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Tower Hamlets Clinical Commissioning Group Governing Body Meeting - Part I Agenda

Tuesday, 24 January 2017, 14.30 – 16.30

The Theatre Room, Oxford House, Derbyshire St, Bethnal Green, London, E2 6HG

1 1.0 General Business

Action Presenter Enc. Time Page

1.1 Welcome, Introductions and Apologies

- Sam Everington,

Chair Verbal

14.30 (10 mins)

- 1.2 Declarations of Interests &

Register of Interests

-

1.3 Chair’s Report For Noting

Sam Everington,

Chair Paper A

5 1.4 Chief Officer’s Report

For Noting Simon Hall, Acting Chief

Officer

1.5 Member Story – CQC Primary Care

For Noting

Virginia Patania, Practice Manager

Representative

- 14.40

(10 mins) -

1.6 Draft Minutes, Matters Arising & Action Tracker of the Meeting held on 1st November 2016

For Approval Sam Everington,

Chair Paper

B 14.50

(5 mins) 11

2 2.0 Commissioning and Strategy

2.1 North East London Sustainability Transformation Plan

Plan Overview Memorandum of

Understanding

For Noting and approval

Jane Milligan, Chief Officer & Executive Lead

for NEL STP

Paper C

14.55 (20 mins) 27

3.0 Performance and Operations

3.1 Board Assurance Framework For Discussion &

Noting

Ellie Hobart, Deputy Director

of Corporate

Paper D

15.15 (5 mins)

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Affairs

3.2 3.2.1 Finance Report M9

3.2.2 Activity Report M9

For Discussion &

Noting

Henry Black, Chief Finance

Officer

Lee Eborall, Director of

Acute Contract Management,

NEL CSU

Paper E

Paper F

15.20 (10mins)

91

107

3.3 Performance and Quality Report

For Discussion &

Noting

Archna Mathur Director of

Performance & Quality

Paper G

15.30 (10 mins)

113

3.4 CQC Report – NHS Barts Health December 2016

For Discussion &

Noting

Jackie Sullivan Managing

Director, Royal London

Hospital, NHS Barts Health

Caroline Alexander – Chief Nurse, NHS Barts

Health

Paper H

15.40 (25 mins)

131

4.0 Commissioning and Strategy (continued)

4.1 Tower Hamlets CCG 2017/18 Financial Plan For Approval

Henry Black, Chief Finance

Officer

Paper I

16.05 (10 mins)

135

5.0 For Information

5.1 Executive Committee Minutes

For Information

Simon Hall, Acting Chief

Officer

Paper

J

16.15 (5 mins)

147

5.2 Transformation Board Minutes Julia Slay, Lay Member for

Public and Patient

Involvement

Paper K

151

5.3 Finance, Performance and Quality Minutes

Mariette Davis, Lay Member for Governance &

Audit

Tan Vandal, Secondary Care Representative

Paper

L

165

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are asking a question at the meeting please use the sign in sheet in the public area of the meeting. You will be asked for your name and the agenda item number your question refers to. You will be expected to retain a copy of your question. Questions that are asked verbally at the meeting will only be answered if an accurate answer can be provided. Otherwise, the question will be taken on notice and will be answered at the next meeting. Please email [email protected] for more information.

7.0 Date of next Governing Body Meeting Chair

March 7th, 14:30 – 17:00, Venue TBC

8.0 Part II- Meeting

Chair

To resolve that as publicity on items contained in Part 2 of the agenda would be prejudicial to public interest by reason of their confidential nature, representatives of the press and members of the public should be excluded from the remainder of the meeting. Section 1 (2) Public Bodies (Admission to meetings) Act 1960.

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Chair’s and Chief Officer’s Report

1 Purpose

The Chair’s and Chief Officer’s report highlights items of interest to Governing Body members and the public. The Governing Body is invited to note this report and pursue any points of clarification or interest.

1.2 Chair’s Report

ELFT win Provider Trust of the Year at HSJ Awards

A big congratulations to East London NHS Foundation Trust (ELFT) who won Provider Trust of the Year at the HSJ awards, proving it is now one of the best NHS trusts in the country. It follows rapidly on the tail of becoming the only mental and community health trust in the country to be given an ‘outstanding’ rating by the health regulator, the Care Quality Commission. ELFT’s winning of such a prestigious award highlights the excellence of health care providers for the people of Tower Hamlets.

The Trust was commended for providing excellent, patient-centred care built on strong engagement and acknowledged for embedding a culture of continuous improvement in partnership with staff, service users and carers.

This year, the HSJ received over 1600 submissions from 600 different organisations and ELFT was shortlisted amongst nine other healthcare providers. Congratulations to all at ELFT.

Outstanding dementia care in Tower Hamlets outlined to MPs

The outstanding work taking place in Tower Hamlets to diagnose and support people with dementia has been outlined to MPs at Westminster. Dr Ashrafi Jabin, Tower Hamlets CCG’s Clinical Lead for Dementia, was formally invited and attended a parliamentary reception at the House of Commons on 25 October to celebrate the achievements of the Dementia Friendly Parliament Initiative.

Latest statistics issued by NHS England show that NHS Tower Hamlets CCG has once again been ranked third in London for its dementia diagnosis rates with 85.8% of patients aged 65 and over receiving a diagnosis. This is compared to a national average of 67.5%.

Professor Alistair Burns, National Clinical Director for Dementia and Older People’s Mental Health at NHS England, is impressed by the work being conducted in Tower Hamlets, saying: “I wanted to acknowledge all the great work which is going on in Tower Hamlets to improve the experience of people with dementia and supporting their families and carers. The importance of a timely diagnosis of dementia which facilitates the provision of high quality post diagnostic support is crucial.

Enclosure A

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“The fantastic work that everyone has done in Tower Hamlets is to be applauded and shows how commitment and focus can bring tangible results. This is reflected in the dementia diagnosis rate, which continues to rise.’’

We would like to thank and congratulate all of our GP members for their hard work and effort. It is our ambition that every person diagnosed with dementia has meaningful care and support following their diagnosis, which supports them and the people around them. We look forward to working together to achieve this – and increasing our rating by the 0.01% that separates Tower Hamlets CCG from the number two spot and helping the estimated 200 people with dementia living in Tower Hamlets without a diagnosis.

Using technology to engage young people on mental health outcomes in Tower Hamlets

Partners in Tower Hamlets launched a pilot this week to engage children and young people who use mental health services (along with their parents and carers) on the outcomes that are important to them.

Over the next eight weeks, six teams will work with local people to understand their experiences and needs, using a touch screen tablet to answer a range of questions. All individual information remains private between the young person and the service they use. The questionnaires are built around recognised and validated outcome measurement scales, plus localised additional questions, related to areas that children, young people and their families have said are important to them but that are not currently asked about by local services.

The pilot will test how using a tablet for this type of engagement on outcomes works in practice, and the experience of staff and families who use it. Once evaluated in January, and if successful, the next stage will be to implement the use of a tablet with this questionnaire as a way of measuring how services are delivering outcomes. CMHS and the Early Detection services in East London Foundation Trust, Family Action, Step Forward, Docklands Outreach and the Council’s Family Intervention Service are all taking part.

Diabetes care centre is now multi-award winning

The Diabetes Care Centre at Mile End Hospital has been presented with five awards by charity X-PERT Health after seeing impressive results for its patients attending diabetes education sessions in 2014 and 2015. The awards recognise the successful delivery of X-PERT Health programs, structured education courses designed to educate and empower patient living with Type 2 Diabetes in Tower Hamlets to self-manage their condition.

At this year's awards, Barts Health Diabetes Care Centre came third out of 90 centres using X-PERT Health in the following categories:

• The best participant attendance score

• The highest participant empowerment and satisfaction score

• The greatest improvement in glycated haemoglobin

The team were also highly commended for their results for:

• The largest impact on body weight and waist circumference

• The greatest improvement in cardiovascular disease risk factors (lipids and BP).

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A big congratulations to the team at The Diabetes Care Centre and all those who have worked to improve the lives of people living with diabetes in Tower Hamlets.

Mulberry University Technical College Opening

On Tuesday, 17 January, I visited the Mulberry University Technical College along with Deputy Director for Corporate Affairs, Ellie Hobart, to attend the colleges’ Opening Evening. This new college is part of the highly regarded Mulberry Schools Trust and will offer students the opportunity to gain both academic and practical experiences within the creative, health and digital technologies sectors and aims to ensure its graduates are ‘industry ready’. The health industry curriculum will be open to students entering Year 12 and focus on public health, clinical practice, and leadership and management in the health service.

The open evening, which attracted over 50 students and also attended by Barts Health Trust, a sponsor of MUTC, gave prospective students the opportunity to speak to staff at all levels from the CCG to find out about the wide variety of careers available within the NHS. Ellie and I also took part in a film for the college’s promotional materials and these will be available on the MUTC website shortly. It was exciting to meet local pupils from Tower Hamlets and discuss the range of careers in the NHS in which our local young people could pursue.

1.3 Chief Officer’s Report

East London NHS Foundation Trust to provide the Community Learning Disabilities Service

We are pleased to announce that East London NHS Foundation Trust (ELFT) has won the contract to provide the Community Learning Disabilities Service and will be providing services from 1 February 2017 since taking over from NHS Barts Health. The new contract focuses on improving the physical health and mental health wellbeing of people with a learning disability. The needs of carers will also be given greater priority and we look forward to seeing the promised improvements for people with learning disabilities in Tower Hamlets.

ELFT plan to make some changes in the skill mix of the team to modernise the service and focus on getting the best health outcomes for people with learning disabilities who have complex physical and mental health needs. The new service design will mean there will be a shorter time between referral and assessment, and care planning will be a more streamlined. The service will also have a clearer focus on mental health and challenging behaviour which can be disjointed at present. Additionally, they will be able to implement NICE guidance to better meet national standards. ELFT also proposes to strengthen care and support for carers who are key in supporting family members who have a learning disability. Health practitioners will work with London Borough of Tower Hamlets to provide this support – the local authority are currently conducting a Carers Dignity Charter Consultation and a new Joint Carers Strategy will be launched in the spring and we look forward to reading this with great interest.

Edwin Ndlovu, Borough Director for Tower Hamlets, will have overall responsibility for the service in addition to mental health services in the borough. Consultant Psychiatrist, Dr Ian Hall, is the Clinical Lead for the service. They will be attending locality meetings to talk in more detail about the proposals and answer any queries.

New Children’s Service – The Bridge Project

The Bridge Project is a ground-breaking innovation in Children’s Services designed to integrate health, social care and education services, for the delivery of care for children and young people with complex needs. It is the UK’s first children’s virtual ward, where a cohort of approximately 50 children are discussed on a monthly basis within a multidisciplinary setting.

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Piloted since July 2015, project evaluation demonstrates the service improves access and prevention of longer term conditions for children, young people and their families in Tower Hamlets, whilst also delivering reductions in referrals to secondary care and hospital admissions, inappropriate use of A&E and length of stay. Evaluation data from 2015-2016 reported:

•21% reduction in A&E attendance

•50% reduction in Out Patient Do Not Attend rates

•29% reduction in hospital Length of stay

The Bridge project is now open for new referrals, so if you or someone you know is caring for a child or young person with complex care needs who lives within Tower Hamlets, concerned about the co-ordination of their care and noticing they are regularly attending A&E or DNA outpatient appointments, contact the Bridge Service at [email protected]

Emergency, Preparedness, Resilience and Response (EPRR) Annual Assurance Process 2016/17

As part of NHSE’s Emergency, Preparedness, Resilience and Response (EPRR) annual assurance programme 2016/17 Tower Hamlets were awarded partial assurance. Overall, the CCG met the majority of core standards. Going forward, Tower Hamlets CCG will strengthen its business continuity plan and review and link in with the multiagency pandemic flu plan process. If any more information is required on this process, please contact one of the Governance Team at the CCG.

New data highlights quality of Tower Hamlets GP practices

The excellent work taking place in GP practices in Tower Hamlets to tackle some of the most common chronic diseases has been highlighted by new data published by NHS England. This illustrates the high quality work being done within local GP practices to address some of the most common diseases and implement preventative measures – with top-three rankings in categories covering blood pressure recording, managing COPD and managing diabetes.

Tower Hamlets is ranked within the top three CCG areas nationally for 10 of the 65 clinical indicators that make up the NHS quality and outcomes framework (QOF) and the results are all the more notable when social and demographic factors are taken into account.

Together with City and Hackney, Tower Hamlets is performing well above average when compared to CCGs with similar levels of deprivation, such as Birmingham, Hull, Bradford and Manchester, and the gap between the two east London CCGs and those with comparable deprivation is widening.

According to the Clinical Effectiveness Group (CEG) at Queen Mary University of London, which supports primary care improvement programmes in Tower Hamlets, the good results seen locally provide clear evidence of a ‘learning health system’ which benefits from:

•Coherent primary care leadership setting clear goals and aims

•High levels of engagement among the GP workforce and providers

•Strong digital infrastructure with well-organised IT programmes

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•Active support that enables practices to fully utilise the IT systems available

In Tower Hamlets, GP practices have access to near real-time data on their own performance, whereas those in many other parts of the country are still not web-connected.

The CEG says that in assessing the latest QOF data, published on October 27, it is very striking that almost all the CCGs doing well have strong digital infrastructure and well-organised programmes. If you have any questions or queries about this, please contact Jenny Cooke, Deputy Director of Primary & Urgent Care, email: [email protected].

Tower Hamlets CCG issues CAMHS statement

A recent report released by the Royal College of Psychiatrists stated that NHS bodies are spending as little as £2.01 per child on mental health care for young people. In this report, Tower Hamlets CCG was listed as one of the CCGs with the lowest allocated spending for CAMHS, allocating £4.45 for every under-18 in our borough. This information is incorrect, mental health services for children and young people in Tower Hamlets has seen more support and investment over the past year. In fact our spending on services for children and young people’s mental health in the borough is nearly ten times the figure reported, with the CCG allocating £3.6million for CAMHS services in 2015/16. We are currently looking in to how the incorrect figure was reported and we are working with NHS England to ensure that the correct figure is reported going forward.

Improving the mental health of children and young people in Tower Hamlets is an absolute priority for the CCG. Over the past year we have been working with partners including Tower Hamlets Council, the local voluntary sector and our providers to develop our CAMHS transformation plans and have already made some huge improvements to services in the borough.

In the last year we have invested funds to establish new services for eating disorders and conduct disorders in children and young people. We have worked with children and young people in Tower Hamlets and local organisations to run a local mental health awareness campaign including video, photography and grime tracks produced by local young people, and a Tower Hamlets webpage with TheMix site for young people.

The CCG and Tower Hamlets Council have been working together with local schools and mental health providers to ensure that children and young people have better access to local specialist mental health services, and that support is consistent across services. We have also helped our local CAMHS to reduce its waiting times for appointments to five weeks.

Children and young people’s mental health really matters, not only for the individual and their family, but for the community as a whole. That is why we will continue to focus our attention on working with our partners and ensuring there is more support and investment over the coming years so that children and young people with mental health concerns have access to the best possible support.

Funding Boost for Tower Hamlets Together (THT)

NHS England has announced that Tower Hamlets Together will receive £3,945,000 of new funding to support the ongoing development and delivery of its vanguard projects during 2017/18.

The vanguards are partnerships of NHS, local government, voluntary, community and other organisations that are implementing plans to improve the healthcare people receive, prevent

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ill health and save funds. Considerable progress has been made since the vanguards were launched in 2015 and there is emerging evidence that they are making significant improvements at a local level.

In addition to the funding, Tower Hamlets Together will continue to receive support from NHS England and other national bodies to implement their plans, including how they harness new technology including apps and shared computer systems. They are also receiving help to develop their workforce so that it is organised around patients and their local populations.

Partners within THT are made up of local service providers, commissioners and the local authority to improve the way care is delivered to the people of Tower Hamlets and we will be building on THT as we develop our local accountable care system in 2017/18. Dr Phil Bennett-Richards, local GP and Chair of Tower Hamlets Together, said: “We are very pleased with the progress we’ve made to improve the way care is provided to people here in Tower Hamlets. By working together to develop new and innovative approaches to providing care, we are bridging the gaps between health and social care services and ensuring the needs of patients are at the heart of everything we do.

“The result will be a health and social care system that is not only operating more efficiently, but is far more responsive to the health needs of our local communities.”

Commissioning Intentions 2017/18

Considerable work was undertaken to ensure that we submitted our 2017-19 operating plan before Christmas. Teams across the CCG and NELCSU worked hard to ensure that two year contracts with our main NHS providers were also agreed to this timescale.

We are now working hard to finalise the investments, redesigned and cost improvements we have to make for 2017/18 and beyond in order to ensure that we deliver the high level plans we submitted to NNHS England is our operating plan. Details of our Quality, Innovation, Productivity and Prevention (QIPP) programme will be bought to our March Governing Body meeting, and we are engaging with all our clinical leads, our membership and our partners to ensure that these are appropriate, prioritised and deliverable.

End of Report

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Minutes of the NHS Tower Hamlets Clinical Commissioning Group Governing Body Meeting (Part 1)

Tuesday, 01 November 2016, 14.30 – 17.00

The Quayside Room, Museum of Docklands

1.1.1 Present

Name Role Organisation

Noah Curthoys Lay Member for Corporate Affairs NHS THCCG Sam Everington Chair, Commissioning Network 6 Representative NHS THCCG Simon Hall Acting Chief Officer NHS THCCG Mariette Davis Lay Member for Governance NHS THCCG Henry Black Chief Finance Officer NHS THCCG Maggie Buckell Registered Nurse Representative NHS THCCG Victoria Tzortziou-Brown

Commissioning Network 3 Representative NHS THCCG

Sarit Patel Commissioning Network 4 Representative Isabel Hodkinson Commissioning Network 5 Representative NHS THCCG Judith Littlejohns Commissioning Network 1 Representative NHS THCCG Virginia Patania Practice Manager representative NHS THCCG Osman Bhatti Commissioning Network 7 Representative NHS THCCG Ali Shah Commissioning Network 8 Representative NHS THCCG Somen Banerjee Director of Public Health LBTH Jane Milligan Chief Officer & Executive Lead for North East

London STP NHS THCCG

Linda Aldous Practice Nurse representative NHS THCCG Julia Slay Lay Member for Public & Patient Engagement NHS THCCG

1.1.2 In attendance


Archna Mathur Director of Performance and Quality NHS THCCG Ellie Hobart Deputy Director of Corporate Affairs NHS THCCG Deane Kennett Assistant Director of Acute Contract Management NEL CSU Justin Phillips Governance Manager NHS THCCG Sophia Beckingham Governance Office NHS THCCG Jackie Sullivan Managing Director, Royal London Hospital NHS Barts

Health Trust Christabel Shawcross

Chair, Safeguarding Adults Board LBTH

1.1.3 Apologies


Denise Radley Director of Adults’ Services LBTH Tan Vandal Secondary Care Doctor NHS THCCG Imrul Kayes Commissioning Network 2 Representative NHS THCCG Lee Eborall Director of Acute Contract Management NEL CSU

Enclosure B

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1.1.4 Welcome

Sam Everington (SE, Chair) welcomed members and attendees to the meeting and declared the meeting quorate, also welcoming Christabel Shawcross (Chair, Safeguarding Board, LBTH) and Jackie Sullivan (Managing Director, Royal London Hospital, NHS Barts Health Trust).

Apologies were received from the following members of the Governing Body (GB): Dr Tan Vandal, Secondary Care Consultant; Denise Radley, Director of Adult’s Services London Borough of Tower Hamlets; Imrul Kayes- Commissioning Network 2 Representative and Lee Eborall- Director of Acute Contract Management, NEL CSU. The Governing Body (GB) noted the apologies for absence received as above and recorded.

1.2 Declaration of Interests

SE asked Members for any declarations of interest relating to matters on the agenda. No additional declarations of interest were noted for Part I of the meeting.

It was noted that a revised Conflicts of Register was available at the meeting and the complete register of interests is published on the NHS Tower Hamlets Clinical Commissioning Group’s website: http://www.towerhamletsccg.nhs.uk/about/conflict-of-interest-register.htm

1.3 Report of the Chair

SE gave a verbal update in addition to the items included in the report. SE, along with Simon Hall (SH), met with the Mayor of Tower Hamlets and discussed the updates on the development of the Royal London Hospital site (which will become the civic centre) formalising the arrangements of joint commissioning and agreeing a direction of travel. Both SE and SH felt the meeting was successful.

London CCG Chairs and Chief Officers met during October to discuss the changing healthcare landscape and its effects on the Healthy London Partnership (HLP) and the future role of the HLP in healthcare. The formation of STPs has highlighted some potential overlaps between items that may take place under STP and items that may take place under the Healthy London Partnership.

SE noted the voice of CCG Chairs in local media and public relations varied across London CCGs. SE also noted the appointment of Tom Coffey by new London Mayor Sadiq Khan as a senior adviser to him on Health Policy. SE informed the Governing Body that he met with Tom Coffey, and suggested the idea of a joint office for the London CCG chairs at the GLA. This could encourage integration amongst CCGs and could help ensure a similar direction of travel which would benefit the health of the local London population. Virginia Patania (VP) queried what the future of the HLP would be. SE explained that the HLP would still exist, perhaps with a changing remit if funding resource moves from HLP to STP, in order for Health and Wellbeing issues to be addressed more at STP level.

VP noted that STP could be an impediment to HLP, the Primary and Urgent Care Academy and the roll out of QI across London. VP asked if this was a risk to Quality Improvement. HB explained that different workstreams within HLP produced different levels of success and that 6 out of 30 would most likely remain, as they were successful. SH noted that Chairs and Chief Officers of CCGs were working to ensure that HLP’s benefits remain and issues that had become present in the HLP would not be repeated.

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Isabel Hodkinson (IS) asked how the CCG ensures that our Health and Wellbeing Board colleagues from the Tower Hamlets borough are included in these plans and discussions surrounding the HLP changes and journey. SE explained that he reports back to the Health and Wellbeing board via role as his deputy chair, therefore helping to ensure integration.

The Governing Body members NOTED the contents of the Chair’s Report and the verbal updates.

1.4 Chief Officer’s Report

SH gave an update surrounding the current STP progress, including the draft STP which was submitted to NHS England on the 21st October for assurance. Following this publication, there will be a period of consultation with staff, patients and the public in order to listen to their views and make improvements before a final plan is developed and published in 2017.

SH informed the Governing Body that NHS England visited Tower Hamlets CCG to discuss integrated personalised commissioning (IPC). The CCG are currently working on a period of consultation and engagement with local members of the public in conjunction with the Local Authority. SH thanked the CCG and LA teams that have been working on the IPC and noted their efforts.

SH gave an update on the CCG’s corporate planning and organisation development, including the ‘Delivering our Corporate Strategic Priorities’ programme which had recently come to an end. New tools for the CCG have been developed out of feedback from this programme. These tools, such as the new Staff Induction Handbook and the Intranet, will ensure that we are better equipped to conduct our roles as commissioners.

SH outlined the new WiFi access that practices across Tower Hamlets now have, noting that this is a key development to ensure that the boroughs’ GP services remain innovative. Osman Bhatti (OB) noted that we are awaiting the outcome of funding bids for patient access in all practices to have access to Wi-Fi which will further improve the patient experience.

SH congratulated SE on becoming Vice President of the Queen’s Nursing Institute.

The Governing Body Members NOTED the contents of the Chairs & Chief Officer’s report.

1.5 Patient Story – Maternity services in Tower Hamlets

Linda Aldous (LA) introduced the patient story regarding Maternity Services, noting the excerpt is part of a longer film regarding choices for women giving birth in Tower Hamlets. The film focuses on encouraging women to engage with a range of decisions if they are low risk pregnancies, including options to give birth either at home or at the Barkantine Centre. In future, a specialised unit the Royal London will also open. LA hoped that the new unit will have its own film which can be shown to women to encourage outside-unit births. Jackie Sullivan (JS, Managing Director, NHS Barts Health Trust) explained that NHS Barts Health Trust were hoping to open the unit on the 7th November.

The Patient Story was made in conjunction with Social Action for Health and the National Childbirth Trust. Pregnant women are currently able to choose from 3 birth options – home births, births at the Barkantine Centre, doctor-led hospital services and soon the new Royal London midwife-led hospital service.

The story followed 3 patients who had birthing experiences outside of a hospital setting. Patient 1 had a homebirth and described how homebirth made the experience more positive, with the focus shifting from ‘something going wrong, to things going right’. She noted the

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midwives were extremely assuring and attentive. She outlined the positives of home births, including lack of childcare issues, lack of parking issues, home comforts and the excellent after care provided by the mid-wife led teams.

Patient 2 gave birth at the Barkantine. She chose the Barkantine as an alternative to the hospital. The patient explained that the Barkantine is an impressive facility and her experience was extremely positive – her room was ready when she arrived and she was made to feel comfortable and reassured. The couple felt they could not have received better care anyway else, including private facilities.

Patient 3 also gave birth at the Barkantine. She noted the facilities were fantastic and that she was able to stay with her partner: a key part of her positive birthing experience.

LA noted that only 12 births in the last quarter took place at home which is a small percentage of overall births within Tower Hamlets. VP commented that the statistic for home births in Tower Hamlets has decreased and LA noted that there is work to be done to encourage home deliveries and that this topic was discussed in the maternity committee, of which LA sits on. VP also noted that people’s circumstances in Tower Hamlets often meant that they do not have the space to accommodate a home birth. Shah Ali (SA) outlined the positives of a home birth and the importance of changing the mindset of the general population – SA often encourages patients to visit the Barkantine as the facilities are world class.

SE stated Tower Hamlets is not currently meeting the national maternity target of 20% of births taking place in the community. LA noted patient experience at the Barkantine is excellent - if more women can be exposed to visits there via their anti-natal bookings, they may be encouraged to continue to visit and have future births at the centre.

The Governing Body Members NOTED the patient story.

Minutes and Matters Arising of the Meeting held 5 July 2016

1.3.1 Minutes

SE asked the GB members to check and confirm the accuracy of the draft minutes of the meeting held on 6 September 2016.

The minutes were APPROVED as an accurate record of the meeting.

1.3.2 Matters arising

The matters arising were discussed and outstanding items were carried forward.

2.0 Performance and Operations

2.1 Finance and Activity

2.1.1 Finance Report Month 6

Henry Black (HB) provided the Governing Body with the financial position of the CCG as of 30th September 2016, including the key risks and issues. The Governing Body was asked to note the contents of the report, the risks highlighted and the management action being taken to mitigate these risks.

HB noted that 2016/17 had been the most challenging since the CCG’s inception – similar to many CCGs across the country. The CCG’s biggest challenge has been the extent of demographic growth that the borough of Tower Hamlets has experienced in recent years. This growth has not been fully accounted for in allocations for several years to come due to the retrospective lag in funding.

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HB highlighted the pressures discussed in previous years, such as the inability to access the historical surplus and the requirement to ensure 1% non-recurrent reserve - this means the CCG has no flexibility to use funds that could be present in these areas. The expenditure pressures mean the CCG have pressures on the acute budget with a forecast of £7.5million overspend overall. The majority of this overspend is at NHS Barts Health Trust, although a substantial amount sits with other providers such as Guys’ and St Thomas’s. This overspill of patients to other providers from NHS Barts Health Trust has been partly driven by RTT issues at NHS Barts Health.

HB informed the meeting that the CCG’s Primary Care Co-Commissioning has a structural deficit. In previous years, the CCG’s ability to absorb this did not pose a problem but this situation has now changed.

HB noted the issues with London Ambulance Service (LAS); CCGs have provided 2 year financial support and HB conceded that the demand pressures remain extraordinary but need to be better managed. It is likely the CCG will have a further request of £300k which has been factored in to the financial position.

The members NOTED the report.

2.1.2 Activity Report

Deane Kennett (DK) presented the Activity Report focusing on the areas in trusts which are driving significant overspend. The report provided a high level overview of finance and activity across Tower Hamlets for the month of September 2016 (based on August 2016 activity data). The report highlighted the key issues, current performance, key actions and a delivery RAG rating for major providers providing healthcare services in Tower Hamlets.

DK informed the Governing Body that NHS Barts Health is currently forecasting a £5.6million overspend which is being driven by key areas such as critical care, elective surgery, day surgery, non-elective activity, outpatient procedures and high cost drugs. DK assured the Governing Body members that the CSU contracts team continue to challenge areas of overspend, via means such as review audits of counting and coding practices. DK also noted that an audit on remission rates is underway and there will be a review of A&E activity at the Royal London Hospital.

DK informed the Governing Body that East London Foundation Trust (ELFT) continue to meet contractual requirements with recovery plans in place for under performance. The CHS contract (currently provided by NHS Barts Health) has been extended until December due to slippage within the procurement process. The new wheelchair service went live on the 1st November. The Community Learning Disability Service is due to go live in December and ELFT are currently forecasting an overspend of £0.3million.

Osman Bhatti (OB) highlighted the London Ambulance Service (LAS) overspend and queried the reasoning behind this. HB stated that there is an unprecedented demand on LAS. CCG Chief Finance Officers and Chief Officers received a letter from LAS executives requesting further funding to address this. HB also noted that the 111 model service is currently being reprocured across NEL and this could aid LAS in meeting its challenges. SH specified that issues with LAS would not be solved by simply injecting more funding.

AM highlighted further support the CCG is giving LAS; the CCG has been working with Tower Hamlets Together (THT) to ensure that mitigations are put in place to cap frequent callers but noted the CCG has faced challenges working with LAS in this regard. AM noted that the CCG

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needs more data from LAS so a clear picture is formed before any funding is contemplated. There has been difficulty in gaining this information from LAS and AM noted that the CCG needs to be assured that LAS are effectively and optimally using the neighbouring services that have been commissioned that could help manage the pressures LAS are under. The requests for further funding have not reflected these services.

SE asked if the CCG was using the good practice from the Sutton Vanguard in regards to their recent successes with elderly patients (using the “Red Bag System”), noting that the reduced hospital stay in Sutton from 12 to 8 days was a success to learn from. AM assured the Governing Body that the CCG were already using the Sutton Vanguard’s template to improve services and that the CCG and Tower Hamlets Together (THT) have been looking at this in depth.

SE queried parts of the paper relating to the new MSK services and referrals, stating that 2 years ago the CCG sent letters asking local GPs to refer elsewhere in regards to MSK services. SE queried if this message ought to be changed in light of the new MSK service that has been commissioned. Josh Potter (JP) explained that it was likely the message ought to be changed and further noted that the new service is meant to be providing for patients earlier on in the pathway rather than those ready for surgery. If people are referring for MSK to other providers without prior work then this would need to be remedied. JP stated that he will investigate the communications surrounding the MSK services and reinforce which appropriate pathways GPs should use.

JP also suggested looking at new referrals in the new service in relation to the old service and check if clinicians are using pathways as intended, noting the historical issues of patients previously being referred in the old pathway. AM informed the Governing Body that the CCG was conducting an elective deep dive with the Royal London and would discuss further with JP. JS is happy to discuss and review the referrals and its system. AM stated that there is need at the Royal London Hospital to establish the differing pathways that each local CCG has implemented that can affect MSK services at the hospital.

SH asked Jackie Sullivan (JS, Managing Director, NHS Barts Health) when the CCG might be able to expect RTT reporting to recommence and queried if there may be a potential backlog which would pose a risk to both the CCG and NHS Barts Health. JS explained that, whilst she did not have the detail to hand, she understood the issues to be known and the validation team are currently working through the data. JS stated she would review this and report back to the Governing Body, noting the challenges affecting the Royal London Hospital and, through its work to make it more efficient and reduce patient waiting times, this has resulted in over performance and higher costs for the CCG.

IH asked JS if different priorities or levels of motivation were present in differing clinical teams in the system at the Royal London and, if so, could this be due to the different management directorate. JS noted that clinical support services are a separate board but clinical services work closely with the support services to ensure integration. JS stated the teams were working together and are joined up but there are capacity issues, particularly in areas like imaging. JS told the Governing Body that she was happy to work with the CCG to review pathways to ensure an appropriate flow of patients.

SE noted that one of the national Vanguards called Emrad had ensured clinicians can see the scans taken of patients anywhere in the healthcare pathway which would be a helpful system to emulate in Tower Hamlets. IH noted that a similar system was supposed to be implemented when Tower Hamlets moved to Choose and Book but this did not occur. JS explained that

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there are pathways that go straight to test (such as cancer) but if any Governing Body members wanted to be involved in Trauma and Orthopaedics then JS would welcome this in order to improve patient experience and treatment. AM noted that the CCG does not have a clear picture regarding the demand and capacity within imaging. JS explained that the deep dive for Trauma and Orthopaedics will involve the clinicians and the teams and there would be clinical support engagement.


2.2 Board Assurance Framework

EH introduced the Board Assurance Framework to the Governing Body Members highlighting that during the month of September 2016, risk management leads had reviewed and updated the risks, controls, assurance and risk ratings.

EH explained that the likelihood of Risk 1.1 occurring had been reduced as the Finance, Performance and Quality Committee felt there was good visibility and appropriate controls surrounding the risk which translated to revised calculations. EH explained that the primary care risks had been rewritten in order to provide clarity and further detail and the primary care co-commissioning funding risk had been removed from the risk register and added to the issue log as it had been both revised and mitigated.

A new risk had been identified regarding capacity in the safeguarding team following resignations but EH assured the meeting that good mitigations are in place, with the recruitment process underway.

EH further explained that the NHS Barts Health financial position risks had been split in order to be more specific and granular. The risks are now more detailed regarding their effects on the CCG, wider health economy and the STP. EH thanked Justin Phillips (Governance Manager) for his work on the BAF.

