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Governing Body 7 July 2015

3.00-5.00pm GlaxoSmithKline Sports and Social Club, Barnard Castle

UNCONFIRMED MINUTES

Present: Annie Dolphin Lay Chair John Whitehouse Lay Member, Audit and Governance Dr Stewart Findlay Chief Clinical Officer Nicola Bailey Chief Operating Officer Mark Pickering Chief Finance Officer Gill Findley Director of Nursing Joseph Chandy Director of Primary Care, Partnerships and Engagement Dr James Carlton Medical Adviser Ian Spencer Secondary Care Clinician Dr Robin Armstrong Locality Lead, Easington Dr Dilys Waller Locality Lead, Durham Dales In Attendance: Dr Jonathan Smith Locality Lead, Easington Denise Elliott Strategic Commissioning Manager, Durham County Council

(representing Lesley Jeavons) Anna Lynch Director of Public Health, Durham County Council Sarah Lambert Head of Corporate Services Margaret Wells Governance Administrator Sue Humpish Executive Assistant – Minutes Apologies: David Taylor-Gooby Lay Member, Patient and Public Involvement Sarah Burns Director of Commissioning Lesley Jeavons Head of Adult Care, Durham County Council Item No

Action

GB/15/050 Apologies for absence AD welcomed everybody to the meeting and noted apologies. JW, who was attending his first meeting, was introduced as the new Lay Member for Audit and Governance.

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GB/15/051 Declarations of conflicts of interest Those present were reminded that the Declarations of Conflicts of Interest Register was a live document and all members were asked to check the register to ensure that their entries were up to date as a matter of routine. ACTION: As a new member of the Governing Body, JW to provide his declarations of conflicts of interest to MW to add to the register. There were no declarations made in relation to specific agenda items.

JW

GB/15/052 Minutes of the meeting held on 12 May 2015 The minutes were accepted as a true record.

GB/15/053 Matters arising from the minutes of the meeting held on 12 May 2015 GB/15/040 Joint Strategic Needs Assessment Consultation ACTION: The final Joint Strategic Needs assessment document would be provided to the next Governing Body meeting in September by NB.

NB

GB/15/054 Review of action log The action log was reviewed and updated.

GB/15/055 2015/16 Planning update Mark Pickering, Chief Finance Officer The planning process for 2015/16 financial year had been an iterative process with the latest version of the plans being submitted on 12 June 2015, including NHS England primary care commissioning allocations and some minor amendments to the narrative. A number of points of clarification were answered around support for dealing with falls in care homes, and the incorporation of a resilience checklist made up of the new 8 high impact changes for urgent and emergency care from NHS England into plans and mental health target setting. The Governing Body: • Approved the amendments to the plans for the 2015/6 financial year. • Approved the decisions in respect of the quality premium indicators.

GB/15/056 Risk Management update Mark Pickering, Chief Finance Officer The paper provided the latest version of the DDES CCG risk register including a summary of DDES-wide risks.

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After a refresh, there was one ‘red risk’ relating to high cost cases, around which there was still some uncertainty. Some risks had been removed and replaced with new risks and it was hoped that members of the Governing Body found the new format to be more succinct. A question was raised as to how the risk around access to safe, high quality services had no mitigation actions recorded, yet had moved from ‘red’ to ‘amber’ status. It was explained that the risk had lessened because of the increased understanding and therefore mitigation actions in place around the issues involved. As the CCG better understood a risk, it could more accurately reflect and mitigate against the possible consequences. In a similar way, the Better Care Fund risk (as a pooled budget development) had lessened. The risk was initially around the impact on budgets when funds transferred between organisations, though the CCG had worked closely with the local authority to mitigate this. ACTION: MP to ensure that where the status of risks changed, that there was adequate narrative in future reports as explanation. The Governing Body: • Received the DDES CCG risk register; • Considered the content and context of the DDES CCG risk register,

identified risks and confirmed whether these were accurate and that appropriate action was being taken.

MP

GB/15/057 Governing Body Terms of Reference - Removed See item GB/15/072 regarding Constitution

GB/15/058 Organisation Development Plan Nicola Bailey, Chief Operating Officer The CCG’s Organisational Development Plan 2014-16 had been revised for 2015-16. This was to reflect changing organisational priorities and areas for further development throughout the year and the refreshed plan also contained a comprehensive workforce development plan. A question was raised as to how the Governing Body’s effectiveness was reviewed. The response given was that this was done through appraisals with the Chair, annual Good Governance Institute assurance process, NHS England external assessment and assurance of the CCG itself and Council of Members assessment of Governing Body performance against its strategic objectives. NB and SL were thanked for the work in improving the plan. The Governing Body: • Approved the Organisation Development Plan for 2015-2016 and agreed

to its implementation

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GB/15/059 Business Assurance Framework update: June 2015 Mark Pickering, Chief Finance Officer The Business Assurance Framework (BAF) brought together the corporate objectives, principal risks, mitigation, controls and assurance into a single document and the latest, refreshed version was presented. A summary assurance document was included which captured the links between the BAF, risk register and discussions at key committees of the CCG in order to help provide assurance that risks were appropriately being considered by the organisation. ACTION: JW and MP to work together to develop the BAF and the risk register including incorporating new items, checking the reasonableness of comments and ensuring that there was adequate narrative against new and changing items. ACTION: MP to include the review of the BAF and Risk Register on the next Audit and Assurance Committee. The Governing Body: • Commented on the Business Assurance Framework and approved the

work that was being done to ensure that assurance mechanisms were in place and robust.

JW/MP MP

GB/15/060 NEAS – Quarterly Clinical Quality update Gill Findley, Director of Nursing The report provided a quarterly clinical quality update on the North East Ambulance Service (NEAS), headlined key issues and provided assurance that actions were being undertaken where appropriate. Attention was drawn to the fact that NEAS was now fully compliant with Disclosure and Barring Scheme requirements and that the new Chief Executive was working on staff recruitment and culture in the organisation after the poor staff survey findings. As a result, NEAS had already recruited an additional 20 paramedics. Due to positive steps being taken by NEAS the regional Quality surveillance group would be asked to consider stepping them down from the escalated level of scrutiny to routine surveillance. As part of CQUIN targets, an Integrated Transport Solution had been introduced where non-emergency transport requests are categorised and where appropriate passed to non-paramedic crews for transport. When asked what NEAS was doing to avoid problems from last winter, it was responded that the performance issues faced were no longer a winter problem, hospitals encountered surge issues all year around with the increased number of people reporting to A&E. NEAS is fully represented at the strategic resilience group and are working with commissioners to address the surge issues. The increasing number of paramedics will

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obviously help address some of the concerns. The Governing Body: • Received and considered the report and agreed the actions being taken

forward with the respective organisation to improve quality and experience for patients.

GB/15/061 Acute and Community Quarterly Clinical update

Gill Findley, Director of Nursing The paper provided an acute and community services quarterly clinical update which headlined the key issues and provided assurance that actions were being undertaken where appropriate. Attention was drawn to the key items contained in the report and it was noted that this was the first report containing patient stories as a way of building patient feedback into the CCG’s systems. The Governing Body: • Accepted and discussed the report; • Supported the actions being taken forward through the CQRGs to

improve quality and experience for patients. DW left the meeting.

GB/15/062 Quality, Performance and Finance report – June 2015 Mark Pickering, Chief Finance Officer The paper provided a summary overview of quality, performance and finance in DDES CCG, including an at a glance summary of key indicators and detail of those in breach with actions to mitigate risk of continued breach. Attention was drawn to the Executive Summary and colleagues discussed the headlines contained therein, particularly around County Durham and Darlington Foundation Trust (CDDFT) which was consistently having issues highlighted. An update was provided on the work that the CCG was doing with CDDFT to address the issues including weekly meetings with the Chief Executive a ‘perfect week’ exercise and the production of a detailed project plan that was expected to be sent to the CCG during the second week of July. A concern was raised about the discharge of patients deemed to be clinically stable before investigation. It was standard in all hospitals that where a patient was well enough to go home, rather than take up a hospital bed they would return at a later date for investigation. If they returned as an emergency during this period they were counted as a re-admission. This was being monitored by both primary and secondary care.

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The Governing Body: • Received the current performance report and noted the progress of the

performance management process; • Received assurance from responses to questions raised.

GB/15/063 Finance update: Month 2 (2015/16) Mark Pickering, Chief Finance Officer The paper provided an update regarding the financial position of DDES CCG as at the end of May 2015. It highlighted the key areas of financial performance against statutory duties, identifying year to date and forecast year end positions. The report was discussed and points of clarification answered. It was highlighted that there was currently pressure in Continuing Health Care because of a number of high cost packages of care and this would be closely monitored. The Governing Body: • Noted the financial position of the CCG as at 31 May 2015.

GB/15/064 Chief Clinical Officer report Stewart Findlay, Chief Clinical Officer The Governing Body discussed the report which provided an update on key issues affecting the CCG since the last meeting. Attention was drawn to key points including: • Contracts with providers were all signed or agreed except for North East

Ambulance Service which was going to mediation; • the introduction of an ambulance divert policy and • the recent NECS Commissioning Awards where Sandra Parrett and

Audrey Quinn were winners in the “outstanding patient involvement” category for their work on Stoma Care.

A question was raised as to whether SeQiHS (Securing Quality in Health Service) and the County Durham and Darlington Foundation Trust clinical strategy would be complementary to each other. Reference was made to comments about the Midwifery Led Unit which seemed to indicate that the CCG did not have a part to play. In response, it was clarified that the CCG would not consult solely on the MLU until it could see how it fitted into the wider picture in order to share this with the public. CDDFT was currently doing engagement work on its strategy, though as with all other organisations, was waiting for a clinically sustainable SeQiHS model. Further information was expected at the end of July. The Governing Body: • Received and discussed the report, noting progress to date.

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GB/15/065 Safeguarding Adults Annual Report James Carlton, Medical Advisor The paper provided an overview of key developments / updates on matters relating to safeguarding adults over the last year. This formed part of the overall assurance process by providing evidence that the CCG was safeguarding vulnerable adults as well as that necessary policies, procedures and development was in place. It was noted that there is increasing overlap of Safeguarding Adults and Children and there is a probability of some further working together of the two teams as this develops. Following discussions around this paper at the Executive Committee it was suggested that Safeguarding adults training should be added to list of potential items for the Quality Improvement Scheme for 2016-17. The report was discussed and the Governing Body was assured by the importance that the CCG was giving to adults safeguarding including training and the resulting awareness raising. Colleagues passed on thanks to the team for their work. The Governing Body:

• Received the report and noted that it provided assurance that the CCG was complying with safeguarding requirements; that policies and procedures were in place and provided evidence that they were working in practice.

• Acknowledged the work undertaken by the safeguarding team. DE left the meeting

GB/15/066 Children, Young People and Families Plan On behalf of Sarah Burns, Director of Commissioning Following consultation, a refresh of the Children, Young People and Families Plan developed in 2014 was provided for information. The Governing Body: • Ratified the Children, Young People and Families Plan 2015-18.

GB/15/067 Internal Audit and Counter Fraud Plan 2015/16 Mark Pickering, Chief Finance Officer The internal audit plan and counter fraud plan for 2015/16 were provided for information and were monitored through the Audit and Assurance and Executive committees. The Governing Body: • Noted the audit plans for internal audit and counter fraud for 2015/16;

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• Noted that audit reports, recommendations and action plans were monitored by the Audit and Assurance Committee and shared with the Executive Committee following publication.

GB/15/068 Annual Infection, Prevention and Control report

Gill Findley, Director of Nursing An annual report was provided containing information on the work on infection, prevention and control and compliance with national objectives for Clostridium difficile and MRSA bacteraemia infections across the health economy during 2014/15 by the Infection, Prevention and Control Team. It had been highlighted in the Executive Committee that the greatest concern currently appeared to be in respect of care homes and this was being addressed as a priority. It was thought that some DDES training activity was not being captured on systems and consideration was being given to developing mandatory training for care homes, perhaps in the form of a time out as provided for primary care. It was pointed out that one of the roles of the Director of Public Health was around assurance that there were effective systems in place. AL chaired an assurance group that had representation from a wide range of providers which received robust information from the Infection Control Team which was well informed as to what was happening, providing a rounded assurance process. The Governing Body: • Received the report which provided assurance about the activities of the

team and the actions being taken.

GB/15/069 Primary Care Commissioning update Nicola Bailey, Chief Operating Officer As part of the Primary Care Commissioning Committee’s Terms of Reference, the committee was to report to the Governing Body on what happened at the most recent meeting. At future Governing Body meetings the confirmed committee minutes would be provided for information. At today’s meeting the key areas for discussion were around the Memorandum of Understanding with NHS England, primary care budget and mapping of CCG spend and estates. The papers were published on the DDES CCG website.

GB/15/070 Commissioning Intentions update On behalf of Sarah Burns, Director of Commissioning The paper was provided to give the Governing Body assurance that the two year operational commissioning plan was on track for full delivery.

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The Governing Body: • Received, discussed and took assurance from the report and progress

made.

GB/15/071 Medicines Optimisation Update James Carlton, Medical Adviser The report provided an end of year position on the prescribing budget and an overview of the work undertaken through 2014/15 within medicines optimisation. Colleagues discussed the report including the monitoring of prescribing spend and the challenge of achieving savings, medicines safety and the Prescribing Incentive Scheme. The group was impressed with the work done and results achieved. The Governing Body: • Received the report; • Noted the content of the report and acknowledged the workstreams that

had been undertaken to drive forward the medicines optimisation agenda in DDES CCG.

GB/15/072 DDES CCG Constitution Nicola Bailey, Chief Operating Officer The Council of Members had agreed amendments to the groups Constitution which were subsequently approved by NHS England. These changes were fully integrated into the document, including revised Governing Body membership and the incorporation of the Primary Care Commissioning Committee. AD reminded members of the Governing Body of the importance of the CCG Constitution as Governing Body members were responsible for ensuring that the CCG acted in accordance with it. The Governing Body: • Received the revised constitution for information.

GB/15/073 Confirmed Minutes to receive The confirmed minutes of the following meetings were received for information: • Health and Wellbeing Board, 11 March 2015 • Audit and Assurance Committee, 21 April 2015 • Executive Committee, 21 April 2015 • Executive Committee (CQF&P Theme), 28 April 2015 • Executive Committee (CQF&P Theme), 26 May 2015 • Executive Committee (CQF&P Theme), 2 June 2015

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GB/15/074 Questions from the public No questions received.

GB/15/075 Any other business The Governing Body recognised that this was AD’s last meeting before she handed over to the new Clinical Chair, JSm. AD had been with the CCG from the beginning, ensuring that the organisation was safe and gaining the admiration of everyone that she worked with. AD was presented with a gift from members of the Governing Body and DDES CCG staff and all joined in thanking her for her service. AD thanked everyone for their support, adding that it had been a fascinating experience, that the CCG had achieved a lot and was moving forward. She felt that JSm would be an asset as Clinical Chair and wished him, the Governing Body and the CCG well for the future. Members of the public were thanked for their attendance and patience.

Next meeting 8 September 2015 at 3pm – 4.30pm at Horden Social Welfare Centre, Peterlee, SR8 4LX

Signed: …………………………………………. Title: …………………………………………. Date: ………………………………………….

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DURHAM DALES EASINGTON AND SEDGEFIELD CLINICAL COMMISSIONING GROUP

Governing Body

TERMS OF REFERENCE

1. Introduction and role 1.1 NHS Durham Dales, Easington and Sedgefield Clinical Commissioning Group

(DDES CCG) was authorised in full and without conditions on 22 March 2013. In accordance with the CCG’s Constitution the Governing Body has been established with the principal purpose to exercise the functions that are delegated to it in relation to the organisation and operation of the CCG.

1.2 In discharging the functions of the CCG that have been delegated to them the

Governing Body and its members must:

i. comply with the Group’s principles of good governance,1

ii. operate in accordance with the Group’s scheme of reservation and delegation,2

iii. comply with the Group’s standing orders,

iv. comply with the Group’s arrangements for discharging its statutory duties,3

v. where appropriate, ensure that member practices have had the opportunity

to contribute to the Group’s decision making process.

vi. ensure that no decision is taken on an issue which affects a locality without representation from that locality

1.3 Where delegated responsibilities are being discharged collaboratively, the joint

(collaborative) arrangements must:

a. identify the roles and responsibilities of those clinical commissioning groups who are working together;

1 See section 4.4 on Principles of Good Governance above 2 See appendix D 3 See chapter 5 above

b. identify any pooled budgets and how these will be managed and reported in annual accounts;

c. specify under which clinical commissioning group’s scheme of reservation

and delegation and supporting policies the collaborative working arrangements will operate;

d. specify how the risks associated with the collaborative working arrangement

will be managed between the respective parties; e. identify how disputes will be resolved and the steps required to terminate

the working arrangements; f. specify how decisions are communicated to the collaborative partners.

1.4 The Governing Body shall take into account at all times the provisions contained in the ‘NHS Codes of Conduct and Accountability’ which, when applied to the Governing Body, requires its members to declare on appointment any business interests or any positions of authority in a charity or voluntary body in the field of health and social care, and any business interests in private healthcare providers or associated partner organisations. Such interests must be entered into a register which will be made available to the public.

1.5 The terms of reference, through the delegation of authority and membership of the

Governing Body recognise the CCG’s development and the membership nature of the organisation.

2. Remit According to the Constitution the Governing Body has responsibility for:

2.1 ensuring that the Group has appropriate arrangements in place to exercise its

functions effectively, efficiently and economically and in accordance with the Groups’ principles of good governance4 (its main function);

2.2 determining the remuneration, fees and other allowances payable to employees or

other persons providing services to the Group and the allowances payable under any pension scheme it may establish under paragraph 11(4) of Schedule 1A of the 2006 Act, inserted by Schedule 2 of the 2012 Act;

2.3 approving any functions of the Group that are specified in regulations;

2.4 The Group’s membership has also decided to confer the following additional

functions on the Governing Body on their behalf: a. leading the setting of vision and strategy b. approving commissioning plans c. corporate budget setting and management d. monitoring operational and financial performance against plans e. providing assurance of strategic risk

4 See section 4.4 on Principles of Good Governance above 2

3. Membership

The Governing Body must comprise 14 voting members and two non-voting roles. Where a single individual holds two roles, they will only be entitled to one vote:

• the CCG chair;

• Three elected general practice leads (one from each locality)

• Two lay members, one of the lay members will lead on audit and assurance and

the other will lead on patient and public involvement matters;

• One registered nurse, the CCG’s Director of Nursing;

• One secondary care doctor;

• The Chief Clinical Officer as Accountable Officer

• The Chief Finance Officer;

• The Chief Operating Officer

• The Director of Commissioning

• The Medical Advisor

• Director of Primary Care, Partnerships and Engagement

In addition the following non-voting members will attend:

• The Director of Public Health for County Durham

• Local Authority representative

Where the Accountable Officer role is not undertaken by a clinician the position of Governing Body Chair must be held by a clinician

5. Secretary 5.1 The secretarial support for the Governing Body is provided by Corporate Support

Team. 5.2 The agenda will be issued seven days prior to the meeting. Requests for items to

be included on the agenda should be sent to the Chief Clinical Officer and Chief Operating Officer at least ten days before the meeting.

5.3 Minutes of each meeting will be formally recorded and submitted to the next

meeting.

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5.4 The agenda and supporting papers will be circulated to all members of the meeting at least five working days before the date the meeting will take place.

6. Frequency of meetings

6.1 Meetings of the Governing Body will be held bi monthly as a minimum.

7. Accountability arrangements 7.1 All minutes and papers from the Governing Body will be available to the public

except those marked ‘in confidence’ or minutes headed ‘items taken in private’. 7.2 The Governing Body will formally report in writing after each meeting by publishing

minutes in a format easily accessible by Member Practices. 8. Quorum

8.1 A meeting of the Governing Body will be quorate when at least one-third of the

whole number of the Chair and members including at least one lay member and one member representative and either the Chief Clinical Officer, the chief operating officer or chief finance officer present.

8.2 If there is a potential conflict of interest where all GPs or other practice representatives could have a material interest in a decision, the governing body will be quorate if more than 50% of the voting members without conflict are present including the Chief Finance Officer or Chief Operating Officer and the requirement in respect of locality representatives is waived. Agreed nominated deputies should attend as required

9. Committees of the Governing Body 9.1 The Governing Body shall appoint the following committees:

• Audit and Assurance Committee: for terms of reference see separate policy document

• Remuneration Committee: for terms of reference see separate policy document

• Executive committee: for terms of reference see separate policy document

• Primary care commissioning committee: for terms of reference see separate policy document

9.2 Such Committees shall be made up of either members of the governing body, any

consultants and/or employees, or any others approved by the Governing Body, and the membership of each Committee shall be set out in its terms of reference.

