Governing Body Room, Sanger House, Brockworth, Gloucester ... · Governing Body Meeting to be held at 2pm on Thursday 26th May 2016 in the Board Room, Sanger House, Brockworth, Gloucester

Governing Body

Meeting to be held at 2pm on Thursday 26th May 2016 in the Board Room, Sanger House, Brockworth, Gloucester GL3 4FE

No. Item Lead Recommendation 1 Apologies for Absence

Chair

2 Declarations of Interest

Chair

3 Minutes of the Meeting held on 31st March 2016

Chair Approval

4 Matters Arising

Chair

5 Final Annual Accounts 2015/16

Cath Leech Approval

6 External Audit - Assurances from Management and those charged with Governance

Cath Leech Information

7 Annual Report 2015/16

Mary Hutton Approval

8

Patient’s Story

Becky Parish Information

9 Public Questions

Chair

10 Chair’s Update

Chair Information

11 Accountable Officer’s Update

Mary Hutton Information

12 Performance Report


13 2016-17 CCG Annual Budget Update

Cath Leech Approval

14 Sustainability and Transformation Plan Update

Mary Hutton Information

15 Assurance Framework


16 Audit Committee Annual Report 2015/16

Colin Greaves Information

17 Integrated Governance and Quality Committee Minutes

Julie Clatworthy Information

A recording will be made of this meeting to assist with the preparation of the minutes. This recording will be made on an encrypted device owned by the CCG and will be held securely for a maximum of one week before being deleted.

18 Primary Care Commissioning Committee Minutes

Alan Elkin Information

19 Priorities Committee Minutes

Chair Information

20 Any Other Business (AOB)

Chair

Date and time of next meeting: Thursday 28th July 2016 at 2pm in Board Room at Sanger House

Page 1 of 16

Governing Body

Minutes of the Meeting held at 2.00pm on Thursday 31st March 2016 in the Board Room, Sanger House,

Gloucester GL3 4FE

Present: Dr Helen Miller HM Clinical Chair Dr Caroline Bennett CBe GP Liaison Lead – North Cotswolds Dr Charles Buckley CBu GP Liaison Lead – Stroud and Berkeley ValeJoanna Davies JD Lay Member – Patient and Public

Engagement Alan Elkin AE Lay Member – Patient and Public

Engagement and Vice Chair Colin Greaves CG Lay Member - Governance Dr Malcolm Gerald MGe GP Liaison Lead – South Cotswolds Ian Goodall IG Associate Director of Operational Planning

and Programme Management Dr Will Haynes WH GP Liaison Lead - Gloucester Cath Leech CL Chief Finance Officer Dr Tristan Lench TL GP Liaison Lead – Forest of Dean Dr Raju Reddy RR Secondary Care Doctor Sarah Scott SS Director of Public Health, GCC Dr Andy Seymour AS Deputy Clinical Chair Valerie Webb VW Lay Member - Business In attendance: Becky Parish BP Associate Director Patient and Public

Engagement Jules Ford JF Cultural Commissioning Project Manager Andrew Hughes AH Locality Implementation Manager Alan Potter AP Associate Director of Corporate GovernanceFazila Tagari FT Board Administrator There were 3 members of the public present.

1 Apologies for Absence 1.1 Apologies were received from Marion Andrews-Evans, Dr Hein Le

Roux, Ellen Rule, Mark Walkingshaw, Helen Goodey, Dr Sadaf Haque, and Margaret Willcox.

2 2 3

3

4 4

4

4

5 5 6 6

6

6

Glo

De

.1 Al

M20

.1 Th20

4 M

.1 30enGo

.2 28adagGo

.3 28re11

Pu

.1 Th

Pa

.1 BPCore

.2 BPanpr

.3 JFthawbe

oucestersh

eclaratio

ll GPs de

inutes o016

he minute016 were

atters Ar

0.07.15 Angagemeoverning

8.01.16 Advised thgreed thaoverning

8.01.16 Aegarding 11 service

ublic Qu

here were

atient’s S

P and JFommissio

elating to

P advisend it waresented

F advisede health

warenessenefits w

ire CCG G

ons of Int

eclared a

of the M

es of the approve

rising

AI 9.7 –ent plan

Body me

AI 8.5 – L hat the fat an updBody me

AI 12.25the Quale had bee

estions

e no ques

Story

F provideoning Prthe self-c

d that thas anticito the Go

d that thehy individs amonghich arts

Governing B

terest

general i

eeting h

e meetinged.

– Accoushould

eeting.

ocality Dfrailty medate woueeting.

5 – Perflity Assuren comp

stions rec

ed a presrogrammecare (diab

e prograipated thoverning

e CCP wduals prost public and cult

Body Minu

interest re

held on

g held on

untable Obe avail

evelopmeeting wuld be av

formancerance releted. Co

ceived fro

sentatione (CCP)betes) pro

amme wahat a fuBody foll

was a keyogrammec serviceture can

tes – Marc

elating to

Thursda

n Thursd

Officer’s lable at

ent Plan was yet tvailable a

e Reportport relat

omplete

om the pu

n relating) and a ogramme

as within urther reowing an

y enabline with the commis

bring to

ch 2016

o primary

ay 28th J

ay 28th J

Report the May

Updates to be heat the Ma

t – The ting to th

ublic.

to the Cpatient’s

e.

its early eport won evaluati

ng projeche aim tossioners people’s

Pa

care.

anuary

January

– The y 2016

– MAE eld and ay 2016

action he NHS

Cultural s story

stages ould be ion.

ct within o raise of the

s health

age 2 of 16

6

Gloucestershire CCG Governing Body Minutes – March 2016 Page 3 of 16

and wellbeing. 6.4 The presentation covered:

background; alignment with other key programmes; a stepped model; and CCP grants programme.

6.5 JF indicated that there was a growing concern with teenagers

not appropriately managing their medications for diabetes and that poor management often lead to surgical interventions. JF advised that the focus was to increase awareness between teenagers.

6.6 RESOLUTION: The Governing Body noted the patient

story.

7 Gloucestershire Clinical Commissioning Group (CCG)

Clinical Chair’s Report

7.1 HM presented this report that was taken as read, with a

summary of key issues that arose during February and March 2016 being highlighted.

7.2 HM advised that she was chairing her final Governing Body

meeting today. HM stated that she had been the Clinical Chair for the previous eight years and thanked everybody for their support. HM specifically thanked Jan Stubbings and Ruth FitzJohn for providing the opportunity to her and having faith in her. HM expressed gratitude to MH, the Governing Body, the staff, the patients and the public for their tremendous support over the years.

7.3 The Governing Body thanked HM and wished her well for the

future.

7.4 The following key areas were highlighted:

Coombe End flat development for local people with

learning disabilities; primary care update; innovative community change model being developed


to increase levels of physical activity across Gloucestershire; and

cardiology update. 7.5 RESOLUTION: The Governing Body noted the contents

of this report.

8 Gloucestershire Clinical Commissioning Group

Accountable Officer’s Report

8.1 The Accountable Officer introduced this report which was

taken as read, and provided a summary of key issues arising during December 2015 and January 2016.

8.2 MH provided an update on the Transforming Care

Programme (TCP). MH advised that transforming care for people with learning disabilities was a programme to improve services for these individuals including those with a mental health condition. It was understood that to achieve the aspirations contained within the TCP plan, the CCG would need to implement a system wide culture change. It was noted that positive feedback had been received on the Plan. MH advised that an estimated bid for £900K of matched funding to support the TCP and the outcome of the bid would be reported to a future meeting.

8.3 Members were updated on the 2016/17 contracting round

and noted that two contracts had not been signed as there were significant issues which were being worked through.

8.4 MH updated members on strategy and prevention and

highlighted that as part of the Sustainability and Transformation Plan, the CCG would need to develop a multi-agency prevention and self-care plan in conjunction with Public Health. MH advised that a strategic action plan to address obesity was being developed to be presented to the Health and Wellbeing Board on the 22nd March 2016. It was noted that four work streams had been identified; adult pathway, children’s pathway, physical activity and healthy workplaces.

8.5 The West of England Academic Health Science Network

(AHSN) was working with a range of partners, including the


CCG, to develop a ‘Diabetes Digital Coach’ test bed in the South West. The CCG would play a significant role in developing the regional bid to become an NHS England Test bed site.

8.6 MH reported that five clinical Pharmacists had joined five

Gloucestershire GP practices as part of the recent initiative called the ‘Clinical pharmacists in General Practice’. HM advised that a pharmacist had recently joined her practice which had been a positive step. HM commended Mark Gregory who had progressed this work stream forward.

8.7 RESOLUTION: The Governing Body noted the contents

of this report.

9 Performance Report 9.1 CL presented the Performance Report which provided an

overview of the CCG’s performance against the organisational objectives and national performance measures for the period to the end of February 2016.

9.2 The report was broken down into the five sections of the

CCG Performance Framework as highlighted in Section 1. CL advised that a Lead Director had been assigned to respond to each area.

Clinical Excellence 9.3 CL advised that areas of good performance included the

Referral to Treat (RTT) and cancer 31 day target.

9.4 CL updated members on the ambulance targets and advised

that South West Ambulance Service NHS Foundation Trust (SWASFT) achieved the Red One performance target. However, this had been proving challenging during the previous few weeks due to a high level of demand and indicated that the March target may not be achieved.

9.5 Members were advised that there was still further work to

undertake in relation to improving the Ambulance Red 2 performance target and noted that there was a detailed recovery action plan in place with SWASFT alongside other actions including publicity campaigns to manage demands.


9.6 Members noted that the 4 hour emergency department target

was still an area of challenge. The CCG continued to implement a programme to increase urgent and emergency care system resilience to ensure that the system can cope with peaks in demand. It was noted that Monitor were undertaking a programme of ‘heightened surveillance’ at GHFT.

9.7 CL updated members on the 62 day cancer performance

target and noted that this had been challenging due to high level of demand. CL reported that the performance against the target was 78.6% in January which was below the target of 85%. The GHFT position was 77.4%, which was 3% below the GHFT recovery trajectory plan.

9.8 CL updated members on the 6 weeks waiting time for

diagnostic procedure and advised that performance was at 2%. CL advised that the issues within MRI were identified and that this was mainly due to the delay in the procurement of new equipment.

9.9 CL advised that a performance notice had been issued to

SWASFT regarding the Out of Hours Service. A remedial action plan had been agreed in order to raise performance to the required levels.

Patient Experience 9.10 MH updated members on patient experience and advised

that a programme of clinical case reviews had been developed to support the delivery of the emergency care programme and to influence service redesign. These include reviewing and evaluating emergency admissions to hospital, with particular focus upon admissions which may have been preventable with appropriate support or through accessing alternative pathways to admission. The reviews also included a focus on the quality of discharge information.

9.11 MH advised that the Friends and Family Test (FFT) response

rate for the Emergency Departments was currently at 1.9% during December 2015 against the national average of 12.7%. The inpatients response rate was at 15.7% against the national average of 23.4%. MH advised that due to the


poor performance in relation to the FFT, it was noted that the Trust had been requested to undertake further patient experience work to understand what the service user experience was like for those patients using the service.

9.12 MH advised that there were 17 C.Difficile cases reported in

the community during January. It was noted that a Root Cause Analysis had been undertaken on all cases and had found no underlying cause for this increase. This situation will continue to be monitored.

9.13 MH informed members regarding the recent mixed sex

accommodation breaches within GHFT and that historically no breaches had been reported since 2013. It was assured that the privacy and dignity had been protected for all these patients.

Partnerships 9.14 MH highlighted the success of the social prescribing initiative.

It was advised that social prescribing now covered the entire county with the scheme available to all GP practices. Referrals were also accepted from staff in the county’s 21 Integrated Community Teams (ICTs) and staff in the community hospitals. MH advised that the scheme was currently being evaluated by the University of the West of England.

9.15 MH advised that Gloucestershire was reviewing the position

relating to devolution and that discussions were progressing.

Staff 9.16 CL provided a brief update on the Staff Perspective and

advised that this was rated as green. CL advised that staff survey results were currently being collated and would be circulated following a review period.

9.17 Members were informed that the CCG Organisational

Development Plan was currently being updated and was on track to be finalised by May 2016.

Finance and Efficiency 9.18 CL provided a brief summary of the 2015/16 financial

performance and reported that the CCG was forecasting to


deliver a surplus of £9.6m against an initial planned surplus of £7.3m in 2015/16.

9.19 It was noted that known risks and pressures had been fully

assessed and included within the CCG’s forecast position, with mitigating actions where appropriate.

9.20 CL advised that there continues to be increased slippage on

QIPP schemes for the financial year and these had been reflected in the financial position.

9.21 CL reported that a number of planned investments had

slipped due to difficulties in recruitment i.e. clinical staff for wound care assessment service.

9.22 CL reported that the CCG had achieved the 95% target to

pay all non-NHS trade creditors within 30 days of receipt of goods or a valid invoice.

9.23 MH advised that the NHS was facing significant financial

pressure nationally. It was noted that the financial position would be reviewed in due course and any impact would be reported.

9.24 JC expressed concerns regarding the compliance against the

performance indicator relating to high-risk transient ischemic attacks (TIA) as the current year to date performance was at 36.5% against a 60% target. CBu advised that there was a lack of match between capacity and demand and that a revised recovery action plan was awaited. CBu advised that a small team managed this service and resources were limited.

9.25 JC drew attention to page 28 of the report relating to the

national quality requirements of the Out of Hours service and questioned the effectiveness of the measures in place. MH advised that there had been unprecedented demands in the service (approximately 500 walk-ins in one day) and that an audit was required in order to understand the high level of demand.

9.26 MGe suggested that there should be a mechanism in place

to fast track any urgent referrals particularly as the average


two week waiting times had increased. 9.27 RESOLUTION: The Governing Body:

noted the performance against local and national targets and the actions taken to ensure that performance was at a high standard;

noted the financial position as at month ten; noted the risks identified in the Finance and

Efficiency report; and noted progress on the QIPP schemes.

10 Operational Plan 10.1 IG introduced the 2016/17 Operational Plan which was

presented as a final draft for approval prior to submission to NHS England. The paper was taken as read.

10.2 Members noted that the document outlined the high level

plan for the CCG in support of its strategic aims i.e. Joining Up Your Care and Sustainability and Transformation Plan.

10.3 IG advised that the CCG was considering forming three new

Clinical Programme Groups in 2016/17. These were head and neck, neurological conditions and urology and renal.

10.4 JC highlighted page 9 of the document regarding the CCG

objectives and felt that there should be a stronger emphasis on patients.

10.5 JC clarified that the Primary Care Commissioning Committee

(PCCC) function was to monitor quality however the assurance was provided by the IGQC.

10.6 CBu drew attention to page 44 of the document regarding

provider engagement and stated that he felt that there was a lack of commitment. CBu felt that there should be stringent requirements in place to ensure that providers had a responsibility to attend relevant meetings and queried if this could be strengthened in the document. HM enquired if this could be stated in the contract and was advised that there were mechanisms in place. HM felt that this should be reiterated as there were important meetings where input would be valuable. The Governing Body agreed that


collaborative working was vital to ensuring success. 10.7 CG considered that the measures of success section on

page 59 of the document should be expanded to cover the areas where improvements were needed. CG also felt that an evaluation should be completed in order to inform the plan going forward. IG advised that an annual review had been completed for the 2015/16 Plan and recognised the further work required.

10.8 RR queried if there was a schedule of meetings which

specified where secondary care presence was required that could be made available to the providers in order to ensure that these were prioritised in their job plan. The Governing Body supported this approach.

ER

10.9 RESOLUTION: The Governing Body:

noted and approved the draft operational plan; and agreed to provide feedback by the 5th April 2016 as

required to inform the final version.

11 Budgets 2016/17 11.1 CL presented the budgets proposals for 2016/17 which

supported the CCGs operational plan.

11.2 CL advised that the CCG had a statutory duty to achieve

financial balance and was planning for a surplus of £7.5m and assumed delivery of a QIPP saving target of £18m.

11.3 CL explained that careful financial control and monitoring

would need to be maintained during the year in order to deliver the planned system changes.

11.4 It was noted that the budget included an allocation for

Primary Care co-commissioning. CL advised that this was presented to the PCCC and was recommended for approval to the Governing Body.

11.5 CL reported that the budgets included the financial planning

parameters required by NHS England which included a surplus of 1%, a minimum contingency reserve of 0.5% and a non-recurrent (headroom) reserve of 1%.


11.6 It was noted that the allocations had been published for the

period of three years. This represented firm allocations for the three years with the subsequent years being indicative only.

11.7 Members noted that the CCG received 3.05% uplift in its

programme allocation and was therefore deemed to be at its target allocation.

11.8 CL advised that the CCG had applied inflation uplifts of 3.1%

and cash releasing efficiency savings (CRES) of -2% to its contracts.

11.9 CL informed members that the contracts with the CCG’s

main providers were not yet signed, however, the estimated impact of the final contracts had been included in the CCG’s budgets. It was noted that the key risk related to the GHFT contract where a financial gap had been identified. CL explained that this may be flagged formally if the issues could not be resolved.

11.10 It was noted that investments included the full year effect of

2015/16 investments, activity and demand driven investments from the previous year and those prioritised as part of the strategic plan through the CCG’s Prioritisation Committee.

11.11 CL updated members on the risks associated with the

budgets and advised that there were mitigating actions to address these.


approved the 2016/17 budgets and noted the risks inherent within the plan; and

approved the Financial Management Framework.

12 Developing a Sustainability and Transformation Plan for

Gloucestershire

12.1 MH introduced the paper which provided an update on the

progress towards developing a system wide Sustainability and Transformation Plan (STP) for Gloucestershire.


12.2 MH explained that STPs were described by NHS England as

an opportunity to develop a local route map to an improved, more sustainable, health and care system. 44 STP footprints had been agreed across England, each convened by a local leader, backed by national bodies.

12.3 MH advised that the STP sets out how the Gloucestershire

system will effectively use resources in the next 1-5 years to ensure that there was a focus on improving health outcomes for the population in Gloucestershire.

12.4 It was noted that the STP would not be a set of new priorities

but would build on the strategy and shared vision set out in Joining Up Your Care and the joint programmes of work described in the Gloucestershire Strategic Forum (GSF) work programme.

12.5 MH drew attention to section 5.1 of the report which outlined

the governance structure for the STP. It was noted that a set of working groups was being established to support the delivery of the key workstreams within the STP. It had been suggested that the Clinical Priorities Forum was the Governing Body to lead on the clinical programmes work.

12.6 MH advised that further consideration regarding the

representation on each group was necessary and that these would be discussed going forward.

12.7 JC felt that the governance structure was unclear and

queried how the GSF would report to the Governing Body.


noted the progress so far towards developing the Sustainability and Transformation Plan; and

noted the April deadline for the next Sustainability and Transformation Plan submission.

13 Primary Care Infrastructure Plan 2016 to 2021 13.1 AH introduced the Plan and provided a background context

to the document. The report which was taken as read.


13.2 AH explained the CCG had developed a five year prioritised Primary Care Infrastructure Plan (PCIP) to set out where investment was anticipated to be made in either new or extended buildings, subject to business case approval and available funding for the period 2016 to 2021.

13.3 AH advised that the plan was presented to the Primary Care

Commissioning Committee earlier that day and the Committee ratified the Plan subject to Governing Body approval.

13.4 AH advised that the Plan aimed to align with local authorities’

strategies on housing. It was noted that there would be significant housing developments in different parts of the County and this would impact significantly on some practices compared to others.

13.5 Members were advised that a strategic prioritisation had

been completed and this had identified eleven core schemes for taking forward for business case development. AH advised that the plan also sets out the business case process for delivering the priorities.

13.6 AH advised that the additional net revenue costs for

delivering the proposed schemes were set out in the document. Members noted that some of these costs could be offset through capital contributions funded via the national Primary Care Transformation Fund.

13.7 JC drew attention to page 29 of the report and requested

clarity that the priorities supported the CCG commissioning intentions and the Health and Wellbeing Board plans.

13.8 CG clarified that the Governing Body had responsibility to

approve the Strategy and that the PCCC responsibility would be to review and recommend approval.

13.9 MGe felt it would be useful to receive further details on the

process and next steps. AH advised that it was anticipated for business cases to be produced during 2016/17 and that these would be presented to the Governing Body when completed. AH advised that the reporting arrangements would need to be reviewed and advised that currently the


premises work stream reported to the Primary Care Operational Group which in turn reported to the PCCC. AH advised that progress would be tracked via this mechanism.

13.10 RESOLUTION: The Governing Body approved the

Primary Care Infrastructure Plan 2016 to 2021.

14 West of England Academic Health Science Network

Board Report

14.1 MH presented the report which was taken as read. This was

the eleventh quarterly report produced by the West of England Academic Health Science Network (AHSN).

14.2 MH advised that the AHSN have offered to support the CCG

on the Sustainability and Transformation Plans.

14.3 RESOLUTION: The Governing Body noted the report. 15 Assurance Framework 15.1 CL presented the Assurance Framework for 2015/16 which

was taken as read. The Assurance Framework identified gaps in assurances and controls regarding the organisational objectives, along with details of the principal risks that have been identified by lead managers.

15.2 CL highlighted that the key issues related to:

risk No T12 regarding the specialised services for children and young people with mental health problems; and

risk No C6 regarding the maximum four hour wait in Emergency Department.

15.3 CBu highlighted risk No Q7 relating to the lack of compliance

with national targets for C.Difficile and MRSA and felt that the rating should be higher noting that further issues had been identified. CL advised that this would be reflected in the next update.

15.4 RESOLUTION: The Governing Body noted the paper and

the attached Assurance Framework.


16 Integrated Governance and Quality Committee Minutes 16.1 The Governing Body received the minutes of the meeting of

the Integrated Governance and Quality Committee held on the 17th December 2015.

16.2 RESOLUTION: The Governing Body noted these

minutes. 17 Audit Committee Minutes 17.1 The Governing Body received the minutes of the meeting of

the Audit Committee held on the 8th December 2015. 17.2 CG drew attention to section 16 of the minutes relating to the

Auditor Panel Arrangements. It was noted that the Audit Committee would incorporate the functions of the Auditor Panel.


minutes. 18 Primary Care Commissioning Committee Minutes 18.1 The Governing Body received the minutes of the meeting of

the Primary Care Commissioning Committee held on the 26th November 2015.


minutes.

19 Any Other Business 19.1 The Governing Body wished a fond farewell to HM who was

leaving at the end of April 2016. MH thanked HM for her contribution to the CCG particularly the enthusiasm and energy that she had brought to the role. HM had supported a lot of people and would be missed dearly. MH informed members that a formal farewell event was being arranged.

20 The meeting closed at 15:55.


21 Date and Time of next meeting: Thursday 26th May 2016

at 2pm in the Board Room at Sanger House.

Minutes Approved by Gloucestershire Clinical Commissioning Group Governing Body: Signed (Chair):____________________ Date:_____________

It2A1

3A9

2A8

tem 28.05.15 Agenda Item18.5

30.07.2015 Agenda Item9.7

28.01.2016 Agenda Item8.5

Matter

DescripReport frof EnglaAcademScience Board (W

AccountaOfficer’s

Locality Developupdates

rs arising fro

tion rom West nd ic Health Network

WEAHSN)

able Report

ment Plan

om previous

ResponseMH felt thIndustry AGloucestersMarch 201meeting da30.07.2015organised and WEAHAdvisory Gmembers foMay 2016MH drew aengagemenactivity planfor a future CBu requcommunity MGe advisreorganisatpart of the that a long that a meet2016 and reported.