The members NOTED the Board Assurance Framework and the changes to the BAF.

2.3 London Borough of Tower Hamlets London Safeguarding Report

Christabel Shawcross, Safeguarding Chair for London Borough of Tower Hamlets, (CS) introduced report and noted the departure of Brian Parrott, her predecessor, stating that the report data was compiled from the previous financial year (2015/16). CS explained that the Safeguarding Adults Board is in a key partnership with the CCG, aiming to improve Adult Safeguarding Services within Tower Hamlets and the partnership working that is taking place is extensive. The Safeguarding Adults Board (SAB) is a statutory body and the CCG is a statutory partner. This provides ample opportunity for challenge and scrutiny and CS noted the benefits this gives both LBTH and the people of Tower Hamlets.

CS introduced the data in the report, highlighting that the number of elderly people in Tower Hamlets is growing and that elderly people are the group most vulnerable to abuse. Tower Hamlets is the 4th highest in London for serious mental health issues.

CS introduced the key areas that the Safeguarding Adults Board focused on in 2015/16. Overall, the Local Authority were seen to be compliant under the Care Act. CS explained that there were issues surrounding the number of safeguarding cases which are presented before court. The number of cases that appear before court are small and the police are working with LBTH to see how this can be improved. CS speculated that this low number could be due to capacity in many areas.

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CS stated that the Adult Safeguarding Board have been focussing on issues with respect to the Deprivation of Liberty Safeguards (DoLS), prevention and health and wellbeing duties. Tower Hamlets has a relatively small number of care homes within the borough but high referral rates.

CS noted the new requirements under the Care Act and where this has impacted services in Tower Hamlets. LBTH published a review which is available on their website and highlights a key area affecting services such as poor discharges from the Royal London. LBTH will be monitoring these services, after poor service resulted in the death of an elderly woman. Other high-profile cases in the borough include the death of a man with a history of drinking living in supported living who died after suffering burns in a fire caused by cigarettes. A review concluded this could have been prevented at various stages of contact with the individual. LBTH initiated a learning process by inviting the borough’s Chief Fire Officer to their board to ensure lessons were learnt. CS also noted that the SAB will be looking at 2 deaths of LD people which were unexpected – this came after awareness highlighted by the Southern Health deaths.

CS noted that the demographics portrayed in the report do not marry to the local population – LBTH have noted this and are keen to review and make changes to ensure this is remedied. CS noted that improved engagement with the local population could help improve this. CS also reminded the Governing Body that November is safeguarding month and highlighted that LBTH will be doing a number of things to promote this and that engagement of the public remains a LBTH priority.

Somen Banerjee (SB) queried if the patient who passed away due to a fire caused by a cigarette was due to fake cigarettes being illegally imported and sold. Tower Hamlets has a chronic issue with fake cigarettes which are highly flammable due to the chemical mix and are a significant cause of fire related deaths. CS was not aware of the nature of the cigarettes but noted the point.

SE thanked CS for the report and the support of LBTH in safeguarding issues across Tower Hamlets.


2.4 Delivering Safe and Compassionate Care (NHS Barts Health)

AM welcomed Jackie Sullivan (JS) and introduced the update on ‘Delivering Safe and

Compassionate Care 2’. AM stated that the Governing Body recognises the work that NHS

Barts Health Trust and the Royal London Hospital site have done to progress on the key areas

which the CQC identified in their most recent report. This has resulted in many areas of

positive work.

JS explained that ‘Delivering Safe and Compassionate Care 2’ was produced after the CQC

visited NHS Barts Health trust in 2014 and rated the trust and the Royal London Hospital as

inadequate. JS stated that NHS Barts Health recognised that the scale of challenge was huge

and the issues for the Royal London Hospital were wide ranging but focused around quality

and risk, issues regarding access, RTT, and staff feeding back morale issues (including

bullying and harassment). There were also concerns around the leadership model which was

clinical speciality rather than site based. JS explained that financial challenges had built up

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over time – the Trust’s deficit is in the region of £135million, further increased by infrastructure

issues on the older sites.

JS noted key areas presented in the leadership and governance slide such as the decision

taken to move to site based management structure in order to implement improvement

procedures; a permanent executive team were recruited and governance structures revised

in line with this. Set governance structures and procedures were implemented on each site

with care taken to ensure these structures mirror each other across the sites to ensure that

reporting could be comparable. JS noted that there could be issues regarding site

communication and this is managed by the Clinical Academic Group. The Clinical Academic

Group network themselves around sites to pull out best practice with sensible pathways and

best learning – this helps communication between sites flow and mediates communication

issues.

JS noted that there is more learning to be done still at the Royal London Hospital but

improvements are very much underway. Alwen Williams (Chief Executive of NHS Barts

Health) implemented ‘Listening In To Action’, a programme designed to change culture and

introduce staff led change and improve morale. JS noted the success stories, in particular

citing a clinic re-organisation which was suggested by front line staff and has resulted in

reduced cancelations for one clinic by 60%. The ‘Listening in to Action’ programme

encourages empowerment of staff and this has helped strengthen the new implementation of

new values and behaviours. These values and behaviours focus on equality and inclusion and

strengthen relations with stakeholders and JS noted the substantial support from CCG. JS

highlighted that changes implemented through ‘Listening In To Action’ have already had an

impact on morale and there has also been a marked improvement in quality. The Royal

London is regularly meeting its 6 week diagnostic requirements, and is fairly regular within the

62 week cancer standard with pressure ulcers falling.

Recruitment at the Royal London Hospital has also seen marked improvements. The Royal

London Hospital faced issues surrounding extensive use of agency and interim staff. Work

has commenced to change this, with new permanent staff now beginning their employment.

This has lessened the Royal London’s reliability on agencies and JS predicted this should

improve quality. JS also noted that there is currently good recruitment turnaround which has

been reduced to 7 weeks after previously taking 14 weeks to hire new staff.

JS stated that the CQC are currently visiting the Royal London and are poised to produce a

report which will be sent to the CCG once it has been published. JS explained that ‘Safe and

Compassionate Care 2’ was designed to move Royal London Hospital from Inadequate to

Good. ‘Safe and Compassionate Care 2’ has worked on changing culture to meet the CQC

standards, rather than implementing a tick box exercise. Therefore, Royal London are focusing

on staff engagement, leadership and staff are very keen to learn from complaints and serious

incidents. JS stated that the hospital is also working towards reducing waiting times and

making sure the hospital is safe. The Royal London is also working on an extensive patient

engagement programme and JS noted that the maternity board is a good example of this. JS

stated that both she and the Trust felt that the working relationship between the CCG and the

Trust was positive and the Trust are happy to take review and comments regarding the recent

work taking place.

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VP noted the positive aspects of the report, the improvements made by NHS Barts Health and

the impressiveness of the dashboards. VP queried the training systems which had been

implemented in order to boost these changes also querying the longevity of the systems and

if the Trust had worked to ensure that these good examples of training continued long after

the change programme is completed. JS gave an overview of the team central to the change

programme; the Transformation Team work on quality improvement and training and once

these aspects have matured, these tools are shared across the trust. The team is non-clinical,

and so is able to reach in and implement change and pull out once the change has become

part of the culture and the teams have taken ownership of the changes. VP stated that similar

training is taking place at CCG level and has worked well in ELFT and other organisations.

VP felt it would be beneficial for all stakeholder groups including Barts Health, ELFT and the

CCG to meet and share good practice and design regarding these tools. JS welcomed this.

SE also noted the positivity regarding the report and queried the staffing developments and

recruitment issues due to financial restraints. JS stated that there were no challenges when

gaining financial consent to recruit to clinical posts and noted that the Royal London Hospital

has 90 new starters and have recruited 97 nurses from Philippines. JS stated that her team

do review non-clinical roles if they become vacant to ensure they are financially viable and fit

for purpose under the new model. MD asked, due to the high cost of living in Tower Hamlets

and the lack of accommodating local housing, where the Royal London envisaged

accommodating the new nurses. JS assured the meeting that the estates team are working

on ensuring accommodation for the new nurses and are treating this as a priority.

AM thanked JS for the report and the recent work that NHS Barts Health has undertaken.

The Governing Body NOTED the report.

2.5 Performance and Quality Report

AM introduced the report and highlighted the key issues and points of recent months within

Performance and Quality in the providers the CCG works with. The report provided a high

level overview of quality and performance across Tower Hamlets reported for the month of

August and September where data and information was available. The report highlighted key

issues, current performance against NHS Constitution standards and actions taken by

providers and Tower Hamlets CCG in managing the provider performance and quality portfolio

for acute, community and mental healthcare in Tower Hamlets.

AM stated that cancer waiting times within NHS Barts Health Trust continued to be good with

Barts Health achieving 7 out of 8 standards in August, including the standards for 2 week

urgent referrals (97.7% vs. 93%); 31 day 1st treatment standard (97.61% vs. 96%) but fell

short slightly against the 62 day standard GP urgent referral standard (83.1% vs 85%) with 21

breaches – AM assured the Governing Body that this shortfall was being managed with robust

controls to help meet the next quarter. Of the 21 breaches, 9 were avoidable breaches, 7 were

unavoidable and 5 were mixed. The majority of avoidable breaches related to gynaecology

and colorectal and extra capacity has been arranged to avoid future breaches. AM explained

that the trust are on track to deliver the 62 day performance standard September and for

Quarter 2, resulting in 3 consecutive complaint quarters. There are 10 patients waiting over

104 days with robust tracking of each patient in place – AM assured the Governing Body that

there are no major concerns with these patients at present.

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AM explained that the next full day of elective deep dives was scheduled for 4 November 2016

to address cancer 62 day and 52 week wait position in challenged specialties that have an

overlap with cancer and specific issues including looking at T&O and colorectal lung.

AM explained that the 18 weeks RTT PTS standard remains challenged at ELFT. A meeting

was held with the Trust on the 11th October to understand the detail behind their demand and

capacity plans and performance trajectory that aims for the end of December to clear the

current backlog. AM assured the meeting that the CCG is working extensively with ELFT to

achieve this target. AM noted that, although support is available from the CCG, this could also

present a significant quality concern stating that she has been assured there is no harm to the

patients experiencing long waiting times and that all patients are receiving additional care.

A&E remains challenged with Q3 position at the Royal London Hospital with an 86.08%

against a trajectory for quarter 3 of 89.37%. The Royal London Hospital site needs to achieve

weekly performance of 89.97% in order to hit the quarter 3 trajectory – AM explained this could

be challenging. Attendances at A&E are up by 4.9% and the site is under constant pressure

and bed occupancy is static at 99%. In order to assist the flow of patients, work has focussed

on adhering to the current plans and maintaining A&E flow. The SAFER model has been

implemented to help maintain flow of patients in ED and best practice is being implemented

during discharges to reduce delayed transfer of care. The CCG and the providers in Tower

Hamlets have come under advanced pressure from NHSE in regards to winter months

planning. AM stated that challenges remained within the system regarding its capacity to cope

under the pressures of a surge in patients during the winter months. The supporting measures

that the Royal London Hospital A&E may need were discussed at the CCG Urgent Care

Working Group reviewing CHC assessments, Royal London Hospital A&E infrastructure and

out of borough social work as a way to manage delays – however, AM noted that the outlook

remains challenging.

The Royal London Hospital site team submitted a revised plan on the 5 August that

encompassed several actions broadly divided into 3 work streams which focused on ED

process and admissions avoidance, site operations and flow and discharge. The format of the

RLH ED Performance meetings has now also been revised to a “deep dive” approach where

clinicians present data and challenges related to each key area of the sustainability plan.

Previous “deep dives” have focused on improving patient flow in medicine and surgery. AM

noted that the clinicians were committed to change and implementing the sustainability plan.

The Governing Body NOTED the report.

3 Commissioning and Strategy

3.1 Developing and Delivering System Transformation

JP introduced the report explaining that this is an update which outlines the development of

commissioning plans for next year and beyond. It is the third paper presented to the Governing

Body regarding CCG’s commissioning intentions for 2017/19. It builds on the paper presented

at the September 2016 meeting.

JP explained that the CCG is required to develop plans to ensure quality and sustainable

commissioned services. The report outlined the current schemes identified to meet a £15m

sustainability gap in 2017/18 explaining that there are further scheme developments required

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to bridge this gap and further work needs to be undertaken for 2018/19. From April 2017, there

will be a proposal to align governance across the CCG and the Tower Hamlets Together

programme in order to facilitate successful development and delivery of system

transformation.

JP asked the meeting to note the main changes within the paper. Previous versions of the

paper presented suggest a QIPP gap of £10million and due to some of the pressures DK and

HB alluded to earlier in the meeting and the mitigations needed to be put in place for NHS

Barts Health, there has been a need to increase the QIPP target to £15million. JP explained

that the Governing Body needed to be aware of this and the more challenged context for the

CCG this now provides.

JP explained that clinical and managerial leads have worked to find the £15million QIPP

through increased efficiency and quality. As well as delivering these QIPP savings the CCG

is part of many partnerships NEL wide and locally – these include STP (Sustainability and

Transformation Plan), TST (Transforming Services Together) and THT (Tower Hamlets

Together). JP gave an overview of the areas these partnerships are currently covering stating

that the STP process is moving forward and is currently looking at provider productivity and

sustainability. TST is also looking to drive some outcomes within Tower Hamlets with particular

focus on acute services transformation. The THT process will begin to take on a greater

significance for the CCG as the next year progresses, as we have agreed to use the energy

from the Vanguard Programme to drive our move towards an accountable care system model

going forward.

The Tower Hamlets health economy needs to identify £10m of system savings per year over

each of the next five years - due to additional pressures within the health economy, this

requirement for 2017/18 has been revised up to £15m. The schemes identified to date are

estimated to achieve £10.8million of the £15million.

VP noted that the QIPP savings come from work streams such as urgent care, querying the

paper’s estimates of £3million from this work stream and noted that there has been significant

work on redesign of the front end and has not seen the same outcomes that are being

projected in paper. SH noted that he also queried this prior to the meeting and discussed with

Jenny Cooke, Deputy Director of Primary & Urgent Care, and stated that this amount was an

estimate which had been created using the information the CCG had at present. HB explained

that investment in the model reduces activity in A&E and therefore should present this

outcome. VP noted that there is not an accurate demographic growth on the models and there

was difference in the models presented and this could make a difference to the outcome. JP

explained he had not seen this section of modelling that VP was referencing and explained

the need to quantify the improvements that have been invested in to and note where these

would affect the system.

JP also noted that the savings target of £15million means the potential ability to invest is more

constrained than normal therefore any investment must see a return. JP stated that the CCG

is aware from information presented in reports and work in emergency care that there is scope

for improvements in this area.

Jane Milligan (JM, North East London STP Lead) and HB attended the meeting to update the

Governing Body on the STP and progress being made to agree as providers and

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commissioning control totals. JM explained that the STP is trying pull together a framework

across NEL which will agree principles and changes that need to occur and move the system

towards capitated budgets. In order to implement this, there would need to be a new approach

to the commissioner provider split. JM stated that the CCGs within NEL would need to agree

recognition of change at strategic level as well as local change within the three systems. JM

explained that assurance needs to be given to local hospitals that demand management plans

actually produce benefits. JM stated that the much needed payment reform would be possible

through the THT mechanism.


3.2 London Health Devolution CCG Update

SH introduced the London Health Devolution CCG update and explained that the paper aimed

to update CCG Governing Bodies on the progress of the London Health and Care Devolution

Programme as we move towards a second devolution agreement and to confirm ongoing

support from CCGs and their Governing Bodies. Through the devolution agreements, London

Partners aim to minimise unnecessary bureaucracy, and provide new opportunities for CCGs

and boroughs to support Londoners to be as healthy as possible and to ensure that the health

and care system is on a sustainable footing. SH gave an update on the devolution pilots’

progress, explaining that pilots have been exploring possibilities within the current system and

what explicit devolved powers are sought. Pilots are setting out their transformation vision,

‘offers’ by the local system to accelerate action and devolution ‘asks’ to overcome identified

barriers to progress.

SH explained that whilst Tower Hamlets CCG had not been directly involved in these

devolution pilots’, neighbouring partners within the STP footprint had been and it was of

interest to Tower Hamlets CCG. SH explained that mechanisms would need to be in place

for devolution to succeed London-wide and locally – the paper explained these mechanisms

in detail. The Governing Body were asked to approve the paper and note the devolution

progress and the forward timescales to the next Devolution agreement for London, building

on the commitments and priorities agreed in December 2015. The Governing Body did not

provide comments on the proposals and supported the development of the final Devolution

agreements and delegated authority to the Acting Chief Officer to agree and sign off the

agreement on behalf of the CCG.

The members NOTED and APPROVED the report.

4 Committee Minutes

4.1 Audit Committee Summary

No further comments were raised. Members NOTED the minutes.

4.2 Finance, Performance and Quality Committee Summary


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4.3 Primary Care Commissioning Committee Summary


4.4 Executive Committee Meeting Summary


4.5 Governing Body Business Cycle 2016/17

No further comments were raised. Members NOTED the item.

5.0 Questions from the Public

No comments or questions were raised by the attending members of public.

6.0 Any Other Business

No comments or questions were raised by the members.

The meeting ended at 17.00 hrs pm.

SE announced that to resolve that as publicity on items contained in Part 2 of the agenda would be prejudicial to public interest by reason of their confidential nature, representatives of the press and members of the public should be excluded from the remainder of the meeting. Section 1 (2) Public Bodies (Admission to meetings) Act 1960.

Matters arising

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Action reference

Action Lead Due Date

Update

Sept 16 # 01

Register of Interests to be updated to include two new declarations.

Deputy Director of C. Affairs

Sept 16

Completed

Sept 16# 03

Recommendations of the Audit Committee held in July 2016 to be implemented before the next Committee meeting on 11 October 2016.


Sept 16

Completed

Sept 16# 04

AM to contact Dr Osman Bhatti to provide information on cancer referrals

Director of Performance & Quality

Sept 16

Completed

Sept 16# 05

Executive Team to address the compliance with mandatory training.

Acting Chief Officer

Oct 16

Completed

Sept 16# 06 CCG’s Executive Team to liaise

with the relevant Director at LBTH re- LAC referrals from Social Services.

Acting Chief Officer

Sept 16

Completed

Sept 16# 07

Deputy Director of Corporate Affairs to liaise with all Chairs of Committees regarding sign off of minutes and actions.


Sept 16

Completed

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Governing Body Meeting Enclosure

Date of meeting 24th January 2017 C

Agenda item 2.1

Title of report: NEL Sustainability and Transformation Plan (STP) and Governance

Author(s): NEL STP Executive

Presented by:

Sponsor (if different):

For further information

Jane Milligan – Chief Officer THCCG and Executive Lead for north east London STP

[email protected]

Executive summary

During 2016, health and care organisations (clinical commissioning groups, providers, local authorities and voluntary and community organisations) across north east London (NEL) have worked together to develop a sustainability and transformation plan (STP). It sets out how the NHS Five Year Forward View will be delivered and how local health and care services will transform and become sustainable, built around the needs of local people. The STP builds on our positive experiences of collaboration in NEL but also protects and promotes autonomy for all of the organisations involved. Each organisation faces common challenges including a growing population, a rapid increase in demand for services and scarce resources. We all recognise that we must work together to address these challenges; this will give us the best opportunity to make our health economy sustainable by 2021 and beyond.

These papers aim to update CCG Governing Bodies on the progress of the NEL STP, outing the vision and priorities, the delivery model, engagement, finance implications and the next steps.

Memorandum of Understanding (MoU) for the NEL STP Governance

The MOU is intended to ensure a common understanding and commitment between the partner organisations on the NEL STP governance arrangements, specifically: • The scope and objectives of the NEL STP governance arrangements • The principles and processes that will underpin the NEL STP governance arrangements • The governance framework / structure that will support the development and implementation of the NEL STP

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The MoU has been developed by the STP Governance Working Group, which was chaired by Marie Gabriel, Chair of East London NHS Foundation Trust, and involved representatives with expertise in governance from across the partner organisations, nominated by those organisations. The MoU has been presented to all members of the STP Board for comment during its development and iterated a number of times.

The intention is to operate the shadow governance for a trial period of six months, during which time it will be reviewed and further amended as it is tested in real time. Feedback from the Boards on the MoU is welcome and this will be fed into the continual review of the governance arrangements.

Recommendation

Information Approval To note Decision

The Governing Body is asked to:

1. Note progress and the next steps of the STP Programme

2. Review and Approve the governance arrangements as outlined in the Memorandum of Understanding for the NEL STP Governance (02 Dec 2016) recognising that there will be opportunity to continue to develop the governance arrangements.

Conflicts of Interest Conflicts of Interest management has been outlined in the proposed MoU.

Report history The STP overview and MoU has been circulated to all NEL Trust Boards, CCG Governing Bodies and the Local Authorities to take through the most appropriate local governance arrangements.

Patient and Public involvement

As outlined in the report.

Link to the Board Assurance Framework

This paper affects all of the risks under Objective 1: to work in partnership to commission high quality hospital services that are accessible, provide the appropriate treatment in the right place, and achieve good patient outcomes for people of all ages living in the borough.

Impact on Equality and Diversity

Monitoring and actively improving service provision across London will have a beneficial impact for all patients in Tower Hamlets.

Resource requirements As outlined in the report.

Next steps The STP is currently being developed further and the latest draft submission is being circulated to health and social care partners.

We anticipate feedback from NHS England and NHS Improvement early in 2017, and will continue to evolve the STP following feedback from our local partners, local people and the national bodies.

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We welcome your comments and input as we further develop the plans. Key questions we are asking are:

• What do you think about what we have chosen to focus on?

• Do you think we have the right priorities? • Is there anything missing that you think we should

include?

To find out about STP-related events, sign up to our newsletter or read a more detailed version of the STP at: www.nelstp.org.uk

For more information please contact us on [email protected]

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NORTH EAST LONDONSUSTAINABILITY & TRANSFORMATION PLAN

Enc. C

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19/01/2017 2

North east London Sustainability and Transformation Plan

During 2016, 20 organisations across eight local authorities have worked together to develop a sustainability and transformation plan (STP) for north east London.

The plan sets out how the ambitions of the NHS Five Year Forward View will be turned into reality and describes how north east London (NEL) will:

• Meet the health and wellbeing needs of its population

• Improve and maintain the consistency and quality of care for our population

• Close the financial gap.

Each organisation faces common challenges including a growing population, a rapid increase in demand for services and scarce resources. Working together to address these challenges will give us the best opportunity to drive change and to make sure health and care services in north east London are sustainable by 2021.

On 21 October 2016 we submitted an updated narrative, updated summary and eight delivery plans describing the main priorities of the STP to NHS England and NHS Improvement.

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Links with other local plans

The STP builds on existing local transformation programmes and supports their implementation including:

• Barking and Dagenham, Havering & Redbridge (accountable care system) and City & Hackney devolution pilots

• Newham, Tower Hamlets and Waltham Forest: Transforming Services Together programme

• The improvement programmes of our local hospitals, which aim to supports Barts Health NHS Trust and Barking, Havering and Redbridge University Hospitals NHS Trust out of special measures.

We are actively seeking to collaborate across NEL where it makes sense to do so and have formed a NEL wide group to share learning from the devolution pilots and transformation programmes which underpin the emerging accountable care systems.

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Our vision and priorities

To measurably improve health and wellbeing outcomes for the people of NEL and ensure sustainable health and social care services, built around the needs of local people.

To develop new models of care to achieve better outcomes for all, focused on prevention and out-of-hospital care.

To work in partnership to commission, contract and deliver services efficiently and safely.

To achieve this vision, we have identified a number of key priorities:

• The right services in the right place: Matching demand with appropriate capacity in NEL

• Encourage self-care, offer care close to home and make sure secondary care is high quality

• Secure the future of our health and social care providers. Many face challenging financial circumstances

• Improve specialised care by working together

• Create a system-wide decision making model that enables placed based care and clearly involves key partner agencies

• Using our infrastructure better

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Delivering the NEL STP

To deliver the STP we are building on existing local programmes as well as setting up eight work streams to deliver the priorities. The workstreams are cross-cutting NEL wide programmes, where there are benefits and economies of scale in consolidating a number of system level changes into a single programme. These are:

• Promote prevention and personal and psychological wellbeing in all we do

• Promote independence and enable access to care close to home

• Ensure accessible quality acute services

• Productivity

• Infrastructure

• Specialised commissioning

• Workforce

• Digital enablement

Each of the eight delivery plans sets out the milestones and timeframes for implementation.

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Involving local people and stakeholders

Our plans and priorities must be developed with those who use, pay for or work for the NHS. Their engagement

• During the summer we produced a summary of progress and shared the first draft STP on our website. We met with a number of MPs; arranged for elected members from each borough to meet the STP executive; engaged with Overview and Scrutiny Committees, Health and Wellbeing Boards and the Local Government Association; involved local authority staff; met with local patient and campaign groups; presented the plans to clinical groups and staff; held events on particular topics and with key stakeholders and discussed the plans at public board meetings of all NHS partners.

• On 21 October we submitted an updated narrative, eight delivery plans and a communications and engagement plan to NHS England. We have published these on our website www.nelstp.org.uk

• Over the coming months we are encouraging staff and stakeholders including councils and Health and Wellbeing Boards to make their views known. We are actively working with local Healthwatches and other community networks to gauge the views of the public and local interest groups.

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Governance

A group (including health organisations, local authorities and Healthwatch) has been set up to review and update the governance arrangements.

As key players in the development and delivery of the STP, especially in ensuring it meets the needs of the many different communities, local authorities will be suitably represented.

The group has developed a shadow governance structure and initial terms of reference which strengthens existing forums such as the STP Board and adds several new bodies, most notably:

• A Community Council – of residents, voluntary sector, councillors and other key stakeholders

• An Assurance Group – an independent group of audit chairs to provide assurance and scrutiny

• A Political Leaders Advisory Group

• A Financial Strategy Group – to provide oversight and assurance of the consolidated financial strategy

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19/01/2017 8

Finances – how will we pay for this?

If we do nothing to address NHS financial challenges we will have a shortfall of £578 million by 2021 as our increased income will not keep pace with expenditure. If we carry on with ‘business as usual’ efficiencies of 2% a year, we will have a shortfall of c£336 million by 2021.

In local authorities and the Corporation of London, if we consider adult social care, the Better Care Fund, children’s services and public health, there will be a £238 million shortfall by 2021 if we take no action to address the issues.

We will find savings and reduce these gaps by:

• Delivering individual organisations’ savings programmes – making them more efficient and effective

• Working together – using our local transformation programmes to achieve savings; combining back office functions such as HR, finance, facilities management and IT to improve services and make savings; consolidating services and sharing good practice, which can improve productivity and save money; using our buildings more efficiently; using our collective buying power to secure better value contracts, for example medicines

• Working with local people to co-design new services that better meet their needs, and identify opportunities for productivity and efficiency improvements

• Accessing funding from the national Sustainability and Transformation Fund, but this is conditional on the quality of our STP.

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Equality

A screening to consider the potential equality impacts of the proposals has been completed. This is on our website www.nelstp.org.uk

The screening includes:

• An assessment of the level at which the analyses need to be conducted (London-wide, regional, local area or borough level)

• A screening of the overarching Framework for better care and wellbeing

• Description of the actions to be taken

The screening recognises the initiatives included in the STP will be implemented at different times and that further analyses will need to be undertaken over the life of the programme.

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Next steps

The STP is currently being developed further and the latest draft submission is being circulated to health and social care partners.

We anticipate feedback from NHS England and NHS Improvement early in 2017, and will continue to evolve the STP following feedback from our local partners, local people and the national bodies.

We welcome your comments and input as we further develop the plans. Key questions we are asking are:

• What do you think about what we have chosen to focus on?

• Do you think we have the right priorities?

• Is there anything missing that you think we should include?

To find out about STP-related events, sign up to our newsletter or read a more detailed version of the STP at: www.nelstp.org.uk

For more information please contact us on [email protected]

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NEL STP Plan on a page

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North East London

Sustainability and Transformation Plan

Memorandum of Understanding for the NEL STP Governance

Version 1.0

02 December 2016

Enc. C

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1. Purpose

This document is a Memorandum of Understanding for the shadow governance arrangements of the North East London Sustainability and Transformation Plan between the health and social care partner organisations in North East London as listed below:

Waltham Forest Clinical Commissioning Group City and Hackney Clinical Commissioning Group Tower Hamlets Clinical Commissioning Group Newham Clinical Commissioning Group Barking and Dagenham Clinical Commissioning Group Havering Clinical Commissioning Group Redbridge Clinical Commissioning Group Barts Health NHS Trust Barking, Havering and Redbridge University Hospitals NHS Trust The Homerton University Hospital NHS Foundation Trust East London NHS Foundation Trust North East London NHS Foundation Trust London Borough of Waltham Forest London Borough of Hackney City of London Corporation London Borough of Tower Hamlets London Borough of Newham London Borough of Barking and Dagenham London Borough of Havering London Borough of Redbridge

This Memorandum of Understanding is not legally binding, but is intended to ensure a common understanding and commitment between the partner organisations listed above on the NEL STP governance arrangements, specifically:

The scope and objectives of the NEL STP governance arrangements The principles and processes that will underpin the NEL STP governance arrangements The governance framework / structure that will support the development and implementation of

the NEL STP

It is proposed that this Memorandum of Understanding will be superseded by a formal partnership agreement between these organisations, no later than April 2017 when the shadow NEL STP governance arrangements are formalised.

2. Introduction

NHS England planning guidance released in December 2015 set out a requirement for local areas to develop a shared five‐year Sustainability and Transformation Plan (STP), articulating how organisations in these areas would work together over the next five years to close the finance, care and quality, and health and well‐being gaps.

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The launch of the STP process signalled a new paradigm, with a move towards working in geographical footprints and the need to develop governance arrangements to support strategy development and change at a system level.

In response to this guidance 20 organisations across north east London – in City of London, Barking and Dagenham, Hackney, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest ‐ have been working together to develop the NEL STP

This plan will describe how these organisations will turn the ambitions of the NHS Five Year Forward View into reality and deliver the vision to:

• Measurably improve health and wellbeing outcomes for the people of North East London and ensure sustainable health and social care services, built around the needs of local people.

• Develop new ways of working to achieve better outcomes for all; focused on prevention of ill health and out of hospital care.

• Work in partnership to commission, contract and deliver services efficiently and safely.

The NEL STP will act as a system level plan for change supported by and aligned to a number of local plans to address certain challenges, such as:

• City and Hackney (CH): Hackney devolution pilot, bringing providers together to deliver integrated, effective and financially sustainable services.

• Barking and Dagenham, Havering and Redbridge (BHR): bringing together health and social care services under a single local accountable care system (devolution pilot)

• Newham, Tower Hamlets and Waltham Forest (WEL): Transforming Services Together programme to improve the local health and social care economy.

An initial set of governance arrangements was established to oversee and manage the development of the draft NEL STP that was submitted to NHS England and NHS Implementation on 30 June 2016. Following this submission the programme moved into the next phase, focused on detailed planning and the mobilisation and implementation of the delivery programmes.

The governance arrangements need to be updated to reflect this change in focus, so that they continue to remain appropriate and effective, and ensure appropriate representation and membership.

A workshop with system partners was held on 8th July 2016 to discuss the future governance arrangements and since then the partner organisations have established a time‐limited Governance Working Group to represent the views of the partner organisations in the development of options and proposals for the governance arrangements.

3. Objectives of the NEL STP governance arrangements

The objectives of the NEL STP governance arrangements are to:

• Support effective collaboration and trust between commissioners, providers, people and carers to work together to deliver improved health and care outcomes more effectively and reduce health inequalities across the NEL system

• Provide a robust framework for system level decision making, and clarity on where and how decisions are made on the development and implementation of the NEL STP

• Provide clarity on system level accountabilities and responsibilities for the NEL STP

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• Enable opportunities to innovate, share best practice and maximise sharing of resources across organisations in NEL

• Enable collaboration between partner organisations to achieve system level financial balance over the 5 year STP timeframe and deliver the system control total (once agreed), while safeguarding the autonomy of organisations

4. Scope of the NEL STP governance arrangements

4.1. In scope

• Governance arrangements for the development of the North East London STP • Governance arrangements for the implementation of the STP schemes defined in the North East

London STP • Alignment with the wider health system plans and governance, including devolution programmes

and regional boards • Development and operation of the governance arrangements for the NEL STP Financial Strategy to

achieve the system control total (once agreed)

4.2. Out of scope

• Local organisational governance arrangements for CCG Governing Bodies, Provider Trust Boards and Local Authorities

• Internal organisational decision making processes • Local governance arrangements for the delivery of local (non‐NEL wide) programmes:

o Hackney devolution pilot

o Barking and Dagenham, Havering and Redbridge (BHR) Accountable Care System (devolution pilot)

o Transforming Services Together programme

5. Principles for NEL STP system governance

The development of effective system level governance arrangements that support the development and implementation of the NEL STP will require collaboration and active engagement from all system partners to ensure the interests of all organisations are appropriately represented.

