NHS Redbridge Clinical Commissioning Group Governing Body meeting 26 January 2017

1.30pm Boardrooms, Becketts House, Ilford, IG1 2QX

Item Time Lead director Attached, verbal or to follow

1.0 1.1 1.2 1.3

Welcome, introductions and apologies Declaration of conflicts of interest Minutes of the meeting held on 24 November 2016 Matters/actions arising

1.30 Chair Attached Attached Attached

2.0 2.1 2.2

Chair and chief officer reports Chair’s report Chief officer’s report

1.40 1.45

Chair TT

Attached Attached

3.0 3.1 3.2

Governing body assurance Governing body risk assurance framework report BHRUT performance risks

1.50 2.00

LM TT

Attached Attached

4.0 4.1 4.2 4.3

Corporate strategy and planning Finance budget 2017/18 BHR CCGs’ Financial Recovery Programme BHR devolution pilot programme & sustainability and transformation plan update

2.10 2.20 2.30

TT TT TT

Attached Attached Attached

5.0 5.1 5.2

Service transformation and development Primary care transformation programme update Urgent and emergency care programme

2.40 2.50

SS LM

Attached Attached

6.0 6.1 6.2 6.3 6.4

Quality and performance Patient experience report Finance and activity report Contract report Quality report

3.00 3.10 3.20 3.30

KA TT TT JH

Attached Attached Attached Attached

7.0 7.1

7.2 7.3 7.4 7.5

Development/governance Update on emergency preparedness resilience and response (EPRR) Finance & delivery committee chair’s report Audit & governance committee chair’s report Remuneration & workforce committee chair’s report Minutes of sub – committees and relevant fora:

• Primary care committee• Investment committee• Patient engagement forum

3.40

3.50 3.55 4.00 4.05

MP

KP KP KP

Attached

Attached Attached Attached

8.0 AOB 4.10

9.0 Questions from the public

1

Item Time Lead director Attached, verbal or to follow

10.0 Date of next meeting – 30 March 2017 4.15

2

Glossary of terms and abbreviations

Term Explanation

AO Accountable Officer

ACS Accountable Care System

ADL Activities of Daily Living

APC Area Prescribing Committee

ASH Accredited Safe Haven

BCF Better Care Fund

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking, Havering and Redbridge University Trust

BPPC Better Payment Practice Code

CAPS Clinical Application Services

CCG Clinical Commissioning Group

CCS Complex Care Service

CDOP Child Death Overview Panel

CEO Chief Operating Officer

CFO Chief Finance Officer

CHC Continuing Healthcare

CHSCS Community Health and Social Care Services

CIL Community Infrastructure Levies

COB Corporate Objectives

COO Chief Operating Officer

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CSU Commissioning Support Unit

CTT Community Treatment Team

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CVS Council of Voluntary Services

CYPP Children and Young Person Plan

DI Discovery Interview

DOH Department of Health

DTOC Delayed Transfer of Care

ECG Electrocardiogram

EHC Education, Health and Care

EoI Expression of Interest

EOL End of Life Care

FNP Family Nurse Partnership

FT Foundation Trust

FYE Full Year Effect

GBAF Governance Board Assurance Framework

GP General Practitioner

H4NEL Health for North East London

HCAIs Healthcare Associated Infections

HE NCEL Health Education North Central and East London

HSC Health Scrutiny Committee

HWBB Health & Wellbeing Board

IAPT Improving Access to Psychological Therapies

ICC Integrated Care Coalition

ICM Integrated Case Management

ICSG Integrated Care Joint Health and Social Care Steering Group

IFR Individual Funding Request

IRS Intensive Rehabilitation Service

IST Intensive Support Team

JAD Joint Assessment and Discharge Service

JET Joint Executive Team

JHWS Joint Health & Wellbeing Strategy

JMT Joint Management Team

JSNA Joint Strategic Needs Assessment

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KGH King George Hospital

KPIs Key Performance Indicators

LAC Looked After Children

LAS London Ambulance Service

LETB Local Education and Training Boards

LMCs Local Medical Committees

LPC Local Pharmaceutical Committee

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

MASH Multiagency Safeguarding Assessment Hub

MLU Mid-wife Led Unit

MSRB Maternity Systems Readiness Board

NEL North East London

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS National Health Service

NHSE NHS England

NICE National Institute for Health and Care Excellence

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

OD Organisation Development

ONEL Outer North East London

PALS Patient Advice and Liaison Service

PEFs Patient Engagement Forums

PELC Partnership of East London Cooperatives

PMCF Prime Minister’s Challenge Fund

PMO Project Management Office

POD Point of Delivery

POLCV Procedures of Limited Clinical Value

PPGs Patient Participation Groups

PSED Public Sector Equality Duty

PTL Patient Tracking List

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QIPP Quality, Innovation, Productivity and Prevention

RAG Red. Amber, Green

RTT Referral To Treatment

SAB Safeguarding Adults Board

SCN Strategic Clinical Network

STP Sustainability and Transformation Plan

TDA Trust Development Agency

TSCL The Transforming Services – Changing Lives

TUGT Timed Up and Go Test

UCC Urgent Care Centre

UCL University College London

UCLP University College London Partners

VFM Value for Money

WELC Waltham Forest, East London and City

WICs Walk in Centres

YTD Year to Date

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Register of interests 2016/17

Declaration of governing body members

Last updated: January 2017

Name Role Organisation Nature of interest

Amendment and date

Dr Anil Mehta

Chair

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

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

Dr Sarah Heyes

Clinical director

The Shrubberies Medical Centre Healthbridge Direct (from September 2014)

GP Partner/Principal Shareholder

Dr Muhammad Tahir

Clinical director Forest Edge practice, Hainault Health Centre

GP Partner

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Name Role Organisation Nature of interest

Amendment and date

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

Medical adviser & club doctor Member Shareholder

Dr Mehul Mathukia

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

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

Dr Shabana Ali

Clinical director

Southdene Surgery

GP Partner/Principal. Daughter is receptionist/admin

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Name Role Organisation Nature of interest

Amendment and date

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

GP with special interest in cardiology Director. Husband is also a director Shareholder Member Member (applying to become a member) GP appraiser (B&D CCG, Havering CCG)

Dr Syed Raza

Clinical director Chadwell Heath surgery Raza Syed Medical Ltd (June 2014) Healthbridge Direct (from September 2014) Redbridge Fairness Commission (March 2015)

Salaried GP Director Shareholder Fairness Commissioner

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Name Role Organisation Nature of interest

Amendment and date

Dr Jyoti Sood

Clinical director Newbury Group Practice ESS Wanstead Ealing Hospital NHS Trust Soods Limited – Locum agency NHS England London Deanery Imperial College Communitas Clinics (Havering) Redbridge LMC Care Quality Commission (CQC) Redbridge GP Alliance Federation

GP Partner (2003) GPwSI – Diabetes & Dermatology (2011) GPwSI – Diabetes & Dermatology (2010) Director. Husband is a partner (2005) GP appraiser (2003) GP trainer (2004) Undergraduate GP trainer (2011) Provide minor surgery (2013) Member (Sept 2016) Special Advisor (Sept 2016) Member (2016)

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Name Role Organisation Nature of interest

Amendment and date

Dr Anita Bhatia Clinical director Southdene surgery Healthbridge Direct Mychem Ltd Phoenix Medics Ltd Essex Local Prescribing Committee

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

Dr Shujah Hameed

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

Locum GP (1/1/2014) Director (1/1/2015) Locum GP (1/3/2015) Locum GP (1/1/2015) Locum GP (1/3/2016)

Ah-Fee Chan

Secondary care consultant

North Middlesex University Hospital NHS Trust Nadia Medical Services

Consultant in Anaesthetics and Intensive Care Medicine Director of the company

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Name Role Organisation Nature of interest

Amendment and date

Ltd (March 2015)

providing consultant services at a range of private facilities in London where practice privileges are given

Charles Beaumont

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

North Essex Partnership Foundation Trust

Non-Executive Director

Conor Burke

Accountable officer

None Your business works (not trading) - removed Jan 2017 Redbridge college – removed Jan 2017