Page 1 of 2

s Governing

at further cAdvisory Gshire. It was5 and that tte.

5 MH adviswith the Loc

HSN in SepteGroup. MH ollowing this

attention to nt activities n was being Governing B

uested furtbased geria

sed that thistion at Ciren locality widterm plan w

ting regardinthat any fee

g Body Meet

clarity was rroup and

s noted that the CCG we

sed that a cal Enterprisember 2015

agreed thameeting. 26

Section 6 oand adviseddeveloped a

Body meetingher informatrician servis work was ncester Hospe frailty pro

was being esg frailty was edback from

tings – Marc

required regwhat it m

a meeting were not advi

meeting wse Partnersh

regarding that she wou6.11.2015 de

of the repord that an enand should bg. ation regaice in South an outcome

pital and thagramme. It stablished. Hbeing held i

m this meetin

ch 2016

arding the meant for was held in sed of the

was being ips (LEPs)

he Industry uld update ferred until

rt outlining ngagement e available

rding the Cotswold.

e from the at this was was noted

HG advised n February ng can be

Agenda Item

Action withMH

MAE

HG

4

h

3A

31.03.2016 Agenda I10.88

Operatioonal Plan RR queriedspecified wthat could ensure thaGoverning

Page 2 of 2

d if there wwhere seconbe made avt these wereBody suppor

as a schedudary care p

vailable to the prioritised rted this appr

ule of meetipresence wae providers in their job

roach.

ings which as required in order to plan. The

Agenda Item

ER

4

Agenda Item 7

Governing Body

Governing Body Meeting Date

Thursday 26th May 2016

Title Annual Report (Review) and summarised accounts 2015/16

Executive Summary This paper presents to the Governing Body the 2015/16 Annual Report (Review) and summarised Accounts. The Report celebrates many of the achievements delivered by the CCG and its partners during the year. It also reflects the challenges and opportunities facing the CCG and wider health and social care community and plans to: place greater emphasis on prevention and

self-care work in partnership to support healthy, active

communities work in partnership to deliver closer integration

of services invest in community services reduce reliance on hospital based services ensure high quality specialist hospital services

when needed and; ensure services are sustainable and

affordable, making best use of the limited funds available.

Key Issues

The Report contains county and locality news features and includes all statutory reports and the accounts in line with the CCG Annual Reporting guidance, published by NHS England. The CCG will produce a limited hard copy quantity of the full Report and ensure wider community stakeholder distribution of an abridged version with a brief/plain English financial summary after the news section.

Page 2 of 2

Both the full report and the Annual Review magazine will be available on-line. The CCG intends to develop a much shorter public facing newspaper style highlights magazine in the Summer for distribution to Gloucestershire households and is discussing distribution arrangements with partner organisations.

Risk Issues: Original Risk Residual Risk

None.

Financial Impact Financial details, including summarised Annual Accounts, are contained within the Annual Report.

Legal Issues (including NHS Constitution)

NHS Gloucestershire CCG has produced a full Annual Report in line with NHS England’s CCG Annual Reporting guidance and the Department of Health’s Group Manual for Accounts 15/16.

Impact on Health Inequalities

The Report promotes the partnership approach to tackling health inequalities.

Impact on Equality and Diversity

The staff report sets out the CCG’s approach to promoting Equality and Diversity with links to comprehensive information on the CCG website.

Impact on Sustainable Development

By producing an abridged version of the Report, there will be a reduction in printing volumes with an emphasis on on-line availability and access through the CCG’s social media channels.

Patient and Public Involvement

The Report includes a summary of the CCG’s engagement activities. The short newspaper style magazine will also include web links to real life patient and clinician case studies.

Recommendation The Governing Body is asked to receive the Annual Report and summarised Accounts 2015/16, subject to any final opinion from the auditors.

Author Anthony Dallimore Designation Associate Director, Communications Sponsoring Director (if not author)

Mary Hutton Accountable Officer

Page 1 of 12

Governing Body



Title Gloucestershire Clinical Commissioning Group Chair’s Report

Executive Summary This report provides a summary of key issues arising during May 2016.

Key Issues

The key issues arising include: End of Life Care Social Prescribing GDoc Primary Care Workforce Plan including the

BMJ advertisement campaign Clinical Programmes Meetings attended


None.

Financial Impact None. Legal Issues (including NHS Constitution)

None.


None.


None.


None.


Not applicable.

Recommendation The Governing Body is requested to note this report which is provided for information.

Author Andy Seymour

Designation Gloucestershire CCG Clinical Chair Sponsoring Director (if not author)

Agenda Item 10

Page 2 of 12

Gloucestershire Clinical Commissioning (GCCG)

Clinical Chair’s Report

1. Introduction 1.1 This report provides a summary of key issues arising during May 2016. 2. End of Life Care

2.1 2.2 2.3 2.4

NHS Gloucestershire Clinical Commissioning Group (CCG) and partner organisations are working together to improve services for people who require palliative and end of life care. The development of an End of Life strategy is an important step in making improvements happens. It is being drawn up with input from a wide range of people, across health and social care providers, the voluntary sector, families and carers. The strategy outlines how we would like to take forward the development of palliative and end of life care services in Gloucestershire over the period 2016-2019. Each year in Gloucestershire approximately 5,900 people die from a wide range of causes. In common with the rest of England, the largest single underlying causes of death are Cardiovascular disease, Respiratory disease and Cancer. Across Gloucestershire, people die in a range of places, 44.6% occur in a hospital setting; 25.2% of people die at home; 24.2% in a care home; and 3.1% in a hospice. The strategy and associated implementation plans will be overseen by the Gloucestershire End of Life Care Board which has director level representation from all providers within Gloucestershire, service users, carers and the Voluntary and Community Sector. It builds upon the good work previously undertaken by all parties across Gloucestershire.

3. Social Prescribing 3.1

Social Prescribing is fully operational across the county with referrals accepted from staff in all 81 GP Practices, 21 Integrated Community Teams and staff who work in community hospitals. As at the end of March 2016, there had been in excess of 1,700 referrals to the programme.

Page 3 of 12

3.2 3.3

Our social prescribing programme is currently being externally evaluated by the University of the West of England (UWE). This is both a qualitative and quantitative evaluation with a final report due in September 2016. It is anticipated that the lead researcher will present the findings to Governing Body members on 29th September to inform the 2017/18 commissioning round. The CCG lead for the programme will present our scheme at the South West Health & Wellbeing Board Chairs Network this month.

4. GDoc 4.1 4.1.1 4.1.2 4.1.3 4.2 4.2.1

Introduction GDoc are launching a new pilot on 20 May 2016 designed to reduce admissions for patients with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) at risk of emergency admission at weekends. These patients will have to meet the following criteria:

have a history of admissions in the past three months; be high users of the GP practice; and have been reviewed by the GP in the last 72 hours.

They are also likely to be patients identified through the 2% Designated Enhanced Service (DES). The key objective of this pilot is to reduce admissions for this cohort of patients. This will improve the patient experience and reduce costs. Often once these patients are admitted they can also have a long stay in hospital. Practices involved in the pilot The practices participating in the pilot were chosen for their high levels of admissions for these COPD patients. They are:

Cheltenham Road Surgery Sixways Clinic Pavilion Family Doctors

Page 4 of 12

4.3

Overton Park Surgery

Process

practices identify those patients they are concerned may be at risk of admission over the weekend;

the practices supply a list of the patients to the GDoc service on Friday using a template provided with what information is required. Patients/carers are given a one page leaflet explaining the service and the number they should call over the weekend for advice when necessary. These documents have been kept very simple to avoid any confusion and not to add to the practice workload. It is made clear to patients/carers that this service is only to support them over that weekend. They are asked for their consent to this support. A report on any activity with their patients will go back to the practice on Monday mornings, or Tuesday after a Bank Holiday;

when the GDoc GP receives a call, they will assess the patient and give advice and guidance;

they may just need to give reassurance, but if they believe a home visit is needed, they will request a Rapid Response Team visit. If the team do not have the capacity and are not available, they will refer the patient to the OOH service. Last resort would be to call an ambulance, but this would be no different to what might happen currently without the service in place. They would also have the option to call an ambulance at the outset of the call if they believed it was clinically appropriate; and

the service will run around the clock from when the practice closes on Friday night through to it opening again on a Monday morning or Tuesday after a Bank Holiday.

4.4 Measurement 4.4.1 The three month pilot will be closely monitored and adjustments made,

as necessary. GDoc are working closely with the CCG Information Team to ensure data is captured and the impact on admissions appropriately captured. The numbers involved are quite small, so case reviews will be conducted, and patient experience surveyed, to ensure both quantitative and qualitative information are recorded.

Page 5 of 12

5. Primary Care Workforce Plan including the BMJ advertisement

campaign 5.1 In respect of workforce, the CCG has been working closing with

stakeholders such as its member practices, Health Education England South West and the Gloucestershire LMC to provide a greater consistency of support to the sustainability of the primary care workforce in the county. Therefore the draft Primary Care Workforce Plan is focused on:

the recruitment, retention and return of the GP workforce using the structure of the GP workforce 10 point plan but with local interpretation. Projects include support of countywide GP recruitment with a Gloucestershire Primary Care campaign, a portfolio career offer to GP’s considering leaving general practice early and the setting up of a Community Education Provider Network (CEPN or training hub);

the education and training of the Practice Nurse workforce, providing consistency in the development of this role with schemes such as practice nurse facilitators and advanced nurse practitioners; and

new skills mixes in primary care, with new roles to support the

current primary care professionals in providing patient care, for example with prescribing pharmacists able to manage clinical caseload.

6. Clinical Programmes 6.1 We are pleased to report encouraging progress with our Clinical

Programmes. Some programmes are already launching new service models that offer patients streamlined, accessible and high quality care. Other programmes are now bringing together partners to collaborate on new work to improve the health of our population and ensure sustainable services.

Page 6 of 12

6.2 6.2.1

Respiratory The Respiratory CPG is undergoing a refresh, under the umbrella of the STP, to test a pathway approach to models of care. This programme provides an exciting opportunity to build on respiratory service development to date and test out multi-disciplinary integrated working across a patient pathway. Over the coming month the priority pathways will be agreed by the clinical programme board, rapidly taken forward into multi organisational planning workshops to develop progressed models of care to test within Gloucestershire in 2016/17.

6.3 Circulatory 6.4 6.4.1

Cardiology A stock take review of cardiology is now complete. Plans are now established that include: addressing increased non–elective activity for chest pain through the development of a pathway for those with suspected cardiac chest pain, which delivers a consistent approach for low, moderate, and high risk conditions, and negates unnecessary admissions and improves outcomes; managed shared care between community services and secondary care for individuals with Heart Failure which will further join up services offer and prevent hospital admissions and at times the need for outpatient appointments; utilisation of remote monitoring (telehealth) for individuals with Heart Failure, to detect exacerbations for management by the community heart failure service; remote monitoring for individuals with a cardiac defibrillator or cardiac resynchronisation therapy to reduce follow up activity; improved access to IV therapies in a community setting closer to/at home for palliative heart failure patients and review of alternative ambulatory ECG services using an annual KPI approach with a view to review service provision across the county.

6.5 Stroke 6.5.1

During 2015/16 additional managerial support was provided to the acute stroke team in making a number of service improvements and business case proposals in order to ensure the service can meet key quality indicators going forward, including: • re-siting of stroke wards

Page 7 of 12

6.5.2

• reorganising how care is delivered • redesigning pathways • development of documentation and protocols • development of business cases (consultant, specialist nurse, therapies and data admin support • development of a nurse education framework • recruitment (therapies) The latest data reports indicate overall performance for hospital based stroke care is showing improvements locally when compared to national and regional indicators, for example: access to stroke consultants, stroke wards and nursing; fewer outliers with more people spending time on the specialist stroke wards; faster access to CT scanning; reduced length of stay and improvements in access to therapies. The work plan for 2016/17 is aimed at ensuring the early improvements within acute care continue and are made sustainable and the development of the community care pathway to include in-reach community beds.

6.6 Eye Health 6.6.1 6.6.2

New community eye care service is on track to go live on 31st May 2016. In the first phase, this will allow patients to have more checks undertaken by their local community optometrist rather than having to travel to Gloucester or Cheltenham hospital which will particularly benefit those living in more rural parts of the county. Community optometrists will be able to make direct referrals for patients with suspected Cataract or Glaucoma into the GHT rather than being delayed by going via their GP. GP’s will be informed of referrals made to ensure they have a complete patient record. Further services will go live throughout the year. There has been very positive feedback from the targeted project aimed at increasing awareness of the increased risk of Glaucoma within the BME population. A session was run with the Black Elders with information giving, Glaucoma screening and a powerful patient story.

6.7 MSK 6.7.1

The programme has carried out an extensive redesign project to understand how Gloucestershire can be the first CCG to deliver an

Page 8 of 12

6.7.2

integrated model of MSK services. This has been a truly collaborative approach, which will see over 20 project managers across a range of organisations feeding into the programme to deliver the vision. Work is underway to deliver a large range of projects, which cover every component of the pathway. It ensures that every service delivers key service elements, which contribute to delivering the vison of “right person, right time, right place and at the right cost”. The programme had sign-off with over 80 major stakeholders and is moving into implementation. Most recently, a successful Voluntary & Community Sector workshop was undertaken to identify all supporting services, which will be embedded as part of the MSK model and facilitate step-down services to relieve follow-up pressure on MSK services. Below is an overview of some of the work currently completed or underway: All Services 1) All will be expected to adhere to triage process and redirect as

defined by criteria 2) There will be a standardisation of service names across e-

referral for clarity of understanding 3) All services will be expected to participate in relevant clinical

network groups which provide a forum for operational, cross-organisation discussion.

4) All services will be expected to participate in any MDT’s the CPG defines as necessary to ensure an effective forum for complex case management.

5) Clinical guidance with regards to pathway will flow. 6) Referral guidance has been produced, which simplifies referral

process, redirects activity but removes blocks/added steps where referral meets criteria.

7) All Services now have detailed specifications in the contract. 8) All services will begin to use consistent outcome measure

throughout the pathway. 9) All services have a collective group of individuals assigned to

various tasks. 10) Pathway guidance to continue to be developed and housed on G-Care.

There is also a range of individual service level projects, which differ dependent on requirements. As an example these include, referral templates, new discharge summary process, a new falls service and an Early Inflammatory Arthritis (EIA) Pathway

Page 9 of 12

6.8 Diabetes 6.8.1 6.8.2 6.8.3 6.8.4

The diabetes Clinical Programme is currently undergoing a refresh following the Clinical Programme approach. A project team has been established to initially undertake preparations for the first workshop on September 1st. The team is currently working on the needs analysis, data and finance packs, patient and clinician questionnaires and project documentation. Digital technology: We are currently working the AHSN on the Diabetes mHealth Challenge which will involve piloting two projects within the county: – Ki-Performance – Map My Diabetes Both utilise technology (monitoring device and software in the case of Ki- Performance and website in the case of Mapmydiabetes) to help patients self-manage and also offer structured education (mapmydiabetes). A project team has been established for implementation of mapmydiabetes with proposed start date of late summer. Diabetes and Care Homes: The care of patients with diabetes in care homes was identified as a key priority in 2014-15. Recently a working group recently established, with multi agency representation to look at clinical education for care home staff within Gloucestershire. All CPGs have been asked to identify key learning points specifically for care home staff, associated with their clinical programme and diabetes and diabetes foot care identified as key priorities for inclusion Diabetes Foot care: A multi-organisational workshop was held in November 2015 bringing key stakeholders involved across the Diabetic Foot pathway together to review current services. This was following national reviews where amputation rates in the region benchmarked high and the workshop aim was to consider how to redesign services to increase early access to the right services at the right time, improve quality and enhance the patient experience. Progress to date includes vast engagement from multiple clinicians

Page 10 of 12

6.8.5 6.8.6

and other stakeholders with redesigning the pathway to ensure that patients are receiving exceptional care and assessments earlier in the pathway. We are aiming to facilitate and support earlier adoption of self-management techniques to avoid, where possible, the need to rely on health services. It is hoped that the new pathway will be finalised and begin to be implemented later this year. Community Enhanced Service: A Community Enhanced Service (CES) was implemented last financial year to encourage GPs to keep more complex patients within primary care and to undertake insulin and GLP4 initiations as part of the CPG plans for a more integrated service. The CPG will update it this year in order to reduce practice variation and improve monitoring and outcomes for patients with diabetes. Diabetes and Frailty: Clinicians from the Diabetes CPG have collaborated with a care of the elderly physician to develop local guidance to support primary and community healthcare teams in managing diabetes in frailty. These guidelines take into account the fact that frail people with diabetes are at increased risk of adverse effects of treatments, such as having a hypoglycaemic episode, which can result in significant physical injury, loss of confidence and reduced likelihood to benefit from the long-term benefits of good glycaemic control. The guidelines are hosted on G-Care and complemented by a podcast which has been produced specifically to address this issue. Ongoing promotion of these guidelines will occur during 2016/17.

6.9 Cancer 6.9.1 6.9.2

The programme's ambitious local development strategy is fully aligned to Achieving World-Class Cancer Outcomes: a cancer strategy for England 2015-16 Early Diagnosis of Cancer: This area of work now completed its second year. The extensive Macmillan GP Master Class series has achieved over 900 GP attendances at interactive educational events, with the latest in April focussing on the Brain and Central Nervous System. In addition all GP

Page 11 of 12

6.9.3

practices are completing their returns into a large-scale quality improvement project that is taking learning from 500 Significant Event Audits, which we have developed in collaboration with the Royal College of General Practitioners. We are now completing joint development work on our pathways to diagnosis in line with the latest NICE guidelines to streamline high quality referrals and ensure as many cancers as possible are detected at an early stage. Gloucestershire Living With & Beyond Cancer Programme: This wide-reaching programme encompasses 7 lead projects transforming patient care with a range of partners across the care pathway, focussing in the current phase on Breast, Prostate and Colorectal Cancer. Within the hospital GHNHSFT have started to implement the Cancer Recovery Package of Holistic Needs Assessments and Care Plans. The service design work is now well progressed for shifting to needs based follow-up approach and the production of Treatment Summaries to improve communications with patients and between health partners. We are especially pleased to announce the launch of our innovative community-based service Macmillan Next Steps that aims to improve the health outcomes for people following a cancer diagnosis. The service will be providing patient education programmes, 1:1 specialist recovery care including physiotherapy, occupational therapy, dietetics and emotional support. The ethos is to encourage health lifestyles and to enable patients to successfully self-manage.

7. Meetings attended 7.1 10th May – Systems Resilience Group, Gloucester

12th May - Sustainability & Transformation Plan(STP)/CEO, Gloucester

12th May – LMC, Gloucester 17th May - HSOSC, Gloucester 18th May - GHFT Council of Governors, Gloucester 19th May - Sustainability & Transformation Plan(STP)/CEO,

Gloucester 19th May - Locality GP Provider Lead Induction, Gloucester 19th May – CCG Vision & Values Launch 19th May - STP Oversight Board, Gloucester 19th May - STP Engagement Event, Gloucester

Page 12 of 12

24th May - Health & Wellbeing Board, Gloucester 24th May - STP/GSF Board, Gloucester

26th May – Leadership Gloucestershire 8. Recommendation 8.1 This report is provided for information and the Governing Body is

requested to note the contents.

Page 1 of 9

Governing Body



Title Gloucestershire Clinical Commissioning Group Accountable Officer’s Report

Executive Summary This report provides a summary of key issues arising during April and May 2016

Key Issues

The key issues arising include: Development of integrated primary and

community led/ based urgent care; Primary Care infrastructure development; Place based model; Early Intervention Programme; Employment for people with a Learning Disability; England/Wales Cross Border Healthcare; Strategy and Planning; and Meetings attended.


None.

Financial Impact None. Legal Issues (including NHS Constitution)

None.


None.


None.


None.


Not applicable.

Recommendation The Governing Body is requested to note this report which is provided for information.

Author Mary Hutton Designation Gloucestershire CCG Accountable Officer Sponsoring Director (if not author)

Agenda Item 11

Page 2 of 9

Gloucestershire Clinical Commissioning (GCCG) Accountable Officer’s Report

1 Introduction 1.1 This report provides a summary of key issues arising during April and

May 2016. 2 Development of integrated primary and community led/ based

urgent care 2.1 Members should note that a large scale project to design and agree a

service model to deliver integrated primary and community based urgent care services seven days per week across Gloucestershire has now started. The scope of the works includes all current urgent care services provided from primary or community care settings, including community hospitals, and where applicable, activity provided in acute hospitals that could be provided in different settings or by different practitioners, where predominantly services are accessed directly by patients (including same day demand for GP appointments, Choice + activity, Gloucester Health Access Centre (GHAC) non registered services, out of hours care, and minor injuries and minor illnesses) .

2.2 An essential element of developing the proposal is through a series of

three, workshops in April, May and June 2016. Involving a range of Providers, locality GPs, patients, voluntary sector representation, Healthwatch and key subject matter commissioning leads from the CCG, the aim is to collectively propose an integrated operating model. Workshop 1 has already happened with over 50 people attending. There was positive discussion around the key issues facing urgent care as well as development of what people see as fundamental to any proposals and the workshop produced initial, high level models. The second workshop will focus on assessing the emerging models against core criteria and final workshop will confirm a preferred model, able to be adapted across the County, ready to be developed in detail.

2.3 This will be done by the completion of a commissioning led business

case. It is expected this will be completed by the Autumn of 2016. Subject to approval, new arrangements will be implemented from the Spring of 2017 onwards.

Page 3 of 9

3 Primary care infrastructure development 3.1 Following the approval of the Primary Care Infrastructure Plan at the

March 2016 Governing Body meeting, individual proposals are now beginning to be taken forward for business case development. Currently, CCG staff are working with identified priorities to complete applications for the NHS England Estates and Technology Fund to obtain some financial support to help complete necessary business case work as well setting out capital contributions towards overall capital costs of new surgery developments. Additionally, a number of practices have submitted requests for smaller proposals to improve their existing buildings. These applications are now due to be submitted to NHS England by the end of June 2016. The CCG will be required to prioritise submissions. The CGG has not been informed yet of the timeline for decision making for approval of any applications

4 Place based model 4.1 The Gloucestershire Strategic Forum (chairs and chief executives from

the Local Authority, Clinical Commissioning Group and the NHS provider organisations) has been meeting to consider the ongoing challenges faced by the Health and Social Care system.

4.2 Like other areas of the country, we are working together, on our

Sustainability and Transformation Plan for Gloucestershire (STP). The long-term ambition is to have a Gloucestershire population, which is:

living in healthy communities and benefitting from strong networks of community support ;

able to access high quality care when needed in the right place, at the right time; and

less dependent on health and social care services. 4.3 One element of our STP is the development of a place based model

and all partners have agreed to develop this in the Stroud and Berkeley Vale locality. Components of the model include:

a local community model with GP practice populations at its core; self-defining systems of populations. In Stroud and Berkeley

Vale, GP Practices have grouped into 4 clusters with a lead GP identified for each cluster. Staff from partner organisations will

Page 4 of 9

wrap around these clusters; the locality is thought to be big enough to give scale e.g. input

from all providers and the clusters small enough to support the feeling of a coherent community system; and

each ‘place model’ will need to keep everyday work going, but also inform and ‘sense check’ from a local perspective planned improvements in countywide clinical pathways and improve and implement local pathways for the benefit of local people.