A key aspect of this process is the agreement of a common set of principles that will guide the development of the new governance arrangements. The proposed set of principles for the NEL STP system governance, which have been developed collaboratively by the Governance Working Group and endorsed by the STP Board, are outlined below:

Participation: Representation and ownership from health and social care organisations, local people and lay members to clearly demonstrate collaborative and representative decision making

Collaboration: All parties will work collaboratively to deliver the overall NEL STP strategy, in the best interests of the wider system and local people

Engagement: Local people will be engaged and involved in the NEL STP governance to ensure their views and feedback are considered in the decision making processes. This engagement should

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operate at 2 levels; individual level and organisational level (i.e. via patient representative forums and other local community groups)

Accountability: Define clear accountabilities, delegation procedures, voting arrangements and streamlined governance structures to support continuous progress and timely decision making. Delegation of work to the groups with the relevant expertise and authority to deliver it

Autonomy: Recognise the autonomy of the health and social care partners of the NEL STP. Operate in a manner that is compliant with legal duties and responsibilities of each constituent organisation and the NHS as a whole (e.g. legal responsibility for consultation on service changes). Ensure alignment with the local organisations’ governance and decision making processes recognising statutory and democratic procedures

Subsidiarity: Ensure subsidiarity so that decisions are taken at the most local level possible, and decisions are only taken at a system level where there is a clear rationale and benefit for doing so

Professional Leadership: Demonstrate strong professional leadership and involvement from clinicians and social care to ensure that decisions have a robust case for change and senior level support

Accessibility: Ensure complete transparency in all decision making to support the development of mutual trust and openness between organisations. Provide the necessary assurance to system partners on key decisions. Collaborative working and information sharing between working groups to ensure consistency.

Good Governance: Recognise that good system level governance will require robust planning and horizon scanning to ensure that proposals are presented to the statutory organisations in a timely way, that align with their local governance and decision making processes. However, where necessary local organisations will try to be flexible to support the system level governance

6. Governance structure

The current proposed shadow governance structure for the NEL STP programme is included in appendix A.

This appendix also includes draft summary terms of reference for the key governance groups in this structure, which will be developed further by the groups.

7. Voting rights and process

Voting rights and processes will be defined relevant terms of reference

8. Key system level decisions

The key system level decisions that will fall under the scope of the NEL STP governance arrangements are outlined below.

This list will be updated from time to time to reflect the latest set of NEL system level decisions:

• Approval of the NEL STP

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• Budget for the NEL STP programme

• System level financial strategy and system control total

• Changes to King George Hospital Emergency Department

• The relevant elements of the NEL Mental Health strategy

• The relevant elements of the NEL Primary Care strategy

• NEL system level estates plan

• The approach to specialised commissioning for the NEL sector

9. Escalation process

The remit of each group will be clearly defined within the respective terms of reference. Where a group is unable to resolve a particular risk or issue, the chair will escalate this risk or issue to the chair of the group to which it reports (as defined in the Terms of Reference).

This will be done through the standard escalation report, which can be provided by the Programme Management Office.

In the case of the NEL STP Board, which reports into a number of statutory organisations, the independent chair of the NEL STP Board will be responsible for deciding on the most appropriate escalation route (i.e. to all statutory organisations, to those that are impacted by the risk or issue).

10. Dispute resolution process

All parties will make every effort to work collaboratively in the best interests of the NEL system, and to avoid disputes. Should disputes arise the parties will follow the agreed dispute resolution process to resolve the disputes as quickly as possible and to minimise impact on delivery.

Individual party’s concerns should be raised in the first instance with the Independent Chair of the NEL STP Board. This should be in writing clearly stating the basis of the concerns, including where applicable the concerns and the rationale behind the dispute. The Independent Chair will endeavour to find an informal resolution to the dispute through discussion and mediation. Where agreement cannot be reached using informal resolution processes the Independent Chair will propose a formal resolution process, which may involve reference to national guidance and best practice.

11. Review process

This Memorandum of Understanding will be adopted by:

Waltham Forest Clinical Commissioning Group City and Hackney Clinical Commissioning Group Tower Hamlets Clinical Commissioning Group Newham Clinical Commissioning Group Barking and Dagenham Clinical Commissioning Group

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Havering Clinical Commissioning Group Redbridge Clinical Commissioning Group Barts Health NHS Trust Barking, Havering and Redbridge University Hospitals NHS Trust The Homerton University Hospital NHS Foundation Trust East London NHS Foundation Trust North East London NHS Foundation Trust London Borough of Waltham Forest London Borough of Hackney City of London Corporation London Borough of Tower Hamlets London Borough of Newham London Borough of Barking and Dagenham London Borough of Havering London Borough of Redbridge

The signatories to this Memorandum of Understanding should be properly authorised to represent their respect organisations in entering into the commitments outlined in this document.

Appendix B outlines the current status of approval of the Memorandum of Understanding by these bodies.

This Memorandum of Understanding will be reviewed and updated from time to time to enable good practice governance to be recognised and built upon and to identify and address areas for development. Where there are material changes to this Memorandum of Understanding an updated version will need to be approved by the bodies outlined above.

12. Code of conduct

The Committee on Standards in Public Life (Nolan Committee) has set out seven principles of public life which it believes should apply to all in public service. The seven Nolan principles are listed in appendix C.

The NEL STP partners are asked to adopt these principles as the basis for collaborative working across the STP governance arrangements.

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Appendix A.1 Shadow Governance Structure for NEL STP

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Appendix A.2 Draft Terms of Reference for NEL STP Governance Groups

A.2.1 Draft Terms for Reference for NEL STP Board

Purpose

• To provide strategic direction to the NEL STP programme (based on the decisions by the statutory organisations)

• To oversee and assure the delivery of all elements of the NEL STP plan • To address / resolve escalated system‐level risks and issues • To generate effective partnership working and a sense of common purpose between the system

partners • To provide oversight and assurance of the funding for the NEL STP programme

Membership

• 1 x Independent chair • 1 x NEL STP Executive Lead • 1 x Chief Executive of Barts Health • 1 x Chief Executive of the Homerton • 1 x Chief Executive of BHRUT • 1 x Chief Executive of ELFT • 1 x Chief Executive of NELFT • Nominated Representative/s of North East London Commissioners (CCGs) • 1 x Chair of Local Workforce Action Board1 • 1 x Chair of the Clinical Senate • 1 x Acute Sector Clinician2 • 1 x Mental Health Sector Clinician2 • 1 x Nominated representative from the Community Council • 1 x Local Authority Chief Executive representative from Barking, Havering, Redbridge area • 1 x Local Authority Chief Executive representative from City and Hackney area • 1 x Local Authority Chief Executive representative from Tower Hamlets, Waltham Forest, Newham area

Additional Attendees / Advisory

• Representative of GP federations • 1 x Healthwatch observer • 1 x representative from the NEL STP Finance Strategy Group • 1 x NHS E representative (regulator) • 1 x NHS I representative (regulator) • 1 x NHSE Specialised Commissioning representative • 1 x Local Authority representative for prevention commissioning • 1 x HEE representative

1 The chair of the Local Workforce Action Board (LWAB) will be represented as an accountable office of one of the partner organisations 2 Endorsed by NEL Clinical Senate

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Quorum:

At least three quarters of the membership of the NEL STP Board, including:

• An Independent Chair (or an agreed deputy) • 1 x acute trust representative • 1 x mental health trust representative • 1 x CCG representative • 1 x Clinical Senate representative • 1 x Local Authority representative • 1 x Community Council representative

Voting arrangements

This is a unitary board, where motions will be passed by a majority vote, where a majority is defined as at least three quarters of the votes cast.

In advance of any vote all voting members must declare any potential conflicts of interest. The Independent Chair will decide on whether any potential conflict of interest should preclude a member from voting on a particular issue.

Reporting

This NEL STP Board reports and is accountable to the statutory organisations in the NEL STP system

Frequency

Bi‐monthly

Under exceptional circumstances extra ordinary meetings of the NEL STP Board may be arranged.

Requests for extraordinary board meetings must be raised to the Independent Chair for consideration.

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A.2.2 Draft Terms for Reference for NEL STP Delivery Alliance

Purpose

• Provide operational direction and assurance to the delivery of the STP plan to provide high quality, sustainable integrated care for the people of NEL

• Hold SROs to account for delivery of the STP plans • Drive the delivery of the NEL STP programme at pace • Escalate key risks and issues to the NEL STP Board

Membership

• 1 x NEL STP Executive SRO (Chair) • 1 x NEL STP Finance SRO • 1 x Provider Productivity SRO and / or Delivery Lead3 • 1 x Infrastructure SRO and / or Delivery Lead3 • 1 x Technology SRO and / or Delivery Lead3 • 1 x Workforce SRO and / or Delivery Lead3 • x Transformation SRO and / or Delivery Lead3 • 1 x Specialised Commissioning SRO and / or Delivery Lead3 • 1 x Communications and Engagement SRO and / or Delivery Lead3 • 1 x NEL STP Programme Director • 1 x representative from the Clinical Senate4 • Representatives from Local Authorities • Clinical Directors

Reporting

Reports and is accountable to the NEL STP Board

Frequency

Monthly

3 Representation from each programme to be agreed by the SRO and Delivery Lead 4 To be nominated by the NEL Clinical Senate

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A.2.3 Draft Terms for Reference for NEL Clinical Senate

Purpose

• To provide clinical / social care advice, oversight and assurance for the programme, ensuring that the approach to implementation is robust sound and that safety and quality are protected during the implementation period.

• Lead on development of NEL wide care solutions

Membership

• 5 x Trust Medical Directors / Chief Medical Officers • 7 x CCG Chairs • Directors of Public Health • 1 x NHS E Medical Director • Social Care representatives • Nursing representatives • NHSE Specialised Commissioning representatives

Quorum

TBC

Reporting

Advisory to NEL STP Board.

The NEL Clinical Senate will provide a clinical and social care view on all issues before these are presented to the NEL STP Board (and these meetings will be scheduled to enable this flow of business).

Frequency

6 weeks

Drafting note: A review of the clinical input into the NEL STP is currently in progress. The outcomes of this review will inform the Terms of Reference for the NEL Clinical Senate. This may include a change of name for this group.

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A.2.4 Draft Terms for Reference for NEL Finance Strategy Group

Purpose

• To lead the development of the NEL integrated financial strategy • To provide strategic direction on the approach to achieving the overall system control total • To oversee the allocation of the Sustainability and Transformation Funding • To manage the central CCG risk pool and other matters delegated by the STP Board

Membership

• 1 x NEL STP Independent Chair • 1 x NEL STP Finance Lead • 5 x Trust Director of Finance • 3 x CCG representatives • 1 x Audit Chair (nominated to represent all audit chairs) • 1 x NHSE representative • 1 x NHSI representative • 1 x nominated Local Authority Director of Finance

Reporting

Reports and is accountable to the NEL STP Board

Frequency

Bi‐monthly / quarterly

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A.2.5 Draft Terms for Reference for the NEL Community Council

Purpose

• An engagement forum for the wide range of stakeholders involved in the NEL STP system, to represent the views of all stakeholders on the NEL STP

• To provide assurance on the overall NEL STP strategy and ensure that the NEL STP remains aligned with Health and Wellbeing strategies

Membership

• Residents’ representatives • Voluntary sector representatives • Healthwatch representatives • CCG representatives • Lay member representatives • Trust Non‐Executive Directors

Reporting

Advisory to NEL STP Board

Frequency

Quarterly

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A.2.6 Draft Terms for Reference for NEL STP Assurance Group

Purpose

• To provide independent challenge and assurance to the NEL STP Board on the NEL STP plan

Membership • Trust Audit Chairs • CCG Audit Chairs • Chairs of Local Authority Audit and Governance Committees

Reporting

Provides assurance to the NEL STP Board

This group will also link in with the Overview and Scrutiny Committees

Frequency

Bi‐monthly /quarterly

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A.2.7 Draft Terms for Reference for Political Leaders Advisory Group

Purpose

• To provide a forum to represent the views of political leaders in North East London on the NEL STP

• To provide feedback to the NEL STP Board on elements of the plan

• To provide a forum for political engagement on the NEL STP

Membership • Independent Chair NEL STP • Leader or nominated representative of London Borough of Waltham Forest5 • Mayor or nominated representative of London Borough of Hackney5 • Chair of Policy & Resources Committee or representative of City of London Corporation5 • Mayor or nominated representative of London Borough of Tower Hamlets 5 • Mayor or nominated representative of London Borough of Newham5 • Leader or nominated representative of London Borough of Barking and Dagenham5 • Leader or nominated representative of London Borough of Havering5 • Leader or nominated representative of London Borough of Redbridge5

Reporting

Advisory to the NEL STP Board

Frequency

Quarterly

5 To be nominated by the respective local authority

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Appendix B – Organisational Sign Off

Through signing this Memorandum of Understanding the partner organisations listed below will:

Agree to the objectives in this document and work collaboratively to achieve these Agree to the governance principles and processes outlined in this document Recognise the governance structure outlined in this document for the NEL STP and support this

locally

The signatories to this Memorandum of Understanding should be properly authorised to represent their respect organisations in entering into the commitments outlined in this document.

Signed on behalf of: Signature: Name: Title: Date:

Barking and Dagenham CCG

Barts Health NHS Trust

Barking, Havering and Redbridge University Hospitals NHS Trust

City and Hackney CCG

City of London Corporation

East London NHS Foundation Trust

Havering CCG

London Borough of Barking and Dagenham

London Borough of Hackney

London Borough of Havering

London Borough of Newham

London Borough of Redbridge

London Borough of Tower Hamlets

London Borough of Waltham Forest

Newham CCG

North East London NHS Foundation Trust

The Homerton University Hospital NHS

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Signed on behalf of: Signature: Name: Title: Date:

Foundation Trust

Tower Hamlets CCG

Redbridge CCG

Waltham Forest CCG

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Appendix C – The Seven Nolan Principles

C.1 Selflessness: Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. C.2 Integrity: Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. C.3 Objectivity: In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. C.4 Accountability: Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. C.5 Openness: Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. C.6 Honesty: Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. C.7 Leadership: Holders of public office should promote and support these principles by leadership and example.

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Governing Body Meeting- Part I Enclosure

Date of meeting 24th January 2017 D

Agenda item 3.1

Title of report: Board Assurance Framework (BAF)

Author(s): Justin Phillips – Corporate Governance Manager

Presented by:


Ellie Hobart – Deputy Director of Corporate Affairs

[email protected]

Executive summary

The purpose of this report is to provide the Governing Body members with assurance on the progress achieved in revising the Board Assurance Framework (BAF) following discussions at the Executive Committee and the input from respective Executive Lead directors and risk management leads. The revised Assurance Framework was also reviewed by the Audit Committee on January 17 2017. The BAF is the main tool that the Governing Body should use in discharging its overall responsibility for ensuring that it has a robust system of internal control in place and seek the necessary level of assurance from the Audit Committee. During the months of Dec 2016 – January 2017, risk management leads have reviewed and updated the risks, controls, assurance and risk ratings resulting in the changes highlighted in this report. The BAF is presented to Audit Committee and Governing Body members to provide oversight and scrutiny of risks to the achievement of the CCG Strategic Objectives. An up-to-date and revised BAF supports the Governing Body members to identify and prioritise risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.


Conflicts of Interest None identified relating to this report.

Key issues The Board Assurance Framework lists the risks that could prevent the achievement of the CCG’s six corporate objectives.

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This is the fifth iteration of the BAF 2016/17. The following risks were updated:

Risk 1.1: Failure to ensure effective systems and processes are in place to monitor, challenge and support Barts Health NHS Trust delivery of NHS Constitution targets and CQC action plan could result in the increased likelihood of poor quality, poor patient experience, delivery of poor clinical outcomes and the trust remaining in special measures in the longer term.

- CQC Inspection of RLH has taken place. RLH was rated Requires Improvement for being for being safe, effective, caring, responsive and well-led. Actions: Post CQC Inspection Quality Summit will take place on January 23rd.

- Monitoring of CQC action plan at CQRM.

- Joint approach with NHSI re: oversight and assurance going forward.

Risk 1.2: Inadequate staff resource transferred from NHS England to cover the requirements for delegated authority could impact on the ability to deliver the Primary Care Strategy and appropriately manage the delegated responsibilities from NHS England.

- The NHS England contracting and finance team are due to be seconded to the NEL STP by April 2017. This will provide greater alignment and oversight of their activities to support CCG co-commissioning. Action: WEL CCGs are working with NHS England to finalise the operating model and transition process for NHS England staff.

Risk 1.3: FPQ discussed the risk regarding capacity in the safeguarding team with the designated nurses for both safeguarding children and LAC (Looked After Children) shortly leaving and a lack of capacity for adult safeguarding with the internal CCG transfer of responsibilities and agreed the risk should be added to the BAF. However, the committee also agreed that there are strong mitigations in place for both of these with recruitment processes underway, which for adults is joint with London Borough of Tower Hamlets.

By the end of Sept 2016 and Oct 2016 the CCG will have lost both the Designated Nurse LAC and Designated Nurse Safeguarding Children respectively to a vacancy position. In addition the Designated Dr Safeguarding Children is also likely to commence long leave from the end of Oct-Early Nov 2016. This will mean the CCG will only have secured 1/4 of the key safeguarding roles as required by statute and NHSE assurance framework for safeguarding people. The most immediate impact will be the following:

1. Being non-compliant with national guidance

2. No CCG designated professional representation at LSCB and its subgroups

3. Unable to oversee the health aspects of two SCRs that have already commenced

4. Limited access to safeguarding advice for GPs and CCG staff

5. Reduced capacity to scrutinise providers safeguarding arrangements (a) through performance (b) by providing supervision to

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all named professionals as per guidance (c) the co-ordination of the CCG safeguarding children through commissioning group

6. There is reduced scrutiny over the LAC services provided by Barts health, the CCG are required to authorise out of borough placement medicals and health reviews payments. This is likely to be seriously delayed

- Recruitment to 2 x Joint Adult Safeguarding posts: 1 x post Strategic & 1: Operational- January 2017. Appointment of substantive Joint designated Safeguarding Nurse and LAC post- November 2016. Risk rating reduced from 4 x 4 to 2 x 4.

Risk 3.1: Adverse Financial Position of Barts Health NHS Trust - The risk description was updated after a discussion with Jackie Brown (Interim CFO) as the controls and assurances articulated related to the potential impact on the CCG’s financial position rather than directly on the wider health economy: Barts Health may significantly overspend against the CCG set budget for 2016/17 which could negatively impact on the CCG’s financial position.

- Updated gaps in controls:

- Pace of implementation of TST programmes leading to a delay in system efficiencies

- Improvements to coding and counting in year may result in additional costs and / or reported activity.

Actions: - TST work streams – further work to review financial models for TST work streams to ensure granularity of the scheme impact and delivery implications. TST schemes require robust implementation plans, project management, delivery outcomes and start dates.

Risk 3.2: Interim Chief Finance Officer has added this new risk onto the BAF based on discussion at the FPQ meeting in September 2016 relating to the deteriorating financial position at Barts Health and the potential impact on the wider health economy: Failure of Barts Health NHS Trust to address its poor financial position could seriously compromise and impact on the stability across the whole local health economy.

Updated gaps in controls:

- Clarity about the Barts Health role in the ACS / capitated budget model, given ongoing issues with delivering financial balance.

Risk 3.6: As contractual payments for Primary Care co-commissioning activities involve two external organisations – NHS England Capita - there is a risk to both the accuracy and timeliness of payments made, and the ability of the CCG to control or influence this process.

- Additional assurance: Review of non- recurrent options to deliver financial balance.

Risk 3.8: Failure to deliver on the Operating Plan, including QIPP would result in:

• A negative financial impact on the CCG.

• Lost opportunity to produce and deliver increased improved outcomes for the people of Tower Hamlets.

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• A negative impact on the reputation of the CCG.

- Overachievement in Integrated Care is counteracting underachievement in Planned Care and delay in the go-live for CHS contract. Risk rating reduction 3 x 4 to 2 x 3 based on current QIPP position.

- Additional assurance: Continuous review of overall financial performance and options to mitigate any shortfalls in the QIPP programme and / or overspends.

Report history Audit Committee – January 17 2017


The BAF is a living document and provides assurance to all internal and external stakeholders.


The BAF is an essential document in providing evidence of THCCG's system of internal control. It aims to provide the Chief Officer and the Governing Body members with sufficient assurance to be able to sign off the annual governance statement of the CCG at the end of the financial year.


Equality and Diversity remains one of the Corporate Objectives of the CCG for 2016/19.

Challenging discrimination and promoting equality both as an employer and a commissioner of health care services.

Resource requirements There are no additional resources required.

Next steps The next round of risk reviews will commence during February / March 2017.

The Audit Committee will receive and review the BAF at each of its meetings. It will choose significant risks, on a rotational basis and subject them to “deep dive” reviews of risks, controls and assurances to ensure that the controls and assurances as recorded on the BAF are operating in practice.

In this way the Audit Committee will look to provide assurance to the Governing Body that the BAF is valid and suitable for the Governing Body’s requirements.

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Board Assurance Framework (BAF) November 2016 – January 2017

Document information

Version 4 Months covered Sept & Oct 2016 Next review Nov/Dec 2016 Author(s) Justin Phillips – Corporate Governance Manager / Andy Nuckcheddee –Interim Governance Manager

Enc D

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1.0 Corporate Objectives (CO) 2016/19

Our corporate objectives relate to the CCG in its entirety, providing the organisation with a clear direction for commissioning intentions and supporting the development of more detailed programme, team and personal objectives. The corporate objectives reflect our direction of travel as well as our obligation to fulfil our statutory duties. The objectives will be used to develop our approach to risk management, inform programme priorities and provide a framework for performance management.

CO (1) - To work in partnership to commission high quality hospital services that are accessible, provide the appropriate treatment in the right place, and achieve good patient outcomes for people of all ages living in the borough CO (2) - To commission person-centred, integrated health and care service that are sustainable and that equally meet the mental and physical needs of our residents CO (3) - To contribute towards a financially sustainable and responsive health and care economy which delivers value for money and innovation and supports the appropriate use of services CO (4) - To support local people and stakeholders to have a greater influence on services we commission CO (5) - To promote equality both as an employer and a commissioner of health care services CO (6) - To create a high performing and sustainable workforce that continuously learns and is engaged in delivering our ambitions.

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Risks to the Corporate Objectives

Objective1: To work in partnership to commission high quality hospital services that are accessible, provide the appropriate treatment in the right place, and achieve good patient outcomes for people of all ages living in the borough

Risk 1.1 Systems and processes to monitor, challenge and support Barts Health provider delivery of NHS Constitution targets and CQC action plan

January 2017 Update: CQC Inspection of RLH has taken place. RLH was rated Requires Improvement for being for being safe, effective, caring, responsive and well-led.

Lead Committee Comment: FPQ reviewed the BAF on September 28 2016 - The committee agreed that the overall risk rating should be reduced from (3x5) to (2x5) on the basis that the CCG has good visibility of the issues at Barts, there are a comprehensive list of controls and all contractual levers and processes are being optimally deployed to ensure both performance management and support to the Trust. The group further agreed that the risk appetite should reflect the current position with Barts Health with respect to quality special measures status and as such retained as “red”.

Risk 1.1 Risk Description Controls Assurances

GAPS in Controls and Assurances

Risk Ratings

Likelihood x Severity

Failure to ensure effective systems and processes are in place to monitor, challenge and support Barts Health NHS Trust delivery of NHS Constitution targets and CQC action plan could result in the increased likelihood of poor quality, poor patient experience, delivery of poor clinical outcomes and the trust remaining in special measures in the longer term.

1-Joint monthly site specific CQRMs / NHS Improvement oversight and assurance 2-Monthly extended contract review group (CRG) ensures greater contractual leverage whilst maintaining detailed performance management of RTT and cancer. 3-Quality and performance of providers discussed at each Governing Body to ensure open culture of discussing risks and give the GB oversight of quality and performance (also reported via the CCG outcomes scorecard). 4-Monthly FPQ ensuring the CCG and CSU have the opportunity to discuss and review improvement strategies and proactively undertake surveillance of core data and CQC intelligent monitoring information as means of identifying early warning signs of

1- CQRM minutes 2- CRG Minutes 3- Governing Body minutes 4- FPQ minutes 5- Quality Leads Minutes 6- CQN + RAP Barts Health achieved compliance in 8/9 cancer waiting time standards in July 2015 7-Minutes of cancer meetings 8-SI panel minutes 9- MSA audit tool 10-Letter to Barts Health re: CQC action plans 11-RAP –minutes 12 – ED performance meeting minutes and site action plan 13- UCWG minutes and actions 14- The Trust provides assurances to the GB on a quarterly basis 15 - Reduction in overdue SI’s

Mar 2016

3 x 5

Date added

May 2016

3 x 5

Q1 2016/17 – risk continued from BAF 15/16 Governing Body Lead

Dr Sam Everington July 2016

3 x 5

Management Lead September

2016

2 x 5 Archna Mathur

Lead Committee Finance, Performance and Quality

December

2016

2 x 5

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underperformance or poor quality 5-Monthly quality leads meeting 6-CPN (contract Performance Notice) –issued A&E, RTT, Cancer and Diagnostics performance 7- Bi-weekly deep dives extended to include RTT; Elective Deep Dive now in place for challenged clinical specialities 8- New Joint WEL Collaborative CCG and Barts Health Serious Incident Panel in place. 9- Mixed Sex Accommodation (MSA) Audit 10-Attendance to the Quality Surveillance Group to share and gain intelligence on Barts Health with Healthwatch and fellow commissioners. 11- Remedial Action Plans (RAPs) 12 – bi-weekly ED performance meetings with GP clinical input 13 – Revised and enhanced Urgent Care Working Group 14. Newly set up A&E Delivery Board chaired by Barts Health Chief Executive Officer reporting into NHSE 15. Monthly meeting of WEL Director of Quality with Barts Health Director of Nursing and Chief Medical Office 16. Maternity Partnership Board

and Datix Backlog 16 – Maternity Partnership Board minutes / action log.

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) Post CQC Inspection Quality Summit will take place on January 23rd.

- Monitoring of CQC action plan at CQRM. - Joint approach with NHSI re: oversight and

assurance going forward.

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Risk 1.2: Primary Care Commissioning

Comment: Tower Hamlets CCG were awarded delegated co–commissioning for primary medical services from 1st April 2015. This provides us with the greater opportunity to shape the way in which primary care develops to ensure it meets the needs of our local population and is aligned closely with our wider strategies. Delegated commissioning offers an opportunity for CCGs to assume full responsibility for commissioning general practice services. Our intention is to act collaboratively across Waltham Forest, Tower Hamlets and Newham (WEL) and work towards the aims set out in the Strategic Commissioning Framework for Primary Care Transformation in London. THCCG has set up its own team that oversees primary care co-commissioning. The team works closely with NHSE to ensure they undertake their support role. In some instances the team takes on additional tasks as NHSE lacks the capacity to do them. Update: The NHS England contracting and finance team are due to be seconded to the NEL STP by April 2017. This will provide greater alignment and oversight of their activities to support CCG co-commissioning. Lead Committee Comment: The November Primary Care Committee reviewed this risk and were assured by the risk management approach.



Risk Ratings


Inadequate staff resource transferred from NHS England to cover the requirements for delegated authority could impact on the ability to deliver the Primary Care Strategy and appropriately manage the delegated responsibilities from NHS England.

1. The CCG established a

Primary Care Commissioning Team to deliver the Primary Care strategy and support co-commissioning activities

2. NHS England London Primary Care Commissioning Team have been re-configured to support co-commissioning functions at CCG level. A dedicated team are in place to support Tower Hamlets and Hackney.

3. Regular team meetings are

in place between CCG and NHS England to discuss contractual, performance

1. Primary Care

organogram

2. Delegation agreement between the CCG and NHS England, clarifying each organisation’s roles and responsibilities.

3. Primary Care work plan,

with named leads and roles and responsibilities

4. London-wide co-

commissioning meeting minutes and action log

5. NHS England and Tower

Hamlets CCG meeting action log and agenda

Currently the timeline for implementing the future organisational design for the devolved NHS England co-commissioning function is unknown. The operating model that will apply to the new organisation design is not yet agreed.

Mar 2016

3 x 4

Date added

April 2016

3 x 4 Q1 2016/17– risk

continued from BAF 15/16 Governing Body Lead

Simon Hall

June 2016 3 x 4

Management Lead

July 2016

3 x 4

Jenny Cooke Lead Committee Primary Care Committee

Sept 2016 2 x 4

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and other co-commissioning issues and activities.

4. Fortnightly teleconferences

are in place between WEL and BHR CCGs and NHS England to discuss any NE London and London-wide co-commissioning actives

5. NHS England have

committed to moving current co-commissioning resource to STP footprints and have been working with NEL CCGs to design this process and the final organisational structure.

Dec 2016 2 x 4

Risk Appetite

<8

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) - WEL CCGs are working with NHS England to finalise the operating model and transition process for NHS England staff (Dec 2016)

- Seek clarity from NHS England team regarding the timeline and process for implementing the new organisational design for primary care commissioning across NE London. (added Oct 2016) COMPLETE Dec 2016

- Work with NHS England and NEL CCGs to develop operating model for new organisational structure across NE London. (added Oct 2016).

Risk 1.3 Safeguarding Capacity (Added Sept 2016)

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Lead Committee comment: FPQ discussed the risk on Sept 28 2016: the risk is around capacity in the safeguarding team with the designated nurses for both safeguarding children and LAC (Looked After Children) shortly leaving and a lack of capacity for adult safeguarding with the internal CCG transfer of responsibilities. However, the committee agreed that there are strong mitigations in place for both of these with recruitment processes underway, which for adults is joint with London Borough of Tower Hamlets.

Dec 2016 Update: Recruitment to 2 x Joint Adult Safeguarding posts: 1 x post Strategic & 1: Operational- January 2017. Appointment of substantive Joint designated Safeguarding Nurse and LAC post- November 2016.

Risk 1.3

Risk Description Controls Assurances GAPS in

Controls and Assurances

Risk Ratings


Reduced substantive capacity for designated safeguarding professionals. By the end of Sept 2016 and Oct 2016 the CCG will have lost both the Designated Nurse LAC and Designated Nurse Safeguarding Children respectively to a vacancy position. In addition the Designated Dr Safeguarding Children is also likely to commence long leave from the end of Oct-Early Nov 2016. This will mean the CCG will only have secured 1:4 of the key safeguarding roles as required by statute and NHSE assurance framework for safeguarding people.

The most immediate impact will be the following:

1. Being non-compliant with national guidance

2. No CCG designated professional representation at LSCB and its subgroups

3. Unable to oversee the health aspects of two SCRs that have already commenced

4. Limited access to safeguarding advice for GPs and CCG staff

5. Reduced capacity to scrutinise providers safeguarding arrangements (a) through performance (b) by providing supervision to all named professionals as per guidance (c)

A recruitment process is underway, joining both the Designated Nurse Safeguarding children with the Designated Nurse LAC as a single post (over a 1 year secondment) interviews for this post are scheduled for 7th Oct. There has been a high level of interest and the CCG are confident in appointing to this role. The Notice period from the field of applicants is between 4-6 weeks and 3 months. Director of Performance & Quality has agreed to cover the SCR aspects of the role through independent consultants, two have been found and are available to cover this aspect. There is x1 PA of a Named GP in post to cover non-urgent advice sort by General Practice Barts health community safeguarding children team will pick up calls in the absence of the designated professionals The CCG safeguarding children policy and safeguarding children through commissioning policy have recently been reviewed and re-circulated.

Cover will only be for the most urgent aspects of the roles not the whole role Scrutiny of LAC services is still very weak The LSCB and its wider structures will not have access to safeguarding children knowledge and expertise

Sept 2016

4 x 4

Dec 2016/ Jan 2017

2 x 4

Date added

73

Q1 2016/17- risk continued from BAF 15/16

the co-ordination of the CCG safeguarding children through commissioning group

6. There is reduced scrutiny over the LAC services provided by Barts health, the CCG are required to authorise out of borough placement medicals and health reviews payments. This is likely to be seriously delayed

Governing Body Lead Maggie Buckell

Management Lead Archna Mathur Lead Committee Safeguarding Committees

Risk Appetite

<8

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) Recruitment to 2 x Joint Adult Safeguarding posts:1 x post Strategic & 1: Operational- November 2016 (added Sept 2016) Appointment of substantive Joint designated Safeguarding Nurse and LAC post- January 2017 (added Sept 2016) COMPLETED

Objective 2: To commission person-centred, integrated health and care service that are sustainable and that equally meet the mental and physical needs of our residents

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Risk 2.1 CHS Re-procurement

Comment: The CHS Procurement is currently in the preferred provider phase. Until the due diligence process has been completed, this risk should remain on this register.

Lead Committee Comment: CHS programme board agreed to take assurance from current risk management approach



Risk Ratings


Failure to appoint a provider of CHS services who is able to adequately deliver all dimensions of the CCG’s procurement requirements will limit the CCG’s ability to deliver the vision for integrated care.

1- CHS Programme governance

arrangements, including: - Programme Board

and supporting groups for: - Patient engagement - Clinical Reference - Specification Development - Finance and payment mechanism - Independent procurement

2- Competitive Dialogue process: to enable development of the specification in conjunction with potential providers

3- Outcome-based contracting approach to enable commissioning alignment of outcomes across providers, contracts and pathways as an overall approach of the CCG going forward.

4- Due Diligence and Mobilisation Programme

5- Due Diligence and Mobilisation Programme

6- Regular GPCG review meetings to review progress and risks.

7- Joint development of outcomes, quality requirements and

1-Bidder PQQ submissions and evaluation methodology 2-Reports of the discussions with potential providers at the recent CHS Dialogue Days 3- Bidder ITPD submissions and evaluation methodology 4- Bidder ITCD and evaluation methodology. 5-Bidders ISFT submissions and evaluation methodology 6-KPMG review of procurement process. 7-Internal audit by RSM. 8-External advice and support from Hempsons re new Alliance model contract documentation. 9-External advice and due diligence assurance from EY.

Completion of Due Diligence

June 2016

4 x 4

Date added

July 2016 4x4 Q1 2016/17– risk continued from BAF 15/16 Governing Body Lead Sept 2016

4x4

Simon Hall, Acting Chief Officer

Dec 2016 / Jan 2017

4 x 4

Management Lead

Josh Potter Lead Committee CHS Programme Board Risk

Appetite <8

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specifications.

