.2.9 Learning Disabilities Dr Jonathan Levy advised that Dr Meena Anand had been appointed as the GP Clinical Lead

for Learning Disabilities and would support practices to make improvements to services for patients with learning disabilities. The Committee welcomed the news.

2.3 Update Reports 2.3.1 London Ambulance Service

The Committee noted the update report on the London Ambulance Service and the deep dive that had taken place by the Systems Resilience Group and Quality and Safety Committee.

2.3.2 In response to a question from Ian Boyle about service delivery for Camden residents,

Lyndsey Abercromby agreed to supply Camden data outside of the meeting. Dorothy Blundell confirmed that Enfield CCG led on the NCL oversight of the LAS contract. Action 2: Lyndsey Abercromby.

2.3.3 Homeless Healthcare The Committee received a summary report on the performance of the Homerless Healthcare

service provided by St Mungo’s Broadway, the challenges the provider had encountered and the actions the CCG had taken to improve the service and support the provider in meetings its contractual obligations.


a) Noted the positive outcomes from the service despite the very small number of

beneficiaries b) Noted the significant reduction in the use of unplanned acute care for service users c) Noted the provider had failed to supply quality and some performance data and that

plans were in place to strengthen contract monitoring d) Noted that an assessment of value for money should be part of routine contract

monitoring e) Requested that there was flexibility within the service to widen the capture of

homeless service users. f) Noted that an independent evaluation of the service was planned g) Reiterated the importance of clearly stipulate the ongoing monitoring requirements if

similar contracts are set up. 2.3.5 The Committee agreed to receive a further paper on the Homeless Healthcare service

in three months’ time that seeks to answer the questions presented on page 11 of the current paper. Action 3: Board Secretary to add to forward planner.

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2.3.6 Resilient Families Richard Lewin introduced a report on the Resilient Families programme which is led by the

Children’s Trust Partnership Board. The report had been requested by the Committee further to the consideration of the All Together Better project, to see the wider context of the Children’s work programme in Camden.


a) Noted the strong links with the All Together Better project b) Noted the programme objectives with the aim of supporting families early enough to

prevent problems getting worse and to manage the majority at the level of universal services.

c) Noted the richness of the service provision and the joining up of services to create a “single front door.”

d) Noted that local government funding would be 50% less by the end of the decade in comparison to 2010/2011 funding levels.

e) Noted the re-design of early support for families to deliver savings as outlined at page 6 of the report.

f) Noted that new models of social work with multi-disciplinary teams and flatter management structures would also help deliver savings in Family Services

2.3.8 The Committee agreed to note the Commissioning Dashboards and Update Reports.

3. Business Cases and Commissioning Items

3.1 IAPT Vision Paper 3.1.1

Anna Hall introduced a vision paper which set out the intentions for Improving Access to Psychological Therapies (IAPT) services from April 2017 for people experiencing anxiety and depression within Camden. The Committee was asked to support the proposed service delivery approach and associated procurement, the contracting model and financial model through an open market tender process.

3.1.2 In response to questions the Committee:

a) Noted that the focus of the paper was on meeting the IAPT metrics with less

emphasis on the problem that needed to be solved. b) Highlighted that Camden IAPT performance in comparison to other London

boroughs was in the middle of the range with a possible demographic issue for current performance levels

c) Noted the complex contractual model required which needed to be flexible to meet the demands of the high needs population and with the necessary access and co-ordination requirements

d) Noted that there was a risk that any provider may deliver a “one size fits all” IAPT service when a much more flexible and co-ordinated approach was needed to meet the varied levels of treatment for the target population e.g. different lengths of treatments/numbers of sessions according to need.

e) Noted that there were similarities between IAPT step 4a and the Team around the Practice (TAP). TAP can be differentiated from IAPT’s step 4a by its main aim to support people who are not engaging with mainstream services. As TAP is still in its infancy, there are no plans at this stage to remove step 4a from IAPT but there are plans to carry out a formal review after one year.

f) Highlighted that there was no incentive in the contract to provide additional services for people needing more sessions.

g) Requested the inclusion of both clinical and non-clinical outcomes in any new contract to encourage the provider to respond to the CCG’s overall strategic aims for the mental health services

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h) Noted that the proposals for outcome measures were subject to further discussion

i) Noted that fixed cost elements needed to be taken into consideration in block contract negotiations

3.1.3 The Committee agreed that the IAPT Vision paper could be submitted to the Governing

Body for consideration and approval subject to: a) Further clarity on the £468k core block funding and its associated service

provision b) Placing the IAPT Vision in the context of the whole Mental Health pathway

including initiatives such as Team around the Practice and Big White Wall c) Revising the paper to focus more on a clinical outcomes approach as opposed

to a purely nationally mandated, KPI approach d) The inclusion of an update on the contract extensions and tender waivers

already used and e) Highlighting to the Governing Body the risk of a reduction in the CCG’s

assurance rating in the event that IAPT metrics are not met. 3.2 Improving Outcomes for those with Long Term Conditions (LTC) and Medically Unexplained

Symptoms (MUS) 3.2.1 The Committee received the above named paper which set out the options to fund the

delivery of psychological therapies in 2016/17. The original project was funded as an investment project by the Long Term Conditions and Cancer programme as a three year project from April 2013 to March 2016 and was designed to coincide with the redesign of IAPT services in Camden. The Committee was asked to continue funding the service in 2016/17 to align with the re-commissioning of IAPT services.


a) Noted that the Sustainable Insights Team was leading on a data refresh of programme evidence and the results would be available in early February 2016

b) Noted the main driver for the programme was to contribute to IAPT service provision and bring together parity of esteem for those patients with long term conditions and medically unexplained symptoms.

c) Acknowledged the success of the programme including contributing 24% of IAPT activity and some early evidence of improvement in physical health outcomes and secondary care use.

d) Noted that the request was for recurrent funds to be incorporated in the overall IAPT budget from 2017.

3.2.3 The Committee agreed:

a) To approve option A to continue to fully fund the LTC/MUS service in 2016/17 to align with the re-commissioning of IAPT services.

b) To allocate £263,812 funding in 2016/17 on the basis that resources are first sought from the Mandate provision before separate resources are committed from central CCG funds. The LTC/MUS psychological interventions service element will be delivered through the new IAPT service specification from April 2017.