9.3 The Governing Body may appoint such other committees as it considers appropriate but committees will only be able to establish their own sub-committees,

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to assist them in discharging their respective responsibilities, if this responsibility has been delegated to them by the Governing Body.

9.4 The Audit and Assurance and Primary Care Commissioning Committees may

include individuals who are not members of the Governing Body. 9.5 An individual shall be ineligible for appointment to or shall otherwise be disqualified

from membership of a committee or subcommittee of the Governing Body if is he or she is a person who is disqualified from membership of a clinical commissioning group’s Governing Body under Schedule 5 of the CCG Regulations.

9.6 All decisions taken in good faith at a meeting of any committee or sub-committee of

the Governing Body shall be valid even if there is any vacancy in its membership or it is discovered subsequently that there was a defect in the calling of the meeting or the appointment of any of the members attending the meeting.

10. Policy and best practice 10.1 The Governing Body will apply best practice in the decision making processes and

in particular it will ensure that decisions are based on clear and transparent criteria. 11. Conduct of the Governing Body 11.1 All meetings will be held in accordance with CCG’s agreed corporate behaviors and

the Nolan Principles of Public Life. 11.2 All papers for discussion must be submitted to the Chief Operating Officer for

approval before the agreed deadline. 11.3 If an item needs to be raised on the day, this will be covered under ‘any other

business’, subject to the agreement of the chair and there being available time.

11.4 At the start of each meeting, members will be asked to confirm the accuracy of the declaration of interests.

11.5 When necessary, a separate confidential agenda of the meeting will be held only

with members or their nominated deputies and individuals ‘in attendance’ may be required to leave the meeting.

11.6 All questions arising will be decided by a simple majority of those present. In the

case of equality of votes, the chair will have the casting vote. 11.7 The decision on whether or not a vote is to be taken and the method of voting on

the issue in question shall be a matter entirely for the discretion of the person presiding as chair of the meeting to decide upon. Their decision will be final.

11.8 It is good practice, at least annually, for the Governing Body to review its own

effectiveness, performance, membership, terms of reference and prepare an annual cycle of business. Any resulting changes to the terms of reference or membership should be approved by the governing body.

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Contact: Cllr John Robinson Direct Tel: 03000 268140 e-mail: Your ref: Our ref:

Nicola Bailey, Chief Operating Officer, Durham Dales, Easington and Sedgefield Clinical Commissioning Group, Sedgefield Community Hospital, Salters Lane, Sedgefield, Co. Durham. TS21 3EE

1 September 2015 Dear Ms Bailey, DDES CCG Review of A&E Ambulance services – Findings of the Independent Review by North East Clinical Senate Following a meeting of Durham County Council’s Adults Wellbeing and Health Overview and Scrutiny Committee on 1st September, 2015 please find attached the Committee’s comments to the DDES CCG Governing Body meeting in respect of the Review of A&E Ambulance services – Findings of the Independent Review by North East Clinical Senate agreed earlier today. The Adults Wellbeing and Health Overview and Scrutiny Committee re-affirms its previous agreement that the case for change has been demonstrated by the CCG, given that the North East Clinical Senate has concluded that:-

(i) There was no evidence of any difference in patient outcomes between an

ambulance staffed by a paramedic and an Emergency Care Assistant and one staffed by two paramedics, and

(ii) The Review team felt that personnel resources would likely be better utilised by moving to the mixed crew model.

The Adults Wellbeing and Health Overview and Scrutiny Committee would request that post implementation monitoring of the proposals be undertaken and that an update report be provided to this Committee 6/12 months after the proposed commencement of the new service model on 1st April 2016.

Members Durham County Council, County Hall, Durham DH1 5UQ Main Telephone (03000) 260000 Minicom (0191) 383 3802 Text 07786 02 69 56

Website: www.durham.gov.uk

In view of the Clinical Senate’s conclusion 5 within the Independent Review report, the Adults Wellbeing and Health Overview and Scrutiny Committee would welcome the proposals detailed “to develop a set of services and relationships that would improve the resilience of rural populations” and would again request that an update report on these issues be brought back to this Committee in due course. The Adults Wellbeing and Health Overview and Scrutiny Committee welcomes the confirmation given at their meeting that the implementation of the proposals will result in an additional Rapid Response Vehicle being introduced within the Durham Dales, Sedgefield and Easington CCG area. Finally, both public representations and the Committee sought clarification on the status of North East Ambulance Service performance information previously provided to the Rural Ambulance Monitoring Group and which has been stopped due to information governance issues. NEAS have confirmed that they are currently reviewing their performance management reporting mechanisms and information to ensure that it complies with Information and Data Governance legislation and are happy to provide such information in the future when it has been approved by the Trust. Accordingly, the Adults Wellbeing and Health Overview and Scrutiny Committee would welcome the re-instatement of NEAS Ambulance Performance Information reports which set out performance across County Durham, including the Durham Dales, Easington and Sedgefield CCG area to the Committee and Rural Ambulance Monitoring Group, subject to compliance with Information and Data Governance legislation.

Yours sincerely, Cllr John Robinson, Chair of the Adults, Wellbeing and Health Overview and Scrutiny Committee Durham County Council

Meeting Date: 8th September 2015 Item No: GB/15/082

Governing Body

Report Title Practice and Clinical Engagement – Recommendations for Terms of Reference

Author Gail Linstead – Head of Primary Care Development and Engagement Sarah Lambert – Head of Corporate Services

Sponsor Director Joseph Chandy – Director of Primary Care, Partnerships and Engagement

Date 14th August 2015 Purpose of report Information sharing Development / Discussion Decision / Action Brief introduction / Purpose of paper

In the 2014/15 financial year an internal audit was undertaken of controls over the management of arrangements for practice and clinical engagement. A report was them produced that summarised the findings and recommendations with agreed deadline dates. One action from this report was revisiting Terms of Reference for CCG’s governance meetings to ensure the effectiveness of practice/clinical engagement and that the group was meeting its responsibilities in relation to practice/clinical engagement. Currently the Governing Body Terms of reference do not contain any reference to Practice and Clinical Engagement

Summary of key points

The aim of this internal audit was to evaluate the design and test the application of controls within the processes for engaging with member practices. Recommendation 2.2a states:-

a) The effectiveness of the Council of Members, GB and committees, DDES Wide, Locality Group, and Clinical Champions Meeting should be assessed annually to determine whether each committee / group has delivered its responsibilities for practice and clinical engagement as set out in the Terms of Reference.

In response to this the CCG are requested to revisit and revise all appropriate terms of reference accordingly. It is recommended that the following be added into the Governing Body Terms of Reference:-

‘The Governing Body considers and reviews the effectiveness of the CCG’s Engagement Strategy in enabling practice and clinical engagement and receives assurance via the annual CCG 360 Stakeholder survey.’

DDES approval route

Practice and Clinical Engagement Action plan approved at CCG Formal Executive Committee on 21st July 2015.

Other consultation routes

Supporting documentation / Appendices

• Governing Body Terms of Reference

Strategic objectives in Assurance Framework supported by this report

Access to safe, high quality services

Development and delivery of commissioning and financial plans including QIPP

Effective internal and external engagement including communications

Effective governance and organisational development

Effective contract management and performance against key targets

Recommendations / Action required from meeting members

The Governing Body is asked to: • Accept this report and adopt the recommendation to include the

advised wording as part of the terms of reference • Agree to review the effectiveness of engagement on an annual basis

by:- • Summarising engagement activity in year • Suggesting improvements that can be made moving forwards • Minuting discussions appropriately to act as evidence

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Impact Assessment and Risk Management Issues X.1 Consideration given and action taken in this report relating to impact assessment and

risk management issues is detailed below:

a) Risk N/A

b) Environmental impact / sustainability N/A

c) Legal implications N/A

d) Resource implications – finance and/or staffing N/A

e) Equality Assessment N/A

f) Quality, Innovation, Productivity and Prevention N/A

g) Patient, public and stakeholder involvement N/A

h) Clinical engagement To ensure appropriate levels of Clinical Engagement

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Special Adults Wellbeing and Health Overview and Scrutiny Committee

1 September 2015

Durham Dales, Easington and Sedgefield CCG - Review of Accident and Emergency Ambulance services – Findings of the Independent Review by North East Clinical Senate

Agenda Item 5

Report of Lorraine O’Donnell, Assistant Chief Executive

Purpose of the Report

1 To provide members of the Adults Wellbeing and Health Overview and Scrutiny Committee with the key findings of the Independent Review by the North East Clinical Senate in respect of the review of Accident and Emergency Ambulance services .

Background

2 The Committee has previously considered reports and presentations from North East Ambulance Service NHS FT, NHS County Durham and Darlington (the former Primary Care Trust), Durham Dales Easington and Sedgefield Clinical Commissioning Group and representatives of the Durham Dales Ambulance Monitoring Group in respect of the ongoing review of Accident and Emergency Ambulance services.

3 At the Adults Wellbeing and Health Overview and Scrutiny Committee’s

meeting held on 29 September 2014, members considered reports and a detailed presentation which set out:-

• The case for change in terms of resource availability, service

performance and clinical need;

• Extensive engagement and communications activity undertaken by Durham Dales, Easington and Sedgefield Clinical Commissioning Group;

• Assurance processes up to and following implementation of proposals.

4 The Durham Dales, Easington and Sedgefield Clinical Commissioning Group

advised that they planned to implement proposed changes to the Accident and Emergency Ambulance service in April 2016.

5 However, in acknowledging the strength of feeling expressed at a number of

engagement events held across the DDES area against the proposals, the CCG proposed to commission an independent clinical review to review the safety and rationale for the proposed provision of a skill mixed paramedic and emergency care assistant crewed Ambulances within the Durham Dales area.

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6 Following questions from Members of the Adults Wellbeing and Health Overview and Scrutiny Committee, other Councillors and members of the public, the Committee

Resolved that:- 1. the reports and presentations be received and the information therein

noted; 2. the Committee agree in principle that the case for change has been

demonstrated by the CCG, subject to the findings of the proposed independent clinical evaluation of the need for double crewed paramedic vehicles in the Dales area;

3. the Committee consider that the engagement activity undertaken by DDES CCG demonstrates an extensive and robust consultation process having been undertaken;

4. the Committee agree the principle of post implementation monitoring of the proposals being undertaken, subject to (i) the results of the Independent clinical evaluation of the need for

double crewed paramedic vehicles in the Dales area, and (ii) the terms of reference for this evaluation to be referred back to

this Committee for consideration.

7 At the Committee’s meeting held on 19 January 2015 the Terms of reference for the independent clinical review by the North East Clinical Senate were presented to the Committee.

Latest Position 8 In accordance with the terms of reference for the review, the Clinical Senate

has now completed its work and produced a report setting out their key findings and associated recommendations. A copy of the report is attached to this report (Appendix 2).

9 Representatives of Durham Dales, Easington and Sedgefield Clinical

Commissioning Group will be in attendance to present the report.

10 Durham Dales, Easington and Sedgefield Clinical Commissioning Group’s Governing Body will meet on Tuesday 8th September 2015 to consider its position in respect of the proposals and the feedback from the Adults Wellbeing and Health Overview and Scrutiny Committee meeting on 1st

September 2015.

Recommendation

11 The Adults Wellbeing and Health Overview and Scrutiny Committee is recommended to receive this report and consider and comment on the key findings and recommendations detailed therein.

Background papers

Reports and presentations to the Adults Wellbeing and Health OSC meetings held on 9 March 2012 and 24 July 2012.

Reports and presentations to the special Adults Wellbeing and Health OSC Meeting on 18 July 2014

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Reports and presentations to the Adults Wellbeing and Health OSC Meeting on 29 September 2014

Report to the Adults Wellbeing and Health OSC meeting on 19 January 2015

Contact: Stephen Gwillym Principal Overview and Scrutiny Officer Tel: 03000 268140

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Appendix 1: Implications

Finance - None

Staffing - None

Risk - None

Equality and Diversity / Public Sector Equality Duty - None

Accommodation - None

Crime and Disorder - None

Human Rights - None

Consultation – Communications and engagement proposals by the North East Commissioning Support unit on behalf of the Durham Dales, Easington and Sedgefield CCG have been previously supported by the Committee and the feedback from this activity has previously been presented to the Committee also.

Procurement - None

Disability Issues - None

Legal Implications – None

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Durham Dales Paramedic Skill-mix

Review

Final Report June 2015

Page 5

Durham Dales Paramedic Skill-mix Review Final Report

1. Introduction

In December 2014, the Northern Clinical Senate received a formal referral from the Durham Dales, Easington and Sedgefield Clinical Commissioning Group to provide an independent clinical assessment of the following issue:

For people in the Durham Dales area, is there any difference in terms of patient care and outcome between an ambulance service staffed by a paramedic with an Emergency Care Assistant (ECA), and one staffed by two paramedics?

In order to provide an appropriate response to this referral, the Northern Clinical Senate drew together clinical experts from across the country on all aspects of the clinical journey that patients would experience in this instance. Their expertise included both the clinical aspects of care based on the latest research and guidance available, and the knowledge and experience of how care is delivered in rural settings. Table 1 shows the Review Team members and their relevant expertise/experience to undertake the review.

Member Background/role

Dr Lesley Kay (Chair)

• Vice Chair – Northern Clinical Senate • Consultant Rheumatologist and Clinical Director – Patient Safety, Newcastle

upon Tyne Hospitals NHS Foundation Trust Mark Millins

• Lead Paramedic – Yorkshire Ambulance Service • UK Ambulance Services Clinical Guidelines Lead • Member of Consultant Paramedic Advisory Group (College of Paramedics) • Vice Chair – National Ambulance Lead Paramedic Group • Member of the Yorkshire and Humber Clinical Senate

Richard Lee

• Assistant Director of Operations (Clinical Modernisation) – Welsh Ambulance Service NHS Trust

• Previously Head of Clinical Services and Regional Director – South East, Central and West Wales (both Welsh Ambulance Service)

• Paramedic • NICE Major Trauma Guidelines Project Executive Team Paramedic member

Dr David Bramley

• Consultant in Emergency Medicine & Pre-Hospital Emergency Medicine – City Hospitals Sunderland

• Medical Director – Great North Air Ambulance Service • Network Director – Northern Trauma Network

Dr Peter Weaving

• GP Clinical Director at North Cumbria University Hospitals NHS Trust • Previously CCG Co-Clinical Chair – Cumbria CCG and GP at a practice

serving a rural community • Northern Clinical Senate Council Member

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David Davis

• Paramedic • NHS 111 Workforce Development Programme National Clinical Lead – NHS

England • NHS Pathways Clinical Lead/Deputy Lead Governor – South East Coast

Ambulance Service • AHP Clinical Lead – South East Coast Clinical Senate Council • Formerly AHP National Clinical Lead for Informatics – Department of

Health/HSCIC • Fellow of the College of Paramedics and formerly Director of

Communications Table 1: Northern Clinical Senate Review Team

The Review Team worked through the methodology outlined within the report to determine a response to the question set. The conclusions drawn from this process underpin the recommendations made to the sponsoring organisation in this Final Report. The sponsoring organisation is not statutorily obliged to implement these recommendations and will need to consider them through their own decision-making process.

The Final Report has passed through the Northern Clinical Senate governance process and has been approved by the Northern Clinical Senate Council.

2. Background The two-paramedic crew service model for the Durham Dales was put in place by the North East Ambulance Service (NEAS) following a review they had undertaken on rural ambulance provision and at the request of the then commissioner of the service, County Durham Primary Care Trust (PCT) in 2008.

As part of the PCT decision, additional investment was made in the provision of a single crewed paramedic Rapid Response Vehicle (RRV) for 12 hours a day to support the dual-paramedic crewed ambulance. Since the introduction of this model, commissioning responsibilities have changed since the enactment of the Health and Social Care Act (2012) with the abolition of PCTs and have moved to the newly formed clinical commissioning groups (CCGs) - in this instance, the Durham Dales, Easington and Sedgefield CCG (DDES CCG).

These crews and RRV operate out of the Barnard Castle and Weardale stations and cover both Weardale and Teesdale.

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3. Methodology

The review process used the following methodology.

Stage 1 – Pre-review information

• Literature review on paramedic skill-mix/ambulance provision in rural areas. • Details of deployment and backup procedures for the Durham Dales. • Details of air ambulance provision in the area (including night flight etc). • Details of pre-alert systems in operation with receiving hospitals. • Details of clinical oversight/supervision for crews to be based in the Dales. • Job descriptions of Paramedic/Emergency Care Assistant/Paramedic Technician

from NEAS and the other nine English Ambulance Services.

Prior to commencing the review, DDES CCG and NEAS had devised a paper audit form to give to crews responding to calls in the Durham Dales (the Review Team members had sight of the form prior to circulation and were comfortable with the questions being used). The data collection ran from the 1st to the 28th February 2015. During this time, only 28 forms were completed by ambulance crews (NEAS responds to roughly 250 calls a month in the Durham Dales area).

It transpired that only 28 NEAS Rural Ambulance Skill-Mix audit forms were completed during February 2015. NEAS felt that neither re-auditing nor extending the audit period further would result in a higher completion. Instead the Review Team agreed to take a sample of Electronic Patient Report Forms (EPRFs – the clinical assessment reports that are completed by crews for each incident NEAS respond to) to provide a representative sample size of information to review.

The Review Team received 471 EPRFs extracted from NEAS’ clinical database which included 335 relating to incidents responded to by crews working out of the Barnard Castle and Weardale stations, and 136 forms relating to incidents in the Durham Dales responded to by crews working from other stations. Both the local audit and the extracted EPRFs were considered by the Review Team.

Stage 2 – On-location Review Day structured around the following sessions:

• Session 1 in Newcastle – NEAS representatives: Medical Director, Consultant

Paramedic, Chief Operating Officer and Operations Manager – South Division • Session 2 in Westgate, Weardale – Rural Ambulance Monitoring Group • Session 3 in Bishop Auckland – paramedics and ambulance staff based in the

Durham Dales Page 8

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Session 3 was arranged to allow the Review Team to hear the views of paramedics and ambulance crews working in the Durham Dales. Unfortunately, due to either operational crews being unavailable as they were responding to calls or off duty staff being unable to attend as they were on annual leave, no paramedics were available for this session. To ensure that paramedics could put forward their views, the offer was made to all those crews covering the Durham Dales to submit individual paramedic’s views electronically or speak to Review Team members after the Review Day. Four paramedics subsequently put forward their views which were taken into consideration by the Review Team in writing this report.

Stage 3 – Collation of supplementary information either requested by Review Team members or identified as relevant by session attendees on the Review Day.

The information provided in all three sessions was collated, analysed and assessed by the Review Team with the conclusions and recommendations outlined in this report.

4. Views expressed on the Review Day 4.1 NEAS

The main views expressed on the Review Day by NEAS were that:

• The current service model in the Durham Dales is unique in the North East

(including other significantly rural areas such as Northumberland) and probably across the rest of the country in areas such as Yorkshire and Wales.

• There are ongoing issues of recruitment, retention and long-term sickness in the crews working out of the two main Durham Dales ambulance stations. NEAS believe that this would be alleviated by moving to the proposed models with paramedic vacancies that have proved difficult to recruit to, being filled with more available non-regulated ambulance care assistants, Emergency Care Assistants (ECAs), also known as Emergency Care Support Workers (ECSWs) in some ambulance trusts.

• Resources released by moving to the proposed skill-mix model would mean an increased level of service to the Durham Dales (through the introduction of an additional RRV) with no additional clinical risk identified or anticipated.

• The risks in the proposed service model already exist in the current service model (e.g. connectivity of communications) and are not affected by the skill-mix change.

• Significant changes have been made to the remote clinical support available to all crews in recent years, e.g. introduction of a 24/7 clinical hub staffed by senior paramedics and the creation of the new Emergency Care Clinical Manager (ECCM) role.

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4.2 Rural Ambulance Monitoring Group (RAMG)

The main views expressed by the RAMG during the session were that:

• The Durham Dales is a unique place (rurality, population changes in summer with significant number of holiday makers, no street lighting, etc) which requires a service model that differs from the norm.

• The current service model was introduced in response to concerns around patient safety in 2008 so why would there be a change now?

