Governing Body AGENDA Thursday, 5 February 2015, 10:30-13 ... Body/5 Feb… · 2. Minutes of the last Governing Body Meeting 6 November 2014 JR GB14-053 3. Matters Arising 3.1 Schedule

Governing Body

AGENDA

Thursday, 5 February 2015, 10:30-13:00

(meet and greet the Governing Body -10:00-10:30) Green Rooms 1&2, Ventnor Town Council, 1 Salisbury Gardens, Dudley Road, Ventnor, Isle of Wight PO38 1EJ

1. 1.1

1.2 1.3

Apologies for absence: Declaration of interests Confirmation that the meeting is quorate

JR JR JR

GB14-052

10:30

2. Minutes of the last Governing Body Meeting 6 November 2014 JR GB14-053 3. Matters Arising

3.1 Schedule of Actions from the 6 November 2014

JR

GB14-054

10:35 4. Chair / Chief Officer Report JR/HS Verbal 5. Items for Assurance 5.1 Governing Body Assurance Framework HS GB14-055 10:40 5.2 Performance Report LO GB14-056 10:55 5.3 Wessex Assurance Action Plan HS GB14-057 11:10 5.4 Risk Register HS GB14-058 11:20 5.5 Cost Improvement Plan Process LO Verbal 11:30 6. Items for Approval 6.1 Primary Care Co-Commissioning HS GB14-059 11:40 6.2 Low Priority Procedures

• Policy Statement 001 – Interventional Procedures for Varicose Veins

• Policy Statement 002 – Assisted Conception Services (IVF)

HS

GB14-060

GB14-061

12:00

7. Items to receive for information / discussion 7.1 CCG Allocation & 2015/16 Operational Plan LO GB14-062 12:35 7.2 Quality and Patient Safety Committee Summary 27.11.14 DN GB14-063 12:55 7.3 Clinical Executive Minutes 20.11.14, 18.12.14, 15.1.15 HS GB14-064 7.4 Audit Committee Minutes 25.9.14 FP GB14-065 8. Urgent Business JR 9. Motion to exclude the Press and Public JR 13:00 - that representatives of the press, and other members of the public, be

excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’, (Section 1 (2), Public Bodies (Admission to Meetings) Act I960)

Date of Next Meeting – Thursday 26 March 2015, 10:30 – 13:00 – Venue TBC

Governing Body Declaration of Governing Body Members’ Interests Sponsor: Helen Shields, Chief Officer

Summary of issue:

This paper sets out the relevant and material interests of the members of the CCG Governing Body. It represents the Register of Interests as required by the Standing Orders in accordance with the NHS Code of Accountability.

This paper supports the CCG Governing Body to fulfil its Standing Orders in accordance with the NHS Code of Accountability.

Action required / recommendation:

The CCG Governing Body is being asked:

• To receive and note the register of interests of members and ensure that members play no part in discussion or decision where a conflict of interest is established.

• To receive any oral updates on the interests of members.

Principle risk(s) relating to this paper:

There are no risks relating to this paper.

Other committees where this has been considered:

This paper has not been considered at any other committee.

Financial / resource implications:

There are no financial or resource implications arising from this paper.

Legal implications / impact:

There are no legal implications arising from this paper.

Public involvement /action taken:

There has been no public involvement or action taken.

Equality and diversity impact:

This paper does not request decisions that impact on equality and diversity

Author of Paper: Rebecca Berryman, Governance Support Officer

Date of Paper: February 2015

Date of Meeting: 5 February 2015

Agenda Item: 1.2 Paper number: GB14-052

1

Declaration of Interest

1. Introduction

1.1 The NHS Code of Accountability requires the Governing Body to declare interests which are

relevant and material to the Governing Body of which they are a member.

1.2 Interests which should be regarded as “relevant and material” are:

• Directorships, including non-executive directorships held in private companies or PLCs (with the exception of those of dormant companies);

• Ownership or part-ownership of private companies, businesses or consultancies likely or

possibly seeking to do business with the NHS;

• Majority or controlling share holdings in organisations likely or possible seeking to do business with the NHS;

• A position of authority in a charity or voluntary organisation in the field of health or social

care;

• Any connection with a voluntary or other organisation contracting for NHS services;

• Research funding/grants that be received by an individual or their department;

• Interests in pooled funds that are under separate management (any relevant company included in this fund that has a potential relationship with the CCG must be declared);

1.3 Any Governing Body Member who comes to know that the CCG Governing Body has entered

into or proposed to enter into a contract in which he/she or any person connected with him/her (as defined in the Standing Orders) has any pecuniary interest, direct or indirect, the Governing Body member shall declare his/her interest by giving notice in writing of such fact to the CCG Governing Body as soon as practicable.

1.4 The Chief Officer will ensure that a Register of Interests is established to record formally declarations of interests of Governing Body Members. Interests will be declared at Governing Body meetings to ensure they are known to the public.

2

2. Register of Interests

Name Relevant and Material Interests Dr Joanna HESSE Clinical Executive Member

Joanna is: A GP Partner at Esplanade Surgery, Ryde, Isle of Wight. Joanna undertakes private practice within Esplanade Surgery, Ryde, Isle of Wight. Joanna undertakes sessions as OOH GP at Beacon, Newport, Isle of Wight.

Last Updated /Noted: October 2013 David NEWTON Governing Body Lay Advisor

David is: Director of Social Enterprise Foundation CIC and Social Enterprise Foundation Members Ltd. A Senior Partner at Corporate Impact. Contracted by Priory Asset Management.

Last Updated / Noted: November 2014 Loretta OUTHWAITE Chief Finance Officer

Loretta is a School Governor at the Island Free School. Last Updated / Noted: December 2013

Frederick Psyk Governing Body Lay Advisor

Frederick has no declarations of interest. Last Updated / Noted: November 2014

Dr Mark Rawlinson Governing Body Nurse

Mark is: A Lecturer at Southampton University. External Examiner – University of South Wales, Manchester Metropolitan University and University of Malta. Vice Chair (retiring) Association of District Educators. A member of the Professional Advisory Group for Community Nursing.

Last Updated / Noted: November 2014 Dr Ian Reckless Secondary Care Doctor

Ian is: Employed by Oxford University Hospital NHS Trust as Consultant Physician, Clinical Director, Neurosciences. Undertakes voluntary ad hoc work with Royal College of Physicians Honorary Senior Clinical Lecturer, Oxford University. Co-applicant on a number of research grants including Engineering and Physical Sciences Research Council. Author, Oxford University Press and Blackwell-Wiley (royalties)

Last Updated / Noted: September 2014

3

Dr John Rivers Chair, Clinical Executive Member

John is: A GP Partner at Shanklin Medical Centre, Shanklin, Isle of Wight. John undertakes private medicals and reports with general practice. President of Cruse Bereavement Care IW

Last Updated / Noted: April 2014 Helen Shields Chief Officer

Helen’s husband is Head of Podiatry and Orthopaedic Triage at IW NHS Trust.

Last Updated / Noted: October 2014

4

Governing Body

Minutes of the Governing Body 6 November 2014 -Part 1

Sponsor: Helen Shields, Chief Officer

Summary of issue: Minutes of the previous Governing Body Meeting 6 November 2014

Action required/ recommendation: To approve the minutes

Principle risks: There are no risks relating to this paper.


This paper has not been considered at any other committees.

Financial /resource implications: There are no financial or resource implications.

Legal implications/ impact: These minutes form a formal public record of the previous meeting.

Public involvement /action taken: The Governing Body was held in public.

Equality and diversity impact: There is no equality and diversity impact relating to this paper.

Author of paper: Rebecca Berryman, Governance Support Officer

Date of Paper: 7 November 2014


Agenda Item: 2 Paper number: GB14-053

1

NHS Isle of Wight Clinical Commissioning Group: Governing Body

Minutes of Part 1 of the CCG Governing Body held on 6 November 2014 at 10:30 at Scout, Guide and Community Centre, North Street, Brighstone, Isle of Wight PO30 4AX

PRESENT: Dr John Rivers (JR) – CCG Chairman (Chair) Helen Shields (HS) – Chief Officer

David Newton (DN) –Governing Body Lay Advisor Loretta Outhwaite (LO) – Chief Finance Officer Frederick Psyk (FP) – Governing Body Lay Advisor Dr Joanna Hesse (JH) – CCG Clinical Executive Dr Mark Rawlinson (MR) – Governing Body Nurse Dr Ian Reckless (IR) – Secondary Care Doctor

IN ATTENDANCE: Caroline Morris (CM) – Head of Primary Care and Corporate Business MINUTED BY: Rebecca Berryman (RB) – Governance Support Officer

14-051 Apologies for Absence There were no apologies for absence received.

14-052 Declarations of Interest The Governing Body received paper GB14-035 Declaration of Interests. The following

changes were declared: • MR is part of the Professional Advisory Group for Community Nursing. • FP is no longer a volunteer business mentor for Enterprise First. • DN is no longer a Voluntary Sector Co-ordinator for Green Towns. JR and JH also declared at interest in items 4.6 and 6.1 – FP agreed to Chair these items.

14-053 Confirmation the Meeting is Quorate Confirmed. 14-054 Minutes of the Last Governing Body Meeting 4 September 2014 The Governing Body received paper GB14-036 Minutes of the last Governing Body

Meeting 4 September 2014. The minutes were approved as accurate, with the following exceptions: • Page 8, 14-043, should read “2.10 Quality Premium Risk will be reduced next month.” • Page 9, last paragraph of 14-043 should read “that key controls, targets and indicators

were included for future reports.”

The Governing Body approved the Minutes of the 4 September 2014 Governing Body. 14-055 Matters Arising

The Governing Body received paper GB14-037 Schedule of Actions from 4 September 2014, noting the following comments: • IR commented that the Governing Body needed to be clear regarding the Isle of Wight

2

NHS Trust (IOWNHST) Cost Improvement Programmes (CIP). • 14-040 – it was discussed that the penalty relating to Ambulance Handover delays were

linked to the rules associated within the terms of the contract.

Items for Assurance 14-056 Governing Body Assurance Framework The Governing Body received paper GB14-038 Governing Body Assurance Framework

(GBAF), presented by HS. The paper was taken as read and the following discussion took place: FP felt it was useful to have the GBAF at the start of the meeting. He requested further detail regarding the risks relating to objective 1, the achievement of the NHS Constitution targets, with failures against Referral to Treatment time targets and additional scrutiny from NHS England regarding emergency admissions and system resilience over the winter and requested more details regarding this. HS highlighted that there has been pressure across the country on Acute Providers particularly in relation to A&E. There has been a national increase in demand on A&E services, and 50% of Acute Trusts have declared a financial deficit. The IOWNSHT declared a Black Alert during the week of the 3 November, due to pressure across the health and social care system on the Island. A meeting is to be held with all partners to determine what happened in detail to enable measures to be put in place to reduce pressures in the future. HS identified that a key issue is the recruitment of staff to the Island. A Workforce Summit has taken place with a range of agencies including Health Education Wessex, Local Authority, IOWNHST and the CCG to try and establish a solution to the recruitment issues. FP queried what the short-term solution was to ease the pressure on Island services. HS confirmed that alternative providers were being sought for elective care, and patients would be asked if they would be willing to travel to the mainland for treatment. System resilience funding has been received and all avenues are currently being explored for a short-term solution, including the Trust using a Nursing Home as a step down facility. JH queried if the system responded well to the Black Alert. HS felt that all external agencies responded as well as they could. The Black Alert should not have come as a surprise as the pressure in the system had been building. Daily sit-reps are now being received to monitor the situation closely. MR asked how a Black Alert could be prevented in the future. It was confirmed that capacity and staffing issues were the key to the issue. The IOWNHST are in the process of a recruitment drive for Nurses in the Philippines. The System Resilience Group are putting plans in to place and are continually monitoring and evaluating the issues. IR requested more detail in relation to Critical Success factor (CSF) 1.10, NHS England asking the CCG to review Governance arrangements, specifically in relation to transparency of decision making. HS commented that this was in relation to Business

3

Cases being approved in private by the Clinical Executive. The Clinical Executive minutes are made public; however a discussion at the Governing Body Seminar was required to establish whether papers should be made public. With regard to CSF 3.30, IR asked for further assurance regarding the IOWNHST cost base. LO confirmed that the first two phases of the cost base exercise had been agreed with completion by March 2015. This piece of work relates to establishing the costs in the four contract areas. The longer term work relates to developing Service Line Reporting which has been proposed to be completed by March 2016. Discussions are taking place as the CCG feel that March 2016 is too late. IR also referred to A2 – Why the IOWNHST’s partnership with Hertfordshire NHS Trust and not progressed. HS confirmed that this had been discussed at the Clinical Executive and at contract meetings. The meeting had been cancelled by Hertfordshire NHS Trust; however the meeting had been rescheduled for January 2015. It was expected that a Memorandum of Understanding (MOU) would be signed by December 2014. IR asked if it was clear how the partnership would work. It was confirmed that the partnership would be a two way learning process for both organisations. HS updated the Governing Body regarding the leadership of Mental Health at the IOWNHST. The vacant Head of Mental Health, Learning Disabilities and Community Partnership post has now been recruited to, and the new post holder is due to start imminently. There are still concerns regarding the Clinical Leadership of Mental Health with the Trust seeking support from Hertfordshire. There has been a dilution of where Mental Health sits within the Trust structure, as it is now part of the Community Health Directorate. There is also a lack of Mental Health experience at Executive and Clinical Director level within the Trust. IR identified that in relation to A7 – CQC finding at IWNHST, the wording around this risk makes the CCG sound passive. IR was assured the CCG are not passive, HS confirmed that the CCG are a major partner monitoring the CQC Improvement Plan in conjunction with the Trust Development Agency (TDA) and the NHS Wessex Area Team. The Improvement Plan has now been approved by the three bodies and a monthly Board Meeting takes place. In response to a further question from IR with regard to how much support is required from the CCG as a result of the CQC Inspection, HS confirmed that this is not yet clear. The CCG have requested the IOWNHST to clearly outline the level of funding they require. The CCG will then evaluate what they can and cannot support. JH asked if the processes were clearly monitored. HS clarified that in addition to the monitoring by the CCG, TDA and Wessex Area Team, high level areas that impact the CCG are being monitored through the Clinical Quality Review Meeting (CQRM). HS identified that the IOWNHST have included a blue category to their RAG rating system. Blue indicates that the action has been completed, and an audit has taken place to check the quality of the implementation of the action.

4

FP requested if the date of when the risk first appeared could be included on the GBAF. He also commented that Nursing Home quality looks alarming, and whose risk this was. HS confirmed this was a risk for the CCG, the CQC have the power to stop the provision of services if they deem it necessary. Further discussion regarding this would take place in part 2 of the meeting. JH asked for an updated regarding the Paediatric review. HS confirmed that the review has been completed; this will be reported to the Clinical Executive. The informal outcome of the review is that there needs to be a wider review, with regard to the clinical sustainability to provide children’s services on the Island. MR queried why there wasn’t a timeframe produced, it was confirmed that there was a timeframe produced and a terms of reference developed. It was agreed it would be useful to put a date next to each update on the GBAF. JR suggested that the detail of the CQC matrix be shared with the Governing Body. HS commented that lessons learnt paper from a CCG perspective would be presented to the Quality and Patient Safety Committee. This will also be shared with the Wessex Area Team. It was therefore agreed that the Improvement Plan would be shared with the Governing Body. DN requested that if financial pressures did not improve relating to objective 3 of the GBAF, that an update was given. LO confirmed that an update would be given in the Finance element of the Performance Report.

The Governing Body noted the Governing Body Assurance Framework. ACTION: To include the date of when each risk was entered on to the register, and a date next to

each update on the GBAF. CQC Improvement Plan to be shared with the Governing Body.

CM

HS 14-057 Performance Report

The Governing Body received paper GB14-039 Performance Report, presented by LO. The report highlighted the following: • There were no Never Events reported for August. • Response rates for the Friends and Family test across all three areas – A&E, Inpatients

and Maternity (births) all demonstrated an improvement in the response rates achieved for August, although with mixed scores achieved, both inpatients and maternity improved, but with A&E scores deteriorated. The like reason for the A&E scores is due to the increased pressure on the system. Overall benchmarking shows the IOWNHST is generally doing better than Mainland Trusts. LO highlighted that the CCG were working closely with the IOWNHST on this as it is one of the CCGs Quality Premium Indicators.

• There were no reported breaches associated with Mixed Sex accommodation in month. However, the one occasion that was reported for April will mean the annual target cannot be achieved.

5

• Performance in August continued to remain above the target level for Venous Thromboembolism (VTE) Risk Assessment.

• The CCG received two complaints and no concerns in August. • Achievement of the target for Accident and Emergency performance for breaches of

four hours waits was maintained in August. Performance for September has been less consistent and a narrower margin for achievement is likely to be produced.

• Diagnostics performance reported for August was within target, with the number of patients who had waited for more than six weeks for tests representing just 0.13% of the total waiting list. The good performance has also been achieved for September and October.

• The CCG’s financial position at the end of August was at break-even plan. • The rate for CCG Mandatory training currently stands at 94.21%. • The total number of Pressure Ulcers (grades 2-4) reported for August (22) was broadly

similar to the adjusted number of the previous month (28), however the overall totals are failing to achieve the planned reduction is numbers for 2014/15 both at monthly and annual levels. A range of activity to promote awareness is underway, and Pressure Ulcers form a CQUIN for the Trust in 2014/15.

• There was a single case of MRSA reported for August. The subsequent root cause analysis process identified the patient as a private one.

• A further five cases of C.Difficile were reported for August. The IOWNHST have now reached their annual target of six per year. Work is being undertaken to establish what can be done to avoid further cases.

• The Ambulance Category ‘A’ targets for Red 1 and Red 2 were missed in month, for the first time in two years, due to a gap in filling paramedic vacancies that had arisen. Rates for September are indicated to be back to achieving target.

• Performance by NHS 111 for responses in 60 seconds was missed in August; early indications suggest that this has been rectified for September, this was also due to staffing issues.

DN commented that a pattern is appearing regarding staff shortages in school holidays. • 18 week referral to treatment (RTT) performance failed to achieved target in month for

all three categories; Non-Admitted target missed for a fifth consecutive month and admitted for a second month. The outcome was due to the performance of the IOWNHST and University Hospital Southampton FT. There were no 52 week waiters reported in month.

• Performance for cancer in August resulted in targets being missed for five treatment areas (three within 5% of target).

• There have been no SIRIS attributed to the CCG that have breached the time limits. The IOWNHST has eight grade 1 SIRIS that breached the 45 day period, with no grade 2 SIRIS that breached the 60 day period.

• The total number of Contract Notices being applied across all providers stands at seven.

MR queried if there was a deadline for the outcome measure in relation to Pressure Ulcers. HS confirmed that milestones were included within the CQUIN for Pressure Ulcers, this is monitored through CQRM. The target for the IOWNHST is a stretched

6

target and the Pressure Ulcer information reported on the NHS Choices website shows the IOWNHST as green. IR asked if the CCG were confident regarding the IOWNHST plans for meeting waiting time targets, particularly following a 52 week waiter in Trauma and Orthopaedics. JH confirmed this is a key area that is struggling and the CCG is reviewing the figures with the Trust, and use of outsourcing and greater use of the Independent Sector Treatment Centre (ISTC). Finance • As at the end of August, the CCG’s year to date position is break-even against plan. The

forecast position is to achieve the planned surplus of 1%. • The Isle of Wight Dermatology contract has seen a significant increase in activity. • Prescribing remains underspent and inflation is below the budgeted level of 2.5%. • Running costs are shown a forecast underspend of £187k, this is partly due to

vacancies, but also in preparation to achieve the 2015/16 10% reduction of running costs.

• IOWNHST contract: Unscheduled Care is £335k above plan due to more complex cases; Planned Care is £538k under plan.

• The CCG has received additional funding to commission extra elective activity to ensure that waiting times (18 weeks) are achieved.

• An additional allocation of c.£1m to support unscheduled care during peak periods have been agreed and a further £1.2m is anticipated.

• The CCG will be using slippage to support the IOWNHST CQC Action Plan.

The Governing Body noted the Performance Report. 14-058 Risk Register

The Governing Body received paper GB14-040 Risk Register. The Risk Register was taken as read, there were no further comments made.

The Governing Body noted the Risk Register. 14-059 IOW NHS Trust and CCG Emergency Preparedness, Resilience and Response Plan (EPRR)

The Governing Body received paper GB13-041 IOW NHS Trust and CCG Emergency Preparedness, Resilience and Response Plan (EPRR), presented by HS. The CCG is required to complete a self-assessment template and to review the same template completed by the IWNHST to understand and improve the system’s ability to respond to emergencies and incidents according to the core standards set down by NHS England. The Wessex Area Team have reviewed and tested both the CCGs response and the process for assuring the IOWNHST’s return and have agreed that the CCG and IOW NHS Trust are partially compliant with the standards, and will be fully compliant by March 2015.

7

The Governing Body noted the IOW NHS Trust and CCG Emergency Preparedness,

Resilience and Response Plan (EPRR), and approved the CCG Work Plan.

14-060 Cost Improvement Plan (CIP) Process The Governing Body received a verbal Cost Improvement Plan process update from LO. Gillian Baker (GB), the CCG’s Deputy Chief Officer and LO have met with Senior Staff from the IOWNHST re the CIP process. The CCG are required to sign off the Quality Impact Assessment (QIA) element of the process. A list of CIPs and their QIAs was received from the Trust on the 5 November. The CCG’s Heads of Commissioning along with GB and LO will go through and report back to the Governing Body. The scale of the savings is £9m, which is at the top of what the TDA and Monitor recommend. LO reported that there are 85 schemes, there are 34 signed QIAs and 13 schemes are under development. IR highlighted that there was no assurance regarding CIPs, and he would have expected to see the process including examples of what the paperwork looked like.

The Governing Body noted the Cost Improvement Plan Process. ACTION: LO to bring back the CIP Process to the Governing Body. LO 14-061 £5 a head ‘over 75 innovation scheme’

The Governing Body received paper GB14-042, £5 a head ‘over 75 innovation scheme’, presented by CM. JR and JH declared an interest in this item, FP took over as Chair. JR and JH stayed in the room. The paper was taken as read. IR queried whether the full £700k had to be made available. CM confirmed that the total amount required to be made available was £700k however the money available to be bid for was £300k as two schemes were mandated. The money will be released in two tranches; the first tranche is for set up of the schemes; further money will not be released until the schemes are progressing. MR asked if any schemes had been rejected. CM clarified that there were no schemes rejected as the CCG’s Primary Care Team rigorously worked through the schemes with practices to ensure all issues were ironed out before the approval process. CM identified that the outcome measures are still being put together. JH commented that 16 out of 17 practices signed up to the scheme. This is a good response rate, as this is additional work that practices are not obliged to undertake. FP asked if all conflicts of interest were identified and recorded. CM confirmed that they were. He also commented that it would be good to consult with patients over 75.

8

The Governing Body noted the £5 a head ‘over 75 innovation scheme’ 14-062 Wessex Assurance Meeting and Action Plan

The Governing Body received paper GB14-043, Wessex Assurance Meeting and Action Plan, presented by HS. The paper was taken as read. IR commented that some of the actions set out by NHS England were ambiguous. He gave the example of Domain 3 referring to the comment that ‘the level of challenge around quality issues seemed light touch.’ HS confirmed that the Area Team expressed concern about having a vacant Director of Quality and Clinical Services post. The CCG responded that the roles of the vacant post had been shared out amongst the CCG’s Senior Team. The CCG and IOWNHST have been on a journey since the split of the Primary Care Trust, the CCG Executive team do challenge the Trust, and feel they now have provider Executive level engagement in relation to Quality, particularly at CQRM.

The Governing Body noted the Wessex Assurance Meeting and Action Plan Items for Decision 14-063 Anticoagulation

The Governing Body received papers GB14-044, Anticoagulation, presented by CM. JR and JH declared an interest in this item, FP took over as Chair. JR and JH remained in the room, but did not contribute to the decision making. The paper was taken as read. FP commented that he would have hoped this would have moved on more quickly. CM confirmed that when the procurement work commenced it was identified that there had been new developments that needed to be considered, and a full anticoagulation service. FP requested that when a further paper is presented to the Governing Body that the procurement is clear. DN queried what the scale of the conflict of interest was, it was confirmed that it related to the financial element as well as competition.

The Governing Body approved the re- contracting of the current anticoagulation service for 12 months.

14-064 Domestic Abuse Pledge

The Governing Body received paper GB14-045, Domestic Abuse Pledge, presented by DN. The paper was taken as read, it was highlighted that the paper was recommended for approval by the Quality and Patient Safety Committee. By signing the Domestic Abuse pledge it was confirmed that the CCG will show their commitment to treating people within the organisation with respect and dignity. It was also confirmed that there would be any additional bureaucracy to the CCG by signing the pledge. JH asked if this would be rolled out to GP Practices. It was suggested that Practices could be informed about the pledge and decide whether it is something they would wish to sign. This was agreed to be picked up at the Quality and Patient Safety Committee.

9

The Governing Body approved the Domestic Abuse Pledge. ACTION: Roll out of the Domestic Abuse pledge to Practices to be picked up at the Quality and

Patient Safety Committee. RB/ DN

14-065 Overarching Safeguarding Strategy The Governing Body received paper GB14-046, Overarching Safeguarding Strategy presented by DN. The paper was taken as read, it was highlighted that the paper was recommended for approval by the Quality and Patient Safety Committee (QPSC). DN commented that the strategy had been revised since the QPSC. MR commented in relation to page 4; section 3.4 how would we know if children and vulnerable adults have their voices heard. DN suggested that this was a vision, and the key element of the document was the work plan. IR questioned if the CCG were doing their bit as leaders in the system, as he wasn’t sure the paper reflected this. HS commented that the CCG’s Designated Doctor and Nurse’s roles were to ensure the CCG were compliant with Safeguarding issues as well as have strategic influence.

The Governing Body approved the Overarching Safeguarding Strategy. 14-066 NHS Litigation Authority Insurance

The Governing Body received paper GB14-047, NHS Litigation Authority Insurance, presented by FP. The paper was taken as read. FP congratulated CM on the comprehensive paper that articulates the legislative framework under which liability could arise and the mitigations in place to support Governing Body members in their work. FP commented that this should now go to be approved by the Membership committee for a clause to be included in the Constitution and before indemnities are published in the Annual Report, to check insurers are happy for this information to be published. It was agreed that the paper could be shared with other CCGs.

The Governing Body approved the NHS Litigation Authority Insurance recommendations. ACTION: NHSLA clause in constitution to be adopted by Membership Council.

Before indemnities are published in the Annual Report, to check insurers are happy for this information to be published.

CM CM

Items to Note/Receive

10

14-067 CCG Election/Constitution Changes The Governing Body received paper GB14-048 CCG Election/Constitution Changes, presented by CM. The paper was taken as read; DN commented that the approach to the elections was a pragmatic and compliant approach.

The Governing Body noted the CCG Election / Constitution Changes.

14-068 The Governing Body noted the following sub-committee minutes: • Quality and Patient Safety Committee Minutes 24.7.14 – IR offered that he would be

happy to look at reported Never Events and check them against Department of Health guidance, if it was felt to be useful.

• Clinical Executive Minutes 18.9.14 & 16.10.14 – it was queried if all BPAS services were off Island. It was confirmed that the service was provided in Bournemouth.

• Audit Committee & Schedule of Business 25.9.14 – FP commented that the new Internal Auditors were TIAA, first impressions were positive. FP informed the Governing Body that the Audit committee had undertaken a self-assessment. He also offered if the Audit plan was felt to need adjusting, to inform him.

14-069 Urgent Business

Director of Quality and Clinical Services – discussion took place if the vacant post should be added to the Risk Registers. It was agreed to be added. HS updated the Governing Body that an Interim post had been advertised. It was hoped that this Interim post would be in place as soon as possible.

ACTION: Vacant Director of Quality and Clinical Services to be added to the Risk Register. HS/

CM 14-070 Motion to exclude the Press and Public

JR read the following statement: “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’, (Section 1 (2), Public Bodies (Admission to Meetings)”

14-071 Date of Next Meeting: Thursday 5 February 2015 – Date and Time TBC

Signed……………………………………………. Date…………………………………….

11

Circulation: Members In attendance:

For Information (Agenda):

Dr John Rivers – CCG Clinical Executive (Chair) Fredrick Psyk – Lay Member (Deputy Chair) Dr Joanna Hesse – CCG Clinical Executive Helen Shields – Chief Officer Loretta Outhwaite – Chief Finance Officer David Newton – Lay Member Dr Ian Reckless – Secondary Care Doctor Dr Mark Rawlinson – Governing Body Nurse

R Berryman (Minutes)

Gillian Baker Clinical Director For Information (Minutes): Karen Morgan, Head of Quality Linda Rann, Sue Lightfoot, Rachael Hayes, Dawn Berryman - Heads of Commissioning, Eleanor Roddick – Head of Performance Andy Brandham, Deputy Head of Medicine’s Management, Caroline Morris – Head of Corporate Business Rebecca Wastall – Deputy Chief Finance Officer

Invited: Gillian Baker

12

Governing Body

Matters arising: Schedule of Actions – Part 1


Summary of issue: Actions identified from previous meeting together with updates on progress to date and expected completion dates

Action required/ recommendation:

To gain assurance that the actions requested by the Governing Body are in train

Principle risks: There are no risks associated with this paper.


This paper has not been considered at any other committee.

Financial /resource implications:

There are no financial or resource implications in relation to this paper.

Legal implications/ impact:

There are no legal implications or impact relating to this paper.

Public involvement /action taken: There has been no public involvement in this paper.


Author of paper: Rebecca Berryman, Governance Support Officer

Date of Paper: 7 November 2014



1

Isle of Wight Clinical Commissioning Group: Governing Body SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES 6 November 2014 – part 1

Date of Meeting

Minute No

Action Lead Update Due Date Status

04.09.14 14-037 QPSC to discuss the CIP position once information available.

RB Next QPSC meeting 27 February 2015. November 2014 Open

06.11.14 14-056 To include the date of when each risk was entered on to the register, and a date next to each update on the GBAF.

CM Actioned. February 2015 Closed

06.11.14 14-056 CQC Improvement Plan to be shared with the Governing Body.

HS Actioned. February 2015 Closed

06.11.14 14-060 LO to bring back the CIP Process to the Governing Body.

LO On February 2015 agenda. February 2015 Closed

06.11.14 14-064 Roll out of the Domestic Abuse pledge to Practices to be picked up at the Quality and Patient Safety Committee.

RB/DN

Discussed at QPSC November 2014. Tracy Keats to look into discussing with Practices.

February 2015 Closed

06.11.14 14-066 NHSLA clause in constitution to be adopted by Membership Council.

CM Actioned. February 2015 Closed

06.11.14 14-066 Before indemnities are published in the Annual Report, to check insurers are happy for this information to be published.

CM Awaiting response from insurers. February 2015 Open

06.11.14 14-069 Vacant Director of Quality and Clinical Services to be added to the Risk Register.

HS/ CM

Interim appointed until June 2015. Interviews for permanent post in February. No longer on the Risk Register.

February 2015 Closed

2

Governing Body Governing Body Assurance Framework


Summary issues:

The CCG continues to run number of high risks and progress towards some objectives is less advanced that one might hope at this stage of the year. Objective One is on track for delivery with some good progress towards strengthening governance arrangements (CSF 1.10), recruitment of new clinical executive members and chair succession (CSF 1.20). Of particular note this time is the reduction in risks associated with partnership working(CSF 1.30) as the JACB starts work and the requirements over planning have become clearer. It remains unlikely that the delivery plan will be fully delivered by the end of the financial year as local project work has fallen to the demands of more operational management, particularly responding to requests for information and the production of trajectories in the last few months (CSF 1.60) Achievement of NHS constitutional pledges, particularly related to 18 week Referral to Treatment Time and 4 hour waits in A&E remain in doubt (CSF 1.80) The System Resilience Board is monitoring and working on an action plan to improve performance, however it should be noted that RTT is unlikely to be achieved locally until March ’15. The interim Director of Quality and Clinical Services commenced with the CCG in January (CSF 2.20) and will develop strategic oversight of the quality agenda which should strength assurance of achievement against the critical success factors in Objective Two. Of note this time is that the IW NHS Trust may miss three of the CQUIN targets (CSF 2.40), particularly associated with reduction of pressure ulcers, safeguarding and friends and family test. QPSC is sighted on this issue. The development Primary Care Strategy remains of concern (CSF 2.60) It is unlikely that a fully formed strategy will now be possible by the end of the year however, the CCG will be in a position to consult with the public about the future shape of primary care. The CCG will be submitted a bid as part of the 5 year forward Vanguard which will support strategic development. At the same time the GP collaborative, now called “One Wight Health” has been established and is working on a number of projects on behalf of practices. Concerns regarding the cost base of IW NHS Trust remain high with a work plan underway but little progress to report in the last two months (CSF 3.30) Locality working has made some steps forward with a concomitant small reduction in risk in this area. GP leads are now in place and two of the three lead nurses have also been appointed.

The Governing Body will want to note that the 360 survey of the CCG will be undertaken towards year end (CSF 4.30). This will coincide with potentially difficult year end conversations with providers which could affect the scores received.

Action required / recommendation:

The Governing Body is asked to note the report and discuss any areas of concern with a view to being assured that the organisation is making progress towards its stated objectives.

Principle risk(s) relating to this paper:

The key risk is that the action plans identified within this paper are not sufficient to mitigate the anticipated risks, or that despite the action plans the level of risk does not decrease due to other factors.


The critical success factors and objectives for this financial year were discussed and agreed at the June Governing Body Meeting. This is the third update since then on progress. Contributions and updates have been provided by all members of the Executive Team and through the Clinical Executive scrutiny of the monthly performance reports. In relation to Objective 3, the QPSC has oversight over the issues raised within this document.

Financial / resource implications:

There are no new financial implications for the CCG in this iteration of the Governing Body Assurance Framework

Legal implications / impact:

Failure to identify and manage risk effectively through the Governing Body Assurance Framework could result in legal challenge should the organisation fail to deliver against its statutory obligations. (Objectives 2 and 3)


All areas of CCG work incorporate public and patient involvement as appropriate, and this is detailed in individual papers and business cases. It should be noted however that there has been slow progress against refresh of patient and stakeholder engagement programme (CSF 4.20) which would provide greater assurance to the Governing Body that the right systems were in place. The CCG will be creating a new post to focus on stakeholder engagement and communications to unblock progress in this area. Initially this will be for six months while the impact on running costs is established.


The duty to deliver reduced inequality and take account of diversity is implicit in a number of objectives particularly those associated with the delivery of the CCG strategy and operational plans and in the delivery of the quality agenda. (Objectives 1 and 2)

Author: Caroline Morris, Head of Primary Care and Corporate Business

Date of Paper: 27 January 2015



Governing Body Meeting 1 January 2015

GOVERNING BODY ASSURANCE FRAMEWORK 2014/15

Key Controls Sources of Assurance Gaps in control/Assurance

(What controls do we have in place to assist in securing the delivery of this objective?)

(Where can the Governing Body gain evidence that our controls/systems on which we place reliance are effective?)

(Where we are failing to put controls/systems in place)

4*2

4*2

4*2

4*3

4*2

3*4

3*4

3*4

3*3

3*3

GB/Audit

Nov

Ass

uran

ce L

evel

CE

Critical Success Factor 1: To achieve “assured status” across the domains measured in the NHS England Assurance process (NOTE: some areas are picked up in other objectives - this is noted in the relevant objective or CSF)

1.10

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel

Action plan to address gapsOwner

Review/Completion date

Objective 1: To finalise and implement our clinical commissioning strategy, making the expected improvement to patient outcomes

Principle Risks

(What could prevent this objective being achieved?)

1.20

Risk that the CCG fails domain 6 (strong and robust leadership) and that the capacity and capability of the organisation to deliver its core task is compromised as the systems are transformed

- April '14 OD Plan -Strong programme Management -Clear project support requirements and budgets in place - Jan '15 Election process in place with the LMC and agreed with membership through membership council and e-mail agreement from practices - Restructuring agreed and discussed at the staff forum and with affected staff.

- June '14 Clinical Executive Seminar minutes detailing conversations about succession planning - Sept '14 Clinical Executive Seminar discussions regarding restructuring due to retirement of senior members of staff - Oct '14 Approach to elections and chair succession agreed at Clinical Executive for recommendation to membership

-April '14 Succession planning for both managerial and clinical roles - CCG Chair succession - Unknown impact and timings on journey to joint/aligned commissioning with potential changes to staffing structures - Overarching approach to workforce development required - Elections to Clinical Executive to be planned (CM)

- Approval of OD Plan and creation of an Implementation Plan required. This should include approach to succession planning - (CM) - Interim restructuring proposal to be produced (GB) - Interim commissioning restructuring proposal out for consultation (GB) - Membership invited to comment on and agree approach to elections (CM)Jan '14 One post appointed. 1 more key post to be appointed to (GB).

HS

-April '14 Internal Audit function and 3 year audit plan - Audit Committee - Constitution - Standing Orders and Standing Financial Instructions - Aug '14 Discussion at Clinical Executive regarding implications of delegating responsibility to Joint Adult Commissioning Board and Delegations - Jan '15 Governing body discussions regarding operation of governing body - Terms of reference for Joint Committee for Primary Care and constitution amendments - JD for additional lay member on Audit Committee

Risk that the CCG fails domain 4 (robust Governance arrangements)

Apr '14 - Governance function with CCG and level of skill demonstrated. - Audit Committee minutes and papers - Internal audit reports and subsequent action plans - Nov '14 Draft Terms of reference for the Joint Adult Commissioning Board - Jan 15 Constitution amendment and agreement process overseen by NHS England

June 14: - Internal audit programme has not yet been agreed for 14/15 - Review of SFIs planned but not yet completed - Constitution due for review to update for new suggestions and review of terms of reference of all committees. - Audit Plan is awaiting Audit Committee agreement. - Joint Adult Commissioning Board Terms of Reference to be finalised. - Nov '14 Concern expressed by NHS England regarding transparency of decision making

- New internal audit plan required (LO) in progress, to be approved at Audit Committee Sept '14 - Detailed SFIs to be produced (LO) in progress, to be approved - Constitution review to be completed (CM) - Terms of Reference for Joint Adult Commissioning Board to be finalised for 2014/15 and agreed by Governing Body (HS) - Governance Structures to be reviewed (CM)

CM






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


4*4

4*4

4*4

4*4

2*2

5*4

4*4

4*4

4*3

4*3

4*3

4*3

4*3

4*3

3*3

1.50

Critical Success Factor 2: A Joint Adults Commissioning Board (JACB) supporting the Better Care Fund is established and working

1.30

1.40

-JACB not yet established - Section 75 for Better Care Fund not yet developed - Project Plans for all schemes not yet in place

- TOR for JACB to be agreed and Board Established (HS) - Meetings set up to develop BCF section 75 (GB) - Project Plans for the following schemes to be produced: MH reablement Locality Working Rehabilitation/reablement self help and self management carers; Care Act; Hospital discharge. - BCF to be agreed by Health and Wellbeing Board for submission in September 2014 - Dashboard for BCF performance to be producedHighlight reports for all schemes produced monthly. Available from February '15 (GB).