Actions

HIGH priority (30 days) CHS Programme Board LOW priority (90 days plus) - Issue of further procurement documentation in

line with programme board Programme plan

- Development of contractual arrangements, subject to contract award.

- Development of mobilisation governance arrangements in preparation for contract award.

Objective 3: To contribute towards a financially sustainable and responsive health and care economy which delivers value for money and innovation and supports the appropriate use of services

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Risk 3.1: Adverse Financial Position of Barts Health NHS Trust Comment: The risk description was updated after a discussion with Jackie Brown (Interim CFO) as the controls and assurances articulated related to the potential impact on the CCG’s financial position rather than directly on the wider health economy. Lead Committee Comment: FPQ agreed to take assurance from current risk management approach September 2016



Risk Ratings


Barts Health may significantly overspend against the CCG set budget for 2016/17 which could negatively impact on the CCG’s financial position.

1- Rigorous process run by the CSU to challenge SLAM data inclusive of penalties and other contractual levers. 2- Finance Performance and Quality Committee review variance analysis against planned contracted activity levels allowing the CCG to address early signs of over performance. 3- Productivity metrics contained within the contract limit the volume of routine activity payable to clinically agreed levels, making better use of Trust capacity and CCG resources 4- POLCV identifies procedures deemed clinically inappropriate which the CCG will not fund, 5- Demand management schemes designed to reduce avoidable admissions or treat lower risk patients in a more appropriate setting 6- Activity management plan within the provider contract requires Barts Health to explain and justify any

1-%age of challenges which are successful 2- TOR, minutes and agendas of the Finance, Performance and Quality Committee 3- Highlight reports from the FPQ to the Governing Body. 4-Monitoring reports demonstrating the effectiveness of demand management schemes. 5-Provider contracts held by the CCG. 6- Approved claims management process 7- Procedures of limited clinical value (POLCV) policy 8- Documented demand management scheme 9- Barts Health Activity management plan 10- Provider performance reports. 11 -Audit report and TOR of scope of Barts Health internal review. (Remedial action reports from

1. Pace of

implementation of TST programmes leading to a delay in system efficiencies

2. STP programme in place

3. Forecasting is based on average prices YTD and may not be accurate

4. Improvements to coding and counting in year may result in additional costs and / or reported activity.

Mar 2016

3 x 4

Date added April 2016

3 x 4

Q1 2016/17 – continued from 2015/16 Q3- Review Governing Body Lead

June 2016

4 x 4

Henry Black, CFO Jackie Brown, Interim CFO

July 2016

4 X 4

Management Lead Sept 2016

4 X 4 Andrea Antoine

Lead Committee Finance, Performance and Quality

Dec 2017 4 X 4

Risk Appetite

<8

77

unplanned increases in activity over agreed tolerance levels. 7- Transforming Services Together (TST) programme – Arrangement between WEL and Barts to bridge financial gap 8 – Some limited reserves available to meet overperformance

the Provider reviewed by the CCG 12- TOR and minutes of Commissioning NIS activity management plan 13- TST long-term financial management group minutes 14- TST - Governing Body Reports

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) - TST work streams – further work to review financial models

for TST work streams to ensure granularity of the scheme impact and delivery implications. - TST schemes require robust implementation plans, project management, delivery outcomes and start dates.

Risk 3.2: Long term adverse Financial Position of Barts Health NHS Trust impacting on the local health economy (added Sept 2016) Comment: Interim Chief Finance Officer has added this new risk onto the BAF based on discussion at the FPQ meeting in September 2016 relating to the deteriorating financial position at Barts Health and the potential impact on the wider health economy.



Risk Ratings


Failure of Barts Health NHS Trust to address its poor financial position could seriously compromise and impact on the stability across the whole local health economy.

1. NEL STP governance has

been put in place. 2. Consultation on NEL STP draft

Financial Strategy has started in September 2016

3. STP submission was

1. THCCG is awaiting Barts

Health confirmation on financial forecast

2. Demand Management Schemes are now in place

3. QIPP schemes are moving demand away from the

1. Approval of STP

Financial Strategy and risk pooling schemes

2. Clarity about the Barts Health role in the ACS /

Sept 2016

4 x 4

Date added September 2016

Dec 2016

4 x 4 Q3- Review 2015/16

Governing Body Lead

78

Henry Black, NEL STP CFO

completed in June 2016 to NHSE & NHS Improvement

4. THCCG has sent Barts Health its financial forecast based on the activity information.

Trust 4. STP reporting into THCCG

FPQ Committee

capitated budget model, given ongoing issues with delivering financial balance.

Management Lead Andrea Antoine Lead Committee Finance, Performance and Quality Risk

Appetite <8

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) Barts Health to agree CCG forecast letter.

NEL STP Financial strategy (added Sept 2016)

Risk 3.3: Barts Health Activity Data Comment: Occurrences of misattributions are still taking place. Work in place with Trust to address issues including on-going challenges by the Acute Contracting Team. NEL CSU are reporting an improvement in the level of uncoded data in 2016 as compared to 2015. Financial forecasting is split into 2 data sets: Flex (uncoded) & Freeze (coded). Flex data is not accurate and therefore, financial forecasting is based on average price. Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – September 28 2016



Risk Ratings


Poor quality Barts Health activity data could result in the CCG being incorrectly invoiced which could impact on the running costs in the longer term.

1-Rigorous process run by the CSU to challenge SLAM data inclusive of penalties and other contractual levers.

2- FPQ Committee monthly monitoring 3- CSU performance and finance team working with providers to

1-%age of challenges which are successful 2- FPQ Committee minutes / reports 3- Contract Review Group minutes / reports 4- Monthly Technical Subgroup

June 2016

3 x 4

Date added

July 2016

3 x 4

Q1 2015/16

Governing Body Lead

Sept 2016

3 x 4

Management Lead Dec 2016

3 x 4 Andrea Antoine

79

Lead Committee address data quality issues relating to flex data in line with contract management regime. 4-NHSE is starting monthly activity review of variances and referral trends 5-Review of GP referral rates- MAR data

6-THCCG reviews the activity reports in CCG Finance & Activity meetings including at the CCC Meetings

meeting with Barts Health with NEL CSU/ THCG and Clinical Commissioning Collaborative (CCC) 5-Monthly meeting of Joint Data Quality Improvement Group with NEL CSU, THCCG & CCC 6.Challenge letters are sent to Barts Health by THCCG via the CSU to interrogate data.

Finance, Performance and Quality

Risk Appetite <8

Actions

HIGH priority (30 days MEDIUM priority (30 – 90 days) LOW priority (90 days plus)

Risk 3.4: Continuing Care Comment: The Local Authority are currently reviewing funding arrangements with health services, therefore there is the potential to increase financial pressure. CSU and CCG leads to be involved in process regarding joint funding re-assessment. - Risk of increased pressure on the Continuing Care budget as demand for complex packages increases. As technology and life expectancy increase, demand for continuing care packages is expected to rise in the coming years. Although the CCG has factored in increases in living wage allowance, the full impact of this increase is currently unknown. Comment: No perceived change in risk position during this period. Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – 30 Sept 28 2016



Risk Ratings


Failure to effectively plan for the potential increase in demand in

1- Robust controls in place to assess eligibility

1- Full documented records for each case, including the

There is no control which can be applied

Mar 2016

3 x 4 Date added

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Q1 2016/17– continued from 2015/16

continuing care could result in a negative impact on the CCG’s running costs.

2- Regular review to ensure all care packages are up to date and appropriate and any change in individuals’ circumstance is appropriately monitored and reflected in the revised package. 3- Development of integrated personal commissioning with Local Authority 4 – CSU carrying out exercise to ascertain 2016/17 increase that could flow from London Living Wage increase.

minutes of assessment panels 2- Process of continual review is recorded, monitored and reported to CCG 3- Broadcare database kept live and updated for all cases

to the CCG’s contribution to the CHC risk pool. This is a national requirement and CCGs are statutorily responsible. Need for ‘who pays’ policies to be updated in respect of joint commissioning.

April 2016

3 x 4

Governing Body Lead

Henry Black July 2016

3 x 4

Management Lead

Sept 2016 3 x 4

Andrea Antoine Lead Committee Finance, Performance and Quality Dec 2016 3 x 4

Risk Appetite <8

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus)

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Risk 3.5: Financial Challenges of Primary Care Commissioning Comment: Risk has been removed from the risk register and added to the issue log (see end page of BAF) as it is now a certainty that there will be a funding gap for the CCG of approximately £0.5million Risk 3.6: Outsourcing of services to NHS SBS and other service organisations for Primary Care Commissioning

Comment: In their external audit findings report 2015/16, KMPG has advised the CCG to ensure that it has robust understanding of the processes and controls in managing Primary Care Commissioning. Balances relating to primary care commissioning are inherently complex. It is, therefore, advised that the CCG should seek the correct level of assurances over these processes and controls in relation to complexes balances in its accounts and seek the right level of assurances from external outsourcing organisations. September review by Acting Chief Officer: SH has asked the Committee to consider removing this risk from the BAF to the Risk Register as he believes there are improved controls in place within the CCG to manage this risk. Lead Committee Comment: The November Committee reviewed the risk and noted the performance management arranges in place between NHS England and Capita. The September Primary Care Committee requested that the risk remains on the BAF despite a reduction in the likelihood of the risk occurring, as the potential outcome of the risk realising remains significant. For example, there was delay in the approval of the CCG’s 2015-16 accounts due to the financial complexities of co-commissioning arrangements, and whilst this was resolved for 2015-16, the committee wish to continue to monitor this risk for the remainder of the financial year.



Risk Ratings


As contractual payments for Primary Care co-commissioning activities involve two external organisations – NHS England Capita - there is a risk to both the accuracy and timeliness of payments made, and the ability of the CCG to control or influence this process.

1. Monthly monitoring and scrutiny at the Primary Care Commissioning Committee and FPQ.

2. External audit review into co-commissioning

3. Dedicated resource within the

Primary Care and Finance team to ensure monthly payments are appropriately checked, review and recorded.

4. Regular meetings between

NHS England and CCG

1. Monthly Primary Care finance report

2. Minutes of FPQ and Primary Care Committee

3. Action plan from external

audit review

4. Tower Hamlets CCG organisational chart.

5. Agenda and actions from

Tower Hamlets CCG and NHS England meetings

As NHS England hold the contract with Capita it is not possible for the CCG to formally manage their performance. Whilst any issues are managed informally between the CCG and NHS England, this is dependent on working relationships rather than contractual obligation.

June 2016

3 x 3 Date added

July 2016 3 x 3 Q1 2015/16– New risk

Governing Body Lead

Sept 2016

2 x 3

Management Lead

Dec 2016

2 x 3 Jackie Brown Lead Committee Finance, Performance and Quality

82

Primary Care Commissioning Committee

colleagues to ensure any concerns and logged and escalated.

5. Regular meetings between

NHS England and Capita to ensure action is taken to resolve any issues.

6. Review of non- recurrent options to deliver financial balance.

Risk Appetite

<8

Actions HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus)

- Establish relationship with Capita so that any issues can be quickly escalated and resolved.

Risk 3.7: Running Costs Allocation

Comment: No perceived change in risk position during this period. For 2016/17 the CCG has established a new Corporate structure which is within the Running Costs Allowance Lead Committee Comment: FPQ agreed to take assurance from current risk management approach –September 2016



Risk Ratings


The CCG has introduced a new structure in 2016/17, without any additional Running Costs Allocation. The expanding workforce of the CCG & failure to develop workforce and programme financial plans could result in a negative impact on the CCG’s running costs.

1- Recruitment of permanent staff 2- Monthly monitoring by FPQ 3- SMT management of resources

4-Efficiencies within each of the management budgets. 5- New CCG structure adopted

1- FPQ reports and minutes. 2 Carnall Farrar working with SMT to implement new structure. 3.Corporate Budgets have been set for 2016/17 Monthly budget holder meetings are now in place to address any slippage or cost pressures in each of the service or directorates.

Mar 2016

3 x 4 Date added

April 2016

3 x 4

Q1 2016/17– continued from 2015/16 Governing Body Lead

June 2016

3 x 4

Henry Black

Sept 2016

3 x 4

Management Lead

Dec 2016

3 x 4

Andrea Antoine Lead Committee

83

Finance, Performance and Quality Risk

Appetite <8

Actions HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus)

Risk 3.8: Delivery of the Operating Plan, including QIPP Comment: The Tower Hamlets 2015/16 QIPP achieved its goal and accordingly achieved a green risk rating in March 2016. However, the 2016/17 QIPP cycle began in April with a new challenge and so the risk rating has been reset to 3 x 4 though with the application of proven control mechanisms this is expected to reduce as the year progresses. Lead Committee Comment: The Transformation Board agreed to take assurance from current risk management approach –September 2016 Month 5 QIPP reporting to FPQC is based on Month 4 data. Current forecast is for breakeven on overall QIPP programmes for 2016/17. Overachievement in Integrated Care is counteracting underachievement in Planned Care and delay in the go-live for CHS contract.



Risk Ratings


Failure to deliver on the Operating Plan, including QIPP would result in: • a negative financial impact on the CCG. • Lost opportunity to produce and deliver increased improved outcomes for the people of Tower Hamlets. • A negative impact on the reputation of the CCG.

1-Provider Productivity Programme is co-ordinated across WELC to ensure delivery at scale. 2-Plans are scrutinised and approved the TIC and Governing Body through a methodical process. 3-Very detailed HRGs exist for where the savings will be made. 4-Re-investment into services is determined by the return of savings e.g. Barts Health NHS Trust recruitment is based on savings.

1- TOR, minutes and

agendas of the Programme Boards, TIC Transformation Board, FPQ and Governing Body

2- QIPP Reporting is based on HRGs analysis which is carried out by NEL CSU.

3- Monthly QIPP report to the FPQ Committee

QIPP programmes under-performing.

Mar 2016

1 x 4 Date added

June 2016

3 x 4 Q1 2016/17 –

continued from 2015/16 Governing Body Lead

July 2016

3 x 4

Management Lead Sept 2016

3 x 4 Josh Potter

Lead Committee Transformation

84

Board

5-QIPP programme management process 6-Monthly monitoring meetings to ensure programme boards are on track; off track programmes are discussed at the TIC. 7-All Programme Boards have a management and Governing Body lead with additional subject matter experts brought in as and when required. 8-Continuous review of overall financial performance and options to mitigate any shortfalls in the QIPP programme and / or overspends.

Dec 2016

2 x 3

Risk Appetite

<8

Actions


Risk 3.9: Programme Management Function on the Delivery of Operating Plan including QIPP Comment: In order to receive the right level of assurances on the progress and achievement of QIPP targets and the CCG delivering on the Operating Plan, the Director of Commissioning proposed the implementation of robust Programme Management function Lead Committee Comment: The Transformation Board agreed to take assurance from current PMO governance process - September 2016



Risk Ratings


Failure to implement a robust Programme Management function and a clear Business Planning and Commissioning Cycle may result in the CCG not complying with NHSE’s assurance framework for planning based on the Operating Plan.

1. The CCG Executive Team has

approved budget for the recruitment of two posts within the PMO

2. Interview for the Band 7 PMO Manager has been scheduled towards the end of October.

1. Substantive post holder,

Head of PMO has started in September 2016

2. Transformation Leads report into their respective programme boards.

June 2016

3 x 3

Date added 16/06/2016

July 2016

3 x 3

Q1 2016/17- New Risk

Governing Body Lead

Sept 2016

3 x 3

85

3. The PMO has introduced

robust process to develop and implement commissioning intentions in alignment with external programmes.

3. Monthly reporting to

Transformation Board by Head of PMO

Archna Mathur

Dec 2016

3 x 3

Management Lead

Josh Potter

Lead Committee Transformation Board

Risk Appetite

<8

Actions


Objective 4: To support local people and stakeholders to have a greater influence on services we commission

86

Risk 4.1: Inadequate engagement with lcoal stakeholders may result into the CCG not meeting its statutory requirements Comment: Insufficient engagement with local stakeholders and in particular, local people may result in the CCG’s commissioning strategies not reflecting local needs. In addition, this may lead to reputational damage to the CCG and potential legal challenges for failing to adequately engage and consult with relevant stakeholders. Lead Committee Comment: The Executive Committee agreed to take assurance from current risk management approach. September 2016 review



Risk Ratings


Failure to adequately engage local people and key stakeholders such as local providers, clinicians and local authority in the CCG’s commissioning plans may impact negatively on the direction of travel, the CCG’s reputation and may also, lead to potential legal challenges.

1- Forums for commissioning conversations with members that are not directly involved in provider group. 2-Clear communication and PPI strategies re: commissioner vs. provider roles 3-Organisational split: primary care team will provide primary care engagement and communication ensuring appropriate consideration is given to local people’s views. 4-The CCG has an Engagement Strategy

1- Conversation Forum Reports 2- CCG receives professional Communications support from NEL CSU 3- Engagement Manager post holder in place

Mori 360 Degree Survey has identified areas of improvement for the CCG in relation to engagement with key partners.

April 2016

3 x 4

Date added

June 2016 2 x 4 Q1 2016/17 –

continued from 2015/16 Governing Body Lead

Sept 2016

3 x 4

Jane Milligan

Dec 2016

3 x 4

Management Lead

Ellie Hobart

Lead Committee

Transformation Board

Risk Appetite

<8

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) Review of Mori 360 degree survey with action plan to address

areas of improvement. (ongoing relationship management with key stakeholders as identified through survey).

87

Risk 4.2: Managing Conflicts of Interest in Clinical Commissioning Comment: Inability to manage conflicts of interest in a robust manner may result into the CCG not meeting NHS England’s regulatory compliance. The CCG has put in place governance arrangements to manage primary care commissioning since taking over full delegated authority. No perceived change in risk position during this period. Lead Committee Comment: The Executive Committee agreed to take assurance from current risk management approach – Sept 2016



Risk Ratings


Inability to manage conflicts of interest in a proactive and robust manner may result into the CCG not meeting NHS England regulatory compliance, reputational damages and may result in potential sanctions.

1-The CCG has a Standards of Business Conduct and Managing Conflicts of Interest Policy 2-Clear communication strategy re: commissioner vs. provider roles 3-Organisational split: primary care team will provide primary care engagement and communication ensuring appropriate consideration of potential conflicts. 4-A comprehensive system for Conflicts of Interest management is in place.

1- Conversation Forum Report 2- Conflicts of Interest policies

3- Register of Interests 4- Primary Care Engagement Plan

5- Conflicts of Interest training for Governing Body has taken place.

April 2016

3 x 4

Date added

June 2016 2 x 4 Q1 2016/17 – cont.

from 2015/16

Governing Body Lead

Sept 2016

3 x 4

Jane Milligan

Dec 2016

3 x 4

Management Lead

Ellie Hobart

Lead Committee

Executive Committee

Risk Appetite <8

Actions


Objective 5: To promote equality both as an employer and a commissioner of health care services

88

Risk 5.1: Failure to actively promote equality across all the groups with protected characteristics could mean that the CCG finds itself in breach of the Equality Act 2010.

Comment: This could lead to a loss of both public and staff confidence. Specific risks include gaps in equality impact assessments, failure to provide accessible information, contracts do not adequately protect groups of people or staff with protected characteristics. The principles of the NHS constitution promote equality duties for staff and service users.

Lead Committee Comment: The Executive Committee agreed to take assurance from current risk management approach. September 2016 Review



Risk Ratings


Failure to actively promote equality across all the groups with protected characteristics could mean that the CCG finds itself in breach of the Equality Act 2010.

1. The CCG has an approved

Equality & Diversity Strategy 2016/19 in place

2. Commissioning decisions on services are equality impact assessed.

3. The CCG adheres to employment law principles in relation to recruitment and retention of its workforce

4. Equality and diversity committee and governing body lead provides strategic oversight and steer

1. The CCG produces and

publishes equality information which provides evidence of how the CCG is delivering against the NHS Equality and Diversity System

1. Current contract

with CSU has come to an end for the EDS service

June 2016

3x3

Date added

July 2016

3x3 Q1 2016/17- New risk

Governing Body Lead

Sept 2016

3x3

Jane Milligan Management Lead

Dec 2016

3x3 Ellie Hobart Lead Committee Executive Committee

Actions

HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) Review of current CCG E&D arrangements by Corporate Governance Manager and Officer. E&D strategy discussion at January Executive Committee.

Issue Log

The below risk has been removed from the risk register and added to the issue log as there is certain to be a funding gap of approximately £0.5million.

Issue Management: Adequate CCG reserves have been identified to meet the existing funding gap.

89

Comment: The CCG has agreed on full delegation of Primary Care Services from NHSE which is to be funded by allocation cost. Several concerns have been identified:

- Financial reports from NHS England are high level with insufficient detail - Adjustments to allocations; not sure what they are and uncertain if allocations factored in growth

The CCG has formulated its own QIPP plans; where there was a gap the CCG has tried to quantify savings within primary care. The 16/17 Primary Care allocation is deemed to be insufficient to meet the existing gap in funding of £ 0.5m and in addition, a gap in funding ‘Save our Surgeries’ has also been identified.



Risk Ratings


Insufficient information from NHSE which makes it difficult for the CCG to comprehensively understand primary care cost pressures could reduce the CCG’s ability to put in place a robust financial strategy.

1- Monthly monitoring at Primary Care Committee

2- Monthly monitoring at FPQ 3 – Local financial reporting and forecasting based on NHS England information 4 - Pan London technical group established to support primary care finance planning, including QIPP

5 – The Primary Care Team have modelled before and after delegation scenarios of full delegation but await NHSE guidance regarding process

1- Primary Care Committee minutes and reports 2- FPQ minutes and reports. 3 – Primary Care Programme Board review and minutes.

Mar 2016

3 x 4 Date added

April 2016

3 x 4

Q1 2016/17– continued from 2015/16 Governing Body Lead

June 2016

4 x 4

Henry Black

Sept 2016

5 x 2

Management Lead Andrea Antoine Lead Committee Finance, Performance and Quality Primary Care Commissioning Committee

Actions


90


Date of meeting 24th January 2017 E

Agenda item 3.2.1

Title of report: Month 9 Finance report – 2016/17

Author(s): Henry Black – Chief Finance Officer Andrea Antoine – Deputy Chief Finance Officer

Presented by:



Henry Black – Chief Finance Officer – NHS Tower Hamlets CCG

Andrea Antoine – Deputy Chief Finance Officer [email protected] - 020 3688 2510

Executive summary

The Month 9 report provides the Governing Body with the financial position of the CCG as at 31st December 2016 and consists of the following:

- Executive Summary,

- Key risks and issues,

- Revenue Financial Position,

- Statement of Financial Position,

- Cash Position and forecast and

- Payment Performance Measures position.

Recommendation


To note the content of the report, and discuss any actions required

Key issues Acute provider position – Specifically Barts Health and LAS Inability of the CCG to draw down any of its Surplus Inability of the CCG to utilise 1% Non recurrent budget Primary Care Co-Commissioning shortfall in allocation Financial implication of the delay in start date of the CHS

Contract Application of reserves and non-recurrent in year measures.

Conflicts of Interest There are no identified conflicts of interests.

Report history Finance, Quality & Performance (FPQ) meetings (CCG)- Information obtained at this meeting helps inform this Board report

91


N/A


Addresses several corporate objectives, those around finance, ensures the governance body is sighted on key finance and performance targets:

Strategic Objective 3: Creating a thriving and stable health and social care economy

Strategic objective 4: Delivering against our statutory duties.


N/A

Resource requirements None

Next steps Action and next steps for each area identified is covered in the report.

92

Enc. E

Month 9 Finance Report – 2016/17

Executive Summary

This report provides an update on the financial position for the CCG at Month 9 (December 2016) and a forecast for the year. At month 9 the CCG is reporting a year to date surplus of £8.958m and forecasting a full year surplus of £11.943m, in line with the CCG’s Financial Plan. However, commissioning reserves and Non-recurrent in year measures are required to offset pressures on contract activity, particularly in the acute sector and co-commissioning areas, in order to achieve the targeted position.

Key Risks and Issues The main financial risks and issues in regards to the CCG’s Month 9 Financial Position can be summarised as follows:

1. Surplus Requirement. The inability of the CCG to draw down on the previous year’s surplus as well as deliver a surplus of £11.9m in 2016/17, limits the CCG’s non-recurrent resource in year. This has meant that we have had to use all our existing reserves as well as a range of non-recurrent in-year measures to achieve our targeted position.

2. Non-Recurrent Investment Reserve. Each year the CCG has to hold a

1% non-recurrent reserve, which in previous years had been used for non-recurrent investments such as TST, CHS procurements etc. However, this year we have been advised by NHSE that this figure is to be held in reserve as it may be needed to help the local economy; we are therefore not permitted to use these funds. This has put additional pressure on the CCG to fund previously non recurrent items from the CCG’s reserves and non-recurrent in-year measures.

3. Acute M9 Position. The acute position at Month 9 is reporting a year to

date over performance position of £6.109m with a forecast over performance position of £8.148m by Year End. This is mainly attributable to the over performance at Barts Health, reporting a year to date over

93

performance of £4.025m and forecast of £5.366m. Other areas of overspend relate to BMI, Guy’s, Overseas Visitors, LAS and Homerton.

Please note however, that the month 7 finance report is subject to a number of caveats regarding availability and accuracy of data especially as these reports are using only 6 months of SUS freeze data. More work is to be completed in the following months to validate and have more assurances over the data supplied by the trusts.

4. LAS – At Month 9 the CCG is reporting a year to date over performance of £345k and a projected full year over performance of £460k. The reported over performance on the LAS block contract is based on; (a) As part of the 2016/17 LAS contract agreement, CCG’s in London were asked to support to LAS’s £10m Quality Improvement Plan – Tower Hamlets share of this amounts to £300k and (b) In year additional activity on the LAS contract for Quarters 2 and 3, as advised by NHSE – Tower Hamlets share amounts to £160k. To date we have not included in the forecast any over performance for quarter 4, as NHSE advise that they have put in place a number of demand management schemes that should start to work in quarter 4, however, if it does not work, to expect even higher additional activity in quarter 4.

5. Primary Care Co-Commissioning – Please see below Primary Care Co-Commissioning table for 2016/17.

The table above outlines a potential shortfall in funding of £521k which relates in the main to the following:

Primary Care Co‐commissioning ‐

Month 9 Financial Position ‐ 2016/17

Annual

Budget

YTD

Budget

YTD

Actual

YTD

Variance

Forecast

Outturn

Full Year

Variance

General Practice ‐ APMS 10,155 7,643 7,927 283 10,569 414

General Practice ‐ GMS 14,574 10,930 11,065 135 14,753 180

General Practice ‐ PMS 5,477 4,107 4,109 2 5,479 3

QOF 2,462 1,846 1,876 30 2,502 40

Premises Cost Reimbursement 7,324 5,492 5,605 113 7,473 150

Other Premises costs 81 61 61 0 81 (0)

Direct Enhanced Services 1,495 1,121 1,121 0 1,495 (1)

Dispensing/Prescribing Drs 143 107 107 0 143 (0)

Other GP Services 454 313 407 93 542 88

GMS Other Delivery (Year end accruals) 0 (300) (300) (300) (300)

QIPP (52) (52)

Totals 42,164 31,622 31,977 356 42,685 521

94

(a) The initial allocation received for the Co-Commissioning budget was lower than the funds needed for 2016/17. This represented a shortfall in funds of £570k

(b) As noted above the CCG is not permitted to use the 1% Non-Recurrent investment Reserve. The investment reserve is calculated using the total CCG Allocation which includes the CCG’s Co-Commissioning Allocation. Therefore the Primary Care’s Co-Commissioning contribution to those funds are £426k.

(c) In previous month’s the CCG had been reporting a Primary Care Co-Commissioning QIPP of £217k – This QIPP relates to NHS England’s business rates review, which they estimated will result in savings for Tower Hamlets. At month 9 following assessment of the QIPP by NHSE, the savings have now reduced from £217k down to £52k.

(d) The budget does not include the non-recurrent funding required for Year 2 of the Locally Commissioned Services programme, which is now being funded by other non-recurrent funds.

(e) The Co-Commissioning position includes the release of £300k of unused accruals carried forward from 2015/16. Further work is in progress with the CCG’s Primary Care Team and NHSE to establish any further commitments against the remaining 2015/16 accruals carried forward.

(f) At month 9, the APMS contracts forecast is a full year overspend position of £414k and GMS contracts forecast is a full year overspend position of £180k, both of these relate to continued growth in the list sizes. The APMS contract value is calculated using the raw list sizes and changes to the funding distribution formula for 2016/17 has added a further £3.65 to the cost of each APMS registered patient.

6. Community Health Services – The delay to the start of the CHS contract

has resulted in a projected full year overspend in this budget of £1.464k.

95

Revenue Resource Allocation The table below shows the CCG’s Revenue Resource Allocation as at Month 9. This shows the opening revenue budgets as at Month 8 and any in month changes in the CCG’s allocation up to Month 9.

In Month 9 the CCG received the following allocations;

- Tower Hamlets share of the Primary Care Access Funds £1,531k - GP Resilience funding - £136k - Quality Premium Awards for 2015/16 - £280k

The CCG is still awaiting confirmation from NHSE in regards to allocations received of £15k for communications to promote the use of Primary Care and £25k in regards to re-directing ambulatory A&E Attendances.

It is worth noting at this point that in Month 8 NHSE made a deduction in error to the CCG’s allocation of £3,545k. This relates to the pass through costs for the Charge for Overseas Visitors payable to ELFT. This deduction should have been made to City & Hackney CCG as they were the lead for the ELFT contract in 2015/16. City and Hackney CCG have noted the error and will be transferring the sums owed via an IAT to THCCG in Month 10.

Tower Hamlets CCG ‐ 2016/2017 Revenue Resource Limit at Month 9M8 Opening

RRL

In Month

movements

Closing M9

RRL

2016/17 Revenue Resource Limit £000's £000's £000's

Return of Surplus/(Deficit) (11,943) (11,943)Initial CCG Programme Allocation (353,213) (353,213)Initial CCG Running Cost Allocation (6,299) (6,299)Transfer to Co‐Commissioning Funds to CCGs (42,590) (42,590)Vanguard Q1 MCP Tower Hamlets (652) (652)Q1 Eating Disorder Service Correction (155) (155)Q1 TB Corrections (25) (25)IR RULES TRANSFER 325 325UCLH Transition Funding for Transfer of Heart Hospital to Barts 500 500HLP & Levis 720 720Quarter 2 Allocation ‐ Tower Hamlets vanguard (1,236) (1,236)Local Evaluation Funding (50) (50)Safeguarding children named GPs (26) (26)08V ‐ GP Development Programme ‐ reception and clerical training (26) (26)Latent TB Q2 ‐ NHS Tower Hamlets CCG (25) (25)CYP Local Transformation Mental Health M7 ‐ NHS Tower Hamlets CCG (65) (65)Q3 Vanguard Funding ‐ THIPP MCP (734) (734)Q2 Local Evaluation Funding ‐ Tower Hamlets MCP (50) (50)Children and Young transformation (24) (24)Mth08 CEOV adjustment 3,545 3,545Primary Care access (GPFV £30M) (1,531) (1,531)GP Resil l iance (136) (136)Waltham forest ‐ comms to promote use of primary care (15) (15)Waltham forest ‐ Re ‐ directing ambulatory A&E Attendances (25) (25)QUALITY PREMIUM AWARDS 2015/16 (280) (280)Total Resource Limit (412,023) (1,987) (414,010)

96

Revenue Financial Position The CCG’s revenue financial position is summarised below.

Tower Hamlets CCG ‐ Financial

Position as at Month 9 ‐ 2016/17

Annual

Budget

£’000

YTD

Budget

£’000

YTD Actual

£’000

YTD

(Under)/O

verspend

£’000

Forecast

Actual

£’000

Forecast

(Under)/O

verspend

£’000

YTD

In‐Month

Movement

£’000

Forecast

In‐Month

Movement

£’000

Delegated

In Sector Acute Trusts 145,654 109,240 113,492 4,252 151,323 5,670 306 (250)Out of Sector Acute Trusts 20,716 15,537 16,711 1,174 22,282 1,566 309 267Other Acute 12,910 9,682 10,365 683 13,822 912 105 44Subtotal Acute 179,279 134,459 140,569 6,109 187,427 8,148 719 61

Mental Health 47,304 35,478 34,696 (781) 46,261 (1,042) (87) (0)Community Health 49,578 37,183 38,369 1,186 51,160 1,582 129 (4)Other Non Acute 20,085 15,064 13,180 (1,884) 13,416 (6,670) 921 1,613Subtotal Non Acute 116,967 87,725 86,246 (1,479) 110,837 (6,130) 963 1,609

Prescribing 31,557 23,668 23,441 (227) 31,255 (302) (77) (78)Primary Care Co‐Commissioning 42,164 31,622 31,977 356 42,685 521 122 74Prime Ministers Challenge Fund 2,761 2,071 2,070 (0) 2,761 0 22 34Other Primary Care Services 10,425 7,818 7,915 97 10,553 128 11 (0)Subtotal Primary Care 86,906 65,178 65,404 226 87,253 347 78 31

Reserves 8,265 6,200 1,344 (4,856) 5,750 (2,515) (1,774) (1,851)

TOTAL CCG 391,417 293,563 293,562 (0) 391,267 (150) (12) (150)

Corporate 10,650 7,987 7,987 0 10,801 151 1 151TOTAL CORPORATE 10,650 7,987 7,987 0 10,801 151 1 151

GRAND TOTAL 402,067 301,550 301,549 (0) 402,068 1 (11) 1

IN YEAR RESOURCE LIMIT (402,067) (301,550) (301,550) 0 (402,067) 0 0 0

IN YEAR (SURPLUS)/DEFECIT 0 (0) (0) (0) 1 1 (11) 1

PRIOR YEAR SURPLUS (11,943) (8,957) (8,957) 0 (11,943) 0 0 0

TOTAL (SURPLUS)/DEFICIT (11,943) (8,957) (8,958) (0) (11,942) 1 (11) 1

97

Acute Contracts The total acute budget is £179.3m. At month 9 the acute position is showing a year to date over performance variance of £6.108m with a full year projected over performance of £8.148m.