3.3 Tier 3 Adult Weight Management Services 3.3.1 The Committee considered a request to transfer commissioning responsibility for tier 3 weight

management services from Public Health to the CCG in line with national guidance and to continue with the current service with a novation in contract until a decision is reached about future procurement. The Committee was also asked to consider a business case and decide on the procurement process for the service.


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a) Expressed concern that this was being considered at such a late stage b) Noted Public Health’s recommendation to move away from the PBR contract to

achieve better value with a block contract for the target group c) Noted the aim to better align and integrate the tier 3 service with tier 4 services in

future d) Noted that Public Health had fully funded the service and would continue to fund Tier

1 and Tier 2 services. Responsibility for Tier 4 services will remain with NHSE for now.

e) Noted that insufficient information regarding activity and quality information had been provided within the existing paper to inform future procurement decisions.

f) Noted that a six month extension to the contract was thought to be sufficient to allow appropriate procurement of a new service and there was a greater risk if the service was withdrawn.

g) Agreed that more detail was required on quality aspects, activity and timelines before a decision could be made on the procurement process for the service.

3.3.3 The Committee agreed:

a) To extend the contract for a six month period as the service provision was one of the Health and Wellbeing Board’s strategic priorities, noting the risk of service termination if this extension was not agreed

b) To consider the procurement process for the service and financial implications at a future meeting when further details were supplied as requested above (3.3.2 g)

3.4 Early Diagnosis of Cancer 3.4.1 The Committee received a business case proposal to improve early diagnosis of cancer in

Camden through three linked initiatives:

1. A continuation of the volunteer led population awareness initiative building on the model and learning from the previous phase of the project.

2. A pharmacy campaign, linking in with the Healthy Living Pharmacies Programme. 3. A GP practice education programme. Cancer is being included in the Planned Care

LCS from 2016/17 and this proposal aligns with the GP learning incentivised through that mechanism.

3.4.2 Early diagnosis of cancer is a national priority and currently Camden’s performance is below

the national average. The combined cost of the proposal was £200k per annum for two years. 3.4.3 The Committee:

a) Welcomed the laudable aims of the business proposal b) Noted the data evidence that had been collected and the link with the Planned Care

LCS work. c) Noted the improved knowledge of the signs and symptoms of cancer d) Questioned the impact on diagnostic capacity given the existing pressures in the

system e) Noted that the anticipated numbers were a minor component of the overall demand

for diagnostic tests f) Noted the significant cost pressures in 2016/17 and that no additional resources were

available nationally for diagnostics. g) Noted that the impact of the business proposal was subject to further work with further

analysis of London-wide referral data h) Suggested that the project link up with other initiatives to include minority groups i) Noted how the funding would be allocated to the project initiatives

3.4.4 The Committee agreed the business case proposal and approved the requested

resources of £200k per annum to fund the Early Diagnosis of Cancer in 2016/17 and 2017/18.

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3.5 Integrated Optometric and Rehabilitation Low Vision Service Re-commissioning 3.5.1 The Committee received a paper to consider the options for re-commissioning the Integrated

Optometric and Rehabilitation Low Vision Service (known as the “Low Vision Centre”). The current contract was due to expire on 31 March 2016

3.5.2 The Committee noted that the Low Vision Centre offered a multi-disciplinary, integrated and

user-centred assessment and rehabilitation service for people living in Camden who have a residual sight problem. The Centre supports residents to retain/ regain their independence, promotes wellbeing, and addresses inequalities.

3.5.3 The Committee was asked to approve funding to re-let the contract for a period of one year,

whilst a scoping exercise is undertaken to ascertain options for the longer term re-commissioning of the service (including options for partnership with other boroughs).

3.5.4 The Committee noted the relatively low monetary value of the contract and that the service

was for Camden residents. 3.5.5 The Committee agreed to approve the funding of the contract for a further year until

options were worked up for any proposed changes to the service specification and procurement of the Low Vision Centre in the longer term.

3.6 Musculoskeletal (MSK) Redesign Scope 3.6.1 The Committee received a paper on the proposed way forward for the redesign of MSK

services, further to earlier Committee discussions and the Governing Body’s decision to limit the scope of the MSK re-commissioning work to the community element in preference to the more ambitious re-commissioning of the full MSK pathway.

3.6.2 The Committee was asked to re-consider the two options of:

1) Re-commissioning only the community element of the MSK pathway or 2) Re-commissioning the full MSK pathway

The paper provided an overview of the advantages and disadvantages of each option and the Committee was asked to consider and confirm the scope of the redesign work to be included in the business case in development for MSK services.

3.6.3 In response to a question from the Chair about what had changed, Dr Tom Aslan and Dr

Steven Laitner were of the opinion that a major opportunity would be missed in limiting the scope of the redesign work to the community element. Re-commissioning of the full MSK pathway to achieve an integrated service was the preferred option.


a) Was assured that a robust case could be developed in the same timescales b) Noted that increased management support for the MSK work had been approved c) Noted that a further tender waiver for the existing contract was not an option d) Noted that there was clarity around the scope of the business case and MSK service

model from a patient perspective e) Noted that there were other MSK integrated pathways in existence and learnings

could be taken from other areas. 3.6.5 Further to the assurances that were received around resources, timescales and clarity

of intent the Committee agreed to the development of a business case to re-commission the full MSK pathway.

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3.7 Community Epilepsy Service 3.7.1 The Committee considered a proposal that the Community Epilepsy Service also include

patients who have presented to their GP with a suspected first epileptic seizure. The proposal had been approved at the December 2015 Programme Implementation Group meeting.

3.7.2 The aim is that this will allow these patients to be seen more promptly in the community, and

it will also reduce the number of patients referred into secondary care for an outpatient appointment when they either do not have epilepsy or do not need to be managed in secondary care.

3.7.3 The Committee noted the proposed version of the epilepsy pathway with the inclusion of first

epileptic seizures. In response to a question Dr Lance Saker agreed to check whether referrals could be made directly from A&E departments. Action 4: Dr Saker

3.7.4 It was confirmed that the proposal didn’t include children. Richard Lewin advised that he

would pick that up in the All Together Better work. 3.7.5 The Committee agreed to approve the inclusion of first epileptic seizures in the

Community Epilepsy Service.