-minutes of JACB meetings - Minutes of Health and Social Care Integration Group - MLFL programme plans progress reports - Minutes of Health and Wellbeing Board - Jan '14 Project plans for schemes as detailed in action plan column

Risk that Joint Adult Commissioning Board doesn't function effectively and deliver transformational change

- Clinical Executive - Health and Social Care Integration group - MY Life a Full Life (MLFL) Programme Board - Jan 15 - JACB interim TOR agreed

- Nov '14 Minutes of JACB - Jun '14 Minutes of Health and Social Care Integration Group - Apr '14 Monitoring of work plans through joint commissioning Board and MLFL programme Board

CEGB

-TOR for JACB to be agreed and Board Established (HS) - Clear PIDs for all schemes agreed across partnerships (GB)- Leads for all priority areas agreed. Jan '15 - Interim JACB TOR to be reviewed in April 2015 to see if CCG constitution needs to be amended by June 2015. (GB)

-Apr '14 Joint Adult Commissioning Board not yet established - Jun '14 Agreement across all partners required in relation to timescales for transformational change in different service areas Sept '14 - JACB is still being established Nov '14 - JACB TOR still to be finalised although membership has been confirmed by both organisations

Risk that CCG fails aspects of Domain 5 (working in partnership) with respect to provider planning footprints across Hampshire

- June '14 SHIP 8 networking meetings - Sept '14 Health and Social Care Integration Group (formerly System Reform Board)

- Jun '14 Minutes of SHIP 8 meetings - Sept '14 TOR of Health and Social Care Integration Board - Jan '14 Minutes of SHIP 8 meeting where decision not to pursue footprint in current form was taken. Discussions taking place as part of lead contracting

CE

- Jun '14 Programme to review planning footprint not yet developed

Risk that better care fund does not deliver integrated services within required timescales

- JACB - Health and Social Care Integration group (formerly System Reform Board) - My Life a Full Life programme Board - Health and Wellbeing Board

GB CE

- Nov '14 Work programme to be developed across SHIP 8 to develop revised provider footprint and pathways due end of November (LO)

HS






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


4*3

4*3

4*4

4*4

3*4

4*3

4*3

4*3

4*3

4*3

- Development of proxy measures to support assurance of annually reported measures (ER) - Engagement programme with patients in primary care regarding system changes (CM) - in progress - Nov 14: Schemes in place to reduce emergency admissions including Crisis Reponse; acute GP service and assistive technology (GB)

1.70

Apr '14- Integrated performance reporting to Clinical Executive and summaries to Governing Body - Apr '14 Minutes of meetings reported to Clinical Executive - Nov '14 Quality Performance Report to QPSC - Jan '15 Minutes of the System Resilience Board

GB CE

GB

- Apr '14 Delivery plan in place articulating agreed goals with commissioners - SLA meetings with providers and performance management regime - Primary Care locality reviews and performance reports - Internal Performance meetings - Team work plans together with resources - OD plan looking at capacity and capability

The six ambitions are not achieved by year end - 1) PYLL, 2) EQ5D score; 3) reducing emergency admissions; 5) positive experience of healthcare; 6)positive experience of GP and community care (NB: ambition 4 does not have a trajectory associated with it)

- Some areas are reported annually in arrears and therefore difficult to track in year. - In year changes to services (particularly primary care) could adversely impact patient satisfaction - Greater assurance regarding provider approach to securing improved patient experience required (see friends and family in objective below)

The QIPP delivery schedule is not achieved across the eight plans - 1) Long Term Conditions, 2) Frail older people; 3) mental health; 4) primary care; 5) unscheduled care; 6) planned care, 7) medicines management 8)children.

Critical Success Factor 3: The Delivery Plan has been delivered as agreed in 2014/15

1.60 CE

- SLA meetings with providers and performance management regime - Primary Care locality reviews and performance reports - Internal Performance meetings - Team work plans together with resources - OD plan looking at capacity and capability

-Review Priorities within Delivery Plan (GB)

-Integrated performance reporting to Clinical Executive and summaries to Governing Body - Minutes of meetings reported to Clinical Executive - Minutes of internal performance reviews and subsequent action plans - Delivery plan quarterly reviews - Jan '15 - Added to risk register to ensure regular progress and review

- Apr '14 No further gaps identified - Sept '14 Slippage has taken place due to extensive additional planning requirements throughout summer 2014 - Jan 15 Plans remain off track due to continued high levels of additional planning and operational reporting required by the NHS hierarchy






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


5*3

5*3

5*3

5*4

5*4

4*3

4*3

4*4

4*4

4*4

CE

Objective 2: To demonstrate measurable improvement in the quality and safety of our commissioned services and the primary care services delivered by our members (also relates to Domain 1 of the CCG assurance framework in objective 1, CSF 1)Critical Success Factor 1: Improvement in quality outlined within the operational plan is realised in 2014/15

2.10 CE / QPSC

- Apr '14 Delivery plan in place articulating agreed goals with commissioners - SLA meetings with providers and performance management regime - Primary Care locality reviews and performance reports - Internal Performance meetings - Team work plans together with resources - OD plan looking at capacity and capability - Acute Commissioning Team in place and fully staffed.

- System Resilience plans are required by NHS England supporting constitution pledges particularly over coming winter period - Consideration to be given into how to exercise more direct control over mainland providers to ensure our patients are not disadvantaged - Detailed monitoring of implementation of plans needs to be agreed - Nov '14 RTT showing not achieved (see performance report)- Jan '14 RTT not likely to be achieved until March and still at risk at being achieved at year end

- System Resilience plans to be put in place (GB) - Performance monitoring of system required (GB) -Performance Notices to be put in place where NHS Constitution not being met - Nov '14 Weekly attendance of senior CCG staff at Trust performance meeting - Jan '14 Activity being moved to mainland providers when patients prepared to go. (GB)

KM

- Apr '14 Integrated performance reporting to Clinical Executive and summaries to Governing Body - Minutes of SLA meetings - Ongoing contract notices in place with providers - Meetings between senior IW commissioners and mainland providers - Minutes of routine contract review meetings with IW NHS Trust - Nov and Jan '15 System Resilience Plan and tracker in place

The CCG fails to meet the quality premium targets: 1) Years of Life Lost(YLL); 2) Avoidable Emergency Admissions; 3) IAPT - referral 4) Friends and Family Test; 4) Healthcare Acquired Infections

- IOW CQRM meetings including CCG quality leads and providers - Links to CQRM with mainland providers via lead commissioners - Unscheduled Care DES with primary Care - Mental Health Strategy and work plan regarding IAPT - System wide programme of work on Healthcare Acquired Infections - System Resilience Group - Nov '14 Quality report at QPSC

-Meetings of minutes of Boards described opposite - CCG delivery plan in relation to mental health and primary care together with quarterly reports on progress - CE and CQRM minutes reviewing progress with Healthcare Acquired Infections - Notes of system resilience group - CQUIN quarterly updates regarding FFT and patient experience - CCG review of IW NHS Trust Action plan regarding implementation of Patient Communication and Experience Strategy at CQRM - Nov '14 Visits to A&E and Maternity to note FFT promotional material and Computer tablets to enable FFT feedback - Nov '14 CE minutes agreeing addition on line IAPT resources

- CCG needs to monitor NHS Trust patient satisfaction strategy implementation - No business case has been developed for growth of IAPT - System resilience group to consider schemes to support avoidable admissions - Nov '14 IAPT trajectory falling short - HCAI numbers higher than trajectory - FFT response rate sustainability at IW NHS Trust

GB1.80

NHS Constitution pledges are not met (At Isle of Wight NHS Trust, University Hospitals Southampton Foundation Trust and Portsmouth Hospital Trust)

- Evidence of implementation of patient experience strategy at NHS Trust required (KM) - Working with IW NHS Trust to produce business case for IAPT (SL) - Planning structure is in development to agree plans (GB) - CCG infection control nurse to be involved in RCA and lessons learnt regarding C Diff cases (EM) - Additional on-line IAPT resources agreed at Clinical Executive - Assurances are being sought from the head of Midwifery that the FFT cards produced by the Trust are being distributed at the 4 points of care






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


4*3

4*3

4*3

4*2

3*2

3*3

3*3

3*3

3*3

3*3

3*3

3*3

3*3

3*3

3*4

3*3

3*3

3*3

3*3

3*3

- Provider contract database to identify monitoring needs (KM)

- Sufficient coverage of mainland providers

HS CE/ QPSC

CE

CE/ QPSC

Critical Success Factor 2: Improvement in quality is seen through the achievement of contractual requirements and CQUINS by all providers

2.50

Off island providers including those lead commissioned by other CCGs fail to meet CQUIN targets

- Lead commissioner arrangements in place with Portsmouth and Southampton CCGs through which the CCG can work

-CQRM minutes for providers - Evidence of CQUIN achievement at mainland hospitals shared with IW CCG Quality Team CE / QPSC

IW Trust as main provider and other smaller providers fail to deliver against CQUINs set in this year's contract

2.20

2.30

2.40

-Ensure monitoring of all providers - Jan '15 CQRM has noted that IW NHS Trust may struggle to achieve three of the cquins

-minutes of CQRM with IW NHS Trust - Minutes of quality and patient safety committee - Ongoing quality monitoring workplan within CCG team - CCG receipt of CQRM paperwork from lead commissioners

Providers do not meet the core quality measures and targets set out in the contracts

- Apr '14 CQRM meeting worth IW NHS Trust - Contract Review Meetings - Quality and Patient Safety Committee

-Apr '14 CQRM with IW NHS Trust minutes - Contract notices - Contract review minutes - Jan '15 quality improvement CQC plans reviewed and monitored

- CQRM and relevant processes in place - Using commissioners to support achievement in providers through work programmes

- Apr '14 Ensure all providers' contracts are reviewed - Jan '15 take account of CQC reports

HS

KM

The CCG fails to meet its statutory functions with respect to safeguarding

- Direct contact with mainland providers (KM) - Hold lead CCG to account (KM)

KM

- CCG vacancies including permanent designated doctor not in post - Gap in CQC readiness - Jan '15 no further gaps identified, CCG covering all statutory duties.

- Review through contract database (KM) - ongoing throughout year

- Apr '14 Children's Improvement Board - Adult Safeguarding Board - Children's Safeguarding Board - CCG Safeguarding Group

- Recruit permanent designated doctor (HS) November update - interim in place. Plans to review in December prior to going out to recruitment - Ensure CQC readiness (HS) - Jan 15 - Permeant post for designated doctor to be agreed in the spring (HS)

- Apr '14 Minutes of Boards/groups - Sept '14 CQC files in place in preparation for inspection - Jan '15 Director of Quality and Clinical Services in post






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


4*4

4*4

4*3

4*3

4*3

3*4

3*4

3*4

3*1

3*1

3*4

3*4

3*4

3*3

3*3

GB

2.70

- Nov'14 Reports from Healthoutcomes - Agreement reached regarding future of services between NHSE and CCG - National Position paper

- Internal review of documentation under way together with requests nationally for clarification - Unclear timescale for changes linked to national tender for PCSS - Jan '15 No further gaps identified

-To be determined following internal review (CM)

CM GB

Outcome of review of Primary Care Support Services (locally known as PPSA) has unknown consequences particularly in relation to the potential for transactional aspects of primary care administration to return to the CCG without additional administrative resources

- Nov '14 Healthoutcomes software in place supporting administrative claiming processes

GP provider market needs to develop and mature to enable different ways of contracting with primary care in a more integrated manner. Risk that primary care (CCG members) do not develop new ways of working sufficiently quickly to match CCG ambitions

2.60

- Apr '14 Outline Strategy published as part of the CCG's wider strategy document. Aligned with operational plan and delivery plan objectives - Application made for greater responsibility in co-commissioning primary care - Contract in place with Healthwatch IW to review current patient expectations in relation to primary care

- Apr '14 Section 256 agreement in place - Reporting arrangements in place

-CCG corporate reporting/decision making structures will need review if more decision making comes to the CCG for primary care - response from NHS England for application for Co-commissioning - Nov '15 implications of the 5 year plan in relation to primary care need to be understood -Jan '15 5 year forward Vanguard project group to be established

Critical Success Factor 3: The primary care strategy has been put in place and implementation begun - Review constitution in light of potential changes to CCG responsibilities (CM) - Review options with Wessex Area Team for co-commissioning (CM) - Nov '15 Proposals for joint commissioning committee to be developed and agreed by March '15 (CM) - Formal application to NHSE for joint commissioning to be made by Dec '14 (CM)

GB2.80

Fast moving external environment makes it difficult to write definitive strategy which can be clearly consulted on with patients - danger that circumstances will overtake CCG

- CCG is supporting GP collaborative working group through the My Life a Full Life Programme. - CCG is supporting practices to plan for the future - Innovation funds under £5/head scheme looking at clinical redesign and workforce development

- Sept '14 MLFL papers regarding release of funding - Nov '14 IW GP Collaborative has established and held first event - Bid for regional funding to support market development made but not successful - Innovation schemes in primary care approved

- MLFL PID for primary care has not yet been drafted and neither has a project plan - Jan '14 Further bid to MLFL for project manager for collaborative to be made (CM)

- PID and project Plan to be drafted by end Nov 14 (CM)

CM

CM






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


5*4

5*4

5*4

5*4

5*4

4*3

4*3

4*2

4*1

4*1

5*4

5*4

5*4

5*3

5*3

5*4

5*4

5*4

5*3

5*3

-Sufficient capacity and expertise in the evaluation of proposals and development of business cases to quantify savings from proposals - ongoing

CE

Failure to identify and agree the Island premium

- Working with IW NHS Trust regarding provider cost base

As above - Jan '15 Agreement to Island premium funding in 14/15 apart of overall financial framework and risk share with Trust

- TOR to include methodology for identifying diseconomies of scale

Implementation of commissioning strategies under the Better Care Fund do not deliver the savings required by the CCG across health and Social Care system

- JACB - Clinical Executive meetings

3.40

Critical Success Factor 2: The CCG and IW Trust has undertaken a review of the provider cost base and agreed the Island Premium

LO CE

As Above

- Discussions to take place with Portsmouth University regarding PHD student to support evaluation of business cases (LO) After discussion agreed that Portsmouth Uni resources would not meet the CCG needs. - Investigating additional resources through the My Life A Full Life Programme Board (LO)

LO CE / GB

- Detailed budgets to be agreed (LO) - drafts for 2014/15 being finalised with executives -Joint working with Local Authority and creation of joint posts (GB) - Monthly running costs forecasts (LO)

LO CE / GB

3.10

3.20

The CCG fails to operate within its running costs allocation and plan to deliver a 10% reduction in future years

- Review of running cost budgets at COG on regular basis

- Budget statements - Central reporting - Performance Reports

- Detailed budgets and apportionments to be determined - Clear strategic way forward for joint commissioning - Clarity on exclusions - Jan '15 - No further gaps identified in the management of this risk

Critical Success Factor 1: The CCG meets all its financial and performance targets as set out in the guidance for 2014/15

Failure to agree the cost base for the IW NHS Trust

3.30

- Jun '14 Joint work plan between IW Trust and CCG put in place to review costing methodology - Nov '14 TOR for review agreed

- Jun '14 Meeting notes between IOW NHS Trust and CCG - Sept '14 TOR for Review

- TOR for review to be agreed - Support still to be agreed - External proposal not agreed by IOWNHST and CCG. - Jan '15 work underway and due to deliver end March '15

- Detailed action plan developed (LO) - Work programme in place and market tested (LO) - Awaiting resource proposal from IW Trust to support piece of work needed (LO) Agreed external proposal (LO)

LO

Objective 3: To meet the financial and performance targets set for us by constructively challenging and supporting our providers, suppliers and members to work with maximum efficiency






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


5*2

5*1

5*1

5*1

5*1

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*3

3*3

CE

- Ensuring ongoing programme of work with NHS England after meeting to keep up pressure

- Develop action plan with NHS England as to how to move forward (LO)

- As above -Island premium not agreed

- PID - My Life a Full Life Programme Board Minutes and reports - Reports to Joint Adult Commissioning Board - Nov '14 Job Description and person specification for lead locality nurses and lead GPs - Agreement between IW council/CCG/Trust on services that will be included in locality model - MLFL Workforce Development Group notes

- Business case for phase 2 locality working is due in September 2014

- Programme plan sets out timelines for completion (GB) - Executive level discussions on interpractice agenda at away days (GB) - recruitment to lead nurse locality posts and for lead GP roles to be completed (SW)- Jan '15 - 1 of the 3 nurse lead posts to be recruited. (SW)- GP locality champions in post, induction to take place. (GK)- Social services to be aligned by 1/4/15. (SW)

GB

LO CE / GB

Failure to deliver the scale of locality working hoped for by the end of the financial year as the project is complicated requiring multiple organisations to move staff and resources as well as change cultures

- My Life a Full Life Locality work plan in place together with project manager and other resources - PID in place -Oversight in place via programme board - Multi-organisational sign up to direction of travel

3.60

Critical Success Factor 3: The CCG has received an acknowledgement from NHS England at the highest level that the allocation needs to be reviewed

LO CE / GB

-Cost base work plan determined with IW NHS Trust (LO) - See 3.50 above

3.50

- Meeting with NHS England Allocations Team set up , agendas developed and invitees are clear on their roles during the meeting.

-Feedback from meeting - ongoing contact with allocations team

Failure of CCG to engage NHS England in debate regarding impact on Isle of Wight

4.10

Failure to achieve recognition from NHS England that there is need for additional funding for IOW due to diseconomies of scale

-As above

Critical Success Factor 1: The Locality model of working is in place by the end of the financial year Objective 4: To work constructively with providers, partners and the public for the wellbeing of our patients and communities






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


3*4

3*4

3*3

3*3

3*3

4*3

4*3

4*3

4*3

4*3

CM

HS GB

Critical Success Factor 3: The CCG scores above average in the 360 survey held annually by the CCGRisk that the high levels of satisfaction amongst partners and members reported in the 360 may diminish over time and as hard decisions need to be made testing relationships across organisations.

4.30

- Senior management roles encompass relationship building - Partnership boards in place to support and regulate joint working - Membership engagement through locality management in place - Staff in place to support partnership working and membership engagement - Joint development opportunities between organisations (e.g. difficult conversations training)

- Health and Wellbeing Integration Group minutes - Joint Commissioning for Adults Board - My Life a Full Life Programme Board minutes - Locality meeting minutes - Annual visits to members

- Structured approach to working with stakeholders outside regular NHS circles - in train - Jan '15 relationship with Trust as we move to year end may become difficult

- Use of stakeholder software to refine approach to senior level relationships (CM) see above

Critical Success Factor 2: Refresh and implement the patient and stakeholder engagement strategy

4.20

Failure to find the time and expertise within running costs to achieve the expected improvement in stakeholder engagement

- Existing Stakeholder Strategy has been updated - Stakeholder engagement database software has been purchased

- VUELIO reports on activity - Jan '15 Agendas and Reports from stakeholder engagement activities throughout the year - Feedback to Healthwatch reports

CE

- Strategy to be fully reviewed to include consideration of an engagement group - Software to be deployed - Additional resource required to support stakeholder engagement

- Refresh Stakeholder Engagement Plan (CM) - in train - Implementation of stakeholder engagement software to support reporting (CM) - Software deployed but implementation not yet complete - following review of running costs additional corporate post within structure under consideration that will support this agenda (CM) - Jan '15 JD for corporate support post to be developed and to be filled on a six month contract initially (CM)






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

4*4

5*5

5*5

5*4

A6

Nursing Home Quality Concerns regarding the quality of nursing care in one of the nursing homes on the Island.

Action Plan in place. Regular meetings being held between Council, CCG and the home.

Nov '14 CCG is supporting home through regular visits and support from Continuing Care Nurses. Regular meetings being held to support the home. Some evidence of good practice but still areas of concern. Action plan in place.

Nov '14 Ongoing review of progress in nursing home

DB CE/ QPSC

CE

A3

A2

Contract notice issued regarding serious concerns in relation to the leadership in Mental Health services at the IW Trust

- Contract notice and contract monitoring in place - Review Group in place - Financial framework agreement in place

- Monthly reports on progress at Trust contract meetings - Monthly reports from IW NHS Trust

-Clear action plan required from NHS Trust - MOU to be established with Hertfordshire NHS Trust - Senior Manager post in NHS Trust to be recruited - Nov '14 Meeting with partner trust unlikely to take place until January '15

-Contract notice will not be lifted until actions plans are being implemented (SL)

SL CE

A5

Contract notice issued to IW NHS Trust regarding concerns in emergency paediatric services

-TOR for clinical review agreed - Contract notice acknowledgement received - Report received by Commissioners - Jan '15 - Action plan received from IW NHS Trust

- Timescale for review not agreed - CCG is seeking independent analysis of urgent care pathways - Review team have commenced

-Action plan to follow from IW Trust. (RH) - Review final reports for actions required (RH) - Jan '15 CCG to contact Wessex Clinical Network for support (RH) - Strategic group to be set up chaired by IW NHS Trust non-executive

RH

Contract notice issued regarding Emergency Paediatric Services

Contract notice issued by lead commissioners regarding 18 Week RTT at All hospitals

Other Serious Corporate Risks

See 1.8 above for description of actions being taken

IW in regular communication with Portsmouth and Southampton CCGs and Isle of Wight Trust - Nov '14 Senior Staff attending weekly operational performance meeting at IWNHST - Jan '15 - Contract variations in place - Fines have been actioned

- Not fully engaged with Southampton CCG and Southampton Hospitals -Nov '14 Contract variations to be put in place for additional funding received to support RTT achievement - Jan '15 Encouraging GPs to refer to mainland. - System Resilience Group has requested capacity plan from IW NHS Trust

- Establish direct contact with Southampton Hospitals (LR) - Hold lead commissioners to account (LR) - ongoing

LR CE






Nov

Ass

uran

ce L

evel

Jan

Assu

ranc

e le

vel

Year

End

Ass

uran

ce

Mar

Ass

uran

ce le

vel

Initi

al R

S (S

ever

ity*L

ikel

ihoo

d)

Jun

Assu

ranc

e le

vel

Repo

rtin

g Co

mm

ittee

Sept

Ass

uran

ce le

vel



Principle Risks


5*5

5*5

5*4

5*5

5*4

Key

HS - Helen Shields, Chief OfficerGB - Gillian Baker, Deputy Chief OfficerLO - Loretta Outhwaite, Chief Finance OfficerCM - Head of Corporate Business and Primary Care ER - Eleanor Roddick, Head of Performance Management and ContractingKM - Karen Morgan, Head of QualityLR - Linda Rann, Head of Acute CommissioningSL - Sue Lightfoot - Head of Mental Health CommissioningRH - Rachel Hayes - Head of Community Commissioning

A7

CQC finding at IW NHS Trust CQC Report identifies a number of significant actions required to secure high quality services at IW NHS Trust

CQRM minutes and reports - Jan '15 Warning Notice lifted

10/14 - CCG review CQC action plan. CQRM taking overview of progress - Jan '15 High level plan has been seen by CCG and additional funding agreed in principle.

Nov '14 Further actions to be determined following discussions with NHSE and Trust.

KM CE/ QPSC

Jan '15 Undertake lessons learnt and prepare for Easter (LR)

LR CEA7

System Resilience Concern regarding the achievement of waiting times for urgent care over the winter period for all providers

System Resilience Group Jan '15 - CCG working with providers regarding individual patient issues and well as system wide review

Governing Body: Performance Report February 2015

Sponsor: Loretta Outhwaite, Chief Finance Officer

Summary of issues:

1. The Governing Body is presented with a CCG Performance Report in a format that seeks to provide assurance on key performance indicators associated with Quality; NHS Constitution; CCG Outcomes Framework and Financial performance to note and comment upon.


The Governing Body is invited to:

Note and comment on the content of the Performance Report.

Principle risks:

Key Risks for the Performance Report include: Complexity and wide range of metrics and indicators with differing measurement for different purposes (eg COF, Quality Premium, CCG Assurance process) – systems in development and embedding – risk of missing vital information on all indicators continuously. Availability of data due to Health & Social Care Act compliance with Patient Identifiable Data for CCGs. New systems not yet agreed at NHS England level.


Information contained in the report has been considered at: Clinical Executive Quality & Patient Safety Committee Contract Review Meetings Internal Performance Review Meetings


Over-performance on contract activity could result in financial pressure where contracts are PBR based.

Legal implications/ impact: There are no significant legal issues within the Report.


Report is publicly available and provides patients and public with information on the CCG’s financial position and use of resources.


Requirement of providers and CCG to ensure all patients are treated in line with rights set out the in the NHS Constitution.

Author of Paper: Eleanor Roddick, Head of Performance and Contracting


Date of Meeting: 5 February 2015 Agenda Item: 5.2 Paper number: GB14-056

Isle of Wight Clinical Commissioning Group

Governing Body

Summary Performance Report

February 2015

(M.I. – November 2014)

Purpose of report

• This is the Isle of Wight Clinical Commissioning Group (CCG) Governing Body Performance Report for February 2015.

• The report remains in development and provides the Governing Body with the structure of future reports, and includes information for Month 8 – November 2014, where available.

• This Performance Report describes the performance for the nationally reportable performance measures which are the responsibility of CCGs as set out in the NHS England documents of “Everyone Counts: planning for patients 2014/15”; the “CCG Quality Premium Guidance” and the “CCG Assurance Framework 2014/15” covering both quality and access measures.

Content

• Part 1 - Summary Comments - Key Highlights and Lowlights, and Balanced Scorecard

• Part 2 - Performance Outcomes o Outcomes for the Quality KPIs and NHS Constitution with further detail on

performance exceptions only. o Financial report M8 Finance Position

Page 1 Governing Body, Performance Report (February 2015)

Part 1 - Summary Comments

Highlights • There were no Never Events reported between September and November.

• Between September and November, the CCG received a total of four Concerns and no (zero) Complaints.

• A general improvement was seen in the Friends and Family Test response rates achieved across the months of September to November 2014, most particularly with the results associated with A&E although a slight decline was seen in the rates achieved for Inpatients and Maternity (Births) for November. Over this period, the rates have been broadly similar to those reported for University Hospital Southampton Foundation Trust, Portsmouth Hospitals Trust and Salisbury Foundation Trust. A revised methodology was introduced from September, replacing the previous Net Promoter Score with percentage rates for those respondents recommending/not recommending the service, with rates achieved by IWNHST having been in line with the three mainland Trusts for which comparison is reported.

• There were no reported breaches associated with Mixed Sex Accommodation in November. However, to date there have been a total of five breaches, one in April and four in October. Subsequently, the Annual target cannot now be achieved.

• Performance has continued to remain above the target level for Venous Thromboembolism (VTE) Risk Assessment.

• Performance by the Island’s NHS111 service for ‘calls answered within 60 seconds’, has consistently met the required target of ≥95%, for the three months September – November. The provisional results for December suggest that the rate for ‘calls answered within 60 seconds’ was met in month. Over the Christmas week the numbers of calls offered were up by approximately 50% on previous weeks – rate achieved for calls answered within 60 seconds w/e 28.12.14 - 96.65% and w/e 04.01.15 - 97.74%.

• Performance for the Ambulance Category ‘A’ targets for Red 1 and Red 2, returned to achieving target in September and have continued to be met for both October and November, with provisional results for December suggesting that targets have continued to be met for both categories.

• Diagnostics performance has remained consistently within the >99% target.

• The financial position at the end of November was £4k better than plan.


Part 1 - Summary Comments

Lowlights • Based only on SIRIs reported in this current year, (from 1 April 2014), there was one Grade One SIRIs at 31 December and

attributed to the CCG that had breached the time limit. The IWNHS Trust had 15 Grade 1 SIRIS that breached the 45 day period, with no (zero) Grade 2 SIRIs that breached the 60 day period. Overall, for both CCG and Trust a total of one Grade 2 SIRIS reported prior to 1 April 2014, remains open. The CCG has formally written to the Trust requesting assurances in respect of their SIRI process.

• Total numbers of Pressure Ulcers (Grades 2-4) have continued to increase over the months of September – November. Overall totals continue to miss the planned reductions in numbers for 2014/15 both at monthly and annual levels. A range of activity to promote awareness is planned for the year and Pressure Ulcers form a CQUIN for the Trust in 2014/15.

• A case of MRSA was assigned to IWNHST in November following completion of the PIR process. Subsequently, the CCG will miss the national target of zero cases for 2014/15. NB: The case originally reported for August was subsequently re-assigned.

• The numbers of cases of CDifficile had reached a total of 24 as at the end of November, exceeding the Annual target of 20. Of these six were associated with IWNHST Acute Trust, one with Portsmouth Hospital Trust and the remainder occurred within the broader CCG Community.

• A decline in the rate for achievement of the target for Accident and Emergency performance for breaches of 4 hour waits was recorded for the months of October and November. Increased levels of attendance in the Emergency Department and pressures on bed availability due to discharge delays continue to contribute to this outcome and the target was missed again in December.

• Performance for the 18 week RTT target has been consistently missed for the past five months while the rate for Non-Admitted was achieved in November for the first time in 2014/15, while the rate for Incompletes was met in both October and November. Contributing to these results have been the rates attributed to the performance given by both the Isle of Wight NHS Trust and University Hospital Southampton NHSFT.

• IWNHST experienced a 52 week waiter in September/October. Further occurrences are anticipated for December and January.

• Year to date, the performance rates achieved for Cancer treatments have failed to meet target in two areas (although within 5%): ‘Seen within 2 weeks of referral - Breast Symptoms’ and ‘Treated in <62 days - urgent referral to treatment’. This is broadly consistent with the performance outcomes reported for October and November. Contributing to these has been the performance achieved across Isle of Wight NHS Trust; University Hospital Southampton NHSFT and Portsmouth Hospitals Trust.

• The total number of Contract Notices being applied across all providers stands at eight.


Part 1 – Balanced Scorecard (Performance on a Page – POAP) Key Metrics to provide a high level early indicator of overall CCG performance against quality, key performance standards, financial efficiency, organisational efficiency. <<A3 copy provided for insertion.>>


Part 2 – Performance Summary – Quality Dashboard This Section provides exception reports and key highlights for quality outcomes. The dashboard provides a summary of outcomes by month, Year to Date and Trend (Dec 2013 – Nov 2014).


Part 2 – Performance Summary – Quality & Patient Experience

• Pressure Ulcers: Local target: Reduce total numbers (Hospital / Community) against IWNHST 2014/15 target reductions.

Local Target Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 YTD Actual

Annual Target

Reduction in Pressure Ulcers - Hospital Grade 2 Pressure Ulcer

50% 2013/14 Total (98) (4 monthly) 6 2 4 5 5 12 4 9 47 48

Grade 3 Pressure Ulcer

50% 13/14 Total (2) (0.1 monthly) 1 1 0 1 1 1 1 0 6 1

Grade 4 Pressure Ulcer 0 1 0 0 3 0 1 0 1 6 0

Reduction in Pressure Ulcers - Community Grade 2 Pressure Ulcer

50% 2013/14 Total (108) (4.5 monthly) 9 17 9 11 13 7 12 8 86 54


50% 2013/14 Total (13) (0.5 monthly) 1 1 1 3 1 0 4 2 13 6


50% 2013/14 Total(23) (1 monthly) 4 3 1 4 2 2 1 6 23 12

Overall there was a marginal increase in the numbers of Pressure Ulcers (Grades 2-4) reported in November. Total numbers in a Non-Acute (Community) setting remained fairly similar to the total for October, although there was a significant increase between months in the number of Grade 4 PUs. An increase in Grade 2 PUs in a Hospital setting contributed to a rise in the overall numbers in month for this area.

The Tissue Viability Nurse Specialist continues to support ward staff with recognition and management of patients at risk of developing pressure ulcers.

NB: It should be noted that cases of Grades 3 and 4 are subject to investigation and may subsequently be re-graded.

Actions: As a part of the Trust’s Local Communication CQUIN, a Pressure Ulcer campaign is now underway. Through Pressure Ulcer Groups there is an intention to gain patient engagement/awareness particularly in the Community setting. Pressure Ulcers are also include within the National Safety Thermometer CQUIN for the Trust, which will be monitored over the course of the year by the CCG Quality Team. The Trust have reported that incidence reporting for moisture lesions is in development and training is starting to be rolled out for this important development in the identification and reporting of preventable skin damage which can arise in the absence of pressure.


Part 2 – Performance Summary – Quality & Patient Experience continued…

HCAI: MRSA – CCG: National Target Zero tolerance A single case of MRSA was assigned to IWNHST in November, following completion of the PIR process. This was indicated to have been a case of MRSA bloodstream infection. NB: Following completion of the PIR process, the case previously reported for August was subsequently withdrawn and applied to a Third Party.

Wessex Area (Cumulative totals as at November 2014)

CCG YTD (2014/15)

Variance to

projected total. at Nov 14

West Hampshire 2 2 Fareham & Gosport 1 1 Isle of Wight 1 1 South Eastern Hampshire 1 1 North East Hampshire & Farnham 0 0 North Hampshire 0 0 Portsmouth 0 0 Southampton 0 0


Part 2 – Performance Summary – Quality & Patient Experience continued… • Healthcare Acquired Infections – C.Difficile: National Target: 20 maximum

Wessex Area (Cumulative totals as at November 2014)

CCG: There were two reported cases for November, both of which were indicated to have occurred in a Community (Non-Acute) setting. This number was both above the projected number for the month and brings the cumulative total to 24, exceeding the Annual Target of 20, which has been missed.

IWNHST: There were no further reported cases in month for IWNHST, the total number assigned remaining at six against an annual target of six. However, the provisional results for December suggest that a further case was reported bringing the cumulative total for the year above the annual target.

Action: The CCG Infection Control Nurse reviews individual cases. It should be noted that the cases that have occurred include many that are unavoidable, particularly for patients requiring on-going antibiotic prescription.


Part 2 – Performance Summary – Quality & Patient Experience continued… • Friends and Family Test: National Targets: Response rates improvement Q1-Q4 / Score Improvement Q1-Q4

From 1 December 2014, the FFT will be rolled out to GP practices and from 1 January 2015 will include Mental Health and Community services. In April 2015 patient transport services covering acute hospital outpatients and day cases will also be included. NB: The NHS England review of the patient FFT, published in July 2014, recommended a move away from the Net Promoter Score (NPS) and the introduction of a simpler scoring system in order to increase the relevance of the FFT data for NHS staff, patients and members of the public. Based on the findings of the review, NHS England is now calculating and presenting the FFT results as a percentage of respondents who would/would not recommend the service to their friends and family. This change was introduced with the release of the results for September and user testing of the presentation of the FFT results is being undertaken on the NHS Choices website.

The following is a summary for the results achieved by IWNHST for the last three months up to and including November 2014:

IWNHST Q2 2014/14 Sep Oct Nov Q4 13/14

Average Q1 14/15 Average

Q2 14/15 Average

Q3 14/15 Average Trend

A&E

Response rate 8.60% 17.67% 23.76% 11.98% 17.50% 14.72% 20.56% Total Eligible/Responses 2,452/211 2,185/386 1,974/469 5,862/702 6,696/1,172 8,023/1,181 4,159/855 % Recommending 81.99% 90.67% 87.85% 69 63 61/81.99% 89.26% - % Not recommending 8.53% 4.92% 4.48% 4.70% -

Inpatients

Response rate 35.31% 40.52% 39.85% 37.32% 33.88% 38.71% 40.20% Total Eligible/Responses 844/298 886/359 813/324 2,334/871 2,314/784 2,542/984 1,699/683 % Recommending 96.31% 94.43% 95.37% 71 73 80/96.31% 94.90% - % Not recommending 1.01% 2.79% 0.93% 1.86% -

Maternity Question 2: Birth Response rate 17.88% 23.03% 21.43% 11.46% 13.83% 16.55% 22.34% Total Eligible/Responses 151/27 165/38 126/27 410/47 412/57 441/73 291/65 % Recommending 100% 100% 92.59% 82 85 80/100% 96% - % Not recommending 0% 0% 3.70% 2% -

There has been a general improvement in the reported response rates across the last three months. Most notably is the improvement seen with the rate for A&E which had fallen significantly in September from the rate of 23.2% reported for August and this is reflected in the average rates shown at quarterly intervals.

For November, the combined average response rate (A&E and Inpatients) for IWNHST was 31.81% which was better than the combined National average of 27.89%.

The Net Promoter Score that has been reported since the Test was introduced in 2013, has now been withdrawn by NHS England and replaced by a percentage rate for those responding and indicating that they would either ‘recommend’ or ‘not recommend’ the service. Across each of the services scored, the rates for those ‘recommending’ have demonstrated some fluctuation across the three months.

Comparison of the performance achieved by Isle of Wight NHS Trust with the three Mainland Trusts in the tables on the next page, the performance achieved in November was broadly comparable.



Mainland Trust performance (Performance comparison):

A&E Inpatients Response rate % %Recommending Response Rate % % Recommending

Sep Oct Nov Sep Oct Nov Sep Oct Nov Sep Oct Nov UHS 21.1% 23.4% 23.4% 91.3% 91.0% 91.2% 37.1% 32.4% 36.7% 94.7% 94.5% 95.8%

PHT 15.4% 18.4% 14.9% 91.4% 91.0% 94.2% 40.2% 42.3% 36.0% 91.6% 92.2% 96.0%

Salisbury 19.1% 27.6% 16.6% 94.8% 91.5% 94.3% 45.3% 49.2% 50.1% 96.1% 97.5% 97.0%

Maternity (Birth - Question 2) Response rate % % Recommending

Sep Oct Nov Sep Oct Nov UHS 24.1% 20.1% 26.4% 97.4% 95.9% 97.6%

PHT 27.9% 37.2% 24.7% 72.6% 71.8% 98.3%

Salisbury 1.3% 6.4% 16.7% - 100% 97.0%

Action: The Trust has introduced IPads in Maternity as a priority, to aid the capture of individual responses and is using volunteers to assist people with use of the technology. Progress with improvement in performance, with a focus on A&E, will continue to be monitored through CQRM.