The projected over spend position relates mainly to the over performance of Barts Health, BMI, Guy’s, Overseas Visitors Accrual, LAS and Homerton. Barts Health – The table below shows the main areas of over performance are in drugs and devices, Elective, Non elective and outpatients.

Full Year YTD YTD YTD YE Forecast

Budget Budget Actual Variance Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000

Barking, Havering and Redbridge Hospital NFT 544 408 497 89 662 119Barts and The London NHS Trust 141,058 105,793 109,818 4,025 146,424 5,366BMI Healthcare Ltd 2,781 2,086 2,402 316 3,203 422Chelsea and Westminster Hospital NHS Foundation T 501 376 367 (9) 489 (12)Great Ormond Street Hospital for Children NHS Foun 335 251 393 142 523 188Guy's and StThomas's NHS Foundation Trust 4,092 3,069 3,420 351 4,560 468Homerton Foundation Trust 4,596 3,447 3,674 227 4,899 303Imperial College Healthcare NFT 675 506 485 (21) 646 (28)King's College Hospital NHS Foundation Trust 578 433 409 (24) 546 (32)Lewisham & Greenwich NHS Trust 431 324 346 23 462 31London Ambulance Service 9,383 7,037 7,382 345 9,843 460Mid Essex Hospital Services NFT 91 68 49 (19) 65 (26)Moorfields Eye Hospital NHS Foundation Trust 4,623 3,467 3,467 (0) 4,623 (0)NCAS/OATS 2,643 1,982 2,132 150 2,846 203North Middlesex University Hospital NFT 154 116 112 (4) 150 (4)North West London Hospitals NFT 176 132 103 (29) 138 (38)Other Acute 884 663 624 (39) 833 (51)Overseas Visitors Barts Health NHS Trust 0 (0) 225 225 300 300Royal Brompton and Harefield NHS Foundation Trust 61 46 49 4 66 5Royal Free Hampstead NFT 466 349 514 164 685 219Royal National Orthopaedic Hospital NFT 430 322 322 (0) 430 (0)St George's Healthcare NFT 137 103 127 24 169 32The Royal Marsden NHS Foundation Trust 81 61 62 1 82 1University College London Hospitals NHS Foundation 4,329 3,247 3,407 160 4,543 214Whittington Hospital NFT 232 174 180 6 240 8Totals 179,279 134,459 140,567 6,108 187,427 8,148

Tower Hamlets CCG 2016/17 Acute Financial Position at Month 9

Provider

Barts Health ‐ Financial Position

@ Month 9 (£000's)

Month 9 YTD

Plan

Month 9 YTD

Actual

Month 9 YTD

Variance

Full Year

Plan

Full Year

Actual

Forecast

Variance

Accident and Emergency 9,025 9,559 534 12,033 12,745 712Community 9 2 (7) 11 2 (9)Critical Care 4,458 5,015 557 5,944 6,686 742Diagnostic Imaging 10,844 10,605 (238) 14,458 14,140 (318)Drugs and Devices 3,897 5,196 1,299 5,196 6,928 1,731Elective 13,089 13,930 840 17,452 18,573 1,121Maternity 14,891 14,625 (267) 19,855 19,500 (355)Non-Elective 29,184 30,782 1,598 38,912 41,042 2,131Outpatients 15,960 19,470 3,510 21,280 25,960 4,680PTS 2,228 1,721 (506) 2,970 2,295 (675)Regular Attenders 1,421 1,562 141 1,895 2,082 187Other 788 (2,648) (3,436) 1,051 (3,530) (4,581)Totals 105,793 109,818 4,025 141,058 146,424 5,366

98

Drugs and Devices – This area is projecting a year to date over performance of £1.299m, with a projected full year over performance of £1.731m against the plan at Month 9. Key drivers of this over performance relates to cytokine modulators, subfoveal choroidal neovascularisation and drugs effecting the immune system. Electives – This area is projecting a year to date over performance of £840k, with a projected full year over performance of £1.121m against the plan at Month 9. Key drivers of this over performance relate to Digestive System Procedures and Disorders and Respiratory System Procedures and Disorders Non electives – This area is projecting a year to date over performance of £1.598m, with a projected full year over performance of £2.131m against the plan at Month 9. The key driver of this over performance is related to Respiratory System Procedures and Disorders. Outpatients - This area is projecting a year to date over performance of £3.510m, with a projected full year over performance of £4.680m against the plan at Month 9. Key speciality drivers for this over performance in the outpatient’s area are within Gastroenterology, Dermatology, Hepatology and General Medicine. Key speciality drivers in outpatient’s procedures are within Female Reproductive System Procedures, Cardiac Procedures, Orthopaedic Non-Trauma Procedures and Breast Procedures and Disorders. Other – This line includes known adjustments which are expected to the Barts Health position. This includes adjustments for Readmissions, productivity metrics, penalties and Qtr. 1 Claims as well as risk adjusted projected claims following the Qtr. 1 claim agreements. BMI – The year to date over performance reported is £316k with the forecast over performance of £422k. The main area of over performance are in Day Case, elective and outpatients relate in the main to Trauma & Orthopaedics. Homerton - The year to date over performance reported is £227k, with the forecast over performance of £303k related mainly to maternity pathways and deliveries. Guy’s - The year to date over performance reported is £351k, with the forecast over performance of £468k related mainly to maternity pathways and deliveries as well as over performances in day cases mainly related to Dermatology. LAS – included in the forecast is a Tower Hamlets provision in relation to the LAS request for an additional £10m funding requirement as well as provisions as advised by NHSE for LAS’s over performances for Qtrs 2 and 3. Overseas visitors - The CCG has included a provision of £300k for the CCG’s share of the costs of any overseas visitor’s charges which are unrecoverable by Barts Health.

99

Healthcare Provision A summary analysis of the year to date and the forecast for healthcare provision budgets are shown below.

Mental Health – The reported underspend is as a result of excess budget incorrectly allocated to Mental Health related to the CCG’s obligation to meet the Parity of Esteem, this will be transferred to the CCG reserves in Month 10. Continuing Health Care – at month 9 the CCG is reporting an over spend of £697k. This is mainly due to a provision included in the projection for the estimated costs of Tower Hamlets share of the joint care packages. Primary Care Co-Commissioning – As stated in the key issues, the CCG is reporting a forecast overspend of £521k – this relates in the main to the shortfall in allocation received for 2016/17. Other – the underspend in this area of £7.367m relates to the use of non-recurrent in year measures, which have been released into the current year forecast position to achieve the CCG’s control total. This includes an adjustment made for the deduction in our resources as mentioned earlier, which relates to the charge in error for overseas visitors, this will be amended by £3.107m in month 10 following the transfer from City & Hackney CCG.

Service Function

Annual

Budget

£’000

YTD Budget

£’000

YTD Actual

£’000

YTD (Under)/

Overspend

£’000

Forecast

Actual

£’000

Forecast

(Under)/

Overspend

£’000

Mental Health 47,304 35,478 34,696 (781) 46,261 (1,042)Community Health 49,578 37,183 38,369 1,186 51,160 1,582Continuing Care 14,130 10,598 11,076 478 14,827 697Other 5,955 4,466 2,003 (2,464) (1,411) (7,367)Primary Care ‐ Prescribing 31,557 23,668 23,441 (227) 31,255 (302)Primary Care Co‐Commissioning 42,164 31,622 31,977 356 42,685 521Other Primary Care 13,186 9,889 9,986 96 13,314 128Total Non‐Acute 203,873 152,903 151,548 (1,355) 198,090 (5,783)

Tower Hamlets CCG 2016/17 ‐ Healthcare Provision Financial Position at Month 9

100

Corporate Costs For this financial year the CCG’s running costs allowance is £6.299m.

As at month 9 the CCG is on target to spend within its running cost allowance of £6.299m. However, the CCG is reporting a projected overspend of £150k against its programme costs, this relates to additional CSU costs received in month 9 for surge management and medicines management, these are still to be confirmed. This will continue to be monitored on a monthly basis, together with ongoing budget holder meetings, with all movements (increases and/or decreases) to the corporate budgets as a whole, being approved by the CCG’s SMT.

Service Function

Annual

Budget

£’000

YTD Budget

£’000

YTD Actual

£’000

YTD

(Under)/

Overspend

£’000

Forecast

Actual

£’000

Forecast

(Under)/

Overspend

£’000

ADMINISTRATION & BUSINESS SUPPORT 56 42 51 9 62 6CEO/ BOARD OFFICE 331 248 299 50 382 51CHAIR AND NON EXECS 529 397 396 (1) 520 (9)COMMISSIONING 321 241 192 (49) 272 (49)COMMUNICATIONS & PR 616 462 450 (12) 595 (21)CORPORATE COSTS & SERVICES 2,221 1,666 1,523 (143) 2,045 (176)FINANCE 1,277 958 1,241 283 1,574 297PRIMARY CARE SUPPORT 595 446 345 (102) 524 (71)QUALITY ASSURANCE 352 264 247 (17) 325 (27)Sub‐total Running Costs Allowance 6,299 4,724 4,742 19 6,299 (0)

PROGRAMME PROJECTS 4,351 3,263 3,245 (19) 4,501 150Sub‐total Running Costs Allowance 4,351 3,263 3,245 (19) 4,501 150

Total Corporate Financial Position 10,650 7,987 7,987 (0) 10,800 150

Tower Hamlets CCG ‐2016/2017 Corporate Financial Position at Month 9

101

QIPP

At Month 9, the QIPP report shows a year to date under-achievement of £93k, with a projected under-achievement of £639k.

The year to date short fall in achievement within the areas of Planned Care and CHS are due to revised profiling and delayed commencement of schemes which has affected the Musculoskeletal CAS, Pain CAS, Dermatology CAS, New streamlined Gastro STT, Ambulatory Unit pilot as well as the late commencement of the new CHS Contract.

However, the unexpected savings expected in the following areas have helped reduce the overall under-achievement position;

- Helicopter Emergency Services, - Primary Care QIPP – relating to NHSE business rates review - Prescribing savings – based on the Community Pharmacy funding review to

which the DOH have cut the generic medicine reimbursement prices from June 2016.

- TST Diagnostic QIPP schemes not included in the 2016/17 QIPP plan - CHP savings on voids and subsidy charges

Tower Hamlets CCG - QIPP Tracker 2016-17

Reporting

Period:

YTD

Plan

YTD

Actual

YTD

Variance

Full Year

Plan

Full Year

FOT

Variance

to

Plan

£'000 £'000 £'000 £'000 £'000 £'000

Planned Care 2,412 1,488 (924) 3,595 2,102 (1,493) Amber

T&O, Pain & Dermatology are not del ivering to plan as the service was not due to be mobi l i sed unti l 1st July 16. QIPP fi gures quoted are FYE.Next s teps:* Action being taken to address low referra l rates into the Integrated MSK & Pa in service* Work being taken forward to to address accurate performance data i ssue for MSK & Pain* Communications sent to practi ces regarding CAS closure and the CCG's preference for T‐OATS to be used (Dermatology) * For Renal , CSU i s reviewing data to unders tand performance discrepancies and to identi fy i f there i s a coding i ssue* Development of a ba lance score card for Gastro to review activi ty and impact of service* Monthly service review meetings scheduled for Gastro

Integrated Care

1,768 3,527 1,759 2,464 4,729 2,265 Green Continued impact on IC investment i s on track

Urgent Care 589 359 (230) 856 588 (268) AmberDes ignated CCG lead to agree and formal i se the contract for 2017/18

Chi ldren 28 0 (28) 39 0 (39) Red

* CCG Project Manager ass igned to support del ivery of the projects* Paediatri c referra l audi t requested to unders tand reasons for referra l at a practice/patient level (pl s see comments in deta i l summary)

CHS 2,352 (0) (2,352) 3,349 0 (3,349) Red

This scheme wi l l not release savings for 2016/17 due to the decis ion to extend the CHS procurement (QIPP should be balanced out with shortfa l l in NR i nvestment)

Menta l Heal th 901 1,070 169 1,201 1,427 226 Green Year to date actua l and forecast outturn fi gure revised. On track

Acute 233 233 (0) 323 323 0 Green

Primary Prescr0 849 849 0 925 925 Green On track

Other0 286 286 0 422 422 Green

* Fol lowing discuss ions with NHSE the forecas t has been revised down to £52k* To date, £27,576 of savings have been confi rmed by NHSE

Diagnostic 0 380 380 0 672 672 Green On track

Total 8,283 8,190 (93) 11,827 11,188 (639)

YTD Full Year

FINANCE

STATUS

(based on

forecast

M9 CommentsWork stream

102

The QIPP will continue to be monitored on a monthly basis, with monthly reports going to the NHSE, the CCG’s Governing Body, the CCG’s Finance, Quality and Performance Committee and the CCG’s Transformation Board, bi-weekly CCG QIPP delivery meetings with all transformation leads as well as this the CCG is in the process of identifying other in year schemes to mitigate the under-achievement reported and bring the projection back to break even by year end. Please note that for a number of schemes at month 9, we are unable to monitor the progress of achievement of QIPP against the plan with a high degree of accuracy, due to limitations in the quality of Month 8 data received or the unavailability of data altogether. However this will be monitored and reported on in future months. Recommendations The Governing Body is asked to note the contents of this report, the risks highlighted and the management action being taken to mitigate these risks.

Appendices

1. Statement of Financial Position 2. Cash Position and Forecast 3. Better Payments Practice Performance

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Statement of Financial Position

Statement of Financial Position

Nov Dec

2016 2016

£000 £000

NON‐CURRENT ASSETS

Property, Plant and EquipmentIntangibleOther Financial AssetsTrade and Other receivables TOTAL Non Current Assets - -

CURRENT ASSETS

InventoriesTrade and Other Receivables 3,889 3,156 Other Financial Assets

Cash and Cash Equivalents (948) (1,381) TOTAL Current Assets 2,941 1,776

TOTAL ASSETS 2,941 1,776

CURRENT LIABILITIES

Trade and Other Payables (60,103) (60,541) Provisions ‐ ‐ Borrowings ‐ ‐ TOTAL Current Liabilites (60,103) (60,541)

NET CURRENT ASSETS/(LIABILITIES) (57,162) (58,765)

Trade and Other Payables ‐ ‐ Provisions ‐ ‐ Borrowings ‐ ‐ TOTAL Non‐Current Liabilites ‐ ‐

TOTAL ASSETS EMPLOYED (57,162) (58,765)

FINANCED BY:

General Fund (57,162) (58,765) Revaluation reserves ‐ ‐ TOTAL TAXPAYERS EQUITY (57,162) (58,765)

Tower Hamlets CCG

Position as at 31st December 2016

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Cash Position and Forecast

Tower Hamlets CCG April May June July August September October November December January February March

Cash - Cashflow position and forecast 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017

Position as at 31st December 2016 Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast

RECEIPTS

Balance bfwd 229,863 203,925 136,230 205,348 335,399 580,351 342,360 1,483,452 5,693 340,972 150,000 150,000

Drawdown 30,106,000 29,496,000 34,547,000 30,653,000 28,921,000 28,944,000 30,638,000 27,567,000 29,226,000 28,308,000 31,154,000 33,165,762

Drawdown - Additional 2,500,000 - - - - - - 1,500,000 4,200,000 - -

NHS Transfers 373,738 63,796 151,952 144,172 9,380 689,799 10,333 277,816 363,647 55,000 - -

BACS 676,475 15,123 241,159 - 1,283 471,876 629,569 152,807 455,372 - - -

Credit Card - Local - - - - - - - - - - - -

Credit Card - SBS - - - - - - - - - - - -

Banking - Local - - - - - - - - 92 - - -

Banking - SBS 300 - - - - - 3,965 - - - - -

CHAPS / Faster Payment - 6,395 - 16,610 480 3,016,683 - - - - - -

VAT 43,840 91,080 81,700 79,536 182,003 153,457 68,149 122,921 88,172 25,000 25,000 25,000

BACS returns - 1,410 4,603 4,181 - - - - - - - -

Salary rejects - - - - - - - - - - - -

Inter-Company Transfer - - - - - - - - - - - -

Other Receipt - - - - 160 - - - - - - -

TOTAL 33,930,217 29,877,728 35,162,643 31,102,846 29,449,705 33,856,167 31,692,376 29,603,996 31,638,977 32,928,972 31,329,000 33,340,762

PAYMENTS

Creditors NHS 23,471,604 20,172,171 25,175,883 22,792,837 21,617,324 22,007,152 22,976,853 22,295,770 21,942,359 23,207,546 23,575,659 23,575,659

Creditors BACS 9,684,001 6,610,500 6,941,601 7,188,996 5,248,686 7,802,211 6,444,885 6,375,202 8,184,654 8,746,824 6,783,928 8,797,038

PHB BACS - - - - - - - - - - - -

Creditors CHAPS / Faster Payment 228,001 2,162,076 2,195,148 - 1,251,986 2,967,169 4,040 160,181 375,921 6,537 - -

Salary CHAPS / Faster Payment 2,920 29,143 - - 3,250 - 253,909 1,700 7,502 - - -

Cleared Cheques 43,959 - 841 63,912 6,253 5,532 13,718 133 929 - - -

Salaries & Wages 165,237 173,138 177,491 206,255 220,779 236,107 - 241,480 255,660 255,000 255,000 255,000

Pensions 47,064 493,349 364,656 413,525 401,925 368,346 379,461 374,435 389,360 427,000 427,000 427,000

Tax & NI 83,448 99,710 101,579 101,861 117,731 127,228 135,997 147,988 141,559 136,000 136,000 136,000

Standing Orders / Direct Debits - - - - 1,348 - - 1,348 - - 1,348 -

Foreign Payments - - - - - - - - - - - -

Inter-Company Transfer - - - - - - - - - - - -

Drawdown Return - - - - - - - - - - - -

Other 58 1,412 95 62 71 61 61 65 61 65 65 65

TOTAL 33,726,292 29,741,498 34,957,295 30,767,447 28,869,354 33,513,807 30,208,924 29,598,303 31,298,005 32,778,972 31,179,000 33,190,762

BALANCE CFWD 203,925 136,230 205,348 335,399 580,351 342,360 1,483,452 5,693 340,972 150,000 150,000 150,000

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Better Payment Practice Performance

Tower Hamlets CCGPayment Performance MeasurePosition as at 31st December 2016

Number Value Number Value£'000 £'000

Non‐NHS Creditors

Total Bills paid in the year 698 6,544 5,286 72,946

Total Bills paid within target 671 6,486 5,065 68,550

Percentage of Bills paid within target 96.1% 99.1% 95.8% 94.0%

NHS Creditors




All Creditors




Comparison with prior Year

Performance (2015/16) Number Value Number Value

Percentage of Bills paid within target ‐ Non NHS 96.4% 99.8% 94.2% 94.8%

Percentage of Bills paid within target ‐ NHS 82.7% 94.7% 88.6% 96.2%

CumulativeDec‐16

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Date of meeting 24th January 2017 F

Agenda item 3.2.2

Title of report: Tower Hamlets Finance & Activity Summary Report

Author(s): Lee Eborall – Director of Acute Contract Management, CSU Deane Kennett – Assistant Director of Contracting, CSU

Presented by:


Lee Eborall – Director of Acute Contract Management, CSU Deane Kennett – Assistant Director of Contracting, CSU – [email protected]

Executive summary

The report provides a high level overview of finance and activity across Tower Hamlets for the month of December 2016 (based on November 2016 activity data). The report highlights the key issues, current performance, key actions and a delivery RAG rating for major providers providing healthcare services in Tower Hamlets.

Recommendation


To note the content of the report, and discuss any actions required.

Conflicts of Interest N/A

Key issues The CCG is predicting a financial year end surplus of £11.9m which is in line with the financial plan for 2016/17. Within this, Board members are also asked to note:

Acute care spend is forecasted to be £8.1m above budget.

Within the above £8.1m, Barts Health (Acute) is forecasting a £5.4m overspend.

Report history Information presented at the CCG Finance, Performance & Quality Committee meeting informs this Board report


N/A


This paper affects:

Corporate Objective 1: - To work in partnership to commission high quality hospital services that are accessible, provide the appropriate treatment in the right place, and achieve good patient outcomes for

107

people of all ages living in the borough.

Corporate Objective 3: - To contribute towards a financially sustainable and responsive health and care economy which delivers value for money and innovation and supports the appropriate use of services.


N/A

Resource requirements

N/A

Next steps Action and next steps for each area identified is covered in the report. Main areas of work include: Acute

CSU to continue to challenge areas of overspend identified in month 9.

CSU to progress Q2 reconciliation.

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Finance & Activity Summary ReportTower Hamlets CCG

January 2017

Enc. F

109

Finance & Activity

Finance & Activity

CCG Finance Performance, M9 2016/17 Action

Ambe

r

Year End position: £11.9m surplus

Key Messages

The CCG is forecasting a full year surplus of £11.9m which is in line with the financial plan for 2016/17.

Acute is forecasting an overspend of £8.1m

The main driver for the overspend being Barts £5.4m. Guy’s £0.5m, BMI £0.4m, Homerton £0.3m, Royal Free £0.2m and GOSH £0.2m are the key drivers of the over performance across Associates. The Board should note a breakeven position was reported through most of 2015/16.

Healthcare Provision (Non Acute incl. Primary Care) is forecasting a £5.8m underspend

Mental Health – the £1m underspend is as a result of surplus budget, having been incorrectly allocated to Mental Health. Other Non‐Acute – the underspend of £6.7m in this area relates to the use of non‐recurrent in year measures, which have been released into the current year forecast position to achieve the CCG’s control total.

Corporate is forecasting a £150k overspend

As at month 9 the CCG is on target to spend within its running cost allowance, however the CCG is reporting a projected overspend of £150k against its programme costs, this relates to additional CSU costs, which are yet to be confirmed.

Tower Hamlets Finance & Activity Headlines: January 2017

Month 9 Financial Position based on Month 8 Activity data Tower Hamlets CCG ‐ Financial

Position as at Month 9 ‐ 2016/17

Annual

Budget

£’000

YTD

Budget

£’000

YTD Actual

£’000

YTD

(Under)/O

verspend

£’000

Forecast

Actual

£’000

Forecast

(Under)/O

verspend

£’000

YTD

In‐Month

Movement

£’000

Forecast

In‐Month

Movement

£’000

Delegated

In Sector Acute Trusts 145,654 109,240 113,492 4,252 151,323 5,670 306 (250)Out of Sector Acute Trusts 20,716 15,537 16,711 1,174 22,282 1,566 309 267Other Acute 12,910 9,682 10,365 683 13,822 912 105 44Subtotal Acute 179,279 134,459 140,569 6,109 187,427 8,148 719 61

Mental Health 47,304 35,478 34,696 (781) 46,261 (1,042) (87) (0)Community Health 49,578 37,183 38,369 1,186 51,160 1,582 129 (4)Other Non Acute 20,085 15,064 13,180 (1,884) 13,416 (6,670) 921 1,613Subtotal Non Acute 116,967 87,725 86,246 (1,479) 110,837 (6,130) 963 1,609

Prescribing 31,557 23,668 23,441 (227) 31,255 (302) (77) (78)Primary Care Co‐Commissioning 42,164 31,622 31,977 356 42,685 521 122 74Prime Ministers Challenge Fund 2,761 2,071 2,070 (0) 2,761 0 22 34Other Primary Care Services 10,425 7,818 7,915 97 10,553 128 11 (0)Subtotal Primary Care 86,906 65,178 65,404 226 87,253 347 78 31

Reserves 8,265 6,200 1,344 (4,856) 5,750 (2,515) (1,774) (1,851)

TOTAL CCG 391,417 293,563 293,562 (0) 391,267 (150) (12) (150)

Corporate 10,650 7,987 7,987 0 10,801 151 1 151TOTAL CORPORATE 10,650 7,987 7,987 0 10,801 151 1 151

GRAND TOTAL 402,067 301,550 301,549 (0) 402,068 1 (11) 1

IN YEAR RESOURCE LIMIT (402,067) (301,550) (301,550) 0 (402,067) 0 0 0

IN YEAR (SURPLUS)/DEFECIT 0 (0) (0) (0) 1 1 (11) 1

PRIOR YEAR SURPLUS (11,943) (8,957) (8,957) 0 (11,943) 0 0 0

TOTAL (SURPLUS)/DEFICIT (11,943) (8,957) (8,958) (0) (11,942) 1 (11) 1

110

Finance & Activity

Finance & Activity

Tower Hamlets Finance & Activity Headlines: January 2017

Executive SummaryAm

ber

Barts Health (Acute)• Barts is forecasting a full year over performance of £5.4m based upon M8 activity data. • Key drivers of over performance include Critical Care, Elective & Day Cases, High Cost Drugs, Non Elective, Outpatients and

Outpatient Procedures.• The process for agreeing Q2 claims has commenced with initial values having been shared with Barts Health and risk rated values

included in the forecasted outturn.• The 2017/19 contract was signed on the 22nd of December.

Mental Health • The ELFT Mental Health Provider continues to meet the majority of contractual requirements. • The Adult DNA rate continues to exceed the 10% threshold at 10.5% in November, an action plan is in place to support recovery. • The 2017/19 contract was signed on the 23rd of December.

Community Health Services • The CHS procurement has been concluded, subject to due diligence and agreement of final contract documentation. • An extension to the current Barts CHS contract has been agreed to the end of March.• The new Wheelchair, MSK/Pain and dermatology services have gone live, with the Community Learning Disability Service (CLDS)

expected to follow on the 1st of February.

Continuing Health Care • Continuing Health Care is reporting a FOT over spend of £697k at month 9, due to a provision included in the projection for the

estimated costs of Tower Hamlets share of the joint care packages.

111


Date of meeting 24th January 2017 G

Agenda item 3.3

Title of report: Performance and Quality Report

Author(s): Archna Mathur - Director Performance & Quality (CCG) CSU Performance team

Presented by:


Archna Mathur – Director Performance & Quality – THCCG Archna Mathur – Director Performance & Quality - THCCG [email protected] (020 3688 2528)

Executive summary

This paper provides a high level overview of quality and performance across Tower Hamlets reported for the month of October and November where data and information is available.The report highlights the key issues, current performance against National Constitution standards and actions taken by providers and Tower Hamlets CCG in managing the provider performance and quality portfolio for acute, community and mental healthcare in Tower Hamlets.

Recommendation


The Governing Body is asked to note the contents of the report, particularly in relation to the Board Assurance Framework.

113

2

Key issues Cancer Waiting Times: Barts Health achieved 8 out of 8 standards in October, including

the standards for 2 week urgent referrals (97.65% vs. 93% standard); 31 day 1st treatment standard (98.16% vs. 96% standard) and the 62 day standard GP urgent referral standard (86.6% vs 85% standard).

Tower Hamlets achieved 6 of 8 standards in October. This included the 2 week urgent referral (98.25% vs. 93% standard) and the 31 day 1st treatment standard (97.96% vs. 96% standard)

Tower Hamlets failed the standard for 62 Day GP urgent referral (73.68% vs. 85% standard) and 31 day subsequent treatment (chemotherapy) (95% vs 98% standard).

A full day of elective deep dives took place on 4 November 2016 to address cancer and > 52 week performance. The cancer deep dives focussed on colorectal, dermatology, Head and Neck and Lung. Deep Dives have been enhanced further to now include review of staging data by speciality.

Referral to Treatment (RTT):

Barts Health continues to underperform against the national waiting time standards at speciality level. The Trust is currently not reporting on RTT although monitoring via the CCGs/TDA continues against the CPN (contract performance notice) in June 2015.

The trajectory for backlog and waiting list clearance is being met with a resulting overall reduction in the waiting list size.

Main area of concern is number of > 52 week waiters due to ongoing need for validation as a result of poor data quality.

Work continues on the data quality plan. Monthly deep dives on the most challenged speciality i.e.

Trauma and Orthopaedics are now in place, focussed primarily on reduction of the > 52 week waiters.

ELFT RTT for Psychotherapies (PTS):

The team continues to work towards it trajectory to clear the backlog by end of December.

Data presented at the local CQRM shows that only 6 patients were waiting over 11 weeks. Meaning the service is on the right track to reducing the waiting list.

The trust has set an 11 weeks monitoring target to ensure they capture patients before they reach the 18 week target.

The team does not have any vacancies any more. The last vacancy was filled in November 2016.

Diagnostics

Barts Health achieved this standard at aggregate level in October 2016 (0.43% vs. 1% standard).

Provisional data shows Tower Hamlets CCG achieved this standard in November 2016 with 0.47% against the 1% standard

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3

A&E: Quarter 3 to date performance for RLH is 81.62% against a

trajectory for quarter 3 of 92.96%. Attendances during the Christmas and post-Christmas period

have been 5.4% up compared to the same weeks the previous year. Admissions have been c7% up on the same weeks last year, but only 1.9% up year to date.

The site come under pressure with surges in attendances during certain times, and combined with staff shortages on account of sickness or last minute cancellations, this adds pressure to the site.

Delayed Transfers of Care (in totality, not just Tower Hamlets patients) have increased, with some days seeing as many as 31 DTOCs. There are also high numbers of repatriations and patients requiring either neurorehabilitation assessments and beds.

THCCG has awarded the site with additional funding through the Operational Resilience funding to support paediatric consultant review in ED, ED nursing staff, discharge co-ordination and internal patient transfer staff.

The Trust is working to a revised (Trust level) STF (Sustainability and Transformation Fund) trajectory in line with the system “reset” paper published by NHSE and NHSI on 21 July where 5 mandated initiatives to improve A&E performance are listed:

Introduce primary can ambulatory care screening in A&E Increase proportion of NHS 111 calls handled by clinicians Implement SAFER and other measures to improve in hospital

flow Implement best practice on hospital discharges to reduce

delayed transfers of care Reform System Resilience Groups (SRGs) into Local A&E

Delivery Boards to focus only on urgent and emergency care, ensuring all statutory bodies are represented and attendees are of Executive level

The RLH site team have undertaken two stocktakes in relation to the 5 mandated actions, outputs of which are overseen by the Urgent Care Working Group.

The format of the RLH ED Performance meetings has now also been revised to a deep dive approach where clinician’s present data and challenges related to each key area of the sustainability plan. Previous deep dives have been on the SAFER bundle and the frail elderly model in development.

A&E (Mental Health Liaison - ELFT):

ELFT continues to underperform against the A&E target. During November 2016, the provider reported a performance of 85.4%, a 4.6 percentage point deterioration on the previous month; performance has remained below 95% during the past year. Due to :

115

4

Delays in doctor reviewing patients as they are busy with Mile End hospital emergencies causing delays in getting to the Royal London Hospital site.

Delays caused by waiting for Approved Mental Health Professional (AMHP) and Section 12 for MHA assessments.

ELFT was continuing to work with neighbouring trusts on out of area pathways

Dementia

The estimated dementia diagnosis rate during November 2016 was 86.34%, achieving the national standard of 66.7%. The CCG’s monthly median average performance since April 2016 to date was 84%.

During November 2016, GP practices reported that there were 884 patients aged 65 years and over on their dementia register within Tower Hamlets CCG.

Referral to face-to-face Assessment within 6 weeks (95% local target): November 2016 – 100% vs 95% standard. Which is the first time in the year the Trust TH borough have achieved this target.

Referral to Diagnosis within 18 weeks (95% local target): November 2016 – 97.6% the first time in the year that the borough has achieved the target.

Early Intervention Psychosis Standard

THCCG October performance (latest) was 100% i.e. 8/8 service users commenced treatment within 2 weeks, above the 50% national target. The target has been met consistently since December 2015. (No change )

IAPT

The NHS Digital reported that 3.67% service users accessed treatment at Qtr1 2016/17, below the 3.75% national target for the quarter. This is deterioration on the 3.94% reported during Qtr1 in 2015/16 data).

This was due to an administrative error which will be resolved in the next reporting period.

the recovery rate for Tower Hamlets CCG was 50.8% during Qtr1 2016/17, above the 50% target and meeting the target for the first time in two years.

LAS (London Ambulance Service) Handover times:

The Royal London continues to fail to achieve against KPI 1 (% turnaround within 15 minutes) with rolling 4 week performance at 43.9% and KPI 2 (% turnaround within 30 minutes) at 89.7%. Performance is strong against the 60min handover target.

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5

SI (Serious Incidents):

Barts Health: 42 overdue SIs for November 2016, 8 of which are at RLH and 0 for community health services. Concerns have been raised in terms of timeliness of reporting from date of incident to STEIS, quality of reports and datix backlog, all of which will be monitored at CQRM and are moving steadily in the right direction.

ELFT: November 2016 – 6 Overdue Sis which is an improvement from previous months where ELFT had 16 overdue serious incidents.

Never Events

Barts Health: 3 further Never Events occurred in November 2016, a retained vaginal swab at RLH, misplaced naso-gastric tube in a neonate at Whipps Cross, and retained guide wire at St. Barts.

The Never Event total at Barts Health is now 11 with 7 of these at RLH.