Louise Mitchell

Chief operating officer None None

Tom Travers

Chief financial officer

Royal Free Foundation Trust

Wife works in finance department

Jacqui Himbury

Nurse director

None

Khalil Ali Lay member Dr Joseph’s GP practice, Family GP 6

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Name Role Organisation Nature of interest

Amendment and date

Collier Row, Romford St Francis Hospice, Havering Cancer Research

Spouse is donor Spouse is a donor

Kash Pandya

Lay member - Governance

Hillcroft College for women, Surbiton Essex Ministry of Justice Advisory Committee Health & Safety Executive Her Majesty’s Inspector of Constabulary Brentwood Citizen’s Advice Bureau Havering CCG Redbridge CCG PricewaterhouseCoopers

Treasurer (2008-17) Lay Member (2010-18) Independent Audit Committee Member (2010-17) Associate Inspector (2011) General advisor (2009) Lay Member Lay Member Kiren Pandya (son) Management consultant (2013)

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Name Role Organisation Nature of interest

Amendment and date

Berwin Leighton Paisner (BLP) University of Essex Southend on Sea Borough Council

Anand Pandya (son) trainee solicitor (2015) Independent Audit Committee member (2013-19) Independent Audit Committee Member (2016-18)

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Draft Redbridge Clinical Commissioning Group Governing Body minutes

held on 24 November 2016 Becketts House

Present: Dr Anil Mehta (AM) Clinical Director and Chair Dr Shabana Ali (SA) Clinical Director Dr Syed Raza (SR) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Anita Bhatia (AB) Clinical Director Dr Joyoti Sood (JS) Clinical Director Dr Shujah Hameed (SHa) Clinical Director Conor Burke (CB) Accountable Officer Louise Mitchell (LM) Chief Operating Officer Kash Pandya (KP) Lay member - governance Khalil Ali (KA) Lay Member-PPI Tom Travers (TT) Chief Finance officer Jacqui Himbury (JH) Nurse Director

In Attendance: Marie Price (MP) Director of Corporate Services Vicky Hobart (VH) LBR Director of Public Health Anne-Marie Keliris (AMK) Company Secretary Robert Kirton NELCSU Cathy Turland CEO Healthwatch Apologies: Dr Ah Fee Chan (AFC) Secondary Care Consultant Dr Mehul Mathukia (MM) Clinical Director Dr Muhammad Tahir (MT) Clinical Director Caroline Maclean Operational director, adult social service, LBR

Item Action 1.0 Welcome and apologies

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

1.2 Declarations of conflicts of interest The Chair reminded governing body members of their obligation to

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

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

1.3 Minutes of the last meeting

The minutes of the meeting held on 29 September 2016 were agreed as a correct record.

1.4 Matters/Actions arising The committee noted the actions taken since the last meeting.

2.0 Chair & Accountable Officer’s Reports

2.1 Chair’s report The Chair presented his report covering the following areas:

• Clinical Director development • RTT • Meetings

KA was pleased to see the pace of development at a locality level and would be helpful to know when patients and PPGs can input. The Chair welcomed this question and reported that the Fairlop locality has involved the Chair of the PPG in its plans. The governing body noted the report. 2.2 Chief Officer’s report CB presented his report covering the following areas:

• BHRUT • CCG transformation programmes • CCG assurance • CCG development • Health and Wellbeing Board update • Meeting attendance

The governing body noted the report.

3.0 Governing body assurance 3.1 Governing body assurance framework

LM presented a report which outlined the key risks to the clinical commissioning group in achieving its corporate objectives as identified in the governing body risk assurance framework. There are five risks on the GBAF:-

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

2. BHRUT referral to treatment times (RTT) performance 3. BHRUT cancer 62 days 4. Barts Health (BH) performance against key targets, A&E, RTT and

cancer 5. BH quality concerns 6. Improving access to psychological therapies 7. Risks to the delivery of the CCG’s budget 8. Planned acute contract activity versus actual activity

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KP referred to objective 7 on financial health and commented that the target was optimistic. The governing body noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken 1.45pm Dr Raza arrived 3.2 BHRUT performance risks CB presented a report which provided a further update on the key actions the CCG is taking to seek performance improvements at the Trust. It is doing this by both holding the Trust to account through its contract and other mechanisms, as well as providing overall support through wider system initiatives overseen through the A&E Delivery Board and partnership governance. A&E – it was noted that each Trust in the country had agreed an STF trajectory on the 4 hour target and BHRUT had put significant focus into this and delivered the target for the first two quarters. Attendances had increased but recently flat lined and there is increasing focus on improving utilisation of the UCC. DTOCs have been increasing mainly due to recording issues. There had been a recent review by the national improvement team and the feedback had been mostly positive with some learning for improvement. RTT – It was noted that there are currently 40-45 patients waiting over 52 weeks and 1200 referrals have been redirected and reduced from going into the Trust but it is important to maintain this progress. Referral rates are increasing in 5 specialities including dermatology which will have a deep dive review. Cancer – It was noted that this is the most challenging area despite significant efforts and a meeting with NHSE would be held shortly to discuss as well as the fortnightly cancer performance board meetings. The CCG continues to support the Trust to make improvements in this area and highlighted the need for clinical leadership. It was reported that the MDT for urology was not working well and the CCG will continue to offer support to the team directly. The recently received cancer recovery plan is more robust and credible and there is confidence that this would be delivered. KA welcomed the report and commented it was good to see progress. He referred to a recent health report in the commons library which detailed reasons for A&E attendances along with detail on demographic use. KA agreed to share the report with the urgent and emergency care transformation lead. The Chair expressed concern on the link between access to GPs/primary care and increases in A&E attendances and felt it was important to

KA

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explore this further. SA reported that most practices now offer walk in clinics which are normally full. Discussion ensued on the increased demand and need to focus on self-management, it was also suggested that all practices need to be made aware of all capacity available in other practices as there are examples where some walk in clinics are not fully utilised. CB commented that success of RTT will be supported by better understanding of demand in primary care along with what patients needs are and locality work will support this. He added that we need to explore alternatives ie develop different intervention using nursing, self-care and voluntary resources. AB suggested that different IT interventions should be explored for ongoing chronic disease management. The Chair also reported on diversions from acute providers back to primary care. JH reported that the medical director at BHRUT has sent a clear message to Trust clinicians that it is their responsibility to follow up tests and diagnositics. The Governing Body noted the action being taken to date to mitigate the performance risks at BHRUT.

4.0 Corporate strategy and planning 4.1 ACS and sustainability and transformation update

CB presented a report which provided an update on the Barking and Dagenham, Havering and Redbridge (BHR) Accountable Care System (ACS) Devolution Pilot Programme and North East London (NEL) Sustainability and Transformation Plan (STP). A revised version of the NEL STP plan was submitted to NHS England (NHSE) on 21 October. Progress on the development of an ACS, across BHR, continues. Recommendations have been made by the Democratic and Clinical Oversight Group (DCOG), to establish a joint BHR Integrated Care Partnership Board (ICP), which would be responsible for strategic health and care commissioning across BHR, including joint commissioning. The DCOG also recommended commencement of work to develop fast-track locality sites. ACS – It was noted that the DCOG had agreed the governance structure and the terms of reference of the joint commissioning board. One locality in each CCG had been identified to be fast tracked ahead of other part of north east London. The devolution pilot comes to an end in December and a revised agreement for next year will need to be signed shortly. VH referred to STP development and reported that the local authority also have financial pressures and will be undertaking more detailed work around social care funding and suggested that it would be in the interest of both the local authority and the CCG to have a discussion about this. The Chair expressed concern that most GPs do not understand the STP programme and the consequences of not engaging on this. SH also expressed concern at how the STP can deliver with continuing cuts. The Chair agreed adding that the large degree of the lack of knowledge and