• Improving Access to Psychological Therapy (IAPT): National Target for Isle of Wight 22%

Indicator Target 2014/15 Apr

14 May 14

Jun 14 Q1 Jul

14 Aug 14

Sep 14 Q2 Oct

14 Nov 14

Improved access to psychological services: The proportion of people that enter treatment against the level of need in the general population.

22%

Numerator: No. of people who receive psychological therapies

216 197 153 566 218 171 161 550 207 187

Denominator: No. of people who have depression and/or anxiety disorders

1,087 1,088 1,087 3,262 1,088 1,088 1,087 3,263 1,088 1,088

Percentage 19.9% 18.1% 14.1% 17.4% 20% 15.7% 14.8% 16.9% 19.0% 17.2%

The Local target of 20% was narrowly missed at the end of 2013/14, with an overall rate for the year of 19.1%, this did however, exceed the National target of 15% and was an improvement on the previous year’s performance.

The annual target of 22% is linked to the Quality Premium which specified a 3% increase on the rate achieved in 2013/14. Performance to date (11.57% as at the end of November 2014) remains below the trajectory rate required to achieve target.

Actions: A Business case provided by the Trust and intended to offset some of the staffing issues previously highlighted, was approved in December 2014. The benefits from this plan should begin to be seen from January 2015 and an assurance has been given that the targets for both numbers entering into and moving to recovery will be met at the end of Quarter 4. Performance will continue to be monitored by the Mental Health Commissioners as a part of the Contract monitoring process.


Part 2 – Performance Summary – Quality & Patient Experience continued… • Emergency Re-admissions: No National Threshold

NB: The analysis includes all readmissions and uses recognised exclusions to facilitate national benchmarking as per PbR guidance. Without clinical review of all admissions it is difficult to determine if the readmission is related to the previous discharge.

Performance in 2013/14 fluctuated across the year from a high of 5.72% in April to the lowest reported rate of 3.29% for both June and July. In the second quarter 2014/15, an improving trend for performance was seen, particularly with the performance for August and September, despite the rates achieved in the first two months being above those reported for the same period in 2013/14. Numbers increased again in October but the initial results for November suggest that some recovery in numbers and subsequent rate may be anticipated. It should be noted that the numbers are subject to on-going review and revisions are made to the numbers and rates in subsequent months to the date of their being reported initially.

2013/14 April May June July August Sept Oct Nov Dec Jan Feb Mar Year to Date

Emergency Re-admissions within 30 days

Actual 858 72 64 76 99 74 68 87 79 619 Admissions 19,555 1,444 1,528 1,462 1,659 1,489 1,566 1,730 1,709 12,587 % 4.39% 4.98% 4.19% 5.20% 5.97% 4.97% 4.34% 5.22% 4.62% 4.92%

Performance. in month 2013/14 5.72% 4.55% 3.29% 3.29% 4.03% 5.32% 4.89% 4.86% 4.64% 3.44% 4.58% 4.29%

Action: An audit of re-admissions in July 2014 for all acute services was undertaken. The report was received at CQRM but failed to identify the related and unrelated episodes. Further work is to be undertaken by the Trust’s Performance, Information and Decision Support team (PIDS). NB: Separate audits of re-admissions are also being undertaken in Mental Health services.


Part 2 – Performance Summary – NHS Constitution


Part 2 – Performance Summary – NHS Constitution continued…

RED – Target missed; AMBER – Performance achieved within 5% of meeting target; GREEN – Target achieved.

The CCG failed to achieve the target for Admitted in November, with the rate for Non-Admitted achieved for the first time in 2014/15, a stepped improvement in rates having been seen since August. While performance for Admitted continues to fail to meet target, some improvement in the rates achieved had been seen since September.

Provisional rates are given for December, which suggest that the CCG has achieved the targets for both Non-Admitted and Incompletes in month, with an improving trend for Admitted.

IWNHST The IWNHST also met the targets for both Non-Admitted and Incompletes in November but missed the target for Admitted, although a gaints a trend of improving performance rates over the last three months. Provisional outcomes for December suggest that the improvement in Non-Admitted treatments in November was not sustained and performance returned to a failure of target. Mainland Trusts Performance attained by the three principal mainland trusts remains inconsistent, failing to achieve target in one or more category. o UHS – targets had been missed consistently up until September, with a mixed set of results in October. November saw some more consistent

improvement with targets achieved in both Non-Admitrtted and Incompletes, contributing to the overall performance achieved by the CCG. o PHT had remained relatively consistent in the areas of acheivement and non-achievement across the three months, although November saw

failures across all three categories. o Salisbury have been the most consistent, but the numbers of patients the Trust is treating remain low.

• 18 week Referral to Treatment: National Targets: Admitted 90%; Non-Admitted 95%; Incompletes 92%

2014/15 IWCCG IWNHST UHS PHT Salisbury Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes

April 92.8% 94.3% 93.9% 95.0% 94.5% 94.2% 71.7% 77.3% 83.6% 86.7% 94.3% 94.6% 66.7% 100% 97.7% May 92.4% 94.97% 91.78% 94.9% 95.3% 92% 65.9% 89.3% 88.4% 84.6% 88.7% 94.2% 100% 100% 97.6% June 91.65% 93.12% 93.45% 92.57% 93.09% 93.77% 77.78% 83.33% 86.06% 100% 93.88% 91.93% 100% 100% 95.74% July 86.68% 94.36% 92.2% 86.91% 94.28% 92.36% 79.66% 91.3% 85.85% 93.94% 94.83% 93.06% 85.71% 100% 97.73% August 83.97% 90.35% 91.75% 83.72% 90.23% 91.90% 84.62% 86.67% 86.38% 90.0% 94.0% 92.41% 100% 100% 87.5% September 80.32% 93.44% 94.93% 79.22% 93.45% 95.60% 82.98% 88.00% 85.60% 90.0% 92.05% 91.39% 100% 100% 82.22% October 80.89% 94.68% 95.14% 82.14% 94.84% 95.46% 70.49% 86.49% 93.48% 79.31% 95.52% 91.14% 50.00% 100% 83.78%

November 82.23% 95.49% 96.26% 82.45% 95.56% 96.60% 74.07% 96.97% 95.05% 75.0% 90.0% 89.73% 100% 100% 92.5% 139/782 100/2,219 263/7,040 119/678 93/2,093 219/6,449 14/54 1/33 11/222 4/16 6/60 15/146 0/2 0/5 3/40

December (provisional) 88.1% 96.0% 96.1% 86.7% 92.0% 95.9%



Actions: IWNHST: The CCG has agreed an Additional Activity Plan as a part of a National Resilience funding initiative. Performance achieved by IWNHST is a part of the on-going challenge made via the monthly contract meetings and is now subject to weekly review and daily monitoring reports. The CCG is working closely with the Trust to gain further assurance regarding sustainability of achievement for the planned activity. The CCG are working closely with the Trust to outsource to local mainland providers, in particular with regard to T&O, Urology and General Surgery. Mainland Trusts: Contract Query Notices via lead Commissioners for RTT performance remain in place with University Hospital Southampton (UHS). Commissioners will continue to work with the Lead CCGs and directly with the Trusts to improve patient waiting times.

• Patients waiting >52 weeks – National Target: Zero

While there were no reported cases applied to the IWCCG for individuals having to wait over 52 weeks in November, there was one case that occurred in September/October at IWNHST.

Provisional indications are that there are a further two cases at IWNHST for December and two more in January.

Actions: The RTT validation process revealed issues with pathway dates and as a result, new control checks have been put in place as a part of an improvement to Waiting List management.


Part 2 – Performance Summary – NHS Constitution continued… • Cancer: Nine National Targets

RED – Target missed; AMBER – Performance achieved within 5% of meeting target; GREEN – Target achieved.

IWCCG - Quarter One 2014/15 Target Q1 Q2 Oct 14 Nov 14 Year to Date

Seen within 2 weeks of referral 93% 94.17% 95.80% 97.17% 97.00% 10/333 95.50%

Seen within 2 weeks of referral - Breast Symptoms 93% 83.66% 91.20% 98.70% 92.16% 4/51 89.56%

Treated in <31 days of diagnosis 96% 96.36% 96.12% 98.77% 98.85% 1/87 96.79%

Treated in <31 days - Surgery 94% 96.49% 94.83% 95.24% 95.83% 1/24 95.57%

Treated in <31 days - Drug Treatment 98% 100% 100% 100% 100% 0/35 100%

Treated in <31 days - Radiotherapy 94% 96.15% 94.87% 100% 100% 0/19 96.39%

Treated in <62 days - urgent referral to treatment 85% 84.21% 84.78% 74.19% 76.32% 9/38 82.39%

Treated in <62 days - Consultant upgrade 86% 100% <<Nil>> <<Nil>> 0/0 100%

Treated in <62 days - Screening service 90% 85.71% 85.71% 100% 100% 0/4 90.48%%

Mainland Trusts – performance for island registered patients

IWNHST - Quarter One 2014/15 Target Q1 Q2 Oct 14 Nov14 Year to Date Seen within 2 weeks of referral 93% 94.10% 96.21% 97.40% 96.97% 9/330 95.49%

Seen within 2 weeks of referral - Breast Symptoms 93% 83.50% 91.63% 98.68% 91.84% 4/49 89.63%

Treated in <31 days of diagnosis 96% 98.30% 98.54% 100% 100% 0/68 98.81

Treated in <31 days - Surgery 94% 100% 95.74% 100% 100% 0/16 98.32%

Treated in <31 days - Drug Treatment 98% 100% 100% 100% 100% 0/31 100%

Treated in <31 days - Radiotherapy 94% <<Nil>> <<Nil>> <<Nil>> <<Nil>> <<Nil>>

Treated in <62 days - urgent referral to treatment 85% 85.14% 87.55% 76.79% 82.35% 6/34 85.02%

Treated in <62 days - Consultant upgrade 86% 100% 100% <<Nil>> <<Nil>> 0/0 100%

Treated in <62 days - Screening service 90% 85.71% 90.91% 100% 100% 0/4 92.31%

2014/15 UHS PHT Q1 Q2 Nov 14 Year To

Date Q1 Q2 Nov 14 Year To Date

Seen within 2 weeks of referral 100% 100% n/a 0/0 100% 100% 100% 100% 0/1 100% Seen within 2 weeks of referral - Breast Symptoms n/a n/a 100% 0/2 100% 100% n/a 100% 0/0 100% Treated in <31 days of diagnosis 92.86% 91.30% 100% 0/11 94.34% 80.95% 76.19% 85.71% 1/7 81.03% Treated in <31 days - Surgery 88.89% 100% 83.33% 1/6 91.67% 75.00% 75.00% 100% 0/2 75.00% Treated in <31 days - Drug Treatment 100% 100% 100% 0/2 100% 100% 100% 100% 0/2 100% Treated in <31 days - Radiotherapy 100% 97.73% 100% 0/9 98.99% 91.67% 90.91% 100% 0/10 93.33% Treated in <62 days - urgent referral to treatment 100% 100% 100% 0/1 100% 55.56% 25%% 0% 1.5/1.5 36.67% Treated in <62 days – Screening service n/a n/a n/a 0/0 n/a n/a 66.67% n/a 0/0 66.67% Treated in <62 days - Consultant upgrade n/a 100% n/a 0/0 100% n/a 100% n/a 0/0 100%


Part 2 – Performance Summary – NHS Constitution continued… Performance has remained consistent in the two month of October and November with just the one treatment ‘Treated in <62 days - urgent referral to treatment’ having failed target consistently across both months. The results are often impacted due to the complexity of treatment requirement and or the range of diagnostic testing needing to be undertaken.

The result in November for ‘Seen within 2 weeks of referral - Breast Symptoms’ was as a consequence of unavailability of the four patients involved.

Performance continues to prove inconsistent with Portsmouth Hospitals Trust with both this and University Hospital Southampton experiencing issues with Elective capacity.

Treated in <62 days - Screening service – A coding query remains outstanding at the time of reporting, which may impact the rate currently reported for IWNHST.

In respect of performance for December achieved by IWNHST provisional results suggest that all targets were met in month.

Action: Performance is subject to active ongoing monitoring and discussion by acute commissioners with all providers. Contract Penalties have been applied.


Part 2 – Performance Summary – NHS Constitution continued… • Category ‘A’ Ambulance Calls: National targets: Red 1 and Red 2 75%; 19 minutes 95%

Early indications suggest that the targets have continued to be met by IW Ambulance Trust for ‘Red 1’ and ‘19 Minutes’, while Red 2 may fail to meet target.

Target April May June July Aug Sept Oct Nov Dec Category A – Red 1 75% 82.61% 87.8% 84.85% 85.29% 72.55% 81.8% 80.5% 78.43% 80.4% Category A – Red 2 75% 76.88% 75.53% 75.67% 75.57% 72.2% 76.1% 75.9% 75.72% 75.0% Category A – 19 mins. 95% 95.82% 96.10% 96.0% 96.25% 95.23% 98.2% 97.5% 95.95% 96.4%

Action: Performance continues to be monitored on a weekly basis by Commissioners.


Part 2 – Performance Summary – NHS Constitution continued… • A&E <4 hour wait for admission, treatment or discharge – National target 95%

Numbers attending A&E were higher for the first two months of the quarter when compared with the same months in the preceding year, and has continued to demonstrate sustained growth based on numbers for August.

IWCCG Apr May Jun Jul Aug Sep Oct Nov Dec YTD

A&E <4 hour wait

13/14 96.53% 98.24% 97.73% 97.93% 95.66% 95.92% 94.90% 98.16% 97.85% 14/15 96.15% 94.23% 95.96% 96.39% 97.05% 95.44% 93.85% 91.58% 92.54% 94.90%

No Attending 5,147 6,481 5,301 7,158 5,352 4,891 5,712 4,523 4,904

Breaches 198 374 214 259 158 223 351 381 366

Overall performance for the CCG in the second quarter achieved the target of 95%. Performance in the third quarter fell short of the 95% target, impacting the overall performance for the Year to Date.

Results continue to be impacted by issues such as pressures for bed availability and delays experienced with transfers of care.

IWNHST Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Year to date Beacon WIC 100% 99.8% 100% 100% 99.9% 100% 100% 100% 100% 99.9% Emergency Dept. 92.1% 90.7% 93.6% 94.6% 96.0% 92.6% 91.0% 86.6% 86.4% 91.8% A&E <4 hour wait 95.3% 94.3% 95.9% 96.5% 97.3% 95.1% 94.2% 91.8% 91.9% 94.8%

Action: Performance is monitored at both a daily and weekly level by commissioners. The CCG is analysing the increased numbers of attendances to understand whether actions in Primary Care, or engagement with the public could help support a reduction to the numbers using A&E.



• Ambulance Handover: National Target 100% for Handovers and Crew Green-Up time

Performance in August continued to be below target. o Handovers completed within 15 minutes (National Target: 100%) – Performance for November was 62.56% (down from 69.74% in

October). Performance has remained fairly static over the three months September – November. o Crews ready to accept new calls within 15 minutes of handover (National Target 100%) – Performance for November was 71.76% (up

from 64.36% in October). A stepped improvement has been demonstrated over the last six months in the performance rate reported.

Action: This has remained a consistent issue for more than twelve months. The Trust is implementing electronic ‘tablets’ to capture time stamping to overcome data recording issues which will improve data accuracy. The CCG and Trust are undertaking audits which should help to demonstrate whether the underlying issue is technical, service delivery/quality or a combination of the two. Contract penalties are currently being applied.



• Other Key Metrics

• Trolley waits – National Target: Zero Local Performance: Zero. Provisional performance for December indicates that performance achieved by IWNHST, remained at zero in month.

• Diagnostics – National Target: >99% Performance for Diagnostics in September was 99.57% (7 patients waiting >6 weeks); October 99.77% (4 patients >6 weeks); November 99.88% (2 patients>6 weeks).

• Cancelled Operations – National Targets: 100% / Zero To date there have been a total of six occasions (from 153) where there has been a breach for ‘cancelled operations rebooked in 28 days’ representing as a rate of 96.23%. There were single cases in the two months September to October contributing to this outcome. September – T&O lack of bed – re-booked October – ENT lack of post-operative bed – re-booked (NB: Adjustments to reported occurrences may be made in subsequent months following investigation and review of occurrences). There were no reported cases for ‘cancelled operation cancelled for a second time’ in the three months of September to November. However, due to the two cases previously reported the target for the year (zero occurrences) has been missed.

• Mixed Sex Accommodation – National Target: Zero There were four reported cases in October, occurring at IWNHST, a result of pressures on bed availability combined with an increase in attendance/admissions through the emergency department. A root cause analysis has been conducted and a meeting held to review the issues that resulted in this breach occurring.

There were no reported breaches for November and none indicated for December 2014, however, the annual target (zero cases) will not be met.

• Mental Health Care Programme Approach – National Target: 95% The target has been met successfully for a full twelve months up to and including November 2014, for those individuals on the Mental Health CPA who were followed up within seven days of discharge,. A rate of 100% was achieved for both October and November. Provisional results for December suggest that the target has continued to be met.


Part 2 – Performance Summary – Contract Query Notices Contract Query notices

The following Contract Query Notices are currently in place:

a) Ambulance - Ambulance Handovers, where performance remains an issue. (On-going). Penalties are now being applied

b) University Hospital Southampton (UHS) – RTT 18 week performance levels achieved – Unsatisfactory remedial plan received. (On-going). IWCCG letter sent to CEO, to which a response has been received.

c) Commissioning Support Unit (CSU) – IT Performance Notice. (On-going).

d) IWNHST - Shackleton Ward including Dementia Intensive Treatment Service (DITS) – concerns regarding performance against service Specifications for a number of clusters. (On-going).

e) IWNHST Mental Health Services – Managerial and Clinical Leadership. (On-going).

f) IWNHST Paediatric Healthcare Service – A need to review current policies and procedures in place for paediatric services together with the working relationships and agreements between the Trust and University Hospital Southampton NHSFT. (On-going). Letter also sent to UHS. External review has now been received and actions need discussion with the Trust.

g) PHT – Diagnostics (6 week wait failure re Ultrasound and MRI). (On-going).

h) PHT – Electronic Discharge Summaries (Failure of dataset / Method of delivery and timescales). (On-going)


Part 2 - Local Priorities

LIPIDS Management

An initial target of 71% has been applied in line with the target given for the Quality Premium. The aspiration is to achieve a level across all practices of at least 80% in line with national top performers. According to eclipse Live data, 12 of the 17 GP Practices had met the 71% target at the end of Quarter 3, with an Island average of 73%. A deterioration overall from the rate of 74% achieved in the previous quarter. Please note these outcomes should be considered as being indicative of the direction of travel being achieved.

Improving the reporting of patient safety incidents:

Quarter 3 - One alert was sent on the 21st October 2014, regarding the prescribing contraindication between oral diclofenac and ischaemic heart disease. 29 patients were identified by Eclipse Live as being at risk of adverse effects and 10 patients were reviewed within one month of the alert being sent. Performance: YTD 19% (28/144) Target ≥20%


Part 2 – Performance Summary – Financial Report M8 This Part provides details of the current financial position of the CCG. A forecast outturn position is included. In-month cost and activity variance is also illustrated.

Finance - Key Messages & Risks: • As at the end of November, the CCG’s year to date

position is £4k better than plan. • Acute - Dermatology £137k overspent YTD due to

activity being higher than contract. Portsmouth £121k overspent with areas such as ICD devices and Cardiac services being above contract. Non NHS activity £91k below contract, which is mainly IVF.

• Mental Health - £169k Y/E underspend - mainly due to high cost mainland placements being repatriated to IW based services.

• Continuing Care - Y/E overspend of £252k due to an increase in patient numbers, partly due to assessments undertaken by Council.

• Prescribing - The Y/E forecast position is an under spend of £105k.

• Running costs - Y/E underspend of £295k against the running cost allocation. This is partly around slippage but also around the CCG preparing to achieve the 2015/16 10% reduction in the running cost allocation.

• Since reporting the month 6 position the CCG's financial flexibilities have been re-assessed and updated. The CCG has un-committed funds of £2m above the planned surplus. Additional non-recurrent investment schemes will be identified, as in previous years these will be assessed to ensure they fit with the CCG's Strategy and have clearly identified benefits. Sign off and approval of spends will be in line with the CCG's Financial scheme of delegation and signed off by the CCG's Officers Group.


Performance on a Page CCG Level Indicators unless othewise noted. RED - Target missed; AMBER - within 5% of Target; GREEN - Target Achieved;

Monthly performance unless otherwise noted.

A

Qua

lity

Pre

m

7 K

ey A

mb

CO

F

M/L

Annual Target/

Required trend

YTD Month Trend B

Qua

lity

Pre

m

7 K

ey A

mb

CO

F

M/L

Annual Target/

Required trend

YTD Month Trend Forecast

Serious Incidents Requiring Investigation: Never Events (All Providers) M 0 0 Nov-14 0 Finance Efficiency: Underlying recurrent surplus L ≥1% 1.0% Nov-14 N/A £2,050k

Finance Efficiency: Contingency utilised (cumulative YTD) Annual Target £1,025k L ≤1% 0.5% Nov-14 N/A £1,025k

Finance Efficiency: Surplus Annual Target £2,050k L ≥1% 1.0% Nov-14 N/A £2,050k

Finance Efficiency: Invoice payment (Value): <30 days % achievement (cumulative %) L 95% 99.98% Nov-14 99.81% 95%

Finance Efficiency: Invoice payment (Volume): <30 days % achievement (cumulative %) L 95% 99.39% Nov-14 98.15% 95%

VTE Risk Assessment (IWNHST) M >95% 98.04% Nov-14 99.6% Finance Efficiency: Debtors >30 days L ≤ 5% 79.20% Nov-14 79.20% ≤ 5%

Slips Trips and falls resulting in injury (IWNHST) M Reduce 17 Nov-14 123 Finance Efficiency: Creditors >30 days L ≤ 5% 1.30% Nov-14 1.30% ≤ 5%

Mortality: Summary Hospital-level Mortality Indicator (SHMI) - IWNHST M Down 1.066 Apr 13 - Mar 14 N/A Finance Efficiency: Liquidity cash balance % of drawdown L tbc 30.73% Nov-14 Strategic Plan: QIPP Savings Achievement % Annual Target £2,805k L % > target 100% Nov-14 N/A £2,805k

Running Costs: Total £25 per head of population (% within target) Annual Target £3,478k L % > target within target Nov-14 N/A within target

Number of new complaints and concerns in month (CCG) L N/A 0 Nov-14 14 Workforce: Mandatory Training Completed % (YTD) L > 95% N/a Dec-14 88.79% Number of complaints referred to the Ombudsman and upheld (CCG) L 0 0 Nov-14 0 Workforce: Appraisals Completed % (YTD) L > 95% N/A Dec-14 91% Friends & Family Test: Response Rate: In-patients (IWNHST) M Increase 39.85% Nov-14 37.28% Workforce: Absence % L < 3% 0.5% Nov-14 0.81% Friends & Family Test: Response Rate: AE (IWNHST) M Increase 23.76% Nov-14 17.18% Workforce: Absence Days Lost in month (YTD = cumulative total to date) L Reduce 8.6 Nov-14 115.7 Friends & Family Test: Response Rate: Maternity (at Birth) (IWNHST) M Increase 21.43% Nov-14 16.96% Workforce: Vacancies (CCG) L N/A 2 Dec-14 N/A

Workforce: Number of FTE GPs per 1,000 weighted population (Recommendation 60) L N/A N/A Dec-14 53.9 CCG Assurance: Quarterly Status (Assured/Assured with Support) M A/AWS AWS Q1 14/15 N/A Q

Healthcare acquired infections: MRSA (CCG) M 0 1 Nov-14 1 Number of Information Governance breaches L 0 0 Dec-14 0 Healthcare acquired infections: C.diff (CCG) M < = 20 2 Nov-14 24 Continuing Care – Number of Appeals that were upheld L 0 0 Dec-14 3 No. of days IWNHS Trust was at Red Alert L N/a 19 Nov-14 142 Number of FOI requests not responded to within 20 working days L 0 N/a Dec-14 0

Operating Plan: Improved Access to Psychological Services (IAPT) – Access (IWNHST) M/L 22% 17.0% Nov-14 11.57% Healthcare Contracts: Contract Notices Outstanding (All providers) L N/A 8 Dec-14 N/A

Operating Plan:Improved Access to Psychological Services (IAPT) – Recovery (IWNHST) M 50% 56.0% Nov-14 N/A Number of Contracted Providers with CQC Enforcement Actions L 0 0 Dec-14 1

Operating Plan: Dementia Diagnosis Rate M/L 67% 62.83% Nov-14 N/A Number of Section 71/75/256 Agreements in place L N/A

Operating Plan: Winterbourne View: achievement of Action Plan milestones M 100% 100% Nov-14 100% Healthcare Contracts: CQUINS: % achieved in quarter (IWNHST) L 100% 81.8% Q2 14/15 N/A Q

CCG Assurance Domain 1: Are patients receiving clinically commissioned, high quality services?

C

Qua

lity

Pre

m

7 K

ey A

mb

CO

F

M/L

Annual Target/

Required trend

YTD Month Trend D

Qua

lity

Pre

m

7 K

ey A

mb

CO

F

M/L

Annual Target/

Required trend

YTD Month Trend Forecast

Ambulance: Cat A calls < 8 minutes (Red 1) M 75% 78.43% Nov-14 81.74% Delivery Plan Milestone Achievement (% achieved in quarter) N/A 36.51% Q2 14/15 42.42% QAE: Patients waiting <4 hours M 95% 91.58% Nov-14 95.16% Patient Engagement: Indicator to be developed

No waits for decision to admit to admission (trolley waits) over 12 hours M 0 0 Nov-14 0 No. demonstrating health improvement (pre vs post course of pulminory rehabilitation) L N/A N/A QRTT: Admitted patients in 18 weeks: CCG M 90% 82.23% Nov-14 86.04% No. of people first attending Type 2 Diabetes Education - Retention Rate (%) L ≥75% 58.5% Nov-11

RTT: Non-admitted patients in 18 weeks: CCG M 95% 95.49% Nov-14 93.84% PYLL - Proxy: Rate for deaths due to Cerebrovascular diseases <75 years M Reduce 175.2 2011/13 N/A QRTT: Incomplete non-emergency pathways M 92% 96.26% Nov-14 PYLL - Proxy: Rate for deaths due to Ischaemic heart disease <75 years M Reduce 530.0 2011/13 N/A QRTT: Patient waiting >52 weeks M 0 0 Nov-14 1 PYLL - Proxy: Rate for deaths due to Neoplasms <75 years M Reduce 682.3 2011/13 N/A QCancelled Operations re-booked in 28 days M 100% 84.60% Nov-14 95.09% PYLL - Proxy: Rate for deaths due to Respiratory diseases <75 years M Reduce 80.1 2011/13 N/A QCancelled Operations - second cancellation M 0 0 Nov-14 2 Operating Plan: Percentage of diabetic patients whose last cholesterol was 5mmol or less M/L 71% Q3 14/15 73% QDiagnostics: Patients waiting >6 weeks from referral M >99% 99.88% Nov-14 99.78% Case Management: Advanced Care Plans in Place (2014/15 target 912 ACPs) L Increase 84 Nov-14 379 Cancer patients seen <14 days after urgent GP Referral M 93% 97.0% Nov-14 95.50% Prescribing: IW GP Practice prescribing performance compared to England Average L Lower Oct-14 -0.1% Cancer: All Cancer patients wait from diagnosis to 1st definitive treatment <31 days M 96% 98.85% Nov-14 96.79% Number of contacts received by GP "Intelligence Line" L Increase 1 Dec-14 40 Cancer: Urgent referral treatment <62 days M 85% 76.32% Nov-14 82.39% My Life a Full Life (metrics to be confirmed) M/LMixed Sex Accommodation Breaches M 0 0 Nov-14 5 Dexa Scan/Osteoperosis drugs - under development L Q

MH: CPA: % people on CPA followed up , 7 days following in-patient episode M 95% 100% Nov-14 97.3% Joint Sensory Impairment - No.s receiving hearing aid maintenance support. L N/A Aug-Oct 2014 834 Q

Activity trends (ALL): YTD: - Acute Elective Spells (Operatng Plan) M <x% of plan 8.1% Nov-14 3.7% Better Care Fund: Delayed transfers of care from hospital in month (YTD: rate per 100,000 population) M Reduce 395 Nov-14 0.282

Activity trends (ALL): YTD: - Acute Non-elective (Operating Plan) M <x% of plan 0.9% Nov-14 -3.9% Activity trends (ALL): YTD: - All First Outpatient Attendances (Operating Plan) M <x% of plan -1.6% Nov-14 6.4% Activity trends (ALL): YTD: - AE Attendances (Operating Plan) M <x% of plan Emergency Readmissions within 30 days (IWNHST) M ≤ 4% 4.6% Nov-14 4.9% GP Referrals to Secondary Care (IWNHST): YOY %>2013/14 L 0% 1.5% Nov-14 N/A Number of potential Emergency Admissions managed by Crisis Reponse Team intervention L Increase

Total Referrals (IWNHST): YOY %>2013/14 L 0% 3.8% Nov-14 N/A Number of Ambulatory Care Clinic Types in Place L Increase 12 Nov-14 12

RAID Programme: under development

MH - Parity of Esteem -under development M Increase N/A Q

Readmissions to Mental Health within 30 days of discharge M Reduce 173.5 2013/14 N/A Q

Proportion of adults in contact with secondary care Mental Health services in paid employment M Increase n/a 2013/14 N/AQ

BLUE - Data not available; Grey - No Target in period being applied

Reported PerformanceNo. / % Period

Hea

lthca

re C

ontra

ct

Act

ivity

Fina

nce

Wor

kfor

ceLe

ader

ship

&

Par

tner

ship

CCG Assurance Domain 2: Are patients and the public actively engaged and involved? CCG Assurance Domain 3: Are CCG Plans delivering better outcomes for patients?

N/A

M

NH

S C

onst

itutio

n

NHS Constitution

CCG Assurance Domain 4: Does the CCG have robust governance in place?CCG Assurance Domain 6: Does the CCG have strong and robust leadership?CCG Assurance Domain 5: Are CCGs working in partnership with others?

CCG Assurance Domain 1: Are patients receiving clinically commissioned, high quality services?CCG Assurance Domain 3: Are CCG plans delivering better outcomes for patients?

Quality Outcomes Finance and Governance

Serious Incidents Requiring Investigation (SIRIS): As at 31.12.2014 total numbers in 2014/15 (all grades) for IWCCG where investigation has not been completed within timescale

Pressure Ulcers: All Grades (2-4) - Number in month (improvement on 2013/14)

Operating Plan: Improved reporting of medication related safety incidents - % of medication Patient Alerts with intervention responses reported to the CCG within 30 days of alert issue

Pat

ient

Saf

ety

Pat

ient

Exp

erie

nce

M/L

Reduce


M

M Increase

Unplanned hospitalisation for chronic ambulatory care sensitive (CS) conditions (adults)

Q

Q

Q


Strategic Plan

Sel

f-Car

e &

Man

agem

ent

Prim

ary

Car

e D

evel

opm

ent

Inte

grat

ed

Car

e

Rate of emergency admissions for asthma, diabetes or epilepsy per 100,000 population - <19 year olds


95.37%

3

26 Nov-14

19% Q3 14/15

181

Gov

erna

nce

19% Q

Clin

ical

Out

com

es

Friends & Family Test: In-patient Responses - % recommending (Likely/Extremely Likely) (IWNHST)

M

M

Increase 95.37% Nov-14

0 1 Nov-14

≥ 20%

Reduce

Men

tal H

ealth

Rate of emergency admissions for children with lower respiratory tract infections

Emergency admissions for acute conditions that should not usually require hospital admission (per 100,000 patients)

M Reduce

M

Better Care Fund: The Percentage of older people (65 years+) remaining at home 91 days from discharge from hospital into rehabilitation/reablement services

Urg

ent

Car

e

M Reduce

Reduce

Q

Q771.4Jul 2013 - Jun

2014prov.

93.2% Q3 14/15

551.5Jul 2013 - Jun

2014prov.

383.3Jul 2013 - Jun

2014prov.

279.0Jul 2013 - Jun

2014prov.

N/A

N/A

N/A

N/A

Governing Body NHS England CCG Assurance – Action Plan and Q2 Letter of Assurance Sponsor: Helen Shields, Chief Officer

Summary of issue:

To note the progress on the CCG Assurance Status Actions Monitoring for issues arising from the previous Quarters’ Assurance Summaries; and to receive the Q2 Assurance Letter (status: Assured) and Action Summary. The Q2 Assurance Meeting took place on 20 November 2014 and the Letter was received by the CCG on 26 January 2015; the issue requiring action will be incorporated into the Actions Monitoring and presented to the next Governing Body meeting. Summary of Q2 Status: Domain 1: Assured with Support Domain 2: Assured Domain 3: Assured with Support Domain 4: Assured with Support Domain 5: Assured Domain 6: Assured with Support


To note the outcome of the NHS England (Wessex) CCG Assurance for Q1 and the attached actions monitoring.

Principle risks: There are no principle risks associated with this paper.


This has been considered at the Clinical Executive.


There are no financial or resource implications relating to this paper.


There are no legal implications or impact associated with this paper.


There has been no public involvement or action taken in relation to this paper.

Equality and diversity impact: There is no equality and diversity impact associated with this paper.

Author of Paper: NHS England

Date of Paper: November 2014



Dear Helen and John CCG Q2 assurance meeting – 20 November 2014 Many thanks for meeting with us on 20 November 2014 for the quarter two assurance conversation. We are grateful to you and your team for the preparation undertaken in advance of the meeting and for the open and transparent nature of our conversation. An action plan is provided alongside this letter that summarises our assurance conversation with you. It captures the themes that we discussed and sets out the agreed actions against each assurance domain. Naturally we will continue to work closely with you on these and we will provide further support where necessary. The agenda that we face is complex and challenging and therefore we would like to take this opportunity to fully recognise the continued hard work and achievements of you and your team in this difficult environment. Thank you again to you and your team for meeting with us and we look forward to continuing to work with you as you progress your ambition to improve health outcomes for your local population. Yours sincerely,

Jacqueline Cotgrove Director of Operations and Delivery (Wessex) NHS England

Helen Shields, Chief Officer Dr John Rivers, Chair Isle of Wight CCG Building A, The Apex St Cross Business Park Newport Isle of Wight PO30 5WN

NHS England Wessex Area Team

Oakley Road Southampton

SO16 4GX

26 January 2015

High quality care for all, now and for future generations

Summary Action Plan from 2014/15 Q2 Assurance Checkpoint (NHS Isle of Wight Clinical Commissioning Group) CCG attendees: Helen Shields (Chief Officer), Dr John Rivers (Chair), Eleanor Roddick (Head of Performance and Contracting), Loretta Outhwaite (Chief Finance Officer), Gillian Baker(Deputy Chief Officer) and Fred Psyk (Lay Member). Area Team attendees: Mark Orchard (Meeting Chair and Director of Finance), Jacqueline Cotgrove (Director of Operations and Delivery), Lawrence Tyler (Interim Head of Assurance and Delivery), Ruth Williams (Director of Nursing) and David Mills (Operations and Delivery Manager). Headline assessment: ASSURED

Domain Assurance level

Particular achievements noted and examples of good

practice

Issues raised from previous quarters and at quarter two

Issues that require actions and actions agreed

Domain 1: Are patients receiving clinically commissioned, high quality services?

ASSURED WITH SUPPORT Rationale: CCG to continue to work with provider around outstanding CQC actions and with improving recruitment levels. Support: CQC report/actions plans suggest actions required.

Winterbourne View: a database is in place, reviewed monthly and 100% of service users are recorded. The MH and LD re-enablement board also meets monthly and regular panels review young people in transition to adult services. HCAIs: educational messages have been communicated across the community.

CQC action plan: some of the actions developed by the provider in relation to the CQC report (prior to enactment) still to be agreed with the CCG. Workforce: the workforce summit was generally successful. Now tackling issue of recruitment. CCG and the Trust have had discussions about the Trust workforce structure. HCAIs: C. Difficile – the CCG has 19 YTD cases against the annual objective of 20; the Trust has 6 YTD cases against the annual objective of 6. One case of MRSA reported for August 2014.

CQC action plan: CCG to review provider actions (prior to enactment) to ensure suitability before CCG sign-off. Board meetings: CCG to attend and observe Trust executive board meetings. Workforce: CCG task and finish group to address the recruitment delay. HCAIs: CCG to continue to build on messaging and increased public health engagement.

Domain 2: Are patients and the public actively engaged and involved?

ASSURED Governance: CCG has increasing confidence that appropriate discussions are starting to be held at the governing body and at the clinical executive.

Support: Area Team representative to attend a CCG governing body meeting. Recording observations: JC to share with the CCG a template for recording board meeting observations. Governance: CCG to further refine arrangements over what discussions take place at governing body meetings (in public) and at clinical executive meetings (not in public).

Domain 3: Are CCG plans delivering better outcomes for patients?

ASSURED WITH SUPPORT

Winter resilience: a stronger evaluation process was developed to evaluate winter schemes drawing on experience from 2013/14. NHS 111: Excellent performance particularly with calls answered within 60 seconds. Ambulance service: the CCG recognised a staffing issue in August 2014 and undertook remedial actions resulting in

Winter resilience funding: tranche 2 monies – the CCG recognised the need for flexibility on how the money is used. There are issues with building of nursing homes. Good assurance around other schemes. Discharge challenges: discharge challenges remain – there are staff shortages in domiciliary care and the local authority is working to overcome challenges with encouraging homes and services to be extended. RTT: referrals have increased over the

Winter resilience: KMT to help the provider with CIPs and to look at flow; the CCG is looking at incentivising staffing and supporting enhanced rates to extend hours. Winter resilience: CCG to continue supporting the local authority by looking at wider recruitment and by attending a system-wide debrief. RTT: The CCG will continue working with the Trust to

vacancies being filled and the recovery of category A performance. Joint management role: paramedics play an active role in ED flow; the IOW also has an integrated approach by the same manager covering both A&E and the ambulance service.

summer period and the system is working to ensure capacity is in place to achieve standards at an aggregated level by December 2014. Some specialties will remain challenging.

address capacity issues and to ensure that aggregated and specialty level performance meets national standards. Joint management role: CCG to provide an update on how the joint management arrangement across A&E and the ambulance service is working.