4. Governance

4.1 MSK Performance Improvement Plan 4.1.1 The Committee considered the performance improvement plans in respect of the Community

Musculoskeletal (MSK) Services and Community MSK Pain Assessment and Management Service (CPAMS).

4.1.2 Lyndsey Abercromby advised that the regular contract monitoring meeting was due to be

held on Monday 1 February. Further improvement was expected in both services. 4.1.3 The Committee noted that waiting times were improving but that there was a lack of quality

information in respect of complaints and patient experience. It was also highlighted that there was no measure of appropriate discharge from the service and that patient experience data was the best source of this type of information to learn about the impact of the high demand for the service. The Chair requested that the Committee see patient experience information at the next meeting. Action 5: Lyndsey Abercromby

4.1.4 The Committee agreed to note the update on the MSK performance plans. 4.2 Commissioning Risk Report 4.2.1 The Committee reviewed the Commissioning Committee Risk and agreed:

a) That the VBC Psychosis risk was missing b) Risk 87 could be transferred to the Finance and Performance Risk Register c) The mitigation for risk 66 was the responsibility of the SRG

4.2.2 The Committee agreed to note the Commissioning Committee Risk Report. 4.3 System Resilience Group (SRG) Report 4.3.1 Dr Matthew Clark provided an update on the work of SRG and explained the scope of the

work as illustrated in the System Resilience Overview Flowchart.

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4.3.2 He advised that a whole system approach was taken to improve A&E key performance indicators and confirmed that the CCG was working with all providers to alleviate pressure in the system. He was of the opinion that there was more that the CCG could do to improve system resilience.

4.3.3 The Committee agreed to note the System Resilience Group Report. 4.4 Joint Commissioning Committee (JCC) Report 4.4.1 The Committee noted the summary report from the December 2015 JCC meeting. Gillian

Dent advised that non-elective admissions were contributing to poor performance. The non-elective performance deep dive had revealed that there had been no overall increase in the number of bed days.

4.4.2 The Committee agreed to note the JCC Report. 5. Items for Information

5.1 Changes to Locally Commissioned Services 5.1.1 The Committee agreed to note the three changes to Locally Commissioned Services. 6. Any Other Business

6.1 February 2016 Agenda 6.1.1 The Committee noted the contents of the draft February 2016 meeting agenda. 6.1.2 There was no further business. The meeting closed at 12:10pm.

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Finance and Performance Committee (‘Committee’)

Minutes of the meeting of the Committee held on 2nd December 2015 from 1.00pm to 3.05pm in

room 4LM2, 4th Floor, Stephenson House, 75 Hampstead Road, London NW1 2PL. Members Present: Dr Ammara Hughes (Chair)

Elected GP Representative, Camden CCG

Ms. Lyndsey Abercromby Assistant Director of Commissioning Development, Camden CCG

Mr Ian Boyle Interim Chief Financial Officer, Camden CCG Ms Pat Elliott Elected Practice Manager Representative, Camden CCG Ms Jenni Frost NCL Deputy POD Director, NEL CSU Dr Lance Saker Elected GP Representative, Camden CCG Ms Ellen Schroder Audit Committee Chair, Camden CCG Governing Body Lay

Member and Camden CCG Vice Chair In Attendance: Mr John Glass Business Manager, PMO, Camden CCG (for item 2.3) Ms Deepa Patel Head of Performance, Camden CCG Mr Ian Porter Chief Operating Officer, Camden CCG Ms Yajna Sooklall Deputy Chief Financial Officer, Camden CCG Minutes: Mr Andrew Spicer Governance Lead, Camden CCG Apologies: Mr John Levite Patient Representative 1. Introduction

1.1 Welcome and Apologies for Absence

1.1.1 The Chair opened the meeting at 1.05pm and welcomed those present.

1.1.2 Apologies were received from John Levite, Patient Representative.

1.1.3 The Committee welcomed the following people to the Committee:

Ian Boyle as interim Chief Financial Officer; and

Lyndsey Abercromby acting in the capacity of Director of Commissioning.


1.2.1 The following Declarations of Interest were made:

Ellen Schroder declared that she is the co-Chair of the Ethics Committee at Great Ormond Street Hospital;

Ellen Schroder declared that she is no longer a Trustee of the Cord Blood Charity;

Ian Boyle declared that he is a director and shareholder of Near Reality Training Ltd which is a company that provides training to the NHS.

1.3 Minutes of the Meeting on 4th November 2015

1.3.1 The minutes were approved as an accurate record of the meeting.

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1.4 Action Log

1.4.1 Of those actions that were not on the agenda or were not cleared the following updates were given:

Action 1: Jenni Frost reported that Central and North West London NHS Foundation Trust (‘CNWL’) did not send the required information to NEL CSU in time for the Committee meeting and the information CNWL did send did not cover the Committee’s request. NEL CSU has contacted the other CCGs to try to obtain the information directly. The action was reset to the February 2016 meeting;

Action 2: The action was completed and closed; Action 3: The action was completed and closed; Action 5: The action was completed and closed; Action 6: The action was completed and closed; Action 7: The Committee agreed that action was completed and could be closed; Action 8: Lyndsey Abercromby updated the Committee on the position with Delayed

Transfers of Care (‘DTOC’) and that the DTOC action plan is closely monitored by the Joint Commissioning Committee. The Committee agreed that the action was completed;

Action 9: Jenni Frost reported that patients are generally being referred to Chelsea and Westminster Hospital mainly due to patient choice for maternity and obstetrics. The Chair noted that the issue has an effect on Camden CCG’s Referral to Treatment Targets (‘RTT’) but that the main issue with RTT is at University College London NHS Foundation Trust Hospital (‘UCLH’) and at Royal Free London NHS Foundation Trust Hospitals (‘Royal Free’). The action was closed.

2. Finance

2.1 Finance Report: Month 7

2.1.1 Ian Boyle introduced the report and discussed the contents of the report as per the report and outlined the key highlights and variances. He noted that in future reports he will be reporting on trends and undertaking trend analysis and there will be changes to forecasts to account for seasonality.

2.1.2 Ian Boyle reported that at month 7 Camden CCG is on plan to deliver the budgeted surplus. In addition the Finance Team has identified approximately £6m in potential opportunities against approximately £5m in risks. However, this may be affected by underperformance and double counting in the Royal Free contract resulting in a £3.5m variance.