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suggested that there are engagement events for members. CB acknowledged the concerns raised and highlighted that the STP is not a separate plan but a way of managing risk across the wider area. He also expressed concern but reiterated that traditional models are not sustainable in the future. KA commented that the language of the STP does not make sense to the public and suggested that this needs to be communicated in a plainer way. Discussion ensued on member and patient group engagement and it was agreed that more PLE focused engagement is needed for clarity on benefits and risk of not being involved in the STP. VH reported that the health and wellbeing strategy is being refreshed and this could be an opportunity to progress engagement. CT commented that there are some concerns around pushing services out of hospital and that the summary document is not accessible and suggested that local stakeholder need to be able to input. The governing body noted the report and delegated authority to the accountable officer to respond to the London Devolution Agreement. 4.2 BHR CCGs Financial Recovery plan TT presented a report which updated on the Barking and Dagenham, Havering and Redbridge (BHR) Financial Recovery Plan (FRP). This follows the most recent report that was submitted to the joint Finance and Delivery (F&D) Committee on 25 October 2016. It includes the additional requirement - following the review of progress undertaken by NHS England - to make further reductions in expenditure in order to eliminate the underlying collective BHR CCGs’ £8m forecast deficit that forms the starting point for 2017/18. It was noted that gross savings opportunities are £33m, Redbridge’s share is £11.7m and will exit this year with more impact on the delivery of FRP. KP welcomed the work to date but highlighted the need to find further savings to break even in 17/18 and future reports should also highlight challenges over next two years. SH commented that patients should be engaged to make different choices. KA agreed and commented that patients should be involved in the five year plan to give an opportunity for their views to be included. VH suggested that the health and wellbeing strategy would be an opportunity to engage patients.

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MP reported that a communications and engagement plan is currently being developed including more participatory exercises across the BHR area. The governing body noted the report and the work necessary to turn around Redbridge and the wider BHR CCGs financial position.

5.0 Service transformation and development 5.1 Mental health programme update

SM/RK presented a report which updated on delivery of the BHR CCGs’ mental health transformation programme and performance against mental health access standards at month 6. The Chair welcomed the well summarised report and reported that feedback from practices had been positive. KA welcome the turnaround and requested an update on CAMHS. SM reported that the Brookside service which is commissioned by NHSE and provided by NELFT has recently been reinstated with a more focused community treatment team following a recent re-inspection visit by the CQC which received positive feedback. The Chair questioned if the 67% IAPT target is achievable. RK responded that with more focus and partnership working with NELFT he was reasonably confident this could be achieved with a sustained approach with PTI and practice visits. SA reported that the crisis line is working well but waiting times for appointments can sometimes lead to patients returning to GPs. KP questioned if there is confidence to meet national standard for 16/17. SM responded that the CCG are expected to meet the dementia target by January 2017, meeting the IAPT waiting time access standard has been a struggle but expects to see improvement in Q3. It was noted that early intervention and psychosis is currently being met. SM reported that crisis care in Redbridge is performing equally with most CCGs in London and actions are being taken by NELFT to review the crisis care pathway. SM suggested that the next report the governing body receives focuses on crisis care. KA questioned if we are making any bids for additional funding. SM reported that there is no access to national transformation funds and will need to be made across the STP. It was noted that a bid for perinatal funds was not successful in phase one but will be using this as a plan to bid for other funds. The governing body noted the report and agreed to receive six monthly reports from the transforming care partnership board, which will focus on crisis care.

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5.2 BHR Stroke rehabilitation pathway transformation update SH presented a report which provided an update following the approval of the stroke rehabilitation pathway transformation business case. It was noted that financial savings could be made as well as better quality outcomes. The Governing Body noted the report.

6.0 Quality and performance 6.1 Patient experience report

KA presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:

• The current plans and activities regarding the Patient Engagement Forum (PEF)

• Relationships with the voluntary and community sector • Wider engagement activities • Engagement strategy and annual engagement report • Progress on Equality and Diversity Standard 2 (EDS2) work

The governing body noted the report. 6.2 Finance & activity report TT presented the month 6 finance and activity report highlighting that the CCG has a year to date deficit of £2079k, with a forecast year end deficit of £10,306k. The main drivers to the slippage are RTT backlog clearance, acute contracts and continuing healthcare. The reported position includes delivery of a RAG rated Finance Recovery Plan which is forecast to deliver £7871k of cost efficiencies for Redbridge CCG. Review of the efficiencies is ongoing as part of the FRP. BHRUT - The most significant variance reported at month 6 is with BHRUT, a £750k year to date over spend with a forecast over spend of £908k. The contract is being managed under full PbR rules.

Barts Health - The year to date variance shown against the Barts Health contract is an under spend of £341k with a forecast over spend of £179k. The contract is being managed under full PbR rules.

Associates and other acute providers - There is high level of over spend emerging across the associate contract portfolio – the current forecast over spend is £1,677k.

Services Delivered in a Primary Care Setting - The total predicted year end value is an under spend of £98k. The main drivers behind this are:

• Prescribing • Walk in centre • Primary care co-commissioning

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• Continuing care • Community services • Mental health and learning disabilities The Chair questioned if the Redbridge CCG is in deficit, will other CCGs be able to support the CCG financially. TT responded that there is agreement in principle for the risk pool to be used. KP commented that whatever savings can be made this year will be helpful for 17/18 and reported that the finance and delivery committee has agreed to meet on a monthly basis to support financial recovery. CB commented that the principle of the STP is to drive better standards across the footprint and will support improved financial health. The governing body agreed the financial position and noted the action taken to achieve it. 6.3 Contracting report TT presented a report which updated on the contract performance for Month 5 2015/16 for Acute, Community and Mental Health services highlighting the following: BHRUT – The Trust are failing to meet several of the national standards required in the Operating Framework. Commissioners continue to manage performance actively through a number of forums held on a weekly basis. There are action plans in place to recover the standards for Accident and Emergency (A&E), Referral to Treatment (RTT), and Cancer and Diagnostics. The Trust has also agreed Sustainability and Transformation Fund (STF) trajectories. A contract performance notice (CPN) has been served for the reporting of serious incidents (SIs) in month 1 (April) and a number of the existing notices from the 2015/16 contract remain open. A second Contract Exception Report was issued to the Trust in July for Failure to meet the recovery trajectory for 62 Days Cancer. Following the required review meeting a remedial action plan (RAP) has been received from the Trust and approved by the CCG. The Trust is held to account on actions required with associated penalties enforced in accordance within the contract. The overall Q1 reconciliation position has now been agreed with BHRUT; the completion of the Q1 position will enable the commencement of contract planning for 2017/19. Barts Health - operational and performance issues are being managed by the lead commissioner (Newham CCG) in line with the contractual governance framework. Barts Health is failing to meet several of the national standards required in the Operating Framework. There are a number of action plans currently in place for 18 weeks waits, Cancer, serious incident (SI) management and data quality that are being actively managed by the Lead Commissioner. The Trust is held to account on actions required with associated penalties enforced in accordance within the contract.

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NELFT – The Trust is performing to contracted standards in their community services and mental health service contracts including improving access to psychological therapies (IAPT). The CQC have recently published their inspection report and rated NELFT as ‘Requires Improvement’. A Quality Summit has been held and the commissioners’ response is being led by the Nurse Director. PELC - The sustainability and accountability of PELC is underpinned by the signing of a 2 year contract by commissioners. Financial performance remains in line with plan. PELC’s performance in recent weeks has been good for the NHS 111 service. Green ambulance re-triage for lower acuity calls have been around 60-65% of all calls re-triaged. Support for the implementation of the ‘Well Led Review’ recommendations has continued through consultants engaged by commissioners. However serious recent concerns regarding governance have arisen. Commissioners have addressed this through formal contractual action via a Contract Performance Notice for breach of SDIP (Service Development Improvement Plan) requirements. The London Ambulance Service - LAS continues to be very challenged in their delivery of the 8 minute response standard, with the year to date for the Redbridge CCG at 61.7% against a standard of 75%. KA commented that category A performance for Redbridge patients is well below that of pan London. KP questioned if LAS handover delays had been investigated. TT reported that this has and will be reporting on the detail of this at the next finance and delivery committee. CT questioned if there are concerns associated with PELC. CB reported that there is an improvement plan as the provider has not met all its requirements. He added that there is temporary leadership in place and performance has not deteriorated but there are concerns. KA questioned if CAMHS performance is due to planned reduction in funding. TT responded that this is a specific item within the contract discussions with NELFT but reported that CAMHS is working well within Redbridge and is of the mental health transformation workstream. CH reported that NELFT has put an action plan in place following concern around funding which affected staff. The governing body agreed the reported M5 position for the two main acute and two main non-acute contracts. 6.4 Quality report JH presented a report to ensure that members are fully assured on all the quality challenges and issues that the CCG is addressing through its commissioning processes. It was noted that the report was divided into two sections which covered: System wide quality performance which includes provider quality performance, CQUINS and Quality Premiums:

TT

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• Provider quality performance challenges and commissioner oversight, monitoring and assurance. The outcome of the NELFT Care Quality Commission (CQC) inspection of ‘Requires Improvement’ is reported, and also the current CQC inspections for Barking Havering Redbridge University NHS Trust (BHRUT) and Barts Health NHS Trust (BH)

• A high level review of performance for the Quarter 1 (Q1) CQUINs that have been agreed for BHRUT, NELFT and BH

• An early review of performance for the BHR CCGs’ Quality Premiums

• The CQC’s recent suspension of some services provided by Marie Stopes International

• The Care Quality Commission (CQC) review of safeguarding and looked after children’s services.

Operational activities and actions aimed at improving quality which includes the GP alert process, medicines management quality improvement plans and provider quality performance issues addressed at the clinical quality review meetings (CQRM).

• The outcome of the review of the GP alert process and the improvements made

• Quality improvement actions that the medicines management team are delivering, this includes quality improvement initiatives in primary care to improve services for people with Chronic Obstructive Airways Disease (COPD) and prescribing

• Provider quality performance for all our main providers that are monitored through the Clinical Quality Review Meeting (CQRM) process.

The Chair referred to pneumonia data and the over simplistic reasons for use of antibiotics. JH responded that retrospective reviews had highlighted the antibiotic issue and that the Trust had responded very quickly to ensure patients received immediate clinical care and antibiotics as appropriate. VH reported that the annual public health report highlights that there are a number of contributors to higher winter deaths including pneumonia and the report recommends improving the uptake of immunisations.

The governing body noted the report. 6.5 Safeguarding annual report JH presented the third annual safeguarding adults report 15/16 which provided assurance on the effectiveness of adult safeguarding arrangements in the Clinical Commissioning Group (CCG) and across the system. The report focus on:

• The prevention of harm and abuse through provision of safe, effective and high quality care

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• Effective responses to allegations of harm and abuse, responses that are in line with local multi-agency procedures: and

• Using learning and the sharing of information to improve service to patients, their families, carers and members of the public.

The governing body noted the report and agreed the recommendations for 2016/17 safeguarding adult priorities.

7.0 Development/governance 7.1 Revisions to governance and committee terms of

reference MP presented a report which detailed the revisions to governance and committee terms of reference agreed at the Audit and Governance Committee held on 5 October 2016:

• Finance and Delivery Committees – will meet as a ‘committee in common’ rather than three separate meetings (each still retaining individual CCG voting rights and ability to make borough-only decisions).

• Executive Committee meetings – will not continue as standalone meetings.

• Joint Executive Team (JET) to become Joint Executive

Committee (JEC) and will: • Be reinstated as a clinically-led meeting focusing on a range

of clinical issues • Take on the functions of the executive committee in addition

to those of the JET • Continue to meet as a ‘committee in common’ across BHR • Lay and secondary care GB members will be invited to

attend (attendance will be on a voluntary basis) • Have the authority to make decisions

The Governing Body noted and endorsed the changes agreed by the Audit and Governance Committee in relation to the CCG’s governance arrangements and committee TORs.

7.2 Finance & delivery committee chair’s report The Chair presented a report which provided key highlights of the finance and delivery committee held on 25 October 2016. The governing body noted the report. 7.4 Audit & governance committee report KP presented a report which provided key highlights of the audit and governance committee held on 5 October 2016. The governing body noted the report.

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7.5 Minutes of sub committees: The governing body noted the minutes of:

• Quality and safety committee held on 18 October 2016. • Primary care commissioning committee held on 14 September

2016. • Investment committee held on 19 October 2016. • Patient engagement forum held on 20 September 2016.

8.0 AOB

There was no other business.

9.0 Questions from the public The following questions were received in advance of the meeting:

Could the Governing Body confirms the CCG's internal process for dealing with a request from a patient for a suitable alternative provider for an elective procedure upon their notification of the expiry of the 18-week RTT period to the CCG? For example, are there internal guidelines about the relevant Regulations and the minimum standard, who should do what and when, a target time for the resolution of the issue, the collection of monitoring data etc. A full written response will be sent to the member of the public who submitted the question and was unable to attend the meeting and is available on request from the Company Secretary. Andy Walker asked a number of questions (available in full on request) which covered the following areas which CB responded to:

• Recording of governing body meetings – the CCG has looked at the practicalities of this and do not feel that is necessary or helpful in terms of transparency. These meetings are advertised on our website and held in public. The papers are shared in advance with our patient engagement forum which has around 20 members of the public and includes representatives from local Healthwatch and the lay member who sits on the governing body. The CCG also appear regularly at the Council’s Health Scrutiny Committee and are partners on the local Health and Wellbeing Board so do not feel there is a need to increase scrutiny further via an electronic recording of this meeting – anyone is welcome to attend or can read the minutes.

• Redirection pilot at Queen’s Hospital – the CCG fully supports the development of the successful A&E redirection which continues at Queen’s Hospital and is improving waiting times for people who really need A&E, the CCG are not able to answer questions on operational issues, these questions need to be directed to the Trust.

• North East London Reconfiguration programme board – it was noted a request has been made via the FOI route which would be responded to in due course.

• King George Hospital A&E – This question has been previously answered and it was confirmed the position remains the same.

10.0 Date of the next meeting 26 January 2016

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Actions arising from the Redbridge CCG Governing Body held on 24 November 2016

Action reference Action required Lead Progress

C/F September 2016 3.3 Update on emergency preparedness resilience and response

KP welcomed the report and the significant work on policies. He added that he would like to see IT tested now the new IT system is in place.

RM/MP A date for testing of IT business continuity arrangements is be arranged. An EPRR update will be presented at the January GB which will include an update. On agenda.

3.2 BHRUT update

KA referred to a recent health report in the commons library which detailed reasons for A&E attendances. KA agreed to share the report with the urgent and emergency care transformation lead.

KA

Completed

6.3 Contract report

KP questioned if LAS handover delays had been investigated. TT reported that this has and will be reporting on the detail of this at the next finance and delivery committee.

TT The Finance and Delivery committee received a deep dive report into LAS which reviewed activity and performance against the delivery of key performance indicator (KPI) targets across BHR CCGs in 2015/16. The report also included the year-to-date position from Months 1-7, 2016/17. The committee has asked for a follow up report for its meeting in February.

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www.southwark.gov.uk

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Dr Anil Mehta, Chair Date: 26 January 2017 Subject: Chair’s report

Executive summary The report provides an overview of key activities undertaken by myself and the CCG since the last governing body meeting.

Recommendations The governing body is asked to note the report.

1.0 Purpose of the report

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

2.0 Referral to treatment (RTT)

2.1 The BHR CCGs continue to make good progress in delivering our demand management element of the plan. Our GP colleagues have now redirected over 16, 000 patients to alternative providers. This has lessened the pressure on BHRUT and enabled them to treat the backlog of patients who had been waiting for an unacceptably long time.

2.2 While we are pleased that the regional office of NHS England has been assured by the BHR system plan and progress, and has applied to the national office to lift the Directions on Havering CCG, we are still focussed on ensuring that the plan fully delivers. It remains a priority for myself and my clinical and officer teams, and is also a focus within the locality developments.

3.0 Financial situation

3.1 There are a number of important reports on this agenda providing an update on the CCG’s current financial situation and our plans for addressing the efficiency requirements in 2017/18. The results of the contract arbitration process have left us in an even more challenging position.