Domain 4: Does the CCG have robust governance arrangements?

ASSURED WITH SUPPORT Support: area team to observe a governing body meeting in an observer capacity and provide feedback.

Governance: the CCG has updated their processes around how they collect information; an examination of other CCG board papers has taken place to ensure robust processes are in place.

Provider CIPs: the CCG is meeting with Trust finance leads and associate directors to review and seek assurance around the Trust’s £3m financial gap. Governance: MO to attend a governing body meeting as an observer.

Domain 5: Are CCGs working in partnership with others?

ASSURED

Partnership working: there is good strategic partnership in place, evidenced through integrated commissioning and provision of services and

CCG finances: CCG discussing with all partners pace of change and how it could be accelerated. As a result scenario discussions are being held to discuss mitigating plans.

Partnership working: the CCG will hold three additional summits on estates, IT and engagement.

working with the voluntary sector.

CCG finances: CCG allocation and higher costs of services for island population was discussed; the CCG believes their allocation is not correct. Provider finances: The IOW Trust is predicting a £3m deficit at year end.

Domain 6: Does the CCG have strong and robust leadership?

ASSURED WITH SUPPORT

Clinical Chair succession: There has been a good response from the younger generation of GPs interested in the position. Appraisals: the CCG has an appraisal programme in place for all clinical executive members and leaders.

Director of Quality and Clinical Services: CCG to appoint on an interim basis (now taken place) and the substantive post will be advertised with interviews scheduled for February 2015. Clinical Chair: CCG to gain members ratification for the extension of John Rivers by one year. Clinical executive: CCG due to elect 2 to 3 new members of the clinical executive group.

RAG Status

RAG Status

Q4 1.1 Action Plan to achieve NHS Constitution CCG to undertake further improvement work around Friends and Family HS/KM

In addition to the national CQUIN the CCG has also set a local CQUIN for communication which has included the introduction of IT tablets for patients to use with FFT. CCG Head of Quality has visited A&E on a number of occasions; FFT promotional materials are visible, with questionnaires and returns box, central in the department.

AThere has been an improvement seen in the response rates for the Friends and Family Tests, although there is still some further work required for Maternity (Births).

A

Q4 1.2 RTT (18 weeks admitted) Q4 not achieved. Monitoring mainland providers in line with contractual clauses GB/LR

The Lead Commissioners have removed Contract Query notices so IWCCG has named links with mainland providers to pursue PTL queries.Performance remains inconsistent. IWCCG has invested additional RTT funding to reduce the backlog at University Hospital Southampton and the waiting list has reduced.

A

RTT remains an issue at Portsmouth Hospitals Trust (PHT) who failed to achieve target for all three categories in December 2014, while University Hospital Southampton achieved target for all three.

Urology - PHT are working through their backlog and are expecting to show an improvement in performance in Quarter 4.

A

Q1 1.1CQC visit: - CCGs main concerns referred to in the CQC report were around programmes of risk and Staffing levels. (Q2)

CCG to Examine external support/advice on action plans to address issues raised by CQC.

HS

The CCG are working with the Isle of Wight NHS Trust to agree and quantify the support required. Non-recurrent funding for additional capacity has been agreed in principle subject to business cases. The CQC improvement plan support required, has still to be quantified.

A

The CQC Action Plan was approved and has been monitored through the Improvement Board. The CQC Warning Notice has been lifted and the CCG Director of Quality and Clinical Services is now taking the lead.

A

Q1 1.2

Friend and Family Tests in Maternity below expected levels for response rates - CCG undertaking further improvement work around Friends and Family and for Maternity with the implementation of Tablets to capture and improve response rates.

CCG will continue to monitor improvement and report at next Assurance meeting.

HS/KM

In addition to the national CQUIN the CCG has also set a local CQUIN for communication which has included the introduction of IT tablets for patients to use with FFT. CCG Head of Quality has visited the maternity department and reported back to the Trust that FFT promotional materials need to be sited outside the ward environment to be seen by patients visiting out patient appointments. Assurances are being sought from the Head of Midwifery that the FFT cards produced by the Trust are being distributed at the 4 points of care. Some improvement has been made and the scores have increased.

A

Maternity (Births) - The performance rate had improved between September and October, with the rate for October of 23.03% being better than the National Average for that month (21.33%).

However, there was a fall in performance for November, the rate achieved being 21.43%, compared with a National average rate of 22.14%.

Performance will continue to be monitored to determine whether this fall in performance was a blip or the improvement previously seen can be sustained.

A

Q1 1.4

Q2 RTT Issues exist for admitted and non-admitted at speciality level for Trauma and Orthopaedics. Nursing staff shortages are believed to be main contributory factor.

CCG undertaking a workforce Summit in October to address and will report back to Area Team on progress.

CMA Workforce Summit has taken place with excellent attendance from Stakeholders. Write up is outstanding. Agreed task and finish group to be established. Caroline Morris - IWCCG representative.

A A Task Group is now in place. Need to ensure that a clear strategy and actions are developed. A

Q1 1.5

Area Team queried that virtual SIRI panels were in placed with a view to better understanding current interim process - The CCG gave assurance around SIRI panels and cover for quality aspects within the CCG and also stated that their Director of Quality post has been filled with expected start date in December. Revised TOR for governing body to ensure capturing of Quality issues.

CCG to share revised TOR with Area Team. HS/CM

All Terms of Reference for Governing Body Committees have been reviewed and agreed with the Membership.

The Quality and Patient Safety Committee lead on this area.

A The Constitution is the Terms Of Reference (TOR) for the CCG. G

Q4 2.2 KLOE:Patient Reference Groups

CCG to further develop processes for capturing feedback to ensure systematic link to service improvement.

CM

Software has been purchased to enable better capture and reporting of patient feedback. CCG is currently implementing the systems and processes to support capture. This issue is also in the GBAF. Making good progress in engaging GP PPGs in scoping exercises - for instance in relation to the Urgent Care Strategy.

A

CCG employing Patient and Public Engagement (PPE) and communications support officer, on a six months contract to accelerate progression in this area. Should be in place in March 2015.

A

Assurance Status - Actions Monitoring 2014/15Progress status as at January 2015

ASSURED (Q4 2013/14) & (Q1 2014/15)

Progress status as at October 2014

ASSURED (Q4 2013/14)

ASSURED WITH SUPPORT (Q1 2014/15)

Focus Period Issues raised from previous quarters and @ Q1


Lead

Domain 1:Are patients

receiving clinically commissioned, high

quality services?

Domain 2: Are patients and the

public actively engaged and

involved?

RAG Status

RAG Status

Q4 3.1

KLOEUnit of Planning - Discussion on approach to and progress with, other CCGs

In partnership with others, CCG to determine impact of strategies and plans on population and providers beyond CCG Geographical boundaries.

LO/GB

LO is working with representatives from the SHIP8 CCGs to develop a draft proposal on what a strategy/plan would look like & the process around them.

Draft due within the next 3 weeks.

A This work is changing to collectively review capacity and impact on providers A

Q4 3.2

KLOE:Unit of Planning - Alignment of implementation plans with Isle of Wight Council

Contribute and input to Wessex wide capacity modelling exercise - expected completion date October 2014

LO/GB

The model has focused on demand modelling, which will be developed in the future into capacity modelling. The model is due to go live next week & has been well received by all CCG teams. We are working internally to identify how it can best be used to support our planning process.

A Demand modelling now in place. G

Q4 3.3

KLOE:Financial ResourcesIAPT and dementia standardsPlans to achieve required standards

CCG to maintain oversight of financial position of partners and impact on CCG plans recognising co-dependency.

LO

Finance summit with IW Council, IW Trust & CCG Executives & senior finance staff was held on 15th October. Financial forecasts were shared & it was agreed that the three organisations would develop a system financial strategy & framework.

The three Finance Directors will meet up within the next few weeks to take this forward.

A Strong shared understanding of organisational position - it has been agreed to develop a joint finance framework. G

Q4 3.4

Q3 discussion on impact and ability to influence larger mainland providers where smaller number of Island referrals may receive differential approach - to be followed up

CCG to continue action being taken with mainland providers to ensure parity of service for Island population

GB/LR

Monthly meetings with University Hospital Southampton have been re-instated; proactively holding telephone and face to face meetings, as appropriate, to discuss specialist, cancer, RTT and any pathway issues.

A log of issues is being maintained and referenced in subsequent discussions.

AMeetings are continuing to take place on a monthly basis.

Any issues raised continue to be logged and actioned.A

Q4 3.5Mortality rates via Dr Foster indicate higher than expected for Island - CCG to confirm outcome from their investigation

CCG has agreed and will monitor processes GB/KM

SHMI Data for January 13 – December 13, published July 14 was 1.099. Data for April 13 to March 14, published October 14 was 1.066. This demonstrates a gradual improvement; the Trust remains in the upper third of Band 2.

The mortality rate is reviewed monthly at CQRM. The Trust's Medical Director reviews all hospital deaths on a monthly basis and the report is shared with the CCG.

A

SHMI Data for July 2013-June 2014, published January 2015 was 1.043, an improvement on the rate given in October 14 for the period April 2013-March 2014 of 1.066 and provides an improvement in ranking for the Trust within Band 2.

The mortality rate is reviewed monthly at CQRM. The Trust's Medical Director reviews all hospital deaths on a monthly basis and the report is shared with the CCG.

G

Q1 3.1

The level of challenge around quality issues seemed light touch – The CCG assured the Area Team that despite Quality director not yet in post, CCG undertakes regular walk rounds with general perception from theprovider that visits were too regular.

CCG to gain assurance that IOW Trust board focus on quality of services generally including MH.

HSCCG reviewed Board papers where quality was discussed, for all meetings. Non-Executive to lay member Board challenge to take place.

R

There is agreement for a Board to Board meeting to take place.

The CCG is to attend the Trust Board in order to gain assurance on the challenge.

A

Q1 3.2

Awareness of staffing levels raised by CQC report. 20% of elective care is provided off island and CCG could commission further services if required.

CCG to consider methodology to gain assurance that agreed actions within IoW Trust are put into place and being sustained throughout all parts of the organisation

HSThe CQC Improvement Plan requires actions to be completed and then a follow-up audit. The audits will need to be reviewed to ensure the coverage is appropriate.

AThe CQC Improvement Plan requires actions to be completed and then a follow-up audit. The audits will need to be reviewed to ensure the coverage is appropriate.

A

Progress status as at January 2015



Issues raised from previous quarters and @ Q1


LeadProgress status as at October 2014

Period

Domain 3:Are CCG plans delivering better

outcomes for patients?

Focus

Progress status as at January 2015RAG

StatusRAG

Status

Q4 4.1 Quality and Patient Safety Committee reporting to Governing Body

CCG to ensure Governing Body oversight of potential impact of Trust CIP on quality and safety.

LO

LO/GB met with the Trust & agreed that a full list of CIP schemes, together with the Quality Impact Assessments, would be shared with the CCG w/c 3rd November. A meeting will be held between the Trust Associate Directors & the Heads of Commissioning during w/c 10th November to go through each scheme, to ensure full understanding. A CCG risk assessment in relation to quality & safety impacts, will be shared with the Governing Body after this work has taken place & updates given on a regular basis.

R

No further updates on CIP schemes and therefore, Quality Impact Assessments.

Isle of Wight NHS Trust is not meeting CIP target.

R

Q4 4.2 Governance of Better Care FundArrangements with IW Local Authority

CCG to agree governance and risk sharing arrangement GB

Governance will be through the Joint Adult Commissioning Board. A dash board is being developed to facilitate high level monitoring of all BCF schemes. The section 75 is being developed which will set out the risk share arrangements. This is due to be completed by January 2015

AOn track for delivery.

Any issues are being taken to the Joint Commissioning Board.A

Q1 4.1

Clinical Execs oversight on provider CIPs has raised some concerns. Provider has sourced outside provision to review. CCG discussions are around what has already been implemented and will be soon.

CCG to ensure Governing Body oversight of potential impact of Trust CIP on affordability, quality and safety.

LO/GB See Q4 4.1: any risks around affordability will also be reported to the Governing Body. R Briefings have been given to the Governing Body on the Trust's

current financial position and slippage experienced with CIPs. A

Q1 4.2

Area Team and CCG discussed governing body and clinical Executive accountability and decision making processes - Governing body meetings are held in public, Clinical Executive meetings are not. Decisions made around the delivery plan which are very detailed are made at the clinical Executive meetings then presented at the Governing body meetings.Strategy plans which are more overarching would be agreed at the Governing body meeting which is held in public.

CCG to examine guidance following Francis Report recommendations regarding transparency of business, to ensure CCG constitution follows good practice in terms of decision making by Governing body in public.

HS/CM

Review of Constitution under consideration and other CCG's Board papers and agendas being scrutinised for learning. Currently all strategic and serious/reputational issues taken to Governing Body in public.

Consideration is being given to publication of papers for Clinical Executive. Clear guidance to be developed for staff regarding expectations of papers in the light of publication.

R

Review of Constitution under consideration and other CCG's Board papers and agendas being scrutinised for learning. Currently all strategic and serious/reputational issues taken to Governing Body in public.

Consideration is being given to publication of papers for Clinical Executive. Clear guidance to be developed for staff regarding expectations of papers in the light of publication.

A

Q4 5.1

Co-Commissioning arrangementsCo-ordination and alignment with specialised servicesPrimary care ambition for re-engineering

CCG to further develop ambitions around primary care transformation to deliver strategy for population.

CM

Primary Care Strategy in development along with specific actions in relation to the development of a GP collaborative and innovative schemes to support practices in difficulty due to recruitment issues.

CCG working through implications of joint commissioning in tandem with review of transparency in constitution in Q1 4.2 above.

AAn application for co-commissioning has been made.

A 'Task & Finish' group is in place to manage the transition.A

Q4 5.2 Commissioning Support Service

CCG to ensure Lay member oversight and assurance around potential conflicts of interest where support services are provided to both commissioner and service provider.

LO Internal audit is being asked to review this as a specific piece of work. It will be timetabled in based on the availability of the internal auditors. A Internal audit is being asked to review this as a specific piece of work.

It will be timetabled in based on the availability of the internal auditors. A

Q4 6.1 Q3 Discussion on succession plan for Clinical Chair, progress update required.

CCG to give further consideration to clinical chair succession opportunities and continue with initiatives to encourage clinical input.

JR/HS See Q1 6.1 A See Q1 6.1 G

Q1 6.1Clinical Chair succession – Current chair agreed to remain in post at present until suitable successor is found.

CCG to pursue process to gain members ratification for extension to tenure of current Chair whilst recruitment process underway for replacement

CM

Proposal agreed by Clinical Executive regarding way forward for new clinical members and chair succession.

The Chair of the Membership Council will review and recommend to members in time for elections to commence in November. If the membership agrees, chair will remain in post for a further year while new chair is developed.

A

The Election process is due to commence in January 2015.

The Membership approved for the current Chair to remain in post for an extra year.

G

ASSURED (Q4 2013/14)


ASSURED (Q4 2013/14) & (Q1 2014/15)

ASSURED (Q4 2013/14) & (Q1 2014/15)

Focus Period Issues raised from previous quarters and @ Q1


LeadProgress status as at October 2014

Domain 4: Does the CCG have robust governance

arrangements?

Domain 6:Does the CCG have

strong and robust leadership

Domain 5: Are CCGs working in partnership with

others?

Governing Body Risk Register Summary Report Sponsor: Helen Shields, CCG Chief Officer

Summary of issue:

The Governing Body is invited to note the changes since the last report: • The number of risks that have been on the risk register for greater

than 12 months has increased from 8 to 10 in this report. • One additional risk regarding the ability of the system to cope with

additional demand has been added. • The issues concerning a domiciliary provider have been resolved and

this risk has now been removed from the register. • Two risk scores have been reduced reflecting reduced risk from the

CQC report at the Trust (although it still remains high) and the improved position with regard to support from the Public Health team.

In general the risk profile of the organisation is showing a larger number of high risks which are taking longer to resolve that the previous year, particularly in relation to issues associated with the CCG contract with the NHS Trust. It is recommended that the Governing Body ask the Clinical Executive to undertake a thorough review of all high risk areas and provide a report to the next Governing Body to provide assurance that all possible mitigating actions are being taken to reduce these risks.


The Governing Body is asked to review the summary report and determine whether it is assured that the CCG is its capturing and managing risks appropriately.

Principle risks:

Failure to produce a meaningful risk register could result in the CCG failing to take the required actions to ensure that it meets its targets and statutory duties.


The risk register is reviewed in detail monthly at the Clinical Executive and the outcomes of that review are detailed within the Clinical Executive minutes.


There are no new financial implications inherent in this report


Taken as a whole there is no material change to the overall risk in relation to legal implications.


Patient and public involvement is undertaken where appropriate to mitigate the level of risk against each line of the risk register.


Impact on equality and diversity is considered in each of the risks raised with a view to ensuring that they do not impact adversely on the CCG’s statutory responsibilities.

Author of Paper: Caroline Morris, Head of Primary Care and Corporate Business.




Governing Body February 2015

GB14-058 Risk register summary

Months >12 >6 >3 New

Risks 10 7 2 1

1 Risks added to register

1 Y2/25 Com Concerns regarding system resillience High

Risks removed from the register

Y2/7 Com Low

Y1/6

Risks with Reduced Score

Ref Score

Increased Scores

Reduced Scores Risks with Reduced Score

Ref Score

Y2/23 16 CQC report into Trust

Y2/16 6 Public Health Support

High RisksCommissioning IW NHS Trust Mental Health Leadership - Contract Notice

Achievement of 18 Week RTT - All providers

Contract Notice regarding Emergency Paediatric Services at IW NHS TrustResillience of system to cope with winter pressuresConcerns regarding quality in nursing home

Corporate -Finance -Quality Level of pressure ulcers in Trust and community

CQC findings at Trust

Implementation of Deprivation of Liberty Safeguards

1

1

20

Title

Concerns about Domiciliary Care Provider

Title

Summary Risk Register

Risk Distribution by Objective

Activity

Total Time on Register

0

2

0123456

Comm Fin Qual Corp

High

Medium

Low

Governing Body

Creation of Primary Care Co-Commissioning


Summary of issue: Paper considered by the Clinical Executive regarding the elections to the Clinical Executive and the approach to the management of succession for the committee and for the CCG chair.


To ratify the decision to apply for joint commissioning with NHS England in respect of primary care for 2015/16.

Principle risks:

The key risks associated with this paper are: • Increased CCG involvement in performance management of its

primary care members – this risk is minimal in the coming year where NHS England will be responsible for any actions required, although CCG executives and Governing Body members will be a part of any decision making process.

• Increased burden of bureaucracy within the CCG with no additional resources provided to undertake this work (see financial implications below)


The application form, terms of reference and changes to the constitution have been discussed at the Co-Commissioning Task and Finish Group and have been informally discussed by the Governing Body in Seminar Session.


There is concern that the co-commissioning agenda will increase the demands on the CCG staff and there is no additional resource provided to undertake this work. While the implications of this will be limited under the joint commissioning arrangements, the CCG will want to monitor any increase in administrative workload particularly in terms of its impact on capacity and running costs.


Once the joint committee is in place, the CCG will have a legally binding responsibility in relation to primary care commissioning. Although this is shared with NHS England, it changes the scope of responsibility of the CCG.


Engagement work has taken place with Healthwatch and with some patient participation groups, however greater engagement with patients and the public needs to take place in the coming financial year to ensure that there has been a clear conversation with the public about the future of primary care.


By engaging in co-commissioning, it will enable a more coherent strategy for tackling areas of local health inequality to be developed by bringing the commissioning of most local services under a single system.

Author of Paper: Caroline Morris. Head of Primary Care and Corporate Business

NHS Isle of Wight Clinical Commissioning Group Constitution - 1 - Version 3: NHS England Effective date tba

Date of Paper: 27 January 2015.



2

Creation of Primary Care Co-Commissioning with NHS England

1. Context

In July 2014, NHS England announced that it would offer the opportunity to all CCGs to become more involved in commissioning primary care. It was increasingly clear that the fragmentation of health systems across multiple commissioners was not supporting the strategic direction for the NHS and preventing the integration agenda from being taken forward, particularly in respect of primary care services.

The Governing Body will recall that it approved the Isle of Wight CCG application to take on additional primary care responsibilities at that time (GB14-18). However NHS England did not set a clear strategic framework for the application process and received applications from most CCGs with each CCG taking a “pick and mix” approach to which aspects of primary medical care it wished to take on. Each was different from the next, making the attempt to delegate responsibility an administrative impossibility.

So in November 2014, NHS England proposed a new approach offering CCGs three potential levels of involvement in primary care. These related only to primary medical care (i.e. GPs) and were:

• Greater involvement – no structural change but an expectation that the CCG would concern itself with the quality and commissioning arrangements for primary medical care

• Joint Commissioning – sharing responsibility through a committee with NHS England • Delegated commissioning – fully delegated responsibility to the CCG with NHS England taking on an

assurance function over the CCG for primary medical care.

2. Process

In mid-December 2014 the rules regarding co-commissioning applications were published with a deadline for CCGs to apply in mid to late January depending on the scale of ambition they had. A number of events for CCGs were held to explore the implications of each level of involvement and a conversation with members and the executive leadership within the CCG began. Following this, the CCG recommended to members that the ambition should be to have full delegation for primary medical care, however with many of the rules and underlying assumptions, particularly regarding the treatment of the primary care budget, still unclear; the immediate proposal was to aim for joint commissioning that would leave all budgets in their current place while greater clarity is developed. It should be noted that the CCG running cost allowance has not been changed to take account of the additional work that joint commissioning will bring with it.

2.1 Stakeholder Involvement in decision-making

The CCG was required to consult with a wide range of stakeholders in relation to the development of co-commissioning locally. At this stage the CCG has undertaken sufficient consultation to move to a joint commissioning approach, but will take the opportunity in this coming year to engage in a much wider conversation with patients and the public to prepare for fully delegated decision making. The following engagement has taken place:

3

• The membership has been consulted in relation to this decision via e-mail and face-to-face discussions as part of a round of practice visits. Each member has formally agreed the direction of travel and immediate approach.

• Healthwatch has been consulted and a short explanatory paper written for their Board that they discussed in January. Healthwatch has written to the CCG demonstrating support for the direction of travel and hopeful that this will offer greater transparency of decision making around primary care. Discussions have also taken place as to how the observer seat on the Committee will be managed.

• The specific issue of co-commissioning has also been raised with members of the Health and Wellbeing Board informally (as no meeting has taken place in the time between receiving the information and the application deadline). This will form an agenda item at the next formal meeting.

• In July 2014 at the request of the CCG, a small number of practices consulted their patient participation groups (PPGs) regarding co-commissioning and the acceptability of the CCG becoming more involved in primary care. Groups were broadly supportive of more local decision making.

• The CCG’s strategy including its strategic approach to primary care development was subject to formal consultation with patients and public in 2014. This set out the ambition to reform primary care to work at scale in a more integrated manner with the newly forming localities.

2.2 Joint Committee for Primary Medical Care

Joint commissioning involves the creation of a new Governing Body subcommittee and a formal delegation of decision making powers on behalf of both the CCG and NHS England to that committee. The committee will take full responsibility for all strategic, commissioning and quality functions in primary medical care.

The Committee is required to have a lay and executive majority. The proposed membership of the committee is attached as part of the Terms of Reference in Annex A.

As this committee is a formal subcommittee of the Governing Body, it has required amendments within the CCG constitution. The Committee will report both to the Governing Body and to NHS England Wessex Area Team and will have formal decision making powers for both organisations.

At the same time updated statutory guidance for CCGs regarding conflict of interest were published, the consequences of which have also been included in this update to the constitution. These are detailed below. Of note is the need to ensure that GP members of the CCG are protected from both real and perceived conflicts of interest. As a consequence of this, the committee will have only one voting GP member, although the GP voice will be heard through the development of papers for this committee.

2.3 The Application Process

A Task and Finish Group was established by the CCG in conjunction with the Wessex Area Team with a view to:

1) Overseeing the application process 2) Managing the transition to the first committee meeting expected in April 2015

This committee was able to meet twice before the application deadline and comment electronically on the proposed application documents. The application process has involved:

• The creation of terms of reference for this committee (Annex A); • The completion of a short 400 word application form that seeks to articulate the benefit to patients of

the joint committee (Annex B);

4

• Consequential Constitutional amendments

In addition, this paper will also be submitted to the Wessex Area to demonstrate that the CCG has met the statutory hurdles required to be considered for joint commissioning.

3. Key changes to the CCG constitution

The move to joint commissioning has required amendments to the CCG Constitution. The key changes are:

• To create the new joint committee for primary care as a subcommittee of the Governing Body. This includes: o changing the strategic scheme of delegation to empower the new committee to make decisions

regarding primary care in all aspects of commissioning, quality and performance management. o consequential amendments in relation to the functions of Quality and Patient Safety Committee

and Clinical Executive to show shared responsibility for primary care in their respective areas. • To strengthen the section on conflicts of interest and transparency to comply with the updated Statutory

Guidance published by NHS England in December 2014 to include: o recognising the impact of perceived conflict of interest, o introducing a conflict of loyalty, which may be a loyalty owed to a professional organisation or

union or an individual o publication of details of all contracts including values on the CCG web site and also in the annual

report o publication of deliberations regarding conflict of interest on the CCG web site o new requirement for the Audit Committee to oversee the operation of the conflicts of interest

approach in the CCG o these amendments are being approved by the Membership Council on the 28th January 2014

4) The future

The CCG will this year engage in a conversation with patients and the public about the future shape of primary care, particularly in the context of the five year forward programme and the opportunity to explore alternative provider models of care and to move integration of services forward. The CCG anticipates that it will need full delegation of responsibility for primary medical care to carry out the results of this work.

Nationally there are also discussions beginning about the potential to delegate other aspects of primary care work, such as pharmacy and optometry to CCGs to support greater innovation in the use of these contractor groups.

5) Recommendation

The Governing Body is asked to ratify the application that the CCG has made to enter into a joint arrangement with the Wessex Area team of NHS England for the purposes of commissioning primary medical care services for the Isle of Wight.

Caroline Morris Head of Primary Care and Corporate Business January 2015

5

Annex A – Terms of Reference

Terms of Reference for Primary Medical Care Joint Commissioning arrangements including Scheme of

Delegation

1. INTRODUCTION 1.1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England

was inviting Clinical Commissioning Groups (CCGs) to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England and CCGs would jointly commission primary medical services.

1.2. The NHS England and Isle of Wight CCG joint commissioning committee is a joint committee with the primary purpose of jointly commissioning primary medical services for the people of the Isle of Wight.

2. STATUTORY FRAMEWORK 2.1. The National Health Service Act 2006 (as amended) (“NHS Act”) provides, at section 13Z, that

NHS England’s functions may be exercised jointly with a CCG, and that functions exercised jointly in accordance with that section may be exercised by a joint committee of NHS England and the CCG. Section 13Z of the NHS Act further provides that arrangements made under that section may be on such terms and conditions as may be agreed between NHS England and the CCG.

2.2. Under section 14Z9 of the NHS Act 2006 (as amended), the CCG has formally delegated certain functions to the joint committee.

2.3. Section 14Z9 of the NHS Act was amended by Legislative Reform Order (2014/2436) (“LRO”) to enable the joint exercise by NHS England and a CCG of any of the CCGs commissioning functions and any other functions of the CCG which are related to the exercise of those functions. Where such arrangements are made, the LRO enabled them to be exercised by a joint committee established between the parties.

6

3. ROLE OF THE JOINT COMMITTEE 3.1. The role of the Joint Committee shall be to carry out the functions relating to the commissioning

of primary medical services under section 83 of the NHS Act except those relating to individual GP performance management, which have been reserved to NHS England and such CCG functions under sections 3 and 3A of the NHS Act as have been delegated to the joint committee.

3.2. This includes the following activities:

3.2.1. NHS England:

i. GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);

ii. Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);

iii. Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);

iv. Decision making on whether to establish new GP practices in an area;

v. Approving practice mergers; and

vi. Making decisions on ‘discretionary’ payments (e.g., returner/retainer schemes).

3.2.2. Isle of Wight CCG in respect of services commissioned from primary medical care or equivalent providers:

i. Strategic planning in respect of primary medical care

ii. Commissioning and procuring services from primary medical care

iii. Assisting NHS England in relation to the improvement of the quality of primary care medical services

iv. Oversight of budget and quality management in respect of primary medical care

v. Integrating health services as defined by the overarching CCG strategies and programmes of work

3.3. In performing its role the Joint Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and Isle of Wight CCG, which will sit alongside the delegation and terms of reference. – [This is the proposed agreement to deal with such as information sharing, resource sharing, contractual mechanisms for service delivery (and ownership) and interplay between contractual and performance list management.]

7

4. GEOGRAPHICAL COVERAGE 4.1. The Joint Committee will comprise NHS England Wessex Area Team, and the Isle of Wight CCG.

It will undertake the function of jointly commissioning and overseeing primary medical services for the Isle of Wight.

5. MEMBERSHIP 5.1. The Joint Committee shall consist of:

i. The CCG Lay Member for Governance (Chair)

ii. The CCG Accountable Officer

iii. The CCG Chief Finance Officer

iv. The CCG Director of Clinical Services and Quality

v. The CCG Head of Primary Care and Corporate Business

vi. The GP member of the Governing Body for the CCG

vii. Either the Secondary Care Doctor or Governing Body Nurse for the CCG

viii. A Wessex Area Team Director of Commissioning

ix. A Wessex Area Team Director of Quality

x. A Wessex Area Team Director of Finance

xi. The Isle of Wight Director of Public Health

5.2. The Chair of the Joint Committee shall be the Lay Member for Governance of the Isle of Wight CCG.

5.3. The Vice Chair of the Joint Committee shall be the Accountable Officer of the Isle of Wight CCG.

5.4. The non-voting attendees at the committee will include:

i. A representative from Isle of Wight HealthWatch

ii. A representative of the local Health and Wellbeing Board

iii. CCG Clinical Lead for primary care

6. MEETINGS AND VOTING 6.1. The Joint Committee shall adopt the Standing Orders of Isle of Wight CCG insofar as they relate

to the:

i. Notice of meetings;

8

ii. Handling of meetings;

iii. Agendas;

iv. Circulation of papers; and

v. Conflicts of interest

6.2. Each member of the Joint Committee shall have one vote. The Joint Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary.

6.3. The primary care joint committee will normally be quorate when there are six members present, including three from of the Wessex Area Team.

6.4. Deputies may attend the meeting in the absence of members, but may not vote or be included in quorum numbers unless formal acting up arrangements are in place.

6.5. The Committee shall meet a minimum of six times per year and normally every other month.

6.6. Meetings of the Joint Committee:

i. Shall, subject to the application of 6.6(ii), be held in public.

ii. The Joint Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

6.7. Members of the Joint Committee have a collective responsibility for the operation of the Joint Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

6.8. The Joint Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

6.9. Members of the Joint Committee shall respect confidentiality requirements as set out in the Standing Orders referred to above unless separate confidentiality requirements are set out for the joint committee in which event these shall be observed.

6.10. The secretariat function to the Joint Committee will be provided by Isle of Wight CCG.

6.11. The secretariat to the Joint Committee will:

i. Circulate the papers and agenda for the meetings a minimum of 5 working days prior to the meeting

9

ii. Circulate the minutes and action notes of the committee with 5 working days following the meeting to all members.

iii. Present the minutes and action notes to Wessex Area Team of NHS England and the governing body of Isle of Wight CCG as required.

6.12. These Terms of Reference will be reviewed from time to time, reflecting experience of the Joint Committee in fulfilling its functions and the wider experience of NHS England and CCGs in primary medical services co-commissioning.

7. DECISIONS 7.1. The Joint Committee will make decisions within the bounds of its remit.

7.2. The decisions of the Joint Committee shall be binding on NHS England and Isle of Wight CCG.

7.3. Decisions will be published by both NHS England and Isle of Wight CCG.

7.4. The secretariat will produce an executive summary report which will presented to The Wessex Area Team of NHS England and the governing body of Isle of Wight CCG quarterly in advance of the formal performance review for information.

8. KEY RESPONSIBILITIES 8.1. The joint committee will take responsibility for the following functions on behalf of the CCG and

NHS England Wessex Area Team:

i. Oversight and assurance of strategic planning processes, including carrying out needs assessments,

ii. Decisions related to the overarching strategy and framework for primary care on the Isle of Wight

iii. Oversight and assurance of the implementation of strategic plans

iv. Oversight to ensure a co-ordinated and common approach to primary medical care, including assuring both organisations that there has been appropriate application of national policies

v. Oversight and assurance of the operational management of primary medical care services on the Isle of Wight

vi. Decisions related to the commissioning and procurement of services

vii. Oversight and assurance of the management of relevant budgets

viii. Oversight and assurance of the duty to improve the quality of primary medical care

10

9. REVIEW OF TERMS OF REFERENCE 9.1. These terms of reference will be formally reviewed by the Wessex Area Team of NHS England

and Isle of Wight CCG in April of each year, following the year in which the joint committee is created, and may be amended by mutual agreement between the Wessex Area Team of NHS England and Isle of Wight CCG at any time to reflect changes in circumstances which may arise.

10. SIGNATURE PROVISIONS 10.1. On behalf of the Isle of Wight CCG:

_________________________________________________________

Helen Shields

Accountable Officer

Date: _____________________________________________________

10.2. On Behalf of NHS England Wessex Area Team:

__________________________________________________________

Dominic Hardy

Area Team Director

Date: ______________________________________________________

11

SCHEDULE 1 – DELEGATION BY CCG TO JOINT PRIMARY CARE COMMITTEE

The CCG Governing Body has delegated to this subcommittee the following functions in so far as they relate to the exercise of its duties in relation to primary medical care. This delegation is reflected in the Overarching Scheme of Delegation and as amendments to the CCG constitution made in January 2015.

Where the Governing Body has delegated these functions, it wishes to receive an executive summary report as detailed within the terms of reference of the Joint Committee that indicates how the committee has gone about delivering their delegated responsibilities.

CCG Functions and General Duties

Level of Delegation to the Joint Committee

1. Working in partnership to develop a joint strategic needs assessment and joint health and wellbeing strategies.

This function is delegated to the clinical executive, however in respect of primary care the joint committee will have oversight of the conclusions reached and actions proposed and should be included in the consultation process

2. To act efficiently effectively and economically

The Governing Body delegates to the joint committee the responsibility for the oversight and assurance in this area, including decision making powers in respect of commissioning services from this provider group.

In respect of primary medical care, the power to agree the overarching strategy is delegated to the Joint Committee (all other strategy is agreed by the Clinical Executive)

3. To Support NHS England to secure the continuous improvement of the quality of services

The Governing Body delegates to the joint committee responsibility to support NHS England in this duty. (Note that other quality issues related to CCG Commissioned services are dealt with by the Quality and Patient Safety Committee)

4. Promoting innovation The Governing Body delegates to the joint committee responsibility to promote innovation in respect of primary medical care (note that this function for all other services within the CCG remit rests with the clinical executive)

5. Promoting education and training for persons connected with the provision of services to the NHS

The Governing Body delegates to the joint committee responsibility to promote innovation in respect of primary medical care (note that this function for all other services within the CCG remit rests with the clinical executive)

6. Promoting integration This function will continue to rest with the Clinical Executive, however the Joint Committee has a legitimate interest in

12

reviewing the CE actions to achieve this in respect of primary medical care and may request updates or offer insights to this committee in the exercise of this duty.

In respect of other duties laid down by statute on the CCG including the duty to:

• have regard to the need to reduce health inequalities

• work to secure public involvement in the planning, development and consideration of proposals for change and decisions affecting the operation of commissioning arrangements

• promote the involvement of patients, their carers and representatives in decisions about their healthcare

• act with a view to enable patients to make choices

• obtaining appropriate advice from persons who taken together, have a broad range of professional expertise

the Joint Committee will work within the policies and procedures laid down by the CCG to secure the exercise of these functions.

13

SCHEDULE 2 - LIST OF MEMBERS

CCG Governing Body Lay Member for Governance Mr Frederick Psyk

CCG Accountable Officer Helen Shields

CCG Chief Finance Officer Loretta Outhwaite

CCG Head of Primary Care and Corporate Services Caroline Morris

CCG Director of Clinical Services and Quality Loretta Kinsella

Wessex Area Team Director of Commissioning Sue Wise

Wessex Area Team Director of Finance Mark Orchard

Wessex Area Team Director of Quality Ruth Williams

Isle of Wight Director of Public Health Dr Rida Elkhir

GP Member of the Governing Body Dr Joanna Hesse

CCG Secondary Care Doctor or Nurse

Note: Greyed members have a clinical background.

14

Annex B – Application Form

PART I: TO BE COMPLETED BY THE CCG

Objectives and benefits: briefly describe the objectives and intended benefits of the joint commissioning arrangements, particularly the benefit to patients <maximum 400 words>

The CCG is seeking to develop integrated patient-centred care through a community-based locality model with primary care a central and controlling element in this approach. The CCG’s overarching aim is to ensure that patients’ health, support and care is directed by the patient themselves and that the agencies around the patient are well coordinated. In doing so, the system will be more efficient and responsive, able to manage the growing demand for care more effectively. Following extensive patient and public consultation, the benefits of this model for the patient were encapsulated into the following “I” statements:

1. I’ll no longer be a patient or a client – I’ll be a person

2. I have access to easy to understand information about health, wellbeing, care and support which is consistent, accessible and up-to-date.