2.1.3 The Committee noted that the Royal Free spend is £2.4m below budget to date with a full year forecast spend of £4m below budget. The Committee asked for the reasons on this. Ian Boyle reported that work is being undertaken to understand the reasons for this.

2.1.4 Ian Boyle reported that there has been work on investments and general overheads. He noted that there is an absence of a definition of running costs nationally a London wide policy was agreed by the London Chief Financial Officers. However, Camden CCG has not technically been operating in line with this policy in its accounting methodology and therefore there will be a change in methodology going forward.

2.1.5 The Committee discussed and noted the report.

2.2 Finance Risk Register

2.2.1 Ian Boyle introduced the report and referred the Committee to risk ID 45 concerning the Estates Strategy. He noted that it is the only red rated risk on the Finance Risk Register. He reported that the Estates Strategy will be a high level strategic document.

2.2.2 Ian Boyle reported that the first outline draft of the Estates Strategy needs to be submitted to NHS England by the deadline of 31st December 2015. He reported that a first working draft of the Estates Strategy has been completed but it needs to be reviewed by clinicians and have their feedback incorporated into the document. He reported that the deadline will be met.

2.2.3 The Committee considered the level of clinical engagement required and requested that Dr

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Tom Huitson send the draft Estates Strategy to Dr Lance Saker, Dr Ammara Hughes and Dr Neel Gupta for review.

Action 1: Tom Huitson to send the draft Estates Strategy to Lance Saker, Ammara Hughes and Neel Gupta for clinical review.

2.2.4 The Committee discussed the Estates Strategy and noted that the Estates Strategy will need to link with the Out of Hospital Strategy and that providers will need to be consulted on the future provider landscape and how this links to estates. The Committee noted that London Borough of Camden will also need to be consulted and that the project is expected to take approximately 18 months to complete.


2.3 QIPP Plan

2.3.1 Ian Boyle introduced the report. He noted that the report focusses on this year’s Quality Innovation, Productivity and Prevention (‘QIPP’) programme but that it is important to shift discussions onto next year’s QIPP programme to ensure Camden CCG has adequately prepared for this.

2.3.2 John Glass presented the report and noted that since the production of the report Royal Free has guaranteed that they will meet their full QIPP target so there will not be the estimated shortfall in this. In addition the Home Care QIPP target will be met.

2.3.3 The Committee discussed the QIPP targets for Financial Year 2015-16 and the progress to date against those targets. The Committee noted that GP referral management and prescribing, targeting patients for particular conditions and transformational schemes account for approximately 20% each with the remaining 40% being from contract negotiations.

2.3.4 John Glass reported that for Financial Year 2016-17 there needs to be a larger QIPP programme with realistic QIPP targets and contingency plans in place in case any of the QIPP schemes do not deliver on their targets. Lance Saker noted that there is a lack of connection between contract negotiation and QIPP and this needs to be addressed. Ian Boyle noted that Camden CCG can learn lessons from other CCGs which have had to embed their QIPP programmes due to lack of financial resources. Ian Boyle confirmed that Better Care Fund projects can be considered as potential QIPP schemes.

2.3.5 The Committee noted that there needs to be a standard reporting of QIPP. Ian Boyle reported that there will be and that a draft QIPP plan for Financial Year 2016-17 will be presented at the next Committee meeting.


3. Activity and Performance

3.1 Performance Report

3.1.1 Lyndsey Abercromby introduced the report and outlined the contents of the report as per the report.

3.1.2 She reported that UCLH conducted a ‘perfect week’ exercise last week. However, the exercise did not deliver the expected results. An analysis in to the reasons for this is being conducted by UCLH and an action plan will be put into place.

3.1.3 The Committee discussed the issues with the Accident and Emergency targets and noted the increase in the number of attendances. The Committee noted the need to have a system-wide solution which includes an effective ED re-diversion strategy.

3.1.4 Lyndsey Abercromby raised the issues with capacity in endoscopy and reported that the NHS England Project Management Office is working with providers to co-ordinate activity across the system to help relive pressures.


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3.2 Breast Cancer Performance at UCLH


3.2.2 She reported that 2 members of staff at UCLH have been absent which has had a significant adverse impact on capacity at UCLH. This resulted in UCLH loosing 30 slots per week out of a normal capacity of 70 slots. Camden CCG has spoken with UCLH regarding UCLH sub-contracting the excess work to private providers. UCLH reported that they currently do not have any contracts with private providers and it will take time to undertake the necessary due diligence to ensure the private providers meet the relevant quality standards.

3.2.3 The Committee reviewed the actions taken by UCLH, Camden CCG and NEL CSU detailed in the report and noted them. The Committee also reviewed and discussed the further actions contained in the report.

3.2.4 The Committee considered the option of sending GPs the waiting times for each of the main specialities for each of Camden CCG’s main providers on a weekly basis. The Committee agreed that information should be sent to GPs to support them and to enable them to have properly informed discussions with their patients on their options.

3.2.5 The Committee considered the option of using CCAS. The Committee agreed that the option should be explored to ascertain if there would be any benefit.

3.2.6 The Committee considered the options of either putting into place a framework agreement for the provision of these services or supporting providers to put into place appropriate sub-contracting arrangements for use during times of increased demand. The Committee considered it unacceptable that providers did not have adequate resilience plans in place and providers need to both ensure they have adequate sub-contracting arrangements with other providers and demonstrate improvements. The Committee agreed that the most appropriate option was to support providers in this regard.


3.3 Great Ormond Street Hospital- RTT Performance


3.3.2 She reported that Great Ormond Street Hospital (‘GOSH’) informed NHS England and Camden CCG as the lead commissioner that they had an issue with the data they use to track patients across their care pathways. The main issue is with those patients required to be treated within 18 weeks of being referred.

3.3.3 She reported that at NHS England’s requested GOSH undertook a review and found that for some patients the 18 week target has been breached and for some other patient there is no assurance that the 18 week target has not been breached. She reported that NHS England is closely monitoring GOSH and an action plan is being implemented.

3.3.4 The Committee discussed the issue and noted that as lead commissioner for non-specialist care at GOSH the Committee is concerned about all patients not just those from Camden. The Committee were assured that NHS England is dealing with the issue and that the Camden CCG Quality and Safety Committee are sighted on this.