3.2 To meet our statutory requirement to balance our books at the end of the financial year will mean that difficult decisions must be made. We will be seeking the views of our GP members and the wider public on these hard choices, but we must be in no doubt that it will mean that we cannot continue to fund everything that we have previously within the available resources at our disposal.

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4.0 Networks and localities

4.1 Positive progress is being made in developing our four primary care networks and integrated care localities. Colleagues are engaged and making a positive input to develop what many of us believe will be part of the critical solution to the challenges we face in our local health and social care system. Regular and frequent meetings will continue to keep up the pace with these important developments.

5.0 Clinical director elections

5.1 There is one clinical director (CD) term that is due to end on 31 March 2017; this happens to be my own CD position. The Governance team have commissioned the Electoral Reform Society (ERS) to run the process as before. GP colleagues from the Fairlop locality will be invited to apply for the available role. A selection process will follow to agree final candidates to put to the local GP membership vote. The process will be completed by the end of the month so that the position is filled from 1 April 2017. The CDs will then select a Chair. I have shared my intentions with GP colleagues regarding the CD role.

6.0 Meetings

6.1 In addition to the many committee meetings that I attend, below is a summary of other meetings I’ve been to since the last governing body meeting.

6.2 Members’ committee: we held our last members’ committee meeting on 18 January where we discussed strategic developments, primary care network and locality progress, transformation programme updates as well as our financial situation and system targets.

6.3 Informal CDs’ meetings: I continue to have regular organisational development (OD) focussed meetings with our clinical leadership team. In recent months we have focussed on RTT, pathway redesign discussions, network/locality development and financial recovery.

6.4 Health and wellbeing board: Unfortunately I was unable to attend the last meeting, but I understand that a wide range of issues were discussed including: the development of the health and wellbeing strategy, special educational needs, the children and young people’s mental health transformation plan and the North East London Sustainability and Transformation Plan.

7.0 Resources/investment 7.1 There are no additional resource implications/revenue or capital costs arising from this

report. 8.0 Equalities 8.1 There are no direct equality implications arising from this report. 9.0 Risk 9.1 The CCG is managing a number of serious risks which are outlined in further detail in the

assurance section of this agenda. 10.0 Managing conflicts of interest 10.1 There are no conflicts of interest arising from this report. 18 January 2016.

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www.southwark.gov.uk

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Conor Burke, Chief Officer Date: 26 January 2017 Subject: Chief Officer’s Report Executive summary This report provides an overview of key activities undertaken by the Chief Officer and the CCG since the last meeting.

Recommendations The governing body is asked to: • Note the progress report

1.0 Referral to Treatment 1.1 We continue to work closely with the Barking, Havering and Redbridge University Hospital Trust

(BHRUT) to help reduce their Referral to Treatment (RTT) waiting times. The CCGs are leading the demand management element of the programme, which as members will see from the BHRUT performance report, we are continuing to make good progress on. Over 16,000 patients have now successfully been diverted to alternative providers, easing the pressure on the Trust.

2.0 Contracting and Financial Recovery 2.1 Governing body members are aware that NHS finances continue to be very challenging and particularly so for BHR. In our financial planning for 17/18 we identified the need to generate financial savings of £43m to balance CCG finances in the coming year, subject to agreement of contracts with providers. 2.2 Following binding arbitration, the contracting round concluded on 23 December and required that a further £12m of costs be recognised in the BHRUT contract. To maintain a balanced financial plan, this would increase the QIPP requirement to £55m, of which £35m relates to BHRUT. In recognition of the scale of this challenge to the system, the commissioners, together with BHRUT, NELFT and primary care have agreed to implement a joint provider system board to co-develop initiatives that address the required transformational change by the end of February 2017, to drive delivery and to oversee any investment to achieve the system transformation requirement. 3.0 BHR Accountable Care System and Sustainability and Transformation Plan (STP) 3.1 Work continues towards the development of locality-based models of care across BHR. This work aims to deliver improved services developed by providers of health and social care, centred around the needs of the local population. Locality development is supported by the Integrated Care Partnership Board, a recently formed system wide body (successor to the democratic and clinical oversight group) designed to support integration between system partners. 3.2 The NEL STP proposal has now been submitted to NHS England, and published online. Simon Stevens, NHSE Chief Executive and Jim Mackey, NHS Improvement Chief Executive, have now written to all STP leads and CCG Accountable officers outlining next steps in the development of STPs. Further information is provided later on the agenda.

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4.0 CCG Transformation Programmes 4.1 Work across our CCG transformation programmes continues to progress well with some positive

results from the combined and collaborative efforts across the three CCGs. We are embedding the staffing arrangements that were trialled for the past six months, with improvements to certain aspects and a more developed primary care transformation team based in each borough. Staff are being engaged from mid-January for a 30 day period, with the new arrangements in place from the beginning of April 2017.

5.0 CCG Development 5.1 As part of the transition to a new way of working, a number of workshops have been held for staff

to contribute and influence the design of the new arrangements and structure. The intention is to embed the arrangements that we have trialled, addressing the elements that needed to be improved and to further develop and strengthen the primary care team. The month long consultation, which begins on 19 January will end on 17 February and the outcome will be advised at the next Governing Body meeting.

6.0 CCG Assurance 6.1 At the NHS England financial assurance meeting on 2 December, discussions focused on the

month 7 financial position, 2016-17 QIPP delivery and the progress of our financial recovery. 7.0 Health and Wellbeing Board update 7.1 At the most recent Health and Wellbeing Board meeting on 12 December discussions focused on

the North East London Sustainability and Transformation Plan, Mental Health transformation strategy and an update on Specialist Education Needs and Disability.

8.0 Meeting attendance 8.1 On 12 December I chaired the launch of London’s Crisis Care Pathway at City Hall. The event,

which included Sadiq Khan, Mayor of London marked the launch of the finalised pan-London Section 136 Pathway with the aim of ensuring that the momentum across the London continues to support implementation.

9.0 Equalities 9.1 There are no equalities implications arising from this report. 10.0 Risk 10.1 There are no risks arising from this report. 11.0 Managing of conflicts of interest 11.1 There are no conflicts of interest issues relevant to this report. 12.0 Resources/investment 12.1 There are no additional resource implications/revenue or capitals costs arising from this report and

no impact on sustainability. 12 January 2017

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To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Louise Mitchell, chief operating officer Date: 26 January 2017 Subject: Governing body risk assurance framework report Executive summary The governing body assurance framework (GBAF) has been reviewed to reflect the current significant risks to the organisation. Risk ratings are based on the November 2016 risk register. There are seven risks on the GBAF:-

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

2. BHRUT referral to treatment times (RTT) performance 3. BHRUT cancer 62 days 4. Barts Health (BH) performance against key targets, A&E, RTT and cancer 5. BH quality concerns 6. Risks to the delivery of the CCG’s budget 7. Planned acute contract activity versus actual activity

The CCG remains in financial recovery and continues to face a potential deficit of £10.3m (total £31.2m across the Barking and Dagenham, Havering and Redbridge (BHR) CCGs. The main drivers to the slippage remain RTT backlog clearance, acute contracts, Quality, Innovation, Productivity and Prevention (QIPP) delivery and continuing healthcare (CHC).

Recommendations The governing body is asked to: • Note and comment on the current risks escalated to the GBAF and the levels of assurance in the

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

risk has reduced de-escalation.

1.0 Purpose of the Report 1.1 The purpose of the GBAF is to outline the key strategic risks to the Clinical Commissioning Group

(CCG) in achieving its corporate objectives and the controls in place to provide assurance that the risks are being managed.

2.0 Background/Introduction 2.1 The CCG’s governing body has a responsibility to maintain sound risk management and ensure

that internal control systems are appropriate and effective, and where necessary to take appropriate remedial action. The CCG’s risk register consists of risks that are local to the borough and risks that the CCG has in common with its collaborative partners, Barking and Dagenham and Havering CCGs.