5 Early Intervention Programme 5.1 The CCG and GCC joint sponsored the use of Positive Behavioural

Support workers as part of the Gloucestershire Challenging Behaviour Strategy. The net impact is to reduce downstream costs by intervening with children and young people earlier and putting in place interventions which de-escalate the issue and lead to better outcomes.

5.2 The Challenging Behaviour Strategy is now closely linked with the

Transforming Care Programme. The Strategy has allowed Gloucestershire to be well positioned in terms of the low amount of patients outside of the county in long stay in-patient units.

6 6.1

Employment for People with a Learning Disability The CCG and GCC have joined forces to improve the national statistics which state that only 6% of people with a Learning Disability are in paid employment. The Gloucestershire figure now stands at 18% some 3 times the national average.

7 England/Wales Cross Border Healthcare 7.1 Background:

In 2013, responsibility for the long-standing protocol for cross-border healthcare between England and Wales transferred from the Department of Health (DH) to NHS England (NHSE). A revised protocol for cross-border healthcare was agreed between NHSE (previously the NHS Commissioning Board) and the Welsh Government (WG), which took effect from April 2013. The current protocol sets out the same operational arrangements for commissioning secondary care for English and Welsh cross-border patients as previous protocols.

Page 5 of 9

7.2 Changes to English NHS legislation which came into effect from 1 April

2013 placed secondary care for English residents under the responsibility of their Clinical Commissioning Group (CCG), even where those patients are registered with a GP in Wales. Therefore, the arrangements set out in the existing cross-border protocol with Wales are unlawful for English resident patients and means that English resident/Welsh registered patients have not received their NHS Constitutional entitlements for consultant-led services, including English waiting time standards and patient choice.

7.3 The English and Welsh NHS are committed to bringing about changes

to the protocol arrangements for English residents patients. A solution has been identified that will redirect these patients into care commissioned by the NHS in England. However, it should be noted that the Welsh GPs are under no contractual obligation to make this change and the project plan is to introduce a phased implementation of this new system along the border.

7.4 What this means for patients in Gloucestershire 7.5 There are currently 8,811 patients living in Gloucestershire who are

registered with a Welsh practice. 7.6 Over the last 18 months, GCCG has worked with NHSE, Aneurin

Bevan University Health Board and other partners from along the border to enable patients to receive their NHS Constitutional entitlements. We have also liaised with Healthwatch Gloucestershire and Action4OurCare, a local campaign group, to support individual patients.

7.7 An information leaflet and personalised letter has been sent to each

patient affected by the changes to the protocol arrangements. All patients should have received a letter by mid-May 2016.

7.8 Three public “Drop In” sessions have been arranged for patients to

come along and talk to GCCG staff: St Briavels – 16 May (3-7pm) Sedbury – 23 May (3-7pm) Tidenham – 24 May (3.30-7pm)

Page 6 of 9

7.9 In summary:

Primary Care

Patients will continue to receive care commissioned by the Welsh NHS, including their entitlement to free prescriptions.

7.10 Secondary Care (consultant-led referrals)

Patients will be offered choice of where they receive their care. If they choose to receive their care in England they should start their planned, consultant-led NHS treatment within a maximum of 18 weeks from GP referral to treatment, unless they choose to wait longer, or it is clinically appropriate that you wait longer. If the patient prefers, they can still choose to receive their treatment and care in a hospital or clinic in Wales instead of England. If they are cared for in Wales they will receive high quality NHS care to the same standards and policies as Welsh patients.

7.11 Referral process – All new consultant referrals for treatment, either in

a hospital or clinic, will be sent by the patients’ doctor to an NHS Referral Assessment Service (RAS). The RAS is a “tried and tested” service, hosted by NHS Shropshire CCG, based in Shrewsbury.

7.12 The RAS will contact the patient directly on behalf of your GP practice,

to offer the patient a choice of available hospitals or clinics and appointment times.

7.13 Community Health Service

Gloucestershire CCG will be responsible for commissioning community health services for this cohort of patients. Work is underway to establish the full range of services that are currently being provided to patients and ensure arrangements are in place to provide continuity of care.

7.14 Financial Impact – Discussions continue on the transfer of funding

and no final decision can be taken until the financial transfer value is agreed.

Page 7 of 9

8. Strategy & Planning 8.1 Cultural Commissioning 8.1.1 A national report on cultural commissioning has recently been

published by the New Economics Foundation. The report brings together the learning and experiences from two national pilots sites (one being Gloucestershire) around integrating arts, culture and health. Local work is continuing across the county to pilot a range of programmes across our clinical programme groups. Some of the projects are summarised below:

A mixed media arts project for men of working age living with chronic- pain, to learn arts based strategies of managing pain. Co-delivered with an expert pain patient.

A drama based project with teenagers living with Type 1 diabetes to increase confidence and diabetes self- management. Co-delivered with a teenage creative arts intern who has Type 1 diabetes

Bespoke choirs for people with chronic obstructive pulmonary disease (COPD) and asthma

Shared art project (wall mural) and connection to nature, to reduce psychological barriers such as stigma and shame for people with significant weight issues

Comedy and animation project for Black and Minority Ethnic (BME) community to raise awareness of early signs of dementia and increase uptake of early support

8.2 Workplace Wellbeing Charter 8.2.1 The CCG have provided funding for 40 organisations across

Gloucestershire to sign up to the National Workplace Wellbeing Charter which is endorsed by Public Health England. A project group has been convened to oversee implementation and involves engagement with Active Gloucestershire, Local Enterprise Partnerships (LEP), County Council and District Councils. The CCG have submitted an application to NHS England for use of a free license for the Patient Activation Measure (PAM). The PAM is a valid, highly reliable tool that assesses an individual’s knowledge, skill, and confidence. Research has also shown that it’s highly predictive of

Page 8 of 9

most health behaviours, self-management and use of health services. The aim would be to implement the tool across a range of pathways to promote person-led care and promote self-management.

8.3 Sustainability and Transformation Plan (STP) 8.3.1 8.3.2 8.3.3

In light of current discussions around the Sustainable Transformation Plan (STP), the Healthy Individuals Programme Group has now formally disbanded with a new strategic group being proposed to lead on prevention and self-care. The new group will be made up of senior representatives from across the system and will look to develop a substantial cross partners prevention plan for the next 5-years. The first meetings of the Child and Adult Healthy Weight partnerships have taken place and these forums are launching the work to improve our pathways using the clinical programme approach. A joint Organisational Development (OD) and workforce planning group has been established, led by Shaun Clee, Chief Executive of 2Gether NHS Foundation Trust. This group is taking forward the development of a shared OD and workforce action plan for the system to underpin the work of our Sustainability and Transformation Plan. The action plan is focusing on 3 key aims – developing the capability we need for our workforce, the capacity we need and the culture we need organisations and individuals to adopt in order to support the changes we need to make together.

8.4 Forest of Dean Community Services Review Over 40 engagement meetings have taken place as part of the review of community services in the Forest of Dean. During the next month we will be drawing together a final engagement report which will then inform the development of options for the future of community services.

9 Meetings 7 Apr GSF/STP Board

7 Apr Locality Executive Chairs 13 Apr Stroud & Berkeley Vale New Models of Care Event,

Nailsworth

Page 9 of 9

25th Apr Better Care Fund Provider Forum, Shire Hall 27th Apr Cityforum Round Table, London 28th Apr NHS Clinical Commissioners Board Day, London 29th Apr Meeting with Geoffrey Clifton-Brown and North

Cotswold 11th May Quarter 4 Partners meeting with Healthwatch

Gloucestershire 12th May Quarter 4 Assurance meeting 17th May Health & Care Scrutiny Committee, Shire Hall

19th May CCG Vision & Values Launch 25th May 8th Big Health check and Social Care Open Day &

Launch of the Special Olympics, Tewkesbury 26th May Leadership Gloucestershire, Shire Hall 26th May Gloucestershire CCG Primary Care Commissioning

Committee

10 Recommendations 10.1 This report is provided for information and the Governing Body is

requested to note the contents.

Page 1 of 58

Governing Body Agenda Item 12



Title Performance Report

Executive Summary This performance framework report provides an overview of Gloucestershire CCG performance against organisational objectives and national performance measures for the period to the end of April 2016.

Key Issues

These are set out in the executive summary within the report.


All risks are identified within the relevant sections of this report.

Financial Impact This report gives detail on the financial position to the end of March


These are set out in the main body of the report.


Not applicable.


There are no direct health and equality implications contained within this report.


There are no direct sustainability implications contained within this report.


These are set out in the main body of the report.

Recommendation The Governing Body is asked to: Note the performance against local and

national targets and the actions taken to ensure that performance is at a high standard.

Note the financial position as at month one. Note the risks identified in the Finance and

Page 2 of 58

Efficiency report. Note progress on the QIPP schemes.

Author & Designation Sarah Hammond, Head of Information and Performance Andrew Beard, Deputy CFO Ian Goodall, Associate Director of Strategic Planning

Sponsoring Director (if not author)

Cath Leech Chief Finance Officer

Page 3 of 58

Gloucestershire CCG

Performance Report

1.0 Executive summary

1.1 Introduction The performance report is broken down into the five sections of the GCCG performance framework: • Clinical Excellence • Finance and Efficiency • Patient Experience • Partnerships • Staff A full summary of performance against all national and local standards is included within the relevant scorecard for that section of the report. An overarching GCCG performance dashboard is included as a supporting appendix; providing an overview of all key national and local targets. A further supporting appendix is provided in relation to the update on 2016/17 budgets. Whilst inevitably this report focuses on areas of concern it should be noted that Gloucestershire is currently achieving the majority of the local and national performance standards.

1.2 Balanced scorecard 2016/17 – up to 30th April 2016

Ref. CCG Internal Perspective Overall rating

Green

P1 Clinical excellence Amber

P2 Patient Experience Green

P3 Partnerships

Green

P4 Staff

Green

P5 Finance & Efficiency Amber

Page 4 of 58

Clinical Excellence – Amber,

Clinical excellence - Perspective highlights:

Strong progress is being reported across all active clinical programme

groups with good clinical engagement across the system

The primary care clinical quality review group have established a quality

assurance framework for primary care. The group has met on several occasions and has considered the outcomes of practice CQC inspections. It has also monitored vaccination performance for last winter, medicines optimisation, QOF and primary care staffing including training and recruitment. Patient experience including the progress with patient participation groups and FFT was also an agenda item.

Challenging performance:

A&E 4 hour target. The YTD performance at the end of February was 87.5%%.

62 day cancer waiting times below constitutional off trajectory – new trajectory agreed.

Cancelled operations SWAST wide Red 1 & Red 2

ambulance target achievement

Good performance:

Reduction in handover delays compared to 2014/15 levels

Improved Incomplete RTT performance, with the 92% incomplete standard

Continued achievement of

Cancer 31 day targets Improvements to patient

transport service targets

Dementia Diagnosis performance above target at 67.2%

Page 5 of 58

Patient experience – Green.

Patient Experience - Perspective highlights:

The Practice Participation Group network held a successful meeting in April 2016. The meeting introduced members to the Joining Up Your Information Project, in addition to providing an opportunity to showcase the work of Romney House PPG’s engagement with patients using an online forum and blog.

Two new Patient Participation Groups established in Gloucester City.

Patient Engagement and Experience continues to develop across a wide range of GCCG projects. Key activities in the last period include:

A wide range of engagement activity to support the Forest of Dean

Community Services Review. In addition to the monthly Locality Reference Group meetings, we have spoken with college students, young parents, PPGs, Carers, staff from GCS, GHT, SWAST and Hospice at Home, Forest CIC and local elected representatives.

The Information Bus has supported the ASAP campaign, holding two

sessions per week in Gloucester City Centre. These have been well attended, with good coverage from local media.


FFT - Results remain amber. Particular concern is the low response rate by patients attending the ED.

GHFT have been requested to undertake focused work on patient experience for people using urgent care services in the Trust as this has not previously been systematically monitored.

Good performance

Comprehensive experience and engagement activity supporting CCG work programme

Most GP practices in Gloucestershire now have a Patient Participation Group (PPG).

To date all GP practice inspected by CQC are good or outstanding.

Page 6 of 58

Partnerships – Green rating with all indicators on target for achievement. Staff – Green.

Partnerships - Perspective highlights:

As a part of the CCG’s prevention and self-care agenda, we have worked with G.Doc, local councils and a range of and third sectors partners and community groups to develop an innovative social prescribing model. Social prescribing now covers the entire county with the scheme available to all GP Practices in the county and referrals also accepted from staff in the counties 21 Integrated Community Teams (ICTs) and staff in community hospitals. As at the end of March there had been over 1,700 referrals from across the county. The scheme is currently being evaluated by the University of the West of England. The CCG will fund social prescribing for the year 2016/17 subject to evaluation.

A system resilience plan has been agreed for 2016/17 including a

series of investments to improve system performance this winter.

A cross system enabling active community groups is meeting regularly. This now involves Town and Parish Councils and all Districts/Borough and City Councils. Predominately the CCG and our partners have a crucial role in working together to break down artificial barriers, championing community endeavour and signposting local people to networks of community support and action, joining up services and reducing duplication and bureaucracy.

Staff - Perspective highlights: Staff sickness level is 1.87% against a target of 3%

A working group is progressing the organisational development plan, and

will complete a refresh for 2016/17.

Page 7 of 58

Finance and efficiency – Amber


Prescribing expenditure was significantly above budgeted level, primarily NOACs.

Activity, primarily emergency, at GHNHSFT was significantly above planned levels

Slippage on QIPP schemes was reported to the value of £2.9m.

Good performance

The CCG was planning to deliver a surplus of £7.3m in 2015/16, however due to the CCG receiving a number of allocations which relate to both the 2015/16 and 2016/17 financial years it was agreed with NHS England to increase this target to £9.6m to enable the CCG to manage these additional allocations across the year end. The CCG surplus within the draft accounts is £9.5m

The better payment practice code performance for the year to date (for non-NHS invoices by value) is 97.0% which is in line with the targeted figure.

Detailed plans for 16/17 have

been submitted to NHS England on the 18th April which reported a £9.5m surplus for 16/17 which corresponds to the reported surplus in 15/16.

Finance and Efficiency - Perspective highlights:

The overall assessment for the finance and efficiency perspective against the NHS England criteria is amber. However, the CCG has, for the third year, delivered all statutory financial targets. The external auditors are now finalised the 2015/16 audit.

Page 8 of 58

1.3 GCCG Performance Framework Overview

The sections below provide an overview of each domain. Each of the sections is broken down into success criteria which when combined provide an overall rating for the domain. The development of the partnerships section is ongoing as this is an area of development for the CCG. All indicators are RAG rated, based on the 2016/17 NHS England planning thresholds. Key national and local indicators are given an overall rating by weighting their importance to the organisation. Indicators which feature in the NHS constitution, Quality Premium and CCG assurance framework receive the highest weighting with local targets being given a lesser value. The overall rating is then derived from the combined score of those targets rated Amber and Red. Areas of performance assessed as being at risk of failure at year end, or other issues that engender concerns throughout the year, for which the Governing Body need to be made aware of, are reported upon within this report. Where standards are reported on a quarterly basis, the Governing Body will be informed of updates as and when data is available or new information comes to light. Performance framework The GCCG performance framework measures the in-year success of the organisation by linking the key organisational objectives to perspectives. Each of the five perspectives is given a Red, Amber or Green rating based on the progress made against a number of locally defined critical success criteria. Key local and national commissioned performance targets are also reported under each domain; however, the overall rating of each perspective is derived from GCCG performance against those targets which link to the organisations objectives:

Internal Perspective Organisational Objective Clinical Excellence (1) Develop strong, high quality, clinically

effective and innovative services. We will deliver this through a multi professional focus, with a particular emphasis on clinical programme approach and developing our member localities.

Finance and Efficiency (3) Transform services to meet the future needs of the population, through the most effective use of resources; ensuring the reduction of harm, waste and variation.

Page 9 of 58

(4) Build a sustainable and effective organisation, with robust governance arrangements throughout the organisation and localities.

Patient Experience (2) Work with patients, carers and the public; to inform decision making.

Partnerships (5) Work together with our partners to develop and deliver ill health prevention and care strategies designed to improve the lives of patients, their families and carers.

Staff (6) Develop strong leadership as commissioners at all levels of the organisation, including localities.

Page 10 of 58

2.1 Clinical Excellence

2.1.1 Clinical Excellence – Period up to 30th April 2016

The overall rating for clinical excellence is Amber for year to date progress against the specified success criteria.

PERSPECTIVE 1 Clinical Excellence Amber

Success criteria: 1. Regular, robust information is available to provide assurance that our service providers are delivering quality, safe & clinically effective services.

Green

Key performance indicators A robust process to timely monitor compliance with NICE, which provides assurance that all NICE publications are considered and Technology Appraisals are implemented within 90 days (or to have a valid reason if not which has gone through appropriate governance process).

Green

Clinical Quality Review Groups meet quarterly and provide assurance to the Governing Body through the production of a bi-monthly provider quality report. Ad-hoc meetings take place with providers on specific concerns.

Green

Success criteria: 2. Commissioning high-quality primary care services through the utilisation of exercising Delegated Commissioning responsibilities within a robust governance structure

Green

Key performance indicators

Commission all Gloucestershire practices through a ‘Primary Care Offer’ enhanced service for 2016/17 that focuses on clinical quality improvement, reduces variation, tackles health inequalities and promotes innovation

Green

Set-up and implement a Primary Care Clinical Quality Review Group (CQRG) and develop a set of indicators to measure primary care quality

Green

Success criteria: 3. Progress in developing and implementing locality plans

Green


Reporting progress on implementation of the seven Locality Development Plans for 2015-2017.

Green

Success criteria 4. Progress to develop outcomes for CPGs CPG success criteria & KPIs Outcomes – CPG programme/timelines in outline in appendix, KPis re staying to timetable, output etc, narrative

In development

Page 11 of 58

to focus, in brief, on one CPG area per month

Success criteria: 5. Key local and National standards relating to Patient Experience

Amber


Achievement of key local and National standards relating to Clinical Excellence – see section 2.2 to 2.8

Amber

2.1.2

Success criteria 1: Regular, robust information is available to provide assurance that our service providers are delivering quality, safe & clinically effective services. The Quality Team has established quarterly Clinical Quality Review Groups (CQRG) chaired by the Executive Nurse and Quality Lead. These are held for Gloucestershire’s main providers, namely Gloucestershire Hospitals NHSFT, 2gether NHSFT, Gloucestershire Care Services Trust and a further CQRG for Care Homes. These meetings report directly to the relevant NHS Gloucestershire CCG/Provider contract boards, and provide a focused opportunity for quality to be discussed between provider and commissioner. In addition extraordinary CQRGs are held with providers to focus on specific service issues. An example of this is the recent meeting to consider staffing issues at GHNHSFT Bespoke datasets are reviewed at the quarterly Clinical Quality Review Group meetings for each of the provider organisations, as well as further CQRG’s for Care Homes and Primary Care CQRG’s have the ability to escalate any issues to the full contract board, and where necessary to the regular wider Quality Surveillance meetings. Updates and minutes from CQRG’s are routinely reported to IGQC for assurance purposes. The Quality Team, in conjunction with the Information Team have produced a Quality Assurance Framework which spans in-county NHS providers allowing for benchmarking of indicators across providers. Development of this assurance tool will continue. In addition to the CQRG meetings the Quality Team has recently established a programme of Quality Summits for the three main Providers. The intention of the Summit is to triangulate intelligence across the CCG Contracting, Commissioning, Finance and Information and Quality Directorates, including ‘soft’ intelligence that may be anecdotal but will help to provide a total picture of where we think the provider is doing well and also identify where action is required to mitigate risk. The intention is that issues raised will be used to inform the commissioning intentions for the year 2016/17. A good example of this is, as a result of the issues

Page 12 of 58

identified at the GHT and 2g summits, there has been service improvement across both teams within the mental health liaison service and GHT. This will improve the experience of patient’s accessing the service and also patient outcomes.

2.1.3

Success criteria: 2: Commissioning high-quality primary care services through the utilisation of exercising Delegated Commissioning responsibilities within a robust governance structure. GCCG transitioned the commissioning of primary care services from NHS England in April 2015, using a robust project management approach. We have established a governance infrastructure, including a Primary Care Commissioning Committee, Primary Care Operational Group and commenced the establishment of work streams relating to workforce, estates, quality and innovation. Since April 2015, in addition to commencement of the development of strategic objectives, we have also managed a number of operational contractual issues, including two GP providers serving notice on their GMS contracts resulting in one GCCG managed dispersal and one procurement, with extensive patient engagement for both. In addition, list closure and branch closure requests have also been received and managed within this period too, along with PMS Reviews, all within a good governance process that minimised real or perceived conflicts of interest. The Primary Care Offer for 2015/16 built on the success of the 2014/15 scheme, with four ‘building blocks’ across the enhanced service for practices to choose from. The new additions for 15/16 included quality indicators relating to antibiotic prescribing, improving Atrial Fibrillation (AF) diagnosis and use of anticoagulants, and identifying patients at risk of Acute Kidney Infection (AKI). The four blocks and the elements they include is summarised in the table below:

Page 13 of 58

For the second year running, we achieved 100% sign-up to the Primary Care Offer, with all practices agreeing to undertake all four building blocks. The Primary Care Offer ‘Improving Quality’ forms the basis of reporting through the year, particularly with regards to the following elements:

Cancer education o GP practices to give significant event consideration to all cancer

diagnoses in the practice during 2015/16. To select one case per 2,000 head of population for conducting an in-depth Significant Event Audit

o GP practices to participate in an education programme, consisting of Macmillan GP “Lunch/Supper & Learn” Master Classes and/or a full-day Cancer PLT.

Practice variation o CCG to provide a practice variation report. The report will provide

activity and performance detail across urgent care, planned care and referrals

o Each practice to pick two areas where they are an outlier (e.g. T&O referrals) to review.

o Practices to aim to reduce any unexplained variation o Each practice will be provided with a refreshed practice variation

report at quarter three 2015. o Practices to discuss internally and develop an action plan in order to

reduce unexplained variation in their two identified domains

Local Quality Improvement Indicators o The CCG has developed four quality indicators as set out below, GP

practices to review the benchmarking data and agree a practice action plan to improve the benchmarked position. This will involve peer discussion at locality level. Smoking – recording status and advice given Antibiotics Prescribing - (Antimicrobial Stewardship) Improving Atrial Fibrillation (AF) diagnosis rates and use of

Anti-coagulants Identifying patients at risk of Acute Kidney Injury (AKI)

The cancer education classes for the Early Diagnosis Programme have been well attended, with 850 GP attendances at the Macmillan GP Masterclasses. In addition, 233 Significant Event Audits have been completed and returned to date. All 81 practices have engaged in the programme and while an in-depth evaluation is underway, we can confirm at this stage that GPs have reported a very significant increase in their confidence to identify “red flag” symptoms and their

Page 14 of 58

2.1.4

awareness of appropriate management and onward referral pathways. With regards to practice variation, practices have used the information supplied to develop action plans that have been submitted to us. The success of the scheme has informed our plans for variation in 2016/17. The Primary Care Offer for 2016/17 has now been finalised and issued to practices for consideration and sign up. The key activity themes are:

Cancer Management Programme Practice based clinical audit Local Quality Improvement Indicators Practice Variation Care for Carers Frailty assessments

Further detail on these themes, and sign-up to them for 2016/17, will follow in future Performance Reports. A Primary Care Clinical Quality Review Group (CQRG) has been established, reporting to the Integrated Governance Quality Committee (IGQC). The Group are now working to develop the indicators and processes that will be used to measure primary care quality, drawing on the Primary Care Offer, the Primary Care Web Tool, the Patient Survey, patient complaints and other relevant data sources to determine a Primary Care Quality Framework.