3. I am able to get skilled advice to plan my care and support

4. I can plan ahead and keep control at times of crises

5. I have considerate support delivered by competent people

In the next two years, the CCG will use the opportunities offered by joint commissioning to further these goals and in particular:

o Ensure convenient and local access for patients through the redesign of urgent care services on the island. This will build on both in hours and out of hours primary care services;

o Commission services for patients with complex and long term conditions that will support joined

up and coordinated care through the locality working model mentioned above and the implementation of shared records systems;

o Ensure sustainable primary medical care services through development of a coherent and

comprehensive approach to workforce development, tackling the GP recruitment crisis locally. o Engage in an in depth discussion with local people and patients on the future shape of health

services and in particular primary and community care as part of the wider five year forward programme.

o Improve the care of people with Dementia by recommissioning services, integrating QOF, DES

and local schemes in a unified approach that aligns both national and local priorities.

15

o Improve outcomes for people with complex conditions by taking the AUA DES, Care Planning

and the local ACP scheme and creating a unified primary care approach that can be contracted locally.

o Recommission local primary care services via outcomes-based contracts, freeing providers to

innovate in the delivery of services based on the needs of their patients at local level.

Declaration: to be completed by the CCG on or before 30 January 2015 I hereby confirm that NHS Isle of Wight CCG membership and governing body have seen and agreed to all proposed arrangements in support of taking on joint commissioning arrangements for primary medical services in partnership with NHS England for 2015/16.

Signed on behalf of NHS Isle of Wight CCG governing body

Name: Dr John Rivers

Position: Chair

Date:

Signed by NHS Isle of Wight CCG Accountable Officer

Name: Helen Shields

Position: Accountable Officer

Date:

16

Governing Body Policy Statement 001 – Interventional Procedures for Varicose Veins Sponsor: Helen Shields, Chief Officer

Summary of issue:

The Southampton, Hampshire, Isle of Wight & Portsmouth Priorities Committee were tasked with reviewing the most recent evidence of clinical and cost effectiveness for varicose vein treatment, to make recommendations to the CCG regarding access criteria. This paper summarises the position.


Approve the proposed Policy Statement 001 – Interventional Procedures for Varicose Veins.

Principle risks:

The recommended policy is not in accordance with NICE guidelines; however clinicians have the ability to refer individual patients to Individual Funding Request (IFR) Panels where they feel there is exceptionality.


Isle of Wight CCG Clinical Executive (November 2014) SHIP8 Clinical Commissioning Group Priorities Committee (July 2014)


The proposed guidance is very similar to the current policy and therefore little change to the current costs.

Legal implications/ impact: The recommendation is not in accordance with NICE guidelines.

Public involvement /action taken: Lay member attendance at SHIP8 Priorities Committee.


The policy statement will ensure equity of application across the SHIP8 CCGs. There is no diversity impact relating to this.

Author of Paper: Helen Shields, Chief Officer

Date of Paper: 27th January 2015



Varicose Veins: Review of Policy Statement

1. Introduction

The Isle of Wight Clinical Commissioning Group when formed in April 2013 agreed to an Individual Funding Request Policy and adopted the existing Isle of Wight Primary Care Trust policy statements. Policy Statement 39: Interventional procedures for varicose veins dated April 2008 was one of these policies (Annex A).

Following an update to the National Institute for Health and Care Excellence (NICE) guideline for varicose veins in the leg in July 2013 (Annex B), the Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP) Priorities Committee was tasked by the Clinical Commissioning Groups (CCG’s) to review current evidence regarding the clinical and cost effectiveness of treatment for varicose veins and the implications of the updated NICE guidelines on the current policy. NICE guidelines are not mandatory to implement.

The purpose of this paper is to summarise the SHIP priorities proposed policy recommendations relating to access criteria to varicose vein treatment.

2. Priorities Committee

The SHIP Priorities Committee comprises of senior clinical and non-clinical members who are representatives of all CCGs across SHIP and also others who provide specialist knowledge. Core members include representatives from Public Health, GP’s, secondary care consultant, health watch, a CCG Chief Officer and lay representatives.

The committee makes recommendations to CCGs who then undertake their own process to come to a decision.

The committee reviewed the NICE guidelines and were provided with further information on the evidence base for treatment and the criteria which would benefit. A key issue was the quality of published studies. NICE reported on 4 studies one of which was graded by NICE as low quality and the other 3 as very low quality.

The Priorities Committee approved policy statement 001: Interventional procedures for varicose veins August 2014 (Annex C) for recommendation to CCG’s.

The revised policy statement 001 August 2014 being proposed is very similar to the previous statement 39 April 2008. The main changes are no specific reference to the use of compression stockings, exercise and daily elevation and additional reference to severe thrombophlebitis may be an indication for treatment.

The revised policy 001 August 2014 differs from NICE guidelines which refers to symptomatic primary or symptomatic recurrent varicose veins, lower limb skin changes and superficial vein thrombosis.

1

3. Individual Funding Request Policy

The Individual Funding Request (IFR) Policy allows for patients who do not meet the criteria of policy statements but have exceptional circumstances to be referred to the IFR panel for consideration.

In 2013/14 5 patients were referred, 4 were not approved, 1 was approved. In 2014/15 (to date) 11 patients were referred, 10 were not approved, 1 was approved.

4. Recommendation

The Clinical Executive considered the revised policy in November 2014 and recommend to the Governing Body to approve Policy Statement 001: Interventional procedures for varicose veins

Helen Shields Chief Officer January 2015

2

Annex A

3

Annex B

4

5

Annex C

SHIP8 Clinical Commissioning Groups’ Priorities Committee Policy Statement 001: Interventional procedures for varicose veins Date of issue: August 2014

1. National Institute for Health and Care Excellence. Varicose veins in the leg: the diagnosis and management of varicose veins (CG168). London: NICE, 2013. (http://guidance.nice.org.uk/CG168)

NOTES: Exceptional circumstances may be considered where there is evidence of significant health impairment and there is also evidence of the intervention improving health status. This policy may be reviewed in the light of new evidence or guidance from NICE.

People with a body mass index less than 32 kg/m2 who satisfy at least one of the following criteria may be considered for interventions to treat varicose veins:

• a first venous ulcer persists despite a six-month trial of conservative management of the ulcer

• a recurrent venous ulcer • haemorrhage from a superficial varicosity

NHS funding for treatment in all other circumstances is LOW PRIORITY.

Varicose veins are veins which have become enlarged and tortuous. They are usually asymptomatic, but can be complicated by inflammation, skin changes including ulceration, and rupture and bleeding.

In exceptional circumstances, recurrent and severe thrombophlebitis in some patients may be an indication for treatment. Such patients should be referred via the individual funding request route.

It would be useful to identify patients with varicose veins at greater risk of developing venous ulceration. In its clinical guideline on varicose veins1, NICE reported four studies about which signs, symptoms and/or patient characteristics are associated with the progression of varicose veins to a more severe stage or to ulceration. One was published only in abstract, and the other three used case-control designs, which have a high risk of bias. NICE graded one as low quality, and the other three as very low quality. This evidence does not provide a reliable indication of which patients will progress to ulceration.

6

Governing Body Policy Statement 002 – Assisted Conception Services (IVF)


Summary of issue:

The SHIP (Southampton, Hampshire, Isle of Wight and Portsmouth) Priorities Committee was tasked with reviewing the most recent evidence of clinical and cost effectiveness for IVF treatments, and the implications of the latest NICE guideline, and to make recommendations to the CCGs regarding access criteria. This paper summarises the review of the clinical evidence, the Priorities Committee recommendations, and the results of public engagement work which was undertaken to inform the decision-making process.


Approve the recommendations of the SHIP8 Priorities Committee, in the light of the results of public engagement

Principle risks:

Possible challenge from patients and clinicians as new statement is still not in accordance with full NICE Guidelines; however clinicians have the ability to refer individual patients to the Individual Funding Request panel where they feel there is exceptionality.


IOW CCG Clinical Executive (recommended for approval - 18th December 2014) SHIP8 Clinical Commissioning Groups Priorities Committee (August 2014)


There will be a small financial impact to the CCG due to the additional frozen embryo transfer. Full implementation of NICE guidelines would significantly increase the CCG’s IVF costs.

Legal implications/ impact: The recommendations are not in accordance with NICE Guidelines


A Public Engagement exercise carried out across all SHIP8 CCG areas from September to November 2014 to gather views on the priority of IVF funding for the NHS and the proposed access criteria for treatment.


An Equality analysis and impact assessment identified both positive and negative impacts which need to be considered

Author of Paper: Steve Rowe (Commissioning Manager, Acute)



Page 1 of 21

Contents 1.0 Introduction ........................................................................................................................................ 3

2.0 Priorities Committee ........................................................................................................................ 3

3.0 Public Engagement .......................................................................................................................... 6

4.0 Equality Impact assessment .......................................................................................................... 7

5.0 Recommendations ........................................................................................................................... 8


Page 2 of 21

Assisted Conception (IVF): Review of Access Criteria 1.0 Introduction To enable access to treatment such as In-Vitro Fertilisation (IVF) a shared policy has been in place for five years across the Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP) region to ensure consistent access for patients requiring fertility treatment. For Isle of Wight patients the decision to provide access to fertility treatment is the responsibility of the Isle of Wight Clinical Commissioning Group. With some procedures costing up to £4000 per patient this requires the CCG to balance funding for this treatment alongside the need for other services within a finite budget. Following an update to the National Institute for Health and Care Excellence (NICE) Guideline for IVF (Annex A) in February 2013, the Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP) Priorities Committee was tasked by the eight Clinical Commissioning Groups (CCG’s) across the region to review current evidence regarding the clinical and cost effectiveness of IVF treatments and the implications of the updated NICE guidelines on the current policy statement. NICE Guidelines are not mandatory to implement. The purpose of this paper is to summarise the SHIP Priorities Committees proposed policy recommendations relating to access criteria to IVF services and the results of the public engagement process. 2.0 Priorities Committee The SHIP Priorities Committee comprises of senior clinical and non-clinical members and is constituted under the direction of the eight CCGs across Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP). Its role is to advise those organisations on the most effective interventions for health gain within available resources and includes making recommendations on the implications of new and updated NICE guidelines. With an independent Lay Chair, core membership includes a Public Health Consultant, GPs, a Secondary Care Consultant, a CCG Quality Lead, Healthwatch representatives, a CCG Lay member, a director of finance and 2 CCG Chief Officers (see Annex D for Terms of Reference). In July 2014 the Priorities Committee asked Solutions for Public Health (SPH) to review the clinical and cost effectiveness of IVF to support the development of local access criteria. The criteria that the review focussed on was age, the availability of fresh and frozen embryos, the number of cycles of treatment, Body Mass Index (BMI) and smoking status. The remainder of the other current criteria were not in the scope of the review. The Committee met in August 2014 to review the findings of the report and again in September 2014 to agree their recommendations. A summary of the Committee’s findings from the review is outlined below and Table 3 provides a comparison between NICE Guidelines, current criteria and the proposed criteria. The current Policy Statement 150 and proposed Policy Statement Recommendation 002 are attached with this report as Appendixes 1 and 2. Age

Page 3 of 21

The review highlighted that there was good evidence that increasing age was a key predictor in determining successful fertility treatment. However, despite recent improvements in IVF treatment the success rate even for the youngest age group (18-34) remains low at 32% and this success rate declines significantly after the age of 34. See Table 1 below.

Woman’s age Live birth rate per treatment cycle started using patient’s fresh eggs in 2011 (%)

All ages 25.4 18-34 32.2 35-37 27.4 38-39 19.9 40-42 13.4 43-44 5.1 45-50 0.8

Table 1: The influence of increasing maternal age on the outcomes of IVF1 Fresh/Frozen There was good evidence to support the use of fresh and frozen embryos in a cycle with live birth rates improving over time and the Committee attached great significance to the fact that any transfer of frozen embryos avoided the need for women to undergo additional treatments associated with a fresh embryo transfer.

Age 2011 (frozen) 2012 (frozen) 2011 (fresh cycle) 18-34 years 21.4% 22.1% 32.2%

35-37 20.7% 20.7% 27.4% 38-39 17.1% 18.2% 19.9% 40-42 13.1% 15.0% 13.4%

Table 2: Live birth rate per cycle started after frozen embryo transfer using patients’ eggs2 BMI The report confirmed that research showed a BMI level of >28kg/m2 had an adverse effect on fertility treatment. Smoking Although clinicians confirmed that very few current IVF patients smoke by the time they reach clinic those who do have limited success. Table 3 - Comparison of IVF Access Criteria Criteria Current SHIP access

criteria – Interim Policy Statement 150

2013 NICE guideline 156

Proposed SHIP access criteria – Policy

Recommendation 002 Age of woman at time of referral

Up to 35 years old (treatment must start before the woman is 35)

Up to and including 42 years old

No Change – it was agreed to leave the current age criteria as the current policy of 35 years

1 Source: HFEA 2012 Report 2 Source: Fertility Treatment in 2012: trends and figures. HFEA 2012.

Page 4 of 21

Availability of fresh and frozen cycles

Fresh treatment only Full fresh cycle and all subsequent frozen cycles

A cycle would now include two embryo transfers either a Fresh/Frozen transfer or a Frozen/Frozen transfer

Number of cycles available

One Cycle Three cycles for women under 40 years old (one cycle for women aged 40 to 42 years)

One Cycle No Change in the number of cycles however see note above). The Committee noted that there has been no new evidence since 2011 to support increasing number of cycles

BMI eligibility Women must have had a BMI of between 19.0 and 29.9 for six months or more

Offer advice to women with a BMI above 29.9 to lose weight in order to increase the success rate and reduce complications during their pregnancy

No change to the current threshold <30kg/m2

Smoking status Couples must be non-smoking

Offer advice and refer to a local smoking cessation programme

No change - The Committee agreed that it was an absolute requirement that couples should stop smoking 6 months prior to IVF treatment and that smoking cessation treatment should start as early as possible in the referral pathway.

Cost The Committee also reviewed the financial modelling in the report which provided estimated cost scenarios based on differing combinations of criteria. Data showed that the eight CCGs currently spend approximately £1.25m a year on infertility treatments. A full implementation of the NICE Guidelines would cost approximately £4.7m per year in total which would represent a recurrent cost pressure of £3.45m across all CCGs. Table 4 below highlights the cost implications of introducing 3 cycles for the Isle of Wight CCG using current patient demand for services based on no change in the age criteria. Isle of Wight CCG

costs Current SHIP access

criteria – Interim Policy Statement 150

2013 NICE guideline 156

Proposed SHIP access criteria – Policy

Recommendation 002 Number of cycles available (based on current levels of demand (24 patients)

One Cycle

Three cycles to women under 40 years old (one cycle for women aged 40

to 42 years

One Cycle (2 Embryo transfers)

£70,488 £243,864 £81,288 Table 4 – IVF Cost modelling for Isle of Wight CCG However the report did suggest that criteria relating to the availability of fresh and frozen embryos would increase the number of live births and improve the cost effectiveness of treatment without incurring a significant increase in the overall level of spending.

Page 5 of 21

3.0 Public Engagement In conjunction with the Priorities Committee review of access criteria a SHIP wide public engagement exercise was undertaken from the 22nd September to the 7th November 2014 using an online survey to ask if IVF was a priority for NHS Funding and further questions related to service provision and criteria. A range of communications including press releases, websites and social media were also used to promote this survey with CCGs also contacting local stakeholders directly to invite them to participate. This exercise met the communication and engagement requirements of the NHS. Engagement Summary In total there were 1133 responses received from residents across the SHIP area, of these 191 (18%) were responses from the Isle of Wight CCG area (0.085% of the IOW population). Figure 1 shows the response to the survey by CCG area. The respondents from the Isle of Wight were younger than the total sample (more than 64% were 39 years or younger compared to just over half for the whole SHIP area) and the proportion of those saying that they had direct experience of IVF treatment (28%) was higher than the total sample (26%).

Figure 1 – Respondents by CCG Area

Table 5 provides a comparison of the responses from the Isle of Wight population to the online survey questions against the responses across the rest of the SHIP region.

Question Options IOW (%) SHIP(%) Do you think IVF is a priority for the NHS

Yes 58 44

No 37 47 Don’t Know/No Opinion 5 8

15.5

14.94

8.21

8.76

18.91

4.43

17.62

11.62

0 10 20

West Hampshire

Southampton

South Eastern Hampshire

Portsmouth

North Hampshire

NE Hampshire and Farnham

Isle of Wight

Fareham and Gosport

Page 6 of 21

Age NICE Guidance in full 61 47

Existing Criteria 17 22 Extend age to 38 years 19 27 Don’t Know/No Opinion 4 4

Fresh and Frozen Transfers

NICE Guidance in full 66 52 Existing Criteria 14 17 Extend to one fresh/one frozen

14 23

Don’t Know/No Opinion 5 8 Number of Cycles NICE Guidance in full 78 66

Existing Criteria 17 26 Don’t Know/No Opinion 4 7

BMI NICE Guidance in full 53 41 Existing Criteria 44 56 Don’t Know/No Opinion 3 3

Smoking NICE Guidance in full 23 27 Existing Criteria 64 71 Don’t Know/No Opinion 1 2

Age Band 22 years or younger 4 1 23-29 Years 61 52 40-49 Years 14 17 50 Years or older 21 30

Had previous IVF treatment or seeking IVF treatment

Yes 28 26

No 72 74

Table 5 – Comparison of survey results isle of Wight/SHIP Annex B provides an illustration of this comparison across SHIP, the IOW CCG and NE Hampshire. All free text comments from the survey have been analysed on a SHIP wide basis and as such are contained in the SHIP Listening Exercise Findings report3, (Appendix 3). 4.0 Equality Impact assessment The Equality Analysis and Impact assessment report (Appendix 5) has been carried out and identifies both the positive and negative impacts relating to the access criteria for IVF treatment and can be summarised as follows: Eligibility criteria for access to NHS funded IVF treatment has a positive equality impact for women under 35 years (this includes single women and women in same sex relationships) as well as men of any age with confirmed fertility problems. Patients with disabilities and other health conditions that impact on fertility can also access treatment under the policy which also has a positive impact for partners and close relatives of those who are unable to conceive. There may be a negative impact on women over 35 years of age as funding will not be available, especially if they are unable to pay for private infertility treatment. However this is mitigated in that patients who don’t meet the criteria can make an Individual Funding Request in exceptional circumstances if supported by their clinician.

3 Help us to shape local IVF services for the future: Listening Exercise Findings, SHIP, 2014 Page 7 of 21

The proposed policy is still more restrictive than NICE Guidelines (although CCGs are not legally obligated to implement NICE Guidelines, unlike Technical Approval Guidance (TAG) that should be implemented within 3 months of publication) and this may have a negative impact for patients who fall outside of the proposed criteria. The assessment states that any negative impacts that may be discriminatory against groups that are protected under the Equality Act 2010 depend on whether policy can be reasonably justified on the basis of evidence. Evidence in the recent report by SPH on clinical and cost effectiveness suggests that increasing age is a key predictor of successful IVF treatment and as such the success rate for women aged 35-37 reduces after that age. However the use of frozen embryos is supported by the evidence and the Committee have proposed that one cycle will now include two separate embryo transfers. In order to ensure that any negative impact for women aged 35-37 or any other groups is mitigated and to support demonstration of due regard to the Equality Act 2010 it is suggested that decision making processes are demonstrably fair and transparent. It also recommends that the collection and analysis of equalities information about people who receive NHS funded infertility treatment and those who apply for funding via the IFR panel is commenced by providers. Analysis of this date may highlight differential access for equality groups to be considered for future reviews and will demonstrate fairness. 5.0 Recommendations The Priorities Committee noted the following: There was strong evidence that maternal age was “a key predictor in determining the likely success or otherwise of fertility treatment”, and set out how the likelihood of success reduces as age increases. They noted that even for the younger age group, (18-24 years of age), the overall chances of a live birth as a result of IVF was slightly less than one in three, based on this the Committee did not recommend any change to the current SHIP policy relating to the upper age limit at which IVF is publicly funded. With regard to the issue of funding subsequent ‘full’ cycles of treatment (including ovarian stimulation and egg retrieval), the Committee found no new evidence presented since the publication of the new NICE guidelines in 2013 relating to the relative chances of success of a first, second or third cycle of treatment. As a result, the Committee members did not recommend any change to the existing SHIP access criteria in terms of funding additional full cycles of treatment. The Committee did find that there was good evidence to support the use of fresh and frozen embryo transfers within a cycle of IVF. This conclusion was based on improving success rates relating to the use of frozen embryos, benefits to woman of being able to attempt another treatment without having to undergo the difficulties associated with the commencement of a fresh cycle and the greater cost-effectiveness of the transfer of a frozen embryo. On the issue of the availability of fresh and frozen cycles of treatment the Committee has suggested an extension of SHIP access criteria could be appropriate. There is a large majority (66%) of Isle of Wight residents who would support a move away from the current criteria. As a

Page 8 of 21

result of these considerations, the Committee recommended that there could be a change to the existing access criteria with regard to the use of frozen embryos. The recommendation was that NHS funding should be made available for up to two separate embryo transfers (either fresh/frozen, or frozen/frozen, as clinically indicated). The survey shows that whilst there was a majority of Isle of Wight respondents (58%) who considered that funding for IVF should be a priority for the NHS the overall, the view across the remainder of the SHIP area did not support the idea that funding IVF is a priority for the NHS (44%). Regarding the other questions the overall response to the survey suggested that in the case of the upper age limit, the number of cycles available, and the availability of both fresh and frozen treatments, the there was a preference for the implementation of full NICE guidelines rather than the existing local policy. However, this view needs to be balanced against the finite financial resources that are available across the SHIP region for commissioning healthcare services. Governing Body Recommendations The Isle of Wight CCG Clinical Executive has reviewed the policies and recommended the approval of Policy Statement 002: Assisted Conception Services (IVF). In the light of both the clinical review, and the results of the public engagement exercise, the Governing Body is asked to approve the following recommendations: 1. That the current policy of funding one fresh embryo transfer be amended to fund up to two

separate embryo transfers in a cycle of IVF. This would require an anticipated additional recurrent annual investment of £12,000 for the Isle of Wight CCG and agreement to Policy Statement 002: Assisted Conception Services (IVF)

2. That the recommendations of the Equalities Impact Study are adopted and a report re-

presented to the CCG Clinical Executive in 12 months’ time.

Page 9 of 21

Annex A – Extract from NICE Clinical Guideline 156 (Fertility) Fertility NICE Clinical Guideline 156 Last modified February 2013 Criteria for referral for IVF Inform people that normally a full cycle of IVF treatment, with or without intracytoplasmic sperm injection (ICSI), should comprise 1 episode of ovarian stimulation and the transfer of any resultant fresh and frozen embryo(s). [new 2013] In women aged under 40 years who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where 6 or more are by intrauterine insemination), offer 3 full cycles of IVF, with or without ICSI. If the woman reaches the age of 40 during treatment complete the current full cycle but do not offer further full cycles. [new 2013] In women aged 40–42 years who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where 6 or more are by intrauterine insemination), offer 1 full cycle of IVF, with or without ICSI, provided the following 3 criteria are fulfilled: They have never previously had IVF treatment There is no evidence of low ovarian reserve (see recommendation 1.3.3.2) There has been a discussion of the additional implications of IVF and pregnancy at this age. [new 2013] Embryo transfer strategies in IVF When considering the number of fresh or frozen embryos to transfer in IVF treatment: For women aged under 37 years: In the first full IVF cycle use single embryo transfer. In the second full IVF cycle use single embryo transfer if 1 or more top-quality embryos are available. Consider using 2 embryos if no top-quality embryos are available. In the third full IVF cycle transfer no more than 2 embryos. For women aged 37–39 years: In the first and second full IVF cycles use single embryo transfer if there are 1or more top-quality embryos. Consider double embryo transfer if there are no top-quality embryos. In the third full IVF cycle transfer no more than 2 embryos. For women aged 40–42 years consider double embryo transfer. [new 2013] Where a top-quality blastocyst is available, use single embryo transfer. [new 2013]

Page 10 of 21

Appendix B - Results and Comparison of IVF Listening Exercise Online Survey Q1 - Do you think funding for IVF is a priority for the NHS?

Q2 – With regard to age do you think we should……..

Q3 – With regard to the availability of fresh and frozen cycles, do you think we should ……

Page 11 of 21

Q4 – With regard to the number of cycles available, do you think we should ……

Q5 – With regard to weight (BMI), do you think we should ……

Q6 – With regard to smoking status, do you think we should ……..

Page 12 of 21

Q7 - Respondents were in the vast majority members of the public (>90%) however there were some responses from GPs (5%) and representatives from other organisations.

Q8 – N/A Q9 - Responses by age band were as follows

Q10 – have you or your partner ever had IVF treatment, or are seeking IVF treatment

(Extracted from the public engagement data results for SHIP, Isle of Wight CCG and North East Hampshire and Farnham CCG areas)

Page 13 of 21

Annex C - Engagement Report (Isle of Wight)

Help us to shape local IVF services for the future Engagement Report: Isle of Wight

1. Introduction

The eight Clinical Commissioning Groups (CCGs) across Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP) commissioned Solutions for Public Health to identify and review the most recent evidence of clinical and cost effectiveness for In-vitro fertilisation (IVF) and Intra-cytoplasmic sperm injection (ICSI).

This review is intended to support the CCGs in reviewing the existing SHIP IVF policy in light of the 2013 NICE Clinical Guideline – ‘Fertility: assessment and treatment for people with fertility problems (CG156)’.

The SHIP Priorities Committee discussed the evidence review and the views of clinical experts in August 2014 and asked Solutions for Public Health to draft a policy recommendation to reflect the conclusions of the Committee. This has been approved by the SHIP Priorities Committee. Concurrently the eight CCGs carried out a joint engagement programme asking key interest groups, stakeholders and local people for their views on IVF. The results of this engagement programme and the SHIP Priorities Committee Policy Recommendation will be considered by the Governing Body of each CCG.

2. Objectives A joint period of engagement was undertaken across the eight SHIP CCGs. The objectives of this work were to:

• Capture the views of key interest groups, stakeholders and local people to inform and add

value to the commissioning process • Inform key interest groups, stakeholders and local people the CCGs will be considering the

SHIP Priorities Recommendation in light of their views • Meet the communication and engagement requirements expected of the NHS.

3. Stakeholders/Audiences

For the purpose of this engagement work, stakeholders and audiences were defined as: Any individual, group, or institution who has a vested interest in the project and/or who potentially will be affected by project activities and have something to gain or lose if conditions change or stay the same. The following stakeholders were identified and approached for their views.

Page 14 of 21

External 1. Key interest groups 2. Local residents 3. MPs 4. Hampshire County Councillors 5. Borough/District Councillors 6. Council Leaders 7. Council Chief Executives 8. Directors of Public Health 9. Health and Adult Social Care Select (Overview and Scrutiny) Committee (Chairs and

supporting officers) 10. Wessex Local Medical Committee 11. Hampshire Health and Wellbeing Board 12. Hampshire Healthwatch 13. Local media 14. Voluntary sector organisations 15. Patient Participation Groups Internal 16. Members of each CCGs Governing Body 17. GP practices 18. CCG Community Engagement Committees (or similar) 19. NHS England Wessex Area Team (for information)

4. Communications and engagement methods and routes Views were gathered using an online survey. The survey asked for views on access criteria and whether we should implement full NICE guidance, retain existing criteria, or – in some cases – extend the criteria. The access criteria in question were:

• Age • Fresh and frozen cycles • Number of cycles • BMI eligibility • Smoking status.

The survey was promoted through a range of communications including:

• Emails/letters to key interest groups and stakeholders (these included groups such as the Infertility Network UK, National Childbirth Trust local groups, minority ethnic representatives and groups, and transgender groups)

• Briefing existing groups such as Community Engagement Committees • Press releases • CCG stakeholder newsletters • Voluntary sector online newsletters • CCG websites and Twitter accounts • PIP sites (Primary Information Portals – extranet sites for GP practices).

5. Equality Impact Assessment

A SHIP wide Equality Impact Assessment has been carried out and is available in full in Appendix C. The conclusions are:

Page 15 of 21

• The CCGs consider increasing the upper age limit to 37 years • Decision making processes are demonstrably fair and transparent to reduce risk of Judicial Review • To support demonstration of due regard to Equality Act 2010, that collection and analysis of

equalities information about people who receive NHS funded infertility treatment, and those who apply for Individual Funding Review is commenced by providers and the CSU. As a minimum this should include age, gender, disability status, sexual orientation and post code. Where this data highlights differential access for equality groups this can be considered as part of future reviews of this policy in order to demonstrate fairness.

6. Survey results

The survey is available in full as Appendix 2, and the full results for the Isle of Wight can found at Appendix 3. Along with all CCGs the Isle of Wight has also reviewed any comments and complaints received about IVF between April 1, 2013 and September 30, 2014.

6.1 SHIP-wide results Sample: In total 1,133 people responded to the survey, which ran from 22 September, until 7 November. The initial engagement period had been set for four weeks, but this was extended to allow more people to participate. More than half of the survey (52.48%) were aged 39 or younger, and more than a quarter (26.37%) of respondents had direct personal experience (either relating to them or their partner) of seeking IVF treatments. The overwhelming majority of respondents (91.38%) described themselves as ‘members of the public’, with the remainder being GPs, or representatives of organisations. During the engagement period the CCGs actively sought to engage with interested parties, including those organisations who represent people who have required the use of fertility services. Result summary: Across the SHIP area, opinion was relatively evenly divided on the overarching issue (Question 1) of whether or not IVF treatments were a priority for the NHS. Slightly more people (46.98%) felt that IVF was not a priority for the NHS, than felt that it was (44.40%). There were 250 ‘free text’ comments relating to this question. Among those stating that IVF was not a priority for the NHS, the primary themes were either a straightforward opposition to the idea, or a belief that IVF was less important than other treatments or priorities. Of those who said that IVF was a priority, most people simply felt that such treatments were important, and should be provided on the NHS. The other themes in the responses included calls for consistency with NICE guidelines and the end of a ‘postcode lottery’, and references to the distress and potential impact on emotional wellbeing/mental health for couples who are unable to conceive. Questions 2-4 all related to issues of provision – respectively, the age at which IVF should be provided, whether or not fresh and/or frozen cycles of treatment should be available, and the number of cycles which should be offered. For each of these three questions, more respondents stated a preference for the local NHS to follow NICE guidelines, than for the available alternatives. For Question 3 (fresh/frozen treatments) and Question 4 (number of cycles) that preference was stated by an absolute majority of the sample.

Page 16 of 21

For the free text responses associated with all of Questions 2-4 there were large numbers of respondents again stating either an outright opposition to the provision of IVF on the NHS, or complete support. Again, a sizeable proportion also advocated the importance or equity of following NICE guidelines, or an opposition to geographical variation. For Question 2 (relating to the maximum age) specifically, other themes included: the SHIP criteria not reflecting the changing patterns of family life, with women increasingly having children later in life, and complaints that IVF treatment could not be funded at a younger age when infertility had been diagnosed in women in their twenties, or earlier. For Question 3 (fresh/frozen) specifically, one additional theme was opposition to the idea of the ‘waste’ – both in terms of efficiency, and morality – of frozen embryos, because only a single, fresh treatment was available in the SHIP area. For Question 4 (number of cycles) specifically, the responses included comments relating to specific reasons why more/three cycles should be funded, usually stating that such an approach was either clinically more likely to succeed, or more cost-effective. There was also a group of respondents who advocated a ‘middle ground’ – either that the NHS should fund two cycles, one additional frozen cycle, or more cycles within specific age limitations. Questions 5-6 relate to the potential recipients of IVF treatment. Question 5 asks for views relating to the weight/Body Mass Index (BMI) of the woman seeking treatment, and Question 6 relates to the smoking status of the couple. In both cases there were clear majorities in favour of retaining the SHIP criteria, particularly so with regard to smoking. Comments submitted for Question 5 (weight) were largely related, once again, to more general opinions about whether IVF treatments should be available. Among those comments specifically related to the question, there were groups (albeit small) of respondents questioning the validity of weight/BMI as a suitable criteria for determining access to funded treatment, and also advocating a more individual-centred approach which took more account of personal circumstances, rather than being based upon broadly-applied criteria. Comments relating to Question 6 (smoking status) were overwhelmingly opposed to funding IVF treatments to people who smoked.

6.2 Isle of Wight Sample: In total 191 responses were received from residents of the Isle of Wight. Notably more of the respondents from the area were aged 39 or younger (64.51%), than was the case for the total sample across SHIP (52.48%). More than a quarter of the Isle of Wight sample (27.51%) said that they or their partner had direct experience of IVF treatment, higher than the figure for SHIP as a whole although not by a significant margin. Result summary: In response to the question “Do you think funding for IVF is a priority for the NHS?” a clear majority of Isle of Wight respondents said ‘yes’ (57.89%) That figure is far higher than was the case across SHIP as a whole, where support for the proposition was 44.40%. With regard to the upper age limit for IVF treatment, a clear majority (60.54%) favoured following NICE guidelines – significantly higher than the proportion for SHIP as a whole (47.47%).

Page 17 of 21

Almost two-thirds (65.95%) of respondents from the Isle of Wight favoured following NICE guidelines regarding the availability of fresh and frozen treatment. That figure was well above the level of support across SHIP as a whole (52.12%). Almost four out of five Isle of Wight respondents (78.45%) said that NICE guidelines should be followed regarding the number of cycles available. Across the whole SHIP area as a whole that figure was 66.03%. For the Isle of Wight there was a small majority (53.26%) in favour of adopting NICE guidelines with regard to the provision of advice and support to women seeking IVF whose Body Mass Index (BMI) was 30 or higher. For the total SHIP sample there was a majority in favour of retaining the SHIP access criteria on this issue, where funding is only available to those who have maintained a healthy weight for at least six months. There was a clear majority (63.78%) of Isle of Wight respondents who wished to retain existing SHIP criteria regarding smoking (that the couple should be smoke-free for at least six months). Please note: Analysis of the ‘free text’ comments submitted by respondents have only been analysed on a SHIP-wide basis, rather than for each individual CCG, because the sizes of the geographical subgroups are not large enough to enable reliable analysis to be carried out.

7. Decision required

Each CCG Governing Body is asked to consider the outcomes of engagement programme and equality impact assessment when reaching a view about the SHIP Priorities Committee recommendation for specialist fertility services.

Page 18 of 21

SOUTHAMPTON, HAMPSHIRE, ISLE OF WIGHT AND PORTSMOUTH CCGS (SHIP) PRIORITIES COMMITTEE

TERMS OF REFERENCE

1. INTRODUCTION 1.1. The Priorities Committee operates as an advisory body to the eight Clinical Commissioning

Groups [CCGs] across SHIP. Its role is to provide them with evidence based, carefully considered recommendations to inform the commissioning policies of the constituent CCGs.

2. FUNCTIONS OF THE PRIORITIES COMMITTEE

Aim

2.1. To make recommendations, using the agreed Ethical Framework and taking into account stakeholder views, to SHIP CCGs on the appropriateness of commissioning and funding of selected healthcare interventions (e.g. specific treatments, procedures and care pathways).

Objectives

• To receive and scope potential topics to be considered by the Committee • To receive evidence appraisals and service reviews, as agreed by the Committee • To take account of relevant expert and patient perspective • To consider the information they receive, in accordance with the SHIP Ethical Framework • To develop recommendations on commissioning policy, with regards to the topics

presented to the Committee, to be then considered by the constituent CCGs • To provide reports on advice issued and activity to commissioning organisations on a

regular basis 3. MEMBERSHIP AND PROCESS

Roles and responsibilities of committee members 3.1. The overall role of all members is to actively contribute to the discussions and recommendations

of the Committee. All members should have a named deputy of similar standing and expertise; all are expected to attend training relating to the Priorities Committee role, as required. Employed members should have this role included in their job description/ job plan. The Committee members are recruited as:

(a) Members representing NHS organisations. They should have sufficient authority and standing

to ensure fully informed recommendations are developed that command the confidence of their organisations. These members are also responsible for communicating recommendations and any relevant issues back to their organisations.

AND

(b) Members performing specialist advisory roles, due to their background or expertise in a

particular area; for example clinical, public health, finance, contracting/IFRs, pharmaceutical 3.2. All members and observers attending a Priorities Committees will be asked to declare any conflict

of interest to the Committee secretariat (annually) or to the Committee Chair, in a meeting.

Page 19 of 21

Membership

3.3. The Priority Committee will draw its membership from the following sources:

• Independent Chair • Up to two members per member CCG. These members will supply the following specialist

knowledge: o CCG Executive with commissioning responsibility o CCG Executive with finance responsibility o Lay members o Pharmaceutical Advisor o Special adviser in Public Health

• Medical Director of an NHS provider organisation: • Legal / ethics advisor • Contracting/IFR Advisor

Chairing of Committee

3.4. The Priorities Committee will have an independent Chair and a named deputy Chair. The Chair will be agreed by the Chairs of the relevant CCGs and will have an agreed job description. The Deputy Chair will be a Priorities Committee member, elected by the Committee members.

Quoracy

3.5. The Priorities Committee meetings will be considered quorate if, as a minimum, the following

members (or their deputies) are present: • representation from at least six of the eight Clinical Commissioning Groups • one Director of Commissioning or Director of Finance • at least two GPs • one Specialist in Public Health • one lay member

3.6. A non-quorate meeting will not have power to take decisions, but may still make

recommendations on topics discussed. Their “draft recommendations” will be circulated via e-mail to all Committee members, seeking a majority approval. If no consensus can be reached in this manner, then that item will be re-considered at the next quorate Priorities Committee meeting. Decision-making

3.7. The Committee’s recommendations are made by a consensus of voting members, at a quorate meeting. On occasions, a vote is taken; a simple majority decides. In the event of no majority, the Chair has the casting vote.

4. MEETING LOGISTICS

4.1. The Priorities Committee will meet bi-monthly, However, if it is clear in advance that a meeting

will not be quorate, the meeting may be cancelled. Meeting location will usually be in Southampton.

4.2. The meetings will be managed and administered by the Priorities Committee secretariat, who are responsible for generating the agenda and sending out papers for each Priorities Committee meeting. The papers will be distributed to Committee members five working days in advance of

Page 20 of 21

each meeting. The Priorities Committee secretariat will also circulate papers to an agreed list of non-member recipients, for information.

4.3. The Chair has executive authority to finalise the agenda.

4.4. Minutes will be drafted by the Priorities Committee secretariat and reviewed by at least one Committee member who has been delegated this responsibility the Committee. Draft minutes will be circulated to and approved at the next quorate meeting.