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3.0 Current risks on the GBAF 3.1 There are seven risks on the GBAF this month with one risk that has been de-escalated. Please

refer to appendix 1 for the full details. These fall under four of our six corporate objectives and are as follows:

Corporate objective 1 Ensuring that planned care is appropriate, timely and of high quality – with a particular focus on tackling the RTT delays.

Risk 1.2: (Revised risk description) BHRUT 18 weeks RTT – BHRUT will not deliver the recovery of the RTT 18 weeks standard if they fail to meet the September 2017 trajectory. Havering CCG, as the lead commissioner for BHRUT, has agreed a system wide RTT recovery plan under the Directions received from NHSE. As a result of our robust plan and good progress made in delivering against the plan NHSE (London) have applied to the national NHSE team for the Directions to be lifted. Given the progress in delivering the risk rating will be reduced to 16 and will be reflected on the next update of the risk register at the end of January 2017. The activity associated with the recovery plan is forecast to cost £20m. It is expected the 1% non-recurrent reserve will offset half of this cost when authorised for release

Mitigation: • System wide RTT recovery plan under the Directions received from NHSE • Weekly Programme Board meeting with BHRUT and the CCGs • Developed CCG RTT demand management plan • Trust plans in place to reduce the over 52 weeks waiters with CCGs’ support around the

reduction of the inflow of activity to the Trust via the establishment of a re-direct scheme and the development of new clinical pathways

• Prioritisation of booking of appointments and treatments of long wait patients, focussing on patients waiting more than 36 weeks

• Outsourcing of patients for both admitted and non-admitted pathways

Risk 1.3: (Revised risk description) BHRUT cancer performance standard: The Trust has consistently not achieved the 62 day cancer waiting time target with potential clinical risk to the patient pathway impacting on early detection and survival rates. Mitigation: • Revised, robust and realistic trajectory (version four) with an associated action plan

developed by the Trust at the end of July 2016 and agreed via NHSE teleconference with BHRUT and the CCGs to deliver recovery of the standard

• Monthly monitoring via the RTT assurance meeting with NHSE which includes cancer • Cancer Performance Recovery Programme Board established meeting fortnightly to review

delivery and manage risks and mitigations against the recovery trajectory plan. • Weekly assurance meeting with BHRUT and NEL Commissioning Support Unit (CSU) to

review the risk mitigations of the Trust’s trajectory for recovery • Weekly monitoring of planned against actual activity • Detailed forward booking reviewed at weekly meeting to assess risk and risk managed

through the Performance Management Framework • Re-launch clinical review group with BHRUT and CCG clinicians to meet every six weeks.

Collaborative objective 3: Implementation of the system wide urgent care strategy and redesign of the urgent care pathway

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Risk 3.1: BHRUT's on-going failure to deliver A/E performance standards will impact, 1) quality improvement in emergency care, 2) put patients at risk, 3) cause reputational damage and 4) delay the implementation of acute reconfiguration programmes. Trust performance has improved significantly over the past year, prior to the onset of winter pressures. In the context of the current nationally reported pressures the Trust is no longer identified as one of the very high risk Trusts in London. It should be noted however that performance is still fragile. Mitigation: • BHRUT being supported and held to account via daily surge calls with the Trust that feed

contractual meetings and reporting to the CCG governing body. • The Accident and Emergency Delivery Board is leading the work to support operational

delivery via the UEC programme delivery board • UEC programme established with five delivery work streams delivering the improvements

required across the system • Friends and family test (FFT) scores recovery plan and performance monitored through

CQRM • Staffing and agency interims re-profiled between King George’s Hospital (KGH) and Queen’s

to mitigate the removal of junior doctors in KGH overnight • Detailed delivery plan for integrated urgent care (NHS 111) is in place to ensure delivery of

the core requirements of the national UEC programme funding

Collaborative objective 5 High quality, compassionate and safe care for all commissioned services – delivering better outcomes.

Risk 5.4 a, b, and c. Barts Health (BH) performance – this risk groups together three performance areas that BH are failing to achieve, RTT, cancer targets and urgent and emergency care. There are also data quality concerns that present a further challenge for commissioners. The risks could threaten the long-term viability of the Trust and could put patients at risk and cause reputational damage. Risk 5.4 a – 18 weeks RTT - significant issues exist affecting the delivery of this target - key issues with the number of patients on the incomplete waiting list and those waiting over 52 weeks. Mitigation: • RTT recovery is reflected in the improvement plan work being undertaken by BH after being

placed in special measures in March 2015 with oversight by our lead commissioners via the RTT and monthly performance meetings with the Trust.

• BHR CCGs' retains oversight of Whipps Cross (WX) specific RTT recovery via the WX improvement plan meeting attended by our lead commissioner and BHR CCGs’ representative

• PTL validation continues and has moved from retrospective to real time from August 2016 • A breakdown of the over 52 weeks waits has been received and being reviewed monthly.

Trajectory to be agreed to reduce these waits to nil. • Performance is reviewed at the contract review group monthly (lead commissioner)

Risk 5.4 b: BH have consistently not achieved a number of the cancer waiting time targets with the potential clinical risk to the patient pathway impacting on early detection and survival rates for Redbridge Mitigation: • Cancer recovery is reflected in the improvement plan work being undertaken by BH and

referenced above.

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• We retain oversight of WX specific cancer standards via the WX improvement plan meeting

which we attend with our lead commissioner representative. • The focus remains on the 62 days cancer target (the Trust is achieving the 2 weeks cancer

target).

Risk 5.4c: Urgent and emergency care - failure to deliver quality improvements at BH (specifically at Whipps Cross hospital) Mitigation: • Bi-weekly performance meetings including the Trust, commissioners and NHSI with regular

updates at the service performance review (SPR) meetings • Contractual processes being followed in line with the contract query notice (CQN) process • Progress against the remedial action plan reviewed jointly by all commissioners • Serious incident issues being addressed via the Clinical Quality Review Meeting (CQRM)

(attended by the nurse director on behalf of BHR CCGs). Risk 5.6 (revised risk description): If BH do not achieve their quality indicators, (Never Events, Serious Incidents - recurring themes and the 4 harms, 1) Healthcare acquired Infections (HCAI), 2) Venous Thrombus Embolisms (VTE), Pressure Ulcers and Falls, patients may receive poor quality of care and suffer harm. More recently further concerns have developed around the management of serious incidents and complaints as well as compliance with Regulation 20 – the Duty of Candour. Mitigation: • Attendance at the Whipps Cross Hospital Clinical Quality Review Oversight and Assurance

meeting which includes the CQC and NHSI • Monitor the impact of the CQC improvement plan delivery overseen by NHSE and NHSI • Strengthened internal monitoring governance and established a formal escalation process

with the lead commissioner • Strengthened internal monitoring governance and established a formal escalation process

with the lead commissioner • Summary risk reports to each meeting of the CCG’s Quality and Safety Committee to

provide assurance of mitigations to manage the risks • Monthly serious incidents (SI) panels attended by senior managers from all seven north east

London CCGs • External Clinical Harm review meetings chaired by NHSE and attended by all

commissioners

Collaborative objective 6: Continued focus on our development as an organisation and health system so that we can meet the challenges ahead and deliver better outcomes, quality and financial efficiency.

The CCG is in financial recovery and is facing a potential £10.3m deficit (total of £31.2m across BHR CCGs). The main drivers to the slippage remain RTT backlog clearance (risk 1.2 above), acute contracts (risk 6.2 below), QIPP delivery and our CHC cost pressures. Additional actions to aid in the achievement of financial recovery: • The CCG has put itself into financial turnaround and has appointed a financial turnaround

director • Increased resource to our financial turnaround programme management office, established

a Financial Recovery Plan Board (FRPB) and developed our financial recovery plan • Executive membership of our FRPB meeting has been extended. Our FRPB has overseen

development of the financial recovery plan which has been considered and approved at our F&D Committee

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• Potential financial risk mitigation via our integrated financial strategy across north east

London sustainable transformation plan (STP) with continued development through the STP process.