• There has been an ongoing erosion of service since 2010, feeling strongly that ambulances were being taken out of the Dales area due to incident volumes in other areas, handover delays at Durham hospitals and returning crews being diverted to other incidents on the way back to the Dales (with suspicion that this may not just be for Red 1 category calls but all the way to Green 2 calls). The RAMG perceive that this leads to significant periods of time when there is no coverage for the Dales (but can’t quantify this as the information provided by NEAS has ceased to be provided on grounds of patient confidentiality and the fact it was a “non-commissioned” report).

• Whilst recognising that two paramedics per crew may be viewed to be a “luxury”, they did not want to see further erosion of service level.

• (Organisational) politics and the new commissioning arrangements were stopping proper joined up discussions on developing services appropriate for rural communities – examples given that RAMG members are directed to staff members in North of England Commissioning Support NECS as opposed to being able to meet with CCG staff.

• There was concern about the pressure on single paramedic from a staff welfare point of view and potential impact on retention of current staff should current model change.

• There was concern that if a paramedic is absent or ill then the Dales would be left with basic life support crews.

• The group had been told by a consultant from James Cook Hospital (in Middlesbrough) that “Complex, multiple-condition patients require two paramedics”.

• There were no community first responders or known location of public access defibrillators in Weardale.

4.3 Paramedics based in the Durham Dales

The Review Team received four individual responses from paramedics working in the Durham Dales between the Review Day and the production of this report.

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• There are current workforce pressures in the Durham Dales due to long

term illness and retirements. Paramedics report that this leaves them working extra overtime in order to keep a vehicle on the road. Due to demands of the service at present, this leads to numerous missed meal breaks and enforced late returns and early starts turning 12 hour shifts into 13, 14 sometimes even 15 hour shifts.

• Crews in the Durham Dales face extended travel times. Journey times from the upper Dales are circa 50 minutes to Darlington with additional journeys if for stroke (University Hospital North Durham) or acute myocardial infarction requiring percutaneous intervention (James Cook Hospital, Middlesbrough).

• One paramedic felt that crews in the Durham Dales often spend time on inappropriate jobs which could be reduced by a more efficient triage system, as opposed to another who felt that patients in the Durham Dales actually use ambulances more appropriately (i.e. when they really need them) than in other areas.

• Crews in the Dales feel that they “are constantly getting pulled into the big towns and quite often the Dales go completely uncovered”.

• Some paramedics felt that co-morbidities, the larger population of older people and unique elements of case-mix (the example given was of high motor-cycle usage in the area) needed to be taken into consideration.

• Some paramedics felt that ECA/ECSWs only had limited training and a lack of on-the-road experience of difficult jobs in rural locations with no backup make responding effectively more difficult.

• One paramedic felt that while it may be difficult to justify having a double- paramedic crew on for every job, there are some jobs where having the skill of two paramedics definitely improves the patient’s experience and possibly the outcome. They feel that this is very hard to prove or disprove however as it is impossible to perform a randomised controlled trial as each job is so individual.

• One paramedic offered the suggestion of introducing the Qualified Technician Role in the Dales and then paramedic burn out would be less likely to occur as an improved skill-mix to the introduction of ECA/ECSW role in the Dales.

• Examples were given of multiple-casualty incidents where paramedics had felt that the dual-paramedic model had helped them manage the situation more effectively, especially due to the distance that back-up ambulances would have to travel to arrive on scene.

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5. Discussion

The Review Team considered the evidence submitted and views expressed on the day and identified the following key issues:

• Paramedic skill-mix in relation to the scene of an incident. • Clinical support available for crews in rural areas. • Clinical risk management. • Ambulance coverage and journey travel times.

5.1 Paramedic skill-mix in relation to the scene of an incident

The Review Team considered the difference in impact that the two different skill-mix models could have at the scene of the incident with arguments heard that more paramedics on scene lead to quicker assessment and treatment and therefore improved patient outcomes.

Neither the experience of the clinical experts on the Review Team or the limited published research in this area supported this argument as dual-paramedic crews tend to spend longer on scene than mixed-model crews when more rapid conveyance to an acute setting may have been more beneficial to the patient. In fact part of the treatment of a seriously ill patient is the packaging and removal to the ambulance which is not a paramedic skill.

The clinical experts on the Review Team feel that there are only a very small number of instances in which there is absolute urgency for treatment on scene (cardiac arrest, choking, exsanguinating haemorrhage or obstetric calls where a baby that has been born requires resuscitation whilst the mother suffers a post-partum bleed). In these most urgent cases, unless an ambulance is in very close vicinity at the time the incident occurs, the chances that a paramedic crew can intervene successfully are very limited (regardless of skill mix).

For cardiac arrest cases, the paramedic/ECA model provides a team capable of commencing advanced life support and there will be cases where a lone paramedic on RRV (with ambulance back-up) will be the first on scene. The immediate priorities at a cardiac arrest are good quality cardiopulmonary resuscitation (CPR) and immediate defibrillation of a shockable rhythm. Both of these skills can be safely undertaken by ECA staff.

In other very urgent cases, often the most important factor affecting the clinical outcomes of the patient is the speed by which the patient can reach a definitive care setting, the treatment by the ambulance crew, whilst essential, must be undertaken en route.

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The argument for multiple-casualty incident, whilst an emotive one, should not be used to justify double-paramedic crews due to the infrequency of these types of incident. It often does not stand that two paramedics will be able to treat a patient on scene more quickly than a single paramedic and an ECA in such instances as there is only one piece of the necessary clinical equipment (e.g. defibrillator) available on each ambulance. As asserted by NEAS, the paramedic resource released from the skill-mix change would also enable the increase in number of RRVs which should lead to a more rapid back-up in such incidents. However, operational and staffing realities may not lead to this occurring in practice at times.

The area also benefits from good access to air ambulance support and this service should be in attendance as often as possible at critical incidents.

Ultimately in all instances, many of the advantages of a two-paramedic crew are lost once the conveyance of the patient begins as one member of the crew is always driving the ambulance. The access to peer support and review is mitigated through remote clinical supervision available from the clinical support function as outlined earlier within the document.

Instances identified in the completed audit forms

Of these 28 forms, three contained indications that paramedics felt that the two- paramedic model had had a beneficial impact on the clinical outcomes of the patients in these instances.

The Review Team looked at these three cases. Two of them were patients being treated for Sepsis. Sepsis is a common and potentially life-threatening condition triggered by an infection that causes a series of reactions including widespread inflammation, swelling and blood clotting. This can lead to a significant decrease in blood pressure, which can mean the blood supply to vital organs such as the brain, heart and kidneys is reduced, and if left untreated mean organ failure and ultimately death. Sepsis is often treated in the first hour with the application of six measures (the Sepsis Six1) which are:

1. Administration of high flow oxygen. 2. Taking blood cultures. 3. Giving broad spectrum antibiotics. 4. Giving intravenous fluid challenges. 5. Measuring serum lactate and haemoglobin. 6. Measuring accurate hourly urine output.

1 http://www.nhs.uk/Conditions/Blood-poisoning/Pages/Treatment.aspx Page 9 of 16

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http://www.nhs.uk/Conditions/Blood-poisoning/Pages/Treatment.aspx


Of these six measures, only two (measures 1 and 4) are able to be given by ambulance crews in the North East, as in many other parts of the country, with the others to be delivered in an acute hospital. The clinical experts on the Review Team noted that ECAs should already have the training to deliver oxygen and assist the paramedic with the administration of IV fluids. These treatments would be best administered within the ambulance during the journey to hospital with the other crew member driving to enable the patient to reach an acute care setting as quickly as possible to receive the other four measures.

It was felt that such cases do not justify a dual-paramedic crew. It is also noted that Sepsis care provision is advancing in the pre-hospital arena, with the introduction of point of care testing and other interventions, but that this would not add power to the argument to retain a double-paramedic crew.

In the third case, the patient was suffering from acute shortage of breath and exacerbation of chronic obstructive pulmonary disorder (COPD) with abdominal pain. The form describes that:

“Having a double-paramedic crew enabled treatment of both drugs and IV fluids where effective monitoring and re-assurance of patient and family. An ECSW (ECA) would have delayed certain aspects of critical care with disastrous consequences”.

The full EPRF for this incident was requested and based on this and the information included in the written account, the Review Team felt that:

• There may have been some immediate temporal benefit to the case described,

however this type of clinical presentation is one that other ambulance services would expect their mixed-paramedic/ECA crews to manage efficiently and effectively as a matter of course.

• The detailed information does not support the suggestion that this incident would require a double-paramedic crew.

In this instance, there were three paramedics present as a RRV was also in attendance. If the mixed-crew model were in place in this instance there would have still been two paramedics on scene.

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5.2 Clinical support for paramedics in rural areas

One of the factors the Review Team felt was an important consideration in the proposals to change the skill-mix for the crews working in the Dales was to ensure that there was sufficient clinical support available. NEAS outlined a range of support mechanism including the 24/7 telephone/radio (Airwave) support access to the Clinical Hub and the introduction of the Emergency Care Clinical Manager role.

The Review Team recognise that ambulance crews working in rural and very-rural areas are at risk of being unable to retain and maintain their knowledge, skills and competencies across a wide range of clinical areas, simply due to the lower volume of incidents attended. This requires greater focus on training of skills on things seldom done by both the individuals in the crews and NEAS as their employer. NEAS outlined the new training needs self-assessment programme that will help target training necessary across stations/areas or to individual needs that demonstrated a robust approach to ensuring crews can maintain both their skills and confidence, particularly if this were to be tailored to those skills areas most likely to lapse due to the case volume and mix experienced due to the rural setting.

Clinical supervision needs to be carefully considered and developed in partnership with the workforce, to support this group of clinicians.

5.3 Clinical risk management

The Review Team took into consideration the management of clinical risks associated with the proposed skill-mix.

NEAS discussed past issues of crews’ ability to recognise ST elevation in electrocardiograms (ECGs), particularly when there was a lack of 3G connectivity (which can impact telemetry transfer to the PPCI centre). In these instances, the clinical risk is managed through the ability of a paramedic to interpret an ECG learned during Advanced Life Support (ALS) training (mandatory on an annual basis) for all NEAS paramedics.

The Review Team noted that NEAS is one of a minority of ambulance trusts in the country currently using telemetry for ECG, So during the times that telemetry is unavailable, this does not negate the ability of the paramedic to autonomously care for the patient to a level below that available anywhere else in the country.

There was also discussion around the risk associated with the Airwave radio system black-spots, especially for new crew members coming to work in the area.



The paramedics on the Review Team felt that the overall risk associated with Airwave black-spots was no greater for a mixed-crew than for a double-paramedic crew, and that Airwave black-spot locations would be well known by local crews. The national Airwave system is being reviewed and NEAS should ensure that known black-spots are addressed in future developments.

5.4 Ambulance coverage and journey travel times

One of the key reflections of the Review Team from hearing the views of NEAS, the RAMG and paramedics working within the Durham Dales is that their needs to be a clear separation of concerns over the impact of changes to the skill-mix of the crews and the general ambulance coverage in the Durham Dales.

Whilst outside of the scope of clinical review, the concerns around the crews being sent out of area are valid ones. It is important to note, however, that maintaining the current skill-mix model may be contributing to these issues, particularly given the current workforce pressures being experienced by the Barnard Castle and Weardale stations and NEAS more widely.

If NEAS is able to re-deploy a number of paramedics through the implementation of the skill-mix change, then the operational response provided may enable a more effective deployment within the Durham Dales.

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6. Conclusions

Based on the information submitted (including the small number of completed audit forms), the meetings with members of the North East Ambulance Service and the Rural Ambulance Monitoring Group and the views submitted by paramedics working in the Durham Dales, the Northern Clinical Senate Review Team has made the following conclusions:

Conclusion 1: There was no evidence of any difference in patient outcomes between an ambulance staffed by a paramedic with an Emergency Care Assistant (ECA), and one staffed by two paramedics.

The case-mix and geographical factors of the Durham Dales area are not significantly different to other rural and very-rural areas in the UK that already operate the mixed-crew model. Whilst it was noted that rurality is linked to extended travel times, this factor should not determine the clinical model as during the journey in a two-paramedic crew, one paramedic is driving the vehicle (with the driver training provided to ECA staff and paramedics is identical).

Conclusion 2: The Review Team feel that personnel resources would likely be better utilised by moving to the mixed-crew model.

Due to the current model of dual-paramedic crew and the use of Rapid Response Vehicles, there are occasions when three paramedics are attending the same incident. To a back drop of pressured workforce and the need to deliver challenging performance targets, the Review Team felt that the mixed-crew model offered a more effective use of resources.

In this regard, whilst it is appreciated that it could be perceived that a change in skill- mix from the dual-paramedic to the mixed-model would be a loss/reduction in service, it would in fact release capacity that would be available to provide a wider range of services and potentially increase the quality of care across the system. On the balance of probability, more vehicles capable of responding to incidents over a rural geography would be of more benefit than fewer vehicles with dual- paramedics.

Conclusion 3: There are practical processes in place and training in the process of being introduced that will support the mitigation of clinical risk in rural and very-rural areas.

The evidence presented by NEAS regarding the availability of the clinical support hub, the introduction of ECCM staff and the systematic self-assessment training needs analysis convinced the Review Team that adequate clinical support is



available to paramedics in the Durham Dales. The Review Team felt that, as well as this, NEAS should offer to do extra training in interpretation of ECGs for crews based in the Durham Dales.

Conclusion 4: Staff would need to be supported through any introduction of service change.

The Review Team recognises the challenges of providing healthcare in rural and extremely rural areas with small teams of dispersed staff. Further, the team recognises the issues this produces in terms of recruitment and retention of staff, and development and maintenance of expertise. NEAS will need to take care and support staff and identify any unforeseen consequences of service change through any introduction of change.

That paramedics and ECAs in the new arrangement will require ongoing clinical and training support to help mitigate the small clinical risks associated with lower incident volume. NEAS will also need to identify clear contingency plans for when there is sickness/absence within the crews covering the Dales. Airwave black-spots should be mapped and made available for new crew members or crew members from out- of-area covering absence. Staff confidence and wellbeing needs to be considered as it will be important to retain competent and capable staff within the context of such long transfer times. This should include:

• The introduction of specialist (primary and critical care) and advanced roles

should be considered and implemented at the earliest opportunity – to provide escalation and supervision opportunities.

• With the future potential of a supervision ratio of roughly 1:1.5 paramedics for students in the coming years, it would make sense to invest in the Dales workforce to ensure that they are all capable for supervision, practice educators in stations and student paramedics.

• All paramedics should have regular supervision shifts as part of their rotations to ensure quality, competence, confidence and patient safety.

• There should be specific focus on the confidence of crews in the interpretation of ECGs as part of the self-assessment of crews’ training needs.

• If the inevitable overruns, experienced by Dales’ ambulance crews, are leading to shifts in excess of 12 hours then consideration should be given to rostering shorter shifts (e.g. 8 or 10 hours) to ensure that even with an overrun the longest working shift is 12 hours.

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Conclusion 5: There are opportunities for NEAS, the commissioner and local communities to work together to develop a set of services and relationships that would improve the resilience of rural populations.

For some of the most urgent cases in rural and very-rural areas, ambulances may not be able to get to the scene of an incident quickly enough regardless of the number of ambulances available or how they are crewed.

In these instances, it is members of the local communities themselves who may be the only people close enough to give basic life-saving treatment until an ambulance arrives. There are opportunities for NEAS, local commissioners and local communities to come together to help develop more resilient local communities in a planned way.

Ideas from the Review Team include:

• To arrange CPR and defibrillator training in local communities on Saturday

mornings and raise awareness/interest in Community First Responder training. • Taking advantage of schemes such as the British Heart Foundation nation of

lifesavers scheme which offers part funding of defibrillators to be used by local communities https://www.bhf.org.uk/heart-health/nation-of-lifesavers/using- defibrillators/applying-for-a-public-access-defibrillator

• Placing public access defibrillators in cabinets in the more populous parts of the Durham Dales so they are accessible to all. Facilities such as phone boxes are used elsewhere in the UK.

• To undertake an online audit in conjunction with community groups and private businesses (e.g. caravan / holiday parks) to map where defibrillators are currently situated.

• NEAS looking to use the Advanced Paramedic role currently in development with Health Education North East.

• Engage in programmes such as Restart-a-Heart (https://www.erc.edu/index.php/events/en/10/2015/12/eid=110/ - a Europe-wide day aimed at teaching secondary school children how to perform life-saving CPR skills) when opportunities arise.


https://www.bhf.org.uk/heart-health/nation-of-lifesavers/using-defibrillators/applying-for-a-public-access-defibrillator



https://www.erc.edu/index.php/events/en/10/2015/12/eid%3D110/


7. Recommendations

The Review Team recommends that the CCG as sponsor organisation should:

• Accept the conclusions drawn from this independent expert review in answering the question posed.

• Support NEAS in their move to introduce the new skill-mix model. • Ensure that NEAS support the crews in the Durham Dales as these changes are

introduced and beyond, and clearly outline contingency plans should there be sickness/absence post implementation.

• Routinely assess the levels of ambulance cover in the Durham Dales area. • Actively engage with NEAS and local groups to develop plans that will create

more resilient local communities. • Work with County Durham and Darlington NHS Foundation Trust to reduce

ambulance handover delays, which contribute to ambulance crews being away from the Durham Dales.

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Financial information

Date Ref Director Owner Description

C L Score

Initial

C L Score

ResidualControls Gaps in controls Gaps in assurancesAssurances

NHS Durham Dales, Easington and Sedgefield CCG Corporate Risk Register

28/08/2015

1 Access To Safe, High Quality Services

118503/02/2015 Gillian Findley Gillian Findley Potential for patients to suffer harm as a result ofdelays in getting diagnostic tests at CDDFTCDDFT are failing the diagnostic target with 8% ofpatients waiting longer than 6 weeks for their diagnostictest. this has been escalated within the trust and anaction plan has been provided but has not yet deliveredthe required improvements. Risk that patients'diagnosis and treatment will be delayed as a result.Also reputational damage as the Trust is an outliernationally.

Potential risk that patients' diagnosis will be delayed asa result. Also reputational damange as the Trust is aoutlier nataionally

4 4 16 the Trusts's position is discussed at the contractmonitoring group. the Trust has provided anaction plan, outlining their intended actions

the action plan isbeing implemented,but the trust positionstill does not appearto be showing theexpected results

action plan in place action plan is nothaving the full effectexpected

3 4 12

ProgressAction plan Start date Target dateAction owner

Trust has provided an action plan, but the actions are not all completed and we have not yet seen any improvementsGillian Findley Some actions completed, although no significant improvement seen yet.

Date Entered : 20/03/2015 08:40Entered By : Kim Lawther

03/02/2015 03/03/2015

Review date Reviewed by Next review dateReview details

20/03/2015 Kim Lawther Risk remains high - monitoring continues 19/04/2015

28/05/2015 Gillian Findley position has improved, but the trust is still an outlyer 27/06/2015

27/07/2015 Gillian Findley position is reported to have improved. once the final validated figures arereceived from CDDFT this risk level will be reduced

26/08/2015

111814/10/2014 Gillian Findley Kim Lawther A&E activityA&E may be overwhelmed by demand which mayimpact on quality of care and service provision, delaysin treatment. There are also financial implications forCDDFT and DDES CCG if more resources required.

3 3 9 NECS to gather information and obtain CDDFTaudit re A&E attendees, in order to establishwhether they are an outlier provider. A&Eactivity closely monitored by both CDDFT, theCCG and NHS England.

Informationunavailable.

Discussed monthly via CQFP Informationunvailable.

3 4 12


NECs (AR) to obtain relevant information and feedback to CCGGillian Findley Information gathered and shared via Exec Committee


14/10/2014 25/11/2014


04/02/2015 Kim Lawther Slight improvement in activity data, however close monitoring still required 05/04/2015

20/03/2015 Kim Lawther No significant changes - monitoring continues 19/05/2015

28/05/2015 Gillian Findley no change to risk or controls 27/07/2015


39402/07/2013 Gillian Findley Kim Lawther Limited capacity of ambulance services provision. Ambulance services could become overwhelmed bydemand for emergency transport which may impact onquality of patient care and service provision - delays in

5 3 15 1. Target agreed with NEAS. 1. Target monitored on monthly basis. 3 4 12

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treatment


To review NEAS performance via DDES CCG Qualtiy review meetings bimonthly, or more frequently as issues arise Numerous meetings held with both providers and stakeholders regarding current proposalswithin NEAS


11/08/2014 12/01/2014


20/03/2015 Kim Lawther Risk rating increased, due to winter resilience funding coming to an end -impact on service uncertain

19/04/2015

21/04/2015 Kim Lawther No change - activity continues to be closely monitored via QRG 21/05/2015

28/05/2015 Gillian Findley Performance has improved as additional paramedics have been recruitedand demand has fallen. However, this still remains an area of concern

27/06/2015

112114/10/2014 Gillian Findley Kim Lawther Urgent Care.Changes in provision of services may impact on qualityand safety of care and service provision. Financialimplications for CCG, due to cost improvementprogramme.