Success criteria 3. Progress in developing and implementing locality plans All seven CCG localities have developed two year Locality Development Plans for 2015 – 2017. Each plan was developed after working with their member practices, CCG colleagues and local stakeholders including Public Health colleagues and representatives from the district and borough councils to understand the influencing factors on health and wellbeing within each locality. These have been shared with a wide range of stakeholders across the county, including practice Patient Participation Groups (PPGs). Progress against all seven Locality Development Plans is being reported six monthly to the GCCG Governing Body, with in-depth reporting on individual localities quarterly to the CCG Development Session. Across the county, the GCCG Primary Care and Localities Directorate are currently also supporting localities in formulating the vision for primary care in the future. Given the current resilience and sustainability issues being experienced

Page 15 of 58

2.1.5 2.2

within General Practice, along with the latest national policy direction of primary care working ‘at scale’ to lead an integrated out-of-hospital care system, the locality infrastructure is well placed to organise and co-ordinate events to help develop the ideas locally. These are being held through January – April 2016, with the support of the Localities team. All localities have also been working on the implementation of the Prime Minister’s GP Access Fund projects, such as Choice+, to pilot the schemes within their areas Success criteria 4. CPG success criteria & KPIs Outcomes – CPG programme/timelines in outline in appendix, KPs re staying to timetable, output etc. narrative to focus, in brief, on one CPG area per month (timetable re which CPG each month) Please see section 3.1.6 Reporting of key local and national standards – Clinical Excellence The following section provides an overview of key local and national standard relating to clinical excellence. Assessment against performance is as per defined local/ national guidance. Issues identified in the following areas:

Red 1 & 2 Ambulance response times A&E 4 hour target Proportion of people at high risk of Stroke who experience a TIA 6 week diagnostic waiting times Cancelled operations Cancer 62 day GP referral OOH Performance

Page 16 of 58

2.2.1 2.3

Areas of good performance include:

Incomplete RTT performance Cancer 31 day targets Improvements to patient transport service targets

As part of the 2016/17 planning cycle and in support of the sustainability and transformation plan for Gloucestershire, the CCG and GHNHSFT have been required to submit agreed performance trajectories for the following constitutional standards. A&E – 4 hours: National standard 95% A&E Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Agreed trajectory 80.0% 85.0% 85.0% 87.0% 87.0% 87.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

RTT incomplete pathways: National standard 92% RTT Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar


Diagnostic 6 week: National standard 1% Diagnostics Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar


62 Day cancer: National standard 85% Cancer 62 days Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar


The finalised trajectories will be submitted on the 23rd May.

Unscheduled care: The dashboard below provides a more complete position statement for Unscheduled care. Each of the Amber and Red rated indicators are reported on by exception in section 2.3.1 This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.

Page 17 of 58

Thresh

oldMonth 6 month trend

75% Mar 67.9% 73.7%

75% Mar 49.9% 63.6%

95% Mar 80.9% 89.4%

<2014/15 Mar 197 1,002

<2014/15 Mar 13 110

95% Mar 77.5% 86.6%

95% Mar 99.7% 99.8%

0 Mar 1 5

80% Jan 81.8% 83.7%

60% Jan 27.7% 36.5%

Over 30 minute ambulance handover delays (GHNHSFT)

Enhancing quality of life for people with long‐term conditions

A&E

Over 1 hour ambulance handover delays (GHNHSFT)

Local and National standards relating to Clinical Excellence

Latest

Performance

YTD

performanceUnscheduled care

Cat A RED 1 Ambulance incidents

SWAST Ambulance indicators

Cat A RED 2 Ambulance incidents

Cat A 19 min response Ambulance incidents

Proportion of people who have had a stroke who spend at least 90%

of their time in hospital on a stroke unit

Proportion of people at high risk of Stroke who experience a TIA are

assessed and treated within 24 hours

4‐hour A&E target GHNHSFT

4‐hour A&E target GCS MIU

12 hour trolley waits

Page 18 of 58

2.3.1

SWAST Ambulance indicators Ambulance targets are monitored at a South Western Ambulance Trust wide aggregate level. The introduction of the Dispatch on Disposition (DoD) has resulted in the prioritisation of responses to Red 1 incidents. As part of the changes to the dispatch process call handlers are provided with extra assessment time for all other classification of 999 calls (including Red 2 incidents). Year-end performance is 73.7% at a Trust level and 64.4% at a Gloucestershire area for Red 1. For Red 2 performance at a Trust level is 63.6% and at a Gloucestershire level is 62.5%. For A19 performance at a Trust level is 89.4% and at a Gloucestershire level is 88.8%. During 2015/16, incidents with response in Gloucestershire have been 1.8% above contracted levels, which equates to 1677 incidents, approx. 140 per month. These additional incidents are from public calls into the 999 service. Additional work between SWASFT and 111 with floor-walkers employed to support Demand Management into the service. Red category incidents during April to February were 10.1% higher than during the same period in 2014/15. When analysed by case type/ outcome, the profile of Ambulance activity remains consistent. During 2015/16 hear and treat cases accounted for 11.2% of activity, conveyance to A&E continues to reduce (proportionately) with 42.2% of incidents resulting in an A&E attendance.

Page 19 of 58

SWAST performance has been affected recently by the introduction of a new computer aided dispatch (CAD) system in February within the north division, which was bought in to match the systems used in the south division. There have also been changes to the Ambulance quality indicators (AQI) by NHS England which have changed the way all calls will be prioritised, these code set changes are now Red; Amber; Green. SWAST have a plan to ensure there is full workforce establishment in the North division by the 1st April 2016, this follows commissioner investment into paramedic bursary programme. They are also in the process of building a storyboard to identify all significant events which have taken place over the last two years and their impact on performance. This has been presented to commissioners, along with highlighted areas of concern which will be further investigated and action plans produced to address them. Commissioners (Gloucestershire as lead) have requested an extraordinary meeting with SWASFT as the performance prior to the CAD in the area was also deteriorating for Red 1 and Red 2. Within April, new performance indicators are planned to be implemented according to NHS England from the 19th April. The impact of this will be closely monitored by local commissioners and through the NHS England team.

4-hour A&E target - Percentage of A&E attendances where the patient spent 4 hours or less in A&E from arrival to transfer, admission or discharge. Threshold – at least 95% of patients should be transferred, admitted or discharged within 4 hours. Performance in April was 85.4%. Performance at Cheltenham General was 88% andGloucestershire Royal was 83.9%. The 2015/16 year-end performance for 4 hours is 86.6% at Gloucestershire Hospitals NHSFT (GHNHSFT); the all type performance (combined GHNHSFT, Gloucestershire Care Services MIU and Primary care in A&E) is 92%. A 4 hr recovery trajectory has been agreed between the Trust and GCCG (and through the STP process) and is monitored as a system response to the delivery of the 4hr target and this is reported monthly to the Gloucestershire System Resilience Group.

Page 20 of 58

2.4

The CCG continues to implement a programme to increase urgent and emergency care system resilience to better enable the system to cope with peaks in demand. These actions are set out in our system resilience plans and focus upon self-care, signposting, admission avoidance, in-hospital care, hospital discharge and community services. As a result of continued poor performance, Monitor hasundertaken a programme of ‘heightened surveillance’ at GHFT, and an Improvement Director is supporting the Trust’s delivery of the 4 hr standard. Proportion of people at high risk of Stroke who experience a TIA are assessed and treated within 24 hours (target 60%). Performance indicator relates to high-risk transient ischemic attacks (TIA) patients need to be assessed by experts and, wherever possible, scanned using magnetic resonance imaging (MRI) within 24 hours of experiencing symptoms. Compliance against this target continues to be of concern with performance year-to-date of 36.5%, and has been raised with the Trust through the Quality Board. This indicator is included within the local quality indicator set for GHFT. Planned care: The dashboard provides a complete position statement for Planned care. Each of the Amber and Red rated indicators are reported on by exception in section 2.4.1 This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.

Page 21 of 58

Thresh


90% Sept 88.7% 89.9%

95% Mar 92.2% 93.7%

92% Mar 92.5% 92.3%

0 Mar 6 226

93% Mar 85.3% 90.9%

93% Mar 96.6% 93.9%

96% Mar 99.3% 99.6%

94% Mar 97.8% 98.1%

98% Mar 100.0% 100.0%

94% Mar 98.1% 99.8%

85% Mar 79.7% 76.3%

90% Mar 100.0% 96.1%

85% Mar 100.0% 93.5%

1% Mar 6.2% 3.9%

1% Mar 41.8% 46.3%

95% Mar 91.5% 93.6%

95% Mar 94.2% 98.9%

95% Mar 98.9% 99.3%

95% Mar 92.5% 95.1%

95% Mar 99.2% 98.3%

95% Mar 90.0% 87.0%

95% Mar 95.1% 92.9%

95% Mar 100.0% 100.0%

95% Mar 100.0% 97.9%

Latest

Performance

YTD

performance

% of non ‐ admitted pathways treated within 18 Weeks

% of incomplete Pathways that have waited less than 18 Weeks

Zero RTT pathways greater than 52 weeks

% of admitted pathways treated within 18 Weeks

Planned care

Local community waiting times

% referred to the Diabetic Nursing Service who are treated within 8

Weeks

% referred to the Parkinson Nursing Service who are treated within 8

Weeks

% referred to the Adult Physiotherapy Service who are treated within

8 Weeks

% referred to the Adult Occupational Therapy Service who are

treated within 8 Weeks

% referred to the Podiatry Service who are treated within 8 Weeks

% referred to the Paediatric Speech and Language Therapy Service

who are treated within 8 Weeks

% referred to the Paediatric Physiotherapy Service who are treated

within 8 Weeks

% referred to the Paediatric Occupational Therapy Service who are

treated within 8 Weeks

% referred to the Adult Speech and Language Therapy Service who

are treated within 8 Weeks

% of patients waiting more than 6 weeks for a Planned/ Surveillance

diagnostic test from their to be seen date – Endoscopy procedures

% of patients waiting more than 6 weeks diagnostic test

Cancer ‐ subsequent treatment for cancer within 31 days ‐ surgery

Cancer ‐ subsequent treatment for cancer within 31 days ‐ Drug

Regime

Cancer ‐ subsequent treatment for cancer within 31 days ‐

Radiotherapy

Cancer ‐ first definitive treatment within 62 days GP referral

% of patients seen within 2 weeks of GP referral for suspected

cancer

% of patients seen within 2 weeks of an urgent referral for breast

symptoms cancer is not initially suspected

Diagnostic waiting times

Cancer waiting times

Referral to treatment (RTT)

Cancer ‐ first definitive treatment within 62 days screening service

Cancer ‐ first definitive treatment within 62 days upgrade

Cancer ‐ first definitive treatment within 31 days of a cancer

diagnosis

Page 22 of 58

2.4.1

Referral To Treat (RTT) incomplete pathways and Referral to treatment (RTT) pathways greater than 52 weeks 6 incomplete pathways of 52+ weeks were reported in March 2016. Of these, 4were at North Bristol Trust (NBT) in trauma and orthopaedics. 2 at GHFT, both inUrology. The CCG continues to closely monitor progress for its patients with the Trusts, and treatment dates are provided for assurance Overall recovery is above trajectory, which is positive. During 2015/16, there have been 226 incomplete pathways of 52+ weeks reported to the CCG. The majority are with NBT and the breaches have occurred within the trauma and orthopaedics specialty; there are capacity issues particularly for complex spinal services across a number of providers within the South West. All patients have been clinically reviewed and offered alternatives where clinically appropriate. The CCG receives updates in terms of the treatment dates for these patients. The CCG regularly receive updates on the progress of treatment for Gloucestershire patients at out of county providers. Performance management is being undertaken in conjunction with the lead commissioner for planned care. As an associate commissioner, we receive the monthly performance position highlighting the issues and have an opportunity to challenge progress. G-care Website

The G-care website has been designed for use by clinicians working in primary care, specifically to support Gloucestershire based GP’s in their work. The website pulls together useful information from a range of sources and includes local care pathways, clinical guidance, referral forms, patient and care information, service information, as well as links to community resources such as social prescribing and voluntary sector groups. Below is a summary table of the number of people for the month of April 2016. There have been 249 new users visit the site in April bringing the total number of unique visitors to the site to 1,247. The site was visited 3,102 times with 12,146 pages viewed.

Page 23 of 58

April 2016

Total Users 1,247

New Users 249

Site Views 3,102

Page Views 12,146

Top Pages Viewed

1. Non-Visible Haematuria

2. Irritable Bowel Syndrome 3. Safeguarding Children 4. Deep Vein Thrombosis 5. Early Inflammatory Arthritis

Top Search Words

1. Deep Vein Thrombosis 2. Irritable Bowel Syndrome 3. Chronic Obstructive Pulmonary Disease

4. Diabetes

5. Social Prescribing

Top Referral Forms

1. Primary Care Transfer Form –Pilot

2. Macmillan Next Steps 3. Irritable Bowel Syndrome 4. Complex Leg Wound Service 5. Early Inflammatory Arthritis

GP Practices Visited

Regent Street Surgery Newent Doctors' Practice Bartongate Surgery Barnwood Medical Practice Chipping Campden Surgery Frampton Surgery Avenue Surgery Romney House Surgery Forest Health Care Rosebank Health Surgery

Top Feedback ‘Excellent’ – re: Social Prescribing – GP, Gloucester City Health Centre

‘Your visit was very helpful. G-Care is wonderful!’ GP, Stonehouse Surgery

Page 24 of 58

2.5

Cancer waiting times – first definitive treatment within 62 days GP referral

Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer Delivery of cancer targets has been challenging throughout 2015/16 to date in the face of significantly increased demand, particularly in the services of urology, colorectal, upper GI, lung and gynaecology. Demand has in part been fuelled by the ‘Be Clear on Cancer’ and other awareness campaigns.

Performance against the 2-week wait target has declined to 85.3% in March, bringing the year-end position to 90.9%.

Performance against the 62-day wait target was 79.7% in March which was below the target of 85%. The GHFT position was 76.7%. Overall CCG performance is running at 76.5% for the year to date. Urology remains the speciality of most concern with 50% of patients being treated beyond 62 days in February & March. The majority of breaches relate to waits for diagnostics tests.

There were 14 over 104 day breaches reported at the end of February. 11 were in urology, 1 in Lower GI, 1 in Upper GI and 1 were in Lung, all 14 pathways started and finished at GHFT. Formal SI’s are not reported for this process, but the Cancer Management Group receives formal reports with lessons learnt. Urology continues to be an area of concern. The Trust is providing the CCG with reports at the 60 day position in order to support effective challenge and review.

Page 25 of 58

78.6%

1,543 366

Mar-16

Sep-15 136 38 72.1%

2015/16 Total 76.3%

Oct-15 140

79.5%

Jan-16 126

29 79.3%

133

138 39 71.7%

May-15 102 29 71.6%

Jun-15

Apr-15 121 32 73.6%

62 day target - GP Referral

Total %

Jul-15 150 47

85% TargetBreaches

18

Nov-15

85.9%

68.7%

73.9%Feb-16 119 31

27

27 79.7%

Dec-15 122 25

Aug-15 128

128 24 81.3%

The majority of breaches have occurred in the following specialties: Urology – 148 breaches Lower gastro-intestinal – 53 breaches Lung – 35 breaches Upper gastro-intestinal - 27 breaches GCCG have an agreed recovery action plan in place with GHFT for Quarter One and Two of 2016/17, with a recovery trajectory of September 2016. In addition we have provided additional CCG support to GHFT to support the recovery plan process with the main providers to ensure that performance improves, with sustainable delivery during 2016/17; however, concerns remain with capacity issues in key specialties. The CCG has commissioned additional external capacity within urology to support this tumour site area’s activity. This has acted to take transfers direct from GHFT and is now operating as a one stop shop to all new referrals since January 2016 through independent provider, GP Care. Since the beginning this service has taken 208 referrals with 71% treated; discharged or maintained within primary care. The CCG is co-ordinating a working group which is working with local providers to understand the impact of the NICE referral guidance for suspected cancer. GHNHSFT and GCCG are also actively engaged in working with the IMAS Intensive Support Team to aid improvements in performance.

Page 26 of 58

2.5.1 2.5.2

Percentage of patients waiting more than 6 weeks for a diagnostic procedure The performance for patients waiting over 6 weeks for a diagnostic procedure has decreased significantly in March (6.4%) from the position in February (2.4%). The key areas are Ultrasound and MRI. A replacement MRI scanner is being procured and the capacity issues with workforce are being supported through locum cover Issues within neurophysiology have been identified and a remedial action plan agreed with GHNHSFT. Other areas for concern are; Urodynamics Cystoscopy. Echocardiography Recovery plans relating to endoscopy have been implemented, with improved performance since September 2015 Elective cancellations:

The dashboard below provides a more complete position statement for elective cancellations. Each of the amber and red rated indicators are reported on by exception in section 2.5.1. This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.

Thresh


0 Mar 15 77

0 Jan 2 6

PerformanceYTD

performance

Cancelled operations ‐ 28 day breaches

Urgent operations cancelled for a second time

Elective cancellations

Cancelled operations - Number of patients who have had an operation cancelled, on or after the day of admission, for non-clinical reasons that have not been offered another binding date within 28 days.

The current year-to-date position shows that so far in 2015/16, 77 patients have been cancelled on the day of admission for non-medical reasons, and have not been provided with another date within 28 days; the threshold is zero. There were 784 last minute elective operations cancelled for non-clinical reasons

Page 27 of 58

2.6

2.6.1

this year. The number of cancellations was 716 in the same period in 2014/15 (9.5% increase). The increase in cancellations can be related back to the delivery of 4 hour performance. The CCG has requested and received additional information and assurance in respect of cancelled operations. This is reviewed as part of the contractual framework with GHNHSFT. Mental Health:

The dashboard below provides a position statement for mental health indicators. Each of the amber and red rated indicators are reported on by exception in section 2.6.1 This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.

Thresh Month 6 month trend

67% Mar 67.1% 66.4%

95%Q4

15/16 97.6% 97.1%

3.5%Q3

15/16 14.0% 14.0%

50%Q4

15/16 48.0% 34.0%

75% Mar 84.0% 87.0%

95% Mar 98.0% 99.0%

Mental health indicators Performance YTD

Care Programme Approach (CPA) discharged from

inpatient care who are followed up within 7 days

The proportion of people who have depression and or

anxiety discorders who receive psychological therapies

Dementia diagnosis rate

The proportion of people who complete therapy who

are moving towards recoveryIAPT ‐ Waiting times: Referral to Treatment within 6

weeks (based

IAPT ‐ Waiting times: Referral to Treatment within 18

weeks (based Dementia diagnosis rate (DDR)

The PCCAG dementia case finding audit in Q3 had 100% practice compliance and the activity identified a cohort of patients not recorded on the dementia register. Based on the audit findings shared with practices in order to update their dementia Registers, PCCAG have indicated that the dementia diagnosis rate for March 2016 is 67.1%. We have agreed with NHSE, a trajectory for 16/17 with a target to reach 70% DDR by the end of Q4 2017. Alongside this, the local primary care dementia pathway will be reviewed during 16/17 to ensure that post diagnostic services can support the rising DDR and anticipate that this will be an area of interest to stakeholders and NHSE going forward.

Page 28 of 58

2.6.2 2.7

The proportion of people who complete therapy who are moving towards recovery There are known discrepancies between nationally reported recovery figures and local reported figures from 2gether NHS FT (2G). 2G have an on-going programme of work that will help ensure better understand of the variances in reporting of data. 2G Staff are being briefed and trained on the issues to ensure that true clinical performance of the service can be reflected within the national dataset, and a new care pathway has been introduced. Throughout the improvement programme 2G are using a reliable improvement rate (local indicator), showing those people who have made an improvement. This indicator is showing a reliable improvement rate of 55%. A member of the national IAPT Team is supporting 2G. They have also had an on-site visit from the NHSE Intensive Support team, and a draft copy of the report has been circulated, and 2G are creating an improvement plan for access and recovery rate which will be shared with the CCG by the end of May. Patient transport: The dashboard below provides a position statement for patient transport. Each of the amber and red rated indicators are reported on by exception in section 2.7.1 This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance. Overall PTS performance has improved since service implementation, but further

Page 29 of 58

2.7.1 2.8

improvement is required in order to achieve all performance targets on a sustainable basis. A performance notice was issued in December 2015 and the CCG is closely monitoring the ATSL Remedial Action Plan.

Thresh


95% Mar 86.2% 84.3%

85% Mar 79.8% 82.0%

85% Mar 87.0% 84.5%

PerformanceYTD

performance

Arrival within 45 minutes before, to 15 minutes after, booked arrival

time

Where booked prior to the day of travel, patients not to wait more

than 60 minutes for their (outbound) journey

Where booked on the day of travel, patients not to wait more than 4

hours for their (outbound) journey (within two hours for end of life

patients)

Patient transfer services

PTS 04 - Arrival within 45 minutes before, to 15 minutes after, booked arrival time – Target 95%

Inbound on-time is an area where performance remains challenging. A significant performance improvement in January 2016, following implementation of actions identified in the ATSL Remedial Action Plan, has not been sustained in February or March. March’s report shows 82.6% of patients arriving with KPI timescales, with year-end at 84.3%. An exception report has been issued against this KPI as the required trajectory, agreed in response to the contract performance notice, has failed to achieve the worst case performance trajectory expected for the month of March and this followed a downturn in performance from February 2016.

PTS 05 - Where booked prior to the day of travel, patients not to wait more than 60 minutes for their (outbound) journey – Target 85%

The response timeframe for these is one hour from the time the patient is ‘made ready’. Analysis for March shows that 79.8% were achieved within the one hour compared to the target of 85%, with year-end reporting 82%. Performance for dialysis patients is significantly higher than for the full patient cohort, reflecting the routine nature of these journeys.

Performance improvement in January 2016, following implementation of actions identified in the ATSL Remedial Action Plan, has not been sustained in February or March. An exception report will be issued against this KPI if there is further deterioration in performance below the agreed worst case performance trajectory in coming months.

Clinical quality: The dashboard below provides a more complete position statement for clinical

Page 30 of 58

2.8.1

quality. Each of the amber and red rated indicators are reported on by exception in section 2.8.1 This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.

Thresh


0 Mar 1 ‐ 11 ‐

0 Mar 0 ‐ 1 ‐

157 Mar 10 157

37 Mar 1 40

0 Mar 89 200

0 Mar 0 2

n/a Q1 0 0

n/a Q1 0 0

n/a Sept 18,034 18,034

Mixed‐sexed accommodation breaches

Clinical quality PerformanceYTD

performance

Number of MRSA infections (Health Community)

Number of MRSA infections (GHNHSFT)

Number of C.diff infections (Health Community)

Number of C.diff infections (GHNHSFT)

Infection control

Mixed sex accommodation

Number of Never Events

Cardiology correspondence backlog

Radiology reporting delays

Outpatient follow‐up pending lists

Other quality indicators

Number of MRSA infections (Health Community) Year-end performance is 11 reported MRSA bacteraemia cases. As per the NHS England Post Infection Review guidance all of these cases were investigated by multi-disciplinary teams.

Number of total C. diff infections (Health Community)

The threshold for 2015/16 has decreased from 201 to 157 cases in line with NHS England guidance. Year-end performance is 157 cases against a threshold of 157. Breaches are reviewed by GCCG quality team.