ELFT: Zero never events reported. Mixed Sex Accommodation:

There were 12 breaches in November of these 8 were at RLH and 4 at Whipps Cross.

Tower Hamlets had 1 breach in November 2016 which occurred at The Royal London

HCAI (HealthCare Associated Infection): The year to date total for Cdiff infections at Barts Health is 20 versus full year threshold of 82.

There are currently no cases of C-diff due to lapses in care. 3 cases of C. Difficile were attributed to Tower Hamlets in

October, against a DH objective of 3 for the month. (YTD total = 9 vs. YTD trajectory of 12)

The MRSA figure for Barts Health is currently 8 Primary Care Quality (Outcome of CQC inspections) 26 of our 36 practices have been received their CQC report:

2 practices have been rated outstanding (Jubilee and St Paul’s Way)

22 practices have been rated as Good

2 practices have been rated as requiring improvement (Harford and East One). Work ongoing with both

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6

Conflicts of Interest There are no identified conflicts of interest.

Report history Information presented at the CCG Performance & Quality meetings informs this Governing Body report.


The Friends and Family Test (FFT) provides patient feedback to improve service provision as well as NHS Choices providing patient comments on services.


This paper affects all of the risks under Strategic Objective 2: Systems and processes to monitor challenge and support provider delivery of the NHS Constitution targets.


Monitoring and actively improving the performance and quality of service provision will have a benifical impact for all patients in Tower Hamlets.

Resource requirements N/A


118

Tower Hamlets CCG Month 8 2016-17

Monthly Acute Performance and Serious Incidents Report

Enc. G

119

Tower Hamlets CCG – Quality Premium: NHS Constitution rights and pledges

Data source: Unify2, HES, Open Exeter, Trust Submissions 2

* For the purposes of the quality premium, the percentage of Incomplete pathways within 18 weeks will be calculated by summing thenumerators (patients waiting within 18 weeks) from each month end and then dividing by the sum of all the denominators (patients waiting)from each month end.

**The A&E CCG Quality Premium is based on data mapping from NHSE, derived from HES figures. This calculates what proportion of eachprovider’s activity can be attributed to a given CCG. Any activity under 1% is ignored.

The Barts Health Trust board has taken the decision to suspend the monthly mandatory reporting of referral to treatment (RTT) waiting times data from October 2014 (including the retraction of September 2014). The Homerton also suspended reporting from October 2015 to February 2016 due to data quality issues.

Tower Hamlets CCG

NHS TOWER HAMLETS CCG

Referral to treatment times (18 weeks Incomplete) (April 2016 to November 2016)* 94.29% Y 92%

A&E waits - All types (April 2016 to October 2016)** 88.61% N 95%

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer (April 2016 to October 2016)

83.33% N 85%

Category A Red 1 ambulance calls (April 2016 to October 2016) 69.83% N 75%

QUALITY PREMIUM 2016-17(NHS Constitution rights and pledges)

Measure 2016-17Measure achieved

Target

120

Key achievements

Cancer Waiting Times

• Barts Health achieved all 8 standards in October, including: the standards for 2 week urgent referrals (97.65% vs. 93%); 31 day 1st treatment standard (98.16% vs. 96%) and the 62 Day GP urgent referral (86.60% vs. 85%).

• Tower Hamlets achieved 6 of 8 standards in October. This included the 2 Week urgent referral standard (98.25% vs. 93%) and the 31 day 1st treatment standard (97.96% vs. 96% standard)

Diagnostic Waits• Barts Health achieved this standard at aggregate level in

October 2016 (0.43% vs. 1% standard).• Provisional data shows Tower Hamlets CCG achieved this

standard in November 2016 with 0.47% against the 1% standard.

C. Difficile • 6 cases of C. Difficile were attributed to Tower Hamlets in

October , against a DH objective of 3 for the month. (YTD total = 19 vs. YTD trajectory of 21)

• There were 3 cases in October assigned to Barts Health giving a YTD total of 37. There is a threshold of 82 for 2016/17 (average threshold is 7 per month).

Performance issues

18 Weeks Referral to Treatment Times

• Without Barts Health data, Tower Hamlets CCG Incomplete Pathway performance for October 2016 was 94.47% (vs the target of 92%).

A&E Waiting Times – All Types

• Provisional November A&E performance for Barts Health is 86.58% against the 95% standard.• The Royal London performance is 82.17% in November against the 95% standard.

Cancer Waiting Times

• Tower Hamlets failed the standard for 62 Day GP urgent referral (73.68% vs. 85%) and the 31 day standard for subsequent drug (chemotherapy) treatment (95% vs. 98% standard).

Mixed Sex Accommodation

• Barts Health had 12 MSA breaches in November. Of these, 8 were at The Royal London and 4 at Whipps Cross.

• Tower Hamlets had 1 breach in November 2016. This occurred at The Royal London.

MRSA

• Barts Health reported 1 case of MRSA in October 2016, taking the year to date total to 8, against a zero tolerance standard.

• 1 case of MRSA was attributed to Tower Hamlets in October, taking the year to date total to 3, against a zero tolerance.

Ambulance Handover

• In November, The Royal London Hospital failed the 15 minute handover (KPI 1) with 52%, narrowly underperformed against 30 minute handover (KPI 2) with 99.70% and data completeness rate (KPI 4) with 88.40%. There were 6, 30 minute breaches and no 60 minute breaches in November.

Category A, Ambulance Response Times

• Category A Red 1 was not achieved in October (69.43% vs. 75% target).• The Red 2 (Cat A 8 min) response was not met in October (66.27% vs. 75% target).• Category A calls: For 19 minutes the target was not met in October (93.76% vs. 95% target).

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Tower Hamlets CCG – Summary of Monthly Performance

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Tower Hamlets CCG Dashboard - Cancer Waiting TimesNote: The NHS Constitution Quality Premium indicators are highlighted in lilac

4back to Main Menu

Data source: Open Exeter


2 Week Cancer Wait NHS TOWER HAMLETS CCG 93.22% 95.16% 98.76% 94.89% 97.96% 98.74% 97.67% 97.42% 98.30% 98.01% 97.26% 97.67% 98.25% 97.79% 93%

2 Week Cancer Wait:Breast Symptoms

NHS TOWER HAMLETS CCG 91.00% 95.41% 100.00% 96.04% 99.18% 98.35% 100.00% 97.37% 96.83% 100.00% 100.00% 97.48% 97.41% 98.36% 93%

31 day Cancer Wait:1st definitive treatment


31 Day Cancer Wait: Subsequent treatment (Surgery)


31 Day Cancer Wait: Subsequent treatment (Chemotherapy)


31 Day Cancer Wait: Subsequent treatment

(Radiotherapy)NHS TOWER HAMLETS CCG 100.00% 100.00% 100.00% 90.91% 100.00% 100.00% 92.86% 100.00% 100.00% 100.00% 100.00% 100.00% 94.12% 98.10% 94%

62 Day Cancer Wait: GP Referral NHS TOWER HAMLETS CCG 93.10% 67.86% 90.48% 75.00% 81.82% 85.71% 92.86% 88.46% 92.86% 80.77% 80.00% 75.00% 73.68% 83.33% 85%

62 Day Cancer Wait: Screening service


62 Day Cancer Wait: Consultant Upgrade

NHS TOWER HAMLETS CCG 0.00% 100.00% 100.00% 100.00% 100.00% 85.71% 100.00% 80.00% 100.00% 100.00% 0.00% 100.00% 86.96%No

thresholds

Ca

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Oct-15 Feb-16 Mar-16 Apr-16 May-16 Jun-16Theme KPI / Measure CCG Nov-15 Dec-15 Jan-162016-17 Target

2016-17 YTD

Jul-16 Aug-16 Sep-16 Oct-16

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Trust wide Performance - Cancer Waiting TimesNote: The NHS Constitution Quality Premium indicators are highlighted in lilacTop ranked Providers by greatest activity proportion

Barts Health 95.75% 96.05% 97.43% 94.84% 97.49% 97.92% 97.81% 97.53% 97.75% 97.96% 97.71% 96.49% 97.65% 97.56%Homerton 98.02% 98.14% 97.67% 95.72% 94.97% 95.54% 96.85% 95.97% 98.26% 96.39% 97.18% 97.26% 97.25% 97.03%BHRUT 96.07% 95.82% 92.16% 91.65% 89.55% 93.00% 89.54% 94.64% 94.82% 94.07% 96.22% 93.30% 96.30% 94.11%




Barts Health 100.00% 100.00% 100.00% 99.40% 100.00% 100.00% 99.36% 100.00% 99.33% 100.00% 100.00% 100.00% 98.67% 99.61%Homerton 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%BHRUT 96.77% 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%

Barts Health 100.00% 98.15% 100.00% 96.04% 98.57% 97.30% 97.20% 98.32% 99.01% 98.89% 100.00% 100.00% 98.47% 98.85%Homerton

BHRUT 100.00% 98.41% 100.00% 91.53% 100.00% 100.00% 98.36% 98.08% 97.06% 100.00% 100.00% 100.00% 100.00% 98.93%


Barts Health 90.48% 100.00% 91.30% 92.00% 94.44% 92.86% 93.33% 94.12% 93.75% 90.00% 91.89% 100.00% 92.86% 93.80%Homerton 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%BHRUT 93.75% 95.00% 97.30% 91.18% 96.15% 94.74% 91.53% 95.00% 100.00% 100.00% 96.15% 91.30% 81.82% 93.23%


Theme KPI / Measure Provider Oct-15 Nov-15 Dec-15 Jul-16 Aug-16 Sep-16 Oct-162016-17

YTD2016-17 Target

Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Theme KPI / Measure Provider Oct-15 Nov-15 Dec-15

Can

cer

Wai

ts

2 Week Cancer Wait 93%

2 Week Cancer Wait:Breast Symptoms

93%

31 day Cancer Wait:1st definitive treatment

96%

31 Day Cancer Wait: Subsequent treatment (Surgery)

94%

Jul-16 Aug-16 Sep-16 Oct-162016-17

YTD2016-17 Target

Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

-

Can

cer

Wai

ts

31 Day Cancer Wait: Subsequent treatment (Chemotherapy)

98%

31 Day Cancer Wait: Subsequent treatment

(Radiotherapy)94%

62 Day Cancer Wait: GP Referral

85%

62 Day Cancer Wait: Screening service

90%

62 Day Cancer Wait: Consultant Upgrade

123

Data source: Barts Health Trust24

Cancer Waiting Times – Barts HealthBarts Health NHS Trust

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There is the possibility of variation in data between that published on the national cancer waiting times database and that released by the trust. This may be caused by cases that are on the trust’s system but were either not uploaded to the national system before the deadline or uploaded under legacy sites which will be rejected by the Exeter system. Late uploads will be captured in the quarterly reports which often show a small amount of variation.

124

Data source: Barts Health Trust28

Cancer Waiting Times – 62 day GP referral Barts HealthBarts Health NHS Trust

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There is the possibility of variation in data between that published on the national cancer waiting times database and that released by the Trust. This may be caused by cases that are on the Trust’s system but were either not uploaded to the national system before the deadline or uploaded under legacy sites which will be rejected by the Exeter system. Late uploads will be captured in the quarterly reports which often show a small amount of variation.

125

29

The Royal London Cancer Waiting Times – 62 day Wait by Tumour

Data source: Barts Health Trust

Barts Health NHS Trust

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Trust wide Performance - A&E 4 Hour Waiting Times and Ambulance Response Note: The NHS Constitution Quality Premium indicators are highlighted in lilacTop ranked Providers by greatest activity proportion

Nov-16(unpublished)

The Royal London Hospital 79.49% 82.03% 83.63% 82.61% 81.01% 82.60% 81.11% 79.95% 80.21% 84.25% 86.08% 87.39% 83.48% 80.32% 83.22%Newham 95.18% 92.31% 91.28% 89.59% 92.07% 92.61% 92.12% 92.17% 90.16% 92.59% 88.52% 92.60% 91.98% 93.46% 91.48%Whipps Cross 75.58% 72.92% 70.56% 71.95% 68.55% 72.38% 71.96% 75.41% 75.65% 80.55% 82.61% 80.52% 73.82% 73.29% 77.24%Homerton 95.23% 95.07% 95.56% 95.66% 93.14% 94.01% 94.06% 93.34% 92.82% 95.44% 96.50% 94.63% 93.33% 93.34% 94.28%Queen's Hospital 87.03% 79.49% 80.68% 80.05% 76.06% 70.24% 76.43% 77.32% 76.74% 80.57% 90.07% 87.52% 84.17% 85.60% 81.78%King George Hospital 91.04% 90.19% 86.43% 82.13% 79.55% 75.73% 82.06% 80.71% 85.24% 86.99% 92.46% 91.88% 91.02% 89.89% 87.15%Barts Health 82.21% 81.92% 81.73% 81.21% 80.21% 82.55% 81.39% 81.75% 81.43% 85.27% 85.66% 86.56% 82.80% 81.61% 83.55%BHRUT 88.24% 82.74% 82.80% 80.73% 77.17% 72.02% 78.27% 78.43% 79.94% 82.65% 90.84% 88.98% 86.36% 87.02% 83.59%

The Royal London Hospital 82.06% 84.50% 85.32% 84.67% 83.32% 84.79% 83.17% 82.22% 82.24% 85.81% 87.60% 88.59% 85.09% 82.17% 84.95%Newham 95.52% 93.91% 93.79% 92.95% 93.97% 94.70% 94.48% 95.16% 93.57% 95.12% 92.72% 95.22% 94.81% 95.86% 94.47%Whipps Cross 83.46% 81.69% 80.92% 81.75% 79.61% 81.85% 81.87% 83.33% 83.46% 86.21% 87.96% 86.68% 82.55% 82.35% 84.56%Homerton 95.23% 95.07% 95.56% 95.66% 93.14% 94.01% 94.06% 93.34% 92.82% 95.44% 96.50% 94.63% 93.33% 93.34% 94.28%Queen's Hospital 87.53% 80.28% 81.42% 80.80% 77.05% 71.27% 77.39% 78.19% 77.78% 81.34% 90.46% 88.11% 84.82% 86.23% 82.55%King George Hospital 94.29% 93.29% 90.43% 87.12% 85.53% 81.96% 87.33% 86.23% 89.62% 90.73% 94.69% 94.12% 93.38% 92.93% 90.82%Barts Health 86.65% 86.45% 86.51% 86.37% 85.57% 87.32% 86.34% 86.73% 86.24% 88.88% 89.29% 89.97% 87.29% 86.58% 87.81%BHRUT 90.02% 85.26% 85.22% 83.32% 80.39% 75.65% 81.37% 81.37% 82.81% 85.02% 92.12% 90.48% 88.19% 88.94% 85.87%

Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barts Health 0 0 0 0 0 0 0 0 2 0 0 0 0 2BHRUT 0 0 0 0 1 0 1 2 0 1 0 0 0 4

Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barts Health 0 1 2 0 0 0 0 0 0 0 0 0 0 0BHRUT 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Category A calls resulting in emergency response

arriving within 8 mins (RED 1)

London Ambulance Service NHS Trust

70.73% 69.04% 73.83% 67.29% 64.68% 65.57% 69.99% 70.27% 72.21% 68.33% 68.71% 70.08% 69.43% 69.83% 75%

Category A calls resulting in emergency response

arriving within 8 mins (RED 2)


65.40% 64.39% 66.42% 60.94% 56.35% 57.94% 64.60% 65.13% 65.27% 63.64% 67.37% 63.27% 66.27% 65.08% 75%

Category A calls resulting in emergency response arriving within 19 mins


93.53% 93.65% 94.21% 92.57% 91.29% 91.05% 94.22% 94.08% 94.38% 93.10% 94.04% 92.88% 93.76% 93.77% 95%

0

Theme KPI / Measure Provider Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Oct-162016-17

YTD2016-17 Target

0

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16

95%A&E Type I Performance

95%

Acc

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an

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mb

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Cal

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Han

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A&E All Types Performance

No of waits from decision to admit to admission (Trolley

waits - over 12 hours)

Urgent cancelled operations 2nd time

127

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10

Trust wide Performance - Ambulance Handover Times Top ranked Providers by greatest activity proportion

Royal London Hospital 56.80% 53.10% 52.80% 50.30% 51.20% 48.50% 51.60% 55.20% 52.50% 53.40% 55.33% 51.10% 52.00% 52.50%Newham 42.10% 34.70% 31.60% 30.70% 33.70% 32.80% 30.90% 29.10% 26.50% 30.50% 28.56% 28.20% 32.10% 29.90%Whipps Cross 38.80% 39.20% 39.50% 38.50% 39.90% 42.40% 43.50% 43.50% 44.40% 44.30% 39.38% 39.80% 34.70% 41.60%Homerton 73.10% 69.30% 73.40% 70.20% 68.60% 72.30% 73.40% 74.50% 73.90% 75.80% 73.05% 71.50% 70.30% 73.10%Queens Hospital 33.35% 31.18% 31.39% 33.06% 31.14% 32.80% 33.33% 32.84% 34.28% 36.85% 31.85% 30.42% 27.66% 32.59%King George Hospital 38.69% 34.61% 30.32% 31.31% 24.57% 31.13% 27.89% 30.00% 27.48% 29.52% 27.29% 28.50% 31.32% 29.14%


Royal London Hospital 0 5 5 11 8 34 2 4 9 1 7 16 6 79Newham 1 3 1 4 5 6 4 3 5 8 8 10 6 50Whipps Cross 71 98 98 138 112 86 84 110 68 79 89 121 127 764Homerton 0 0 1 0 0 4 0 0 0 0 0 0 0 4Queens Hospital 320 395 415 498 580 451 370 414 454 275 318 422 405 3109King George Hospital 69 57 78 93 148 113 129 124 113 102 111 96 89 877

Royal London Hospital 0 0 1 0 4 0 0 0 0 0 0 0 0 0Newham 0 0 0 0 0 0 0 0 0 0 0 0 0 0Whipps Cross 0 1 10 23 3 2 13 6 0 1 0 15 24 61Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0 0Queens Hospital 2 0 0 0 0 1 0 1 0 0 0 0King George Hospital 0 0 0 0 3 0 0 0 0 0 2 5


Theme KPI / Measure Provider Nov-15 Dec-15 Jan-16 Feb-16 Nov-162016-17

YTD2016-17 Target

Mar-16 Oct-16

Ac

cid

en

t &

Em

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en

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an

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all

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nd

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% Ambulance Handovers within 15 mins: KPI 1

100%

% Ambulance Handovers within 30 mins: KPI 2

100%

Number of Ambulance Handover-30 minute breaches

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16

0

Number of Ambulance Handover-60 minute breaches

0

% Patient records captured electronically: KPI 4

90%

128

Tower Hamlets CCG Dashboard – Quality StandardsNote: The NHS Constitution Quality Premium indicators are highlighted in lilac

11back to Main Menu


MRSA reported infections NHS TOWER HAMLETS CCG 2 1 1 0 1 0 1 0 0 0 1 1 3Zero

tolerance

C. Difficile reported infections NHS TOWER HAMLETS CCG 5 1 2 2 2 1 2 3 3 4 0 6 19 36

Mixed Sex Accommodation (MSA) (Number of breaches)

NHS TOWER HAMLETS CCG 4 15 13 4 13 5 3 5 4 3 9 4 1 34Zero

tolerance

Jul-16 Aug-16 Sep-16

Qu

alit

y

Theme KPI / Measure CCG May-16Nov-15 Oct-16 Nov-162016-17

YTD2016-17 Target

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Jun-16

129

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Trust wide Performance – Quality standards Top ranked Providers by greatest activity proportion.

12

Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0Barts Health 2 2 2 2 3 1 2 0 0 1 3 1 8Moorfields Eye Hospital 0 0 0 0 0 0 0 0 0 0 0 0 0UCLH 0 0 0 0 0 0 0 0 0 1 0 0 1Royal Free London FT 0 0 0 0 0 0 0 0 0 0 0 0 0Guy's and St. Thomas' 0 0 0 0 1 0 0 0 0 0 1 1 2St. George's FT 0 0 0 0 0 0 0 0 0 0 0 1 1

Homerton 1 1 0 0 0 0 1 0 0 1 0 1 3 7

Barts Health 8 6 6 3 4 7 4 3 6 7 7 3 37 82

Moorfields Eye Hospital 0 0 0 0 0 0 0 0 0 0 0 0 0 0

UCLH 8 5 5 10 5 5 7 10 7 12 7 6 54 97

Royal Free London FT 6 4 5 4 6 6 2 6 9 7 8 4 42 66

Guy's and St. Thomas' 2 1 3 4 6 9 2 2 4 3 1 1 22 51

St. George's FT 0 1 2 3 1 1 2 2 2 2 3 6 18 31

Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barts Health 32 67 43 29 42 27 12 16 12 18 17 11 12 125Moorfields Eye Hospital 0 0 0 0 0 0 4 0 0 0 0 0 3 7UCLH 15 12 4 30 28 8 7 17 9 18 12 34 19 124Royal Free London FT 12 12 12 4 4 0 6 7 15 15 22 34 17 116Guy's and St. Thomas' 22 10 1 4 2 3 2 12 16 2 7 3 4 49St. George's FT 0 0 0 6 0 0 0 0 0 0 0 0 0 0

Homerton 93.23% 97.84% 97.63% 97.47% 97.39% 96.50% 96.30% 95.60% 93.87% 95.46% 96.10% 95.64%Barts Health 96.27% 95.43% 96.08% 96.35% 95.61% 95.83% 95.42% 96.56% 96.20% 95.55% 95.66% 95.87%Moorfields Eye Hospital 98.24% 98.75% 99.00% 98.78% 98.45% 99.25% 99.03% 99.18% 98.88% 99.16% 98.96% 99.08%UCLH 95.00% 95.93% 94.40% 95.00% 95.93% 96.27% 96.22% 96.18% 96.30% 96.63% 96.05% 96.28%Royal Free London FT 97.79% 96.86% 98.25% 95.57% 97.48% 96.88% 96.48% 95.49% 96.64% 96.80% 96.08% 96.41%Guy's and St. Thomas' 96.91% 97.06% 96.95% 97.49% 97.42% 97.43% 97.28% 97.05% 97.34% 96.64% 96.49% 97.03%St. George's FT 96.76% 96.51% 96.61% 96.71% 97.05% 96.84% 97.59% 97.55% 96.93% 96.74% 96.33% 97.00%

Feb-16 Mar-16

C. Difficile reported infections

95%VTE

(% Admitted patients assessed for VTE risk)

Qua

lity

Apr-16 May-16 Jun-16

MRSA reported infectionsZero

tolerance

Zero tolerance

Mixed Sex Accommodation (MSA) (Number of breaches)

Theme KPI / Measure Provider Nov-15 Dec-152016-17 Target

Jul-16 Aug-16 Sep-16 Oct-16 Nov-162016-17

YTDJan-16

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1 | P a g e

Governing Body Meeting- Part I Enclosure

Date of meeting 24th January 2017 H

Agenda item 3.4

Title of report: CQC Report – NHS Barts Health December 2016

Author(s): Jackie Sullivan, Managing Director, Royal London Hospital, NHS Barts Health

Caroline Alexander – Chief Nurse, NHS Barts Health

Presented by:


Jackie Sullivan, Managing Director Royal London & Mile End Hospitals

[email protected]

Executive summary

NHS Barts Health Trust underwent a CQC Inspection in July 2016. The inspectors reviewed eight core services: Urgent and Emergency Care, Medicine (including older people’s services), Surgery, Critical Care, Maternity and Gynaecology, End of Life Care, Services for Children and Young People and Outpatients and Diagnostics. Overall the Royal London Hospital has improved from a rating of Inadequate in 2015 to Requires Improvement in 2016. The site leadership team is now working on a detailed action plan to address all of the CQCs concerns and a detailed plan will be fully discussed at the CQC Summit to be held on 23rd January 2016.

Recommendation:


The Governing Body is asked to note the contents of the report and the areas of which the Trust will focus improvement works on.

Conflicts of Interest None identified relating to this report.


The Friends and Family Test (FFT) provides patient feedback to improve service provision as well as NHS Choices providing patient comments on services.


This paper affects all of the risks under Strategic Objective 2: Systems and processes to monitor challenge and support provider delivery of the NHS Constitution targets.


Monitoring and actively improving the performance and quality of service provision will have a beneficial impact for all patients in Tower Hamlets.

Enclosure H

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2 | P a g e

Resource requirements As outlined in the report.

Next steps As outlined in the report.

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Barts Health Royal London Hospital CQC Report December 2016 Initial briefing for the Tower Hamlets CCG Governing Body – 24th January 2017

The CQC inspected the Royal London Hospital in July 2016. The inspectors reviewed eight core services: Urgent and Emergency Care, Medicine (including older people’s services), Surgery, Critical Care, Maternity and Gynaecology, End of Life Care, Services for Children and Young People and Outpatients and Diagnostics.

Overall the Royal London Hospital has improved from a rating of Inadequate in 2015 to Requires Improvement in 2016

The full report is available in the public domain but the table below shows a very high level comparison between the 2015 and 2016 inspections.

Areas of improvement include:

• Outstanding in Caring in Adult Critical Care. The service had also developed a programme of learning to

ensure best practice and improve patient care for a frequently changing workforce.

• Acknowledgement of the positive changes in the management structure

• Outstanding practice identified relating to innovation in trauma services, excellent sexual health services,

code black protocol for patients with head injuries

• A change from inadequate to good for caring in end of life care and a move from requires improvement to

good for well led in the same specialty

133

• Inadequate ratings reduced from seven to three

The Trust recognises that there is more work to be done and areas of specific focus include:

• Maternity services where the hospital was rated inadequate

• Particular focus on security and baby wrist bands

• High levels of agency staff. Concerns were raised that maternity services were not meeting the 1:28 ratio

• Flow throughout the hospital needs to be improved

• Caring has moved from Good to Requires Improvement in three specialties

The site leadership team is now working on a detailed action plan to address all of the CQCs concerns and a detailed

plan will be fully discussed at the CQC Summit to be held on 23rd

January 2016. There have been many specific areas of improvement since the inspection in July 2016 including:

• a revision of the abduction policy within maternity which is now formally tested on a monthly basis along the

lines of major incident testing protocol

• New baby wrist bands have been developed with the supplier and these are now in use throughout the

maternity unit. Daily audit of use of wrist bands in place.

• Baby tagging system being sourced by PFI provider

• Staffing into permanent posts across the RLH has increased by 4%

• Agency usage on site has reduced by 31%

• The hospital has achieved a 40% response rate in the staff survey and early indications are positive. This

level of response rate will facilitate a meaningful plan to improve areas of concern.

However it is recognised that there is much to be done and the RLH Leadership Team and Executive are now preparing for the CQC summit where there will be a focus on the following themes:

Workforce

Patient Flow

Training & Education

Focus on Maternity (including security, staff wellbeing, leadership and culture)

Assurance and Governance

Jackie Sullivan

Executive Managing Director, Royal London, Mile End Hospital & Community Health Services 16th January 2017

134


Date of meeting 24th January 2017 I

Agenda item 4.1

Title of report: 2017/18 Financial Plan

Author(s): Henry Black – Chief Finance Officer Andrea Antoine – Deputy Chief Finance Officer

Presented by:



Henry Black – Chief Finance Officer – NHS Tower Hamlets CCG

Andrea Antoine – Deputy Chief Finance Officer [email protected] - 020 3688 2510

Executive summary

The 2017/18 Financial Plan provides the Governing Body with the following;

- Executive Summary,

- Business planning rules/Planning Assumptions

- Planned Income and Expenditure budgets

- Planned Surplus

- Risks & mitigations

Recommendation


To approve the content of the report, and discuss any actions required

Key issues Sign off of the CCG Financial Plan 2017/18 Note the contents of the Financial Plan 2017/18 Note the key risks inherent in the Financial Plan for 2017/18

Conflicts of Interest There are no identified conflicts of interests.

Report history Finance, Quality & Performance (FPQ) meetings (CCG)- Information obtained at this meeting helps inform this Board report


N/A


Addresses several corporate objectives, those around finance, ensures the governance body is sighted on key finance and performance

135

targets:

Strategic Objective 3: Creating a thriving and stable health and social care economy

Strategic objective 4: Delivering against our statutory duties.


N/A

Resource requirements None


136

Tower Hamlets CCG 2017/18 Financial Plan

Summary The attached report sets out the Financial Plan for 2017/18 for Tower Hamlets CCG, which was submitted to NHSE on 23rd December 2016. The Financial Plan forms the basis of the CCG’s Budget for 2017/18. The CCG is currently conducting the annual budget setting process for 2017/18 and a paper will be presented to the Governing Body in March 2017. This paper outlines the Financial Plan and seeks to advise the Committee of inherent risks to the CCG incorporated within the Financial Plan for 2017/18. Purpose The CCG’s financial allocations for 2017/18 were issued in November 2016. The purpose of this paper is to set out the financial allocations for the CCG and their basis, any allocation issues, set out the CCG’s running costs allowance, set out the overall commissioning financial plan and inform the Committee of the known potential risks to the CCG Financial Plan for 2017/18. Business Planning Rules For 2017-18 the budgets have been planned to meet the required business and planning rules of NHS England, as per table 1 below.

As noted above the business planning rules recommend a requirement of 1% surplus. However, the CCG Financial Plan is planning to deliver a 2.4% surplus. As in previous years, the CCG is required to have a 1% non-recurrent investment reserve, of which 0.5% is available for CCG investment, the remaining 0.5% as indicated by NHSE is to be held in reserve and cannot be used. This provides a

Table 1. 2017/18 Business Planning Rules %

Surplus requirement 1.00%Non‐Recurrent Investment Reserve ‐ uncommitted funds (0.5%)

0.50%

Non‐Recurrent Investment Reserve ‐ Held in Reserve as per NHSE (0.5%)

0.50%

Contingency 0.50%

Enc. I

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degree more flexibility than in 2016/17, where the entire 1% was required to be held uncommitted in reserve. Planning Assumptions The Financial Plan has been developed based on the 2016-17 outturn adjusted for known changes and uplifted for expected levels of inflation, growth and technological change. The acute contracts have all been based on forecast outturn activity for 2016-17, uplifted for expected levels of growth. This is a realistic planning methodology and should ensure that the CCG does not see high levels of unplanned over performance on acute contracts. All of the provider contracts have been adjusted for the national recommendations on tariff reduction as per the table below.

At this time, a number of our acute contracts have not yet been agreed in terms of activity and finance. The financial plan assumes a funding envelope for these contracts which is a maximum amount. 2017/8 QIPP The Financial Plan is required to support the CCG’s commissioning intentions for the year ahead. These intentions are the same as the CCG’s QIPP plans, all health care commissioning change can be equated to one of the quality, innovation, productivity or prevention aims of the QIPP. The table below details the main components of the CCG QIPP plan for 2017- 18. Where appropriate these have been secured within the 2017-18 Contracting process.

Table 2. 2017/18 Financial Planning

Assumptions

Gross

Provider

Efficiency

InflationNet tariff

inflation

Activity

Growth

(Demog)

Activity

Growth

(Non‐

Demog)

Acute Services ‐2.0% 2.1% 0.1% 3.25% 0.8%Mental Health Services ‐2.0% 2.1% 0.1% 3.25% 0.0%Community Health Services ‐2.0% 2.1% 0.1% 3.25% 0.0%Continuing Care Services ‐2.0% 2.1% 0.1% 3.25% 0.0%Primary Care Services 0.0% 0.0% 0.0% 3.25% 2.3%Other Programme Services 0.0% 0.0% 0.0% 0.0% 0.8%Running costs 0.0% 0.0% 0.0% 0.0% 0.0%

Table 3.2017/18 Net QIPP Plans‐(Recurrent) £'000

Children £36CHS £3,841Integrated care £1,334Mental Health ‐£935Other ‐£496Planned Care £2,087Urgent care £2,782Diagnostics £1,957Grand Total £10,606

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2017/18 CCG Allocation Table 4 below shows the breakdown of the CCG allocation for 2017/18.

The CCG has an allocation of £425.1m for 2017-18 of which £6.384m relates to the Running Cost Allowance 2017/18 Financial Plan (Expenditure) The table below details the main areas of spend for the CCG as included within the financial plan submission.

2017/18 Planned Surplus The CCG has submitted its Financial Plan to NHSE on 23rd December 2016, with a planned surplus of £10.243m, which is 1.4% above NHSE business planning rules of 1%.

Table 4. 2017/2018 TH CCG Revenue Allocation

(income)£'000s

Recurrent Baseline Allocation £364,541Primary Care Co‐Commissioning £43,956Running Cost Allowance £6,384Brought Forward Surplus £10,243Non‐Recurrent In Year drawdown £1,700Non‐Recurrent IR Changes ‐£2,728Non‐Recurrent HRG4 changes £1,013

Total Revenue/Income Budget £425,109

Table 5. 2017/2018 Financial Plan (expenditure) £'000s

Acute £189,331Mental Health £46,641Community £49,294Continuing Care £14,961Primary Care £43,391Other Programme £18,816Primary Care Co‐Commissioning £43,957Total Programme Costs £406,391

Running Costs £6,384

Contingency £2,091

Total Costs £414,866

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Risks Please see below the CCG’s assessment of its Financial Risks (fully illustrated in Appendix 3);

The above table sets out the potential risks of the CCG for 2017/18. In setting the Financial Plan for 2017-18 recognition must be given to potential risk that the CCG will be unable to achieve its financial requirements and duties. The above table uses all the available contingency, reserves and investments available and indicates a shortfall in funds of £8.7m. The main risks identified above are as follows: � Activity growth for services subject to cost and volume payment systems e.g.PbR and CHC (Continuing Health care). In this financial year 2016/17, at Month 9, the acute over performance is projected at £8.1m and Continuing Health Care over spend is £0.7m, however, this have been mitigated through the use of uncommitted investments and other non-recurrent in-year measures. In 2017/18 the CCG cannot place reliance on these resources to mitigate any over performances/over spends as these resources have been exhausted in 2016/17. � Committed Investments/Costs not included in the Financial Plan. There are a number of investments/costs to which the CCG will have to find in year savings to fund. These include the following; CHS Transitional costs £5.6m Associate contracts over and above Financial Plan £0.95m Re-Procurement of CSU £0.35m � Unexpected cost pressures – The Financial Plan does not allow for any unforeseen cost pressures.