4 3 12 To establish safe, high quality and effectivemodel of care, as an alternate to current Urgent& Emergency Care provision.

Lack of agreementregarding bestmodel to implement.

Collate data regarding current services andundertake consultation exercise withstakeholders.

3 3 9


various groups established to review urgent care and the progress towards the constitutional standards. Progress will bemonitored at the systems resilience group

Stewart Findlay 27/07/2015 31/12/2015


20/03/2015 Kim Lawther Audits complete, report and recommendations to follow 19/05/2015

04/06/2015 Kim Lawther Urgent care working group managing risks.Additional resources, including GP appointments, community nursingteams now in place.

03/08/2015

27/07/2015 Gillian Findley Increasing focus in this area by NHSE 25/09/2015

104915/07/2014 James Carlton Kate Huddart Financial risk to CCG prescribing price and volume impact 2014/15 Financial resilience

4 2 8 1. CCG wide prescribing incentive agreed 2. Practice pharmacist aligned across the CCG3. Regional Drugs and Therapeutic Committeemonitoring prescribing.4. Area team committee established

1) Monitored via Clinical Champions meetings2) Any issuses reported back via CQFP3) Any issues reported back to CCG viaregional groups4) Relevant issuses discussed and brought toExec as appropriate

3 3 9


Recruitment in progress re pharmacist postService specs also being finalised

Gillian Findley 07/12/2014 26/01/2014


18/05/2015 Mark Pickering Responsible director changed 17/07/2015

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3220/03/2013 Gillian Findley Kim Lawther Continuing Health Care Risk to accuracy of financial reporting owing to limiteddata quality, from both internal teams and from externalproviders, particularly in relation to learning disabilitypatients being discharged from inpatient facilities.201516

3 2 6 Close internal financial monitoring within theCCG

Regular financial update reports to CQFPmeeting

Internal audit underway to identify specificissues

Internal audit not yetcompleted -findings/actionsunavailable atpresent

Completion of audit and action plan

Quarterly meetings with NHSE now in place.Information has been shared in paper format.still no electronic information and there aresome issues with data quality

No regular electronicdata flow

regular meetings in place

2 2 4


28/05/2015 Gillian Findley Internal audit report now completed. working through actions andinplications with the team in NECS

26/08/2015


139528/08/2015 Nicola Bailey Nicola Bailey SeQIHSProject to ensure hospital services meet all approvedclinical standards and provide high quality and costeffective services for the population of Durham,Darlington and Tees. Delay in implementation wouldmean that services would be unable to meet clinicalstandards and the healthcare system would not befinancially resillient.

4 3 12 1. Robust governance process.

2. Adequately resourced ProgrammeManagement Office.

3. Clear clinical buy-in and leadership.

4. Effective cross-agency working.

4 3 12

2 Development & Delivery Of Commissioning & Financial Plans Inc QIPP

133810/06/2015 Mark Pickering Mark Booth Estates and property charges - uncertainty around charges for property from NHSProperty Services directly to commissioners and viaprovider occupiers may lead to in year cost pressures.

3 3 9 1. All parties agree to schedules of propertycharges for financial year 2015/16.

1. Awaiting updatefrom NHSPSregarding leasesand licences.

1. Receipt of robust charging estimates for theyear.

1. Invoices andschedule of costs stilloutstanding forquarter 1 of 2015/16.

3 3 9


08/07/2015 Mark Booth Reviewed, no changes 07/08/2015

84610/02/2014 Mark Pickering Mark Booth Better Care Fund - creation of pooled budget destabilises current healthand social care market so increasing risk forcommissioners.

4 5 20 1. BCF partners working closely to understandimplications of all schemes prior to agreementand implementation.

1. BCF Task Group with CCG representation.Regular BCF progress reports to ExCommittee. Final BCF submission signed offby all stakeholders in September and signedoff by NHS England in December.

1. Detailed risk sharearrangements still indevelopment.

2. Review of services contained within thescope of BCF.

2. Joint decision made around reprocurementof reviewed services.

3. Understanding of BCF reportingrequirements.

3. Release of HFMA pooled budget guidanceplus guidance on ledger accountingrequirements.

4. Section 75 agreement required between allpartners for 15/16.

4. Section 75 agreement has been signed byall parties.

3 2 6


02/06/2015 Mark Booth Controls 3 and 4 updated. 02/07/2015

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28/08/2015

08/07/2015 Mark Booth Control and gap in assurance 4 updated. 07/08/2015

106808/08/2014 Mark Pickering Mark Booth Community Contract split is currently on a fair shares basis which may not beappropriate as some services are largely delivered inthe north or south of the county. An alternative splitmay result in a cost pressure to the CCG.

4 3 12 1. Existing split of contract revisited on anactivity basis.

1. Revised split agreed by ND and DDESCCGs with minimal financial impact. To beimplemented in 2015/16.

3 1 3


02/06/2015 Mark Booth Reviewed, no changes. 02/07/2015


111709/10/2014 Mark Pickering Mark Booth The 2014/15 contract with our main acute andcommunity services provider is unsigned. Financial reporting therefore requires a number ofassumptions and the final outcome may require actionin order to achieve financial balance.

3 4 12 1. Understanding of the financial risk associatedwith an unsigned contract.

1. Scenario modelling undertaken with NECScolleagues to understand risk and areas ofdispute.

1. Some high valueinvoices remain indispute at completionof 2014/15 year endaccounts.

2. Engage in mediation process. 2. Mediation unsuccessful, next step arbitrationprocess.

3. Complete arbitration process for formalresolution.

3. Arbitration process complete, outcomesknown.

3. Contract is stillunsigned, however,only 1 or 2 issuesremain.

3 2 6


02/06/2015 Mark Booth Gap in assurance 1 updated. 02/07/2015


129212/05/2015 Mark Pickering Mark Booth Primary Care Co-Commissioning - additional commissioning responsibilities taken on byCCG with additional funding. Will require effectivegovernance, organisational development and financialcontrol.

3 3 9 1. Co-commissioning committee andgovernance structure established.

1. Development session held in April andcommittee dates set for the year.

2. Confirmation of allocation for 2015/16. 2. Budgets in ledger and reporting underway.

3. Ongoing budget management meetings withPrimary Care experts in NHS England.

3. Reassurance given and risks andopportunities discussed.

3 2 6


02/06/2015 Mark Booth Risk description updated. 02/07/2015

08/07/2015 Mark Booth Gaps in control and assurance 2 removed, control and assurance 3 added,residual risk score reduced.

07/08/2015

133509/06/2015 Mark Pickering Mark Booth Financial planning does not deliver agreed financial control in financialyear 2015/16.

4 3 12 1. Robust scenario planning. 1. Robust monthly activity data for 2015/16. 1. Awaiting frozenactivity data forMonth 1.

2. Internal and external audit support. 2. Receipt of in year audit reports.

3. Forward thinking commissioning plansincluding QIPP.

3. High level QIPP plan agreed, progress willbe reported monthly through relevantcommittees and contract negotiations ongoing.

4 3 12


08/07/2015 Mark Booth Assurance 1 updated and gap in assurance added. 07/08/2015

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133609/06/2015 Mark Pickering Mark Booth The 2015/16 contract with our main acute andcommunity services provider is unsigned. Financial reporting therefore requires a number ofassumptions and the final outcome may require actionin order to achieve financial balance.

3 4 12 1. Understanding of the financial risk associatedwith an unsigned contract.

1. Financial values agreed.

2. Engage in ongoing negotiation or arbitrationas appropriate.

2. Negotiation successful. 2. Contract valuesagreed, 1 or 2 issuesto resolve prior tosignature.

3 3 9


08/07/2015 Mark Booth Assurance 1 and 2 updated, gap in assurance 2 added, residual risk scorereduced.

07/08/2015

109918/09/2014 Gillian Findley Gillian Findley Potential financial destabilisation due to high number ofhigh cost casesFollowing a series of care and treatment reviews, thereare an increasing number of high cost case patientscoming through the continuin health care process.There is limited information available to help the CCGplan financially for the cases. There is potential todestabliise CCG finances

3 3 9 Concerns have been raised with area team andspecialist commissioning staff. SpecialisedCommissioning have indicated they are sharinginfo with NECS staff.

More information becoming available duringDecember 2014, which may clarify volumes ofcases and help quantify the risk. Earlyindications are that DDES CCG has a numberof cases.

unclear processesfor informationsharing

Information gathered and shared, followingindividual Care & Treatment reviews. Numberof cases for respective CCGs now known,however actual costs remain uncertain.

Information is now coming from the specialisedcommissioning team at NHSE.

Still insufficnetinformation in atimely way

regular meetings in place. High cost casespanel has been reviewed and will now includea finance rep

4 4 16


Ensure Exec kept up to date, as information becomes available.Kim Lawther 04/02/2015 31/03/2015


27/07/2015 Gillian Findley quarterly meetings with NHSE now established and finance reps to beincluded in hoigh cost cases so risk reduced

25/09/2015

28/08/2015 Mark Booth Residual risk score increased from 12 to 16. 27/10/2015

3 Effective Internal & External Engagement Inc Communications

4 Effective Governance & Organisational Development

5 Effective Contract Management & Performance Against Key Targets

133709/06/2015 Mark Pickering Mark Booth Financial resilience - Impact of ageing and growing population andtechnological / drug advances driving service andtherefore cost pressures above affordable levels overthe life of the financial plan (2015/16).

4 3 12 1. Commissioning initiatives aimed at managingrisk of ageing population, e.g. IC+ and VAWASschemes.

1. Impact of IC+ andVAWAS remainsunclear.

1. Activity monitored at DDES level throughreports to CQFP.

1. Awaiting froxenactivity data forMonth 1.

2. Medicines Optimisation and NECS identify inyear NICE approvals.

2. Early understanding of NICE approvalsobtained.

4 3 12


08/07/2015 Mark Booth Gaps in control and assurance 1 updated. 07/08/2015

139628/08/2015 Stewart Findlay Mark Pickering NHS Constitutional StandardsRisk to health, wellbeing and patient experience of thelocal population as a result of non-achievement ofnational targets.

4 4 16 1. Robust performance monitoring andmanagement across primary, secondary andtertiary care.

1. Lack of accurateand timelyperformance data.

4 4 16

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28/08/2015

2. Deep dives into areas of concern.

3. Patient trackers on individual patientpathways.

4. Commissioning of adequate activity volumesto meet the needs of the population.

5. Effective solutions to underperforming areas. 5. In someinstances, waitinglist patients are notbeing seen in clinicaland chronologicalorder.

Page 6


GOVERNING BODY

Report Title Risk Management Update Author Julie Rutherford, Senior Governance Officer Sponsor Director Mark Pickering, Chief Finance Officer DATE 28.08.15 Purpose of report Information sharing Development / Discussion Decision / Action Brief introduction / Purpose of paper

The purpose of this report is to provide :

• A Durham Dales, Easington and Sedgefield Clinical Commissioning Group (DDES CCG) risk management update

• A summary of the current DDES CCG wide risks for consideration and review

• A DDES CCG wide red risk (risks rated 15 or above) summary and movement update for consideration and review.

•

During the period between 24 June and 28 August 2015

• There are two red risks on the CCG risk register • One new red risk has been added this period • One existing red risk remains unchanged • No red risks have been closed • All risks have been reviewed and updated in line with schedule. •

DDES approval route Formal Executive Committee 18.8.15

Governing Body 8.9.15



• Appendix 1 DDES CCG risk matrix profile illustrates the CCG’s wide risks, by consequence and likelihood residual scores 28.08.2015

• Appendix 2 DDES CCG Corporate Red Risk Register 28.08.2015 • Appendix 3 DDES CCG Full Risk Register








The Governing Body is asked to:

• Receive the DDES CCG Risk Management Update as at 28.08.15 • Note the summary of the current DDES CCG wide risks • Consider the content and context of the DDES CCG red risk

register and confirm whether these are accurate and that appropriate action is being taken

Impact Assessment and Risk Management Issues Consideration given and action taken in this report relating to impact assessment and risk management issues is detailed below:

a) Risk Risk register attached

b) Environmental impact / sustainability No impact

c) Legal implications No impact

d) Resource implications – finance and/or staffing No Impact

e) Equality Assessment No impact

f) Quality, Innovation, Productivity and Prevention No impact

g) Patient, public and stakeholder involvement No impact

h) Clinical engagement No impact

2

Risk Management Update – 28th August 2015 1. Introduction The purpose of this report is to provide:

• A Durham Dales, Easington and Sedgefield Clinical Commissioning Group (DDES CCG) risk management update

• A summary of the current DDES CCG wide risks for consideration and review • A summary of the current DDES CCG wide red risks rated 15 or above consideration

and review. 2. CCG wide corporate risk registers update The CCG wide risk register has been reviewed for consistency and accuracy by Directors, aligned Heads of Service and the Chief Finance Officer providing assurance to the committee that risks are being reported, managed and escalated appropriately. Following internal review the NECS Senior Governance Manager has produced the DDES CCG risk management report within an agreed DDES CCG risk management framework to further support risk review and ongoing assurance. 3. CCG wide risk register summary The number and nature of risks recorded in the DDES CCG wide risk register is set out in the tables below. The CCG’s integrated approach to risk management ensures that all risks are captured, monitored and aligned to the appropriate corporate objective for the organisation, in line with the CCG’s Risk Management Policy. Current and potential risks are captured in the CCG’s risk register and include actions and timescales identified to minimise such risks. The risk register is a log of risks that threaten the organisation’s success in achieving its aims and objectives and is populated through a risk assessment and evaluation process. The register is updated and reviewed as delegated by the Governing Body to the Executive Committee. In terms of assurance and reporting: • Risks rated 15 or above are reported to the Governing Body on a bi-monthly basis and

will be reported to each meeting of the CQFP

• Top risks within each corporate objective will be highlighted to the Executive Committee. This will highlight which corporate objectives the organisation’s highest risks are impacting upon

• Green (low) risks will be considered solely at team level.

3

Tables 1& 2 below illustrate the CCG risk profile as at 28.08.15. Appendices 1, 2 & 3 provide further detail related to the CCG wide risk register management this month for information and review:

• Appendix 1 DDES CCG risk matrix profile illustrates the CCG’s risks by consequence and likelihood residual scores as at the 28.08.15.

• Appendix 2 DDES CCG Corporate Red Risk Register as at 28.08.15.

• Appendix 3 DDES CCG Full Risk Register as at 28.08.15

Table 1 Illustrates the summary of CCG risks by Corporate Objective

Table 2: Overall Summary of CCG Risks June 2015 August 2015 Direction

Red 1 2

Amber 11 10

Yellow 2 4

Green 1 1

TOTAL 15 17

Table 2 illustrates the number of risks on the current corporate risk register as at 28th August, 2015 compared with the risk register produced on 24th June 2015. Red Risks summary and movement update during this period:

• There are currently two red risks on the CCG risk register

• One new red risks have been added to the risk register this month:

4

Risk 1396 - a NHS constitutional risk which relates to the health, wellbeing and patient experience of the local population as a result of non-achievement of national targets. This risk has is scored as a red 16 risk derived from a consequence score of 4 and likelihood score of 4.

• Risk 1099 – an existing red risk remains unchanged

• No Red Risks have been closed in this period

4. Governing body is asked to:

• Receive the DDES CCG Risk Management Update as at 28th August 2015 • Note the summary of the current DDES CCG wide risks • Consider the content and context of the DDES CCG red risk register and confirm

whether these are accurate and that appropriate action is being taken

5

GOVERNING BODY - IN PUBLIC

Tuesday 8th September 2015

2.00pm – 4.30pm

Horden Social Welfare Centre, Miners Hall, Seventh Street, Peterlee SR8 4LX

AGENDA Item No

Item Time Format

GB/15/076 Apologies for absence – Stewart Findlay / Nicola Bailey / Lesley Jeavons

2.00pm Verbal

GB/15/077 Declarations of conflicts of interest • When declaring an interest, please clearly state the reason and the

action to be taken as a result of the declaration Note: All GPs will be conflicted on the Urgent Care Strategy paper but as this is a strategic document they can all discuss and vote on it.

2.02pm Attached

GB/15/078 Minutes of the meeting held on 7th July 2015

2.05pm Attached

GB/15/079 Matters arising from the meeting held on 7th July 2015

2.10pm Verbal

GB/15/080 Review of action log

2.15pm Attached

Items for Decision GB/15/081 Final Urgent Care Strategy 2015-20

Stewart Findlay, Chief Clinical Officer Anita Porter, Senior Commissioning Support Officer, NECS

2.20pm Attached

GB/15/082 Practice and Clinical Engagement – Recommendations for Terms of Reference Joseph Chandy, Director of Primary Care, Partnerships and Engagement Gail Linstead, Head of Primary Care Development and Engagement

2.30pm Attached

GB/15/083 Risk Management Update Mark Pickering Chief Finance Officer Julie Rutherford, Senior Governance Officer NECS

2.40pm Attached

GB/15/084 Children and Young People’s Mental Health, Emotional Wellbeing and Resilience Transformation Plan Gill Findley, Director of Nursing Catherine Richardson, Public Health

2.50pm To Follow

1

GB/15/085 Skills mixing of the Durham Dales Ambulance Crews and the Clinical Senate Recommendations Nicola Bailey, Chief Operating Officer Joseph Chandy, Director of Primary Care, Partnerships and Engagement (presenting)

3.00pm Attached

Items for Discussion GB/15/086 Quality, Performance and Finance Report

Mark Pickering, Chief Finance Officer Andrew Rowlands, Commissioning Manager, Provider Management, NECS

3.10pm Attached

GB/15/087

Finance Update – Month 4 2015/16 Mark Pickering, Chief Finance Officer Mark Booth, Head of Finance

3.20pm Attached

GB/15/088 Chief Clinical Officers Report Stewart Findlay, Chief Clinical Officer Mark Pickering, Chief Finance Officer (presenting)

3.30pm Attached

GB/15/089 Safeguarding and Looked After Children Annual Report 2014-15 Gill Findley, Director of Nursing Diane Richardson, Designated Nurse for Safeguarding and Looked After Children

3.40pm Attached

Information Only Reports GB/15/090 Transforming Care Update- Learning Disabilities

Gill Findley, Director of Nursing Donna Owens, Joint Commissioning Manager, NECS

3.50pm Attached

GB/15/091 School Nursing Service and 0-5 Services (Health Visiting and Family Nurse Partnership) Stewart Findlay, Chief Clinical Officer

Attached

GB/15/092 Mental Health Services Quarterly Clinical Quality Update Gill Findley, Director of Nursing Daniel Webber, Senior Clinical Quality Officer (Acting) NECS

Attached

GB/15/093 North East Combined Authority Leadership Board Stewart Findlay, Chief Clinical Officer

Attached

GB/15/094 Acute and Community Quarterly Clinical Quality Update Gill Findley, Director of Nursing Daniel Webber, Senior Clinical Quality Officer (Acting) NECS

Attached

GB/15/095 North East Ambulance Service Quarterly Clinical Quality Update Gill Findley, Director of Nursing Kirstie Hesketh, Senior Clinical Quality Manager, NECS

Attached

2

GB/15/096

Confirmed minutes to receive: a) Primary Care Commissioning Committee 22nd May ‘15 b) Formal Executive Committee – 16th June ‘15 c) Formal Executive Committee CQFP – 23rd June ‘15 d) Formal Executive Committee – 30th June ‘15 e) Formal Executive Committee – 14th July ‘15 f) Formal Executive Committee – 21st July ‘15 g) Formal Executive Committee CQFP – 25th July ‘15 h) Formal Executive Committee – 4th August ‘15 i) Health & Wellbeing Board – 14th May ‘15

4.00pm Attached

GB/15/097 Questions from the public (none received)

4.05pm Verbal

GB/15/098 Any Other Business

4.10pm Verbal

Next meeting: Tuesday 11th November 2015 3pm – 4.30pm Spennymoor Town Hall, Spennymoor DL16 6DG

Chair: Jonathan Smith – [email protected]

Apologies to: [email protected] – 0191 371 3220

Deputy / Admin Support: [email protected] – 0191 371 3224

3

mailto:[email protected]



GB/15/0 Questions from the public None received.