4.5. The arrangements with, and functions of ,the Priorities Committee secretariat in supporting the work of the Priorities Committee are set out in a Service Level Agreement, agreed with the lead CCG on behalf of the SHIP CCGs.

5. GOVERNANCE AND RELATIONSHIP WITH COMMISSIONING ORGANISATIONS 5.1. The Committee’s core function is to provide CCGs with evidence-based recommendations on

commissioning priorities and policies, using the agreed SHIP Ethical Framework.

5.2. The CCGs fund the infrastructure and provide operational support to the Committee and are core members of the Priorities Committee.

5.3. Committee members who are representatives of commissioning or provider organisations are responsible for making decisions and recommendations at the Committee on behalf of their organisation and for reporting back, through appropriate routes, to their organisation.

5.4. CCG representatives are responsible for ensuring Committee commissioning recommendations are taken to appropriate decision-making groups for discussion and for formal adoption.

5.5. Reports on the operation and activity of the Priorities Committee should be taken to appropriate senior groups within each organisation at least annually. It is for each CCG to determine the group/committee which should receive reports from the Priorities Committee.

30 June 2014

Page 21 of 21

SHIP8 Clinical Commissioning Groups’ Priorities Committee (Southampton, Hampshire, Isle of Wight and Portsmouth CCGs) Policy Recommendation 002: Assisted Conception Services Date of Issue: September 2014 Specialist assisted conception treatments, including In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI), will be commissioned for patients who meet the criteria for access described in pages 2-5 below. Outside of the defined access criteria, all assisted conception treatments remain a LOW PRIORITY. The management of infertility includes both primary and secondary care assessment; diagnosis; and interventional support (for example, lifestyle changes that may improve a couple’s chances of conceiving). Patients/couples who require specialist infertility treatments in order to improve their chances of having a baby must meet all of the criteria described in pages 2-5 below. Commissioning notes: 1. Patients/couples requesting specialist infertility treatment and meeting the eligibility criteria must be referred for specialist infertility treatment(s) by an NHS Consultant Gynaecologist using the standard referral form available from the CCG Commissioners. 2. The CCG Commissioners will confirm funding, and advise the patients’ managing clinician of the preferred provider of their infertility treatment. NB NHS-funded specialist assisted conception services are commissioned only from approved providers. 3. The NHS-funded specialist fertility unit providing the care will be solely responsible for initial consultation; treatment planning; counselling/advising patients; treatment consent; all drugs; egg collection; semen analysis; embryo transfer; pregnancy test(s); all consumables; pathology tests; scans; and the HFEA fee. 4. All fertility drugs, such as anti-oestrogens, (eg clomiphene citrate), gonadotrophins, (including gonadorelin analogues), and progestogens, should be prescribed only by the treating consultant. GPs are advised not to prescribe any drugs for fertility. 5. There are existing, related commissioning policies specific to addressing PGD and gamete

storage which CCGs may wish to refer to in conjunction with this policy recommendation.

NOTES: Exceptional circumstances may be considered where there is evidence of significant health impairment and there is also evidence of the intervention improving health status. This policy may be reviewed in the light of new evidence or guidance from NICE.

Criteria for Access to IVF and Related Fertility Treatments

1.1 All women will be expected to have gone through the primary and secondary care pathways as defined in the NICE Clinical Practice Algorithm1 appropriate to them before eligibility for IVF is considered.

1.2 CCGs will fund one cycle of IVF treatment per eligible couple. In cases where this cycle is abandoned for medical reasons, a new cycle of ovarian stimulation will be funded.

1.3 In line with HFEA strategy and mandatory requirements2, the CCGs wish to promote elective single embryo transfer, and the avoidance of multiple pregnancy.

1.4 One cycle of IVF treatment is defined as one cycle of ovarian stimulation, egg retrieval and fertilisation and up to 2 separate embryo transfers (fresh/frozen or frozen/frozen as clinically indicated). It includes appropriate diagnostic tests, scans and pharmacological therapy. It is anticipated that, rarely, patients who are not eligible for treatment because they do not fulfil these criteria may, by virtue of their personal circumstances, be considered an exceptional case for NHS funding. If this is thought to be applicable, the patients’ GP or Hospital Consultant may contact the relevant CCG IFR panel which is responsible for considering funding for individual cases.

1 https://www.nice.org.uk/guidance/cg156/resources/cg156-fertility-full-guideline3 2 http://www.hfea.gov.uk/docs/Code_of_Practice_8_guidance_note_7_-_Multiple_Births.PDF

Title

Criterion

1 Age of woman at time of referral to tertiary care from secondary care

The age at referral should be before the female’s 35th birthday. Women approaching the age of 35 years must be referred in time to be able to commence treatment before their 35th birthday.

2 Age of male partner

No upper age limit for male partner (as per adoption laws).

3 Previous infertility treatment

Any previous NHS funded IVF/ICSI treatment will be an exclusion criterion.

People who have previously self-funded treatment are eligible for one NHS-funded cycle as long as they have not already received more than 2 self-funded cycles, and have no frozen embryos stored from a previous cycle.

4 Women in same sex couples/ and women not in a partnership

Sub fertility treatment will be funded for women in same sex couples or women not in a partnership if those seeking treatment are demonstrably sub fertile.

In the case of women in same sex couples in which only one partner is sub fertile, clinicians should discuss the possibility of the other partner becoming pregnant before proceeding to interventions involving the sub fertile partner.

NHS funding will not be available for access to insemination facilities.

In circumstances in which women in a same sex partnership or individuals are eligible for sub fertility treatment, the other criteria for eligibility for sub fertility treatments will also apply.

Women in same sex couples and women not in a partnership should have access to professional experts in reproductive medicine to obtain advice on the options available to enable them to proceed along this route if they so wish.

5 Egg donation IVF using donated eggs from UK clinics licensed by the HFEA will be commissioned.

6 Transfer of frozen embryos

If a couple has had frozen embryos transferred as part of earlier self-funded treatment the frozen cycles will not be counted as previous cycles, when assessing eligibility for NHS funded IVF.

The transfer of frozen stored embryos from previous cycles of IVF will not be funded. It is expected that all frozen embryos from a previous cycle will be used in advance of a fresh cycle of ovarian stimulation and subsequent IVF/ICSI.

7 In vitro maturation IVM will not be funded, due to limited evidence of effectiveness.

8 Intra uterine insemination

IUI will not be funded.

NOTES: 1. Potentially exceptional circumstances may be considered by the patient’s CCG where there is evidence of significant health status

impairment (e.g. inability to perform activities of daily living.) 2. This policy will be reviewed in the light of new evidence or guidance from NICE. 3. Priorities Committee Minutes and policy recommendations can be viewed at http://www.sph.nhs.uk/ebc/policy-recommendations

3

Title

Criterion

9 Gamete storage Sperm storage will be funded for post-pubertal males under the age of 55 years who are about to undergo medical treatment which is likely to result in long-term sub-fertility. Subsequent assisted conceptions procedures using the sperm will not be funded unless the other eligibility criteria are met. .

Oocyte (egg) preservation and ovarian tissue preservation are still experimental treatments, and will not be funded.

10 Storage of surplus embryos following a fresh cycle of NHS funded IVF

Freezing and storage of viable embryos from NHS funded IVF will be funded for up to 3 years (or the female’s 42nd birthday if this is sooner) so that couples have the option to use stored embryos at a later stage if they choose to do so.

11 Specific diagnosed causes of infertility

Couples with a diagnosed cause of absolute infertility which precludes any possibility of natural conception, and who meet all the other criteria, will have immediate access to IVF on reaching the eligible age range. All other couples must have infertility of at least 1 to 2 years duration.

12 Blood borne viruses and sperm washing

Sperm washing for the prevention of transmission of blood borne viruses will not be funded, due to limited evidence of clinical and cost-effectiveness. However, the evidence will be kept under review.

13 Surgical sperm retrieval

Surgical sperm retrieval will be commissioned in appropriately selected patients, provided that the azoospermia is not the result of a sterilisation procedure or the absence of sperm production.

14 Childlessness Treatments for sub fertility will be funded if the couple does not have a living child from their relationship or from any previous relationship. This includes a child adopted by the couple or in a previous relationship.

Once accepted for treatment, should a child be adopted or a pregnancy leading to a live birth occur the couple will no longer be eligible for treatment.

15 Sterilisation Fertility treatment will not be available if the sub fertility is the result of a sterilisation procedure in either partner.

In addition, the surgical reversal of either male or female sterilisation will not be funded except in exceptional circumstances. If the individual’s situation is thought to warrant such consideration, the patients’ general practitioner should contact the relevant CCG so that such an application might be made.

16 BMI Women must have a BMI of between 19.0 and 29.9 inclusive for a period of 6 months or more before receiving any treatment.

They should be informed of this criterion at the earliest possible opportunity in their progress through infertility investigations in primary care and secondary care. GPs are encouraged to provide unambiguous and clear information about BMI criteria to infertile couples.



4

Title

Criterion

17 Smoking Only non-smoking couples will be accepted on the IVF treatment waiting list. Couples should stop smoking at least 6 months prior to infertility treatment.

Smoking cessation treatment should start as early as possible in the referral pathway.

Couples must be informed of this criterion at the earliest possible opportunity in their progress through infertility investigations in primary care and secondary care. GPs are encouraged to provide unambiguous and clear information to infertile couples.

A statement should also be issued at the time of publishing the eligibility criteria, emphasising the importance of an active, healthy lifestyle and highlighting the dangers of smoking and passive smoking, obesity, alcohol and caffeinated beverages as important causes of infertility.

18 HFEA Code of Ethics

Couples not conforming to the HFEA’s Code of Ethics, will be excluded from having access to NHS funded assisted fertility or other treatment. This includes consideration of the ‘welfare of the child which may be born’ which may take into account the importance of a stable and supportive environment for children as well as the pre-existing health status of the parents.



5

Help us to shape local IVF services for the future: Listening Exercise findings

Data prepared on behalf of the eight CCGs serving people in Southampton, Hampshire, the Isle of

Wight, and Portsmouth

November 2014

Summary: sample

• The survey initially ran for a month, from 22 September to 19 October, but the deadline was then extended to 7 November

• In total 1,133 responses were received

• A relatively high proportion of respondents (26.39%) said that they, or their partner, had direct experience of seeking IVF treatment

• The younger population was well represented, with 52.48% of the sample describing themselves as 39 years or younger

• The vast majority of the sample (91.38%) described themselves as ‘members of the public’.

Summary: responses

• In response to the question “Do you think funding for IVF is a priority for the NHS?”, more people said ‘no’ (46.98%) than said ‘yes’ (44.40%)

• With regard to the upper age limit for IVF treatment, there was more support for following NICE guidelines (47.47%) than the other options

• A majority (52.12%) said that NICE guidelines should be followed regarding the availability of fresh and frozen treatments

• A large majority (66.03%) said that NICE guidelines should be followed regarding the number of cycles available

• There were majorities in favour of retaining the SHIP8 criteria which withholds funding for those who are obese (55.91%) and for couples where one or both partners smokes (70.98%)

Results

0 10 20 30 40 50

No opinion

Don't know

No

Yes

Q1. Do you think funding for IVF is a priority for the NHS?

44.40%

46.98%

7.02%

1.60%

Sample: 1,126 Comments: 250

Question 1: Comment themes

• General support (61 comments): It is important / a priority (for couples) / it should be funded / it is a medical condition (and so should be treated)

• General opposition (67): Shouldn’t be funded / couples should pay / infertility is not an illness / having a family is not a right

• Distress (24): Infertility causes distress / damages emotional and mental health

• Conditional opposition (68): Not a priority (compared to other things) / resources are limited / can’t afford it

• Equity (22): NICE should be followed / no postcode lottery / a family is a basic right / nobody choose infertility / it isn’t self-inflicted

• Specify extending criteria (19): Includes dropping restriction based on having children from previous relationship / more cycles / means-tests

• Specify restricting criteria (19): Includes number of cycles / children from previous relationship

Results

0 10 20 30 40 50

No opinion

Don't know

Extend access to 38thbirthday

Keep existing SHIP criteria(before 35th birthday)

NICE guideline in full (up to 42years old)

Q2. With regard to age do you think we should…

47.47%

21.93%

2.08%

1.71%

26.81%



• General opposition to IVF (37): should not be funded / it isn’t an illness / money should be for saving lives

• General support for change (25): 35 is too young / women can have babies in their 40s / should be older / everyone should have the chance / right

• Practical support for change (29): Women have children later now / why should people be penalised for having a career / waiting for the right moment / people may not be in a position to have a family sooner / infertility may not be discovered until later

• Equity (34): NICE should be followed / no postcode lottery / should be the same for all • Lower age limit (19): Reduce the lower age limit / why make people wait when infertility is

diagnosed? / focus on younger women with more chance of success / more cost effective • Individualise (15): Each case on its merits / age not the only factor / shouldn’t discriminate

on age / look at the individual / women of 42 can be healthier than younger women • Others in favour of limit (13): Including 35 is old enough / fertility declines with age /

people choosing to wait for a family is not a reason to fund IVF • Others in favour of extension (10): Including older woman are more financially secure /

should concentrate on those who find it hardest to conceive

Results

0 10 20 30 40 50 60

No opinion

Don't know

Extend availability to onefresh, one frozen

Keep existing SHIP criteria(one fresh)

NICE guideline in full (freshand subsequent frozen)

Q3. With regard to the availability of fresh and frozen cycles, do you think we should…

52.12%

16.71%

5.60%

2.53%

23.04%



• General opposition to IVF (31 comments): Should not be offered on the NHS / not a priority / should be self-funded

• General support for extension (19): One cycle is not enough / should give people the best possible chance

• Consistency (13): Postcode lottery / should be same everywhere / NICE guidelines should be followed

• Efficacy (7): Gives an extra chance at a low(er) cost / more cost effective / frozen cycles are effective

• Waste/morality (19): All embryos should be used / should not waste frozen embryos / wrong not to use frozen embryos / it is immoral/damaging not to allow couples to use a frozen embryo/make them pay

• Specific support (7): Frozen cycle is less invasive / traumatic / reduces risks of multiple transfers and births / can learn from first attempt

Results

0 10 20 30 40 50 60 70

No opinion

Don't know

Keep existing SHIP criteria(one cycle)

NICE guidelines (3 cycles forages <40, 1 for 40-42 years)

Q4. With regard to the number of cycles available, do you think we should…

66.03%

26.37%

5.22%

2.38%



• Equity (29 comments): NICE guidelines should be implemented / followed / no postcode lottery / should be the same everywhere

• NICE-plus (11): All age groups should be offered three / should be three for people aged up to 42 as well

• General support for three / all cycles (22): Give people every chance / should be three cycles / one is not enough

• Specified support for more cycles (21): Better chance of success / more clinically effective / more cost effective / the first is a ‘test’ / lessons can be learned from the first attempt

• Middle ground (28): Two cycles / one fresh and one frozen / more cycles but within age criteria

• General opposition to IVF (25): Should not be funded / infertility is not an illness

• Restrictions (7): Keep the limit / no treatment for over-40s / only one cycle for all

Results

0 10 20 30 40 50 60

No opinion

Don't know

Keep existing criteria (musthave BMI <30 for six months)

NICE guidelines (advice towomen with BMI > 30)

Q5. With regard to weight (BMI), do you think we should…

41.03%

55.91%

1.53%

1.53%



• General resistance to change (42 comments): existing criteria are right / women should take responsibility (for maximising their chances of success) / if someone is desperate for a child they should be prepared to do this / people should be prepared to lead healthy lifestyle

• Opposition to NHS funding (15): IVF should not be funded / infertility is not an illness / IVF should be self-funded

• Calls for equity (5): NICE guidelines should be followed, there should be a national / uniform policy

• Criticism of BMI / weight as a criteria (14): weight should not be a factor / is not a reasonable criteria / evidence is mixed / BMI in isolation is insufficient / women with BMI of 30+ can conceive naturally

• Support for change, with specific reasoning (11): Refusing treatment is discriminatory / should look at the individual / each case is different / some woman may be suffering depression / PCOS and need help

• General support for change (14): Support and advice should be given / are needed / are (more) effective

• Support for extending help / criteria (12): should give advice to those whose BMI is 30+ / six months is too long / BMI limit should be raised

• Others in favour of SHIP criteria (7): Including restrictions should be tighter

Results

0 10 20 30 40 50 60 70 80

No opinion

Don't know

Keep existing criteria (smoke-free for six months)

NICE guidelines (advice tosupport cessation)

Q6. With regard to smoking status, do you think we should…

26.95%

70.98%

0.81%

1.26%



• General resistance to change (36 comments): If a couple wants a baby, they should give up / they should show commitment / couples should take responsibility (for maximising their chances) / IVF shouldn’t be for smokers

• Health-focused (22): Smoking is harmful (to mother/child) / child should not be harmed / if you cannot live a healthy lifestyle you should not get help

• Opposition to NHS funding (16): IVF should not be funded / infertility is not an illness / the NHS cannot afford to fund IVF

• General support for change (12): Support should be given / is effective / can help people to stop smoking

• Calls for equity (6): NICE guidelines should be followed / should be a national / uniform policy

• Others in favour of SHIP criteria (9): Including restrictions should be tighter / financial waste

• Others opposed to SHIP criteria (8): Including unfair on the woman to apply to couples / smoking is unhealthy but legal / six months is too long

Results

0 10 20 30 40 50 60 70 80 90 100

Representative of anorganisation

GP

Member of the public

Q7. Are you responding to this survey as…

91.38%

4.22%

4.40%


Results

0 10 20

West Hampshire

Southampton

South Eastern Hampshire

Portsmouth

North Hampshire

NE Hampshire and Farnham

Isle of Wight

Fareham and Gosport

Q8. Which CCG area are you from?

11.62%

17.62%

4.43%

8.76%

18.91%

8.21%

14.94%

15.50%

Sample: 1,084

Results

0 10 20 30 40 50 60

50 years old or older

40-49 years old

23-29 years old

22 years old or younger

Q9. How old are you?

0.92%

51.56%

17.25%

30.28%

Sample: 1,090

Results

0 10 20 30 40 50 60 70 80

Yes - I/my partner have had /are seeking IVF

No - I/my partner have neverhad / are not seeking IVF

Q10. Have you or your partner ever had IVF treatment, or are seeking IVF treatment?

73.63%

26.37%

Sample: 1,092

Help us to shape local IVF services for the future: Listening Exercise findings

Data relating to respondents from the Isle of Wight CCG area

November 2014

Summary: sample Isle of Wight

• The survey initially ran for a month, from 22 September to 19 October, but the deadline was then extended to 7 November

• In total 191 responses were received from the Isle of Wight area

• The respondents were younger than the total sample (more than 64% were 39 years old or younger, compared to just over half for the whole SHIP8 area)

• The proportion of respondents saying that they or their partner had direct experience of IVF treatment (27.51%) was slightly higher than for the total sample (26.39%).

• In response to the question “Do you think funding for IVF is a priority for the NHS?”, a majority (57.89%) said ‘yes’ – that is markedly higher than across the SHIP8 area as a whole, where 44.40% of respondents expressed this view

• With regard to the upper age limit for IVF treatment, a clear majority (60.54%) favoured following NICE guidelines, compared to the other available options – far higher than for the total sample (47.47%)

• A large majority (65.95%) supported following NICE guidelines regarding the availability of fresh and frozen treatments - higher than for the whole sample (52.12%)

• A large majority (78.45%) said that NICE guidelines should be followed regarding the number of cycles available

• Most people (53.26%) favoured followed NICE guidelines with regard to weight – across SHIP8 as a whole 55.91% were in favour of retaining the local criteria. For couples who smoke 63.78% favoured retaining local criteria.

Summary: responses Isle of Wight

Results

0 10 20 30 40 50 60 70

No opinion

Don't know

No

Yes

Q1. Do you think funding for IVF is a priority for the NHS?

57.89%

36.84%

4.74%

0.53%

Isle of Wight sample: 190 Comments: 43

Results

0 10 20 30 40 50 60 70

No opinion

Don't know

Extend access to 38thbirthday

Keep existing SHIP criteria(before 35th birthday)

NICE guideline in full (up to 42years old)

Q2. With regard to age do you think we should…

60.54%

16.76%

2.16%

1.62%

18.92%


Results

0 10 20 30 40 50 60 70

No opinion

Don't know

Extend availability to onefresh, one frozen

Keep existing SHIP criteria(one fresh)

NICE guideline in full (freshand subsequent frozen)

Q3. With regard to the availability of fresh and frozen cycles, do you think we should…

65.95%

14.59%

2.70%

2.16%

14.59%


Results

0 10 20 30 40 50 60 70 80 90

No opinion

Don't know

Keep existing SHIP criteria(one cycle)

NICE guidelines (3 cycles forages <40, 1 for 40-42 years)

Q4. With regard to the number of cycles available, do you think we should…

78.45%

17.13%

2.21%

2.21%


Results

0 10 20 30 40 50 60

No opinion

Don't know

Keep existing criteria (musthave BMI <30 for six months)

NICE guidelines (advice towomen with BMI > 30)

Q5. With regard to weight (BMI), do you think we should…

53.26%

43.48%

2.17%

1.09%


Results

0 10 20 30 40 50 60 70

No opinion

Don't know

Keep existing criteria (smoke-free for six months)

NICE guidelines (advice tosupport cessation)

Q6. With regard to smoking status, do you think we should…

23.42%

63.78%

0.54%

0.54%


Results

0 10 20 30 40 50 60 70 80 90 100

Representative of anorganisation

GP

Member of the public

Q7. Are you responding to this survey as…

93.65%

3.70%

2.65%


Results

0 10 20 30 40 50 60 70

50 years old or older

40-49 years old

23-29 years old

22 years old or younger

Q9. How old are you?

3.76%

60.75%

14.52%

20.97%

Isle of Wight sample: 186

Results

0 10 20 30 40 50 60 70 80

Yes - I/my partner have had /are seeking IVF

No - I/my partner have neverhad / are not seeking IVF

Q10. Have you or your partner ever had IVF treatment, or are seeking IVF treatment?

72.49%

27.51%

Isle of Wight sample: 189

Equality Analysis and Impact Assessment Name of project/ proposal

In-Vitro Fertilisation (IVF) and Intra-Cytoplasmic Sperm Injection (ICSI) review by Clinical Commissioning Groups (CCGs) across Hampshire and Isle of Wight

Contact name Nick Birtley, Equality and Diversity Lead West Hampshire Clinical Commissioning Group

Department

Joint project between the 8 CCGs across Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP): • Fareham & Gosport CCG • Isle of Wight CCG • North Hampshire CCG • North East Hampshire and Farnham

CCG • Portsmouth CCG • South Eastern Hampshire CCG • Southampton City CCG • West Hampshire CCG

Intended publication date

To be decided by each CCG

Summary The review of the IVF and ICSI policy has a high equality impact on the protected characteristics defined in the Equality Act 2010 of age, disability, gender, pregnancy and maternity, and sexual orientation. The eligibility criteria for access to NHS-funded IVF have a positive equality impact for women under the age of 35 years (including single women and women in same sex couples), as well as for men of any age, who have confirmed infertility problems. People with disabilities and health conditions that do or may impact on their fertility can also access NHS treatment under the policy. The policy also has a positive impact for partners and close relatives of people who are unable to conceive. For women over the age of 35 years NHS funded fertility treatment is not available locally, and this may have a negative equality impact on them and their partner, especially if they are unable to afford to pay for infertility treatment privately. This is mitigated to some extent by the fact that people who do not meet the criteria set out in the local policy, can – in exceptional circumstances – make an Individual Funding Request via their clinician, to have their case looked at again.

1

The local policy is more restrictive than the guidelines published by the National Institute for Health and Care Excellence (although the CCGs are not legally obliged to implement NICE guidelines in full). Again this may have a negative equality impact for people who fall outside the local criteria. Whether any negative impacts are discriminatory against groups protected by the Equality Act 2010 depends on whether the policy can be reasonably justified on the basis of evidence. The review of evidence of clinical and cost effectiveness suggests: • Although female age is a key predictor of the likely success of IVF treatment, the

success rate for women aged 35-37 years is only around five percentage points less than for those aged under 34 (27.4% and 32.2% respectively). CCGs should consider increasing the current upper age limit to reduce inequity

• There is good clinical evidence to support use of frozen embryos (the Priorities Committee have proposed that one cycle now include up to two separate embryo transfers (fresh or frozen, or frozen/ frozen as clinically indicated)

In terms of an Equalities Impact Assessment it is recommended that: • The CCGs consider increasing the upper age limit to 37 years • The CCGs consider bringing the SHIP policy in line with that of Surrey CCG • Decision making processes are demonstrably fair and transparent to reduce risk

of Judicial Review • To support demonstration of due regard to Equality Act 2010, that collection and

analysis of equalities information about people who receive NHS funded infertility treatment, and those who apply for Individual Funding Review is commenced by providers and the CSU. As a minimum this should include age, gender, disability status, sexual orientation and post code. Where this data highlights differential access for equality groups this can be considered as part of future reviews of this policy in order to demonstrate fairness.

Purpose for the project or proposal Background In February 2013 the National Institute for Health and Care Excellence (NICE) published updated clinical guidelines1 regarding NHS funding for assisted conception. In response, NHS commissioners across Hampshire and the Isle of Wight agreed an interim policy position2 in March 2014. Then in July/ August 2014 they asked an independent organisation called Solutions for Public Health to review recent evidence of clinical and cost-effectiveness for In Vitro Fertilisation (IVF) and Intra-

1 National Institute for Health and Care Excellence, February 2013, NICE clinical guideline: Fertility: Assessment and treatment for people with fertility problems (CG 156) 2 Southampton, Hampshire, Isle of Wight and Portsmouth PCTs priorities Committee, February 2013) Priorities Committee Statement – Assisted Conception/IVF

2

http://www.westhampshireccg.nhs.uk/documents/doc_view/269-whccg13-089-priorities-committee-statement


Cytoplasmic Sperm Injection (ICSI). This review helped the joint CCG Priorities Committee to develop a proposed new policy in August 2014. As a final step, the new recommendations need to be agreed by each individual CCG. Infertility • The evidence review3 says that infertility is a recognised medical condition and

can occur at any age. It may be due to a variety of causes such as ovulatory disorders (25%), tubal damage (20%), and factors in the male causing infertility (30%). In 25% of cases, the cause is unexplained.

• NICE has defined infertility as a failure to conceive after regular unprotected

sexual intercourse for one or two years. • The Human Fertilisation and Embryo Authority (HFEA) estimate that infertility

affects 1 in 7 heterosexual couples in the UK. A total of 13,703 pregnancies were reported as a result of IVF treatment which started in 2011. 40.3% of IVF treatment cycles were funded by the NHS in 20114.

• In Vitro Fertilisation (IVF) is a technique by which eggs are collected from a

woman and fertilised with a man’s sperm outside the body. Usually one or two resulting embryos are then transferred to the womb. If one of them attaches successfully, it results in a pregnancy.

• Intra-Cytoplasmic sperm injection (ICSI) is a variation of IVF in which a single

sperm is injected into an egg. Cost • A full cycle of fresh IVF can cost the NHS around £3,000 (which includes ovarian

stimulation, removing the woman's eggs, insemination of the eggs in the laboratory, embryo culture, transfer of 1 or 2 embryos back into the body, and freezing of any spare suitable embryos)

• A cycle of Intra-Cytoplasmic sperm injection (ICSI) costs the NHS about an extra £500 in addition to the £3,000

• The thawing and transfer of frozen IVF embryos costs the NHS significantly less than fresh IVF.

Currently, the local NHS funds one cycle of IVF treatment to women who meet the following eligibility criteria: Criteria Current SHIP access

criteria 2013 NICE guidance

Age of woman at time of referral

Up to 35 years old (treatment must start before the woman is 35)

Up to and including 42 years old

Availability of fresh and Fresh cycle only Full fresh cycle and all

3 Solutions for Public Health, August 2014, Review of the clinical and cost effectiveness of infertility treatments 4 Human Fertilisation and Embryo Authority, 2013, Fertility treatment in 2012: Trends and figures

3

frozen cycles subsequent frozen cycles Number of cycles available One cycle Three cycles to women

under 40 years old (one cycle for women aged 40 to 42 years)

BMI eligibility Women must have had a BMI of between 19.0 and 29.9 for six months or more

Offer advice to women with a BMI of 30 or over to lose weight in order to increase the success rate and reduce complications during their pregnancy

Smoking status Couples must be non-smoking for at least six months in order to improve the likelihood of success.

Offer advice and refer to a local smoking cessation programme

Based on the evidence, Solutions for Public Health set out a number of commissioning options for consideration by the SHIP Priority Committee and individual CCGs. The Priorities Committee have proposed that the existing policy be extended to allow one fresh and one frozen cycle, otherwise to remain unchanged:

002 Assisted Conception Services P Consultation

Has a consultation been carried out? Yes. In addition to the review of evidence, the 8 Clinical Commissioning Groups (CCGs) serving Fareham and Gosport, Isle of Wight, North East Hampshire and Farnham, North Hampshire, Portsmouth, South Eastern Hampshire, Southampton and West Hampshire, have sought the views of local people. The public’s feedback will be considered as part of each CCG’s decision about funding of, and eligibility for, IVF treatment. The CCGs in Southampton, Hampshire, the Isle of Wight and Portsmouth (SHIP 8 CCGs) undertook a period of involvement with local people, their representatives, GPs and interest groups. This commenced on Monday 22 September 2014 and initially ran until Sunday 19 October 2014. This deadline was then extended to 7 November 2014. The aim was to:

• Gather views on whether funding for IVF is a priority for the NHS and,

4

• On the access criteria for treatment.

The information shared with members of the public and other stakeholders is below:

IVF Engagement paper FINAL.pdf

In total 1,133 responses were received. Also more than a quarter of respondents had direct experience (either themselves or a partner) of IVF. This is the report outlining the views gathered from local people:

SHIP8 IVF results.pptx

Statutory considerations

Impact Age High/ medium/ low Disability High/ medium/ low Sexual orientation High/ medium/ low Race High/ medium/ low Religion or belief High/ medium/ low Gender reassignment High/ medium/ low Sex High/ medium/ low Marriage and civil partnership High/ medium/ low Pregnancy and maternity High/ medium/ low Other policy considerations

Poverty Medium impact on people with low incomes

Rurality Low impact on people living in rural areas

Other factors High impact on partners of infertile/ sub-fertile people, medium impact on relatives and carers

Geographical impact On populations of Hampshire and the Isle of Wight, including cities of Portsmouth and Southampton

Have you identified any medium or high impact

Yes

Equality statement This equality analysis aims to identify any unlawful discrimination, and opportunities to advance equal opportunities and foster good relations, in line with each CCG’s public sector equality duties (part of the Equality Act 20105).

5 HMSO, 2010, Equality Act 2010

5

The SHIP 8 CCGs have considered the equality impact of the proposed local guidelines for NHS funded assisted conception, and identified the following: Positive impacts The local clinical guidelines regarding NHS funding for assisted conception have a positive equality impact for: • Women and men who have unexplained infertility or who have an identified

cause of infertility (that has lasted for more than 36 months)

• Women in same sex couples/ and women not in a partnership who are infertile/ sub-fertile. To comply with the Equality Act 2010 assisted conception services must be available to gay, lesbian and bi-sexual people and well as heterosexuals

• The partners (same sex and opposite sex) of infertile individuals, in that they may

be able to conceive/ have a child when previously unable to. There is a similar positive impact for relatives and carers of individuals with fertility problems

• People with a disability or long-term health condition. Some physical disabilities

may impede sexual intercourse. Also some medical treatments can cause long-term infertility and so an individual may request harvesting of eggs or sperm prior to treatment. Where a disability is a cause of infertility (for example male factor infertility related to spinal injury) the applicant is considered in the normal way.

Equality related issues like previous pregnancy, childlessness, same sex couples and single women were outside the scope of the evidence review completed by Solutions for Public Health. However, the proposed eligibility criteria for NHS funded IVF and ICSI do include these equality groups and so have a positive impact: • ‘Sub fertility treatment will be funded for women in same sex couples or women

not in a partnership if those seeking treatment are demonstrably sub fertile’ • ‘Treatments for sub fertility will be funded if the couple does not have a living

child from their relationship or from any previous relationship. This includes a child adopted by the couple or in a previous relationship’.

Individuals who fall outside of the criteria for NHS funded fertility treatment can make an Individual Funding Request (IFR). Most of the cases the CCGs supported outside of policy related to cryo-preservation ahead of chemotherapy. The number of people that have received NHS funded IVF under the existing policy and so benefited positively: Fareham and Gosport CCG locality 27 individuals in 2013/14 Isle of Wight CCG locality Data not available North Hampshire CCG

6


43 individuals in 2013/14 North East Hampshire and Farnham CCG locality 39 individuals in 2013/14 Portsmouth CCG locality 32 individuals in 2013/14 South Eastern Hampshire CCG locality 29 individuals in 2013/14 Southampton CCG locality 61 individuals in 2013/14 West Hampshire CCG locality 75 individuals in 2013/14 If individuals are turned down because they do not meet the criteria set out in the IVF policy, they can appeal by making and Individual Funding Request (IFR). The number of IFR applications is outlined below: 2013/14 Fareham and Gosport CCG 5 requests – all declined North East Hampshire and Farnham CCG 13 requests, 5 supported, 8 declined. North Hampshire CCG 8 requests, 2 supported, 5 declined, 1 further info was sought but none provided Portsmouth CCG 10 requests, 5 supported, 5 declined South Eastern Hampshire CCG 7 requests, 2 supported, 5 declined Southampton CCG 10 requests, 4 supported, 6 declined West Hampshire CCG 21 requests, 12 supported, 8 declined, 1 awaited info which was not received 2014/15 (to 30 Sept) Fareham and Gosport CCG 2 requests, both declined North East Hampshire and Farnham CCG No requests pre 30/9 North Hampshire CCG 3 requests, 2 supported, 1 declined Portsmouth CCG 5 requests, 1 supported, 3 declined, 1 awaiting info which wasn’t received South Eastern Hampshire CCG 2 requests, both supported Southampton CCG 4 requests, none supported West Hampshire CCG 9 requests, 5 supported, 3 declined, 1 currently with our Panel The CCGs only collect equalities information that is directly relevant to the decision

7

for eligibility to NHS funded fertility treatment (age and gender). Where disability is a factor in the cause of infertility, this is captured. As a result it is not possible to breakdown access to NHS funded IVF by all the protected characteristics defined in the Equality Act 2010. The Human Fertilisation and Embryo Authority do collect data from fertility clinics, but only publish information for the equality characteristics of age and gender. This lack of information means identifying potential differential access by equality groups to NHS funded IVF, or in applications for Individual Funding Requests is problematic. For example, we cannot analyse how many same sex female couples received NHS funding for infertility treatment locally compared to the expected local population of gay female couples/ prevalence of infertility. Potential negative impacts • Women who are infertile/ sub-fertile and over the age of 35 years, are excluded

from the local eligibility criteria. The NICE guidance recommends at least one cycle of IVF to women up to the age of 42 years. Of the people that responded during the consultation 47.47% felt that NICE guidelines should be implemented, compared to 22% for existing SHIP criteria (35 years), and extending eligibility to 38 years at 27%. This upper age limit is not discriminatory if it can be justified on the basis of clinical evidence/ effectiveness. The evidence summary produced by Solutions for Public Health concludes that increasing maternal age is a key predictor of failure to have a live birth following IVF treatment, and so arguably it can be justified. The previous version of the local IVF policy was amended to remove the lower age limit (set at 30 years of age) in line with Department of Health guidance on age discrimination. Also keeping NHS funding to a single cycle may have the benefit of allowing more people to access treatment and reduce waiting times.

• The local eligibility criteria limit individuals to one cycle of IVF funded by the NHS. This compares to 3 cycles as recommended by NICE. This may have a negative impact on local people with fertility problems, although is not discriminatory if it can be reasonably justified on the basis of evidence. The evidence review notes that there is good evidence that singleton pregnancies after the transfer of frozen thawed embryo are associated with better perinatal outcomes, compared to those after fresh IVF embryo transfer. Given this, the CCGs need to consider whether more than one cycle should be funded. 66% of local people that responded to the consultation felt that we should implement NICE guidelines so people up to 40 years can have up to 3 cycles.

• The policy disqualifies couples who have children from their current or previous

relationships. This can be reasonably justified as spending on IVF and ICSI by the NHS prioritises childless people.

• One cycle of NHS funded infertility treatment is available to any woman/ couple

8

that meet the eligibility criteria, irrespective of their income. People that can afford to self-fund infertility treatment also have that option. People on low incomes are potentially less likely to be able to pay for treatment privately and so have reduced options. The local NHS does not analyse post code details of patients who receive NHS funded IVF and ICSI against areas of multiple deprivation. This may help identify any differential access so that the policy could be adjusted to advance equal opportunities.

• Psychological impact of infertility. Parenthood is one of the major transitions in

adult life for both men and women. The stress of the non-fulfilment of a wish for a child has been associated with emotions such as anger, depression, anxiety, marital problems and feelings of worthlessness. Partners may become more anxious to conceive, ironically increasing sexual dysfunction and social isolation. Relationship discord often develops in infertile couples, especially when they are under pressure to make medical decisions. Couples experience stigma, a sense of loss, and diminished self-esteem in the setting of their infertility6

• The evidence review notes that there are some patient sub groups whose needs

have not been addressed by the review or the NICE guidelines, and for whom the recommendations may not be appropriate or applicable. Any negative impact here can be reduced by sensitive clinical interventions, and promotion of the Individual Funding Request process to diverse groups. Also equality monitoring will help identify whether equal opportunities are advanced when implementing the policy.

• Additional local commissioning policy restrictions may increase inequalities for

people outside of the eligibility criteria

• The Surrey CCG policy is less restrictive than the SHIP policy and creates inequalities within the North Hampshire and Farnham CCG locality

When considering these potential negative equality impacts, and whether to maintain the more restrictive local policy compared to the NICE guidelines, the CCGs must make a decision that strikes a balance between: • The needs of a proportionately small number of people with fertility problems who

are likely to be experiencing significant cultural and psychological issues as a result of not being able to conceive

• With the potential to have a greater positive impact by spending finite NHS funds on tackling other health conditions and inequalities.