£000's £000's

Risks

Qipp Under‐delivery 2,099Acute SLA's Overperformance 3,829Prescribing ‐ price changes 125Continuing Care SLA's ‐ backlog 451Re‐Procurement of CSU 350Out of Sector Contracts Over & Above Operating Plan 950CHS Non‐Recurrent 5,600Total Risks 13,404

Mitigations

0.5% Contingency 2,091Current Reserves available to offset CCG Risks 857Uncommitted Investments 1,720Total Mitigations 4,668

Total Unmitigated Risks 8,736

Tower Hamlets CCG ‐ Risk Assessment ‐ 2017/18Total Risks

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� Delay or failure of QIPP schemes to deliver the planned savings

Please find above the net QIPP included within the Financial Plan for 2017/18. For clarity the CCG’s Financial Expenditure has been reduced by £10.606m – this means that the CCG is reliant on the QIPP Plan achieving this projected saving, any deviance from this Plan is a huge risk to the CCG. In the January Transformation Board meeting the 2017/18 QIPP Plan was fully prioritised, based on clinical and financial performance as well as expected delivery of the schemes, which altered the 2017/18 QIPP Plan figures as follows;

The 2017/18 QIPP Plan will continue to be monitored on a monthly basis, with monthly reports going to the NHSE, the CCG’s Governing Body, the CCG’s Finance, Quality and Performance Committee and the CCG’s Transformation Board. The CCG will continue to have bi-weekly CCG QIPP delivery meetings with all transformation leads to monitor the delivery of the schemes and identify other in year schemes should there be any deviations from plan.

Saving Investment £000's

Acute 13,336 3,385 9,951Mental Health 50 985 (935)Community 3,155 0 3,155Continuing Care 0 302 (302)Primary Care 255 818 (563)Other Programme 0 700 (700)Primary Care Co‐Commissioning 0 0 0

Total QIPP Plan 16,796 6,190 10,606

Tower Hamlets CCG ‐ QIPP Plan ‐ 2017/18

QIPP built into the Financial

Plan £'000

Net QIPP Plan

2017/18

Saving Investment £000's

Total QIPP Plan 16,796 6,190 10,606

January 2017 Transformation Board QIPP Changes (262) (909) 647Total QIPP Plan 16,534 5,281 11,253

Tower Hamlets CCG ‐ QIPP Plan ‐ 2017/18QIPP built into the Financial Net QIPP Plan

141

A detailed breakdown of the Financial Plan is in the attached appendices. Appendix 1 – Financial Plan Summary 2017/18 Appendix 2 – Financial Plan 2017/18 Waterfall (THCCG Income and Expenditure report for 2017/18. Appendix 3 – Financial Risks 2017/18 Waterfall Appendix 4 – 2016/17 Outturn compared to 2017/18 Financial Plan Recommendation Members of the Governing Body are invited to: � Note and comment on the contents of this report and the risks highlighted.

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Appendix 1

£000's £000's

Income Budgets

Recurrent Baseline Allocation 364,541Primary Care Co‐Commissioning 43,956Running Cost Allowance 6,384Brought Forward Surplus 10,244Non‐Recurrent In Year drawdown 1,700Non‐Recurrent IR Changes (2,728)Non‐Recurrent HRG4 changes 1,013Resource Limit as per Operating Plan 425,110

Less Expenditure Budgets

Commissioning Budgets

Acute 189,331Mental Health 46,641Community 49,294Continuing Care 14,961Primary Care 43,391Other Programme 6,858Primary Care Co‐Commissioning 43,957

394,433

Reserves

Other Investments (not related to QIPP)1 3,6891% Non Recurrent ‐ 0.5% Ring Fenced as per NHSE 1,823Operational Resilience 1,200Current Reserves available to offset CCG Risks 857Risk pool 01% Non Recurrent ‐ 0.5% available 2,091

9,660

Total Commissioning Budget 404,093

Operating Budgets

Running Cost Allowance 6,384Other Corporate Projects 4,388Total Operating Costs 10,772

THCCG Projected Surplus 10,244

Tower Hamlets CCG ‐ Financial Plan ‐ 2017/18

Operating Plan

Dec 2016 Submission

Other Investments (included in Reserves Projection) £000's

UCLH Transition Funding for Transfer of Heart Hospital to Barts

500

TST & STP 1,700HLP + Levies 973Post Approved 30NEL 111 Integrated Urgent Care Procurement 24Weight Management Programme 312HIE Recurrent funding 150Total 3,689

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Appendix 2

414,880

10,244 (15)

(189,331) (205,102)

(10,772) (9,660) 10,244

(300,000)

(200,000)

(100,000)

0

100,000

200,000

300,000

400,000

500,000

Recurrent Baseline Allocation Brought Forward Surplus Non‐Recurrent Allocation Acute Expenditure Non Acute Expenditure Operating Expenditure Reserves Forecast Surplus in 2017/18 ‐ ControlTotal Met

£'000

TH CCG Operating Plan Submission

144

Appendix 3

10,244

(2,099)(3,829)

(125) (451) (350) (950)

(5,600)

2,091 857 1,720 1,508

(8,000)

(6,000)

(4,000)

(2,000)

0

2,000

4,000

6,000

8,000

10,000

12,000

Forecast Surplus in 2017/18‐ Control Total Met

Qipp Under‐delivery Acute SLA'sOverperformance

Prescribing ‐ price changes Continuing Care SLA's ‐backlog

Re‐Procurement of CSU Out of Sector ContractsOver & Above Operating

Plan

CHS Non‐Recurrent 0.5% Contingency inReserves

CCG Mitigation to RisksIdentified ‐ Balance from

Reserves

Uncommitted Investments Revised Forecast Surplus in2017/18

£'000

TH CCG Operating Plan Submission ‐ Risks & Mitigations

145

Appendix 4

Tower Hamlets CCG ‐ Financial Plan Summary 2017/18

v's 2016/7 Outturn

£000's £000's £000's £000's £000's £000's

Income Budgets

Recurrent Baseline Allocation £353,213 £364,541 £11,328Primary Care Co‐Commissioning £42,590 £43,956 £1,366Running Cost Allowance £6,299 £6,384 £85Brought Forward Surplus £11,944 £10,244 ‐£1,700Non‐Recurrent In Year drawdown £0 £1,700 £1,700Non‐Recurrent IR Changes £0 ‐£2,728 ‐£2,728Non‐Recurrent HRG4 changes £0 £1,013 £1,013Other Non‐Recurrent Changes ‐£2,022 £0 £2,022Resource Limit as per Operating Plan £412,024 £425,110 £13,086

Less Expenditure Budgets

Commissioning Budgets

Acute £187,366 £189,331 £1,965Mental Health £45,361 £46,641 £1,280Community £49,155 £49,294 £139Continuing Care £14,545 £14,961 £416Primary Care £42,467 £43,391 £924Other Programme £6,134 £6,858 £724Primary Care Co‐Commissioning £42,610 £43,957 £1,347

£387,638 £394,433 £6,795

Reserves

Other Investments (not related to QIPP) £0 £1,989 £1,9891% Non Recurrent ‐ uncommitted funds (0.5%) £0 £1,823 £1,823Operational Resilience £1,792 £1,200 ‐£592CCG Mitigation to Risks Identified £0 £857 £857Risk pool £0 £0 £0TST & STP (business case for drawdown) £0 £1,700 £1,7000.5% Contingency £0 £2,091 £2,091

£1,792 £9,660 £7,868

Total Commissioning Budget £389,430 £404,093 £14,664

Operating Budgets

Running Cost Allowance £6,299 £6,384 £85Other Corporate Projects £4,351 £4,388 £37

Total Expenditure £400,080 £414,866 £14,786

THCCG Projected Surplus £11,944 £10,244 ‐£1,700

2017/18 Financial Plan Variance 2016/17

Projected Outturn

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Minutes of the Executive Committee

15th November 2016, 13:30 – 15:30, 2nd Floor Meeting Room

1 Chairs welcome and introductions


Simon Hall Acting Chief Officer NHS TH CCG Josh Potter Acting Director of Integrated

Commissioning NHS TH CCG

Jenny Cooke Deputy Director of Primary Care NHS TH CCG Archna Mathur Director, Performance and Quality NHS TH CCG Isabel Hodkinson Principal Clinical Lead NHS TH CCG Victoria Tzortziou-Brown Principal Clinical Lead NHS TH CCG Ellie Hobart Deputy Director, Corporate Affairs NHS TH CCG Jackie Brown Interim Chief Finance Officer NHS TH CCG Raana Ali Joint Head of Medicines

Management CSU

Stephen Crane ELFT Rachael Sadegh ELFT Alex Verner Consultant Psychiatrist (RESET) ELFT Lynne Smith PA and Administrator (minutes) NHS TH CCG

1.1 Declarations of Interest & Deferred Decisions

Nothing noted.

1.2 Apologies


Sam Everington Chair NHS TH CCG Somen Banerjee Director of Public Health LBTH

Enc. J

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1.3 Minutes of previous meeting

Agreed as accurate.

Governance

2.1 Learning and Development Policy

This item originally went to SMT where a number of revisions where identified. The revisions included a more detailed description around eligibility. The issue of external development opportunities such as at STP was discussed and it was agreed that the policy should state that such requests also need to be agreed by the individual’s line manager. With that amendment the committee approved the policy.

2.2 SMT TOR

The basis of the TOR came from the notes from the away day and the aim is to make it clear what business flows to the Executive Committee and what flows to SMT. It was agreed that investment in transformation will follow the PMO process and go to the Transformation Board for approval. Alternatively running cost resource allocations should go to the Executive Committee for approval. The committee agreed that one of the roles of SMT should be to help to distinguish where an item might get signed off and provide an opportunity for a more detailed discussion before the decision making process is triggered.

2.3 GB Away Day 6th December

The agenda was agreed yesterday at SMT. Isabel proposed that the accountable care system item should be facilitated using the co-production approach, following on from Julia Slay’s presentation in the first hour. It was agreed that Louise and Katie should facilitate and that the session will be interactive with twenty minutes content and then the rest discussion. A planning session will also be set up.

Action:

EH will feedback to Louise and Katie that it will be an interactive session. EH will set up a planning meeting for the session

Operations

3.1 THCVS Commissioning Intentions 17-18

This has been funded over the past two years supporting the work of the Health and Wellbeing forum to build voluntary sector capacity in support of the social prescribing agenda. The current proposal being put forward is for £70,000 in 2017-18 which EH is keen to continue to fund. It was agreed that this would be funded and EH will ensure that there is a letter which sets everything out clearly.

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3.2 THS Health and Welling Being Strategy 2016/20 – 26th November

This is an event which takes place on Saturday which Jessica and Ellie are attending. The idea is that they engage people on the five areas of the strategy. Ellie and Jess will be dealing with community development element of the strategy. The plan going forward is to hold these events on a quarterly basis in advance of the Health and Well Being Board.

3.3 Personal Health Budgets for continuing Care - Deferred

3.4 Substance Misuse strategy

The strategy follows on from the previous strategy and has been widely consulted on. It has been approved by the full council within LBTH. There is a greater emphasis on recovery. Isabel commented that abstinence and recovery is not always an option for many addicts who have wider social issues. The DAT team confirmed that each person has a care plan where they describe what the person feels should be part of their recovery. It was agreed that the CCG should be part of the strategy as we haven’t had any input to date.

Action

EH to add to 6 Dec GB away day agenda.

3.5 Substance Misuse Prescribing Budgets

A paper setting out the impact of the new Substance Misuse strategy on the shared substance misuse prescribing budget was discussed. The options discussed were

To continue prescribing via FP10s for substance misuse patients for the drugs listed above for patients engaged in structured treatment for substance misuse.

For the CCG to continue funding the prescribing budget associated with these costs (currently approx. £300k per year)

For LBTH to contribute £150k per annum to the prescribing costs to reflect the SAU costs transferred into the Public Health Grant.

For LBTH to continue investment in a primary care NIS to support prescribing of Opiate Substitution Therapy in general practice.

A new set of prescribing policies for substance misuse services to be developed via an advisory board which includes representation from THCCG, ELFT, Barts Health and LBTH. This group would facilitate agreement to, and authorisation of, future prescribing policies to ensure prescribing is appropriately agreed, authorised and monitored.

149

The Executive committee agreed that such a decision would sit better with the joint commissioning executive. Medicine management queried the ePACT data that informed the calculation for the CCG prescribing costs of £300k. It was agreed further information was required to check the baseline ePACT data and that further decisions should be taken to the Joint Commissioning Executive.

Action

To be presented to Joint Commissioning Executive and then reported back.

ePACT data to be checked.

3.6 Update on TST and STP

This is now gathering pace and the latest draft of the document is on the website. There is also lots of communication nationally. It is now getting to the point where it needs a ‘what next’ but there are no answers as yet. It will need resourcing next year which is something that should be discussed by the Governing Body as soon as possible. TST is the delivery arm against WEL so should need no additional resources. A number of key programmes will continue with clinicians to attend. We are moving towards having one PMO that covers both areas - CCGs will then have a clearer role.

3.7 Tower Hamlets Together – Value Proposition

THT had to submit a value proposition to the New Models of Care team. It was proposed that a joint strategy statement between THT and the CCG is developed for 2017- 2020 that outlines what we want to achieve as a partnership.

AOB

None noted.

Next Meeting: 20th December 2016, 1.30-3.30pm, 2nd Floor Meeting Room, Alderney Building

150

Tower Hamlets CCG Transformation Board Tuesday 13th December 2016

12.30 – 17.00pm 2nd Floor CCG Meeting Room, Alderney Building MEH, E1 4DG

Minutes:

No Item Lead 1 Welcome, introductions and apologies. JS

Meeting started at 12.30 and JS (Chair) welcomed the members and took apologies.

2 Declarations of Interest All GP members declared that there could possibly be times when they could be conflicted around items that came to the meeting for decision. It was agreed that on any such items those members conflicted would leave the meeting whilst those decisions were made. No new declarations were made.

3 Review of Previous Minutes / Actions All Previous minutes were accepted with amendments below and the actions agreed as ongoing.

1. Amendment to section 4, second last paragraph – IH asked that it be noted that pop ups could also run in EMIS.

2. Amendment to section 5, last paragraph – IH asked that this be amended to reflect that she had commented with regard to the social impact bond that there was an unhealthy relationship to PFI.

4 Prioritisation Process JP

JP presented the prioritisation tool and spoke about how the scoring would work for each business case. JP confirmed that the scoring would be compiled after the meeting and would be used to further inform the Board. Action: Completed scoring to be distributed to Board.

5 For Decision: Maternity & Early Years / Young People Complex Care Programme.

‐ Bridge ‐ Refining Secondary care Pathways

CR

CR presented the business case and a slide deck to the Board. The Bridge ‐ Project description: For children and young people who are highest users of health care, and have acute complex needs. It provides a case manager and project co‐ordinator who ensure:

• Care is coordinated between agencies, with a named contact professional for the family • MDT meetings take place regularly, involving schools and a range of health professionals • Liaison between specialists, including palliative care and respiratory nurses • Regular communications with patients’ GPs • Regular communication and input from families

Background to the business case:

Attendees

Julia Slay (JS) Chair, Sam Everington (SE), Josh Potter (JP), Isabel Hodkinson (IH), Judith Littlejohn (JL), Victoria Tzortziou (VTB), Carrie Kilpatrick (CK), Rachel Perry (RP), Jackie Brown (JB), Finbarr Hanna (FH), Martin Bould (MBd), Noah Curthoys (NC), Maggie Buckell (MB), Cheryl Rehal (CR), Mba Chujor (MC), Jenny Cooke (JC), Julie Dublin (JD), Rahima Miah (RM), Caroline Billington (CB), Neal Douglas (ND)

Apologies Henry Black (HB), Dennise Radley (DR), Simon Hall (SH), Somen Banerjee (SB), Louise Phillips (LP), Archna Mathur (AM), Barbar Shafiq (BS),

Enc. K

151

• In 2014 Barts Health NHS Trust implemented a small scale 6‐month pilot for 20 children with complex health needs, resulting in a reduction in A&E attendances and emergency admissions.

• For 2015/16 the CCG invested £126k for a 1 year expansion of the pilot for 50 children. This ran from August 2015 to July 2016.

• In 16/17 the CCG agreed to extend the pilot to align with the financial year. The quantitative and qualitative evaluation evidenced positive patient experience and a reduction in overall activity equating to c. £45k, slightly short of 15/16 target of £63k. This was based on a static patient cohort.

Proposal for 2017/18: 1. Based on the quantitative and qualitative evaluation, review the staffing model with providers 2. Implement recommendations from the evaluation: including establish a rolling cohort, agree a discharge

plan with the family upfront, expand MDT membership, and review of acceptance criteria to align with intended outcomes and maximise impact

3. Target savings of £63k through avoided acute activity 4. Develop a business case and implementation plan to establish a sustainable service model for this patient

cohort, in order to conclude the pilot and agree a service spec as part of core contracts with providers IH asked when moving from a static to rolling cohort how this was going to be measured. CR confirmed that this would be measured using anonymised SUS data and patient level data. IH added that when we step down from this it was imperative that the data continues to be monitored. JB commented that Barts Health do not wish to continue to host this and asked whether this should go out to tender. CR confirmed that this currently sits within the CHC contract. Action: Project approved in principle pending the finance team’s affordability analysis CR presented the business case and a slide deck to the Board. Refining Pathways into Secondary Care – Project Description A programme of interventions targeting the reduction of secondary care paediatric activity 1. Development of clinical guidelines, particularly for referrals into General Paediatrics 2. Timely access to paediatric consultant advice and guidance 3. Case based reviews presented by secondary care consultants to GPs on a regular basis 4. A care pathway for children who need to be seen rapidly, but not on an emergency basis

Background to the business case: • In 2015/16, the CCG reviewed OP appointments for CYP at RLH for 14/15. General paediatrics and paediatric

dermatology represented the majority of referrals ‐ 4,500 appts at a cost of £774k. • Based on the TST case for change & engagement with TH GPs, it was identified that some referrals could be

avoided. As a result, a programme was initiated in 2016/17 • QIPP savings of £39k were proposed for year 1. This is behind schedule due to late start of some of the

workstreams. A recovery plan is being put in place to address this. Proposal for 2017/18:

1. Develop a programme plan and regular monitoring to ensure: • Guidelines are published • These are communicated and embedded with GPs • Locality paediatric MDT take place (min quarterly), with a rolling evaluation and a forward plan • Evaluation of the quality of referrals and impact of the Paediatric Rapid Access Clinic to date 2. Review of future opportunities: • Analysis of current referral data to identify any other conditions to be targeted. The audit by primary care

will provide insights into reasons for referral to acute paediatric services. • Analysis of paediatric A&E presentations to identify any other potential opportunities • Explore virtual consultation or telehealth routes for paediatric specialities,

eg for asthma and dermatological conditions

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CR added that the Royal London has recently appointed 3 general paediatricians and they will be able to do the locality meetings. In addition we also will be looking at the successes that have happened in adults and utilise those to continue to improve this service. JB highlighted that we need to know that the clinicians are seeing Tower Hamlets patients and commented that £26k seemed a small sum to cover the MDT meetings. IH questioned the extent of the scoping out of the network capacity for this and was not sure if the infrastructure had been scoped out correctly. ND confirmed that the plan had been taken round to localities for viability agreement and a pilot had been run earlier this year at one locality and was successful. VTB commented that we would need to review the purposes of MDT’s if they were to be also used for educational purposes as this would need to be agreed and highlighted that this may not work for all networks as they would be reliant on 1 person feeding back from those meetings. ND added that the MDT’s were keen not to be seen in isolation and were happy that this could be used as a forum for a variety of subjects that could be useful to all. VTB highlighted that an audit on paediatrics had been carried out a year ago and need to look at the data from that. Action: Project approved in principle pending the finance team’s affordability analysis

6 For Decision: Maternity & Early Years / Young People Complex Care Programme.

‐ Diabetes Preconception Care MC

MC presented the business case and a slide deck to the Board. Project description:

• Diabetes is associated with so many adverse outcomes for mother and baby– stillbirth, congenital conditions etc. The numbers of women presenting as ‘intensive’ on the antenatal pathway are growing, as are the numbers of more complex births.

• In TH 7% (1327) of women of child bearing age have pre‐existing diabetes – national average is 5% • NICE guidance highlights importance of preconception care to minimise risks associated diabetes in

pregnancy. • The pilot aims to provide preconception care to:

o all women of reproductive age during their annual diabetes review in primary care. o refer women intending to get pregnant (within a year) with poor glycaemic to the preconception

clinic in Mile End Hospital for management. Background to the business case:

• In Dec ‘15 TIC agreed a funding of 51k for a 1 year Diabetes preconception clinic from Apr’16 – Mar’17. • The primary and secondary care clinical pathways have been developed (see Appendix). • The pilot was delayed and started in Nov’16 with scheduled end date of Dec 2017. • The Maternity, Early Years and Young People’s Programme Board agreed in November 2016 to carry over

the underspend of £25,375 (service provision) and £7,500 (evaluation cost) to 2017/18. • The pilot will therefore run for a full 12 months from Nov 2016 – Oct 2017.

Proposal for 2017/18: • The pilot be extended for a further 12 months ( Nov 2017 – October 2018) • Agree additional funding of £43.5k to enable implementation :

o £18,125 from Nov 2017 – Mar 2018. o £25,375 from Apr 2018 –Oct 2019.

• Evaluation of the pilot’s outcomes will be undertaken in Q3, 2018/19 MC highlighted that due to the delayed start date of the project that we would not see or be able to measure the benefits and outcome realisation until the current cohort had had their babies. At that point we will then be able to evaluate. JL asked how realistic was it to expect the benefits proposed to materialise. MC confirmed this was based on clinician and consultant advice.

153

IH asked whether a tariff is charged by Barts as well. CR confirmed it is by number of appointments and added that a diabetic specialist nurse was also part of the community services contract. IH added that currently diabetic nurses are not at full establishment. MB commented that if this were to work, there would presumably be less sick children / babies but there did not appear to be a line in the business case showing this. JP confirmed that currently any savings from this area currently go to NHSE but may be coming to CCG’s in the future. IH added in relation to folic acid that GP’s have been discouraged from prescribing this and if GP’s are to start prescribing on this where was the budget for that coming from. IH commented that overall the clinical case was ok but the business case needed more work. JB confirmed that finance would meet regarding this area to look at the financing and contract in detail. Members agreed to vote in principal but was subject to greater clarity within the business case. Action: Project approved in principle pending the finance team’s affordability analysis

7 For Decision: Adults Programme

‐ Primary Care & Urgent Care JC

JC presented the business case and a slide deck to the Board on “Developing resilience in general practice”. Background overview General Practice in Tower Hamlets is facing significant challenges; a growing population, increased demand, changes in contracts resulting in funding changes, and challenges in recruitment and retention. Recent years have seen rising volume and complexity of workload, and rising running costs, while the workforce and investment have not kept pace with other parts of the NHS. 86% of general practice staff in Tower Hamlets believe that change has to take place in order to meet future and current demands and 16% of 330 participants surveyed have described their workload as ‘unmanageable’. Demand for primary care services is increasing. National data suggest that patients are finding it difficult to book primary care appointments as a result of increasing demand in local populations. The recent ‘Save our Surgeries’ campaign, which resulted from the loss of Minimum Practice Income Guarantee from general practice contract funding evidenced the need for the workforce to do more with less resource. It also proved the need for general practice to evolve and innovate in the medium‐term if it is to survive. This can only be achieved if the general practice workforce has the skills to manage its own change. Programme overview The Building Resilience in General Practice work stream was announced in October 2015 to strengthen and build further resilience into primary care through the delivery of strategic and operational support to General Practices in Tower Hamlets. A component of the CCG’s strategic priority to achieve system and individual resilience through implementing new ways of working to address demand for General Practice services1, this work stream was conceptualized to lay the foundations for the long term re‐design of primary care services (CCG Primary Care Work stream 2). The project will deliver this by providing the primary care workforce with a robust quality improvement methodology to help teams to think strategically, make operational changes, and use data to track the impact of these changes. This programme, termed as the CCG’s Work Stream 1 aims to address the significant challenges being faced by general practice in the immediate term, whilst also supporting the longer‐tem re‐design of services (Work Stream 2). What are the programme’s strategic priorities The work stream’s original proposal identified three strategic priorities (see fig.1 as per business case documentation): 1. To develop a strategic data resource relating to the operational and financial status of general practices within the borough of Tower Hamlets (see appendix pack for example metrics) 2. To provide rapid strategic and operational support to organisations delivering primary care services in Tower Hamlets (see appendix pack for range of operational tools and interventions offered) 3. To embed a culture of continuous quality improvement in primary care services through capacity building in established quality improvement methodologies (see appendix pack for QI methodology used) What has happened as part of this programme to date?

154

In October 2015, CCG began piloting the Building Resilience in General Practice programme with four practices in Tower Hamlets. Separately, Jubilee Street Practice, one of the GMS practices in Tower Hamlets, has also undertaken a similar, ‘in‐house’ programme based on the same quality improvement design principles. The pilot practices have already started to deliver impact in a range of areas including improved telephone access, reduction in DNAs, and increased staff satisfaction. The design and implementation of this work has been performed iteratively, and informed by stakeholder consultations, which aims to address the needs of primary care services by consulting directly with providers. The GP Care group, Practice Manager’s Forum and Medical Councils (both locally and London‐wide); all have been engaged in oversight and endorsement of this work. Having now reached a stage with the pilots where some we will switch from high to low intensity support, this business case sets out a case for investment in the continued delivery of the aforementioned priorities to the remaining interested practices in the borough over a period of 2 years with expected completion in March 2019. What is the total investment being requested? The total investment request for the complete delivery of this programme is a fixed sum of £789,860. What are the operational and strategic benefits of the programme? 1) From the practice/provider perspective: • Embedded quality improvement methodology throughout the practice to work on practice’s key issues • Access to on‐going coaching, team development and mentoring to improve practice communications and effectiveness • Improved financial planning and data analysis capabilities • Access to high‐quality real time practice operational data benchmarked against peers • Depending on projects chosen – improved patient access, staff satisfaction and appointment/ resource optimization 2) From the CCG/commissioner perspective: • Benchmarked primary care data to drive design/commissioning decisions • Tools to support providers to deliver measurable improvements • Improved patient satisfaction & safety • Platform to implement the Primary and Urgent Care Strategies • A more sustainable Primary Care landscape to deliver the significant expectations and QIPP savings for the CCG’s strategic priorities JC highlighted that we have been working with 4 practices over the last year and generally their feedback has been positive on the effects the programme has had. Currently 21 of the 36 practices have signed up to the programme. JP asked whether we would have the capability to monitor by practice that the required activities are taking place so that we can track progress and monitor QIPP potential. JB added that we may also need to focus heavily on practices that are not performing as well to see how they improve. MB asked in relation to finances how much capacity will this create if any and does this cover population growth. JC confirmed at this point for example, we do not know how many appointments we have on any given day and the work we are undertaking will give us much better data and insight into practices resilience and resourcing which will allow us to make more informed choices. JB agreed with MB and asked whether we knew if this initiative would really work. JC confirmed that there is evidence in other sectors to show this does work. Action: Project approved in principle pending the finance team’s affordability analysis

New Model for Urgent Care JD presented the business case and a slide deck to the Board. What is being proposed

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The CCGs corporate priority outlines an ambition to ensure people in need of urgent care receive patient‐centred quality and efficient care in the right place, by the right professional at the appropriate time 24 hours a day, every day. “Urgent Care” is defined as the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly for needs that are not considered life threatening. It is recognised that people use A&E to address their urgent needs and the business case outlines proposals to transform the current system. Why is it being proposed Growing pressure on A&E is impacting on their ability to achieve the 4‐hour standard and provide a quality service, maintaining the current model is not sustainable or financially viable. Many people use the service to address their urgent need and this trend is set to continue as people are living longer with complex conditions and population growth. In 15/16, a total of 530,980 people accessed Tower Hamlets based UC services at a cost of £22.8m. Of the total activity 458,281 is attributed to TH residents versus 72,699 non‐TH residents with the majority of this activity distributed between A&E, UC, WiCs and GPOOH. Further analysis identifies that 161,836 people entered A&E with 107,464 coming from TH and the remainder 54,372 non‐TH residents. Total spend across all users residents amounted to £17.8m split between A&E, £17m, and £884k for UCC. In 15/16 A&E attendances reached 95,627 an increase of approximately 7% compared to 14/15 activity of 89,860, costing £10.3m (2014) and £11.9m (2015). An analysis of the A&E data during 6pm – 10pm indicates that attendance rates in 14/15 was 19,961 or 24% of the overall total activity for A&E increasing to 21,285, around 27% in 15/16. How much it will cost and how it will be funded Costs for delivering the strategy from 17/18 amounts to £3,978,000. Resources will be funded through re‐provision costs available through ED & UC funding and new investment from the CCG. A list of the schemes and funding is shown in Table 1 below: What benefits it will bring The level of activity currently utilising UC provision would be distributed to appropriate services in the hospital, primary care in‐hours and out of hours’ provision and the community. The 111 service would be bolstered by the addition of a clinical assessment service (CAS) with clinicians supporting call handlers in reaching the correct disposition with callers. Changes would redesign UEC provision creating a new front door for A&E providing a triage, assessment and treatment service complete with access to a multi‐disciplinary team of health and social care professionals including specialist input, diagnostics and testing. Only cases deemed an emergency or life threatening would directly access the Emergency Department which would reduce attendance levels in A&E making achievement of the 4‐hour standard realistic. The benefits for the wider system and patients is improvement of patient flow, quality of service and experience of primary and urgent care. How benefits are being measured Benefits are being scoped and appropriate indicators identified to monitor progress using 16/17 activity across all points of delivery as a baseline to monitor trend. When it will be implemented and how long will it take The timeframe to achieve transformation is phased over a 2 year period. A comprehensive project plan and governance structure is being developed to support delivery of each component. This business case is covering re‐design of urgent care which includes:

Extended access during out of hours through the locality hubs (April17) Redesign of the Urgent Care and Acute Care to provide a 24/7 service (phased from April 17) Recommission Ambulatory Emergency Care (April 17) Delivering the 111 Integrated Urgent Care standards making 111 the single point of entry incorporating GP

OOH (February 18) Self‐Care and development of a Self‐Care App (to be determined) Directory of Service (on‐going)

What the savings will be and when will it be achieved The savings of £5.963k would be generated by end of financial year 17/18.

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Where the savings will be realized The savings will be gained from reducing HRG tariff associated:

non elective non elective same day non elective short stay length of stay

VTB commented that it was not clear what was being proposed for Walk‐in Hubs. JD confirmed that they will only seeing Tower Hamlets residents 8.00 to 8.00 and general walk‐in’s will be re‐signposted to 24/7 walk‐in centre and book later appointments. IH asked how the £350k is being used and how does this sit with THT work etc.. JD confirmed this for external support. JP added that this amount is an estimate and before any funds were allocated a detailed breakdown would be available. IH added that mental health crisis issues need to be included as well so that their impact has been taken into consideration. VTB added that social care implications also need to be detailed. JB highlighted that it was hard to agree this in this forum as there are a lot of implications that are not fully clear and would need a breakdown of the £350k and a commitment to review the OD element. Action: Project approved in principle pending the finance team’s affordability analysis

8 For Decision: Complex Adults

‐ Combined Complex Adults Initiatives RM

RM presented the business case and a slide deck to the Board. Background Overview

• The overarching aims of the complex adults programme are to: Improve experience and outcomes, through providing more pro‐active, personalised, co‐ordinated

and responsive care Empower people and their carers Ensure consistency and efficiency of care Help to build a sustainable health and social care system

• The complex adults programme believes that an integrated model of care is one of the key vehicles through

which to achieve this.

• Tower Hamlets CCG has had a programme of work around integration in place since 2013. To date, this has largely been focused on commissioning a community based model of care for this group of people. The new model of care seeks to ensure that: Adults with complex needs are identified early They have a person‐centred care plan in place Their care is pro‐actively managed and co‐ordinated in the community, with access to physical

health, mental health, specialist and non‐medical support as required Where their condition deteriorates and/or they need to go into hospital, services are in place to

provide rapid/urgent assistance and get them home as quickly as possible They are empowered and supported to manage their own care, where appropriate and possible

• The business case for 2017/18 includes a mixture of a continuation of existing projects/schemes, coupled with a number of new proposals

• All of the initiatives within the 2017/18 business case can be grouped against one or more of the following themes:

o Continued refinement and monitoring of the new model of care that has been implemented to date

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o Improving integration in areas where we know there are still quality concerns e.g. cancer and last years of life

o Embedding person‐centred care into the integrated care model, with the ability to be able to offer integrated personal budgets (health and social care) at scale

o Parity of esteem, with more explicit attention on identifying and addressing mental health, as well as physical health and social care needs

o Enhancing our focus on people with long term conditions, with a particular view to empowering them and their carers, to reduce their likelihood of increasing complexities further down the line

o Strategic planning for 2018/19 and beyond

• Overall, the proposals will require the following: o Recurrent investment: £186,000 o Non‐recurrent investment: £984,500

• The programme is also expected to yield the following benefits in 2017/18:

o £1,873,779 in savings in 2017/18, largely as a result of reductions in non‐elective activity o Improvements in patient experience and outcomes o The focus of this presentation will be on the proposals that require investment for 2017/18

Initiative 1: End of Life Care Drivers for change:

• % of deaths in hospital is 60% in Tower Hamlets, compared to the England average of 47% (Public Health England, 2015)

• Ambitions for palliative and end of life care (2015‐2020), strongly recommends that every person at the end of life should have access to 24/7 services in the community

Proposals: • Review the need for access to 24/7 specialist palliative care (SPC) in Tower Hamlets; define the service

model to address any shortfalls (it has been identified that there is a potential gap for access to urgent visits/face to face support from SPC professionals from 9pm‐9am Monday‐Sunday; telephone advice only is available during these times at present). This proposal is being compiled by the Transforming Services Together (TST) programme, and will be shared with the Transformation Board in January 2017

• Implement a 1 year pilot project to improve access to end of life medication, through commissioning up to 2 chemists to stock and dispense end of life care medication, either urgently or pre‐emptively both in and out‐of hours.