Verbal

GB/15/0 Any other business

Verbal

Next Meeting: 10th November 2015 – 3pm – 4.30pm Spennymoor Town Hall, DL16 6DG

Chair: Jonathan Smith – [email protected] Apologies to: [email protected] – 0191 3713220 Deputy / Admin Support: [email protected] – 0191 371 3224

4




C L Score

Initial

C L Score


NHS Durham Dales, Easington and Sedgefield CCG Red Risk Register

28/08/2015

1 Access To Safe, High Quality Services

2 Development & Delivery Of Commissioning & Financial Plans Inc QIPP

109918/09/2014 Gillian Findley Gillian Findley Potential financial destabilisation due to high number ofhigh cost casesFollowing a series of care and treatment reviews, thereare an increasing number of high cost case patientscoming through the continuin health care process.There is limited information available to help the CCGplan financially for the cases. There is potential todestabliise CCG finances

3 3 9 Concerns have been raised with area team andspecialist commissioning staff. SpecialisedCommissioning have indicated they are sharinginfo with NECS staff.

More information becoming available duringDecember 2014, which may clarify volumes ofcases and help quantify the risk. Earlyindications are that DDES CCG has a numberof cases.

unclear processesfor informationsharing

Information gathered and shared, followingindividual Care & Treatment reviews. Numberof cases for respective CCGs now known,however actual costs remain uncertain.

Information is now coming from the specialisedcommissioning team at NHSE.

Still insufficnetinformation in atimely way

regular meetings in place. High cost casespanel has been reviewed and will now includea finance rep

4 4 16


Ensure Exec kept up to date, as information becomes available.Kim Lawther 04/02/2015 31/03/2015


27/07/2015 Gillian Findley quarterly meetings with NHSE now established and finance reps to beincluded in hoigh cost cases so risk reduced

25/09/2015

28/08/2015 Mark Booth Residual risk score increased from 12 to 16. 27/10/2015

3 Effective Internal & External Engagement Inc Communications

4 Effective Governance & Organisational Development

5 Effective Contract Management & Performance Against Key Targets

139628/08/2015 Stewart Findlay Mark Pickering NHS Constitutional StandardsRisk to health, wellbeing and patient experience of thelocal population as a result of non-achievement ofnational targets.

4 4 16 1. Robust performance monitoring andmanagement across primary, secondary andtertiary care.

1. Lack of accurateand timelyperformance data.

2. Deep dives into areas of concern.

3. Patient trackers on individual patientpathways.

4. Commissioning of adequate activity volumesto meet the needs of the population.

5. Effective solutions to underperforming areas. 5. In someinstances, waitinglist patients are notbeing seen in clinicaland chronologicalorder.

4 4 16

Page 1 DDES Corp RR4

Risks Distribution Matrix 28/08/2015

NHS Durham Dales, Easington and Sedgefield CCG

Consequence/Severity

Rare1

Unlikely2

Possible3

Likely4

Almost Certain5

Likelihood

Catastrophic5

Major4

Moderate3

Minor2

Negligble1

1335, 1337,1395

1099, 1396

1068 846, 1117, 1292 1121, 1049,1338, 1336

1185, 1118, 394

32

DDES MAT8


GOVERNING BODY

Report Title Skills mixing of the Durham Dales Ambulance Crews and the Clinical Senate Recommendations

Author Joseph Chandy, Director of Primary Care, Partnerships and Engagement

Sponsor Director Nicola Bailey, Chief Operating Officer Date 1st September 2015 Purpose of report Information sharing Development / Discussion Decision / Action Brief introduction / Purpose of paper

At the Governing Body meeting held on 11 November 2014, members considered reports and a detailed presentation which set out:-

• The case for change on the proposed skills mixing of the Durham Dales Ambulance Crews in terms of resource availability, service performance and clinical need;

• The extensive engagement and communications activity that had been undertaken to date;

• The feedback from the Adults Wellbeing and Health Overview and Scrutiny Committee meeting held in September 2014.

After consideration, the Durham Dales, Easington and Sedgefield Clinical Commissioning Group Governing Body agreed the case for change and proposals presented, and to NEAS implementing the proposed changes to the Durham Dales ambulance staffing skill mix configuration from April 2016. This was to form part of an overall package to improve response times for Red 1 calls across the CCG. However, in acknowledging the strength of feeling expressed at a number of engagement events held across the DDES area against the proposals, the CCG proposed to commission an independent clinical review into the safety and rationale for the proposed provision of a skill mixed paramedic and emergency care assistant crewed Ambulances within the Durham Dales area. In order to provide an appropriate response to this referral, the Northern Clinical Senate drew together clinical experts from across the country on all aspects of the clinical journey that patients would experience in this instance. Their expertise included both the clinical aspects of care based on the latest research and guidance available, and the knowledge and experience of how care is delivered in rural settings.


As a result of the independent clinical review undertaken by the Clinical senate they have made the following recommendations to the CCG: 1. There was no evidence of any difference in patient outcomes

between an ambulance staffed by a paramedic with an Emergency Care Assistant (ECA) and one staffed by two paramedics.

2. The review team feel that personnel resources would likely be better utilised by moving to the mixed crew model.

3. There are practical processes in place and training in the process of being introduced that will support the mitigation of clinical risk in rural and very rural areas.

4. Staff would need to be supported through any introduction of service change.

5. There are opportunities for NEAS, the commissioner and local communities to work together to develop a set of services and relationships that would influence the resilience of rural populations.

On the 1st September 2015, the Adults Wellbeing and Health Overview and Scrutiny Committee re-affirmed its previous agreement that the case for change has been demonstrated by the CCG, and felt assured of this given that the North East Clinical Senate concluded that:-

(i) There was no evidence of any difference in patient outcomes

between an ambulance staffed by a paramedic and an Emergency Care Assistant and one staffed by two paramedics, and

(ii) The Review team felt that personnel resources would likely be better utilised by moving to the mixed crew model.

The Ambulance Patient Reference Group meeting is to be held on 7 September 2015. The verbal feedback from that meeting will come back to Governing Body.

DDES approval route

• Executive Committee – 5 August 2014 • Executive Committee – 30 September 2014 • Governing Body – 11 November 2014 • Governing Body – 8 September 2015


Adults, Wellbeing and Health Overview and Scrutiny Committee held on 1st September 2015


• Overview and Scrutiny report and feedback from meeting on 1 September 2015

• Ambulance Engagement report submitted to Governing Body Nov ‘14 • November ’14 confirmed Governing Body minutes • Clinical Senate Report • Letter from Cllr Robinson – findings of the independent review

2








The Governing Body is asked to:

• Note the comments from the Adults, Wellbeing and Health Overview and Scrutiny Committee held on 1st September 2015

• Note the content and approve the recommendations of the Clinical Senate Report

• Re-affirm the decision made by the Executive Committee on 30 September 2014 and the Governing Body’s decision on 11 November 2014. This was to ask NEAS to implement the change proposals in April 2016 dependent on the outcome of the independent clinical evaluation of the need for a double paramedic crew in the Durham Dales area.

• Agree the continuance of the ring fenced investment in NEAS for Teesdale and Weardale of £650k

• Approve the introduction of an additional Rapid Response Vehicle as a result of the implementation of this change.

3

Skills mixing of the Durham Dales Ambulance Crews and the Clinical Senate Recommendations

1. Introduction

At the Governing Body meeting held on 11 November 2014, members considered reports and a detailed presentation which set out:-

• The case for change on the Skills mixing of the Durham Dales Ambulance Crews in terms of resource availability, service performance and clinical need;

• Extensive engagement and communications activity undertaken; • The feedback from the Adults Wellbeing and Health Overview and Scrutiny Committee

from September 2014. 2. Background The Durham Dales, Easington and Sedgefield Clinical Commissioning Group advised that we planned to implement proposed changes to the Durham Dales configuration in April 2016 as part of an overall package to improve response times for Red 1 calls across the CCG. As this is a change to operational staffing deployment it would ordinarily be NEAS as the provider who would make this decision. However in view of the history of ambulance provision in Weardale and Teesdale with the predecessor Primary Care Trust and County Durham Adult and Wellbeing Overview and Scrutiny Committee (OSC) and the public interest in the issue it was felt important to engage the public in understanding why these changes were being made and what the proposed outcomes from these changes would be for patients across the DDES area.

• On 14 May 2013, the findings of the ORH and Explain Reports, both commissioned by the predecessor PCT, to look at the arrangements within the Teesdale and Weardale area were discussed by the DDES CCG Governing Body, Plans were approved for involving stakeholders within a newly formed Ambulance Patient Reference Group (APRG) in relation to the these two reports and any further work on the potential deployment options.

• The APRG met over a 14 month period and gave continuous input and feedback to the CCG in relation to its future commissioning intentions for Ambulance provision and the current performance across DDES. This formed part of an engagement process which culminated with the full public engagement process undertaken between July and the end of September 2014.

• On the 5th August 2014 the CCG Executive Committee supported the NEAS proposals for staffing changes with a recommendation to conduct a public engagement exercise in conjunction with NEAS to outline these to the public.

• This approach to public engagement was supported by the OSC committee at their meeting on 18 July 2014.

• The engagement exercise was completed at the end of September and the results of the exercise were re-presented to OSC on 29 September 2014.

• On 30 September 2014, the CCG Executive Committee received the feedback from the public engagement as planned. The Executive reviewed and confirmed their earlier decision to support the changes but revised the time scale for implementation in order to allow for an independent clinical review to be undertaken.

It was agreed with OSC that the changes required to ambulance services did not constitute the need for a formal public consultation as there was to be no major change in the service available to the people of Weardale and Teesdale (i.e. no change to the number of ring

4

fenced vehicles, hours or numbers of staff) and that the extensive engagement process suggested was considered an appropriate approach. At the Governing Body of 11th November 2015 the following recommendations were agreed:

• Confirmed that the Governing Body was assured that extensive and robust engagement had taken place during the pre-engagement and full public engagement process;

• Confirmed that the views and feedback from the public were duly considered prior to a final decision being made by the CCG’s Executive Committee;

• Ratified the decision made by the Executive Committee on 30 September 2014. This was to ask NEAS to implement the change proposals in April 2016 dependent on the outcome of the independent clinical evaluation of the need for a double paramedic crew in the Durham Dales area.

• Confirmed that the Governing Body had assurance that the process leading up to the proposed implementation date of April 2016 was appropriate. This assurance was through an independent clinical evaluation being undertaken by the Clinical Senate, an objective and independent clinical body separate from the CCG.

• Agreed to the continuance of the ring fenced investment in NEAS for Teesdale and Weardale of approximately £650k until April 2016 in line with the CCG planning commitments;

• Noted the efforts that would continue to improve performance across DDES CCG in the meantime and emphasised the need for clear metrics to monitor service improvements and regular reports on progress at future GB meetings.

The Clinical senate have made the following 5 recommendations as a result of their independent clinical audit:

• There was no evidence of any difference in patient outcomes between an ambulance staffed by a paramedic with an Emergency Care assistant (ECA) and one staffed by two paramedics.

• The Review Team feel that personnel resources would likely be better utilised by moving to the mixed crew model.

• There are practical processes in place and training in the process of being introduced that will support the mitigation of clinical risk in rural and very rural areas.

• Staff would need to be supported through any introduction of service change • There are opportunities for NEAS, the commissioner and local communities to work

together to develop a set of services and relationships that would influence the resilience of rural populations.

On the 1st September 2015, the Adults Wellbeing and Health Overview and Scrutiny Committee re-affirmed its previous agreement that the case for change has been demonstrated by the CCG, given that the North East Clinical Senate has concluded that:-

• There was no evidence of any difference in patient outcomes between an ambulance

staffed by a paramedic and an Emergency Care Assistant and one staffed by two paramedics, and

• The Review team felt that personnel resources would likely be better utilised by moving to the mixed crew model.

The Ambulance Patient Reference Group meeting is to be held on 7 September 2015. The verbal feedback to come back to Governing Body.

5

3. Impact Assessment and Risk Management Issues 3.1 Consideration given and action taken in this report relating to impact assessment and


a) Risk Details here – Has this item been added to the risk register?

b) Environmental impact / sustainability Details here – Please address each issue

c) Legal implications Details here – Please address each issue

d) Resource implications – finance and/or staffing Details here – Please address each issue

e) Equality Assessment The assessment has lead to the case for change

f) Quality, Innovation, Productivity and Prevention Details here – Please address each issue

g) Patient, public and stakeholder involvement This is addressed in the report

h) Clinical engagement

This is addressed in the report

6

DDES Declaration of Conflict of Interest Register (all) - @ 1/9/2015

First Name Surname DOI

receivedY / N

Position/Role Place of work Source of Declaration

A

Date of Declaration

Written confirmation

received?Potential or actual areas where interest could occur

Personal interest or that of a family member, close friend or

other acquaintance

Is this conflict:P - personal

F - family memberC - close friend

A - acquaintance

Is this conflictF - financial

NF - non financial

How will the conflict be managed?

Ahmad Naeem N Form sent to him by email on 25.8.15

Review of declarations - form received March/April '15 Yes

Mgmt Committee member of Witton Gilbert Community Centre Cooper Hall / Forum member of Durham AAP Personal

Review of declarations - form received 15.5.15 Yes

School Governor Witton Gilbert Primary School / Vice Chair 3 Towns Area Action Partnership Personal


Vice Captain of Elvet Striders Running Club - the club has historically applied for funding from public organisations. Family member, husband


Vice Captain of Elvet Striders Running Club - the club has historically applied for funding from public organisations.Foundation Trust member (public membership) CDDFT

Personal P NF

Amanda Simpson Y GP - Caradoc Review of declarations - form received 19.02.15 Yes Nothing declared

Andre Prinsloo YGP / Practice Lead for Prescribing / Council of Members

Jubilee Medical GroupNewton Aycliffe

Review of declarations - form received 20.8.15 Yes Nothing declared

Andrew Clarke Y GPPease Way Medical Centre

Newton AycliffeReview of declarations - form

received 19.8.15 Yes Practice Primary Care research network

Andrew Henderson N

Andrew Hetherington y GPStation View Medical Centre

Bishop AucklandReview of declarations - form

received 19.8.15 Yes Durham Dales Federation P F

Anna Lynch YNon voting Governing Body member / Non Voting member Primary Care Commissioning Committee


Director of Public Health Country Durham employed by Durham County Council / Non voting member of North Durham CCG Governing Body / Chair of NHS County Durham and Darlington Health Improvement Fund /

Anna Swaddling N

Annie Dolphin n/a CCG Chair Has now left Review of declarations - form received March/April '15 Yes

Member Pioneer Care Partnership / NHS CD and Darlington Health Improvement fund panel member / Teesdale area Action Partnership Forum and Board member

Personal

Annie Dolphin n/aLay Chair of Performer List Decision Panels - NHS England

Has now left Review of declarations - form received March/April '16 Yes

Member Pioneer Care Partnership / NHS CD and Darlington Health Improvement fund panel member / Teesdale area Action Partnership Forum and Board member

Personal

Anthony Long N

Anthony White Y Practice Manager Deneside Medical Centre

Blackhall & Peterlee PracticeGPTeamnet return template 12/03/2015 Yes On the Practice Managers Council of SDH CIC

April Futter Y Practice Manager Bishopgate Medical Centre Woodview Medical Practice

Bishop AucklandGPTeamnet return template

27.5.1525.8.15

Yes Nothing declared

A Challis N

Brian Wilson Y Office Manger Review of declarations - form received 19.02.15 Yes Nothing declared

Brian Woodhouse Y Business Manager Silverdale Family Practice

South HettonReview of declarations - form

received 18.8.15 Yes Director - Netprofitplus LtdMember of Practice Manager South Durham Health

PP

FNF

C Siripurapu n/a Was GP at Deneside - left in Jan '15

Specialist Nurse / Locality Lead / Clinical Champion

17.2.15 YesNo change from previous year - (have checked DOI for Feb '15 and nothing declared for her so need a new form completing)

Alison Ayers Y Commissioning Manager SCH

Carol Hardy Y


receivedY / N


A

Date of Declaration




other acquaintance



A - acquaintance


NF - non financial


Clinical Champion / Deputy Clinical Lead / Specialist Nurse

Horden Group Practice Review of declarations - form received 27.8.15 Yes Nothing declared

Catherine Doidge N

Catherine Harrison YGP / Rep for Council of Members & Dales Locality / GP Prescribing Lead for Durham Dales

Review of declarations - form received 19.02.15 Yes GP partner full range of GMS and extended services

Charles McGarrity YGP/Council of Members Representative


Current clinical lead - West Cornforth - overview responsibility for Hallgarth / Member of Intrahealth

Personal

Charles Tijsseling N

Christine Keen N

Director of Commissioning NHS England Area Team / Attends DDES CCG Primary Care Commissioning Committee

Clair White Y Head Of Commissioning CCG Review of declarations - form received 16.02.15 Yes Nothing declared

Claire Elder N

Claire Lazenby N

Colin Cuthbert Y GP Barnard Castle Surgery Review of declarations - form received 26.8.15 Yes Nothing declared

Colin Scott Y GP PartnerPease Way Medical Centre

Newton AycliffeReview of declarations - form

received 19.8.15 Yes Nothing declared

Craig Heath N

Dan Newsome N

Member Practice Review of declarations - form received 19.02.15 Yes OMD Intrahealth - Director Intrahealth

GP William Brown Centre Review of declarations - form received 17.8.15 Yes Organisational Medical Director IntraHealth P F

David Catterick n/aGP representative Durham Dales Locality and DDES Council of Members

Has now left North House Surgery Crook

Review of declarations - form received 19.02.15 Yes GP Partner North House Surgery

David Craggs Y PRG member of Locality Group n/a Review of declarations - form received 27.8.15 Yes

Son (Ian Craggs) is Finance Director of UOCAREDaughter (Helen Louise Allen) is Senior Support Officer at NECS

David Robertson Y GP / Practice Representative Barnard Castle Surgery Review of declarations - form received 1.9.15 Yes

Director of Durham Dales Health FederationPartner in Dr J J White and PartnersHonorary Secretary of County Durham and Darlington LMC

P

P

F & NF

NF

David Taylor Gooby YGoverning Body Lay Member for Engagement


Member Patient Forum William Brown Peterlee surgery / Chair Apollo Pavilion Community Assoc / Board Member representing NHS Weardale Action Partnership unpaid / Member Labour Party / Member Socialist Health Assoc / Member Church of England / Member NHS Clinical Commissioners Lay Members Network / Freelance writer for several local newspapers / Author two books about NHS

Dawn Nelson N

Deborah Jordinson YCommissioning Support Demand Management DDES CCG

Review of declarations - form received March/April '15 Yes Nothing declared

Deborah Perry Y Corporate Support Manager Review of declarations - form received 4.3.15 Yes Nothing declared

Married to Dr Timothy Cunliffe GPwSI in Dermatology (South Tees NHS)

Denis Hackett N

David Anderson Y

Carol Hardy Y


receivedY / N


A

Date of Declaration




other acquaintance



A - acquaintance


NF - non financial


Denise Scott N

Denise Simpson Y Practice Manager North House Surgery - Crook /

patient at another practice GPTeamnet return template 11.3.15 Yes Nothing declared

Diane Robinson N

Dillys Waller Y GP / Locality Lead Review of declarations - form received 19.2.15 Yes Governor DHS

Dinah Roy N

Dolores Mansour Y GP / Partner - Southdene Review of declarations - form received 19.2.15 Yes Named GP for Safeguarding Children Easington Personal

Edward Staines Y GP / Council of Members Review of declarations - form received 19.2.15 Yes

Partner in practice / occupational health physician / Federation Board Member SDH CIC

Personal

Fiona Aschcroft Y Practice Manager Old Forge Surgery

Horden Group practice GPTeamnet return template 25.2.15 Yes Nothing declared

Practice Manager Review of declarations - form received 19.02.15 Yes Nothing declared

Practice Manager Shinwell Practice - Pinfold

Medical Practice - GPTeamnet return template 10.4.15 Yes Nothing declared

Gail Cook N

Head of Primary Care Development and Engagement


Head of Primary Care, Development & Engagement SCH Review of declarations - form

received 20.8.15 Yes Nothing declared

Garath Chin YGP Partner Willington / CCG Lead for practice


Gert Gammellin N


Director of Magnitas PLC - this is an environmental management consultancy firm operated by Mr I Findley. I am seconded to the Chief Nurse post (Part time) for Darlington CCG. . School Governor for South Stanley Junior School.

I am related by marriage to the McCardle family who own Helen McCardle care homes

22.5.15 Yes

Director of Magnitas PLC - this is an environmental management consultancy firm operated by Mr I Findley. I am seconded to the Chief Nurse post (Part time) for North Durham CCG. . School Governor for South Stanley Junior School.