Interestingly the public feedback suggests that local people do not think funding for IVF is a priority for the NHS (Do you think funding for IVF is a priority for the NHS? ‘Yes’ = 44.40%, ‘No’ = 46.98%

6 Nachtigall RD, Becker G, Wozny M. The Effects of gender-specific diagnosis on men’s and women’s response to infertility. Fertil Steril 1992; 57:113-21

9

Potential mitigating actions and recommendations • The CCGs should consider raising the upper age limit to 37 years in light of

clinical evidence

• The CCGs should consider the most recent clinical evidence to identify whether maintaining a single NHS funded IVF cycle can be reasonably justified. The evidence seems to suggest that the likelihood of success of individual, subsequent IVF cycles is particularly influenced by embryo viability and the ability of the mother to become pregnant, rather than the number of cycles per se. Arguably keeping NHS funding to a single cycle may have the benefit of allowing more people to access treatment and reduce waiting times

• The CCGs should consider bringing SHIP policy in line with that of Surrey CCG

which funds 3 full cycles for women up to 39 years of age

• The CCGs need to ensure their decision making processes are fair and transparent due to the risk of claims by individuals or Judicial Review

• Collection and analysis of the protected characteristics of individuals should be

completed who o Have received NHS funding for assisted conception services and, o Made an individual funding request for assisted conception services

In addition to age and gender as a minimum this should include the protected characteristics of sexual orientation, disability status, and post code (to identify fair access for lower socio-economic groups). Ideally race, and religion or belief should also be monitored. This will provide better evidence of equitable access and due regard to the Equality Act 2010. This data can be used to inform future policy review decisions.

Date to review actions Final decision date: Different for each CCG depending on

governance timetable Final decision date due Decision to be made by

10

Governing Body CCG Allocation & 2015/16 Operational Plan Sponsor: Loretta Outhwaite, Chief Finance Officer

Summary of issue: This paper is a summary of the planning guidance from NHS England for Commissioners for 2015/16 and will inform the work programmes of the organisation for the next planning period

Action required/ recommendation: For discussion.

Principle risks:

This paper contains a number of must do work programmes and targets against which the CCG will be monitored over the year. The key risk at this stage would be the failure to plan appropriately to achieve these objectives


The planning guidance has been considered at the CCG Clinical Executive committee and an internal task and finish group has been set up to ensure that this document is translated into actions for the CCG.


The contents of this paper will affect the way in which the CCG prioritises its investment plans for the coming period.


This document reiterates the importance of the legal requirements the CCG is under to deliver the NHS constitution targets.


The CCG will be involving patients in the development of the local response to this document. Consideration is being given to the extent and nature of public involvement that is possible given the timescales for finalisation of this plan


A key section of this document deals with the need to address directly the known local health inequalities in the CCG’s plans .

Author of Paper: Gillian Baker, Deputy Chief Officer

Date of Paper: 22nd January 2015


Agenda Item: 7.1 Paper number: CE14-062

Isle of Wight CCG Operational Plan 2015/16

Presentation for Governing Body 5.2.15

Gillian Baker Deputy Chief Officer

The Forward View into Action • Operational plan focusing mainly on 2015/16. • Refresh of current operational plans. • Few new national requirements for planning apart from new access

standards for mental health. • Same unit of planning basis as 2014/15 i.e. IOW system. • Focus remains constitution targets and intense focus on achievement of

performance standards. • BCF plans must align with wider operational plans. • Operational plans must be shared with partners.

Messages and Priorities Prevention

• Radical upgrade in prevention and six different approaches. CCG’s with LA must set in 2015/16 quantifiable levels of ambition to

reduce local health and healthcare inequalities and improve outcomes for health and wellbeing. Agreed actions required in areas such as smoking, alcohol and obesity.

National action on prevention. National evidence based diabetes prevention programme (nationwide

implementation from 2016/17). Helping individuals work or stay in employment. Workplace health programmes for employees. NHS employers significant additional action to promote physical and

mental health and wellbeing.

Empowering Patients • Progress now towards interoperable digital health records by 2018. • Major expansion in 2015/16 of personal health budgets. By 2016 integrated

personal health budgets in health and social care for people with a learning disability; also includes SEND reforms for children. Goals for expansion in Health and Wellbeing strategy.

• 15/16 first steps towards integrated personalised commissioning year of care budgets.

• Choice – patients entitlement to choose includes choice in mental health and maternity.

Engaging Communities • Focus on how CCG meets statutory duties on public and patient

involvement in commissioning decisions. • Support for carers, including young carers and NHS employees with caring

responsibilities. • Strengthen volunteering and engage with Third Sector using grants. • Progressive employers. Boards must review workforce against race equality

standards.

Co-Creating New Models of Care • Need to consider new care models in 2015. Multi-skilling community providers Integrated primary and acute care systems Additional approaches to creating viable small hospitals Models of enhanced care in care homes.

• First pilots in 2015/16 where primary care is central to the model. Additional funding available.

• Need to develop shared vision of model with partner organisations, patients and communities to develop local system wide plan.

• New models of urgent and emergency care, maternity, cancer and specialised services. Priority 2015/16 implementation of urgent and emergency care review. Cancer – better prevention, diagnosis, treatment and after care.

Priorities for Delivery in 2015/16 Improving Quality and Outcomes

• Improving outcomes in the NHS Outcomes Framework. • CQC reports tuned to drive quality through joint plans. • Clear clinical accountability with a named doctor responsible for a patients care within and

across different settings.

Improving Patients Safety • Safe and compassionate care – Francis Report – Active part in local Patient Safety

Collaboratives. • Tackling sepsis and acute kidney infection – CQUINs • Antibiotic prescribing in primary and secondary care. • Implementation of five of the ten clinical standards for seven day services.

Meeting NHS Constitution Standards • Focus on achieving performance. • Ensuring capacity. • System Resilience Groups ensuring capacity all year.

Achieving Parity for Mental Health • Sustain existing mandate objectives – dementia diagnosis/ IAPT. • Introduction of new waiting time standards in 2015/16. • 50% of people with first episode of psychosis treated in 2 weeks. • Liaison psychiatry – further investment. • Crisis Care Concordat – NHS 111, 24/7 Crisis Home Treatment. • CAMH’s and good transition – effective community service, eating disorders.

Transforming Care of People with a Learning Disability • Winterbourne View Concordat. • Market Management with sufficient community provision.

Driving Efficiency NHS Funding in 2015/16

• IOW CCG growth 1.7% overall but includes £1m for system resilience therefore net – 1.4% - lowest growth/no more SRG funds.

• Mental health spend must grow at least in line with overall growth allocation. • National guidance is to plan for: 1.0% surplus 0.5% contingency 1% non-recurrent headroom (for investment in strategic plan – must be

bid for). 10% reduction in running costs.

NHS and Monitor’s proposals on the National Tariff • Inflation assumed at 3%. • Uplift on tariff assumed at 1.93%. Tariffs not yet published. • Provider efficiency requirement of 3.8% therefore decrease 1.9%. • Marginal rate on non-elective activity increased from 30% to 50%.

Planning Assumptions • Plans must be aligned across organisations including activity and financial

trajectories. • Much more accurate demand plans and capacity plans locally. Need to focus

on capacity and commission elsewhere if required and if possible.

CQUIN’s 2015/16 Continues to be 2.5%. Four national indicators:

• Existing improving dementia and delivery of care. • Existing – improving the physical health care of patients with mental health

conditions. • New – Sepsis and acute kidney injury. • New – improving urgent and emergency care – to choose from menu of

options.

Planning Timetable Milestones

By 23 Dec 2014 Publication of 2015/16 planning guidance Jan 2015 Publication of revised National Tariff, standard contract for 2015/16

Jan – 11 Mar 2015 Contract negotiations – including voluntary mediation 13 Jan 2015 Submission of initial headline plan data (CCGs, NHS

England, NHS Trusts) From 29 Jan 2015 Weekly contract tracker to be submitted each Thursday (CCGs, NHS

England, NHS Trusts and NHS FTs) 13 Feb 2015 Checkpoint for progress with planning measures and trajectories

(CCGs, NHS England) 20 February National contract stocktake – to check the status of Contracts 27 Feb 2015 Submission of full draft plans (CCGs, NHS England, NHS Trusts, FTs) 27 Feb – 30 Mar 2015

Assurance of draft plans (CCGs, NHS England, NHS Trusts and FTs)

6 Mar 2015 Checkpoint for progress with planning measures and trajectories (CCGs, NHS England)

11 Mar 2015 Contracts signed post-mediation (CCGs, NHS England, NHS Trusts and FTs)

12 – 23 Mar 2015 Contract arbitration (CCGs, NHS England, NHS Trusts and NHS FTs) By 25 Mar 2015 Arbitration outcomes notified to commissioners and providers

(CCGs, NHS England, NHS Trusts and NHS FTs) By 31 Mar 2015 Plans approved by Boards of CCGs, NHS Trusts and Foundation

Trusts 10 Apr 2015 Submission of full final plans (CCGs, NHS England, NHS Trusts and

FTs) From 10 Apr 2015 Assurance and reconciliation of operational plans

Comments/Issues • Despite only refresh – still significant numbers of new/stretching initiatives to

be addressed. • IOW CCG will have aligned plans with NHS Trust in terms of activity and

contractual finance but significant issues re risk share and shortfall in system funding availability leading to potential failure to reach agreement on Trust contract.

• Issue of capacity in the Trust to deliver targets possibly leading to more shifts in activity to mainland reducing Trust income.

• CCG needs to have prioritisation process for this year as it will not be able to find all desired areas for investment.

• We need much closer working with Public Health on prevention agenda to agree priorities and targets for outcomes.

• Major drive for transformational change, but still not got the basics right in terms of quality.

• Capacity to address transformation, deliver targets and improve quality in services is stretched across CCG and its partners. Even more important to align priorities.

Governing Body Summary of the Quality and Patient Safety Committee 27 November 2014

Governing Body Sponsor: David Newton, Quality and Patient Safety Committee Chair

Summary of issue: Summary of the Quality and Patient Safety Committee (QPSC) Minutes 27 November 2014. Full minutes to be available once approved by the QPSC in February 2015.

Action required/ recommendation: To note the summary of the QPSC minutes 27.11.14.

Principle risks: There are no principle risks relating to this paper.

Other committees where this has been considered: This has not been considered at any other committee.

Financial /resource implications: There are no financial or resource implications relating to this paper.

Legal implications/ impact: There are no legal implications or impact relating to this paper.




Report Author: Rebecca Berryman, Governance Support Officer

Date of Paper: November 2014



1

For the attention of the Governing Body – Summary of the Quality and Patient Safety Committee 27.11.14, Apex House, St Cross Business Park, Newport

1. The CCG has offered the role of Interim Director of Quality and Clinical Services to an experienced individual following a recent recruitment process. A permanent post will be advertised in the New Year.

2. Pressure Ulcers have seen an increase by 75% in September on August figures although the Trust is not a national outlier. A strong focus is continuing on this area of work. The Trust may not meet the related CQUIN.

3. The Friends and Family response rate has dropped, and the Island is currently the lowest in Wessex. The Trust is taking action. QPSC will monitor closely. The Trust may not meet the related CQUIN.

4. The Quality Team are undertaking a piece of work on Trust Complaints that seems timely following reports that the Isle of Wight NHS Trust had the highest number of ombudsman investigated complaints in the country per patient treated.

5. There are concerns that the Trust does not have the capacity to meet its safeguarding responsibilities as DoLs remain a significant concern and discussions around new safeguarding posts are not being progressed. The Trust may not meet the related CQUIN.

6. An Independent Hospital on the mainland is under strict supervision following concerns around safeguarding. The IW CCG has one patient there and is monitoring the situation closely.

7. The QPSC has examined the learning for the CCG from the Trust’s CQC inspection and was assured that, while there are opportunities for improvement, appropriate levels of support and challenge were in place.

2

Governing Body

Minutes of the Clinical Executive 20 November 2014, 18 December 2014 and 15 January 2015.


Summary of issue: Minutes of the Clinical Executive.

Action required/ recommendation: To note the minutes of the Clinical Executive.



There are no other committees where this has been considered.


There are no financial or resource implications relating to this paper, other than the matters raised in the meeting.





Author of Paper: Rebecca Berryman, Governance Support Officer

Date of Paper: November – January 2015



1

Clinical Executive 20 November 2014

Minutes of the Clinical Commissioning Group (CCG) Clinical Executive held on 16 October 2014 at 12:30 at Block A, The APEX, St Cross Business Park

PRESENT: Helen Shields (HS) – Chief Officer (Chair) Dr Anitha Ande (AA) – CCG Executive Gillian Baker (GB) – Deputy Chief Officer Dr Peter Coleman (PC) – CCG Executive Dr Joanna Hesse (JH) – CCG Executive Dr David Isaac (DI) – CCG Executive Loretta Outhwaite (LO) – Chief Finance Officer Dr John Rivers (JR) – CCG Chairman

IN ATTENDANCE: Ali Barton-Smith (ABS) – Commissioning Manager – Acute (Item 6) Rachael Hayes (RH) – Head of Community Commissioning (Items 7 & 8) Nikki Turner (NT) –Acting Associate Director– IOWNHST (Item 7) Becky McGregor (BM) – Clinical Centre Manager – EMH (Item 8) Sue Lightfoot (SL) – Head of Mental Health & LD Eleanor Roddick (ER) – Head of Performance and Contracting (Item 10&17) Karen Baker (KB) – Chief Executive – IOWNHST (Item 20) Alan Sheward (AS) – Executive Director of Nursing and Workforce (Item 20) MINUTED BY: Rebecca Berryman (RB) – Governance Support Officer

14-140 Apologies for Absence Apologies were received from Rida Elkheir. 14-141 Declarations of Interest

The Declaration of Clinical Executive Members was agreed as accurate, with no changes.

For the attention of the Governing Body:

• Agreed to extend contact with Echotech for 2 years. • Approved Community Growth Business Cases for dietetics, podiatry, pelvic obstetric and gynaecological

physiotherapy, orthotics and district nursing. • Approved expansion of Lymphedema Service until March 2015, the recurrent scheme to be considered

with other schemes during the development of the Operational Plan. • Approved expansion of the current IAPT service. • Approved Commissioning Intentions including giving the IOW NHS Trust notice on the Island Premium and

any support to be interim. • Approved Individual Funding Request Panel Terms of Reference. • IOW NHS Trust updated on the Black Alert.

2

14-142

Minutes of the last Clinical Executive meeting The minutes of the last meeting on the 16 October 2014 were agreed as an accurate record, with the following exceptions: • For the attention of the Governing Body box should read “Approved a 2 year extension to

the Phoenix project, a specialist service for adults with learning disabilities.” • 14-132 – should read, “it has been highlighted that a move to a new practice system may

impact…” • 14-133 – the finance summit took place on the 15 October 2014.

14-143

Matters Arising i. Schedule of Actions from the CCG Executive16 October 2014 The Clinical Executive received the Schedule of Actions from the CCG Clinical Executive meeting on the 16 October 2014, noting the following comments: • 14-034 – Isle of Wight NHS Trust (IOWNHST) Cost Improvement Plan (CIP) – these have

now been received, it was agreed this action can now be closed. • 14-111 – Sustainability of Medical Specialities - a vacancies paper has been produced by

the IOWNHST, it will form part of a planned piece of work to review future sustainability of the provider in various scenarios. It was agreed this action can now be closed.

• 14-103 – Post-Operative Physio – community physiotherapy has now been commissioned to be provided on the Island for follow up to mainland surgery. It was suggested information should go out to GP Practices to update them on the services, GB agreed to discuss this with Linda Rann. The action could now be closed.

• 14-129 – Phoenix Contract – all contracts will now be monitored closely at Performance meetings. This action could now be closed.

• 14-134 – Pharmacy First – GB clarified that a number of System Resilience campaigns were taking place, this included Pharmacy First.

The Clinical Executive received the Schedule of Actions. ACTION: GB to discuss with Linda Rann re Post-Operative Physio information to GP Practices. GB 14-144 Chair Update Session

The Clinical Executive received an update from JR with regard to the 5 Year Forward View. It was agreed that key areas for discussion were obesity prevention, sustainability and future models for healthcare on the Island. Further detailed discussion would take place at the December Clinical Executive Seminar. GB highlighted the CCG would need to remain neutral when reviewing future integration models.

The Clinical Executive noted the Chair update. ACTION: 5 Year Forward View to be discussed at the Clinical Executive Seminar in December. HS/

RB For Decision 14-145

Inhealth Echotech Ltd The Clinical Executive received paper CE14-100 Inhealth Echotech Ltd, presented by ABS.

3

The paper was taken as read. LO queried if there would be any likely challenge from any other providers. ABS confirmed that none to her knowledge would challenge. DI commented that there had been a change in attitude from the hospital Cardiologists which resulted in many tests not being duplicated.

The Clinical Executive agreed to adopt a single tender waiver and extend the Inhealth Echotech Ltd Contract for a further 2 years.

14-146 Community Growth Business Cases

The Clinical Executive received papers CE14-101 Community Growth Business Cases, presented by RH and NT. HS declared an interest in this item as her husband is Head of Podiatry at the Isle of Wight NHS Trust. HS remained in the room, however did not make any contribution to the item. LO took over as Chair for this item. Dietetics This Business Case sought additional funding for a 0.5wte Band 6 to support increasing activity. This funding will come from volume growth. JR queried how this would work alongside Mental Health. NT confirmed that the Dietetics service work in an integrated way with Mental Health and each case is personalised to the individual patient. The Dietetics Business Case was approved. Podiatry This Business Case sought additional resource to enable the Podiatry Department to meet the increased Podiatric dependency resulting from an increasing elderly population and additionally the increasing referrals for lower limb gait analysis. Funding of a 0.8wte Band 6, 1wte Band 5 and a 0.4wte Band 3 would support the increased activity in Community Clinics and Specialist Biomechanics to bring access times back to a safe return period, and enable the service to maintain access times. The funding is to be provided from volume growth. No further discussion took place, the Business Case was approved. Pelvic Obstetric and Gynaecological Physiotherapy (POGP) The POGP service is a specialist area of physiotherapy requiring post graduate training. It identifies that the current resource allocation of a Specialist Band 7 0.4wte is now insufficient to meet the demand for delivery of the service by the Trust. Referrals to the service have increased in the past five years. This funding request supports an additional 0.6wte Band 7 and 0.4wte Band 3 administrative support. The funding is to be provided from volume growth. It was discussed that GPs need to be clear regarding the referral process. The Business Case was approved. Orthotics Review of the Orthotics and Prosthetics Service has identified a shortfall in funding requested by the IOWNHST from the Community rebasing exercise in 2011/12 and a need for volume growth support from 2013/14. The funding is to be provided from transition funding. The Business Case was approved. District Nursing The Business Case proposed an investment plan to bring the capacity of the Community Nursing Service in line to match the current level of demand whilst auditing the changes

4

from this investment and also the introduction of Locality Management Groups. The funding request supports 1.0wte Practice Educator and 5.0wte Band 5 Community Nurses. Funding is to be provided from volume growth. Discussion took place regarding the Out of Hours (OOH) Service and how funding for OOH will not be available within the funding for District Nursing. This service will not cease until a new service is put in place. Further discussion will need to take place regarding the future provider of the OOH service. Option 3 A was agreed. The issue of HR processes was raised and the need for a swift appointment process was required.

The Clinical Executive approved the Dietetics, Podiatry, Pelvic Obstetric and Gynaecological Physiotherapy, District Nurses and Orthotics Business Cases.

14-147 Lymphedema Service

The Clinical Executive received paper CE14-102 Lymphedema Service, presented by RH and BM. It was noted that this has previously been discussed at the Clinical Executive Seminar. The paper was taken as read. Discussion took place regarding the difference between option 2 – staged development of staffing, and option 3 - fully developed service in line with Lymphoedema review. It was confirmed that the difference was the difference in the banding of the staff. Option 3 allows the focus to be on training and education and expanding this in to localities. DI asked if the posts will easily be recruited to, BM confirmed it was difficult to say, however there was a potential candidate for the Band 6 post. The service was highlighted to be a new investment, which is not included in the Operational Plan. RH identified that some money from the Hospice contract can be utilised for this service. Option 2 was agreed non recurrently, with additional funding from slippage utilised until March 2015. The recurrent option will be considered with the other schemes within the planning process.

The Clinical Executive approved Option 2 non-recurrently to fully develop the Lymphedema Service, with the recurrent option being considered within the planning process.

14-148 IAPT ‘Growth’ Business Case

The Clinical Executive received paper CE14-103 Improving Access to Psychological Therapies (IAPT) ‘Growth’ Business Case, presented by SL. The paper was taken as read. LO queried that with regard to the statement that the IOWNHST recommend option 3, did the Commissioners also agree with this option. SL confirmed that they did. JH asked for an update with regard to the different resources that GPs could refer to. SL confirmed that she would be having a teleconference with Silver Cloud and from that would develop a leaflet for GPs. GB commented that £29k non recurrent funding has been allocated to reduce the waiting

5

list, in order to achieve the target. JR stated that this was a good way forward; however it would need to be clear how the service works, with a leaflet that outlines the range of options that GP’s can access.

The Clinical Executive approved Option 3, Phased expansion of Current IAPT service. ACTION: Development of the IAPT leaflet for GPs. SL 14-149 Commissioning Intentions

The Clinical Executive received paper CE14-104 Commissioning Intentions, presented by GB. GB highlighted that the Commissioning Intentions were not significantly different from the previous year. However there was more focus on 7 day a week services. The Commissioning Intentions document reflects the strategy, and what is known so far regarding the national priorities. The Clinical Executive was asked what their views were regarding carrying on the risk share agreement. After discussion it was agreed that notice would be given on the Island Premium, interim instead of transition funding would be put in place. It was also agreed that 3.43 and 3.44 of the document would be removed and a covering letter would outline this, as they were Trust specific.

The Clinical Executive approved the Commissioning Intentions, subject to the ammendments to the Risk Share and 3.43 and 3.44.

14-150 IFR Terms of Reference

The Clinical Executive received paper CE14-105 Individual Funding Request (IFR) Terms of Reference, presented by HS. It has been identified that the current membership of the IFR panel requires some more clinical representation. It is therefore proposed that the Director of Quality and Clinical Services and a Director/Consultant in Public Health is added to the membership. It was confirmed that the Consultant in Public Health does not necessarily need to be a clinician.

The Clinical Executive approved the revisions to the membership of the IFR Panel. 14-151 Varicose Veins Policy Statement

The Clinical Executive received paper CE14-106 Varicose Veins Policy, presented by HS. There has been very little change between Policy statement 39 – April 2008 and Policy statement 001 August 2014. PC commented that it was important that these were reviewed regardless of whether many changes had been made. JR queried how many requests the IFR panel had received. HS confirmed that a couple had been received but none had been approved.

The Clinical Executive recommended for approval to the Governing Body the adoption of the Varicose Veins Policy Statement.

6

For Information 14-152 NHS Support for Social Care Section 256 2014/15

The Clinical Executive received paper CE14-107 NHS Support for Social Care Section 256 2014/15, presented by GB. The agreement is largely similar to 2013/14, with additional projects in relation to self-management. GB commented that the quarter 1 and 2 report had not yet been received from the IOW Council. The Clinical Executive expressed their disappointment that this had not been received.

The Clinical Executive noted the NHS Support for Social Care Section 256 2014/15. 14-153 Governance

Procurement Decisions There were no procurement decisions.

14-154 Risk Register

The Clinical Executive received paper CE14-108 Risk Register, presented by HS. The report highlighted that there are three new risks this month: • Y2/24 – Cancer Targets – this is a result of closing a previous risk and reframing as the

situation has changed. • Y2/25 – opened to reflect risks the CCG is running as there is no Quality of Quality and

Clinical Services in post. • Y2/26 – concern raised as a result of an Ebola table top exercise exposing poor planning

within the IOWNHST to manage a suspected case. It was recommended that the following risk was closed: • Y2/7 – regarding domiciliary care provider where two continuing healthcare patients have

now been successfully resettled and the risk has been managed. It was recommended that risk Y2/6 CCG allocations was increased. LO flagged that this was a long term risk to the CCG, so should therefore be included on the Governing Body Assurance Framework rather than the Risk Register.

The Clinical Executive noted the Risk Register. ACTION: Risk Y2/6 to be included on the Governing Body Assurance Framework. CM 14-155 Information Management and Technology (IM&T)

The Clinical Executive received paper CE14-109 GP/GMSIT presented by LO. The paper outlined the GP/GMS IT performance from the South Commissioning Support Unit (CSU). It was highlighted that the project management office usage for CCG IT and GP IT related projects are currently underutilised. However it was explained that a significant number of days will be utilised to support the development of the IM&T strategy. The days are currently managed across the SHIP CCGs, as a risk pool. This needs discussion and agreement with the CCG Chief Finance Officers. LO commented that an IM&T summit will take place, a joint strategy will be pulled together and all partners will need to be in agreement for the way forward.

7

LO referred to the Hampshire Healthcare Agreement (HHA), and whether the CCG should sign up to this. HS confirmed that at the SHIP 8 meeting, it was agreed that the CCG are not in a position to make a decision. However a recent case study identified that the Island already has many of the principles of the HHA.

The Clinical Executive noted IM&T update. 14-156 Performance and Contracting

Performance Report The Clinical Executive received paper CE14-110 Performance Report, presented by ER. The report highlighted: • £350k will be received from the Quality Premium. All gateways were achieved. The CCG

failed with regard to Emergency admissions, Friends and Family and MRSA. • Constitution targets are red. • 18 week referral to treatment (RTT) performance failed to achieve target in month for

both the admitted and non-admitted categories with the margin from target widening in month for admitted.

• The IOWNHST reported a 52 week plus waiter from the month of September resulting from a number of failures with the processes followed in the treatment of the patient.

• Achievement of the target for A&E performance for breaches of 4 hour waits was maintained in September, although with a reduced percentage rate achieved. It is anticipated that the target will be missed for October and is proving challenging for November.

• The Friends and Family test saw a fall in response rate across all categories in month. • A further two cases of C.Difficile were reported for September, in line with the target in

month but with a combined total of 19, puts achievement of the Annual target at risk of failure.

• There was one breach of operations cancelled and not rebooked within 28 days. • Ambulance Handover target was not achieved.

The Clinical Executive noted the Performance Report. 14-157 Contracts Report

The Clinical Executive received paper CE14-111 Contracts Report, presented by ER. There was some concern raised regarding some Medicines Management and Continuing Healthcare contracts. This would be discussed at the Commissioning Officers Group (COG).

The Clinical Executive noted the Contracts Report. ACTION: Contracts Report to be discussed at COG. HS/

RB 14-158 Finance Forecast

The Clinical Executive received paper CE14-112 Finance Forecast, presented by LO. It was noted that the CCG will have c£2m surplus. Further discussion would take place at the Clinical Executive Seminar in December.

8

The Clinical Executive noted the Finance Forecast. ACTION: Finance Forecast to be discussed at the December Clinical Executive Seminar. HS/

RB 14-159 Notes of Sub-Committees

The Clinical Executive received the following notes of sub-committees: • Clinical Quality Review Meeting 3.10.14 • Contract Monitoring and Service review meeting 21.10.14 • October Locality Meetings • Clinical Effectiveness Committee 25.9.14

The Clinical Executive noted the Sub-Committee notes. 14-160 Any Other Business

Black Alert KB and AS attending the Clinical Executive to give an update regarding the Black Alert that recently took place at the IOWNHST. KB confirmed that the Trust were currently awaiting more detailed data analysis regarding the situation, this information would be available by the Wash Up meeting that would be taking place on the 2 December 2014. The Black Alert took place during the October half term holidays; therefore there was an increase in annual leave during this time. There is no significant difference between the same school holidays in 2013; however a deep dive will take place to investigate further. AS identified that when the Trust is on red alert, this tends to be accepted as the norm and they were not quick enough off the mark to recognise the full extent of the issue. As a result there is now a term named ‘Back Door’ truth, which translates in to one truth of how many patients are fit to be discharged. This one truth is shared at the Central Control Hub in the Conference Room in the Trust, where a group of people across all sectors of Healthcare can work together to understand the situation. The details are currently shared on a spreadsheet and updated on a 2 hourly basis. This was highlighted to be business as usual from now on. Discussion took place regarding the number of beds taken out by the provider due to estates work and the number of new beds that were to be opened in the coming weeks. AS agreed to share the spreadsheet with the CCG. With regard to the recruitment of posts, it was highlighted that there were concerns with the European market. However, DI identified that he believed Italy may be a good place to recruit from. The Philippino training was similar to UK training, recruitment is still taking place, but delayed until January.

ACTION: AS to share additional bed spreadsheet with the CCG. AS 14-161 Date of Next Meeting: Thursday 18 December 2014 – 12:30 – 15:30, Block A, The Apex –

Carisbrooke Room.

9

Circulation: Members In attendance: For Information (Agenda): Peter Coleman – CCG Executive Joanna Hesse – CCG Executive David Isaac – CCG Executive John Rivers – CCG Executive (Chair) Helen Shields – Chief Officer Loretta Outhwaite – Chief Finance Officer Rida Elkheir – Associate Director of Public Health

Gillian Baker Rebecca Berryman (notes)

Rebecca Wastall For Information (Minutes): Matthew Leek, CCG Commissioning Finance Mgr Shaun Sweatman, CCG Commissioning Finance Mgr Linda Rann, Sue Lightfoot, Rachael Hayes, Dawn Berryman - Heads of Commissioning, Eleanor Roddick – Head of Performance, Andy Brandham, Deputy Head of Medicine’s Management, Caroline Morris – Head of Corporate Business, Rebecca Wastall – Deputy Chief Finance Officer

10

Clinical Executive 18 December 2014

Minutes of the Clinical Commissioning Group (CCG) Clinical Executive held on 18 December 2014 at 12:30 at Block A, The APEX, St Cross Business Park

PRESENT: Helen Shields (HS) – Chief Officer (Chair) Gillian Baker (GB) – Deputy Chief Officer Dr Peter Coleman (PC) – CCG Executive Rida Elkheir (RE) – Associate Director of Public Health Dr David Isaac (DI) – CCG Executive Dr John Rivers (JR) – CCG Chairman

IN ATTENDANCE: Eleanor Roddick (ER) – Head of Performance and Contracting Russell Ball (RBa) – IOWNHST Business Co-ordination (Item 6) Sue Lightfoot (SL) – Head of Mental Health and Learning Disabilities (Items 8&9) Rachael Hayes (RH) – Head of Community Commissioning (Items 10-12)

Loretta Kinsella (LK) – Interim Director of Quality and Clinical Services (items 7, 11, 12, 14 17.1 & 17.2.)

Karen Baker (KB) – IOWNHST Chief Executive (Item 17.1) Chris Palmer (CP) – IOWNHST Executive Director of Finance (Item 17.1) MINUTED BY: Rebecca Berryman (RB) – Governance Support Officer

14-162 Apologies for Absence Apologies were received from Dr Anitha Ande, Dr Joanna Hesse and Loretta Outhwaite.

Eleanor Roddick deputised for Loretta Outhwaite.

14-163 Declarations of Interest

The Declaration of Clinical Executive Members was agreed as accurate, RE formally declared the following interests; these will now be formally recorded on the Declaration of Interests paper. Rida is: Associate Director in Public Health, Clinical Director in Leicester (until December 2014) Director of SPHCG, a not for profit health for Africa voluntary consultancy and advocacy


• Approved recurring support of the GP in Acute business case, the scheme has demonstrated up to 35% of patients have been discharged without the need to admit.

• Approved expansion of filtering and assessment service with Community Mental Health Services. • Approved the Crisis Response business case. • Approved extension to Autistic Diagnostic resource Centre contact for 18 months. • Received Urgent Care Paediatric Review and required an action plan from the IOW NHS Trust. • CCG IT- CSU issued a contract notice to the IOW NHS Trust re service issues. • Received a presentation by IOW NHS Trist Chief Executive and Director of Finance. Concern about the

level of CIP gap and delayed sign up of the Mental Health services partner.

1

group.

14-164

Minutes of the last Clinical Executive meeting The minutes of the last meeting on the 20 November 2014 were agreed as an accurate record.

14-165

Matters Arising i. Schedule of Actions from the CCG Executive 20 November 2014 The Clinical Executive received the Schedule of Actions from the CCG Clinical Executive meeting on the 20 November 2014, noting the following comments: • 14-124 – Anticoagulation Service – it was confirmed that IT is compatible with the Anti-

coagulation system. This action can now be closed. • 14-143 – Post Operative Physio GP Update – agreed to keep action open, Steve Rowe is

co-ordinating. • 14-160 – Isle of Wight NHS Trust Bed State Spreadsheet - spreadsheet received however

need to understand the data, therefore action to remain open.

The Clinical Executive received the Schedule of Actions. 14-166 Chair Update

• JR highlighted he had a useful meeting with Peter Close, Radiologist from the Trust regarding diagnostics. He would like to discuss this further at the Clinical Executive Seminar.

• Practice visits are taking place and are proving useful. • Three locality champions have been recruited.

The Clinical Executive noted the Chair update. ACTION: Diagnostics to be added to the Clinical Executive Seminar agenda. RB 14-167 Chief Officer Update

• HS highlighted there is increased national pressure regarding performance targets. • The planning guidance is due on 23.12.14 • Dominic Hardy has been appointed as the Wessex Area Team’s Chief Executive.

The Clinical Executive noted the Chief Officer For Decision 14-168

GP in Acute Business Case The Clinical Executive received paper CE14-120 GP in Acute Business Case. A 13 month pilot of having a GP based in the Accident and Emergency/Medical Admissions Unit is taking place and is due to end in March 2015. The service reviews all patients that are scheduled as ‘GP Emergency Admissions’. The scheme has demonstrated that up to 35% of patients have been discharged without the need to admit. The Clinical Executive were asked to decide whether the scheme should be taken forward on a recurring basis. Discussion took place regarding the GP’s access to diagnostics, and how beneficial this was

2

to be able to diagnose effectively. It was confirmed that the scheme is valued by the Trust.

The Clinical Executive approved option 2 to continue funding the service on a recurring basis within a financial block arrangement.

14-169 IVF Policy Statement and Feedback from Public Engagement

The Clinical Executive received papers CE14-121 IVF Policy Statement and Feedback from Public Engagement. HS highlighted that the SHIP 8 Clinical Commissioning Group’s Priorities Committee has reconsidered the Policy Statement 150: Assisted Conception Services and has recommended a revised policy statement 002. There has also been an engagement exercise via an online survey conducted across the SHIP 8 area. The results from the IOW are very different from the SHIP 8 positions with the majority of respondents in favour of funding IVF (57.89%) and a clear majority (60.54%) favouring following NICE guidelines. There total number of respondents was 191 of which 27.51% stated that they or their partner had direct experience of IVF treatment. It was confirmed that other CCGs were in agreement with approving Policy Statement 002. Discussion took place regarding does the IOW have evidence to do things differently to the rest of Wessex. It was agreed that the Clinical Executive based on a clinical perspective that recommend the Governing Body approve Policy Statement 002. It was also agreed the Governing Body should be briefed regarding IVF prior to the Governing Body meeting.

The Clinical Executive recommended for approval to the Governing Body Policy Statement 002.

ACTION: HS to arrange an IVF briefing prior to Governing Body meeting on 5 February 2015. HS 14-170 MH Crisis Concordant Declaration

The Clinical Executive received paper CE14-122 MH Crisis Concordant, presented by SL. The declaration was discussed at the Clinical Executive Seminar, and was re-tabled to be formally approved at the Clinical Executive meeting. SL confirmed that the action plan would be presented in February.

The Clinical Executive approved the Isle of Wight Mental Health Crisis Care Concordat Declaration.

14-171 Business Case Community Mental Health Service

The Clinical Executive received paper CE14-123 Business Case Community Mental Health Service (CMHS), presented by SL. It was highlighted that the recent CQC Inspection found that the CMHS was poor across all domains. A Quality Improvement Plan is currently in place and identifies the need to undertake a Commissioner/Provider review and redesign of the CMHS. It was highlighted that the number of urgent referrals received each month over the last six months has doubled in comparison to the same period in 2013. To keep the service safe agency staff have been deployed, the service has not seen any additional resources since 2008. The Clinical Executive were recommended to approve Option 3 (subject to final agreement of finance) to recruit 2.0 WTE Band 6 RMN posts in Filtering and Assessment Service to meet the increasing demands on the service and provide a safe and sustainable service for patients.

3

It was confirmed that mandated reporting on this service would come in to force on the 1 April 2015, and the CCG are expected to support some of the CQC recommendations.

The Clinical Executive approved Option 3 to recruit 2.0 WTE Band 6 RMN posts in the Filtering and Assessment Service, subject to final agreement of finance.

14-172 Crisis Response Business Case

The Clinical Executive received paper CE14-125 Crisis Response Business Case, presented by RH. A Crisis Response Team has been commissioned on a pilot basis until March 2015, with the aim to deliver a range of services closer to people’s homes in order to reduce admissions to hospital and long term care placements. Discussion took place regarding the service needing to be cost neutral, and the Trust needs to be comfortable that the service does save admissions. GB highlighted that the cost outlined from Age UK is challenging regarding overheads, there is a meeting to take place to discuss costs to outline what is reasonable. Discussion took place that in order to continue the existing service savings would need to be matched from the Demand Plan. The funding would be recurrent; however the CCG can give notice and reconfigure the service if they are not happy with the service. DI queried the hours the service operated, it was confirmed the service operated 7 days a week between 8:00 and 16:00. DI also queried why the service was restricted to over 65’s when the service had been provided to those under 65. It was confirmed that anyone using assistive technology were supported. It was agreed to approve option 2, to continue the existing service, however this would be subject to finance approval. A meeting between GB, LO, Alan Sheward and Chris Palmer from the Trust should take place to work out the finance.

The Clinical Executive approved option 2, to continue the existing service, subject to finance

approval.

Loretta Kinsella (LK), Interim Director of Quality and Clinical Services joined the meeting and

was formally introduced. She attended for items 7, 11, 12, 14 17.1 & 17.2.

14-173 Autistic Diagnostic Resource Centre (ADRC) Extension to Contract

The Clinical Executive received paper CE14-124 ADRC Extension to Contract, presented by RH. The existing contract with ADRC is due to expire on the 31 March 2015. The contract was put in place to bring the referral to assessment time within the NICE clinical guidelines of 18 weeks. Once the backlog had been cleared and the 18 week referral to assessment timescale achieved the contract was due to be handed over to the IOWNHST to manage. The Trust are not in a position to manage the service at the current time and therefore it was proposed a one year extension of the current contract with ADRC. It was agreed this was a good service that should continue until the Trust were in a position to take back the contract. It was suggested in order to stagger the renewal of contracts that the current contract is extended for a further 18 months.