Further detail is available in the BHR CCGs’ Financial Recovery Programme paper (ref.4.2 on the agenda) being presented at this GB meeting. Continuing health care (CHC); The CCG also has a cost pressure arising from the delivery of our CHC service with the following three risks. The introduction of the Living Wage policy which has increased costs for CHC providers who are looking to pass these additional costs onto the CCG, a 40% increase in the price of funded nursing care and the budgetary pressure on our CHC team staffing structure to deliver service requirements.

The CCG is mitigating this by the CHC QIPP target being sized to manage the pricing increases and the CHC team structure revised which will reduce the agency spend. Risk 6.1: Failure to deliver the CCG’s budget could: 1) adversely impact on the contractual activity, including payment by results agreements with relevant providers, 2) threaten delivery of an operating plan commitment which will impact on CCG assurance and 3) threaten the overarching year end budget delivery required for 16/17. Mitigation: • Review and escalation to the F&D Committees based on four specific trigger criteria;

finance, activity, milestones and risk • Confirm and challenge sessions implemented and continue to agree and sign off schemes • London and national horizon scanning to supplement locally developed schemes • Linking to transformational activities and ensuring QIPP benefits trackers are applied

through transformational projects governance • QIPP performance reviewed and actions taken at our Finance and Delivery (F&D)

Committee • Financial planning included a challenging level of QIPP. The conclusion of the Operating

Plan assurance process and the outcome of the BHRUT contract arbitration process increased the QIPP requirements for Redbridge CCG and our collaborative CCGs - Barking and Dagenham CCG and Havering CCG. To date, not all QIPP against this increased requirement has been identified.

Risk 6.3: If the acute contract activity is greater than planned, under payment by results (PbR) this could result in higher costs. (Excluding the pressures relating to RTT, BHRUT have moved to a PbR contract which exposes the CCG to price and volume risks). Mitigation: • Financial turnaround delivery plan developed and submitted to the CCGs F&D Committee

and NHSE. • Fully populated QIPP plans for implementation and delivery • Robust contract management and contract challenge underpinned by robust data validation • Discussions continue with NHSE regarding the use of our 1% contingency budget to

mitigate this risk.

4.0 De-escalated risk The improved access to psychological therapies (IAPT) risk has been de-escalated this month

from the GBAF but remains on the CCG’s risk register.

Failure to deliver improved access to IAPT services could: 1) restrict people who would benefit from a service in accessing it and 2) threaten delivery of an operating plan commitment for a

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national mental health standard which will impact on CCG assurance ratings; it is not within the CCG’s operating plan to achieve the target in quarter one.

This risk has been reviewed and, given the progress made the risk rating has decreased to an amber rating of 9 as the CCG has progressed against target and is on track to achieve.

5.0 Resources/investment 5.1 There are no additional resource implications/revenue or capital costs arising from this report.

The cost of operating effective risk management arrangements is met from within existing resources.

6.0 Equalities There are no equalities considerations arising from this report

7.0 Risk 7.1 This report also links to the following GB papers being presented at this meeting and provide

greater detail on key risks mentioned above and the organisations mitigations.

GBAF ref. 1.2, 1.3 and 3.1 relates to item 3.2 GBAF ref. 3.1 relates to items 3.2 and 5.2 GBAF ref. 6.1 and 6.3 relates to items 4.2, 6.2 and 6.3

8.0 Managing conflicts of interest 8.1 There are no conflicts of interest considerations arising from this report.

Attachments: Appendix 1 - Governing body assurance framework and summary Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 6 January 2017

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Appendix 1 – NHS Redbridge CCG

Corporate objective 1: Ensuring that planned care is appropriate, timely and of high quality – with a particular focus on tracking the referral to treatment (RTT) delays.

Risk Description: (revised) BHRUT 18 Week RTT - BHRUT will not deliver the recovery of the RTT 18 weeks standard if they fail to meet the September 2017 trajectory.

Lead director: Louise Mitchell Risk ref: 1.2

Initial Risk

Rating 5/2014

Controls Assurances I = internal

E = external

Current risk

rating

Evidence for assurance

Gaps Proposed actions

Target Risk –

31/03/17 Control Assurance

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1. Monthly RTT escalation and assurance meeting with NHSE, NHSI, CCG and BHRUT.

2. Weekly Programme Board with BHRUT and CCG.

3. Implementation of the approved

demand management GP re-direct scheme from April 2016.

4. RTT clinical summit established

monthly – BHRUT and CCG’s clinical staff.

5. Weekly operational performance meeting with CCG, BHRUT.

6. Contractual meetings – SPR / CQRM – and levers used fully.

7. Clinical harm external review panel

led by NHSE.

1. Minutes of the RTT

escalation and assurance meeting – performance and delivery reports to NHSE. (E)

2. Programme Board minutes

and to receive progress status on any clinical harm reviews undertaken against plan. (I)

3. See point 2.

4. Clinical summit meeting

action notes. (I) 5. Minutes of the operational

performance meetings. (I) 6. Minutes of monthly

contractual meetings – SPR / CQRM. (I)

7. Clinical harm external

review panel notes. (E)

Clinical harm review framework outcomes monitored at the monthly CQRM where harm is identified. (I)

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Item 3.2, 4.2 and 6.3 on the agenda – BHRUT performance risks, BHR CCGs’ Financial Recovery Programme and Contract reports provides greater detail on the management of this risk.

1. Return to

national RTT reporting by December 2016 – subject to approval by BHRUT’s Board

2. System wide

RTT recovery plan submitted by Havering CCG to NHSE in response to legal directions

1. National reporting

is Board (Trust) approved and resumes from December 2016

2. RTT recovery

plan reviewed by NHSE

The BHRUT performance report contains details of the issues, risks and mitigating actions.

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Risk Description: (revised) BHRUT cancer performance standard::The Trust has consistently not achieved the 62 day cancer waiting time target – with potential clinical risk to the patient pathway impacting on early detection and survival rates.

Lead director: Louise Mitchell Risk ref: 1.3

Initial Risk

Rating 5/2015

Controls Assurances I = internal

E = external

Current risk

rating

Evidence for assurance

Gaps

Proposed actions Target Risk –

31/03/17 Control Assurance

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1. Monthly NHSE RTT and Cancer Assurance meeting.

2. Contractual meetings – SPR

/ CQRM. 3. Weekly informal briefing with

NHSE and BHRUT.

4. Fortnightly cancer performance recovery board – BHRUT and CCG.

1. Minutes of the NHSE

RTT and Cancer Assurance meeting. (E)

2. Minutes of monthly contractual meetings – SPR / CQRM and remedial action plans. (I)

3. Weekly cancer performance pack. (E)

4. Minutes of the cancer performance recovery board. (I) L

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1. Recovery

trajectory and plan to be received.

1. Delivery of

trajectory and plan as per the agreed deadlines.

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Collaborative objective 3: Implementation of the system wide urgent care strategy and redesign of the urgent care pathway

Risk Description: BHRUT's on-going failure to deliver A/E performance standards will impact, 1) Quality improvement in emergency care, 2) Put patients at risk, 3) Cause reputational damage and 4) Delay the implementation of acute reconfiguration programmes.

Lead director: Alan Steward Risk ref: 3.1

Initial Risk

Rating 6/2013

Controls Assurances I = internal

E = external

Current risk

rating

Evidence for assurance

Gaps Proposed actions

Target Risk –

31/03/17 Control Assurance

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

2. Urgent and Emergency

Care (UEC) programme delivery Board.

3. Contractual meetings –

SPR / CQRM – and contractual levers.

4. Winter only - daily surge

calls with the Trust and reassurance with NHSE

1. Minutes of the monthly

Accident and emergency Delivery Board. (E)

2. Minutes of the monthly

UEC Programme Board Delivery Board. (E)

3. Minutes of monthly contractual meetings – SPR / CQRM. (I)

4. Notes of daily surge

call. (E)

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Items 3.2, 5.2 and 6.3 on the agenda – BHRUT Performance risks, UEC programme and Contract reports provide greater detail on the management of this risk.