I am related by marriage to the McCardle family who own Helen McCardle care homes

Gillian Ford N

Gill Johnson Y Practice Manager Review of declarations - form received 19.02.15 Yes

ENT City Hospital Sunderland at Jubilee / Anpera Frail Elderly Host Emp0lyer of ANP's

Gordon Gowans N

Harbhaja Mangat N

Hazel Dendle YPractice CCG LeadGP partner + Prescribing Lead + GP Trainer


Heather Collins N

Practice Manager Bewick Crescent Surgery

Review of declarations - form received 19.02.15 Yes Run the Suicide Prevention Pilot for South Durham CIC

GP Dr Welsh helps run the community ent. clinic.

Practice Manager Bewick Crescent Surgery and attend DDES Wide meeting

GPTeamnet return template 13.3.15 Yes Nothing declared

Clinical locality and quality lead / Clinical Champion for dermatology


GP partner, also provide vasectomy and skin surgery service for locality

Director of Nursing

Hobson

Frances

Moore

Y

Y

Y

Hindley

Gail Linstead Y

Helen

Helen

Y

Gill Findley


receivedY / N


A

Date of Declaration




other acquaintance



A - acquaintance


NF - non financial


Clinical Locality Lead / Clinical Champion Dermatology

SCH / Ferryhill Review of declarations - form received 20.8.15 Yes

GP Partner / provider of skin surgery services / provider of vasectomy services / provider of teledexmatology services

P F

Helen Taylor N

Hugo Minney YSouth Durham Health CIC / Federatin Comp

Review of declarations - form received Feb '15 Yes

Federation Company Secretary / Director and owner The Social Return Company formerly contracted by Co Durham PCT / member of committee Bizd Charity formerly Chief Exec / APM Committee member and BNI Leadership team - both professional associations.

Personal

Ian Bremner Y GPBishopsgate Medical Centre

Bishop AucklandReview of declarations - form received 18.8.15 Yes Nothing declared

Ian Russell Y GPWilliam Brown Centre

PeterleeReview of declarations - form received 24.8.15 Yes GP - William Brown Centre - IH P F + NF

Ian Spencer Y Secondary Care Clinician Review of declarations - form received 19.5.15 Yes Nothing declared

Ian Waldin Y GP / Council of Members Review of declarations - form received 19.02.15 Yes Nothing declared

J E Staines Y GP / CCG board Review of declarations - form received 26.3.15 Yes Board member SDH CIC Personal

Jacqueline Waldock YMedicines Optimisation Admin SupportFinance Administrator

Review of declarations - form received

March/April '1525.8.15 Yes Nothing declared

James Carlton Y Medical Advisor DDES CCG Review of declarations - form received 25.2.15 Yes Nothing declared

James Larcombe YGP Partner / Practice Lead Council of Members DDES CCG / Research Innovation Lead DDES CCG


GP Partner - Dr Jones Practice / Director/owner JMed Ltd - Medical Assessment Services / Medical Consultancy / Member study team ANTIC project NHS funded

Personal

Jane Dickson Y Practice Manager Review of declarations - form received Feb '15 Yes Nothing declared

Jane Laws Y R & I Working Group Review of declarations - form received 27.02.15 Yes Nothing declared

Jane Lawson N

Janet Robson N

Janet Stephenson Y Practice Manger Review of declarations - form received 19.02.15 Yes Nothing declared

Janice Lawson N

Jean Armstrong Y Lead Infection Control Nurse SCH Review of declarations - form received 19.8.15 Yes Nothing declared

Jenna Spencer N

Practice Manager Review of declarations - form received Feb '15 Yes Nothing declared

Practice Manager - Ferryhill & Chilton GPTeamnet return template 19.6.15 Yes Nothing declared

Jill Gleave N

Joan Sutherland Y Advanced MO Pharmacist Review of declarations - form received 3.3.15 Yes

Meds Opt lead for ND CCG for 3 days a week/ husband works in Queen Road Practice as IT support

John Hannon Y Patient Rep - R & I Group Review of declarations - form received 25.2.15 Yes Clerk To Trustees Sedgefield charities Personal

John Whitehouse Y Lay member - Governance & Audit SCH Review of declarations - form received 17.8.15 Yes

Lay member for North Durham CCG / Daughter is employed by L.E.T (hosted by CDDFT)

Jonathan Nainby-Luxmoore N

GP Partner / Locality Lead Review of declarations - form received Yes Declared his cousin is an actuary at PWC Personal

YSilverdale Family Practice

South Hetton /

YJennifer Wood

MooreHelen Y

Jonathan Smith


receivedY / N


A

Date of Declaration




other acquaintance



A - acquaintance


NF - non financial


GP Partner / Clinical Chair 1.9.15 Yes

Partner at Silverdale Family Practice, South HettonMember of South Durham Health FederationCouncil Member of the NHS England Northern Clinical SenatePartner in North East Medical Chambers


Partner Shinwell Medical Group / Premises interest in Peterlee Health Centre, Wheatley Hill and Shinwell Medical Centre / Partner Wheatley Hill & Thornley Practice / Shinwell Medical Group is a member of the Federation / Trustee Dr Joseph Chandy Charitable Trust incorporating Roseby Road Well Being Centre/ Partner Caradoc Practice in Wingate / Partner and provider Jupiter House Practice / Partner NEMC (NE Medical Chambers)

9.6.15 Yes

Partner and provider Shinwell Medical Group / Partner Wheatley Hill & Thornley Practices / Partner Caradoc Practice / Partner and provider Jupiter House practice / Premises interests in Peterlee Health Centre, Wheatley Hill and Shinwell Medical Centres, Practices are members of South Durham Federation / Partner NEMC (NE Medical Chambers) / Trustee Dr Joseph Chandy Charitable Trust incorporating Roseby Road Wellbeing Centre.

Judith Mashiter YMember of Primary Care

Commissioning CommitteeReview of declarations - form received 31.7.15 Yes

Director Mosaic (Teesdale )Ltd / Chair (and currently interim manager) of Healthwatch County Durham Community Interest Company

Personal and husband is director at Mosaic

Judith Shotton YAdvanced Nurse Practitioner - Intrahealth


Julia Pickworth N

Julia Steele YPractice Manager - Willington Medical Group / PM Link Dales


K S Baliga Y GP Review of declarations - form received 19.02.15 Yes Nothing declared

Kamal Fernando YGP Partner - Station View Medical Centre


Karen Kennedy YPA to Gill Findley/ James Carlton / Kim Lawther


Karen Soks N


Husband owns Specsavers Peterlee and Seaham within DDES CCG

19.8.15 Yes School Governor, Red House School NortonHusband owns Specsavers Peterlee and Seaham within DDES CCG

Kaukutla Venkat Reddy Y Senior Partner, Practice Lead Review of declarations - form received March/April '15 Yes Nothing declared

Kavya Ahuja Y GP / Partner Review of declarations - form received 19.02.15 Yes GP Partner Deneside Medical Group

Keith Tallintire n/a Has now left

Kieran Devereux N

Kim Lawther Y Head of Clinical Quality Review of declarations - form received March/April '15 Yes Nothing declared

Husband works in policy department Gateshead MBC

Koko Naing N

Laura Kirkbride Y NECS Research Manager Review of declarations - form received 25.2.15 Yes Nothing declared

Laura Kirkup N

Lee Grimes N

Lesley Anne Williams N

Lesley Jeavons NHead of Adult Care, Durham County Council / DDES CCG Governing Body member

Y

South Hetton /DDES CCG SCH

Head of Medicines Optimisation SCH

Joseph ChandyDirector of Primary Care,

Development and EngagementY

Kate Huddart Y

Jonathan Smith


receivedY / N


A

Date of Declaration




other acquaintance



A - acquaintance


NF - non financial


Linda Khali N

Linda McCann Y Business ManagerIntraHealth Ltd

West Cornforth Medical Centre


Employed by IntraHealth Ltd private company and work alongside directorsIntrahealth Ltd directors are share holdersCornforth Partnership Committee Member

PAP

FFF

Liz Norman Y Corporate and Primary Care Admin SCH Review of declarations - form received 18.8.15 Yes Nothing declared

Louise Taylor Y Medicines Optimisation Pharmacist Review of declarations - form received 03.03.15 Yes Locum pharmacist within community pharmacy two days per week

Lyndsey Jones-George N

Lynn Fleming Y Practice ManagerStation View Medical Centre


Mags Wells Y Admin Support Review of declarations - form received 13.4.15 Yes Nothing declared

Margaret Ross YPractice Manager - Marlborough Surgery

GPTeamnet return template 2.6.15 Yes Member of SDH CIC

Margaret Taube- Brown Y Practice Manger Review of declarations - form received 19.02.15 Yes Nothing declared

Maria Uehlein Y GP - Station Road surgery GPTeamnet return template 5.3.15 Yes Nothing declared

Marie Carfoot N

Mark Booth N

Mark Pickering Y Chief Finance Officer Review of declarations - form received 18.5.15 Yes Foundation Trust Member (public membership) of CDDFT NHS Trust

Wife is a director of Tees Esk and Wear Valleys NHS Trust, local provider of mental health services

Martin Jones YGP + Prescribing Lead for Sedgefield Locality

Bewick crescent SurgeryNewton Ayclliffe


Martin Oriandi N

Matthew Hackett Y Review of declarations - form received 19.02.15 Yes Nothing declared

Meena Mascarenhas N

Melanie Robinson Y Nurse Practitioner Willington Medical Group Review of declarations - form received 25.8.15 Yes Nothing declared

Michael Neville Y GPGainford Medical Practice Review of declarations - form

received 18.8.15 YesDirector of DDHFGP in Gainford Personal

PP

FF

Michael Spence YPractice Manager - Peaseway Medical Centre


Monica Walsh N

Naomi Hopper N

Nari Pindolia Y GP + Locality LeadStation View Medical Centre

Bishop AucklandReview of declarations - form received 18.8.15 Yes GP partner at Station View Medical Centre Personal P F

Neil Bunney Y Practice Manager Skerne Medical Group Review of declarations - form received 17.8.15 Yes Nothing declared

Nicola Bailey Y Chief Operating Officer Review of declarations - form received March/April '15 Yes Nothing declared Husband is employed within CQC

Nicola Finch Y Practice Manager Pinfold Medical CentreGainford Surgery GPTeamnet return template 12.3.15 Yes Nothing declared

Nitish Sahoo N

Oliver Barnsley N

Pat Jobson Y Practice Manager - Peaseway Medical Centre GPTeamnet return template 13.4.15 Yes Nothing declared


receivedY / N


A

Date of Declaration




other acquaintance



A - acquaintance


NF - non financial


Peter Foster N

Peter Jones N

Philip Jackson YPractice Manager Bishopgate & Evenwood


Raj Dusad YGP Partner/ Member of Council of Members

Review of declarations - form received 19.2.15 Yes Owner of Seaham Premises

Rajiv Mansingh N

Ramakrishna Gupta N

Rebecca Duncanson N

Richard Abbott N

Richard Pickworth Y Principal in General PracticePinfold Medical Practice


GP - Bewish Crescent / Council of Members


Partner GP - Bewick Crescent Practice / Chair South Durham Health CIC Federation / South Durham Primary Care Director / Clinical lead Mental Health Suicide Prevention Project / Interest in mental health - previous mental health lead / Wife is a doctor at NTHFT

Dr Welsh partner GPSI ENT / Wife is a doctor

GPBewick crescent Surgery

Newton AyclliffeReview of declarations - form received 20.8.15 Yes

Chair of Federation South Durham Health CICWife is employed by NTHFTDr Welsh - Partner - GPSI EntDr Jones - Partner - Prescribing Lead

PF

FNF

Robin Armstrong Y GP Partner / Locality Lead Review of declarations - form received 19.02.15 Yes Trustee Hartlepool Hospice / Adopted GP MacMillan Facility

Ruth Taylor Y Infection Control Nurse SCH Review of declarations - form received 28.8.15 Yes Nothing declared

Ryan Smith Y Medicines Optimisation Pharmacist SCH Review of declarations - form

received 26.8.15 Yes Partner works for IntraHealth Pharmacy, organisation within the CCG area Family member F NF

Samir Mansour Y GP / Senior Partner Southdene Medical Centre Shotton Colliery


Santhi Bethapudi N

Sarah Burns Y Director of Commissioning Review of declarations - form received March/April '15 Yes Non recurrent funded pilot commissioned from Gentoo Husband works for Gentoo

Sarah Lambert Y Head of Corporate Services SCH Review of declarations - form received 14.8.15 Yes Nothing declared

Sarah Paylor YPA to Director / Head of Commissioning


Sean Hayes N

Shanthi Santhanakrishnan Y GP / Partner Review of declarations - form received 19.2.15 Yes Nothing declared

Sharada Gupta N

Sharon Cockroft Y Receptionist/Admin Support Review of declarations - form received Feb '15 yes Nothing declared

Sharon Gooch N

Sharon Milton YCorporate & Primary Care Co-ordinator

SCH Review of declarations - form received 18.8.15 Yes Nothing declared

Shashikiran Chandrasekhar YGP - Pinfold Medical Practice / Attend Council of Members & DDES meetings

Review of declarations - form received 8.7.15 Yes Salaried GP (Part time) Urgent Care Centre, Bishop Auckland

Shelley Calkin Y Medicines Optimisation Pharmacist


Employed by Dr Jones as practice pharmacist one day per week / also employed by CCG one day per week as practice support pharmacist working in CCG GP practice

Rob McKinty Y


receivedY / N


A

Date of Declaration




other acquaintance



A - acquaintance


NF - non financial


Shona Harrup YNECS Senior Manger Research & Development


Collaborator in Peripheral Arterial Disease evaluation in primary care / Funding from LCRN as Senior Manager / Funding from NHS England to lead evaluation of NHS 111 Learning & Development programme

Stephen Muscat Y GP / Partner Review of declarations - form received 19.2.15 Yes Nothing declared

Steven Fox N

26.5.15 Yes

GP Partner at Bishopgate Medical Centre /Bishopgate Medical Centre also provide occupational health services for Cummins (Serco), Health Sure (Serco), Health Management, Norwich Union, Sunllight Services, Healthcare Connexions, OCCHEA, Connought Compliances, Nexus, TMD Friction /Bishopgate provide Dr Bowron in his role as Medical Referee at the Wear Valley Crematorium at Coundon, Bishop Auckland / Bishopgate provide a GP Clinical Tutor and Apprisal lead within the Durham Dales area (Dr Bowron) / I am a member of the Durham Dales Health Federation.


Part owner of Bishopgate Medical Centre and past partner in the practice until 31/8/15Vice Chair of County Durham Health and Wellbeing Board

Sue Humpish YExecutive Assistant to CCO and COO in DDES CCG


Partner holds senior position at Hartlepool Borough Council which will contract with NHS Services

Surendra Baliga Y GPShildon Health Clinic

ShildonReview of declarations - form received 18.8.15 Yes Nothing declared

Susan Atkinson YPractice Manager - Auckland Medical Group - attend CCG meetings


Susan Lightfoot N

Susan Stewart Y Reception / Admin SCH Review of declarations - form received 18.8.15 Yes Nothing declared

Teresa Davies N

Terri Bartlett Y Practice ManagerHallgarth Surgery

ShildonReview of declarations - form received 20.8.15 Yes Nothing declared

Tracey Martin Y Practice Manager St Andrew's Medical Practice Review of declarations - form received 20.8.15 Yes Nothing declared

Tracey Milburn N

Venkat Patil YGP Lead Shinwell Medical PracticeGP - locum


Venkat Reddy N

Vicky Watson Y Business Manager - Weardale Practice GPTeamnet return template 22.6.15 Yes I have been appointed as Chair Person of the Teenage Cancer Trust North East Fund raising Board.

Winny Jose Y Deputy Clinical Lead Sedgefield / GP Review of declarations - form received 19.2.15 Yes Bethany House care Home Newton Aycliffe

source

Chief Clinical Officer SCHStewart Findlay Y

Source

Audit and Assurance meetingCommissioning, Quality, Finance and Performance Committee meetingCouncil of Members meetingDDES wide meetingExecutive Committee meetingGoverning Body meetingGPTeamnet return templateLocality Group meeting - Durham DalesLocality Group meeting - EasingtonLocality Group meeting - SedgefieldLocality Leads meetingPatient Reference Group meetingPrimary Care Co-commissioning Committee meetingRemuneration Committee meetingReview of declarations - form received

Confirmed in writing?

YesNo

AtTotal names on

register

Total forms not required / relevant

Total completed forms required

Yes - forms

returned

No - forms still

outstanding

% - complete

17th August '15 178 3 175 83 92 47.40%

1st September '15 180 5 175 112 63 64%

DDES CCG Declaration of Conflict of Interest - returns

Meeting Date: 11th November 2014 Item No: GB/14/297

Governing Body

Report Title Engagement on the ambulance service model changes in Durham Dales Easington and Sedgefield (DDES) Clinical Commissioning Group (CCG)

Author Joseph Chandy Sponsor Director Joseph Chandy, Director of Primary Care, Partnerships and

Engagement Date 4 November 2014 Purpose of report Information sharing Development / Discussion Decision / Action Brief introduction / Purpose of paper

The purpose of the engagement exercise was to outline and to explain to the public the clinical rationale behind the proposed changes to the existing double paramedic crews in Weardale and Teesdale by North East Ambulance Service (NEAS). As this is a change to operational staffing deployment it would ordinarily be NEAS as the provider who would make this decision. However in view of the history of ambulance provision in Weardale and Teesdale with the predecessor Primary Care Trust and County Durham Adult and Wellbeing Overview and Scrutiny Committee (OSC) and the public interest in the issue it was felt important to engage the public in understanding why these changes were being made and what the proposed outcomes from these changes would be for patients across the DDES area.

• On 14 May 2013, the findings of the ORH and Explain Reports, both commissioned by the predecessor PCT, to look at the arrangements within the Teesdale and Weardale area were discussed by the DDES CCG Governing Body, Plans were approved for involving stakeholders within a newly formed Ambulance Patient Reference Group (APRG) in relation to the these two reports and any further work on the potential deployment options.

• The APRG met over a 14 month period and gave continuous input and feedback to the CCG in relation to its future commissioning intentions for Ambulance provision and the current performance across DDES. This formed part of an engagement process which culminated with the full public engagement process undertaken between July and the end of September 2014.

• On the 5th August 2014 the CCG Executive Committee supported the NEAS proposals for staffing changes with a recommendation to conduct a public engagement exercise in conjunction with NEAS to outline these to the public.

• This approach to public engagement was supported by the OSC committee at their meeting on 18 July 2014.

• The engagement exercise was completed at the end of September and the results of the exercise were re-presented to OSC on 29 September 2014.

• On 30 September 2014, the CCG Executive Committee received the feedback from the public engagement as planned. The Executive reviewed and confirmed their earlier decision to support the changes but revised the time scale for implementation in order to allow for an independent clinical review to be undertaken.

This report covers the proposed way forward.


It was agreed with OSC that the changes required to ambulance services did not constitute the need for a formal public consultation as there was to be no major change in the service available to the people of Weardale and Teesdale (i.e. no change to the number of ring fenced vehicles, hours or numbers of staff) and that the extensive engagement process suggested was considered an appropriate approach. NEAS are proposing changes to the way the service is being delivered operationally, involving the re-configuration of the crews, which will allow NEAS to staff an additional Rapid Response Vehicle in the Durham Dales area

DDES CCG has supported the clinical rationale and case for change made by NEAS. However the strength of opinion in parts of the Durham Dales has told us that this part of the population we serve do not have the same confidence in this clinical rationale and case for change.

It is a duty of the CCG to involve the public and patients in meeting our aim of improving the quality of patient services. In light of the Durham Dales public feedback given through the engagement process the planning for these changes has been influenced as follows:

• The CCG Executive has proposed a revised date for these

changes to be implemented. This is to now to be the 1st April 2016.

• The CCG will use the lead-in time to implementation of the changes to independently clinically assess the need for double paramedic crews in Weardale and Teesdale. This independent clinical evaluation will be overseen by the clinical senate.

This delayed implementation will mean that NEAS are unable to guarantee an improved ambulance response time across DDES prior to 1 April 2016 as we had intended with the proposed changes. The CCG will, however, continue to work to support improved ambulance performance across the CCG area. This includes the use of a redesigned integrated transport scheme, continuing to work with our acute hospitals to reduce patient handover times at A&E and working with 111 to reduce unnecessary and duplicated activity.