4. Governance

4.1 Terms of Reference

4.1.1 Ian Porter introduced the report and outlined its contents.

4.1.2 He reported that he reviewed the Terms of Reference and whilst they generally contain the provisions he would expect to see he and recommended the following changes:

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The membership is updated and clarified;

The duties are clarified and strengthened with enhances focus on performance improvement.

4.1.3 Andrew Spicer noted that the Secretariat was also in the process of conducting reviews of committee Terms of Reference and that an additional recommendation is to build in an express authority for the Committee to delegate its powers to a member of the Committee to make decisions on its behalf outside of Committee meetings. He noted that the Committee already has the implied authority.

4.1.4 The Committee discussed the revisions to the Terms of Reference. Regarding membership the Committee considered the following proposals:

Removing the Director of Strategy and Planning;

Removing the Director of Public Health;

Changing the NEL CSU representative from being a voting member to a non-voting member;

Changing the Lay Representative from being a voting member to a non-voting member;

Adding the Deputy CFO as a non-voting member;

Adding the Head of Performance as a non-voting member.

4.1.5 The Committee discussed the proposals to change the membership and agreed with each of the recommendations. It noted that the Director of Strategy and Planning role no longer exists, Public Health are not normally in attendance as they feel they do not add sufficient value to justify the allocation of resource, NEL CSU are an important partner but are external, changing the status of the lay representative from voting to non-voting member is good governance and adding the deputy CFO and Head of Performance as non-voting members will add value to the Committee’s work.

4.1.6 The Committee agreed to strengthen the duties of the Committee in the following ways:

It will maintain oversight of the annual contracting round;

Clarify its position regarding its powers to make recommendations and following up on these and other actions;

It will remove the requirement to ensure there are systems in place to identify and manage significant and financial risks facing the CCG as this is the role of the Audit Committee. However, the Committee will continue to provide oversight and scrutiny of key finance and performance risks facing the CCG.

4.1.7 The Committee noted that some of the revisions will need to be considered in greater depth. It agreed that a revised version of the Terms of Reference would be drafted and circulated to Committee members outside of the meeting for members to suggest further changes. The Committee delegated authority to the Chair to approve the Terms of Reference on the Committee’s behalf.

Action 2: Ammara Hughes to review and approve the Committee’s Terms of Reference on the Committee’s behalf.

4.1.8 The Committee discussed and noted the report. The Committee agreed to delegate its authority to the Committee Chair to approve the Terms of Reference on the Committee’s behalf.


5.1 January 2016 Agenda

5.1.1 The Committee noted that the January 2016 meeting will be held on 13th January 2016 and will be for 1 hour.

5.1.2 The Committee noted that the Terms of Reference could be removed from the draft agenda. The Committee also noted that an update on the annual contracting round would be

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scheduled for the February 2016 meeting.

5.2 Forward Planner

5.2.1 Andrew Spicer reported that the Forward Planner for 2016 needs to be formulated. He asked if members of the Committee could work with him in this regard. The Chair reported that she will meet with Lyndsey Abercromby and Ian Boyle and discuss the Committee’s forward plans.

5.3 Deadline for Submission of Reports for 13th January 2016

5.3.1 The Committee noted that the deadline for submission of reports is Monday 4th January 2016.

5.4 Deputy Chair

5.4.1 The Chair proposed that Lance Saker be Deputy Chair of the Committee. The proposal was seconded by Pat Elliott and Ellen Schroder. The Committee voted and unanimously agreed to the proposal.

6. Date of Next and Future Meetings

6.1 Date of Next Meeting

6.1.1 The next meeting of the Finance and Performance Committee will be held on 13th January 2016 in room 4LM2, Stephenson House, 4th Floor, 75 Hampstead Road, London NW1 2PL. The time of the meeting is 1-3pm.

6.2 Meeting Finish

6.2.1 The meeting finished at 3.05pm.

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Finance and Performance Committee (‘Committee’)

Minutes of the meeting of the Committee held on 13th January 2016 from 9.30am to 10.45am in

room 4LM2, 4th Floor, Stephenson House, 75 Hampstead Road, London NW1 2PL. Members Present: Dr Ammara Hughes (Chair)

Elected GP Representative, Camden CCG

Ms. Lyndsey Abercromby Assistant Director of Commissioning Development, Camden CCG

Mr Ian Boyle Interim Chief Financial Officer, Camden CCG Ms Pat Elliott Elected Practice Manager Representative, Camden CCG Ms Jenni Frost NCL Deputy POD Director, NEL CSU Mr John Levite Patient Representative (for items 1 – 3) Dr Lance Saker Elected GP Representative, Camden CCG Ms Ellen Schroder Audit Committee Chair, Camden CCG Governing Body Lay

Member and Camden CCG Vice Chair In Attendance: Mr John Glass Business Manager, PMO, Camden CCG (for item 2.3) Ms Deepa Patel Head of Performance, Camden CCG (for items 2.3 – 6) Mr Ian Porter Chief Operating Officer, Camden CCG Ms Yajna Sooklall Deputy Chief Financial Officer, Camden CCG Minutes: Mr Andrew Spicer Governance Lead, Camden CCG Apologies: Ms Melody Woolcock Assistant Director of Commissioning, Camden CCG 1. Introduction

1.1 Welcome and Apologies for Absence

1.1.1 The Chair opened the meeting at 9.30am and welcomed those present.

1.1.2 Apologies were received from Melody Woolcock, Assistant Director of Commissioning.


1.2.1 The following Declarations of Interest were made:

Ian Boyle confirmed that he is the owner and director of Near Reality Training Limited which is a company that provides training to the NHS;

Ammara Hughes confirmed that she is a stakeholder governor at University College London NHS Foundation Trust Hospital (‘UCLH’).

1.3 Minutes of the Meeting on 4th November 2015

1.3.1 The minutes were approved as an accurate record of the meeting with the following amendment:

Paragraph 5.1.1: ‘The date of 2015’ be replaced with ‘2016.’