4

The Clinical Executive approved the extension of the current contract for delivery of the

ADRC service in 2015/16 for a further 18 months.

For Information 14-174 Paediatric Review

The Clinical Executive received paper CE14-126 Paediatric Review, presented by RH. It was commented that it was disappointing to see that not all of the detail contained in the draft report was included in the final report. It was agreed that a formal letter should be sent to seek assurances that the clinical issues and actions that the CCG are aware of are taken forward. The Action Plan from the review is due at the end January 2015 and will be monitored via CQRM.

The Clinical Executive noted the Paediatric Review. ACTION: Formal letter written to seek assurance that clinical issues and actions that the CCG are

aware of in relation to Paediatrics are taken forward. RH

14-175 IW Council Integration Paper

The Clinical Executive received paper CE14-127 IW Council Integration Paper, presented by HS. The paper has been supported and approved by both the Isle of Wight Council and Isle of Wight NHS Trust (IOWNHST). JR commented that is was a powerful statement that fitted in with the My Life a Full Life (MLAFL) programme. DI queried if there would be any corporate memory problems as a result of the Council redundancies. It was confirmed that social care was not expected to be at risk, however GB agreed to clarify this with Martin Elliott. RE confirmed that with regard to Public Health, although their funding is protected they would still go through the Council evaluation process, and may have to justify their position.

The Clinical Executive noted the IW Council Integration Paper. ACTION: GB to clarify with Martin Elliott whether social care posts are expected to be at risk. GB 14-176 Screening and Immunisation

This item was deferred to the Clinical Executive Seminar in January 2015.

14-177 Governance

Procurement Decisions There were no procurement decisions.


The Clinical Executive received paper CE14-129 Risk Register, presented by HS. The report highlighted the following: • Y2/7 – Domiciliary Care provider of CHC – was recommended for closure, as both

patients are now settled. GB confirmed this related to Reeves Court and the risk could be

5

closed. • Y2/6 – CCG Allocations – HS commented that the assurance that next year’s allocation

will not be affected by the new allocation formula should be rescinded. The risk level should remain the same.

• Y2/12 – Mental Health Leadership - a new head of MH and LD services commenced at the IOWNHST. A Business Case has also been put together to create a head of psychological services. The risk has not been resolved however the risk is moving in the right direction.

• Y2/13 – 18 weeks – the 18 weeks at the IOWNHST is unlikely to be achieved in November or December. The risk remains high.

• Y2/5 – Local Provider Long Term Support - there was an error in the previous risk register, this risk should have been high risk.

• Y2/15 – Ambulance Handover - HS highlighted that the Trust are now being fined, the CCG have agreed to reinvest the money to help solve the problem. It was agreed the risk should remain on the register.

• The Clinical Executive agreed to add a new risk regarding the ability of the system to meet key urgent targets such as the 4 hour waits. GB agreed to take this forward.

The Clinical Executive noted the Risk Register. ACTION: GB to add risk regarding the ability of the system to meet key urgent targets such as the 4

hour waits. GB

14-179 Information Management and Technology (IM&T)

The Clinical Executive received a verbal update from ER. CCG IT The Commissioning Support Unit (CSU) has issued a Contract Notice to the sub-contracted service provided by the IOWNHST. There are significant service and equipment issues. GMS IT A formal report regarding GMS IT timescales was requested for the January Clinical Executive meeting.

The Clinical Executive noted IM&T update. ACTION: GMSIT Report to include timescales to go to the January Clinical Executive meeting. CM 14-180 Performance and Contracting

Isle of Wight NHS Trust Financial Framework Agreement The Clinical Executive received paper CE14-130 Financial Framework Agreement, presented by KB and CP. The report highlighted the following: • Cost Base – the validation process to establish the baseline, identify risks and make

recommendations to ensure the cost and income information is materially accurate is due for completion on the 31 January 2015.

• Cost Improvement Plan (CIP) – as at month 8 CIPs show a gap of £2.3m. It was discussed that the CCG and Trusts assumptions need to tally, CP confirmed that LO had seen the detail for month 8 assumptions.

6

• Pressure Ulcer - good progress has been made with the Pressure Ulcer campaign. The IOWNHST is showing below the national trend line. More work is still required, particularly in the community, and with getting the reporting of ulcers correct. It has been recognised that more training is required in these areas.

• Strategic Estates Joint Venture - the hospital estate needs to align with the clinical strategy. The strategy will be refreshed to be in line with what the estate should look like. An estates summit is being arranged.

• Mental Health Services Partner – a meeting between the Trust and Hertfordshire Partnership University NHS Foundation trust has been delayed until February 2015. The MOU has not yet been signed.

• Psychological Therapies – it was confirmed that the business case had not been rejected, however further work was required to get the model right.

• NHS Constitution Commitments – a further MRSA and C Difficile was reported. The Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital Level Mortality Indicator (SHMI) are in the right direction.

Discussion took place regarding poor performance and how an Executive to Executive meeting was going to take place between Christmas and New Year. KB highlighted that an interim Chief Operating Officer was being recruited. JR queried when service line reporting would be available for diagnostics. It was confirmed that it will be completed by August 2015. JR confirmed he had been in discussion with Peter Close regarding the diagnostic pathway and it would be useful to understand the cost base. CP highlighted that the validation process would need to take place first however diagnostic imaging could be timetabled earlier.

The Clinical Executive noted the Financial Framework Agreement. 14-181 Performance Report

The Clinical Executive received paper CE14-131 Performance Report, presented by ER. The report was taken as read.

The Clinical Executive noted the Performance Report 14-182 Notes of Sub-Committees

The Clinical Executive received the following notes of sub-committees: • Clinical Quality Review Meeting (CQRM) November 2014. HS commented that letters are

being sent to the Trust before Contract Notices are issued. 7 letters have been sent to date regarding a range of issues. The December CQRM was a challenging meeting; actions are building up as a result of capacity issues.

• Contract Monitoring and Service review meeting November 2014 • November Locality Meetings JR queried what progress had been made regarding the Black Alert. It was confirmed that not all data was provided at the wash up meeting, and the data is yet to be provided to date. There is still not a diagnosis as to what caused the Black Alert. The common theme relates to issues regarding discharge and staffing.

7


IOWNHST response to CQC Warning Notice The IOWNHST response to the CQC Warning Notice was tabled by HS. The Trust are not compliant in three areas highlighted in the notice. It was commented that there is not enough detail regarding the actions taken in some areas. There are issues with the named Consultant, as Consultants are working to wards rather than to patients. This will be picked up at CQRM where the audit in to named Consultants will be requested. There are still issues regarding Nursing vacancies, the CCG are requesting a month by month report regarding the vacancies.

14-184 Date of Next Meeting: Thursday 15 January 2015 – 12:30 – 15:30, Block A, The Apex –

Carisbrooke Room.

Circulation: Members In attendance: For Information (Agenda): Peter Coleman – CCG Executive Joanna Hesse – CCG Executive David Isaac – CCG Executive John Rivers – CCG Executive (Chair) Helen Shields – Chief Officer Loretta Outhwaite – Chief Finance Officer Rida Elkheir – Associate Director of Public Health



8

Clinical Executive 15 January 2015

Minutes of the Clinical Commissioning Group (CCG) Clinical Executive held on 15 January 2015 at 12:30 at Block A, The APEX, St Cross Business Park

PRESENT: Helen Shields (HS) – Chief Officer (Chair) Gillian Baker (GB) – Deputy Chief Officer Dr Peter Coleman (PC) – CCG Executive Rida Elkheir (RE) – Associate Director of Public Health Dr Joanna Hesse (JH) – CCG Executive Dr David Isaac (DI) – CCG Executive Loretta Kinsella (LK) – Interim Director of Quality and Clinical Services Loretta Outhwaite (LO) – Chief Finance Officer Dr John Rivers (JR) – CCG Chairman

IN ATTENDANCE: Rachael Hayes (RH) – Head of Community Commissioning (Item 6) Mark Rawlinson (MR) – Governing Body Nurse (observing)

Eleanor Roddick (ER) – Head of Performance and Contracting (Items 9.1 & 9.3) MINUTED BY: Rebecca Berryman (RB) – Governance Support Officer

14-185 Apologies for Absence Apologies were received from Dr Anitha Ande. 14-186 Declarations of Interest

The Declaration of Clinical Executive Members was agreed as accurate, with no changes.

14-187

Minutes of the last Clinical Executive meeting The minutes of the last meeting on the 18 December 2014 were agreed as an accurate record.

14-188

Matters Arising i. Schedule of Actions from the CCG Executive 18 December 2014 The Clinical Executive received the Schedule of Actions from the CCG Clinical Executive meeting on the 18 December 2014, noting the following comments: • 14-127 – Infection Prevention and Control Nurse – Public Health have given the CCG six

months notice on the Infection Prevention and Control Nurse Post. LK and RE agreed to set up a meeting to discuss the CCG’s requirements in this area.


• Approved investment in paediatric therapy services to ensure national special education needs are met. • Approved £1m year-end support to the IOW NHS Trust as transitional support. • Approved delegation of year end spending to the Chief Officers Group. • Received Q3 Delivery Plan and Support for Social Care Report. • Discussed new models of care and potential Vanguard sites.

1

• 14-143 – Post-Operative Information – GB to chase. • 14-148 – IAPT Leaflet – information has been sent out to Primary Care regarding

Silvercloud. The IAPT Leaflet is pending. GB to chase. • 14-166 – Bed Capacity Spreadsheet – the spreadsheet has been received; however

greater assurance is required particularly with regard to System Resilience. LK and GB to seek assurance from the Isle of Wight NHS Trust (IOWNHST).

• 14-169 – Governing Body IVF Briefing – a conference call has been arranged for the 2 February 2015.

• 14-174 – Paediatric Formal Letter - it was agreed two letters need to be sent to the IOWNHST from HS. One in relation to the action plan following the Paediatric Review to Karen Baker and a second letter regarding Clinical assurance to Mark Pugh.

• 14-175 – Social Care Posts – As far as GB is aware no front line posts are at risk. Action to be closed.

• 14-178 – Risk Register – System Resilience has been added to the Risk Register. Action to be closed.

• 14-179 – GMSIT Report – report to go to the February Clinical Executive.

The Clinical Executive received the Schedule of Actions. ACTION: LK and RE to meet to discuss the Infection Prevention and Control Nurse role.

GB to chase the IAPT Leaflet to be sent to Primary Care. LK and GB to seek great assurance regarding Bed Capacity, particularly with regard to System Resilience. Two letters to be sent to the IOWNHST regarding action plan from Paediatric Review and Clinical Assurance.

LK/RE GB GB/LK RH

14-189 Chair Update

JR reported that he is half way through the GP Practice visits. The visits are valuable; there is a clear message that transformation is needed in Primary Care. Two Locality Nurses have been recruited, and the integrated locality model is starting to take shape.

The Clinical Executive noted the Chair update. 14-190 Chief Officer Update

HS highlighted the issue regarding the ongoing system pressure. There has been numerous performance returns required, which has impacted on staff capacity for other areas of work.

The Clinical Executive noted the Chief Officer update. For Decision 14-191

Business Case SEND Reforms Physiotherapy & OT The Clinical Executive received paper CE14-138 Business Case SEND Reforms Physiotherapy and OT, presented by RH.

2

The current Occupational Therapy and Physiotherapy services for children require investment to increase capacity in order to meet the statutory requirements laid out in the SEND reforms, it will also ensure a more equitable and cost effective service for the local population. It was proposed that a part time band 6 Physiotherapist and a full time Band 6 Occupational Therapist (OT) are recruited. HS queried if the posts would be able to be recruited to. RH confirmed that a number of Band 5 OTs have undergone additional training to give them the knowledge and skills to work at a Band 6 level. It was highlighted that the number of children diagnosed with Autistic Spectrum Disorders (ASD) is high on the Island. It was suggested that it may be useful to Public Health to look at the figures. RH welcomed the support.

The Clinical Executive approved the investment to the paediatric therapy service to ensure statutory duties are delivered.

For Information 14-192 Procurement Decisions

There were no new Procurement Decisions.


The Clinical Executive received paper CE14-139 Risk Register, presented by HS. • Y2/23 CQC Action Plan – the executive was asked to consider whether they feel that

sufficient progress is being made against the action plan in a timely enough manner. LK agreed to take this away.

• Y2/17 Safeguarding Adults – it was queried whether Paediatric issues should be added to the Risk Register. It was suggested that once the two Paediatric letters as previously discussed in the meeting has been sent a decision could be made whether to add it as a risk or not.

• Y2/10 GMS IT – it was agreed that the current risk should be closed and a new risk opened regarding the GMSIT Transition programme. PC raised concern that the transition was sponsored and owned by the GP Collaborative. LO agreed to discuss the support they would require with CM.

The Clinical Executive noted the Risk Register. ACTION: LK to look into Y2/23 CQC Action Plan to see if enough progress is being made against the

action plan. LO to discuss the GMSIT Transition programme and support the GP Collaborative would need.

LK LO

14-194 Information Management and Technology Update

The Clinical Executive received a verbal IM&T update from LO. LO met with Paul Dubery, Deputy Director for IT at the IOWNHST. She highlighted the ISIS and Discharge Summary issues that had been experienced. He suggested meeting to discuss some examples of the issues. JR felt that this would be appropriate for the Joint Clinical Seminar with the Trust.

3

The Clinical Executive noted the IM&T Update. ACTION: JR to add ISIS/Discharge Summary issues to the Joint Clinical Seminar agenda. JR 14-195 Performance Report

The Clinical Executive received paper CE14-140 Performance Report, presented by ER. The report highlighted: • There was one reported case of MRSA reported in month. • A further two cases of C.Difficile were reported for November, bringing the cumulative

total for the CCG to 24. • One grade 1 SIRI attributed to the CCG has breached the 45 day period. • Total numbers for reported Pressure Ulcers continue to exceed those numbers required

to achieved the intended reductions in year. In month there was a marked increase in the number of PUS occurring in the Community from a revised rate of one in October to six in November. LK commented that a Root Cause Analysis (RCA) she has recently read highlights that the Pressure Ulcer could have been avoided, and learning needs to be taken from this. RE commented that Public Health could play a part regarding awareness of Pressure Ulcers, LK and RE to meet to discuss this.

• There have been an increase in falls, this has been discussed at the Clinical Quality Review Meeting (CQRM). Karen Morgan and LK are picking up issues with Alan Sheward, Executive Director of Nursing and Workforce at the IOWNHST.

• The IOWNHST is an outlier nationally for cancelled operations. • Referral to Treatment (RTT) target failed for November, December and is predicted to fail

for January. HS commented that patients from the Island are being encouraged to be treated on the mainland.

• There are currently 5 patients waiting over 52 weeks. The additional patients were identified after an audit carried out by the Trust’s Internal Audit team.

• Ambulance and 111 has achieved its target for November and December. • A&E failed its target for November, December and is likely to fail for January too. • Breast Cancer targets achieved 100% in December. A plea from the Trust is for GPs not to

refer if they know the patient is not available to attend an appointment with two weeks from point of referral.

• Only 50% of the Independent Treatment Sector contract has been utilised, GPs are urged to remind their patients they can use this service.

• LO reported that as of month 9 the CCG plan to deliver their planned surplus of zero. There is however £1m of slippage to be spent. A discussion took place over the year end position and the Clinical Executive approved £1m year-end support to the IOW NHS Trust as transitional support.

JR queried if it was possible to include performance reporting for localities. ER highlighted that the CCG is restricted as they cannot access patient identifiable data, however she could get Jo O’Neill to do some analysis.

The Clinical Executive noted the Performance Report. The Clinical Executive agreed £1m year-end support to the IOW NHS Trust as transitional support.

4

ACTION: RE and LK to meet to discuss Pressure Ulcers. RE/LK

14-196 System Resilience

The Clinical Executive received a verbal System Resilience update from GB. The plans have been taken to the overview and scrutiny meeting. The CCG will be held to account to ensure the right plans are in place and delivered.

The Clinical Executive noted the System Resilience Update. 14-197 Formal Letters

The Clinical Executive received a Formal Letters list tabled by ER. The letters are sent prior to a contract notice being issued. JR asked if a log could be kept regarding the smaller issues that have not had a response from the Trust. It was highlighted that the Trust is under immense pressure and it was agreed at the Executive to Executive meeting that certain areas would be prioritised. It was suggested that if individuals have problems to keep a list themselves to flag.

The Clinical Executive noted the Formal Letters update. 14-198 Delegations for End of Year Spending Decisions

The Clinical Executive received an update from LO regarding delegations for end of year spending decisions. The decisions will be delegated to the Commissioning Officers Group (COG) and reported to the Clinical Executive as per last years arrangements.

The Clinical Executive noted the Delegations for End of Year Spending Decisions. 14-199 Delivery Plan Monitoring Report – Q3

The Clinical Executive received paper CE14-141 Delivery Plan Monitoring Q3, presented by GB. It was highlighted that a lot of work has taken priority in relation to System Resilience and Referral to Treatment (RTT) which has meant that certain areas of work including Pathway work has been delayed. There has been pressure for the Mental Health Team, who have been unable to recruit to a vacant commissioning post. Some additional support will be in place to focus of Shackleton and CMHS. Business Cases including IAPT, GP Acute have been approved and work regarding Dementia and the DITs service are progressing. Going forward workload will tend to focus more on assurance than development. Areas of work will therefore be prioritised in to priority 1 and priority 2 categories.

The Clinical Executive noted the Delivery Plan Monitoring Report Q3. 14-200 Support for Social Care Report Q1-3

The Clinical Executive received paper CE14-142 Support for Social Care Report Q1-3, presented by GB.

5

It was highlighted that the information regarding Support for Social Care has been impossible to get from the Local Authority. In future this area will be under the Better care Fund, which is managed by the CCG. The Clinical Executive expressed their disappointment with this report.

The Clinical Executive noted the Support for Social Care Report Q1-3. 14-201 Operational Plan and Guidance

The Clinical Executive received a presentation outlining the 2015/16 Operational Plan from GB.

The Clinical Executive noted the Operational Plan and Guidance. 14-202 Quality Premium

Discussion took place regarding whether or not Lipid Management would stay as the priority area for 2015/16. It was agreed to continue it for next year as it was clinically worthwhile to do so. Further discussion would be needed at the Clinical Executive Seminar.

ACTION: Quality Premium Lipid Management to be discussed at the Clinical Executive Seminar. RB 14-203 Notes of Sub-Committees

The Clinical Executive received the following notes of sub-committees: • Clinical Quality Review Meeting (CQRM) December 2014. • Contract Monitoring and Service review meeting December 2014 • December Locality Meetings • Clinical Effectiveness Committee November 2014


Clinical Lead JH confirmed that Yaso Browne has accepted 1 session per week as the Mental Health Clinical Lead. New Models of Healthcare JR informed the Clinical Executive that he had been to a meeting held by the PWC to look at different models of Healthcare. Two models have been identified, a PAC system which refers to Primary Care and Acute Care, whereby the Trust would take over GP Practices. The second model refers to a more multi-disciplinary community approach. Expressions of interest are to be sought for Vanguards to look at implementing the new models and the IOWNHST are keen to express an interest. There is currently no guidance however there has already been discussions regarding a second phase of Vanguards. It was agreed that the rules need to be understood, and GP Practices need to be engaged in the process. LO highlighted that a different model of care would need to be looked at anyway due to the CCG allocation being potentially reduced.

14-205 Date of Next Meeting: Thursday 19 February 2015 – 12:30 – 15:00 – Clinical Executive

6

following by Clinical Executive Seminar 15:00 – 17:00, Block A, The Apex – Carisbrooke Room.

Circulation: Members In attendance: For Information (Agenda): Peter Coleman – CCG Executive Rida Elkheir – Associate Director of Public Health Joanna Hesse – CCG Executive David Isaac – CCG Executive Loretta Kinsella – Interim Director of Quality and Clinical Services Loretta Outhwaite – Chief Finance Officer John Rivers – CCG Executive Helen Shields – Chief Officer (Chair)



7

Governing Body Minutes of the Audit Committee Meeting 25 September 2014

Governing Body Sponsor: Frederick Psyk, Lay Advisor Governance

Summary of issue: Minutes of the Audit Committee 25 September 2014.

Action required/ recommendation: To note the minutes of the audit committee.


Other committees where this has been considered: This has not been considered at any other committee.

Financial /resource implications: There are no financial or resource implications relating to this paper.





Report Author: Rebecca Berryman, Governance Support Officer

Date of Paper: 26 September 2014



1

Audit Committee: Minutes of the Clinical Commissioning Group (CCG) Audit Committee held on 25 September 2014 at 13:00 in the Bembridge Room, Block A, The APEX, St Cross Business Park

PRESENT: Frederick Psyk (FP) – Lay Advisor, Governance Dr Ian Reckless (IR) – Secondary Care Doctor (via telephone)

IN ATTENDANCE: Paul King (PK) – Ernst and Young – External Audit (via telephone) Will Barnard (WB) – TIAA – Internal Audit Mike Townsend (MT) – TIAA – Internal Audit Joanne Penney (JP) – TIAA – Internal Audit (Item 6)

Loretta Outhwaite (LO) –Chief Finance Officer Caroline Morris (CM) – Head of Primary Care and Corporate Business (Items 6&10.2) David Newton (DN) – Governing Body Lay Advisor, PPI

MINUTED BY: Rebecca Berryman (RB) – Governance Support Officer

14-018 APOLOGIES FOR ABSENCE Apologies were received from Peter Coleman and Doug Stevens. It was agreed with

Samantha Willoughby, Local Counter Fraud Service that it was not necessary for her to attend every meeting. SW would attend the Audit Committee meetings when required (at least once per year) or join the meeting or via telephone should there be a pressing matter to discuss. Similarly Helen Shields will also attend meetings when required.

14-019 DECLARATIONS OF INTEREST

The Audit Committee received the Declaration of Audit Committee Members’ Interest paper. This was agreed as accurate, and there were no new declarations made.

14-020

CONFIRMATION THAT THE MEETING IS QUORATE Confirmed.

For the attention of the Governing Body: • Following a review of the processes underpinning the Governing Body Assurance Framework the committee

recommended that the Governing Body continues to review this framework at each meeting but also considers a more detailed review of at least one risk area at each meeting.

• The committee met with the new internal auditors TIAA and approved the Internal Audit Charter and Audit Plan for 2014/15.

• The committee supported the preparation work being carried out by the CCG in advance of completing a formal self-assessment of compliance with current counter-fraud procedures and regulations.

• The committee approved its schedule of business for 2014/15 and invites the Governing Body to review this schedule to ensure the committee’s work is aligned with the current work plans of the CCG.

2

14-021

MINUTES OF THE LAST MEETING 4 June 2014 The minutes of the meeting were noted and agreed as accurate, with the following exceptions: • P.5 14-009 should read “IR drew the committee’s attention to the total balance figures

presented in page 3 and 53 of the Annual Accounts, and asked whether and how they were related.”

• P.6 14-009 should read “He also questioned the absence of March data.”

14-022

MATTERS ARISING FROM THE LAST MEETING 4 June 2014 i. SCHEDULE OF ACTIONS TAKEN FROM 4 June 2014 The Audit Committee received the Schedule of Actions from the Audit Committee meeting on 4 June 2014, noting the following comments: • 13-081 – Internal Audit Customer Feedback – this action can now be closed as it has been

picked up and will be actioned as part of the new Internal Audit contract with TIAA. • 13-083 – Counter Fraud Self-Assessment – Samantha Willoughby has put a proposal

forward that is contained within the Counter Fraud Service update.

The Audit Committee received the Schedule of Actions from 4 June 2014 14-023 GOVERNING BODY ASSURANCE FRAMEWORK

The Audit Committee received the current Governing Body Assurance Framework, presented by CM. CM outlined that the GBAF captures risks that might happen during the year. In contrast the Risk Register highlights current risks. The Clinical Executive review the Risk Register on a monthly basis, and the Governing Body receive a summary report for assurance. It was highlighted that not enough time has been spent on the Governing Body Assurance Framework (GBAF) at Governing Body meetings. LO agreed and it was suggested that it could be made meaningful by drilling down in to a certain area on the GBAF at each meeting. FP commented that it would be useful to see dates included on the GBAF. CM confirmed that these would be included on the next iteration of the GBAF. IR queried in relation to 3.30 the Provider cost base, it doesn’t appear that progress is being made. LO explained that it had been a complex process. A Stakeholder workshop has taken place and the CCG have commissioned an external professional to support the Trust to put a proposal together. A Finance Summit is also due to take place on the 15 October 2014, between the CCG, Local Authority and Isle of Wight NHS Trust to share forecast financial positions. Discussion took place regarding a Non-Executive to Non-Executive meeting and how it would be useful to set up. LO explained that such a meeting had been discussed at Executive level with the Trust and they were keen. FP agreed to discuss the possibility of such a meeting with John Rivers. IR queried that with regard to the Contract Notices included on the GBAF, should the risks

3

not have changed in light of the CQC Report. CM clarified that the GBAF being presented was put together prior to the release of the CQC report, the next iteration of the GBAF will be update to reflect the CQC report accordingly. PK commented that it wasn’t clear how the GBAF risks relate to the domains. CM agreed to make this clearer within the next iteration of the GBAF.

The Audit Committee noted the Governing Body Assurance Report. ACTION: FP to discuss Non-Executive to Non-Executive level meeting with John Rivers.

CM to show clearly how risks link to the domains on the GBAF. FP CM

14-024 EXTERNAL AUDIT UPDATE

ANNUAL AUDIT LETTER FOR YEAR END 31 MARCH 2014 The Audit Committee received the Annual Audit Letter for Year End 31 March 2014 presented by PK. The Audit letter has been circulated to all Governing Body members. There are no material changes since June when the Annual Report and Accounts were approved by the Audit Committee and Governing Body.

The Audit Committee received the Annual Audit Letter for Year End 31 March 2014. 14-025 INTERNAL AUDIT UPDATE

The Audit Committee received the Internal Audit 2014/15 Annual Plan, Internal Audit Charter and Internal Audit Reporting Protocol presented by WB and MT. MT and WB commented that they have had a good start to working with the CCG. LO has met with Doug Stevens, WB and JP to finalise the proposals. It was highlighted that TIAA’s audit ratings are slightly different to what the Audit Committee may be familiar with, TIAA’s ratings range from Substantial Assurance to No Assurance. INTERNAL AUDIT CHARTER The Internal Audit Charter defines the purpose of internal audit activity, its authority and its responsibility. MT confirmed that the charter can be amended to meet the CCG’s requirements. FP commented he would prefer Chairman to be amended to Chair within the Charter. With regard to page 7 and the performance targets it was queried why the ‘reports issued’ section target was 95%, and whether this could this be 100%. It was confirmed that the target could be set to 100%, but it was noted that a delay usually occurs with responses coming back to Internal Audit. The two ammendments were made; the Audit Committee approved the Charter. The Internal Audit Charter was then signed by LO and FP. INTERNAL AUDIT REPORTING PROTOCOL The Internal Audit Reporting Protocol outlines the internal audit process. The Audit Committee will receive the final Audit Report. IR queried what TIAA stood for; MT confirmed it stood for The Internal Audit Association. IR agreed with the proposed process however felt it would be beneficial for the Audit Committee to review the Terms of Reference for each Audit prior to commencement and comment as necessary. This was agreed providing timescales allowed.

4

DN commented that he expected relevant Audit reports to be circulated to the relevant committees. The final report will go to the lead Executive Director who should then ensure the report goes to the relevant committee. This was agreed to be reflected on page 2 of the protocol. INTERNAL AUDIT 2014/15 ANNUAL PLAN Discussion took place regarding the apparent absence of compliance and commissioning within the Audit Plan. MT and WB confirmed that compliance would be highlighted when the Standing Financial Instructions are Audited. With regard to commissioning assurance will come from all Audits that are undertaken as the key function of the organisation is commissioning. Discussion also took place regarding contracting and whether processes and controls were complied with. JP and WB confirmed that this will be covered within Performance Management Audit. Conflicts of Interest will also be tested within contracts as part of the work plan. IR highlighted that a key focus should be quality and patient outcomes. It was confirmed there were 7 days allocated to performance management and quality/process and 5 days on CQUINS. IR commented that it needs to be clear what will be audited. WB confirmed that the Audits have not yet been scoped and that details will be shared in advance of the scope being finalised. IR commented that the CQC didn’t pick up on areas the CCG had concerns with, for example Mental Health. LO advised that in addition to the Internal Audit Plan the CCG will be reviewing the areas highlighted by the CQC to understand whether it’s quality processes had picked up the issues and if so why they weren’t addressed, and if they weren’t picked up whether the process can be improved to do so in the future. MT commented that TIAA need to be careful to not become the Trust’s auditors, so any audit work needs to be CCG focussed. FP queried how the CCG would know if the Trust’s Internal Audit gave an adverse review in one of their Audits. LO confirmed it would depend on the issue, if it affected quality or service delivery the CCG would expect contractually to be informed. It was noted that all audit reports are disclosable. DN commented that in relation to the Quality and Patient Safety Committee the committee cannot expect colleagues to produce a significant number of individual reports for the committee’s assurance. However the work of internal audit can provide a valuable additional tool. He asked whether the terms of reference for each audit could include testing for evidence of important ‘golden threads’ that processes are focused on delivering high quality, integrated and sustainable healthcare. Wherever appropriate, audits should seek assurance that processes and work streams are being clinically led, are patient centred and evidence based. It was therefore agreed that the terms of reference for audits should be sent to FP and DN for review, prior to finalisation. It was agreed that the Internal Audit Plan does allow for flexibility. The Audit Committee therefore agreed the Internal Audit Plan.

5

The Audit Committee approved the Annual Plan for 2014/15, the Internal Audit Charter and

noted the Internal Audit Reporting Protocol.

ACTION: Page 2 of the Internal Audit Protocol to be updated to highlight the Executive Director to

cascade Audit Reports to the relevant committee. Internal Audit Terms of Reference to be sent to DN and FP for comment.

WB/MT WB/MT

14-026 SAFEGUARDING AUDIT REPORT

The Audit Committee received the Safeguarding Audit Report presented by LO. This report was revised as some of the terminology used was incorrect on the previous report. The terminology has therefore been amended; all actions are in progress and are being monitored by the Quality and Patient Safety Committee.

The Audit Committee noted the Safeguarding Audit Report. 14-027 LOCAL COUNTER FRAUD SERVICE UPDATE

The Audit Committee received the Local Counter Fraud Service (LCFS) Update. IR raised concern that the Audit Committee were not aware of the fraud committed by a GP Practice Manager. LO advised this was a Primary Care and GP Practice issues and therefore not within the CCG’s responsibilities. The CCG and LCFS did provide some informal support to the Practice. LO highlighted that with regard to the Counter Fraud Self-Assessment, up until recently there has not been a requirement for CCGs to complete a Self-Assessment. However, CCGs will have to complete one in the future. SW has offered to complete a Self-Assessment within the contract with the LCFS on behalf of the CCG to ensure that when it is becomes mandatory the CCG will have all the requirements in place. SW believes that the CCG Self-Assessment will show that the relevant procedures are in place; the Audit Committee therefore agreed that it was healthy to complete a Self-Assessment now. MT commented that it would be useful if the Primary Care elements of the LCFS report were highlighted in a separate part of the report, for awareness and information.

The Audit Committee noted the Local Counter Fraud Service Update and that SW is to

undertake a Self-Assessment on behalf of the CCG.

ACTION: SW to include Primary Care separately for information within the LCFS Update.

SW to undertake a Self-Assessment on behalf of the CCG. SW SW

14-028 GOVERNANCE, RISK AND INTERNAL CONTROL ARRANGEMENTS

GOVERNANCE, RISK AND INTERNAL CONTROL REPORT The Audit Committee received the Governance, Risk and Internal Control Report, presented by LO. LO highlighted that in month 6, due to an NHS England instruction to move the funding of specialised services to a national methodology, the CCG’s programme allocation will reduce recurrently. To meet the c£2m pressure this creates, the CCG will initially utilise its contingency of c£1m and slippage on investment schemes, which have not yet started.

6

FP requested clarification around the timescale pressures that led to the single tender waiver for the E-Rostering system. LO confirmed that the E-Rostering system is shared with the Isle of Wight NHS Trust. The current software does not support two separate organisations, so the CCG needs to move to its own version. Within the next few weeks the Trust are moving on to their own system and the CCG needs to take immediate action to prevent being without a system. It is a requirement of the payroll contract for the CCG to have electronic timesheets and expenses. Due to the required timescales and to avoid duplication of effort in the HR/payroll team that supports the Trust and the CCG, a single tender waiver was approved by the Clinical Executive to purchase and implement the new instance of the system from Allocate. PK highlighted that some CCGs have gained and some have lost with the specialist allocation. LO commented that most of the country initially used the national methodology.

The Audit Committee noted the Governance Risk and Internal Control Report. 14-029 NHS LITIGATION AUTHORITY INSURANCE

The Audit Committee received the NHS Litigation Authority (NHS LA) Discussion Paper, presented by CM. The Governing Body lay and clinical members requested clarification regarding the scope of their liability in relation to their CCG duties. Statutory Indemnity To mitigate risk to any individual CM confirmed that the CCG has been advised to indemnify an individual Governing Body Member or Officer from liabilities when they are discharging their duties towards the CCG. Insurance In general, liability arising from Governing Body members’ work on the CCG would be corporate rather than individual. CM highlighted that it would be at the CCG’s discretion to determine whether to purchase additional insurance to cover the residual risks. Recent Treasury guidance from July 2013 states insurance should not be purchased from the commercial sector as it does not present good value for money. However should any liability arise outside of the NHSLA scheme, the costs of supporting the individual and any damages awarded would be incurred from the CCG’s revenue. Discussion took place which identified the risk to Governing Body lay and clinical members were low. FP identified that the word employee is used within the guidance, and lay and clinical members are not strictly employees. CM confirmed that the wording is interchangeable and as lay and clinical members are on CCG payroll they will be covered by the NHSLA. Further discussion took place with regard to an indemnity clause that would need to be incorporated into the CCG’s Constitution, and once approved by the Governing Body, recommended for adoption by the Membership. MT commented that this would be helpful to be included within the Constitution. He complemented the comprehensive paper and with CM’s permission would share this with other CCGs. FP also suggested he took this to the Audit Chair’s meeting that he attends.

7

CM asked the committee whether to include disclosure of indemnity and disclose insurance within the annual report and accounts, despite this not being a requirement. It was agreed for openness and transparency to include it in future reports.

The Audit Committee noted the NHS Litigation Authority Insurance paper and recommended it for approval by the Governing Body including a recommendation to the membership council for insertion into the CCG Constitution. It was also agreed that including disclosure of indemnity in future annual report and accounts was preferable.

ACTION: NHS LA Insurance Paper to be approved at Governing Body meeting.

Disclosure of indemnity to be included in future annual reports and accounts. RB CM

14-030 REVIEW OF WHISTLEBLOWING ARRANGEMENTS

The Audit Committee received a verbal update regarding the Whistleblowing Policy review from LO. Work is ongoing to revise the Whistleblowing policy, and will explore whether whistleblowing by contractors on other contracts can be included in the policy. An update will be given at the next Audit Committee by CM. FP queried how we would know if there had been any whistle-blowing events with our providers. LO was unsure and would need to check with CM. IR commented that section 7.1.1 could include a paragraph that highlights staff can raise issues with their line manager before going through the Whistleblowing route. It was confirmed that the CCG had not had any reported whistleblowing events.

The Audit Committee noted the Whistleblowing Policy review. ACTION: Update to be given on Whistleblowing Policy at December Audit Committee.

LO to check how the CCG would know if there had been any whistleblowing events with our providers with CM.

CM LO

14-031 REVIEW OF CONFLICTS OF INTEREST AND REGISTER OF GIFTS AND HOSPITALITY

The Audit Committee received the Conflicts of Interest Register, presented by LO. FP commented that the Conflicts of Interest register should have date included on it LO explained that if any conflicts of interest are identified, they are discussed at the Commissioning Officers Group (COG). The Committee felt that refusals should also be declared. It was confirmed that no gifts or hospitality had been declared. MT commented that this was unusual. It was queried what the £1 share in Lighthouse Medical meant. It was confirmed that all

8

shares are valued at a nominal value, however shareholders can control the dividend that comes out of the company.

The Audit Committee reviewed the Conflicts of Interest and Register of Gifts and

Hospitality.

ACTION: Conflicts of Interest register to have a date included on it.

RB to remind staff about declaring any gifts or hospitality, including refusals. RB RB

14-032 AUDIT COMMITTEE SCHEDULE OF BUSINESS

The Audit Committee received the Draft Audit Committee Schedule of Business presented by LO.

The Audit Committee approved the Audit Committee Schedule of Business. 14-033 ANY OTHER BUSINESS

PK expressed his thanks for allowing him to dial in to the meeting. He also commented that the CCG deadline for sign of off Annual Reports and Accounts had been rumoured to be brought forward a week to the end of May. WB commented that the February meeting contained on the agenda was not reflected in the Schedule of Business. It was confirmed that the February meeting may not be required; discussion would take place outside of the meeting regarding this.

ACTION: FP, LO and RB to discuss whether the February Audit Committee meeting was required. FP/

LO/RB

DATE OF NEXT MEETING: Thursday 4 December 2014, 13:00 - 15:00, Bembridge Room, Block A, The Apex, St Cross Business Park, Newport.

Circulation: Members: In attendance: Frederick Psyk – Lay Member (Chair) Peter Coleman-CCG Executive Dr Ian Reckless – Secondary Care Doctor

Helen Shields – Chief Officer Loretta Outhwaite – Chief Finance Officer Rebecca Berryman (notes) – Governance Support Officer

Invited: Doug Stevens, TIAA Mike Townsend, TIAA Will Barnard, TIAA Paul King, Ernst & Young Samantha Willoughby, Hampshire & IW Counter Fraud

9

Documents

Governing Body AGENDA Thursday, 5 February 2015, 10:30-13 ... Body/5 Feb… · 2. Minutes of the last Governing Body Meeting 6 November 2014 JR GB14-053 3. Matters Arising 3.1 Schedule