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DDES approval route

• Executive Committee Meetings – 15th July 2014, 5th August 2014, 30th September 2014

• Governing Body Meetings – 14th May 2013, 9th July 2013, 11th November 2014 and Chief Clinical Officers’ Report to Governing Body on 9 September 2014

Other approval routes

• Adults, Wellbeing and Health Overview and Scrutiny Committee (OSC) Meetings – 18 July 2014 and 29th September 2014


• Appendix 1 - Summary of 2012 Operational Research in Health (ORH) report and Explain report

• Appendix 2 - Update on communications and engagement activities • Appendix 3 – Communications and Engagement Plan

o Appendix 3.1 – Engagement Event Records • Appendix 4 - Adults Wellbeing and Health Overview and Scrutiny

Committee cover paper • Appendix 5 – Presentation to OSC • Appendix 6 – Map showing NEAS vehicles and staff locations across

County Durham • Appendix 7 – Evidence of NEAS Activity in the Durham Dales








In view of the Executive Decision made and the ongoing public interest and feedback from the Durham Dales public regarding these proposals, the Governing Body (GB) is asked to:

• Confirm that the GB are assured that extensive and robust engagement has taken place during the pre-engagement and full public engagement processes

• Confirm that the views and feedback from the public were duly considered prior to a final decision being made by the CCG Executive.

• Ratify the decision made by the Executive Committee on 30 September 2014. This was to ask NEAS to implement the change proposals in April 2016 dependent upon the outcome of the independent clinical evaluation of the need for a double paramedic crew in the Durham Dales area.

• Confirm that the GB has assurance that the process leading up to the proposed implementation date of April 2016 is appropriate. This assurance is through an independent clinical evaluation being

3

undertaken overseen by the clinical senate, an objective and independent clinical body separate from the CCG.

• Agree the continuance of the ring fenced investment in NEAS for Teesdale and Weardale of £650k until April 2016 in line with the CCG planning commitments.

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Engagement on the Ambulance service model changes in DDES CCG

1. Introduction The purpose of this paper is to provide members of the Governing Body with a report on the engagement exercise undertaken by DDES CCG regarding the proposed amendments to the ambulance service provided by North East Ambulance Service (NEAS) across the DDES CCG area. This engagement exercise was undertaken to outline and to explain to the public the changes that NEAS wanted to make to improve ambulance response times across the DDES area and to explain the clinical rationale behind the proposed changes to the double paramedic crews in the Weardale and Teesdale areas. As this is a change to operational staffing deployment it would ordinarily be NEAS, as the provider, who would make this decision to deliver the requirements of the contract. However, in view of the history of ambulance provision in Weardale and Teesdale, as well as the public interest in the issue, it was felt important to engage the public in understanding why these changes were being made and what the proposed outcomes from these changes would be for patients across the DDES area. This delayed implementation will mean that NEAS are unable to guarantee an improved ambulance response time across DDES CCG area prior to 1 April 2016, as intended with the proposed changes. However, the CCG and NEAS will continue to work to support improved ambulance response time performance. This includes the use of a redesigned integrated transport scheme, continuing to work with our acute hospitals to reduce patient handover times at A&E and working with 111 to reduce unnecessary and duplicated activity. 2. Background The previous County Durham Primary Care Trust (PCT) agreed an element of additional funding for rural ambulance services. This was used by North East Ambulance Service NHS Foundation Trust (NEAS) to support a ring fence funding in the region of £650K for the provision of vehicles in the Weardale and Teesdale areas of the Durham Dales locality, This was with the aim of improving ambulance response times in this part of the county, the outcomes of which was to be evaluated.

In April 2013 the newly formed DDES Clinical Commissioning Group inherited the position indicated above. As part of the process required to progress the previously agreed evaluation, a group called the Ambulance Patient Reference Group (APRG) was developed which included members of the Dales Rural Ambulance Monitoring Group. County Durham PCT and NEAS had also commissioned an additional two studies into ambulance service performance in Teesdale and Weardale. These reports are known as the Operational Research in Health (ORH) report and the Explain report. Appendix 2 summarises the main points of these two reports. 3. The Review and pre-engagement When the CCG became established the additional ambulance resource allocation for Weardale and Teesdale previously agreed by County Durham PCT was accepted by DDES CCG who agreed to continue this allocation until 1 April 2014. This was to enable the

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evaluation to be undertaken at which point decisions determining future funding and provision would be made.

As part of this evaluation process ongoing dialogue regarding the outstanding issues relating to A&E Ambulance service response times has taken place at the CCG Ambulance Patient Reference Group (APRG). This group was formed to help progress things by ensuring the involvement of the patient and public representatives including some members of the Rural Ambulance Monitoring Group. The group has been involved in the discussion and the collation of data relating to performance, both locally and regionally, since April 2013. As mentioned previously in this report, County Durham PCT and NEAS commissioned an additional two reports relating to ambulance services. These were the Explain report and the ORH report, both of which formed part of the evaluation undertaken. The modelling showed that if DDES vehicles remain in the DDES area there are sufficient vehicle hours to hit the 75% performance target for 8 minute response. However, DDES vehicles respond to calls outside DDES during periods of clinical escalation (when the service is under extreme pressure) and take patients to the nearest hospitals which are situated in Darlington and Durham City. This is called a Peripatetic model (Appendix 2).

Following the previously agreed additional investment in ambulance provision and the ring fencing of vehicles by NEAS in 2008 and 2012, the Ambulance response times for Red 1 and Red 2 calls responding to a person in need within 8 minutes have improved but still remain significantly below the National target. In June 2014 the ambulance response time for DDES CCG was 63.25%. This is against a national target of 75%. All clinical evidence relating to health outcomes demonstrate that having assistance arriving quickly dramatically improves a person’s health outcomes. Therefore having such poor ambulance response times across the DDES area does not support or improve the health outcomes of patients who require immediate assistance and therefore does not improve patient care. As a result the CCG is very clear that it needs to ensure it can improve ambulance response times for the whole of the DDES population and therefore the CCG believes that doing nothing is not an option. Following the review and evaluation of the reports, evidence and data, the CCG as the commissioner had the following options to consider:

1. Keep the status quo 2. Cease the additional investment of £650k in Durham Dales over and above the NEAS

baseline contract 3. Apply the additional investment of £650k across DDES for the benefit of the whole

DDES population 4. Subsidise Darlington CCG and North Durham CCG with the additional investment to

provide them with more vehicles. This would reduce the need for DDES vehicles responding to out of area calls.

5. Maintain the investment for the Durham Dales area for an additional 2 years but then to align the vehicle ambulance crew staffing to be consistent with the rest of the North East. The common North East staffing model is made up of one Paramedic and one Emergency Care Assistant (ECA) on each vehicle. The funding and paramedics released by the change in the Durham Dales would then be used to support crewing an additional Rapid Response vehicle. This vehicle would be stationed in the CCG Dales locality (possibly Bishop Auckland.)

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The APRG met over a 14 month period and gave continuous input and feedback to the CCG commissioning intentions for the Ambulance provision and its current performance. This formed part of an extensive pre-engagement process. 4. The Public Engagement On the 5th August 2014 the CCG Executive Committee supported the NEAS proposal outlined as option 5 above with a recommendation to conduct a public engagement exercise in conjunction with NEAS. This approach to public engagement was supported by the OSC committee at their meeting on 18 July 2014. Five public meetings were agreed: three in Durham Dales, one in Sedgefield and one in Easington. A questionnaire and e-survey was also used to gain public feedback. An update on the public engagement undertaken and the feedback received is included in Appendices 2 and 3. Part way through the engagement process a mid-point review was conducted which is line with good practice. This review informed our continued delivery of the public engagement process and as such the style and format of some meetings was altered. County Durham Healthwatch were involved in developing the Engagement Action Plan and Healthwatch also facilitated the public events to ensure the public voice was heard and noted. They acted as an independent observer throughout the process and are very satisfied with the depth and breadth of the CCG process of engagement. The engagement exercise finished at the end of September and the results were re-presented to OSC on 29 September 2014. The main public feedback can be themed as follows:

• Several other health system issues impact ambulance performance, particularly handover delays at Emergency Departments (and related discharge delays), lack of Emergency Department in DDES area

• The travel distances (rurality) in Weardale and Teesdale make response time targets very difficult, to achieve.

• All paramedics do a very good job under difficult circumstances. • Recruitment and retention of paramedics is an issue for NEAS as well as other

ambulance trusts nationally • Where is the released funding going to be used (will it be outside of Weardale and

Teesdale when it was ring-fenced for that area)? • Why is extra funding going to Weardale and Teesdale when the response times in

other parts of DDES are also a concern? • What is the evidence of clinical effectiveness and safety of a skill mixed crew (a

paramedic and an Emergency Care Assistant) compared to a double paramedic crew?

On 30 September 2014, the CCG Executive Committee received feedback from the public engagement process that the public felt the new staffing arrangements would have an impact on quality and safety. The Executive reaffirmed its commitment and decision that the clinical case for change was made. However, in light of the Durham Dales public’s concern the Executive decided to revise the time scale for implementation in order to allow for an independent clinical review to take place to ascertain if there is a clinical need for double paramedic crews in the Durham Dales area.

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5. Rationale and Analysis It is a key point to note that the options presented above were not designed to save money or to make efficiency savings. The options the CCG have considered are all about ensuring the CCG maximises the impact of the resource it invests, in order to improve ambulance performance over the whole DDES CCG population. The Durham Darlington and Tees CCGs have already, this year, committed a further 2% investment on top of the standard ambulance contract to compensate for additional activity in 2013/14. In addition, DDES CCG proposes continuing to commit the additional funding of £650k in the Durham Dales area for a further two years.

The ambulance trust in the North East introduced Emergency Care Assistants (ECA) in 2007. Since then, NEAS has responded to a total of 784,200 Category A/Red potentially life-threatening incidents throughout the North East using either a paramedic/ECA crew, a rapid response paramedic or community first responders. In that time, there have been no patient safety alerts or serious incidents reported relating to the skill mix of the paramedic/ECA crew which makes up the majority of the staff responding to 999 calls each day

As part of the evaluation a comparison exercise took place looking at the clinical effectiveness of two ambulance stations in Northumberland that operate with one paramedic and one ECA and two stations in Weardale and Teesdale that currently operate with double paramedic crewed vehicles. This comparison cannot be used as empirical evidence but it does indicate that there is no appreciable difference in clinical outcomes between the two crewing models. Since then NEAS has developed a more extensive audit which will be built on during the proposed independent clinical audit.

The CCG Executive is convinced that the new model, if implemented in the Dales would achieve better patient outcomes. It would reduce the number of out of boundary calls the Weardale and Teesdale ring fenced vehicles respond to and would therefore free them up to be more responsive to local calls. In the 12 months between 1 September 2013 and 31 August 2014, ambulance crews from Weardale and Teesdale responded to a total of 5,378 incidents. Just under half of these (2,565) occurred in the Durham Dales postcode area. One fifth of the activity (1,133 incidents) is accounted for in a five-mile radius of Bishop Auckland town centre (Appendix 6). Table 1 lists the locality responses times for DDES as well as the specific breakdown in the Weardale and Teesdale parts of the Dales locality.

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Current NEAS response times for Red 1 and 2 calls (1 April to 31 July 2014)

Location Response time

Dales 64.03%

Sedgefield 59.63%

Easington 61.88%

Weardale 44.19%

Teesdale 60.27%

DDES 63.90%

North East 75.20%

National Target 75%17/09/2014

Table 1: NEAS response times for Red 1 and Red 2 calls

6. Conclusion The changes proposed by NEAS did not require a formal public consultation to be undertaken as there was to be no major service change. This approach taken by DDES CCG and NEAS to public engagement was confirmed as appropriate by the OSC. This is due to the fact that NEAS are making changes to the way the service is being delivered operationally. There is no reduction to the ring fenced vehicles, hours or numbers of staff. This is a change to the configuration of the crews and in addition this would support NEAS to staff an additional Rapid Response Vehicle that will reduce the number of out of area calls that DDES vehicles respond to. The OSC did confirm that the level of public engagement undertaken from July to September 2014 by DDES and NEAS was extensive and thorough enough to actually meet the requirements of the Health and Social Care Act 2012 for a public consultation exercise. DDES CCG has supported the clinical rationale and case for change made by NEAS. However the strength of opinion in parts of the Durham Dales has told us that this part of the population we serve do not have the same confidence in this clinical rationale and case for change. It is the public feedback that has informed the CCGs planning with NEAS for the changes they are proposing, these changes are:

• To set a revised date for these changes to be implemented to the 1st April 2016.

• To use the lead-in time to implementation of the changes to independently clinically assess the need for double paramedic crews in Weardale and Teesdale. This independent clinical evaluation will be overseen by the clinical senate.

Governing Body members need to be aware that this delayed implementation will mean that NEAS are unable to guarantee an improved ambulance response time across DDES prior to 1 April 2016 as we had intended with the proposed changes. We will, however, continue other work to support improved ambulance performance across the CCG area. This includes the use of a redesigned integrated transport scheme, continuing to work with our acute hospitals to reduce patient handover times at A&E and working with 111 to reduce unnecessary and duplicated activity.

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Appendix 1

Summary of 2012 Operational Research in Health (ORH) report and Explain report

1.1 The Operational Research in Health Report

Operational Research in Health (ORH) are an industry leading company that uses complex computer software to model predicted response times for all emergency services. ORH were commissioned to model the response times for ambulances in a variety of scenarios. These were:

• Nearest vehicle responds across the whole of the NEAS area (this is the service is provided as NEAS currently operates)

• Nearest vehicles responds from County Durham and Darlington only (vehicles are restricted to the County Durham and Darlington area, without reciprocal arrangements to cover from neighboring areas)

• Nearest vehicle responds in the DDES CCG area only (vehicles are restricted to the DDES CCG are only without reciprocal arrangements from Darlington or North Durham)

In each of these scenarios a second variable was added, which was the implementation of a ring fenced rural Dales service, in line with current arrangements.

This modelling exercise showed that if DDES vehicles remain in the DDES area there are sufficient vehicle hours to hit the 75% performance target for 8 minute responses. The reason that the target is not consistently achieved is that the vehicles that are stationed within DDES respond to calls and take patients to the nearest hospitals which are situated in Darlington and Durham city. As the vehicles clear the hospital and are returning to the DDES area they will often be required to attend (as the nearest vehicle), to incidents happening in the more populated areas of Durham and Darlington. They are therefore often not in the DDES area when a call comes in from one of our patients, causing a delay in response.

The report concludes that in order to achieve better performance in the DDES area there should be additional vehicles across the whole of the County Durham and Darlington area, but not in the Dales vicinity. This is because if the Dales vehicles remain at the current level of provision and are available to respond to calls from the Dales area rather than responding to calls in Darlington and Durham, the performance in DDES CCG area will improve to the required level.

The report identifies that the ring fenced Dales vehicles result in an improvement in service to the Dales area of approximately 20%.

The report was not asked to look at the skill mix of crews attending patients.

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1.2 Explain report

Explain are a market research company. The main points from the Explain report are as follows:

• There are high levels of satisfaction, particularly in relation to the compassion and caring of the crews

• Strong positive reputation for the current ambulance service provider

• There were no consistent themes for improvement of the current service model

• People appreciated the additional primary care duties of the paramedics working in the Dales

• The majority felt that there were weaknesses in the current model of service

• Ambulance control staff feel that the model is “above and beyond requirements”

• There are strained relationships between stakeholder groups and a call for transparency

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Appendix 2 DDES CCG ambulance service engagement - Update on communications and engagement activities as at 17 September 2014 Author: Simon Clayton NHS North of England Commissioning Support Unit (NECS) communications and engagement team provides a comprehensive communications and engagement service to the NHS Durham Dales, Easington and Sedgefield Clinical Commissioning Group (CCG). The team has supported the CCG throughout the ambulance service engagement work. An initial press release, entitled ‘Have your say on proposals to improve ambulance services across the Durham Dales, Easington and Sedgefield area’ was distributed to media outlets across the North East on 31 July 2014. This included the Seaham & Houghton Star, BBC Look North, BBC Radio Tees, BBC Tees Online, Bishop FM, Darlington & Stockton Times, Durham Times, Durham Voice, Ferryhill & Chilton Chapter, Sunderland Echo, ITV Health, Newton News, Northern Echo, Radio Hartlepool, Radio Teesdale, Shildon Town Crier, Spenny News, Star FM, Teesdale Mercury, TFM, Bishop Press, The Journal, Tyne Tees TV and the Weardale Gazette. Media coverage The following media coverage has been logged as part of the CCG’s ambulance services activity. 7 May – Teesdale Mercury – ‘MP brands plans for ambulance service as cretinous’ 9 May – Teesdale Mercury – ‘Watchdog attacks plans to reduce number of Teesdale paramedics’ 21 May – Teesdale Mercury – ‘Ambulances’ - letters page 27 May – Teesdale Mercury – ‘Plea for talks over ambulance crisis’ 16 July – Teesdale Mercury – ‘Talks to keep 999 crews in Dale’ 17 July – Weardale Gazette – ‘Weardale’s ambulance service under threat again’ 17 July – Weardale Gazette – Letters page 30 July – Teesdale Mercury – ‘Staff fears over plans to cut Paramedics’ 30 July – Teesdale Mercury – ‘Say no to diluted ambulance service in the Dales’ – letters page 1 August – The Northern Echo – ‘Move to improve 999 times’ 4 August – The Northern Echo – ‘Council official slams 999 staff plan’ 8 August – The Northern Echo – ‘Plan to dilute 999 crews abandoned’ 12 August – The Northern Echo – ‘Leaked ambulance email sparks anger’ 13 August – Teesdale Mercury – ‘Paramedic cuts are a done deal, memo reveals’ 13 August – Teesdale Mercury – ‘Deal struck over 999 response times ahead of shake up’ 13 August – Weardale Gazette – ‘Ambulance service update’ 14 August – The Northern Echo – ‘U-turn as extra 999 meeting is added by chiefs’ 27 August – Weardale Gazette – ‘Facts which you need to know’ 30 August – The Northern Echo – ‘Opposition to ambulance crew proposals’ 3 September – Peterlee Star – ‘Changes proposed for ambulance service’ 4 September – The Hartlepool Mail – ‘Views on ambulance shake up’ 9 September – The Northern Echo – ‘Public give thumbs down to plans for mercy crews’ In broadcast media CCG spokespeople have appeared on BBC Radio Tees as part of the engagement activity. This includes interviews with Dr Stewart Findlay on 4 August and 12 August, and Joseph Chandy on 2 September.

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Paid for Media As part of our activity planning we had made contingency to buy space in local publications to raise awareness of our plans and the public events. The extent of interest in the issue generated following our initial press release resulted in coverage that made this action unnecessary. My NHS Promotional material was distributed via the CCG’s My NHS engagement mechanism, with an email sent to 178 recipients on 7 August and via hard copy through the post to 337 members on 4 August. The feedback document was emailed to 180 members on 21 August 2014. Distribution 10 copies of the feedback document were delivered to 162 community association and pharmacy addresses across the Durham Dales NHS Locality. 15 copies of the feedback document were distributed to the 24 public libraries in the DDES area. Both were completed in the week ending 29 August. Media enquiries The NECS communications and engagement team has received 13 media enquiries relating to the CCG’s ambulance service activity: 31 July – The Northern Echo 4 August – BBC Tees 11 August – Teesdale Mercury 12 August – BBC Tees 12 August – The Northern Echo 13 August – The Northern Echo 14 August – Teesdale Mercury 14 August – TFMradio 18 August – Teesdale Mercury 29 August – The Northern Echo 2 September – The Hartlepool Mail 5 September – BBC Tees 8 September – Teesdale Mercury 19 September – The Northern Echo The NECS communications and engagement team has responded to media enquiries to requested deadlines, where possible, liaising with the CCG to provide an appropriate response. The NECS team has responded to requests verbally, in writing, and by arranging for spokespeople to be interviewed by broadcast media. Public Engagement Events Five public events were arranged for the general public: Tuesday 2 September – Sedgefield. Number attended = 24. Monday 8 September – St John’s Chapel. Number attended = 147. Thursday 11 September – Murton. Number attended = 32. Monday 15 September – Middleton-in-Teesdale. Number attended = 165 Tuesday 16 September – Barnard Castle. Number attended = 194. Contemporaneous notes were taken of the points raised by members of the public at the meetings. These are found in Appendix 3.1 Survey responses NECS communications and engagement team 4 postal and 12 online responses to the CCG’s feedback form.