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1.4 Action Log

1.4.1 Of those actions that were not on the agenda or were not cleared the following updates were given:

Action 3: Jenni Frost explained that the reference costs are produced differently by each provider and therefore the figures do not show a true like for like comparison. She noted that it would take the team at North and East London Commissioning Support Unit (‘NEL CSU’) 6-8 weeks to complete a conversion of the data. The Committee considered the position and decided that it would not be a good use of NEL CSU’s time and that the data could be triangulated through other methods. The Committee agreed to examine whether external companies could provide benchmarking data and asked Ian Boyle and Jenni Frost to contact companies in this regard.

Action 1: Ian Boyle and Jenni Frost to contact external companies regarding providing benchmarking data of Camden CCG’s spend on community health care services for the over 65s against the spend in City and Hackney, Newham, Tower Hamlets, Barnet and Enfield CCGs.

2. Finance

2.1 Finance Report: Month 8

2.1.1 Ian Boyle introduced the report and discussed the contents of the report as per the report.

2.1.2 He reported that Camden CCG is on track to deliver the planned £8m surplus agreed with NHS England. He also reported the following variances on budgeted spend:

Acute has a £2.1m adverse variance;

Non-acute has a £1.3m favourable variance;

Investment programmes have a £1m favourable variance;

General overheads has a £0.8m adverse variance;

Quality, Innovation, Productivity and Prevention scheme (‘QIPP’) has a £0.2m adverse variance.

2.1.3 Ian Boyle reported that Camden CCG is forecasting full delivery of QIPP by year end.

2.1.4 Ian Boyle reported on the risks and opportunities detailed on page 17 of the papers. He noted that it shows a net opportunity of £2.5m with two key issues. The first issue is agreeing a year end deal with Royal Free London NHS Foundation Trust (‘Royal Free’). The second is that at UCLH and St Bartholomew’s Hospital the cardiac and cancer strategy will cost an additional £0.8m per year for the following three years totalling an additional £2.4m.

2.1.5 The Committee discussed overseas visitors’ costs and noted that NHS England has not provided Camden CCG on an update on this.

2.1.6 The Committee discussed the Camden CCG premises cost and rent review. The Committee noted that the rent review has not yet been completed and will be backdated to September 2013. The Committee noted that it budgeted for an increase in costs but there may be an additional budgetary pressure when the review is completed.

2.1.7 The Committee noted the Year To Date underspend of £0.6m in the Primary Care Investment Programme and noted that the Primary Care Team are making good progress in this regard.


2.2 Finance Risk Register

2.2.1 Ian Boyle introduced the report and outlined the contents of the report as per the report.

2.2.2 Ian Boyle noted risk 87 regarding under spending the annual budget allowance. He reported that Camden CCG will not underspend in this financial year and that the post-mitigation risk score is reduced to 9.

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2.3 Draft QIPP Plan 2016-17

2.3.1 John Glass introduced the report and outlined the contents of the report as per the report.

2.3.2 He noted that it is anticipated that Camden CCG will need to deliver an £8m QIPP saving in Financial Year 2016-17. He reported that Camden CCG has identified a number of programmes from which QIPP savings can potentially be identified and once these have been worked through the appropriate ones included in the QIPP plan.

2.3.3 John Glass asked the Committee to provide feedback on the paper and noted that it was previously presented at an Executive Team meeting and their feedback was that the QIPP plan needed to demonstrate the impact of QIPP on activity.

2.3.4 Ian Boyle noted three key issues with QIPP. The first is that Camden CCG needs to become more sophisticated in its recording of QIPP. Many of Camden CCG’s programmes reduce costs but these savings are currently not all recorded against QIPP. The second is that in the medium term the QIPP plan needs to link to the collaboration work in North Central London. The third is that QIPP needs to be built into contract negotiations with the providers.

2.3.5 The Committee noted that the Governing Body needs to have a wider strategic discussion on QIPP and in this regard needs to have a seminar on QIPP. The Committee asked Ian Boyle and Lance Saker to liaise with Tyrieana Long, Board Secretary, to arrange this.

Action 2: Ian Boyle and Lance Saker to liaise with Tyrieana Long, Board Secretary, to arrange a Governing Body seminar on QIPP.

2.3.6 John Glass confirmed that an update paper on QIPP will be presented at the February 2016 Finance and Performance Committee.


3. Activity and Performance

3.1 Performance Report

3.1.1 Ian Boyle introduced the report and outlined the contents of the report as per the report.

3.1.2 He reported that for the 18 week Referral to Treatment (‘RTT’) pathway in October 2015 Camden CCG achieved compliance of the incomplete standard and that the position has been consistently above the standard in 2015-16. UCLH has maintained performance above the standard throughout the year but Royal Free has failed the incomplete standard for 5 consecutive months. He reported that the trajectory for recovery at Royal Free is September 2016 if the programme for recovery is implemented at an accelerated pace but this may not be achievable so December 2016 may be more realistic.

3.1.3 He reported on the 31 day Cancer Wait target and noted that subsequent treatment for chemotherapy and radiotherapy is at 100% year To Date verses a target of 94%.

3.1.4 He reported on Diagnostic waits under 6 weeks and referred the Committee to page 38 of the papers. He reported that the Year To Date figure is 97.2% verses a target figure of 99%. He noted that UCLH confirmed that they expect to have cleared the backlog of endoscopies and be compliant with the target in January 2016. He confirmed that UCLH’s planned actions are under review. He reported that Royal Free has a long diagnostic waits in Endoscopies and that they are putting in additional capacity to address the issue.

3.1.5 He reported on cancer performance and noted that Camden CCG is compliant with five of the eight national standards. However, UCLH is not compliant with 6 of the 8 national standards. He referred to pages 39-42 of the report and noted that they detail the actions being taken to improve performance. In addition, meetings have been held between the Chief Officer/Executives before and after the Christmas period in this regard.

3.1.6 Ian Boyle reported on the actions and progress on Overall Cancer Performance and referred the Committee to page 39 of the papers. He reported that UCLH has provided Camden CCG

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with a recover plan against all standards. Camden CCG has reviewed the plan and requested that further work and improvements are undertaken both in its ambition and in identifying alternative capacity. He noted that breast cancer 2 week waits and the 62 day targets are particular areas of focus. He reported that the Contract Query Notice is still in place and the CCG is considering further contractual levers.

3.1.7 Ian Boyle reported on Royal Free performance and noted that Camden CCG is working closely with Barnet CCG in reviewing the trajectories for recovery.