Expected benefits: • Increase in % of deaths in the usual place of residence (baseline of 26% in 2015) • Decrease in % of deaths in hospital (baseline of 60% in 2015)

Associated investment 24/7 access to specialist palliative care – 175k non‐recurrent Commission up to 2 chemists to stock and dispense end of life care medication 24/7 (1 year pilot ) – 5k non‐

recurrent RM highlighted that the proposals are being developed and will come back in January with further detail but confirmed there would no change to costs. Initiative 2: Cancer Drivers for change:

• Cancer is the largest cause of death in people of all ages and of premature death in Tower Hamlets

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• Tower Hamlets Cancer Joint Strategic Needs Assessment and Strategy (2015), both of which highlighted that early diagnosis has the potential to improve 1 year cancer survival rates

• CCG Improvement and Assessment Framework: Indicators around cancer form part of the CCGs annual assessment/assurance process with NHS England. Performance is as follows: One year survival rate: 66.5% % of cancers diagnosed at stages 1 and 2: 43.9%

Proposals: • Continue to implement the RCGP audit tool in primary care, to better understand patient and system

factors in late diagnosis and to support interventions to increase earlier detection • Continue to implement cancer care reviews in primary care, to identify, at an early stage (i.e. no later than 6

months of diagnosis), the needs of a patient, ensuring that they are provided with the appropriate support Expected benefits:

• Increase in 1 year survival rates for cancer (baseline of 66.5% in 2015/16) • Increase in % of cancers diagnosed at stages 1 and 2 (baseline of 43.9% in 2015/16)

Associated investment: RCGP audit tool, via the Network Incentive Scheme – 52k recurrent Cancer Care reviews, via the Network Incentive Scheme – 34k recurrent

Initiative 3: Respiratory Drivers for change:

• NHS Right Care evidence shows Tower Hamlets as an outlier against our benchmarked peers in respiratory, both in terms of financial and quality outcomes. They estimate the following opportunities: £628k in COPD non elective spend £629k in prescribing spend for Seretide (across all respiratory conditions) 47 lives saved <75 mortality from bronchitis, emphysema & COPD

Proposals: • Over 2017/18, planning will be undertaken with the key stakeholders to identify the drivers, and potential

solutions for the discrepancies outlined above. This will help to inform commissioning intentions for 2018/19 and beyond

• In the short term i.e. over 2017/18, the proposal is to implement an 18 month pilot project for 0.4 WTE specialist respiratory pharmacist to carry out medication reviews of patients with COPD

Expected benefits: • Outcomes/metrics will be developed as part of the evaluation framework for the project. As a minimum,

the following will be tracked pre and post the pilot period: - Concordance with maintenance inhalers - Prescribing levels of inhaled steroid combination inhalers - Prescribing levels of reliever medications - Flu immunisation uptake - COPD related A&E attendances and non‐elective admissions

Associated investment: 0.4 WTE specialist respiratory pharmacist, over an 18 month period – 60k non‐recurrent

IH voiced concerns that the existing asthma pharmacist did not visit all practices currently which created an inequity and need to ensure that there is equity across the practices. Initiative 4: National Diabetes Prevention Programme (NDPP) Drivers for change:

• There are approx. 20,000 people in Tower Hamlets at risk of developing Type 2 diabetes

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• The NDPP was announced in the NHS Five Year Forward View (2014), which set out the ambition to implement, at scale, a national evidence‐based diabetes prevention programme

• The prevention programme has been commissioned by NHSE; Tower Hamlets, together with Hackney, Newham and Waltham Forest are part of the first wave of the roll out of this initiative across the country

Proposals: • Continue to incentivise primary care, through the Network Incentive Scheme, to identify, contact and

consent people onto the programme • Over the course of 2017/18, the expectation is that:

1600‐3000 people will be contacted 750‐1500 will consent to having their details to the NHSE commissioned prevention programme

provider (Reed Momenta) 600 people will be eligible to participate in the programme

Expected benefits: • Decrease in risk of developing Type 2 diabetes within the cohort of people participating in the programme • Reduce, or at least help to contain, the prevalence of Type 2 diabetes (long term)

Associated investment: NDPP referrals, via the Network Incentive Scheme – 42.5k non‐recurrent

Initiative 5: Personalisation Drivers for change:

• Integrated Personalised Commissioning (IPC) is a national must do. The Five year Forward View pushes for a major expansion in the ability of CCGs to be able to offer personal health budgets, and CCGs and Local Authorities to be able to offer integrated health and social care budgets, allowing individuals to exercise more choice and control over how their own care and support is provided

• Tower Hamlets is a demonstrator site for IPC, with the expectation that 1% of the population will have a personalised care and support plan in place by 2018 (2 years ahead of the Five year Forward View national expectation)

Proposals: • Continue to implement the IPC programme amongst 4 cohorts: adults with learning disabilities, children and

young people with special educational needs and disabilities, adults with multiple long term conditions and adults with severe and enduring mental health needs

• Programme costs of approx. £487k are in place to fund the management and delivery of the programme • However, additional investment is required to provide a maximum of 400 people with up to £1,250 in care

package costs. This will be for them to use flexibly to spend on services that help to meet their goals, as identified through the person centred planning process

Expected benefits: • Outcomes/metrics are being developed as part of the evaluation framework. The following will be tracked

as a minimum: ‐ Impact on quality of life ‐ Impact on patient activation ‐ Impact on cost / usage of the system

Associated investment: Care package costs – 500k non‐recurrent

JB asked whether the savings would be made in 2017 / 18. RM confirmed they would but we be tracking the and evaluating those people involved to fully understand what the impactors are and what the future potential would be. Initiative 6: Learning Disabilities (LD)

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Drivers for change: • Nationally we know that people with a learning disability continue to have poorer health outcomes and a

poorer experience of health services than people without learning disabilities • Transforming Care Plan (TCP), 2015: A national plan to develop community services and close inpatient

facilities for people with a LD and/or autism who display behaviour that challenges, including those with a mental health condition. The TCP has outlined as aspirational model of delivery ‐ ‘Building the Right Support’, which defines what good care provision looks like for this cohort

• CCG Improvement and Assessment Framework: Indicators around LD have now been included as part of the CCGs annual assessment/assurance process with NHS England. Performance is as follows: Proportion of people with a LD on the GP register receiving an annual health check: 57% (target of

85% by 2018/19) Reliance on specialist inpatient care for people with a LD and/or autism: 7 in CCG commissioned

beds, 3 in specialist commissioned beds (2015/16) Proposals:

• Appointment of a 1 WTE band 7 nurse to: undertake annual health checks (AHCs) for Tower Hamlets LD patients in an accessible setting Provide support and training to primary care staff to undertake AHCs

• Undertake a review (as part of the national LD Mortality Review (LeDer) Programme) of all LD mortalities to clarify any potentially modifiable factors associated with the death of a person with LD

• Implement a range of initiatives to ensure compliance with the national ‘Building the Right Support’ Framework as follows: Audit and implement a recovery plan to ensure better preventative and holistic planning for people

on the TCP risk register (i.e. a database of people with LD and/or autism who are at risk of hospitalisation due to behaviours that challenge)

Commission a voluntary sector organisation to develop a user led quality checker scheme, to help improve the accessibility and suitability of local health services for people with a LD and/or autism

Commission John Howard (local forensic services centre) to provide ongoing outreach and supervision support to the Community Learning Disabilities Services (CLDS) to enable them to better manage high risk forensic cases

Appointment of 1 WTE Band 7 Positive Behaviour Practitioner (PBS) within CLDS, to support the service to become NICE compliant in the management of challenging behaviour

Continued 1 year of funding for a fixed term 1 WTE band 8a Commissioning Manager to lead on the LD programme of work, as outlined above

Expected benefits: • Increase in % people with a LD having an AHC (baseline of 57% in 2015/16; target of 80% by 2018/19) • Increased health activation in people with LD measured by take up of appropriated health screening.

Baselines in Q2 of 16/17: Cervical (38%), Breast (14%) and Bowel (80%) • Reduction in mortality rates for people with a LD (local baseline to be established in 2017/18) • Reduction in serious incidents (SI’s) involving people with LD (baseline of 6 SI’s in 2015/16) • Decrease in number of people with LD and/or autism in inpatient facilities (baseline of 7 for CCG

commissioned beds and 3 specialist commissioned beds in 2015/16) • Decrease in number of people with LD and/or autism in contact with specialist forensic services or the

criminal justice system. Baselines in November 2016: • 3 in contact with specialist forensic services, 3 in prison and 23 in the criminal justice system

Associated investment: • 1 WTE Band 7 Nurse to undertake Annual Health Checks – 68k non‐recurrent • User led quality checker scheme – 95k recurrent • Outreach and supervision for CLDS with forensics cases – 5k recurrent • 1 WTE Band 7 Positive Behaviour Practitioner (PBS) within CLDS – 68k non‐recurrent • 1 WTE Band 8a Commissioning Manager – 66k non‐recurrent

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IH asked in relation to the user led quality checker scheme who the current provider was. CB confirmed this was ELFT JB commented that not all of the above schemes may be affordable and will be required to go through the prioritisation tool. Action: Projects approved in principle pending the finance team’s affordability analysis

9 For Decision: Mental Health

‐ Five Year Forward View CK

CK presented the business case and a slide deck to the Board. Background Overview Tower Hamlets, along with other areas, must plan to deliver, in full, the implementation plan for the Five Year Forward View for Mental Health. This incorporates commitments to improve access to and availability of, mental health services across the age range, and enhancement of community services to take pressure off inpatient settings. In identifying the key priorities for 2017‐2019 we are focusing on areas where additional investment and transformation is required to deliver key standards. These are areas which, if left unaddressed, are likely to have a detrimental impact on both our compliance with MHFYFV standards and perhaps more significantly patient experience and outcomes. They are also the improvements which can, over the longer term have the most significant impact on the numbers of people requiring admission and treatment in secondary mental health services. These areas are summarised as:

1. Meeting the challenging access trajectories for Improving Access to Psychological Therapies (IAPT) between 2017 and 2020,

2. Meeting the access standards and compliance with the fidelity model for Early Intervention in Psychosis (EIP) for all age groups.

3. Implementing a plan to improve crisis care for all ages. This includes the specific requirement to ensure the effective 24 hour accessible crisis teams through the provision of 24 hour home treatment teams, so reducing the reliance on crisis services based in A&E settings.

The current pathway for psychological therapies appears to be disjointed with a number of points of entry; providers describe confusion about inclusion criteria and acceptance thresholds. As such we are recommending that an in‐depth review of provision is undertaken to determine the future pattern of services to be commissioned over the next 5 year period. This is in the context that all contracts for Compass, Mind and CELEBS are due to expire in April 2018 and so will be subject to a competitive tendering process during 2017. Pending the Outcome of this Review additional investment will be made in 2017‐18 with Compass Well‐being to ensure delivery of the access target trajectories for the period between 2017 and 2019. Capacity modelling suggests this to be an additional 2 therapists at a cost of £200k for this period. Longer term investment requirements will be considered as part of the review. It is vital that in order to improve the outcomes for individuals and improve their experience when in crisis, we develop a crisis model able divert people away from attendance at A&E. The CCG will undertake a project between now and the end of February to map existing pathways for those in mental health crisis to ensure they offer an alternative to attendance at A&E and the RAID Service. This priority will ensure that our crisis pathways continue to be robust and that access is in line with national expectations. Outline assessment of gaps in provision suggest that investment to support development of the pathway is required at £500k per annum; to be phased over a 2 year period 2017‐019 as the model is embedded. Phase one of this project is to conduct a baseline audit and review of the CRHTT to assess staffing levels and caseloads and current best practice, this will inform a funded plan is being implemented to address the gaps that have been identified. Following the modelling of these new requirements an additional 2.5 additional psychologists were funded from non‐recurrent monies to support an anticipated additional case load of 77 cases a year. These psychologists ensure the service is able to meet the NICE guidelines and comply with the requirements for evidence based treatment, in CBT and Behavioural Family Intervention. The additional funding request was authorised by the transformation and

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Innovation Committee in 2016 on a non‐recurrent basis for £288,000 for an18 month period to enable the service to be up and running for a full year. Continuation of this funding being subject to a full evaluation taking place in the Spring of 2017. This business case is recommending the recurrent continuation of this investment‐ to be phased over a 2 year period as the existing pilot comes to an end. VTB asked if the waiting times and activity targets were part of the existing block contract. CK confirmed they were not currently and we have two contracts, 1 with ELFT and 1 with Compass. JL added that it is only recently that targets and NICE guidance has had this impact and that is why this funding is being requested. IH commented that from the papers it felt like the resources to firstly clear backlogs and secondly to maintain the work were bundled together and it didn’t feel like we were ever getting to a stage where we are dealing with current workloads. IH added that it would be good to see something next year that shows saving; in A&E usage, reduced drug prescriptions, etc. Action: Project approved in principle pending the finance team’s affordability analysis

10 For Decision: Mental Health

‐ CAMHS Transformation MBd

MBd presented the business case and a slide deck to the Board. Background Overview This business case proposes the next steps in our joint plan with partner agencies to transform CYP MH and wellbeing services and meet the requirements of Implementing the Mental Health Five Year Forward View (MHFYFV). It focuses on the need for investment to see more children and young people (CYP) in line with the targets and investment set out in that document. (Further local transformation work will be the subject of business cases which do not require additional investment.) It is driven by the joint local priority to refresh child and adolescent mental health (CAMHS) pathways and improve services; by urgent local mental health need in our poor, young, deprived, diverse and rapidly growing population; and by the national NHS priority (with its published funding increases and trajectories for growth in MHFYFV). It contributes to the overall direction and priorities of the STP. The net total cost to the CCG in 2017/18 is £352k, with a recurrent cost of £308k in 2018/19. (This net figure excludes other income – details of which are in section 8 which is described in the body of the business case). Detailed changes are set out in section 8. Together they will bring the following high level benefits in 2017‐19:

Increase the number of CYP who receive evidence‐based mental health services, whilst reducing waits from 28% in 2016/17 to 35% of diagnosable population in 2020/21.

Improve self‐care and accessibility, so mental health needs are better met by earlier intervention without referral to secondary CAMHS

Intervene earlier and in better coordinated ways to meet the mental health needs of vulnerable young people with social care needs

Begin to reduce inappropriate referrals to crisis services in A&E and emergency services, and coordinate urgent and crisis responses to CYP with mental health needs, paving the way for reduced admissions to CAMHS inpatient care over five years

These steps drive forward the strategic changes envisaged in the local Transformation Plan of CYP Mental Health, and are part of wider local and MHFYFV trajectories to 2020/21. In addition, some elements of the transformation are being funded by NHS sources external to the CCG:

Workforce development by CYP IAPT training and a CYP Psychological Wellbeing pilot funded by NHS England and Health Education England (HEE)

Youth Justice worker funded by co‐commissioning for NHS England The Local Transformation Plan also includes areas such as integrated early years support (driven forward by Tower Hamlets Together) and outcomes based commissioning. Both of these will come forward for future business cases,

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although no additional investment is currently planned. All these initiatives contribute to the overall impact of CYP mental health transformation. The social and economic benefits of improved children’s mental health are:

Reductions in the use of public services because of better mental health Increases in earnings associated with the impact of improved mental health on educational attainment.

Later life health service costs are reduced by improved mental health services, from psychiatric services, physical health costs, and reduced use of emergency services. However, quantification of the cost and activity savings from investment in children’s mental health is not possible from current data. Benefits will therefore be measured by Tower Hamlets Outcomes Frameworks, MHFYFV trajectories and access standards, relevant LBTH plans such as the Children Looked After Strategy and the Children and Families Plan 2016‐19, service performance targets in contracts or in local service agreements. The business case is not built on cashable savings, but on MHFYFV requirements to see more CYP and the associated investment profile in that document. This business case covers the first two years of the MHFYFV five year trajectory, aligned with the ELFT contract and the developmental nature of the transformation. The five year plan to switch costs from inpatient CAMHS to community services will require the full five years to yield benefits, according to the timetable set out in MHFYFV. Changes in perinatal mental health services in that document starting in 2019/20 will also not bring savings until after 2020/21. MB ask whether this investment was over and above national investment and is the national investment ring fenced. MBd confirmed it was and clarified that if the national investment funding was not used we would not be able to use it for anything else. JP added that going forward the modelling needs to be visited. Action: Project approved in principle pending the finance team’s affordability analysis

11 Commissioning Intentions & QIPP 2017/19 Update JP / RP JP updated highlighting and confirming the areas that will have impact next year. JP added that overall currently we have identified 16.3m in savings but when these are offset will come down to 12.7m. RP confirmed that TST work will be coming in January and this should have savings that will also have an impact.

12 AOB All None Date of next meeting: 10th January, 12.30 to 14.30 2nd Floor CCG Meeting Room, Alderney Building, MEH Alderney Building, MEH

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NHS Tower Hamlets Clinical Commissioning Group Finance, Performance and Quality Meeting Part I – Performance and Quality Date and Time: Wednesday 26 October 2016, 13:00 – 14:00 Venue: Room 3, Education Centre, Mile End Hospital Chair: Tan Van Dal (TV), Secondary Care Consultant Governing Body Member Attendees: Archna Mathur (AM), Director of Performance and Quality, NHS TH CCG

Dee Parker (DP), Interim Head of Performance & Contracts (WELC POD), NEL CSU Jackie Brown (JB), Interim Chief Finance Officer, NHS TH CCG Pacifique Kimonyo (PK), Performance Manager and Quality, NHS TH CCG Jenny Cooke (JC), Deputy Director of Primary and Urgent Care Sandra Moore (SM), Deputy Director of Performance and Quality, NHS TH CCG Selina Bailey (SB), Performance and Quality Business Manager, NHS TH CCG

(Minute Taker) Steven Jones (SJ) – Director of Finance, NEL CSU Julia Panayiotou (JP), Mental Health Quality Manager, NHS TH CCG

Apologies: Alison Glynn, Andrea Antoine, Deane Kennett, Henry Black, Isabel Hodkinson, Josh Potter, Mariette Davis and Simon Hall.

Agenda items

1. Welcome and introductions TV

TV welcomed all to the meeting and noted the apologies.

2. Conflicts of Interest TV

As per CCG conflicts of interest register. None declared.

3. Review of minutes and action log TV

The previous minutes were approved and agreed as an accurate record. The action log was reviewed and updated.

Enc. L

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4. Barts Health Review of performance and quality report and existing escalations on red areas for Barts Health

DP and SM

The committee discussed the structure of the meeting and whether in the future the meetings may be divided into Part A – private and Part B – public. Action: AM to provide an update at next meeting on how the FPQ (Part 1) meeting should be structured going forward. DP provided the following updates regarding A&E, Diagnostics, Cancer and LAS performance: A&E - is under performing against site level trajectory (A&E performance hasn’t been reached for 44 days in a row) and attendances and activity are increasing. A detailed A&E plan for the STP has been submitted for 20th October 2016. A meeting has been set up with the Chief Operating Officer to discuss the plan in detail alongside the system management plan which provides details of the senior management staff in place. Diagnostics - TH and BH have met their targets in July and August.

Cancer – August data is showing the RLH site to be underperforming. Compliance is currently at 80% against the 85% for 62 day standard. 5 patients out of 25 breached the 62 day target.

LAS – DP did not have up to date information for this provider. SM presented the Barts Health Quality Report for August. The following exceptions were highlighted. FFT – BH and RLH remain low, especially in ED performance still declining, 3% in August compared to 3.2% in July. The matter has been escalated to CRG and a remedial action plan is expected on Nov 4th 2016.

MSA – 17 breaches reported in August 2016 compared to 8 breaches reported in July. This will be closely monitored at CQRMs. SM explained that delayed discharge (or step-down) from critical care requires a hospital wide approach, linked to improving patient flow. This is being addressed within the Emergency Care and Patient Flow work-stream. SM has also completed a Quality Assurance visit to the Critical Care department to review the MSA breaches. This was discussed at the last CQRM. Safer Staffing – Fill rates for RN/RMs in August was below 80% in the following areas: Paediatric Critical Care 6c – (66%), Maternity 8f – (60%) Barkantine (77%). The neonatal department, 8d, reported 5 red flags due to staffing issues. Action: SM to investigate the neo natal staffing issues as part of quality assurance visit. Training – Infection control level 1&2 (clinical) training was below the 85% threshold. SM updated the group that at the next CQRM will be focused on safeguarding and training will be discussed. MRSA – to date Barts Health have reported 8 MRSAs. All these were reported from RLH. C Diff – 37 cases have reported across Barts Health. 10 were from the RLH site who have an

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annual target of 34. Although the cases of C Diff for the RLH site is likely to increase through winter, the site is on course to achieve the target. Datix backlog – at the October CQRM the backlog was at 91 incidents. The expectation is that November CQRM the RLH site should have 0 overdue incidents.

Complaints – RLH site still not meeting target to respond to complaints within 25 working days. This has been escalated to CRG and an action plan has been produced. TV queried what departments are poor performing with regards to complaints response. Action: SM to request that RLH site produce a complaint report to highlight the specialities not meeting the 25 day response target.

Mental Health Services

5. Mental Health Performance and Quality JP

Memory Clinic Referrals

Dementia and Memory Clinic performance have improved. This is due to close monitoring from the CCG staff who have been meeting with the Trust leads to ensure the backlog is brought down for waiting times.

At present there are no patients waiting longer than 6 weeks. JP has viewed the September data which shows the compliance is at 90% for 6 week waiting times.

PTS

JP is working with ELFT on how they will bring down their backlog. There are 32 patients waiting over 18 weeks and 77 patients over 11 weeks. Patients waiting over 11 and 18 weeks are being contacted during their waiting time. There is a follow up meeting arranged in December 2016 and weekly data reports from ELFT on how the backlog is being managed and what are the risks to patients.

The next ELFT CQRM is on Tuesday 01 November 2016 there has been a request for PTS data to be presented.

AM went to the ELFT Quality Summit was very good. There has been recognition by ELFT in the areas that need improvement. NHS England and NHS Improvement have released their reports for Trusts ratings. BH is in the 4 category and ELFT is in 2 – not met their control total.

Action: AM to send the NHS Improvement Trusts ratings.

At the ELFT Quality Summit, the Trust was also commended on staff satisfaction levels. JC commented that a comparison of ELFT staff survey from 5 years ago to the current date shows that they have taken proactive steps to improve staff satisfaction.

SM explained that the Trust also invest in the development of their staff. Staff can be recommended into the QI program and there are leadership development programs as part of compliance with the Implementing the Workforce Race Equality Standard (WRES).

6. Mental Health CQUINS Update 2017-18 JP

The CQUIN schedule is in line with the 2 year contract. There are 5 national indicators for Mental Health:

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Improving staff health and wellbeing: flu vaccination Child and Young Person MH Transition Physical Health for people with Severe Mental Illness Improving services for people with mental health needs who present to A&E Preventing ill health by risky behaviours – alcohol and tobacco

Primary Care

7. Service Alerts PK

There have been no CQC reports since the last FPQ thus the primary care update was focused on service alerts raised by GPs. 25 service alerts were reported in August 2016 of which 13 have been responded to. The three main specialities GPs are complaining about are maternity, Community Health services and dermatology. Service alerts relating to maternity (midwives turning up late, announced or without ID) will be discussed at the December CQRM which will focus on the service.

Community Services

8. BH (CHS) Performance and Quality Dashboard PK

Serious Incidents Children’s Service – Serious incident reported in June 16 regarding discharge summaries from Wellington Way not being sent to GPs and other professionals following a health assessment. The SI report has been received. Action: PK to arrange Quality Assurance visit for Wellington Way to ensure that actions from the SI report have been implemented. GP OOH - The service had to be closed on three occasions in September (Wednesday 7th, Thursday 8th and Sunday 10th September 2016) due to insufficient clinical/medical cover. Director of Performance and Quality escalated the issues to site leaders to ensure that protocols are in place and are followed before the service has is closed. There has been no closure to the service in October. Incidents (Adults) – The number of overdue incidents has increased. There were 13 overdue incidents reported in September compared to 5 incidents reported in August 2016. Contributory factors to the number of overdue incidents include to staff sickness and annual leave. Overdue incidents discussed regularly at CQRMs. Complaints - Several complaints have been received in the last months regarding the District Nursing service. Complaints are regarding poor care provided to patients requiring wound dressing and frequency of visits. Complaints are still open as the CHS team are still completing the investigation. Action: Complaints relating to district nurses to be discussed at next SPR and PK to arrange Quality Assurance visit for district nurses by locality. CHC – project manager has been recruited to lead on the implementations of the recommendations from the NHS Continuing Healthcare – Governance and Assurance report produced in June 2016. The Joint Continuing Healthcare Committee has also been put in place and meets monthly to discuss CHC issues and DTOCs relating to Barts, CCG and the Local authority.

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Action: Update on programs in place to improve DTOCs to be discussed at next meeting.

For Information

9. CRG Report July BH CQRM August BH CQRM Agenda

Noted for information.

10. AOB All

Nil noted.

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NHS Tower Hamlets Clinical Commissioning Group Finance, Performance and Quality Meeting Part II – Finance Date and Time: Wednesday 26th October 2016, 14:00 – 15:30 Venue: Room 3, Education Centre, MEH Chair: Jackie Brown (JB), Interim Chief Finance Officer, NHS TH CCG Attendees: Archna Mathur (AM), Director of Performance and Quality, NHS TH CCG

Deane Kennett (DK), Assistant Director of Contracts, NEL CSU Dennise Friday (DF), Finance Business Manager, NHS TH CCG Jim Dodds (JD), NEL CSU Finance NELCSU Alex Jackson, (AJ), Finance Manager, THCCG Sandra Moore (SM), Deputy Director of Performance and Quality Stephen Jones (SJ), Moira Coughlan (MC), Joint Head of Medicines Management Tan Van Dal (TV), Secondary Care Consultant Governing Body Member

Apologies: Mariette Davis (MD), Lay Member for Governance, NHS TH CCG

Deane Kennett (DK), Assistant Director, NEL CSU Andrea Antoine (AA), Deputy Chief Finance Officer, NHS TH CCG

Henry Black (HB), Chief Finance Officer, NHS TH CCG

Agenda items

Welcome and introductions JB

JB welcomed all to the meeting and noted the apologies.

15. Conflicts of Interest

As per CCG conflicts of interest register. None declared.

16. Review of minutes and action log

The previous minutes were approved and agreed as an accurate record. The action log was updated accordingly. Action: Minutes of August meeting to be redrafted and sent to Chair for review asap. The minutes to be brought back to the next FPQ for approval

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Committee - Part II Wednesday 26th October 2016

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17. CCG Finance Report Month 6 JB

(JB) provided the update on the financial position for the CCG at Month 6 (September 2016) and a forecast for the year. At month 6 the CCG is reporting a year to date surplus of £5.972m and forecasting a full year surplus of £11.942m, in line with the CCGs Financial Plan. However, commissioning reserves and unused accruals from 2015/16 are required to offset pressures on contract activity, particularly in the acute sector and co-commissioning areas, in order to achieve the targeted position. The following points were discussed:

The organisation can still achieve the surplus of £11.9m but within that there are significant budget variances requiring use of commissioning reserves both recurrent and non-recurrent, creating a problematic opening financial position for 2017/18.

Last month’s forecast variance for acute contracting was £1.8m lower so there has been a material worsening since last month and only just over half is accountable to the Barts Health contract.

There is a trend materialising with maternity referrals and activity taking place outside of Barts, causing overspends in other acute trusts.

The bill for overseas visitors is 50% chargeable to the CCG. The BAF has been updated since the last FPQ meeting in respect of the financial risks. It was agreed the revised reporting containing more detail is useful and should be adopted

going forward.

Barts Heath Contract

The £7.4m acute trust overspend is largely, but not wholly, attributable to the Barts contract.

An outpatient variance of £4.292m is the biggest issue within this contract. The RTT backlog position at Barts is not fully understood, and as the backlog is cleared

so will the CCG spend increase. A letter from Barts has been received stating provider intentions in respect of coding

changes. The contracting team are working through this to assess any financial consequences for 2017/18.

BMI

The forecast position has worsened following receipt of more robust information regarding BMI activity.

Some double counting by BMI was identified (7 patients)

ACTION: (JB) to review the BAF again in light of the deteriorating financial positions

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18. QIPP Report Month 6 JB

At the April 2016 Board the CCG Budgets including the associated QIPP plans for 2016/17 were approved. At that time the CCG had a net QIPP plan of £8.7m.

In the subsequent May submission of the operating plan the CCG amended the QIPP Plan for 2016/17 – the amendments made to the QIPP plan removed all investments which were not associated with the saving schemes, thereby showing the net effect of the CCG’s QIPP schemes for 2016/17 of £11.8m.

At month 6 the QIPP report shows a year to date under achievement against the revised plan of £478k, with a projected full year break even position. The Month 6 Finance QIPP report is subject to a number of caveats regarding availability and accuracy of data and therefore should be read and interpreted in this context.

Also note the following

Any new schemes will be added in as the current financial year progresses, in order to mitigate the growing financial pressures now being seen.

Prescribing efficiencies due to price changes have resulted in savings and these have now been incorporated into the QIPP programme.

Part of the problem with activity for Barts is due to the late start of schemes, which is a critical issue to be addressed when it comes to planning for 2017/1.

Future QIPP schemes needs to be clearer regarding the impact on activity plans, as some acute based schemes reduce activity and release capacity, some reduce activity and enabled capacity to be reduced and some reduce demand for services.

TST and STP schemes will have an impact on the financial positions in future years.

19. Finance and Activity:

19.1 Review of overall financial position

19.2 Review of acute position

19.3 Contract Update – BH including CHS, ELFT, Associates

JD

19.1 Review of overall financial position The CCG has forecast a full year surplus of £11.9m which is in line with the Financial

Plan for 2016/17. This section of the discussion focusses on the detail behind the financial activity and seeks to link financial performance with activity variances.

19.2 Review of acute position Acute budgets are forecasting a £7.4m overspend. The main driver for the over-spend

being Barts at £5.6m. 19.3 Contract Update – BH including CHS, ELFT, Associates

Maternity is showing £400k overspend across all providers. Outpatient activity has increased, but electives have not increased. £4.5m overspend in outpatients should be scrutinised in great detail, understood and a

plan put in place to address the issues.

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There has been an increase in dermatology outpatients, although TELEDerm is in operation.

There is increased counting for diagnostic imaging. The finalised Q1 Barts position is currently being discussed and may result in an increase

to the forecast position next month depending on the outcome of CFO negotiations around claims.

Emerging pressures need to be identified and investigated as to whether these can be delivered elsewhere and more efficiently.

Pressures need to be identified and investigated as to whether these can be delivered elsewhere and more efficiently.

The CHS contract has been extended to the end of November. Any further delays in implementing the new CHS contract are likely to have an adverse effect on the overall CCG financial position.

Further analysis on out of hours in included in the pack. Contracts next year will need to be set using this year’s forecast as the starting point. The Barts contract starting point will be based on 9 months of this year and 3 months of

last year. Allowing for seasonality and getting plans correct and affordable. Performance against activity plans this year should be used to influence the pipeline of

demand management schemes for next year.

ACTION: (JD) to provide details of market shares for maternity services at the next meeting ACTION: (JD) to provide a slide for each key driver of activity variances and overspends at a detailed level to inform 2017/18 QIPP planning. ACTION (JP) The use of TELEDerm to be reported on. ACTION: (JB/AM) meet with Simon/Josh to discuss the approach to QIPP planning next year.

Prescribing

Tower Hamlets CCG were £448k over plan for High Cost Drugs at BH YTD at M5. The two biggest drivers of this over performance are Subfoveal choroidal neovascularisation (£209k over plan) and Cytokine Modulators (£199k over plan).

Also note:

The Prescribing Board is overseeing the delivery of work plans and annual visits within practices.

Business cases for biosimilar drugs should be accelerated due to the likely benefits to patients and system wide finances.

ACTION: (MC/RA) Determine what are the drugs referred to in the meeting and what specialities they are used for.

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LAS (SJ)

Pan London performance in August saw an improvement against the July position. The 2016/17 contract has been agreed and signed off by the LAS and Lead Commissioner. The 111 service contract is expected to be signed off early next year.

20. AOB

ACTION: (AA) Arrange for individual finance team members to shadow prescribing visits to practices.

ACTION: (JB) Consult (MD) on the prescribing report format.

CLOSE

Date of next meeting: Wednesday 23rd November 2016 – Room 7, Education Centre, MEH

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