Page 31 of 58

The targets for 2016/17 are to remain the same with 157 for the CCG, and 37 for GHFT. Mixed Sex Accommodation breaches During March, 19 breaches (affecting 89 patients) have been declared. 18 of the 19 breaches occurred in the Acute Care Units. This is an ongoing trend and may be related to the patient flow through the hospital and delivery of the 4 hour target in the Emergency Department. All breaches have been reviewed against the delivering same sex accommodation decision matrix agreed with the Trust and CCG. Early indication for April is an improved figure, with fewer breaches occurring. The trend continues to be breaches in Acute Care Units. The Trust have not reported any complaints due to mixing of bays, however, every breach is followed up by the infection control team to remind the clinicians of the importance of not mixing sexes and review if would have been possible to manage the beds in any other way. Fractured Neck of Femur Mortality GHFT Between November and December 2015, the NHFD performed a case mix adjusted analysis of 30-day mortality using externally validated data from the ONS and Northern Ireland. After case mix adjustment, four hospitals, which includes, GRH, were identified as ‘outliers’ – with 30-day mortality rates above the upper 99.8% (3SD) control limit. The crude mortality rate at Gloucestershire Royal Hospital has remained above the NHFD average for a number of years. Its adjusted mortality was 12.5% in 2014. The national average is 7.5%. Dr Foster report information to November 2015 indicates GHT NHS Foundation Trust level, HSMR- outlying diagnosis group - fracture of neck of femur (hip) as statistically significantly higher than expected relative risk: with the Gloucester Royal site as having a statistically significantly higher than expected relative risk. At CQRG in February we received the draft action plan from GHT including actions recommended following the FRCS visit. This will be monitored and reviewed at subsequent meetings, however, we remain concerned at the length of time the Trust has been indicating these mortality statistics.

Page 32 of 58

OOH

The SWAST Out of Hours Service commenced on 1st April 2015. The graph below shows the total number of weekly OOH contacts split by face to face and telephone; face to face contacts predominantly include Treatment Centre, Home Visit and ED/MIU Referral contacts. The peaks in activity coincide with bank holidays.

Excluding the bank holiday weeks, contacts remain consistent with the predicted rise in activty through the winter months.

The OOHs service has had a total of 10,241 contacts during March 2016 which is the highest number since the contract commenced. This is the first time that activity has been above the contract baseline by 6% although the Easter bank holiday is likely to have impacted on this figure. Performance in a number of KPIs remains underperforming and the CCG are working closely with SWASFT to ensure an improvement in performance across a number of critical areas. Actions include ongoing recruitment initiatives, including shift incentives and review of current rotas. SWAST are working closely with other urgent care providers to ensure where possible services are working in an integrated manner and that all available resources are being effectively utilised across the out of hours period. Work is also underway to review existing pathways for patients who access the OOHs service without contacting NHS111. This demand is increasing and SWASFT are eager to review ways in which this flow can be suitably prioritised and assessed.

The dashboard below provides performance data for a number of key quality indicators.

Page 33 of 58

Mar 16Year to Date Compliance

Requirement 10: (Walk in)

All immediately life threatening conditions to be passed to the ambulance service within 3 minutes following face to face clinical assessment in PCC

100% 100%

Requirement 10a: (Adult Walk in)

For urgent adult patients - % definitive face to face clinical assessments started within 20 minutes of arrival in PCC.

68.00% 72.19%

Requirement 10a: (Children Walk in)

Children, who are ill and have an urgent OOH need, will receive definitive clinical assessment within 15 minutes of arrival in PCC

31.58% 38.98%

Requirement 10b: (Walk in)

Definitive clinical assessment for less urgent cases presenting at PCC to start within 60 minutes 93.93% 94.49%

National Quality Requirements

Page 34 of 58


Emergency face to face consultations started within 1 hours of completion of the last telephony definitive clinical assessment

60.00% 75.86%

Urgent face to face consultations started within 2 hours of completion of the last telephony definitive clinical assessment

89.49% 93.26%

Less urgent face to face consultations started within 6 hours of completion of the last telephony definitive clinical assessment

98.20% 98.40%


50.00% 66.67%


77.21% 80.58%


98.39% 97.57%


75.00% 68.09%


79.39% 86.36%


87.94% 91.24%


20.00% 39.60%


73.30% 75.13%


90.38% 93.37%

National Quality Requirements

Requirement 12 (Presenting at PCC) - Priority

assigned on triage

Requirement 12 (Presenting at PCC) - Priority

following F2F PCC Assessment

Requirement 12 (Home Visit) -

Priority assigned on triage

Requirement 12 (Home Visit) -

Priority following F2F home visit

assessment

Page 35 of 58


LI1All calls to the OOH clinical service must be answered within 60 seconds

79.11% 79.66%

For calls prioritised as emergency: Timely calls backs within 1 hour of notification from the NHS 111 service where a call back is required

79.05% 92.16%

For calls prioritised as urgent: Timely calls backs within 2 hours of notification from the NHS 111 service where a call back is required

67.42% 82.19%

For calls prioritised as less urgent: Timely calls backs within 6 hours of notification from the NHS 111 service where a call back is required

62.93% 86.16%

LI5Qualified response to urgent paramedic requests for advice within 20 minutes of the request

59.87% 62.76%

LI8 Transfers to Emergency Departments 3.88% 3.69%

Local Quality Requirements

LI2

NHS 111

Target Calls % Calls %

Calls Offered 14111 96.80% 14111 96.80%

Weekday calls answered in 60 seconds >=95% 6285 90.73% 6285 90.73%

Weekend calls answered in 60 seconds >=95% 5404 80.31% 5404 80.31%

Total calls referred to ED <=6% 871 6.38% 871 6.38%

Total Ambulance Dispatched <=10% 1438 10.53% 1438 10.53%

Calls transferred to 111 Clinical Advisor 3121 22.85% 3121 22.85%

Calls warm transferred to Clinical Advisor >=98% 810 25.95% 810 25.95%

Call backs in 10 mins >=95% 1051 45.48% 1051 45.48%

YTD: 2016/17Apr‐16

NHS 111 has seen a significant increase in call volume during April 2016 which has exceeded predicted levels. The service has also noticed an increase in the total call handling time which has impacted upon capacity and demand modelling. NHS111 are working closely with staff to identify the possible cause but it is felt that this may correlate with the increase in activity that creates a reduction in staff productivity. NHS111 are reviewing the modelling assumptions into May to ensure learning from April is reflected within planning. Care UK report improvements in staff absence which has had a positive impact and have maintained the 999 Clinical Validation line throughout May. 12.

Page 36 of 58

2.9

Blended warm transfer (warm transfer plus call backs in 10 minutes) have seen a slight improvement.

Other Key Performance Issue: Outpatient follow-up pending list In line with new information sharing request set out in the contract agreement with Gloucestershire Hospitals NHS Foundation Trust (GHFT), detailed information regarding outpatient follow up pending lists is now being received, and will be progressed through the follow up plan in 16/17. The monthly updates are reviewed to ensure that progress against follow-up backlog clearance is on track. There are indications that the overall follow-up pending list has grown in recent month; however, the number of very long waits in excess of 1 year have reduced.

District Nursing In response to concerns initially raised by Primary Care, the CCG and GCS committed to jointly understand and address the specific concerns raised in relation to District Nursing and a joint action plan was subsequently developed .The joint CCG/GCS 2014-15 District Nurse action plan has been refreshed with a new plan developed for the next 18 months. The refreshed plan is aligned with the recently published NHSE commissioning framework for community nursing whilst recognising some of the challenges that are specific to Gloucestershire. A significant element of the 16/17 DN action plan to focus on the skills and behaviours required of the DN workforce and opportunities to develop the DN career structure with Gloucestershire. To support the development of the Community Nursing Service the CCG has recently agreed to release £500K to fund more nursing posts. Band 5 recruitment remains stable and has significantly improved since 18 months ago, and we are beginning to see improvement in the band 6 recruitment. In relation to HCA positions it should be noted that there are minimal vacancies and the HCA workforce remains stable. The change of shift pattern between the hours of 08:00-20:00 that took place in November 2015 was in part to create additional capacity for planned work to be undertaken during these hours and not rolled over to the overnight service. GCS have reviewed overnight DN activity and are moving towards having 3 district nurses on duty for the county overnight. The CCG have requested a timeline for this change.

Page 37 of 58

3.1 Patient Experience 3.1.1 Patient Experience – Period to 30th April 2016

PERSPECTIVE 2 Patient Experience Green

Success criteria 1: Patient safety is at the heart of the work of the CCG and is considered when planning service change and developments.

Green

Key performance indicators Outcomes measures for patient safety have been developed based on the CCG Outcome framework and sign up for safety initiative.

Green

Quality Impact Assessments are undertaken for all new proposed initiatives and service developments. This is considered by the QIPP assurance board before decisions are made to support new initiatives. Mitigation is planned where necessary to ensure patient safety.

Green

Success criteria 2: Reporting: Improve reporting of patient experience including FFT (Marion Andrews‐Evans)

Green

Key performance indicators All providers of NHS funded services commissioned by GCCG participating in patient

and staff FFT Green

All providers of NHS funded services commissioned by GCCG achieving at or above

national average in patient and staff FFT score Amber

All providers of NHS funded services commissioned by GCCG participating in

National Patient Survey Programme (2015/16) Green

All providers of NHS funded services commissioned by GCCG achieving at or above national average results in National Patient Survey Programme (2015/16)

Green

Success criteria 3: The CCG has a programme of case reviews in place across urgent care reporting into system resilience to influence service redesign including CPGs.

Green


CCG has a programme of case reviews across urgent care, which feed into System resilience / clinical programme groups as appropriate. Green

Focus on emergency admissions and discharge. Green

Success criteria 4: National targets‐PROMs Green

Key performance indicators All providers of NHS funded services commissioned by GCCG participating in PROMs (2015/16)

Green

All providers of NHS funded services commissioned by GCCG achieving at or above national average PROMs results (2015/16)

Green

Success criteria 5: All active Clinical Programme Groups are working with Green

Page 38 of 58

patients to ensure experience is incorporated into the programme and outcomes


All CPGs have regular ‘lay’ input Green

All CPGs receive and review patient experience data Green

Work to ensure PE is incorporated within QIPP schemes TBC

Success criteria 6: Develop patient experience work within primary care through working with PPGs to help inform and influence commissioning across the whole spectrum

Green


PPGs are informing countywide priorities and Locality developments Green

All GP practices in Gloucestershire have a PPG by 31 March 2015 Green

3.1.2

Success criteria 1: Patient safety is at the heart of the work of the CCG and is considered when planning service change and developments. The CCG has a strong focus on patient safety and this forms a standing item on the agenda of the Clinical Quality Review Groups. In addition the CCG is fully involved as an active member of the South West Patient Safety Collaborative. GCCG is a ‘Beacon CCG’ and was one of the first CCGs to commit to the ‘Sign up to Safety’ campaign. The campaign is now approaching its second birthday and is truly national, stretching across 360 organisations. GCCG’s support of this campaign is indicative of the high level of commitment the organisation places on improving harm free care and supporting staff in speaking up when things do go wrong. To further highlight the Sign up to Safety (SU2S) campaign and engage CCG member practices, a new section of CCG Live is currently being developed to bring safety resources together. This new section will link Sign up to Safety to other initiatives such as ‘Quality Alert’ and act as a repository for briefings from the Central Alerting System. It is being developed with the intention of being a single destination for safety information and resources and aims to launch on SU2S’s second birthday on 24th June. Quality Alert continues to develop and the new CCG Live page will aim to publish themes and trends and increase its profile further. Currently the themes from reported Alerts focus on discharge and delays. However, this is likely to be as a result of a past request for these types of alerts. As part of our ongoing work with the West of England Academic Health Science Network (AHSN), the CCG has identified an ‘innovator’ practice

Page 39 of 58

3.1.3

within to county to work with them on improving safety reporting and associated learning in Primary Care. The AHSN project is being developed across the whole of the West of England and aims to focus GPs and practice teams on the idea of increasing openness and transparency around patient safety, which will in turn improve the patient experience. Success Criteria 2: Improve reporting of patient experience including FFT The Friends and Family test no longer has a CQUIN attached and has become part of the national contract for all providers. The data included in this report has been taken from the NHSE FFT website. All FFT data (including current and historic acute and staff FFT data) can now be found at: https://www.england.nhs.uk/ourwork/pe/fft/friends-and-family-test-data/ It is very disappointing to note that the GHNHSFT FFT response rate in January 2016 for the Emergency Department has dropped further to 0.70% and the % recommend figure is also well below the national average. However, the response rate is so low that these results cannot be considered statistically valid. An Action Plan to address this, including the use of hospital volunteers to promote FFT in ED, has been presented to the Emergency Care Board, attended by the GCCG Senior Commissioning Manager: Urgent Care. 2GT recorded an improved % recommend rate taking them back up above the national average having dropped below the national average in the previous month. GCSNHST data remains stable. FFT response rates in primary care (GP) were disappointing in January 2016:

Number of responses: 0 – 187 % recommend: 67% – 100% % not recommend: 33% - 0% 24 practices submitted no data 18 practices reported <10 responses

In order to address this, the Primary Care Contracting Team has contacted practice managers to encourage them to promote the use of the FFT. In addition, GCCG took the opportunity to promote FFT in primary care to Patient Participation Groups (PPGs) at the Gloucestershire PPG Network at

Page 40 of 58

the beginning of April 2016. PPGs were encouraged to challenge their practices to maximise the use of FFT and to look for opportunities to ‘piggy back’ on the FFT to ask additional questions, thereby gathering more useful patient experience feedback.

3.1.4 Success criteria 3: Programme of case reviews

A programme of clinical case reviews has been developed to support the delivery of urgent/emergency care programme. Future case reviews will continue to inform the urgent care system of the increase in emergency admissions, however, rather than random selection of case studies the cases selected will be focussed on the following 4 themes.

Case reviews informed by intelligent data analysis of the areas where an increase in admissions is indicated

Case reviews informed by reviewing a % of risk stratification patients who have been admitted as an emergency admission

Cases identified by Emergency department clinicians, where feedback on pathway compliance would enhance patient experience

Cases identified by the Gloucestershire Urgent Care Clinical Governance Group

A summary of these reviews will be shared with the Strategic Resilience Group (SRG). This is in addition to a programme of work to review the management of discharge from hospital. This includes a focus on the quality of discharge information. These case studies are being undertaken with input from Governing Body GPs and localities and are being carried out in partnership with provider organisations. As a result of the case reviews information is being collated to improve compliance with unscheduled care pathways to improve patient experience.

Page 41 of 58

4.1 Partnerships

4.1.1 Partnerships – Period to 30th April 2016

PERSPECTIVE 3 Partnerships Green

Success criteria 1: Building effective partnership working by putting in place a joint planning and governance framework to improve outcomes for the Gloucestershire population

Amber

Key performance indicators Developing a plan for Gloucestershire, via Gloucestershire Strategic Forum, to identify the most appropriate service roadmap for Gloucestershire to take forward the five year forward view

Amber

GSF work plan – develop further and deliver with partners including GCC. GSF work plan to be attached as an appendix in January, update on one area of the programme each month.

Amber

Further develop and maintain system wide BCF forum encompassing all providers across health and social care, independent sector and voluntary sector and housing.

Green

Success criteria 2: Work with the voluntary sector alliance to take forward the work with the voluntary and community sector in Gloucestershire.

Green

Key performance indicators Roll out social prescribing and build on the existing evaluation to take forward learning

Green

Develop the “kitemark” for voluntary sector organisation Green Develop a cultural commissioning programme in conjunction with the New Economics Foundation, National Voluntary of Community Council’s and Arts Council England

Green

Build capacity in the voluntary sector (re work with VCS)

Green

Success criteria 3: Effective urgent care pathway to enable more patients to stay in their own home

Amber

Key performance indicators Effective relationships across adult social and health care to enable:

i) Reduce non-elective admissions which can be influenced by effective collaboration across the health and care system.

Green

Page 42 of 58

ii) Reducing inappropriate admissions of older people (65+) in to residential care

Green

iii) Rehabilitation / reablement, increase in effectiveness of these services whilst ensuring that those offered service does not decrease

Green

iv) Effective joint working of hospital services (acute, mental health and non-acute) and community-based care in facilitating timely and appropriate transfer from all hospitals for all adults.

Amber

v) To develop a system which measures patient experience of integration over time, allowing any improvements to be demonstrated.

Year-end assessment

vi) Enhancing quality of life for people with care and support needs. Year-end

assessment

4.1.2

4.1.3

Success criteria 1: Building effective partnership working by putting in place a joint planning and governance framework to improve outcome for the Gloucestershire population (Amber) A series of facilitated workshops for GSF (Gloucestershire Strategic Forum) members have been held, with more planned over the coming months to review the current service models and review against the objectives within the Five Year Forward View. Success criteria 2: Work with VCS to take forward the work of the voluntary & community sector organisations in Gloucestershire. Roll out social prescribing and build on the existing evaluation to take forward learning As a part of the CCG’s prevention and self-care agenda, we have worked with G.Doc and a range of voluntary and statutory partners to develop an innovative social prescribing model. Social prescribing is a structured way of linking patients with non-medical needs to sources of support within a community and of providing one to one support where this is needed. These opportunities may include: arts; creativity; physical activity; learning new skills; volunteering; mutual aid; befriending; and self-help, as well as support for a wide range of problems including: employment; benefits; housing; debt; legal advice; and parenting problems. This scheme is now fully operational across the county with social prescribing hub coordinators accepting referrals from all 81 GP Practices in the county and from staff in the county’s 21 Integrated community Teams (ICTs) and staff from community hospitals. As at 31st March there had been in excess of 1,700 referrals from across the county. The external evaluation by the University of the West of England (UWE) has commenced with a final report due in September 2016.

Page 43 of 58

The CCG will fund social prescribing for the year 2016/17 subject to evaluation. Develop the “kitemark” for voluntary sector organisations engaged in social prescribing The VCS Alliance has been instrumental in the development of a kitemark for social prescribing. To date 56 organisations have completed the questionnaire which seeks assurance in areas such as staff training and support, policies and procedures and insurance. A graphic for a kitemark for social prescribing is now in use. Develop a cultural commissioning programme To build on our work on social prescribing, Gloucestershire has also been working alongside the New Economics Foundation, National Voluntary of Community Council’s and Arts Council England to understand how arts and culture can be used to improve the health and wellbeing of our local population. During the summer, Arts and Cultural organisations from the VCSE were invited to apply for funding via the cultural commissioning grant programme. The aim of the grant programme is to test out opportunities for arts and culture interventions to support health and wellbeing outcomes for participants. The CCG received a total of 24 applications and awarded grants to six of the nine projects. Examples of successful applicants include singing for respiratory disease, mindfulness based art approach for chronic pain in men and a multi-art programme for young people exploring themes of social media; bullying; self-harm & violence in relationships. Clinical Programme Groups will be working alongside clinicians, lay members and the VCSE to co-develop appropriate and effective service models. This will provide the opportunity for commissioners and the public to ensure that the pilots are designed in a way that provides meaningful and measurable outcomes. The grant programme has been support by a number of partners including the VCS Alliance, Forest of Dean District Council, Gloucester City Council and Tewkesbury Borough Council. Create Gloucestershire (the county umbrella organisation for art and culture) have also supported the grant programme by developing capacity within the VCSE sector. This included supporting organisations with their applications and acting as a bridge between the sectors The national cultural commissioning programme formally finishes in April 2016. The CCG and partners (CREATE Gloucestershire, Gloucester City Council, Tewkesbury Borough Council and the Forest of Dean District Council) have been working alongside the New Economics Foundation (NEF) and the National Council for Voluntary Organisations (NCVO) to help disseminate the work which has been undertaken in Gloucestershire. This includes contributing to national reports and presenting at a number of conferences (including the All Party Parliamentary Group for Arts, Health

Page 44 of 58

4.1.4

and Wellbeing) The CCG recently re-advertised two grant projects focusing on how arts and culture opportunities may reduce barriers to engaging with weight loss programmes and how arts and culture could promote confidence and healthy lifestyles for people diagnosed with colorectal and prostate cancer. Bids received are currently being evaluated. Work is ongoing to co-develop and deliver the other 9 grant projects. Build capacity in the voluntary sector (re work with VCS) The CCG approved a draft framework and action plan which suggested ways in which we might work with, support and learn from the VCSE in future. We are on target in terms of the delivery of the action plan and led a conversation with partners on the areas covered by the framework during November. As part of our work on Enabling Active Communities (EAC), the aim is to have a joint framework with Gloucestershire County Council. The VCS Alliance will continue to support this piece of work. Gloucestershire Health and Wellbeing Board and Leadership Gloucestershire have ratified a policy outlining how they will work to enable local communities to become more active, stronger and more sustainable, and in turn improve the health and wellbeing of local people. The Health and Well Being Board aims to ensure that this activity is joined up and learning is shared from community to community across the county. Its Enabling Active Communities objectives are designed to build community appetite and capacity for neighbourhood-level working, through three separate strands: Using existing assets e.g. workforce, buildings and community hubs;

Building knowledge and resilience within individuals and communities and

ensuring effective provision of advice and information; Developing local solutions – working with communities to identify local needs

and how these might be better met using new or existing partnerships. Success criteria 3: Partnership working group established to review dashboard and set targets. As part of the Better Care Fund submission, Gloucestershire health and well-being board (H&WB) have committed to delivering a number of key indicators/ outcomes for the residents of Gloucestershire:

Page 45 of 58

Reduction in non-elective admissions (general and acute) Avoidance of hospital admissions helps to ensure the most effective management of social care requirements. Minimising delayed transfers of care and avoidable admissions transforms the quality of care of individuals, enabling service users to receive the most appropriate care in the most appropriate location. Within Gloucestershire we have seen 2.5% growth in non-elective admissions over the period January 2014 to December 2015. The 2.5% has been calculated using the defined BCF metrics (based on providers monthly activity returns MAR). The Gloucestershire BCF plans for reducing non-elective admissions are aligned with the Gloucestershire CCG and Gloucestershire Hospitals NHSFT plans for 2016/17. Gloucestershire CCG’s plan is for a 1.6% reduction in non-elective admissions. Within this assumption growth is 2.5%, while revised contract baseline and admission avoidance schemes are estimated to make a 4% reduction.

Reducing inappropriate admissions of older people (65+) into residential care This indicator is part of the Adult Social Care outcomes framework (ASCOF). The number of permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population.

Page 46 of 58

Gloucestershire plans to continue the trend in the reduction of service users entering residential and nursing care. The CCG forecast for 2015/16 is a 2% reduction on the 2014/15 baseline, which equates to a 17% reduction on the BCF baseline period.

Increase in the number of people at home 91 days post discharge This indicator is part of the ASCOF. Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into re-ablement / rehabilitation services. The proportion of people who were still at home 91 days after discharge increased by 4.6% during 2014/15, the plan is to improve to meet the south west average which represents a 4.1% increase by the end of 2016/17. Focus and prioritisation continue in this area to ensure we have robust preventative and crisis management services in the community, in particular effective re-ablement services that support people post-discharge and help them to achieve their full potential recovery.

Page 47 of 58

Reduction in Delayed Transfers of Care (DTOC) This indicator is based on the ASCOF Delayed transfers of care from hospital per 100,000 population metric. Gloucestershire performance on delayed transfers compares favourably to the England average. The figures reported at the end of the BCF period (Q3 2015/16) show an increase in the number of delayed transfers, the forecast for quarter 4 has been factored through an additional increase due to the pressures within the healthcare system.