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All the following attached separately:

Appendix 3 – Communications and Engagement Plan Appendix 3.1 – Engagement Event Records Appendix 4 - Adults Wellbeing and Health Overview and Scrutiny Committee (OSC) Cover Paper Appendix 5 – Presentation to OSC

14

Appendix 6: Map showing NEAS vehicles and staff locations across County Durham

NEAS currently have 17 two-crew ambulances staffed by a paramedic and Emergency Care Assistant across County Durham and three double-crew ambulances staffed by two paramedics in Weardale and Teesdale. There are a further six rapid response paramedics and five two-crew ambulances staffed by an urgent care crew consisting of 2 ECAs in the county.

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Appendix 7 Evidence of activity from Middleton and Teesdale responding currently to Bishop Auckland calls to justify RRV will support the Upper Dales In the 12 months between 1 September 2013 and 31 August 2014, ambulance crews from Weardale and Teesdale responded to a total of 5,378 incidents. Just under half of these (2,565) occurred in the Durham Dales postcode area, identified here to the left of the long dotted blue line. One fifth of the activity (1,133 incidents) is accounted for in a five-mile radius of Bishop Auckland town centre – seen here as the red circle. By placing a paramedic rapid response in Bishop Auckland, it will potentially prevent a Dales crew being called as an initial response to an emergency call.

16

Impact Assessment and Risk Management Issues Consideration given and action taken in this report relating to impact assessment and risk management issues is detailed below:

a) Risk None.

b) Environmental impact / sustainability None.

c) Legal implications None.

d) Resource implications – finance and/or staffing None.

e) Equality Assessment None.

f) Quality, Innovation, Productivity and Prevention None.

g) Patient, public and stakeholder involvement This was not a formal public consultation, but rather an engagement process, due to the fact that there will be no change in the service available to the Dales.

h) Clinical engagement

None.

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GOVERNING BODY ACTION LOG UPDATED 8 AUGUST 2015

No Date

action agreed

Action Responsible officer

Agreed completion date

Progress Outcome

1. 10/03/15 GB/15/05 Matters arising from the meeting held on 13th January 2015 With regards to item GB/14/329 – Due North Report, it was noted that a report would be brought back to the Governing Body in September 2015 and this would be included in the action log.

Mike Lavender / Anna Lynch

Nov 15 (Report to go through Exec in Oct 15)

2/6/15 – item has been added to the planners - Exec Committee on 4th Aug and GB meeting on 8th Sept. 7/7/15 – The report has not yet been published so deferred to November meeting.

On-going

2. 10/03/15 GB/15/15 Urgent Care Strategy 2015-20 All comments to be sent via email to SF /NB or Anita Porter where they will be fed into the strategy as it develops. Received the draft strategy, agreed to feedback comments and would receive the final strategy for approval in May/July prior to submission to the Health and Wellbeing Board.

ALL

8/4/15 - No comments back from DDES CCG. Steps are now being put in place to work towards finalising the strategy, working with Stewart and leads from the other 2 CCGs. Final strategy not yet available to bring back to the Governing Body.

Complete

1

No Date action agreed



Progress Outcome

S Findlay

September (report to go through Exec in August)

12/5/15 – A meeting had been arranged for the next month to update and incorporate comments 2/6/15 – item has been added to the planners – Exec Committee on 4th Aug and GB on 8th Sept. 7/7/15 – On track for September. 10/8/15 - All comments to be sent via email to SF /NB or Anita Porter where they will be fed into the strategy as it develops. Received the draft strategy, agreed to feedback comments and would receive the final strategy for approval in May/July prior to submission to the Health and Wellbeing Board. 28/8/15 (MW) Urgent Care Strategy went to Exec on 18th Aug and will be going to GB on 8th Sept.

2




Progress Outcome

3. 7/7/15 GB/15/051 Declarations of conflicts of interest As a new member of the Governing Body, JW to provide his declarations of conflicts of interest to MW to add to the register.

J Whitehouse

28.8.15 Form completed

Complete

4. 7/7/15 GB/15/053 Matters arising from the minutes of the meeting held on 12 May 2015 The final Joint Strategic Needs assessment document would be provided to the next Governing Body meeting in September by NB.

N Bailey

5. 7/7/15 GB/15/056 Risk Management update MP to ensure that where the status of risks changed, that there was adequate narrative in explanation for future reports.

M Pickering

1.9.15 Update from MP Risk narratives reviewed as part of risk report sign-off. Additional risk refresher training will emphasise this requirement.

Complete

6. 7/7/15 GB/15/059 Business Assurance Framework update: June 2015 JW and MP to work together to develop the BAF and the risk register including incorporating new items, checking the reasonableness of comments and ensuring that there was adequate narrative against new and changing

J Whitehouse M Pickering

7/8/15 - Have met with MP and discussed how we may develop the process of improving the outputs from AF/RM process in a manner which provides area of debate on patient critical issues (JW)

3




Progress Outcome

items. ACTION: MP to include the review of the BAF and Risk Register on the next Audit and Assurance Committee.

M Pickering

Sept 15

7. 10/03/15 GB/15/11 Business Assurance Framework MP to check that all corporate objectives were covered and that all entries were completed.

M Pickering

July 15 or Sept 15 (Report to go through Exec in June or Aug)

12/5/15 – Carry Forward. A report would be ready for the July or September meeting. 2/6/15 – item has been added to the planners – Exec Committee on 16th June and GB on 7th July. On agenda for 7 July 15 Recommend this is noted as complete

Complete

8. 12/5/15 GB/15/28 Showcase presentation – Tackling alcohol harm in Durham CS to inform SH if the presentation was appropriate to publish on the DDES CCG website.

C Shevills S Humpish

ASAP

Confirmation received. Shared with GB by e-mail and added to GB page of website Recommend this is noted as complete

Complete

4




Progress Outcome

9. 12/5/15 GB/15/33 Review of Action Log GB/15/20 Acute and Community Services Quarterly Clinical Update Should a member of the Governing Body wish to have a query answered formally in the meeting, they should ask SH to add to the agenda or ask the relevant officer to address in their report.

All

Ongoing for future

Recommend for the purposes of the action log that this is noted as complete

Complete

10. 12/5/15 GB/15/35 Primary Care Commissioning Update NB to produce a report for the July Governing Body meeting to update the group on the constitution, including terms of reference.

N Bailey

July 2015 (report to go through Exec in June)

Primary Care Commissioning has been added as a standard verbal item for future GB meetings Recommend this is noted as complete

Complete

11. 12/5/15 GB/15/36 Planning update presentation MP to report to the GB when the plan and financial forecast was approved. Anticipated to be July.

M Pickering

July 2015 (report to go through Exec in June)

2/6/15 – item has been added to the planners – Exec Committee on 16th June and GB on 7th July. Recommend this is noted as complete

Complete

12. 12/5/15 GB/15/44 Risk Management update MP to take into account the comments made on the format and content of the

M Pickering

Comments noted and will be part of ongoing risk report

Complete

5




Progress Outcome

report with a view to streamlining information at a strategic level.

development Recommend this is noted as complete

13. 12/5/15 GB/15/49 Any other business Nepal AL to forward details of ML’s Twitter account to SH to share with Governing Body colleagues to follow his progress in Nepal.

A Lynch

Information shared via e-mail with GB members Recommend this is noted as complete

Complete

6


GOVERNING BODY

Report Title Final Urgent Care Strategy 2015-20 Author Anita Porter, Senior Commissioning Support Officer, NECS Sponsor Director Stewart Findlay, Chief Clinical Officer Date 11th August 2015 Purpose of report Information sharing Development / Discussion Decision / Action Brief introduction / Purpose of paper

This report invites members of the Formal Executive Committee to agree the final version of the County Durham and Darlington Urgent Care Strategy 2015-20 and recommend for it to be approved at Governing Body. A previous report was received by the Formal Executive Committee in February 2015 inviting feedback on the draft strategy. The strategy has since been significantly revised and updated to:

• incorporate feedback received; • progress in local and regional urgent and emergency care

developments; • learning from Winter 2014/15; and • recent guidance on implementing the National vision for urgent

and emergency care, locally.


• This is a high level strategy with each Clinical Commissioning Group responsible for developing local implementation and engagement plans;

• Following Winter 2014/15 NHS England have focussed heavily on releasing guidance to support local implementation of the National vision for urgent and emergency care;

• The two key elements of the National vision are: • People with urgent but non-life threatening needs have local

responsive services as close to home as possible; • People with serious or life-threatening emergency needs should

be treated in centres with the very best expertise and facilities in order to reduce risk and minimize their chances of survival and recovery;

• Locally as well as implementing the National vision, the strategy aims to address the historical challenges in achieving the Accident and Emergency (A&E) four hour wait and ambulance response times constitutional targets by improving understanding of surge pressures, ambulance handover times, patient flow processes including hospital discharges and prevention of unnecessary admissions;

• Implementation of the strategy is focused on a collaborative approach across commissioners and providers, developing an evidence based urgent and emergency care system, with equitable access to high quality, safe and effective urgent and emergency care services at the right time and in the right place, that comfortably achieves the constitutional standards for urgent and emergency care.

DDES approval route

• Formal Executive Committee 18th August 2015 • Governing Body 8th September 2015


• Formal Executive Committee February 2015 • All System Resilience Group members organisations including

Healthwatch during December 2014 – end March 2015 • This final strategy is currently making its way through local Patient

Reference Groups, Area Action Partnerships, Overview and Scrutiny Group and will be ratified at the Health and Wellbeing Board November 2015


• Appendix A – County Durham and Darlington Urgent Care Strategy 2015-20

• Appendix B – V0.10 Final Durham and Darlington UC Strategy








The Governing Body is asked to: • Receive the report; • Approve the final strategy ahead of it going to the Health and

Wellbeing Board for ratification; • Give Stewart Findlay and the Chair of Governing Body delegated

responsibility to make any final material changes to the document that may arise from engagement meetings.

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APPENDIX A

FINAL URGENT CARE STRATEGY 2015-20

1. National Context 1.1 This strategy (Appendix A) has been developed by the County Durham and

Darlington System Resilience Group and has been shaped by the standards encompassed within NHS England’s Planning Guidance, Everyone Counts 2015/16 to 2019/20, key National and local reviews of urgent and emergency care services, NHS England’s Five Year Forward View and the recently introduced Eight High Impact Interventions for urgent and emergency care.

1.2 The Transforming Urgent and Emergency Care Review1 proposed a new National

vision urgent and emergency care which has now been adopted and is being heavily promoted by NHS England. The National vision has two key aims:

1.2.1 People with urgent but non-life threatening needs must have a highly

responsive, effective and personalised service outside of hospital – as close to home as possible, minimising disruption and inconvenience for patients and their families;

1.2.2 People with serious or life-threatening emergency needs should be treated in

centres with the very best expertise and facilities in order to reduce risk and minimise their chances of survival and recovery.

1.3 NHS England have recently published further guidance to help local commissioners

and providers understand the practical elements of the vision and are providing support to facilitate local implementation. The main elements of the National approach underpinning the aims of the vision are:

• Self-care – through more easily accessible information about self-treatment option, pharmacy promotion and better access to NHS 111

• Right advice or treatment first time – through an enhanced NHS 111 service which is easier to access and supported by a range of clinicians

• Faster, convenient, enhanced service – to General Practice, primary and community care services aimed at providing care as close to home as possible and prevention unnecessary admissions to hospital

• Identify and designate available services in hospital based emergency centres - aiming to ensure that urgent and emergency care services work cohesively together as an overall Urgent and Emergency Care Network so that the whole system becomes more than just a sum of it’s parts

1.4 In addition to the above there has been a great deal of learning resulting from the

challenges experienced throughout the urgent and emergency care system during Winter 2014/15. Some of the key messages from NHS England have included:

• Higher patient acuity resulted in longer length of stay especially frail elderly; • The impact was earlier and lasted the whole winter and the system struggled

with flow through the system including discharge;

1 Transforming urgent and emergency care services in England. Urgent and emergency care review end of phase one report High quality care for all, now and for future generations. Professor Sir Bruce Keogh, November 2013

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• It was a relatively mild winter with no major flu outbreak which leads to the question could the system have coped under a different scenario;

• The NHS111 service faced similar unprecedented demand, dealing with 4.6 million calls this winter –which is an increase of one million calls or 27% on last winter. NHS111 call handlers and support reduced unnecessary pressures on A&E and emergency ambulance services by directing people to the right place for their care such as GPs, walk-in centres or pharmacists. Of all the calls triaged, just 11% had ambulances dispatched and 7% were recommended to A&E.

1.5 With this learning from Winter 2014/15 NHS England developed eight High Impact

Interventions for urgent and emergency care (Appendix B) that are designed to provide focus for local commissioners and providers on elements of the system which are crucial to be in place to ensure effective patient flow and patient experience within urgent and emergency care services. These eight High Impact Interventions are must do’s. Local System Resilience Groups are required to provide assurance to NHS England that these high impact interventions are fully met. Any gaps in full achievement will be challenged by NHS England.

1.6 To support the implementation of the National vision on a regional level the current Urgent Care Network is in the process of being replaced by a new Urgent and Emergency Care Network. 1.7 These new groups will work across several Clinical Commissioning Group geographical areas, and provide strategic oversight and improve the consistency and quality of urgent and emergency care by addressing together challenges in the urgent and emergency care system that are difficult for single System Resilience Group’s to achieve in isolation. 2. Local Strategic Approach 2.1 The County Durham and Darlington System Resilience Group (SRG) has developed

the County Durham and Darlington Urgent Care Strategy 2015-20 and has overall responsibility for the capacity planning and operational delivery across the health and social care system for urgent and emergency care. The local System Resilience Group will be responsible for overseeing the implementation of the Urgent Care Strategy locally.

2.2 The SRG is chaired by the Chief Clinical Officer from Durham Dales, Easington and

Sedgefield Clinical Commissioning Group with representation from North Durham Clinical Commissioning Group, Darlington Clinical Commissioning Group, both Local Authorities and all key stakeholders involved in the delivery of urgent and emergency are across County Durham and Darlington.

2.3 The strategy has been developed in line with the National vision. The initial draft

strategy developed during Summer 2014 and consulted on with all System Resilience Group member organisations during Winter 2014/15 has now been substantially revised and updated to incorporate:

• Feedback from System Resilience Group partners • Local developments within the urgent and emergency care pathway; and • Recent National learning and implementation guidance including the 8 High

Impact Interventions.

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2.4 In line with the National vision, the local vision for urgent and emergency care is:

‘Patients are seen by the right health/social care professional, in the right setting, at the right time, to the highest quality and in the most efficient way providing the best outcome for the patient.’

2.5 This vision incorporates the whole urgent and emergency care system from pharmacies, GP Practices and other primary care services, secondary care community services and acute hospital provision. 2.6 To implement the vision, the identified actions have been aligned to seven objectives:

• People are central to designing the right systems and are at the heart of decisions being made;

• Patients will experience a joined up and integrated approach regardless of the specific services they access;

• The most vulnerable people will have an a plan to help them manage thei r cond it ion ef fect ively to avo id the need for urgent and emergency care;

• People will be supported to remain at their usual place of residence wherever possible;

• The public will have access to information and guidance in the event of them needing urgent or emergency care;

• The patient will be seen at the right time, in the right place, by a person with the appropriate ski l ls to manage their needs;

• The patient will not experience any unnecessary delay in receiving the most appropriate care.

2.7 The County Durham and Darlington System Resilience Group would like to ultimately see the following model commissioned for patients requiring urgent and/or emergency care.

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2.8 The main focus of the model is the availability of a range of community based services including pharmacy, promotion of self care, NHS 111, GP Paramedic Support, extended primary care joined up with secondary community care services providing a timely and effective service to patients who are quickly and safely directed to access the relevant service to meet their presenting health needs. 2.9 For those with urgent needs they will be quickly and safely directed to attend an urgent care service and those will serious or life threatening health conditions will be quickly, safely and effectively assessed and treated in an Accident and Emergency Department. 2.10 The County Durham and Darlington Urgent and Emergency Care Strategy 2015-20 is a high level strategy with each Clinical Commissioning Group responsible for developing implementation plans including appropriate local engagement to deliver on actions they have responsibility for leading on. 2.11 Implementation of the strategy is focused on a collaborative approach across

commissioners and providers, developing an evidence based urgent and emergency care system, with equitable access to high quality, safe and effective urgent and emergency care services at the right time and in the right place, that comfortably achieves the constitutional standards for urgent and emergency care;

2.12 It is important to note that the urgent and emergency care system locally, in inextricably linked to wider regional provision as acute hospitals provide mutual aid to each other at times or pressure and the North East Ambulance Service being responsible for the co-ordination and response to both emergency and urgent healthcare needs through 999 services and NHS 111 across the region. 2.13 For this reason the action plan within the strategy identifies both local and regional

actions with the regional actions. Local actions will be the responsibility of local commissioners and providers across County Durham and Darlington. The SRG members will contribute to the development and delivery of regional actions but overall responsibility will sit with the Urgent and Emergency Care Network for the implementation of these actions across the region to ensure consistent service and effective use of resources.

2.14 All Clinical Commissioning Groups have now been invited to share the final strategy

with their Patient Reference Groups and other local engagement meetings with a view to advising on any errors ahead of final sign off and also to make suggestions about how best to implement the strategy within each local area and who else needs to be involved.

2.15 As part of this process the strategy will be taken to the Countywide Forums for Mental

Health and Investing in Children, Area Action Partnerships and Overview and Scrutiny Committee with a view to the final strategy being ratified at the Health and Wellbeing Board on 3rd November 2015.

2.16 North of England Commissioning Support Unit Communications Team are in the

process of proof reading the final strategy to address any grammatical errors and have been requested to develop some examples of a logo and strapline to go onto the published version of the strategy to provide a clear identify for the System Resilience Group. Options will be taken to the System Resilience Group on 28th August 2015.

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3. Impact Assessment and Risk Management Issues 3.1 Consideration given and action taken in this report relating to impact assessment and


a) Risk There are risks within the current urgent and emergency care system to the consistent and comfortable achievement of the key constitutional standards including breaches of the four hour 95% A&E target and ambulance response times. This strategy will reduce the risk by implementing a more joined up approach which aims to ensure that patients are treated by the right professional, at the right place, first time.

b) Environmental impact / sustainability

The System Resilience Group will consider the sustainability implications of local initiatives developed in line with the implementation of this strategy.

c) Legal implications

There may be some legal implications in relation to potential procurements or re- procurements during the life of this strategy. Where appropriate relevant legal or procurement advice will be sought.

d) Resource implications – finance and/or staffing The strategy action plan will review the use of existing resources and seek to improve efficiency and productivity across the system overall.

e) Equality Assessment Not included.

f) Quality, Innovation, Productivity and Prevention The strategy action plan will review the use of existing resources and seek to improve efficiency and productivity across the system overall.

g) Patient, public and stakeholder involvement Healthwatch Darlington and Healthwatch County Durham are members of the System Resilience Group. The strategy is currently working it’s way through Patient Reference Groups across all Clinical Commissioning Groups across County Durham and Darlington and will also be taken through Area Action Partnerships

h) Clinical engagement System Resilience Group members and Clinical Commissioning Group Executive Groups have been given opportunity to feed into the development of the strategy.

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APPENDIX B– Eight High Impact Interventions for Urgent and Emergency Care

No. High Impact Interventions

1 No patient should have to attend A&E as a walk in because they have been unable to secure an urgent appointment with a GP. This means having robust services from GP surgeries in hours, in conjunction with comprehensive out of hours services.

2 Calls to the ambulance 999 service and NHS 111 should undergo clinical triage before an ambulance or A&E disposition is made. A common clinical advice hub between NHS111, ambulance services and out-of-hours GPs should be considered.

3 The local Directory of Services supporting NHS 111 and ambulance services should be complete, accurate and continuously updated so that a wider range of agreed dispositions can be made.

4 SRGs should ensure that the use of See and Treat in local ambulance services is maximised. This will require better access to clinical decision support and responsive community services.

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Around 20-30% of ambulance calls are due to falls in the elderly, many of which occur in care homes. Each care home should have arrangements with primary care, pharmacy and falls services for prevention and response training, to support management falls without conveyance to hospital where appropriate.

6 Rapid Assessment and Treat should be in place, to support patients in A&E and Assessment Units to receive safer and more appropriate care as they are reviewed by senior doctors early on.

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Consultant led morning ward rounds should take place 7 days a week so that discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the week. This will support patient flow throughout the week and prevent A&E performance deteriorating on Monday as a result of insufficient discharges over the weekend.

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Many hospital beds are occupied by patients who could be safely cared for in other settings or could be discharged. SRGs will need to ensure that sufficient discharge management and alternative capacity such as discharge-to-assess models are in place to reduce the DTOC rate to 2.5%. This will form a stretch target beyond the 3.5% standard set in the planning guidance.

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