3.1.8 He reported on Improving Access to Psychological Therapies (‘IAPT’) performance and noted that the CCG is achieving 6 of the 18 week waiting time targets, access is at 3.65% versus the 3.75% target and Moving to Recovery performance is at 45.14% versus the 50% target.

3.1.9 Ian Boyle reported on Accident and Emergency (‘A&E’) Performance. He noted that the CCG’s Year to Date position is 96.4% versus the 95% target. He reported that performance at UCH remains a key risk. The UCLH recovery trajectory for a return to standard by the middle of February 2016 was challenged by NHS England due to its ambition. Therefore, a stretch target was agreed with UCLH based on a range of outcomes with the best case scenario seeing UCLH returning to trajectory by mid-January 2016.

3.10 He reported on London Ambulance Service (‘LAS’) and reported that their Category Red 1 Year to Date position is 67% versus a target of 75% and their Category Red 2 Year to Date position is 65% versus a target of 75%.

3.11 He noted that LAS under-performance is a London-wide issue and Camden CCG is working closely with Brent CCG as the lead commissioners. He noted that LAS are currently in special measures.

3.1.12 In terms of Quality Performance he reported the following:

MRSA: There has been no reported case of MRSA in Month 7. There have been two cases Year to Date against a target of zero;

CDIFF: There have been 8 reported cases in Month 7. There have been 52 cases Year to Date against a target of zero;

Mixed Sex Accommodation: There have been six reported cases in Month 7. There have been 13 Year to Date against a target of zero.

3.1.13 Ian Boyle confirmed that root cause analysis work is continuing with engagement from Camden CCG’s Quality and Safety team and the infection control specialist at NEL CSU.

3.1.14 The Committee discussed performance at UCLH. The Chair reported that she is now attends the Patient Tracker List (‘PTL’) meeting at UCLH. She noted that each cancer divisional director attends the meeting to discuss their long waiters and the reasons for this. The meeting considers both patients that have breached and will breach the targets. The Chair noted that the main reasons for the long waiters are the complexity of the cases. She noted that the meetings have provided her with assurance that UCLH is trying to deal with these patients.

3.1.15 The Committee considered the issue of capacity at UCLH. It noted that whilst the two members of staff on long term sick leave in the breast cancer department have returned to work full time UCLH needs to significantly improve its resilience planning. UCLH has agreed to work on this but Camden CCG is not assured on UCLH’s resilience plans. In addition, UCLH needs to increase its capacity. Ian Boyle confirmed that the action plan with UCLH needs to address these key issues and that resilience planning will be kept under continued review.

3.1.16 The Committee considered whether to activate any financial penalties against UCLH and decided that it would not do so at this time but will keep the option under review.


3.2 Performance Incentives Report

3.2.1 Lyndsey Abercromby introduced the report and outlined the contents of the report as per the report. She noted the incentives contained in the report and asked the Committee to

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consider them and provide feedback.

3.2.2 Ian Boyle noted that any incentives need to: Be supportive and give providers positive incentives to build in capacity; Ensure that contracts contain sufficient resources to allow providers to deliver NHS

constitutional standards; Be affordable.

3.2.3 Lance Saker noted that he would like to see incentives which engage and motivate the clinicians in the provider organisations. Lyndsey Abercromby feedback that she will share the proposed incentives with providers at an early stage and ask them to consider how the incentives could be framed to achieve the desired outcome whilst engaging clinicians.

3.2.4 The Chair noted that any incentives need to be measured to ensure the approach delivers system-wide impact and has greater clinical focus. Lance Saker noted that there should be greater availability of face to face Consultant clinics.

3.2.5 The Committee considered the incentives and performance levers and recommended that they be taken forward subject to the recommendations in the above discussion.

3.2.6 The Committee discussed and noted the report. The Committee considered and approved the recommendations subject to the incentives delivering system wide impact, greater clinical focus and the addition of greater availability of face to face Consultant clinics.

4. Governance

4.1 Terms of Reference

4.1.1 The Chair introduced the report setting out the Committee’s updated Terms of Reference which was taken as read. The Chair noted that the Committee delegated its authority to her at the December 2015 Committee meeting to review and approve the Terms of Reference on its behalf. She noted that the paper contains the updated and approved Terms of Reference.



5.1 February 2016 Agenda

5.1.1 Due to time constraints this item was not discussed.

5.2 Forward Planner

5.2.1 Due to time constraints this item was not discussed.

5.3 Deadline for Submission of Reports for 3rd February 2016 Meeting

5.3.1 The Committee noted that the deadline for submission of reports is Monday 25th January 2016.

5.4 Financial Allocations

5.4.1 Ian Boyle reported that NHS England has informed Camden CCG of its financial allocations for the next three years. He reported that the NHS England Board has taken the decision to follow and aggressive pace of change policy and therefore Camden CCG will receive minimal growth.

5.4.2 He reported that there was a rebasing exercise undertaken by NHS England to revise the CCG’s relative position to the fair shares target which is applied to all CCG’s in England. This rebased Distance From Target (‘DFT’) saw Camden move from just under 15% over target to 23% over target. This will have adversely affected allocations in future years.

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5.5 Meeting Schedule

5.5.1 The Chair noted that the scheduling of Committee meetings needs to be considered in order to ensure that the Governing Body receives the most up to date information. Therefore, the dates of future meetings may change.

6. Date of Next and Future Meetings

6.1 Date of Next Meeting

6.1.1 The next meeting of the Finance and Performance Committee will be held on 3rd February 2016 in room 4LM2, Stephenson House, 4th Floor, 75 Hampstead Road, London NW1 2PL. The time of the meeting is 1-3pm.