Across 2016/17 we have shown a 5% reduction from the Quarter 4 positon across the year as this is an area of focus for our system. Improved Patient Experience This is a locally set metric based on the Gloucestershire Care Services Integrated Community Teams Rapid Response Experience Comment Card. The expectation is that this metric will assess the services ability to look at individual patient needs and improved health and social care outcomes. A baseline was recorded during quarter 4 of 2014/15, with the following question asked of ICT rapid response clients, 'How likely are you to recommend our service to friends and family if they needed similar care or treatment': 2014/15 baseline results: 131/133 clients (98.5%) provided a positive response (95 extremely likely and 36 likely)

Page 48 of 58

The latest results collated at the end of December 2015 indicate that from the 1st of April 98.93% of respondents have provided a positive response. The main question is supported by 6 further questions based on NHS voices:

1. I always knew who the main person in charge of my care was 2. I didn’t need to keep repeating how I was feeling and explain what I needed to

different people 3. I was involved in discussions and decisions about my care as much as I wanted

to be 4. Information was given to me when I wanted it 5. The information given to me was appropriate to my condition and circumstances 6. I feel the people I met were kind to me

The plan for 2016/17 is to increase the response rate from 14.6% during 2015/16 to 15% in 2016/17; this is in line with the national guidance on the Friends and Family test.

Page 49 of 58

Enhancing quality of life for people with care and support needs. Locally selected measure which is part of the ASCOF. The indicator is based on responses to 6 questions within the Adult Social Care Survey. Ambitions against the above indicators have been set by Gloucestershire Health and Well-Being Board. Health community QIPP schemes have been mapped to each of the relevant indicators to assess the impact and progress made against these ambitions. Results for the 2014/15 survey showed a 3.8% reduction in quality of life from the 2012/13 baseline. The plan for 2016/17 is to reach the England average by meeting the original BCF target of 7.9 (6.4% increase on 2014/15).

Carers Gloucestershire hosts the Gloucestershire Carers Alliance whose mission is to provide a strong, independent, diverse and inclusive carer-led and carer-centred group influencing policy and services to improve outcomes for all carers. Plans are in place to further develop relationships with the Alliance/Carers Gloucestershire to provide a route through which providers and commissioners of services can engage and hear views and feedback from carers. All of the ‘carers’ services’ contracts include satisfaction surveys and are showing a strong positive response, with an increase in the number of carer’s assessments undertaken and evidence of meeting the 6 week target from referral to assessment. In addition, each contract in turn will be subject to a carer peer group evaluation, which includes monitoring of contracts and interviews with carers.

Page 50 of 58

5.1 5.1.1

Staff Staff – Period to 30th April 2016

PERSPECTIVE 4 Staff Amber

Success criteria 1: Attracting and retaining high quality staff aligned to the CCGs vision and values

Green


Turnover - % of employees leaving the organisation 0.39%

Number of current Vacancies in structure 11

Success criteria 2: Personal development processes that are linked to the strategic plan

Due May 2016


All staff should have a PDP (90% target) and should have had an appraisal in the last 12 months

Figures available May 2016

95% of staff who have completed their mandatory training by the end of March 2016 – update from

Figures available May 2016

Success criteria 3: Staff are Happy and Motivated Amber


Staff sickness levels 1.87%

Staff Survey Completed

Completion of OD plan by 31st May 2016

5.1.2

Attracting and retaining high quality staff aligned to the CCGs vision and values Monthly turnover in April was 0.39%. The number of leavers since the 1st April is 1, giving a monthly average of 1 leaver per month. As at the end of April 2016, there were 11 jobs in the recruitment process.

Page 51 of 58

5.1.3 Personal development processes (PDP) that are linked to the strategic plan The CCG has commenced the collection of staff PDPs. Once collated a review against strategic objectives will take place.

5.1.4

Staff are Happy and Motivated Staff survey has taken place, and the results are being collated and will be reported on shortly. Staff sickness levels up to the 31st March have equated to 1.87% which is below the GCCG target of less than 3%.

Page 52 of 58

6.1 Perspective 2. Finance and Efficiency 6.1.1 Finance and efficiency – Period to 31st March 2016

Summary:

The CCG has delivered a surplus of £9.5m against an initial planned surplus of

£7.3m; Known risks and pressures have been fully assessed and included within the

CCG’s position. There was significant over performance in emergency activity against contracted

levels. There was slippage on QIPP schemes within the financial year. This is both in

terms of implementation and associated investments as well as in terms of benefit realisation.

A number of planned investments slipped due to difficulties in staff recruitment. The better payment practice code performance (for non-NHS invoices by

volume) is 97% which is in line with the targeted figure. The quality premium allocation of £533k has been included within running cost

budgets (as per national guidance), however expenditure has been incurred in programme budgets in ways that improve both the quality of care/health outcomes and reduce health inequalities as follows:

Success criteria: QIPP Full year Forecast

95%

QIPP ‐ full year forecast delivery to planned performance (%)

95% 75% Amber

Threshold Lower threshold RAG

Amber

Running costs forecast outturn (variance to running costs allocation) Within RCA Green

80% Green

Cash drawdown in line with planned profiles (%age variance) 2% 5% Green

BPPC performance on non‐NHS invoices by value (year to date)

Perspective 5 Finance & Efficiency Amber

Success criteria: To ensure a financially viable commissioning organisation with an

underlying recurrent surplus

2% 1% Amber

Surplus ‐ year to date variance to planned performance (%age) 0.10% 0.50% Green

Amber

Threshold Lower threshold RAG

Underlying recurrent surplus (%age)

Running costs year to date (variance to running costs allocation) Within RCA Green

Surplus ‐ full year variance to planned performance (%age) 0.10% 0.50% Green

Page 53 of 58

Description £’000Learning Diability Services 170Facts 4 Life 124Art on prescription 60Healthcare for children with complex needs 179

TOTAL 533

The overall assessment for the finance and efficiency perspective is amber for which more detail is provided in the following sections. However, this assessment should be read in conjunction with those risks outlined within paragraph 6.9.

6.2 Resources The CCG’s resource limit (see Appendix 2) is £811.4m. This includes all primary

care co-commissioning delegated budgets which now total £75.4m. There were no in-month adjustments.

6.3 Expenditure The financial summary as at 31st March 2016 reports a surplus of £9.5m, further

detail is shown at Appendix 3. There has been slippage in investments, particularly relating to QIPP and service redesign. These primarily relate to difficulties in recruitment of clinical staff due to shortages in a number of areas, these are national shortages. The CCG has reviewed non-recurrent investments which fit with the CCG’s strategic plans, particularly around workforce within providers and pump priming developments which are already planned for 2016/17 to bring forward a number of investments, including the prevention agenda. Key budget areas with either a financial risk or forecast outturn variance are highlighted below: Key

Indicates a favourable movement in the month

Indicates an adverse movement in the month

Trend

Forecast Over/

(Under) Spend £’000

Gloucestershire Hospitals NHS FT Discussions regarding the forecast outturn over performance have been ongoing at Executive Director level and have recently come to a conclusion. The overspend reflects the significant overperformance in emergency department and inpatient emergency activity during the year. The most significant increases in attendances and admissions were seen in adults of working age (18 – 64 years), there was also growth in attendances from other age ranges. Significant increases were also seen in a number of areas such as genitourinary, infectious conditions, respiratory and signs and symptoms. Outpatient and elective day cases

£13.5m

Page 54 of 58

and inpatient activity also overperformed, though to a lesser degree than emergency activity. The Trust cleared backlogs in a number of areas in the year including cataracts and gastrology totalling £2.5m. The other significant area of overperformance is in the use of excluded drugs, specifically Lucentis. The impact of contract performance in 2015/16 has been built into planning assumptions for 16/17. Winfield Hospital Elective and outpatient activity continued to under-perform against the contract. Elective activity is below plan by 543 spells (19.5%), predominantly in trauma, orthopaedics, spinal and pain management. Outpatient attendances are significantly below contracted levels by 1,296 (15.9%) again within trauma, orthopaedics, pain management and general surgery. There is 1 non admitted 52 week waiter in February in urology.

(£610k)

Oxford University Hospitals NHSFT The over performance has stabilised this month with a slight increase in activity from the previous month. Non Elective activity increases have been seen within trauma, orthopaedics and gynaecology for elective activity and general medicine, gastroenterology and obstetrics. There was a query raised regarding devices which has now been confirmed as a CCG patient however a SUS challenge regarding remains outstanding. A long stay patient has now been discharged.

£413k

North Bristol NHS Trust The issues with the new activity system continues and this could not be relied upon for a forecast position therefore month 7 (when the data was accurate) has been extrapolated to a full year. The contract as a whole is significantly underperforming within all areas in the specialities of T&O, pain management, hip, shoulder, foot and knee procedures.

(£1,010k)

Royal United Hospital Bath NHSFT There was a minimal adverse movement this month with overspends continuing within most contract areas. Elective activity, within the areas of T&O for reconstruction procedures without complications, major foot procedures for trauma with critical care and malignant lymphoma costs. Non-elective activity has over performed due to high activity during first part of the year which pushed activity above the full year plan.

£131k

Page 55 of 58

University Hospital Bristol NHSFT Day cases have increased activity for paediatric urology and T&O reconstruction. Overspends are also reported in emergency admissions for pancreatic necrosectomy, T&O and paediatrics ear, nose & throat. Cardiac ITU activity has increased for 3 & 4 supported organs due to costs previously being categorised as specialist. There is however an underspend in Non PbR local prices for elective inpatients in paediatric and cardiology specialties.

£176k

University Hospital Birmingham NHSFT Activity dropped again this month with underspends in no- elective hepatobiliary surgery which is being offset by over spends in day cases for endoscopic/radiology category 2 & 3 with complications & interventional radiology and non PbR in adult critical care.

£62k

South Warwickshire NHSFT The position continues to remain stable overall with underspends in elective activity for orthopaedics and cardiology and underspends against the contract position for non-elective activity within orthopaedics and care of the elderly.

(£115k)

Planned Care Nutricia –There has seen a slight adverse movement to the position due to additional activity.

£150k

Oxford Fertility – Underspends continue to be seen with no signs of the revised IVF policy impacting on the position.

(£337k)

Learning Difficulties The position worsened significantly this month. Income expectations have been revised downwards for the joint financing of a mental health patient. Also, the CCG were informed of a high cost patient costing in excess of £5,600 per month for the foreseeable future.

£444k

Page 56 of 58

Continuing Healthcare Activity continues to be volatile with an increase in expenditure on the previous month predominantly within adult fully funded. Numbers of claims relating to older people increased by 40 with the average package increasing in cost by 8% to £33,114. However this is still 11% lower than last financial year.

(£3,688k)

Prescribing When comparing February 2016 against February 2015, there has been a significant increase in growth of 5.58% for the month itself. This has had the effect of slightly increasing the YTD Growth to 5.74%. The forecast assumes no increase on growth for March.

The graph highlights the growth, month by month, compared

£4,833k

Page 57 of 58

to the same time last year and the year to date impact of these fluctuations. Running costs There has been a slight decrease in the underspend within corporate budgets; this is due to movements in a number of non pay lines including premises.

(£1,454k)

6.4 QIPP The CCG set a £17m QIPP target for 2015/16. Delivery against this plan has

reported as under-achieving by £2.9m. Additional programmes have been reviewed in year to mitigate any shortfall. Recognising that all forecasts have been based only on information available at the end of February, Appendix 4 reports the extent of QIPP performance against programme areas whilst Appendix 5 highlights scheme reports by exception.

6.5 Run Rate

The graph above highlights the expenditure relating to programme budgets for this and last financial year, compared to the resource available for programme excluding any reserves and the surplus. March is showing that programme is in excess of anticipated spend by £8m and cumulatively the CCG is above estimated spend for

Page 58 of 58

Programme by £11.8m – this has been offset by a reduction in the commitments in reserves (which have now come to fruition).

6.6 Cash (Appendix 6) By the end of March, the CCG has drawn down 100% of the total cash limit and the

cash balance at the end of March was £24k.

6.7 Better Payment Practice Code (Appendix 7) It is a national target that requires the CCG to pay 95% of non-NHS trade creditors

within 30 days of receipt of goods or a valid invoice. The final performance for the year stands at 97.32% invoices paid by value and 97.00% by volume; both being on target.

6.8 Statement of Financial Position This has been included within the 2015/16 annual accounts presented to the

meeting.

6.9 Financial Risk The following risks have been taken account of in the reported financial position:

Contract Performance Prescribing Better Care Fund performance QIPP slippage Continuing Healthcare Specialised Commissioning National position

Appendices: Ref Description 1 GCCG Dashboard 2015/16 2 Resource Limit Position 3 Summary Financial Position 4 QIPP Programme 5 QIPP scheme reports by exception 6 Cash 7 Better payment practice code

Target2014-15 Outturn

Apr-15 May-15Jun-15 /

Q1Jul-15 Aug-15

Sep-15 /Q2

Oct-15 Nov-15Dec-15 /

Q3Jan-16 Feb-16

Mar-16 /Q4

Year / Quarter to

date

Year End Forecast

Perf.Measured

DirectorResponsible

Manager

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

GRH 88.1% 89.4% 92.2% 93.7% 92.3% 82.2% 85.4% 83.3% 85.8% 79.1% 76.1% 69.0% 71.8% 83.3% 83.3%

CGH 93.3% 95.2% 95.8% 97.2% 96.2% 92.1% 94.9% 91.1% 92.3% 89.2% 87.3% 88.7% 87.6% 92.3% 92.3%

GHNHSFT total 90.0% 91.5% 93.5% 95.0% 93.7% 85.8% 89.0% 86.1% 88.1% 82.7% 80.1% 76.3% 77.5% 86.6% 86.6%

GCS - MIU 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.7% 99.5% 99.8% 99.7% 99.8% 99.9% 99.7% 99.8% 99.8%

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

GRH 0 0 1 0 0 0 0 0 0 1 2 0 1 5 5

CGH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

GHNHSFT total 0 0 1 0 0 0 0 0 0 1 2 0 1 5 5

GCS - MIU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0%

SWASFT 75.2% 79.0% 75.4% 75.3% 75.3% 76.2% 75.0% 76.9% 73.1% 75.3% 72.0% 66.0% 67.9% 73.7% 73.7%

Glos only 66.4% 72.7% 69.8% 64.9% 62.4% 60.0% 64.0% 76.2% 62.7% 68.8% 58.9% 55.1% 58.5% 64.4% 64.4%

Target 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0%

SWASFT 71.4% 68.3% 66.3% 65.9% 66.7% 69.0% 68.1% 69.4% 65.1% 63.9% 60.6% 54.5% 49.9% 63.6% 63.6%

Glos only 66.4% 64.8% 62.3% 65.2% 61.9% 63.8% 63.4% 68.4% 67.8% 67.1% 64.4% 56.3% 48.0% 62.5% 62.5%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

SWASFT 93.6% 92.7% 91.8% 91.1% 90.7% 91.7% 91.5% 91.8% 90.9% 90.3% 88.8% 83.9% 80.9% 89.4% 89.4%

Glos only 91.5% 90.2% 89.8% 89.7% 89.1% 90.3% 90.4% 90.1% 91.4% 90.8% 88.9% 85.4% 81.4% 88.8% 88.8%

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 1,038 51 85 50 37 88 70 66 66 82 92 118 197 1002 1002

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 141 4 10 4 3 14 11 6 2 20 5 18 13 110 110

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 1,201 142 159 179 188 181 188 176 152 187 182 181 233 2,148 2,148

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 105 13 20 12 16 14 26 8 13 22 9 9 30 192 192

GHNHSFT target 14 14 14 14 14 14 14 14 14 14 14 14 14 14

GHNHSFT actual 10.9 8 9 11 11 16 13 8 26 19 16 16 10 13.6 13.6

Local Reimbursable Days for Acute DTOCs (Attributable to Social Services) GHNHSFT 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

GCS target 10 10 10 10 10 10 10 10 10 10 10 10 10 10

GCS actual 2.3 3 3 5 2 2 5 8 3 5 3 2 4 3.8 3.8

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 90.0 97.6% 96.5% 95.9% 94.8% 96.7% 88.6% 91.6% 94.7% 94.4% 93.7% 89.4% 74.8% 92.4% 92%

Target 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%

Actual 2.6% 0.4% 0.6% 0.7% 1.0% 0.7% 2.1% 1.0% 0.7% 4.3% 1.0% 1.7% 5.9% 1.7% 2%

Target 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0%

Actual 79% 81.0% 82.2% 81.9% 82.1% 80.7% 82.0% 85.3% 87.5% 86.2% 84.7% 89.6% 84.8% 84.0% 84%

Target 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%

Actual 5.8% 5.1% 4.9% 6.0% 6.2% 5.9% 6.1% 6.8% 6.4% 6.2% 6.2% 6.4% 6.2% 6.0% 6%

Target 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0%

Actual 55.8% 41.3% 34.7% 38.3% 31.4% 38.7% 35.5% 41.5% 42.3% 48.1% 42.0% 34.0% 30.6% 38.2% 38%

Target 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00

Actual - 00:05:45 00:10:11 00:07:11 00:09:34 06:49:00 08:42:00 06:27:00 00:11:39 00:12:34 00:08:29 00:12:31 00:15:32 08:42:00 08:42:00

Target 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00

Actual - 00:16:24 00:30:09 00:06:45 01:03:06 08:14:00 08:42:00 07:21:00 01:29:48 00:13:49 00:16:45 08:10:00 00:07:29 08:42:00 08:42:00

Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

Actual 90.4% 88.6% 90.8% 90.1% 90.5% 89.2% 88.6% 89.7% 89.7%

Target 0 0 0 0 0 0

Actual - 6 2 6 8 3 3

Local Number of specialties where admitted standard was not delivered Actual - 8 7 7 8 8 7

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 95.4% 95.8% 95.6% 95.2% 95.8% 95.0% 94.2% 93.3% 92.9% 91.9% 91.3% 91.2% 92.2% 93.7% 93.7%

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual - 0 3 3 2 0 1 1 4 2 1 1 3 - -

Local Number of specialties where non-admitted standard was not delivered Actual - 6 4 4 6 7 8 10 11 14 14 13 14 - -

Local

Gloucestershire CCG 2015/16 Integrated Performance Scorecard

Number of completed non-admitted pathways greater than 52 weeks

Local % calls referred to ED

Local

Longest wait for a call back

Calls warm transferred

Mark Walkinshaw

Maria Metherall

E.B.S.5

E.B.15.iiCat A 8 min response - The percentage of Category A RED 2 incidents, which resulted in an emergency response arriving at the scene of the incident within 8 minutes.

Mark Walkinshaw

Maria Metherall

Ambulance handover delays - over 60 mins (GHNHSFT)

12 hour trolley waits (no A&E attender should wait more than 12 hours from the decicision to admit to admission)

Cat A 19 min response - The percentage of calls resulting in an ambulance arriving at the scene of the incident within 19 minutes.

C

C

Clear up delays of over 30 minutes

Ambulance

Clear up delays of over 1 hourE.B.S.8

E.B.S.7

E.B.S.7

C

C

Percentage of non - admitted pathways treated within 18 WeeksE.B.2

E.B.S.4

Number of completed admitted pathways greater than 52 weeks

C

C

E.B.1 Percentage of admitted pathways treated within 18 Weeks

Acute Care Referral to Treatment

Planned Care

Longest wait for an answerLocal

Local Calls abandoned after 30 seconds

E.B.15.iCat A 8 min response - The percentage of Category A RED 1 incidents, which resulted in an emergency response arriving at the scene of the incident within 8 minutes.

Delayed Transfers of Care (DTOC)

Ambulance handover delays - 30 to 60 mins (GHNHSFT)

E.B.S.8

CLocal Number of Delayed Transfers of Care for acute patients

E.B.16

Principal Delivery Targets

Unscheduled CareAccident & Emergency

4-hour A&E target - Percentage of A&E attendances where the patient spent 4 hours or less in A&E from arrival to transfer, admission or discharge

E.B.5 C

M

Harmoni 111

Local Calls answered within 60 seconds

M

E.B.S.4

Local Number of Delayed Transfers of Care for non-acute patients

Calls triaged

Local

Mark Walkinshaw

Annemarie Vicary

Maria Metherall

Ellen Rule

1



Q1Jul-15 Aug-15

Sep-15 /Q2


Q3Jan-16 Feb-16

Mar-16 /Q4

Year / Quarter to

date

Year End Forecast

Perf.Measured

DirectorResponsible

Manager



Target 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0%

Actual 92.0% 92.1% 92.2% 92.2% 92.1% 92.3% 92.3% 92.5% 92.4% 92.3% 92.5% 92.7% 92.5% 92.3% 92.3%

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual - 20 23 21 17 21 25 24 19 19 17 13 6 225 225

Local Number of specialties where incomplete standard was not delivered Actual - 8 8 9 8 8 6 7 5 9 8 9 9 - -

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual - 6 6 5 2 8 8 8 4 3 2 11 15 78 78

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual - 0 1 0 1 0 1 0 1 0 2

Target 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0%

Actual breaches 464 568 365 512 621 425 143 122 186 186 232 602 4,426 4,426

Actual Perf 5.0% 6.3% 3.9% 5.2% 6.6% 4.5% 1.5% 1.3% 2.0% 2.0% 2.4% 6.2% 3.9% 3.9%

Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93%

Actual breaches 1,290 137 81 131 180 150 87 79 107 171 192 108 249 1,672 1,672

Actual Perf 92.0% 90.3% 94.1% 90.8% 89.0% 89.7% 94.1% 94.7% 93.3% 89.9% 87.8% 93.2% 85.3% 90.9% 90.9%

Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93%

Actual breaches 287 14 4 10 25 17 17 19 10 11 13 12 7 159 159

Actual Perf 87.8% 93.9% 97.8% 95.3% 90.5% 92.3% 92.9% 91.0% 95.5% 94.6% 93.7% 94.3% 96.6% 93.9% 93.9%

Target 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96%

Actual breaches 25 2 3 4 0 1 1 0 0 1 0 0 2 14 14

Actual Perf 99.2% 99.2% 98.6% 98.5% 100.0% 99.6% 99.6% 100.0% 100.0% 99.6% 100.0% 100.0% 99.3% 99.6% 99.6%

Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94%

Actual breaches 21 3 2 3 0 0 1 1 0 0 2 0 1 13 13

Actual Perf 96.2% 94.5% 96.0% 93.5% 100.0% 100.0% 98.0% 98.7% 100.0% 100.0% 97.0% 100.0% 97.8% 98.1% 98.1%

Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98%

Actual breaches 0 0 0 0 0 0 0 0 0 0 0 0 0% 0 0

Actual Perf 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94%

Actual breaches 4 0 0 1 0 0 0 0 0 0 0 0 1% 1 1

Actual Perf 99.6% 100.0% 100.0% 98.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.1% 99.8% 99.8%

Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

Actual breaches 266 32 29 39 47 18 38 29 24 25 27 31 27% 339 339

Actual Perf 82.7% 73.6% 71.6% 71.7% 68.7% 85.9% 72.1% 79.3% 81.3% 79.5% 78.6% 73.9% 79.7% 76.3% 76.3%

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Actual breaches 18 0 1 0 1 1 2 0 2 1 4 0 0 12 12

Actual Perf 93.2% 100.0% 93.8% 100.0% 96.7% 92.3% 93.1% 100.0% 92.3% 96.9% 84.0% 100.0% 100.0% 96.1% 96.1%

Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

Actual breaches 3 1 -- 1 0 1 0 0 0 0 1 0 0 4 4

Actual Perf 93.5% 50.0% 50.0% 100.0% 83.3% 100.0% 100.0% 100.0% 100.0% 85.7% 100.0% 100.0% 93.5% 93.5%

Target 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

Glos 70.6% 82.6% 86.0% 70.5% 81.7% 88.0% 91.3% 95.6% 82.4% 81.8%

Target 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0%

Glos 52.3% 38.1% 58.7% 38.1% 35.4% 28.1% 25.6% 36.0% 25.0% 27.7%

Target 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7%

Glos 65.0% 64.5% 65.5% 66.4% 66.9% 68.2% 67.2% 67.1%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 97.9% 96.0% 99.0% 90.0% 85.0% 94.0% 97.0% 97.0% 98.0% 98.0% 85.0% 93.0% 91.5% 93.6% 93.6%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 99.4% 100.0% 100.0% 99.7% 99.8% 100.0% 99.8% 99.2% 98.0% 100.0% 100.0% 96.5% 94.2% 98.9% 98.9%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 97.7% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 97.3% 96.8% 98.9% 99.3% 99.3%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 91.5% 93.0% 91.0% 99.0% 96.0% 98.0% 98.0% 95.0% 94.0% 93.6% 94.5% 96.0% 92.5% 95.1% 95.1%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 90.3% 98.0% 99.0% 99.0% 98.0% 98.0% 98.0% 97.0% 98.0% 99.0% 98.3% 98.1% 99.2% 98.3% 98.3%

C

C

C

C

Percentage of patients who have waited more than 6 weeks for one of the 15 key diagnostic tests

Cancelled Operations

Local

Adult

E.B.S.2Cancelled operations - Number of patients who have had an operation cancelled, on or after the day of admission, for non-clinical reasons that have not been offered another binding date within 28 days

Percentage of patients referred to the Adult Speech and Language Therapy Service who are treated within 8 Weeks

LocalPercentage of patients referred to the Paediatric Speech and Language Therapy Service who are treated within 8 Weeks

E.B.13

E.B.14

Percentage of patients receiving subsequent treatment for cancer within 31 days where that treatment is a Radiotherapy Treatment

Percentage of patients referred to the Paediatric OccupationalTherapy Service who are treated within 8 Weeks

Local

E.B.6

E.B.4

Percentage of patients seen within 2 weeks of an urgent GP or GDP referral for suspected cancer

Percentage of patients receiving first definitive treatment for cancer within 62 days from an NHS Cancer screening service

Percentage of patients receiving first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status

Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer

Local

Percentage of patients referred to the Podiatry Service who are treated within 8 Weeks

LocalProportion of people at high risk of Stroke who experience a TIA are assessed and treated within 24 hours (GHT Only)

Local

Paediatric

E.B.8Percentage of patients receiving first definitive treatment within 31 days of a cancer diagnosis

E.B.12

Local

Long Term conditions

CPercentage of patients receiving subsequent treatment for cancer within 31 days where that treatment is an Anti-Cancer Drug Regime

E.B.9Percentage of patients receiving subsequent treatment for cancer within 31 days where that treatment is surgery

C

E.B.S.6

Urgent operations cancelled for a second time - number of urgent operations that are cancelled by the trust for non-clinical reasons, which have already been previously cancelled once for non-clinical reasons

E.B.10

E.B.S.4

E.B.11

C

CE.B.7Percentage of patients seen within 2 weeks of an urgent referral for breast symptoms where cancer is not initially suspected

Cancer Waits

Diagnostics

Percentage of incomplete Pathways that have waited less than 18 Weeks

E.B.3

Number of incomplete pathways greater than 52 weeks

Helen FordC

C

C

C

C

C

C Annemarie Vicary

C

C

C

Ellen Rule

Ellen Rule

Percentage of patients referred to the Paediatric Physiotherapy Service who are treated within 8 Weeks

C

Proportion of people who have had a stroke who spend at least 90% of their time in hospital on a stroke unit (GHT Only)

Dementia diagnosis rateE.A.S.1

Community Care Referral to Treatment (GLOUCESTERSHIRE only)

Annemarie Vicary

Ellen Rule

Debbie Clark

Helen Vaughan

Ellen Rule Annemarie Vicary

Annemarie Vicary

2



Q1Jul-15 Aug-15

Sep-15 /Q2


Q3Jan-16 Feb-16

Mar-16 /Q4

Year / Quarter to

date

Year End Forecast

Perf.Measured

DirectorResponsible

Manager



Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 99.8% 99.0% 86.0% 85.0% 85.0% 85.0% 83.0% 87.0% 85.0% 90.0% 82.0% 87.0% 90.0% 87.0% 87.0%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 96.9% 99.0% 93.0% 91.0% 92.0% 94.0% 92.0% 86.0% 92.0% 94.6% 93.7% 92.6% 95.1% 92.9% 92.9%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 99.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 98.0% 100.0% 100.0% 100.0% 96.0% 100.0% 96.0% 95.0% 96.0% 97.0% 97.3% 97.6% 100.0% 97.9% 97.9%

Target 95% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Glos 97.7% 98.0% 96.5% 96.4% 97.6% 97.1% 97.1%

Glos target 3.75% 7.5% 11.25% 15.0% 15.0% 15.0%

Glos actual 16.9% 4.4% 7.6% 12.1% 16.8% 16.8% 16.8%

Glos target 50.0% 50.0% 50.0% 50.0% 50.0% 50.0%

Glos actual 48.1% 43.0% 31.0% 25.0% 48.0% 34.0% 34.0%

Glos target 50.0% 52.7% 57.0% 75.1% 75.1% 75.1%

Glos actual - 89.0% 90.0% 81.0% 84.0% 87.0% 87.0%

Glos target 60.0% 63.0% 72.0% 95.1% 95.1% 95.1%

Glos actual - 99.0% 99.0% 99.0% 98.0% 99.0% 99.0%

GHT 0 0 0 0 0 0 0 37 0 30 50 0 87 204 204

Care Services 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2gether 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

GHT 3 0 0 0 1 0 0 0 0 1 0 0 0 2 2

Care Services 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1

2gether 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

SWAST 0 - - - - - - - - - - - - - -

Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

GHNHSFT 94.3% 93.9% 95.4% 94.9% 94.4% 94.4% 95.1% 94.5% 93.0% 93.6% 94.1% 93.2% 94.2% 94.2%

GCS 96.7% 97.8% 96.5% 90.2% 90.6% 84.4% 76.1% 65.9% 77.3% 84.7% 95.2% 98.5% 87.8% 87.8%

Glos HC target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Glos HC actual 11 2 1 0 0 1 0 2 1 1 0 3 1 12 12

GHNHSFT target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

GHNHSFT actual 10 0 0 0 0 0 0 0 1 1 0 0 0 2 2

Glos HC target 162 15 12 12 16 16 8 12 10 9 16 16 15 157 157

Glos HC actual 153 15 14 16 10 11 15 11 13 7 17 18 10 157 157

GHNHSFT target 52 3 3 3 4 4 2 3 2 2 4 3 4 37 37

GHNHSFT actual 37 4 4 0 4 4 2 3 4 2 6 6 1 40 40

E.H.1_B1The proportion of people that wait 6 weeks or less from referral to their 1st IAPT treatment appointment against the no. of people who enter treatment in the reporting period.

C

Methicillin Resistant Staphylococcus Aureus (MRSA)

Mental Health and Learning DisabilitiesAdults of Working Age

C

C

E.A.S.5 Number of total C Diff infections (Health Community)

C

Eliminate mixed-sexed accommodation breaches at all providers sites

The proportion of people that wait 18 weeks or less from referral to their 1st IAPT treatment appointment against the no. of people who enter treatment in the reporting period.

Number of post 48 hours MRSA infections post 48 hours (Acute Trust)

Cleanliness and HCAIs

Quality

E.B.S.1

Quality Indicators

C

E.A.S.4 Number of MRSA infections (Health Community)

Number of post 48 hour C Diff infections (Acute Trust)

Clostridium Difficile (C.Diff)

C

E.H.1_B2

C

Number of Never Events

Percentage of all adult inpatients who have had a VTE risk assessment

Improving Access to Psychological Therapies (IAPT)

Percentage of patients referred to the Diabetic Nursing Service who are treated within 8 Weeks

E.A.S.2

E.B.S.3Proportion of those patients on a Care Programme Approach (CPA) discharged from inpatient care who are followed up within 7 days

LocalPercentage of patients referred to the Parkinson Nursing Service who are treated within 8 Weeks

Percentage of patients referred to the Adult Physiotherapy Service who are treated within 8 Weeks

Local

LocalPercentage of patients referred to the Adult Occupational Therapy Service who are treated within 8 Weeks

Local

Eddie O'Neill

C

C

Kay Haughton

C

C

Marion Andrews-Evans

Mark Walkinshaw

C

Mark Walkinshaw

C

C

Specialist Nurses


Teresa Middleton


Kay Haughton

Debbie Clark

Debbie Clark


Teresa Middleton

Kay Haughton


Eddie O'Neill

E.A.3The proportion of people who have depression and/or anxiety disorders who receive psychological therapies

The proportion of people who complete therapy who are moving towards recovery

3

Appendix 2

Cash

R NR TOTAL Limit

AS AT Month 12 2015/16 £000 £000 £000 £000

2015/16 baseline excl growth 678,642 678,642 678,642

Growth 28,774 28,774 28,774

B/f surplus 8,494 8,494 8,494

BCF 11,596 11,596 11,596

ETO Funding 2,300 2,300 2,300

Co -Commissioning 76,802 76,802 76,802

GPIT 1,622 1,622 1,622

Risk Share Agreement 1,430 1,430 1,430

Planned Surplus (7,300)

MCD Adjustment (2,492)

Capital Cash Allocation 200

Waiting List validation/improving operational processes 22 22 22

Eating Disorders and Planning in 15/16 319 319 319

Transfer To Specialist Commissioining (35) (35) (35)

Transfer to Specialist Commissioining 505 505 505

BCF Support 30 30 30

Liaison Psychiatry - Mental health 140 140 140

UEC Network 60 60 60

CAMHS Transformational Funding 798 798 798

MoD - Out of hours 13 13 13

Liaison Psychiatry 140 140 140

14-15 Quality Premium award 533 533 533

Capital Grant: - shared care information 750 750 750

Capital Grant: - Equipment provided by LA to enable

discharge from hospital 3000 3,000 3,000

2015-16 CEOV and non-rechargeable services allocation adjustment (513) (513) (513)

Agreed change in 15/6 PC allocation to £75,440k (1,362) (1,362) (1,362)

M11 allocation transfer with SC (2,606) (2,606) (2,606)

Last month total 795,814 15,640 811,454 801,862

Adjustments in month

Adjustments actioned in month

TOTAL NATIONALLY REPORTED LIMIT 795,814 15,640 811,454 801,862

NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUP

Current Assumed Resource Limit Position as at 31st March (Month 12)

2015/16

Appendix 3

Full year position

Budget Actual (Under)/Over

spend

£000 £000 £000

Acute servicesAcute contracts -NHS (includes Ambulance services) 356,325 349,114 (7,211)

Acute contracts - Other providers 9,687 15,977 6,290

Acute - NCAs 7,467 7,185 (281)

Pass-through payments

Sub-total Acute services 373,479 372,276 (1,202)

Mental Health Services

MH contracts - NHS 76,181 76,412 231

MH contracts - Other providers 4,697 5,245 549

Sub-total MH services 80,878 81,657 779

Community Health Services

CH Contracts - NHS 91,248 91,148 (100)

CH Contracts - Other providers (5,684) (5,393) 291

CH - Other

Sub-total Community services 85,564 85,755 191

Continuing Care Services

Continuing Care Services (All Care Groups) 22,575 21,689 (886)

Local Authority / Joint Services 4,010 2,347 (1,663)

Free Nursing Care 9,515 8,376 (1,139)

Sub-total Continuing Care services 36,100 32,412 (3,688)

Primary Care services

Prescribing 91,686 96,519 4,833

Co-Commissioning and Enhanced services 75,440 75,430 (10)

Other 17,987 18,160 173

Sub-total Primary Care services 185,113 190,109 4,996

Other Programme services

Re-ablement funding

Other 24,668 25,122 454

Sub-total Other Programme services 24,668 25,122 454

Total - Commissioned services 785,801 787,332 1,530

Specific Commissioning Reserves 4,285 2,053 (2,232)

(Inc headroom and Contingency)

Total - Programme Costs (excl Surplus) 790,087 789,385 (702)

Running Costs (incl reserves) 13,534 12,613 (921)

Quality Premium 533 (533)

Total - Admin Costs (excl Surplus) 14,067 12,613 (1,454)

Surplus 7,300 (7,300)

Total Application of Funds 811,454 801,998 (9,456)


Summary Financial Position

Overall financial position as at 31st March 2016 (Month 12)

Appendix 4

Theme

Planned

Gross

Savings

2015/16

£'000

Forecast

£'000

Variance

£'000

Theme

RAG

Savings

RAG

Recurrent

/ Trend

RAG

Urgent Care 7,433 4,670 (2,762) A A A

Planned Care 2,910 3,264 354 A A A

Community 1,200 600 (600) A A A

Prescribing 4,070 3,694 (376) A A A

Transactional 1,430 1,930 500 G G G

Unidentified 0 0 0

Grand Total 17,043 14,158 (2,884)

Additional Schemes 0 n/a n/a n/a

Additional QIPP / Slippage /

Contingent resources / Application

of QIPP rule

2,884 2,884

Grand Total 17,043 17,043 0

QIPP Programme 2015/16


Appendix 5

Project Integrated Community Teams (ICT)

Project Older People’s Assessment Liaison (OPAL)

Project Integrated Discharge Team (IDT)

Project Ambulatory Emergency Care (AEC)

Project Urgent Care Respiratory Pathways

Project Mental Health Liaison

Project Community Hospitals (Investment in relation to Medworxx)

GM expecting revised trajectory from Information on 11th March.

Draft Abdo pain pathway presented to ECB. Patients will flow from ED to AEC with potential for urgent outpatient appointment the following day where

appropriate. To be signed off. Start date TBC.

The respiratory CPG has a new Programme manager (Kelly Matthews). This is a major priority for the CCG and it has been decided that the programme

requires a refresh, with key stakeholders to create a vision for the next 5 years and identify the transformational change required. The refresh will be

following the Clinical Programme Approach.

Ongoing development includes extending access to Liaison function to cover 10pm to 8am which is now in place via enhanced Crisis service and reduce age

criteria to 12+ (this will initially be via CYPS clinicians 8am – 10pm).

Ongoing development of tri-partite agreement of outcome reporting structure (GCCG / GHT / 2G).

Closely aligned to Crisis Care Concordat implementation & re-commissioning Crisis response service.

Medworxx has not been implemented by GCS. TPP and Medworxx have agreed on the data feed and are working on GAP analysis.

The report provides information on all 2015/16 QIPP schemes

Urgent Care Schemes

The total number of Patients seen, treated and discharged from Rapid Response on a weekly basis covering the period 30/08/2015 – 06/03/2016 was 1301

Patients (Target was 1500 for this period). The average number of Patients seen, treated and discharged from Rapid Response on a weekly basis was

52.04% (Target 60) covering the period 30/08/2015 -06/03/2016.

The ‘Rapid Response – Preventing Hospital Admissions’ sub group regularly meets on a weekly basis (The group comprises CCG & Rapid Response

representatives -chaired by GCCG). To date the group has met on six occasions (29/01/16 -10th March 2016).

Scheme continues to record greater activity at Gloucester Royal Hospital (GRH) compared to Cheltenham General Hospital (CGH). CGH service availability

reduced due consultant resignation and difficulties with recruitment. Interviews 11th March for replacement consultant post.

7 day service implemented at GRH with support from on-call medicine consultants. GHFT organising a meeting with Specialty Nurses and Geriatricians to

discuss re-modelling. Interdependent with Community Geriatrician Posts development.

A revised escalation process has been agreed and implemented within IDT to ensure that where patients have remained on the Medically stable list longer

than the agreed time period that clear escalation processes are in place. This is to link with the complex patient panel. Case reviews are also being brought

to the IDT programme Board to help with the escalation and learning.

The CCH is commissioning an independent review of the IDT model and its operations. This will be reopened to SDG. Full delivery of the IDT QIPP 16/17 is

assumed for both GCS and GHFT contracts.

Project Signposting

Project Single Point of Clinical Access (SPCA)

Project Diabetes Enhanced Service

Project Respiratory Pathways

Project Follow Ups

Project Irritable Bowel Syndrome (IBS)

Project Cancer (Living with and Beyond)

Project Dermatology

Currently MIIU attendances across Gloucestershire are up on this period last year by 3.5% YTD. Recent work with NHS111 to reduce 999 dispositions has

seen an increase in ED dispositions as patients are being offered this option as an alternative to an emergency ambulance. It must however be recognised

that these patients are likely to have resulted in ED conveyance. Nil financial outlay to date to support this QIPP.

Planned Care Schemes

Diabetes CPG agreed to review and refresh the LES for 16/17. Senior Commissioning Manager, CCG GP lead and Clinical Lead will meet to discuss further

and processes for monitoring performance and will then bring any proposals back to the CPG for approval.

The Respiratory CPG is a major priority moving into 16/17. With a new programme manager in place the programme will undergo a refresh, with key

stakeholders, playing an important role in the re-design of the system as part of the five year view.

A meeting has taken place with the GHFT scheme leads, who have confirmed that no further actions are planned in year for this scheme. GHFT believe that

the actions taken to date – use of open follow ups and stratified approach to follow ups are working (particularly the open follow ups).

Data on the uptake of open follow ups does support that GHFT suggestion that this approach is having the desired effect, although it must be noted that

there are some issues the quality of this data. Paediatrics have been using this approach for the longest, and issued 462 open follow ups in the first 6

months of the year, the majority of which have not been taken up by the patient. This suggests that the actions taken may be resulting in a number of

‘avoided’ follow ups, but this is not translating into an overall reduction in follow up activity.

A proposal has been developed for the CCGs approach to follow up reduction in 2016/17 for internal discussion.

Faecal Calprotectin test is now available on the ICE system for GPs to request. The full IBS pathway has now also been published on G-Care, and publicised

through ‘What’s New This Week’, providing clear guidance for GPs on the management of IBS. A new referral form has been published on G-care for the

Refractory IBS clinic at GHFT. This scheme starts from February 2016 and there has been some uptake. Although delayed implementation means that the

scheme is not delivering against the QIPP target, which assumed benefit realisation from October 2015. A follow-up meeting with GHFT will take place

shortly.

Work has taken place to model the impact on Consultant Gastroenterology appointments.

Holistic Needs Assessments (HNA) now being done in all 3 cancer site clinics and feedback/evaluation being collated by project manager, however

workforce planning now required to enable implementation. Numbers of completed HNA and Care Plans are still very low.

March 16 project plan and delivery to be developed and agreed with GCS.

Areas of focus include:

• Systems and processes

• Training development of service and team

• Information and performance

• Collaboration and partnership working.

Diversion rate for Feb 16 is 33%

Intermediate tier Contract Variation Order awaiting sign off. New service should be embedded in new GHNHSFT contract. Old GHAC Dermatology service

to be removed. Savings starting to be delivered - evaluation to be carried out April 2016.

Awaiting board decision on Dermoscopy.

Project Community Hospital Programmes

Project Rehabilitation Pathways

Project Continuing Health Care (CHC)

Project Complex Leg Wound Service (CLWS)

Project Centralised Continence Supplies

Community Schemes

Centralised procurement will not progress. NHSE have advised against this approach. This proposal is being taken forward as part of the CCG

commissioning of GCS to become the main provider in the redesign and provision of the wider continence care pathway across the community in

Gloucestershire. A GCS project development group has been set up to lead on this, which Mark Gregory is currently attending whilst it is in the care

pathway development stage.

The CSCP Project Team has taken over the active work streams that were formerly managed by The Transforming Community Hospitals Group (TCHG) which

is no longer operational.

Financial activity modelling is now complete and has confirmed there will be no cost savings in the short term. However better outcomes for patients may

lead to savings over a number of years.

A series of Steering Group meetings have been arranged and the project lead will be attending the Cardio-Vascular Clinical Programme Group to provide an

overview of the project, gain views and set out next steps.

Date of 1 April 2016 has been set for the switch over to Care Track for GCC staff. This will be used for invoicing and setting up rate cards for all new

packages of care.

Scheme name changed heading from ‘Leg Ulcers’ to Complex Leg Wound Service (CLWS).

Now in implementation phase. Cheltenham and South Cotswold localities 'went-live’ 30th November 2015.

Stroud and Berkley Vale locality is on target to go-live in March 2016 dependent on remedial building work being completed on time. Contract variation has

gone for executive sign-off and will form part of the 2015/16 contract.

Prescribing Schemes

Actual/Forecast Charges in Month

Drawn Prescribing Home Oxygen

Advance

Drugs

Payments

co

Commissioning

CHC inc Risk

pool

contribution

Capital

Allocation

TOTAL

MONTH

TOTAL

YTD

CASH

LIMIT

1/12ths

CASH AT

MONTH

END

% CASH LIMIT

DRAWDOWN

Bal/Cash

Limit

Month Status £000 £000 £000 £000 £000 £000 £000 £000 % %April Act 70,000 6,364 82 80 6,244 82,770 82,770 66,822 1,460 10.35% 0.18%May Act 50,000 7,149 89 (107) 9,169 66,300 149,070 133,644 2,429 18.65% 0.30%June Act 51,000 6,887 91 93 6,385 1,154 65,610 214,680 200,466 1,133 26.86% 0.14%July Act 60,000 6,756 87 (36) 6,232 73,039 287,719 267,287 3,735 36.00% 0.47%

August Act 46,000 7,147 91 19 6,122 59,379 347,098 334,109 802 43.42% 0.10%September Act 49,000 7,392 90 (272) 6,075 62,285 409,383 400,931 6,747 51.22% 0.84%

October Act 55,000 6,652 89 278 5,657 67,676 477,059 467,753 211 59.68% 0.03%November Act 53,000 7,317 92 (15) 5,606 66,000 543,059 534,575 5,561 67.94% 0.69%December Act 45,500 7,250 89 10 1,054 53,903 596,962 601,397 5,172 74.68% 0.64%

January Act 56,000 7,022 93 (51) 5,679 68,743 665,705 668,218 914 83.28% 0.11%February Act 51,000 7,781 89 (79) 5,563 64,354 730,059 735,040 254 91.33% 0.03%

March Act 55,837 6,717 83 305 6,327 69,269 799,328 801,862 23 100.00% 0.00%

Overview of current position

At the end of March £799.3m had been drawn down which was £2.5m under the maximum cash limit available of £801.9m. The CCG had a cash balance in the bank of £23k at 31st March.

Appendix 6

NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUPCash Performance Indicators

As at 31st March 2016 (Month 12)

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

be

r

Oct

ob

er

No

vem

be

r

De

cem

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

£'0

00

Proportion of Cash Limit Utilised Actual and Forecast

Cash used YTD

Cash Limit

Appendix 7


Performance against better payment practice code

Reported Performance (£)

As at 31st March 2016 (Month 12)

In Month Year to DateNHS Non NHS NHS Non NHS

By volumeTotal number of invoices 349 803 3,578 7,791Number paid within target 344 782 3,526 7,557Performance 98.57% 97.38% 98.55% 97.00%

By valueTotal value of invoices (£'M) 43.79 8.10 484.16 49.24Value paid within target (£'M) 43.68 7.83 482.77 47.92Performance 99.76% 96.64% 99.71% 97.32%

The target performance level is 95%

70%

75%

80%

85%

90%

95%

100%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

%age Performance by value

NHS Non-NHS Target Performance

70%

75%

80%

85%

90%

95%

100%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

%age Performance by volume

NHS Non NHS Target Performance

Page 1 of 6

Agenda Item 13

Governing Body

Meeting Date Thursday 26th May 2016

Title 2016-17 CCG Annual Budget - Update

Executive Summary This paper provides an update to the budget approved by the Governing Body in March 2016. Careful financial control and monitoring will need to be maintained during 2016/17 in order to deliver the planned system changes, to ensure that the planned surplus of £9.456m is achieved and also to ensure that the CCG has a recurrently balanced financial position.