There are no gaps and the commentary below provides update. UEC Delivery Board leading the transformation programme to deliver Operating Plan commitments. BHRUT – with the support of partners – was delivering the agreed STP trajectory but winter surge has impacted on this. The A&E Delivery Board invited ECIP – the national UEC experts – to review our plans and progress. Key feedback was the focus on the patient flow / discharge. Continued monitoring and management through local performance management framework Continued liaison with NHS England and the NHSI to provide assurance on delivery, particularly through winter surge arrangements.

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Collaborative objective 5: High quality and compassionate and safe care for all commissioned services – delivering better outcomes

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

Lead director: Louise Mitchell Risk ref: 5.4 a, b, & c – (groups the three performance risks together)

Initial Risk

Rating 7/2014

Controls Assurances I = internal

E = external

Current risk

rating

Evidence for assurance

Gaps Proposed actions

Target Risk –

31/03/17 Control Assurance

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1. Monthly Collaborative Commissioning Committee (CCC) - CCGs only meetings led by the lead commissioner, Newham CCG (Chief Officer).

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

3. Bi-monthly Technical Sub Group

(TSG) and monthly Contract Review Group (CRG) meetings, led by Newham CCG, attended by BH, monitoring cancer and diagnostics performance – sustainability action plan in place for cancer performance.

4. Monthly RTT assurance meeting, led

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

5. Monthly BH Internal (BHR CCGs)

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

6. Monthly site specific CQRM meetings -

WX CQRM attended by BHR CCGs’ quality director.

1. Minutes of the CCC meeting. (E)

2. Minutes of the A&E

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

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

assurance meeting. (E)

5. Monthly BH Internal

Escalation Review meeting report. (I)

6. Minutes of the monthly

WX (BH) CQRM. (E)

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1. RTT RAPs in place and monitored. Agreed target date for return to reporting of October 2017 (STP linked to return to reporting).

2. STP trajectories agreed for Cancer and A&E (including local site level trajectories).

1. RTT RAPs

(overarching and site level) signed off by BH and lead CCG (April 2016) and monitored.

2. STP trajectories

signed off by BH, lead CCG and NHSI and NHSE for delivery by 31 March 2017.

BHR CCGs in attendance at Barts Health improvement plan meetings for Whipps Cross as associated commissioner.

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Risk Description (revised): If Barts Health do not achieve their quality indicators, (Never Events, serious incidents - recurring themes and the 4 harms, 1) Healthcare acquired Infections (HCAI), 2) Venous Thrombus embolisms, pressure ulcers and falls), patients may receive poor quality of care and suffer harm. More recently further concerns have developed around the management of serious incidents and complaints as well as compliance with Regulation 20 – the Duty of Candour.

Lead director: Jacqui Himbury Risk ref: 5.6

Initial Risk

Rating 2/2015

Controls Assurances I = internal

E = external

Current risk

rating

Evidence for assurance

Gaps Proposed actions

Target Risk –

31/03/17 Control Assurance

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6 1. Contract performance notice issued.

2. BH Contract Review Group,

attend by the lead commissioner and BHR CCGs

3. Monthly system escalation

and assurance route from BHR CCGs (Redbridge as lead) to the Lead Commissioners AO – Newham.

4. Barts Health (Whipps Cross)

monthly Clinical Quality Review and Oversight Assurance (CQRO) meeting with NHSI and NHSE.

5. Performance enforcement

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

6. Quality reports to every

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

7. Monthly SI panels including

al NEL CCGs

1. Remedial action plans and recovery trajectory. (E)

2. Minutes of monthly

CRG (E)

3. Letters of escalation

to lead commissioners (November 2016) (E)

4. Minutes of the CQRO meeting (E)

5. WX to self-assess to

determine if any notices can be closed

6. Minutes of the Q&S

Committee

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

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plans for SI and Duty of Candour by end October 2016

1. Remedial action plans reviewed and if robust signed off by Waltham Forest CCG

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Page 5 of 12 43

Collaborative objective 6: Continued focus on our development as an organisation and health system so that we can meet the challenges ahead and deliver better outcomes, quality and financial efficiency.

Risk Description: (Revised) Failure to deliver the CCG’s budget could: 1) adversely impact on the contractual activity, (include payment by results) agreements with relevant providers, 2) threaten delivery of an operating plan commitment which will impact on CCG assurance and 3) threaten the overarching year end budget delivery required for 16/17

Lead director: Tom Travers Risk ref: 6.1

Initial Risk

Rating 8/2015

Controls Assurances I = internal

E = external

Current risk

rating

Evidence for assurance

Gaps Proposed actions

Target Risk –

31/03/17 Control Assurance

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20 1 Weekly Finance Recovery Plan Board

(FRPB) and monthly review of mitigating actions and risks per scheme where off plan (finance and activity).

2 Fortnightly FRPB Senior Executive

meetings.

3 Formal escalation route to Finance and Delivery committee as due governance for all schemes.

4 Dedicated PMO in place - part of FRP

delivery infrastructure. 5 Confirm and Challenge model for all new

QIPP / RightCare pipelines to ensure continual identification of schemes.

6 Clinical engagement and leadership

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

7 Independent review of finances jointly

commissioned with NHSE 8 Monthly NHSE London Assurance

meeting

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

2 Minutes of the FRPB

Senior Executive meetings (I)

3 Minutes of the bi monthly

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

4 Monthly FRP delivery

summary reports against trajectory (I)

5 Minutes of Confirm and

Challenge sessions (I) 6 Minutes of bi monthly

Governing Body meeting (I)

7 Report of the independent

review (E)

8 Minutes of the NHSE London assurance meeting (E)

9 Minutes of the JEC (I)

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20 Items 4.2 on the agenda - BHR CCGs’ Financial Recovery Programme, report provides greater detail on the management of this risk.

1. Schemes

identified to cover the savings gap.

2. Fully

functioning programme management office (PMO).

1. Schemes

developed and project initiation documents for delivery approved by FRPB in November 2016.

2. PMO

strengthened with additional as planned in November but with staff turnover further support being sought.

Dedicated FRP dashboard to inform review by October 2016. Utilise our 1% non-recurrent budget to fund a proportion of spend.

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Risk description: If the acute contract activity is greater than planned, under payment by results (PbR) this could result in higher costs Lead director: Tom Travers Risk ref: 6.3

Initial Risk

Rating 30/06/16

Controls Assurances I = internal

E = external

Current risk rating

Evidence

for assurance

Gaps Proposed

actions

Target Risk –

31/03/17 Control Assurance

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1 Terms & Conditions of the NHS Standard Form Contract supporting contract management, the claims and challenges processes in conjunction with the CSU.

2 Activity management plans

reconciled to the Operating Plan and Constitutional Standards trajectories, owned by and monitored with the transformation work programmes.

3 Management information reporting analysing activity and cost drivers with recommendations for contract management and remedial actions.

4 Independent review of finances

jointly commissioned with NHSE

5 Monthly NHSE London Assurance meeting.

1 Monthly contract reporting. (I)

2 Contract Management

Framework with activities owned by executive leads. (I)

3 Activity management plans

monitored through dedicated groups, e.g. RTT Board. (I)

4 Minutes if the bi monthly

Finance and Delivery Committee. (I)

5 Minutes of the weekly

Finance Recovery Board. (I) 6 Minutes of the weekly

Executive Delivery Team meeting. (I)

7 Report of the independent

review (E) 8 Minutes of the NHSE London

assurance meeting (E)

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Items 4.2, 6.2 and 6.3 on the agenda - BHR CCGs’ Finance Recovery Programme, Finance and activity report and Contract reports provides greater detail on the management of this risk.

Continued discussions with NHSE regarding the utilisation of the 1% contingency budget to fund a proportion of the spend. Agreement on quarter reconciliation exercises with providers – achieved as planned 31 October 2016. Commissioning intentions and contract variations to respond to PbR issues.

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NHS Redbridge CCG Governing Body Assurance Framework - overall summary (2015 – 2016)

Lead / GBAF

ref. Risk description (summarised)

Previous risk ratings Current rating End of year

forecast Target risk level May

2015 Aug 2015

Oct 2015

Dec 2015

Feb 2016

April 2016

June 2016

July 2016

S