6.2 Meeting Finish

6.2.1 The meeting finished at 10.45am.

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GLOSSARY

Acronym Meaning A AHSNC Academic Health Science Networks and Centres ALB Arms Length Body AoMRC Academy of Medical Royal College AQP Any Qualified Provider B BAU Business as usual BC Business Continuity BCDR Business continuity and disaster recovery BCF Better Care Fund BEHMHT Barnet, Enfield and Enfield Mental Health Trust BMA British Medical Association BNF British National Formulary C C2C Clinician to Clinician CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Services CAP Common Assurance Process CCG Clinical Commissioning Group CCU Critical Care Unit CDS Commissioning Data Set CDF Cancer Drugs Fund CG Caldicott Guardian CHC Continuing Health Care CIT Clinical Information Technology CKD Chronic Kidney Disease CMHT Community Mental Health Team CMT Controlled Medical Terminology COPD Chronic Obstructive Pulmonary Disease CPRD Clinical Practice Research Datalink CQC Care Quality Commission CQN Contract Query Notice CQRG Clinical Quality Review Group CQUIN Commissioning for Quality and Innovation CSIPS Continuous Service Improvement Plans CSU Commissioning Support Unit D DES Directed Enhanced Service DH or DoH Department of Health DNA Did not attend DR Disaster Recovery DTOC Delayed Transfer Of Care (where patients are ready to

return home or transfer to another form of care but still occupy a hospital bed)

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http://www.camdenccg.nhs.uk/

http://www.haringeyccg.nhs.uk/Downloads/Board%20Papers/20140130/Item%203.3a%20-%20Better%20Care%20Fund%20cover%20sheet.pdf

http://www.beh-mht.nhs.uk/

http://www.nhs.uk/chq/Pages/2392.aspx?CategoryID=68

http://www.nhs.uk/Conditions/Kidney-disease-chronic/Pages/Introduction.aspx

http://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx

http://www.haringeyccg.nhs.uk/about-us/new_page.htm

E EA Equality Analysis E&D Equality and Diversity ED Emergency Department EMT Executive Management Team EOLC End of Life Care EPR Electronic Patient Record F FBC Full business case FFT Friends and Family Test FNC Funded Nursing Care FoI Freedom of Information FT Foundation Trust G GDP Gross Domestic Product GP General Practice (or General Practitioner) H HEE Health Education England HPA Health Protection Agency HPSS Health and Personal Social Services HSCIC Health and Social Care Information Centre HSSI Higher Severity Service Incident HWBB Health and Wellbeing Board I ICAS Independent Complaints Advocacy Service ICO Information Commissioner's Office ICP Integrated Care Pathway ICT Information and Communication Technology IFR Individual Funding Request IG Information Governance IHM Institute of Healthcare Management IPC Integrated Personal Commissioning IPU Integrated Practice Unit ISBHaSC Information Standards Board for Health and Social Care ISIP Integrated Service Improvement Programme ITT Invitation to Tender J JCC Joint Commissioning JGPITC Joint GP IT Committee K KPI Key Performance Indicator L LAs Local Authorities LAS London Ambulance Service LES Locally Enhanced Service LGA Local Government Association LHB Local Health Board LHS Local Hospital Strategy

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http://www.haringeyccg.nhs.uk/about-us/EDHR.htm

http://www.haringeyccg.nhs.uk/about-us/EDHR.htm

http://www.nhs.uk/planners/end-of-life-care/pages/end-of-life-care.aspx

http://www.nhs.uk/chq/Pages/what-is-nhs-funded-nursing-care.aspx

http://www.foundationtrustnetwork.org/about-foundation-trusts/

http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/NHSGPs.aspx

http://www.hscic.gov.uk/

http://www.haringeyccg.nhs.uk/about-us/individual-funding-requests.htm

http://www.londonambulance.nhs.uk/

LMC Local Medical Committee LSP Local Service Provider

M MASH Multi-Agency Safeguarding Hub MHRA Medicines and Healthcare products Regulatory Agency MCP Multispecialty Community Providers N NCLs National Clinical Leads NEL CSU North East London Commissioning Support Unit NES National Enhanced Service NHSE National Health Service England NHS IQ NHS Improving Quality NIB National Information Board NICA National Integration Centre and Assurance NICE National Institute for Health and Care Excellence NIHR National Institute for Health Research NMUH North Middlesex University Hospital NPSA National Patient Safety Agency NQB National Quality Board NSF National Service Framework O OBC Outline Business Case OBR Office of Budget Responsibility OOH Out of hours P PACE Post-Acute Care Enablement PACs Primary and Acute Care Systems PAS Patient Administration System PASA Purchasing and Supply Agency PBC Practice-Based Commissioning PC Primary Care PCT Primary Care Trust PDT Programme Delivery Team PH Public Health PID Person Identifiable Data PID Project Initiation Document

PPE Patient and Public Engagement

PPI Patient and Public Involvement PPG Patient Participation Group

PROMS Patient Related Outcome Measures

Q QIPP Quality, Improvement, Productivity and Prevention QOF Quality Outcome Framework (Assessor Validation

Reports) R RACI Responsible Accountable Consulted Informed

RAID Rapid Assessment, Intervention and Discharge Service (a mental health service)

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http://www.northmid.nhs.uk/

http://www.haringeyccg.nhs.uk/about-us/patient-and-public-engagement-strategy.htm

http://www.hscic.gov.uk/proms

http://www.nhs.uk/Services/Trusts/Overview/DefaultView.aspx?id=2418

http://www.nhs.uk/Services/Trusts/Overview/DefaultView.aspx?id=2418

RAG Red Amber Green (a rating system for indicating the status of something using the red, amber or green of traffic lights)

RCP Royal College of Physicians

RCGP Royal College of General Practitioners

RCT Randomised Controlled Trials

RF Royal Free London NHS Foundation Trust consisting of

Barnet, Chase Farm and Royal Free Hospitals RTT Referral to Treatment S SBS Shared Business Services SCR Serious Case Review SHA Strategic Health Authority SHOT Serious Hazards of Transfusion SIs Statutory Instruments SI Serious Incident SLA Service Level Agreement

SMT Senior Management Team

SPA Single Point of Access T TDA NHS Trust Development Authority TREAT Triage and Rapid Elderly Assessment Team TTA Tablets to Take Away TUPE Transfer of undertaking protection of employment

regulations TWR Two-week referral U UCLH University College London Hospital V

VBC Value Based Commissioning

VSNAG Voluntary Sector National Advisory Group W WHO World Health Organisation

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http://www.haringeyccg.nhs.uk/downloads/policies/Incident%20and%20Serious%20Incident%20Policy.pdf

http://www.ntda.nhs.uk/

http://www.haringeyccg.nhs.uk/talk-to-us/Value%20based%20commissioning%20presentation%20for%20CCG%20engagement%20network.pdf

http://www.connectingforhealth.nhs.uk/engagement/public/voluntary