Key Issues

Contracts with the CCG’s main providers have been agreed and are in the process of being signed and the impact has been included in the CCG’s budgets. The CCG’s savings requirement totals £18m; plans have been developed for schemes and have been risk rated.

Risk Issues: Original Risk

The key risk within the plan is the non-achievement of the planned surplus through:

In-year contract overperformance Under delivery of savings plans An increased trend for continuing health

care cases Primary care expenditure exceeding the

budget set

3 x 4 = 12

Financial Impact The CCG has a statutory duty to achieve financial balance. The CCG is planning for a surplus of £9.456m

Page 2 of 6


Not Applicable.


Not Applicable.


There are no direct health and equality implications contained within this report. Impact on health inequalities is contained within detailed programmes for the year.


The are no direct sustainability implications contained within this report


Not applicable

Recommendation The Governing Body is asked to: approve the revised budgets and note the

risks inherent within the plan.

Author & Designation Andrew Beard, Deputy Chief Finance Officer



Page 3 of 6

Agenda Item 13

Gloucestershire CCG - 2016/17 Budget Update

1. Introduction 1.1 This paper presents an update to the report approved at the

March Governing Body on the 2016/17 budget

2. 2016/17 Budgets 2.1 2.2

Updated budgets for the CCG are shown in Appendix 1. These budgets show a revised planned surplus of £9.456m for the year and are presented after allocating planned QIPP savings to the relevant budget line(as highlighted in Appendix 2). Although the majority of contracts have been agreed, further budget changes will need to be made to reflect changes in out of county agreements and the final timing of investment decisions. Such budget changes and amendments will be reflected in the budgets, and future finance reports to the Governing Body.

2.3 Savings plans and risk sharing against delivery of savings plans

have been allocated across headings within the plan and these are currently the subject of discussions with providers. There remains some further outstanding work to finalise some of the detail around schemes.

3. Resources 3.1

The CCG’s initial allocation for 2016/17 is £831.9m which represents:

programme funding of £730.3m delegated Primary Care allocations of £78.5m running costs of £13.6m returned 2015/16 surplus of £9.5m

3.2 It should be noted that since the March paper, the returned

Page 4 of 6

surplus has increased in line with that reported within the 2015/16 Annual Accounts. However, it is worth reiterating that this has not given the CCG any further flexibility as the target surplus for 2016/17 has also increased accordingly. Consequently, although the surplus is in excess of the 1% national requirement, NHSE have advised that the CCG will not have access to drawdown funding in 2016/17.

3.3 It is anticipated that there will be a recurrent transfer of resources

during the year for the following items:

To NHS England reflecting the planned transfer for some specialist services (such as adult morbid obesity) to NHS England.

From the Welsh Assembly Government (via NHS England) for the healthcare of Gloucestershire residents registered with Welsh GP practices. The anticipated allocation should be in line with the amount per head of population that the CCG currently receives.

3.4 Both instances are assumed to have a neutral financial impact on

the CCG during the year. 4. Expenditure Budgets 4.1 The CCG is planning to spend £808.8m on commissioning health

and wellbeing services in 2016/17 including primary care; accounting for over 98% of our expenditure as a clinical commissioning group.

4.2 Key changes to the budget since March are:

Alignment with confirmed and proposed contract values; particularly Gloucestershire Hospitals NHS FT

Proposed investments being included within agreed contracts where appropriate

Detailed budget review following reporting of March 2016 expenditure

Agreed impact of QIPP plans (see Appendix 3)

Page 5 of 6

4.3 Expenditure budget associated with allocation transfers for cross border specialist commissioning transfers are not yet included. Work is underway to establish the expenditure budgets required for these areas.

4.4 Primary Care Budgets 4.4.1 The indicative allocation for Gloucestershire’s delegated primary

care budgets under the co-commissioning initiative is £78.5m. This funding is fully committed and the budget proposals have been reviewed by the CCG’s Primary Care Commissioning Committee.

5. Risk Management 5.1 To enable the management of risks during the year and in line

with national guidance, a contingency reserve has been built into the CCG’s budgets in line with national guidance.

5.2 Key risks and mitigating actions are shown in Appendix 4. 6. Capital 6.1 The CCG has bid for capital funding of £1.5m to cover:

Primary care technical refreshes and network infrastructure

(£1,073k) CCG network infrastructure (£190k) Practice minor improvements (£242k)

6.2 Additional bids mill be made against centrally held capital funds

for Transforming Care Partnerships (LD) and the Primary Care Infrastructure Fund.

7. Recommendation 7.1

The Governing Body is asked to: approve the revised budgets and note the risks inherent

within the plan.

Page 6 of 6

8. Appendices:

Appendix 1 – 2016/17 Budget proposals Appendix 2 – 2016/17 Allocation of QIPP Appendix 3 – 2016/17 Savings Plans Appendix 4 – Risk Management

APPENDIX 1

Admin/Prog (net

of QIPP)

Primary Care Co-

Commissioning TOTAL CCG

Changes

since

original

£'000 £'000 £'000 £'000

Resources

Programme Allocation 730,316 730,316 135

Primary Care Co-Commissioning 78,523 78,523

Running Costs Allocation 13,563 13,563

2015/16 Surplus returned 9,456 9,456 2,156

753,335 78,523 831,858 2,291

Expenditure

Programme

Acute 368,978 368,978 4,669

Community 86,088 86,088 1,195

Mental Health 82,893 82,893 1,094

Primary Care 116,120 77,345 193,465 2,445

CHC 31,254 31,254 79

Other 23,416 23,416 532

Reserves Headroom 7,303 785 8,088 (231)

Contingency 3,768 393 4,161 2

Other, specific reserves 10,496 10,496 (9,439)

Corporate (Running Costs) 13,563 13,563

Total Expenditure 743,879 78,523 822,402 346

SURPLUS 9,456 9,456 1,945

Gloucestershire CCG

2016/17 Budget

APPENDIX 2

Gross Budget

Excl QIPP

QIPP Applied

to Budgets

Net

Expenditure

Changes

since

original

£000 £000 £000 £'000

Programme

Acute 382,154 (13,176) 368,978 4,669

Community 86,088 86,088 1,195

Mental Health 82,893 82,893 1,094

119,986 (3,866) 116,120 2,445

CHC 32,254 (1,000) 31,254 79

Other 23,416 23,416 532

Reserves Headroom 7,303 7,303 231-

Contingency 3,768 3,768 2 Other, specific

reserves 10,496 10,496 9,439-

Corporate 13,563 13,563 -

Total Expenditure 761,921 (18,042) 743,879 346

Primary Care including

prescribing

Gloucestershire CCG

2016/17 Application of QIPP (Programme Budgets only)

APPENDIX 3

CALC

2

Scheme Description Category

2016/17 In the

baseline / BAU

£'000

2016/17

Remaining opp re

15/16 £'000

2016/17 New

Savings £'000

2016/17 Total

£'000

ICT - Rapid ResponseExisting

Scheme Urgent Care 1,538 1,407 1,407

ICT - HIS / Case management - step up

functionality

2nd Stage of

ICT Urgent Care 1,320 1,320

OPALExisting

Scheme Urgent Care 1,200

IDT (Discharge Team)Existing

Scheme Urgent Care 500 500

AEC Existing

Scheme Urgent Care 783 717 1,500

Respiratory Pathways

New Scheme Urgent Care 300 300

Choice + - Primary Care (prime ministers

challenge) - ED AttendancePilot Urgent Care 168 168

Social prescribing

Pilot Urgent Care 75 75

PC in ED (PAU element) 2nd Stage Urgent Care 22 94 94

PC in ED (PAU element) -NON PaediatricExisting

Scheme Urgent Care 88 270 270

MH - Liaison Existing

Scheme Urgent Care 5 135 135

Highly Sensitive Troponin TestingNew Scheme Urgent Care 136 136

Falls and Bone Health

New Scheme Urgent Care 232 232

Elective demand management (Enhanced Pathway

compliance)New Scheme Planned Care 512 512

Follow ups - Other areasNew Scheme Planned Care 250 3,547 3,797

Diabetes ESExisting

Scheme Planned Care 263 263

Respiratory PathwaysNew Scheme Planned Care 100 100

Ophthalmology - Commissioning Policy for Eyes

New Scheme Planned Care 400 400

Ophthalmology PathwayNew Scheme Planned Care 134 134

MSK New Pathway - OutpatientsNew Scheme Planned Care 92 92

IFRExisting

Scheme Planned Care 980 500 500

IBSExisting


Cancer New model (including Living with and

beyond cancer) New Scheme Planned Care 56 200 200

Dermatology tariff changeExisting


Dermatology pathwayNew Scheme Planned Care 125 125

CHCNew Scheme Community 500 1,000 1,000

Leg Ulcers New Scheme Community 50 50

Primary Care Prescribing New Scheme Prescribing 3,500 3,500 3,500

Home OxygenExisting

Scheme Prescribing 12

Centralised Continence SuppliesNew Scheme Prescribing 69 69

Care Homes pharmacist medication reviewsExisting

Scheme Prescribing 24 366 366

Secondary Care Partnership - Biosimilars - CCG

50%New Scheme Prescribing 318 318

Secondary Care Partnership (specials / homecare)Existing

Scheme Prescribing 52 170 170Total #REF! 4,668 13,374 18,042

Gloucestershire CCG

2016/17 Savings Plans

2016/17 SAVINGS PROGRAMME

APPENDIX 4

Risk Mitigating Action

Further changes to the CCG's allocation as a result of transfers between

commissioning organisations may not be cost neutral

Work with the Area Team, local providers and the Health Board to ensure that

adjustments are cost neutral and transacted on the correct basis.

Assumed allocations may not materialise Ongoing liaison with NHSE and other relevant parties to ensure that all issues are

known together with a phased approach to the release of expenditure commitments

to mitigate the risk of a reduced allocation.Expenditure on Primary Care Co-commissioning may not be contained

within the budget due to pressures within primary care and also external

pressures such as NHS PS charging

Close monitoring and forecasting to enable early warning of financial issues arising.

Regular contact with NHSE and other relevant parties.

Non achievement of the required level of savings through slippage in

implementation or benefits not being realised as anticipated:

Close review of resources allocated to each project to ensure sufficient to ensure

robust implementation and delivery, enhanced monitoring of the project to ensure

timely warning of slippage or benefit realisation differing to the forecast project.

Development of robust exit strategies for projects to ensure that these can be

stopped at short notice if they do not deliver against agreed objectives

Overperformance on acute contracts Strengthening the contract management & monitoring processes.

Plans to improve practice engagement to ensure that pathways followed are the most

appropriate for the presenting condition.Potential loss of control over service priorities or cost changes where the

CCG is an associate commissioner to a contract

Establish stronger working relationships with other commissioners to ensure early

warning of pressures within other contracts

Increased growth in prescribing Monthly enhanced monitoring in place. Prescribing working group set up to

implement savings plans.Increases in continuing health care and placements Monthly monitoring of trends. Joint plan to manage process improvement in year.

Costs of nationally approved NICE developments in excess of that

provided for (both in cost and take-up)

Increased profile of NICE horizon scanning and close liaison with contract

management.

Population growth above planning assumptions Continuing work to benchmark services to identify areas to review to ensure value for

money from all services

Gloucestershire CCG

Mitigating Actions Covering all risks:

Non release of development funds unless key to delivering service change or contactually committed, until planned financial targets are forecast to be delivered

with a reasonable degree of confidence.

Utilisation of contingency and activity reserves

Increased financial management awareness throughout the organisation and member practices

2016/17 Risk Management

Page 1 of 9

Agenda Item 14

Governing Body



Title Sustainability and Transformation Plan (STP) Update

Executive Summary This paper provides an update on the progress towards developing the STP for Gloucestershire.

Key Issues

To note the progress so far towards the development of the STP for Gloucestershire towards the June 30th submission.


• political risks associated with strategic change;

• capacity - to deliver change at scale and pace alongside business as usual;

• financial risk – challenge of maintaining financial balance vs allocations positions and transition; and

• engagement risk - ensuring that all stakeholders are engaged and involved through a very challenging planning timeline.

Financial Impact The STP sets out a system wide resources plan for Gloucestershire for the next five years.


The STP will include a commitment to ensure compliance with NHS Constitution Standards and meet the requirements set out in the national planning frameworks.


The STP will include a clear commitment to reduce health inequalities.


The STP includes a commitment to ensure equality and value diversity and, therefore, there will be a net positive impact as a result of developing and implementing the plan.


The STP will support sustainable development.


Patients and the public are involved in developing the STP through the work done on Joining Up Your Care. Patient and public representatives are engaged through the

Page 2 of 9

stakeholder events planned as we develop the STP.

Recommendation The Governing Body is requested to:

note the key requirements of the national planning guidance relevant to the STP; and

note the progress made towards the development of the STP.

Author Ellen Rule Designation Director of Transformation and Service

Redesign Sponsoring Director (if not author)

As above

Page 3 of 9

Agenda Item 14

Governing Body


Sustainability and Transformation Plan Update

1 Introduction

1.1 The national planning guidance from NHS England tasks local systems to develop a shared system level strategic plan to set out how local systems will deliver the Five Year Forward View; the Sustainability and Transformation (STP) plan. Gloucestershire is working to a local footprint for the STP. Our system submitted an outline plan as required by the 15th April and has been assessed as being a 'low risk' system.

2 Our Population Context

2.1 2.2

Our STP will be clearly grounded in the characteristics of our local footprint, seeking to improve health and wellbeing by delivering joined up care for all people in Gloucestershire. The Gloucestershire STP footprint covers an area of 2,653 km2comprising one upper tier and six lower tier local authority areas with a projected 2016 resident population of 618,2001 and a registered population of 635,481 across 82 GP Practices and seven GP Localities. The Gloucestershire footprint has 71% of its population concentrated in the urban areas of mainly Gloucester and Cheltenham, while 29% are spread across the remaining rural areas. Though the population is characterised by a comparatively small Black and Minority Ethnic population (4.6% versus national 14.6%), it is becoming increasingly diverse with over 51.4% increase in ‘Other White Other’ population from 2001 to 2011. Deprivation is lower than average, and is spread in pockets across the county.

1 ONS 2012‐based sub‐national population projections

Page 4 of 9

2.3 2.4

Fig 1: Our Footprint Characteristics:

Gloucestershire has an age structure that is older than England with the population of people aged 75 to 84 years set to increase by almost 20% by the end of the STP in 2020/21. The number of people aged 85 and over is however set to see the fastest growth in the longer term. Gloucestershire does relatively well compared to the national average on many health outcomes and indicators. The health of people in Gloucestershire is generally better than the England average with life expectancy at birth being higher than the England averages for both genders. However, healthy life expectancy at birth for males has over the past couple of years been on the downward trend since 2010/12, and is now similar to the England average, rather than better. Life expectancy at 65 years though still better than the England average for both genders seem not to be improving in line with the national experience, especially for females. The major causes of death in our

Page 5 of 9

2.5 2.6

community are cancer, cardiovascular problems and respiratory problems. Fig 2: Our Population Profile:

Our ageing population, changing patterns of disease (more people living with multiple long-term conditions) and rising public and patient expectations mean that fundamental changes are required to the way in which care is delivered in our county. We will support our vision to deliver joined up care with a radical shift to more fully involve individuals in their own health and care. This will include making shared decision-making a reality by intensively training our clinicians to work in a new way with people they care for, giving people the support and information they need for effective self-management and involving their families and carers to support them in making the changes needed to keep healthy. Evidence is clear that most people want to be more involved in their own health, and that when they are, decisions are better, health and health outcomes improve, and resources are allocated more efficiently. To deliver change we will build on our existing collaborations between the NHS, local government, the third sector, employers and others – evidenced in our delivery of social prescribing across our county as a partnership between all of these partners and our new initiatives to tackle workplace health with our local LEP being developed for

Page 6 of 9

delivery in 2016/17. 3 Our Programme Priorities 3.1 3.2

The Gloucestershire STP builds on the strategic commitments set out in our joint strategy: Joining Up Your Care and responds to the three gaps in the Five Year Forward View. Our shared transformation work programme will set clear ambitions for radical improvement informed by national and local benchmarking, to ensure we have a sustainable health and care system for Gloucestershire – for now and for the future. Our STP work programme priorities are local priorities identified from the outcomes framework, NHS right care, our population health priorities and a range of other local and national data sources. We have prioritised two key pilots to deliver in the first half of 2016/17 – our system wide Respiratory programme and our 30,000 population integrated model. These work programmes represent a significant scaling up of ambition, as well as building on our track record of successful delivery Fig 3: A Summary of our STP Priorities:

Page 7 of 9

4 Leadership and Governance

4.1 4.2

4.3 4.4 4.5

We have a long and positive history of working together in Gloucestershire through our joint strategic forum. Building on this, our system has agreed a collaborative leadership approach for our STP, with system leaders taking ownership of key STP work programmes on behalf of partners across Gloucestershire. Each STP footprint is required to identify a formal lead; Mary Hutton (GCCG Accountable Officer) has been nominated as the Gloucestershire STP footprint lead. The main partners in our Gloucestershire STP are: Gloucestershire Clinical Commissioning Group Gloucestershire Hospitals Foundation Trust Gloucestershire Care Services 2gether Partnership Foundation Trust Gloucestershire County Council South West Ambulance Foundation Trust Primary Care in Gloucestershire In addition to the governance architecture supporting the STP, our Health and Wellbeing Board will take a key role in supporting the prevention and self care strategy and the Enabling Active Communities STP programme. Clinicians are active participants in all of our STP working groups. To support our programme we are developing a health community wide organisational development approach including skills in health coaching and behaviour change for clinicians, and developing a system wide quality academy for Gloucestershire. Our Governance Structure for our STP Programme is set out in the diagram on the next page:

Page 8 of 9

Fig 4: Our STP Governance Structure:

5 Engagement and Involvement

5.1 5.2

Our shared system vision for our Health and Care Community, Joining Up Your Care, was built from extensive community and staff engagement. Where relevant, our delivery groups for the STP will include lay, Healthwatch and / or patient representation and where any change is planned we undertake extensive patient engagement to support the development of new ways of working. A communication and engagement strategy and plan is in development to support the STP approach, to ensure comprehensive and planned engagement and communication with interested parties throughout the life time of the programme. The purpose of the strategy and plan will be to: ensure the Communication and Engagement work programme is

Page 9 of 9

integrated into the Governance and overall STP programme structure (shared milestones/timelines);

ensure robust and sustainable communication arrangements are in place so that all identified audiences are kept up to date with progress (development of the plan and implementation);

ensure the approach to Communication and Engagement is system wide – emphasising system wide ownership – both constituent organisations and Communication and Engagement leads;

ensure that stakeholder groups are communicated with in the right way and in a timely manner e.g. staff and community partners are aware of developments before other external audiences; and

ensure communication and engagement activity, materials and messages are relevant to each target audience. ensure that the STP programme engages with all interested

stakeholders – including the seldom heard ensure that key stakeholders know how they can have their say

and influence the work of the programme demonstrate and inform stakeholders of the impact that their

feedback has made.

6 Timetable

6.1 The national planning guidance sets out a forward calendar of key dates. The key dates for the board to note are as follows: Timetable Date

Submission of full STPs End June 2016

Assessment and Review of STPs End July 2016

7 Recommendations

7.1 The Governing Body is requested to:

note the key requirements of the national planning guidance relevant to the STP; and

note the progress made towards the development of the Gloucestershire STP.

Page 1 of 4

Agenda Item 15

Governing Body



Title Assurance Framework 2015/16

Executive Summary The attached final update of the Assurance Framework for 2015/16 provides details of the assurances provided to the Governing Body regarding the achievement of the CCG’s objectives. The Assurance Framework identifies gaps in assurances and controls regarding the objectives along with details of the principal high-level risks that have been identified by lead managers. The paper also outlines progress on the proposed refinements to the format of the Assurance Framework.

Key Issues

A number of risks have been identified which could adversely affect achievement of the objectives. Action plans have, however, been devised and are being implemented to minimise the effect of these risks.


The absence of a fit for purpose Assurance Framework could result in gaps in control or assurances not being identified and addressed. 8 (2x4) 4 (1x4)

Financial Impact Not applicable Legal Issues (including NHS Constitution)

Not applicable

Page 2 of 4


None


None


None


Not applicable

Recommendation The Governing Body is requested to note this paper and the attached Assurance Framework.

Author Alan Potter

Designation Associate Director of Corporate Governance



Page 3 of 4

Governing Body


Assurance Framework 2015/16

1. Introduction 1.1 The Assurance Framework provides the Governing Body with a

structure and process that enables the organisation to: focus on those high-level risks that could compromise

achievement of the organisational objectives; map out the key controls in place to manage the objectives; identify the assurances that will be received by the Governing

Body regarding the effectiveness of those controls. 1.2 The Assurance Framework is also a key source of evidence for

the Annual Governance Statement. 1.3 The primary benefit of the Assurance Framework is that it

provides a structure for individuals within the CCG to consider and plan for the achievement of the organisation’s objectives in a proactive manner.

2. The Assurance Framework 2.1 The Assurance Framework is based upon the six summary

objectives outlined in the 2 Year Plan for 2014/16. 2.2 The document outlines the principal high-level risks, control

systems and assurances provided to the Governing Body regarding the achievement of each summary objective. Details of the action plans to address the risks, gaps in controls or gaps in assurance are also provided.

Agenda Item 15

Page 4 of 4

2.3 Progress regarding the achievement of each objective is monitored separately through the performance management process.

2.4 This version of the Assurance Framework was considered at the

March 2016 meeting of the Integrated Governance and Quality Committee (IGQC). Further updates of the document will be provided to future meetings of both the IGQC and the Governing Body.

2.5 A revised Assurance Framework is being prepared to reflect the

2016/17 Strategic Objectives and will be presented to the July meeting of the Governing Body.

3. Recommendation 3.1 The Governing Body is invited to note this paper and the

attached Assurance Framework. 4. Appendix

Appendix 1: Assurance Framework

Gloucestershire Clinical Commissioning Group ‐ Assurance Framework 2015/16 Appendix 1

Actions / Status

Risk ID Principal Risks to achieving strategic

objectives

Risk Owner(s) Original

Risk

Ratings

(LxC)

Current

Risk

Ratings

(LxC)

Key Controls Gaps in

Controls

Sources of Assurance Gaps in Assurances Actions

L2 Risk to the quality, resilience and sustainability

of Primary Care due to GP practices running at

maximum capacity and certain practices not

being financially viable.

Increasing examples in 2015/16 of practices

becoming unsustainable, with this likely to

continue through 2016.

Furthermore ‐ NHS Property Services are

notifying practices occupying health centres of

significant increases in facility costs in 2016/17.

Helen Goodey 12 (3x4) 12 (3x4) Practice visits by Executive Team

and CCG Lead GPs; Senior Locality

Manager attendance at Locality

Executive meetings; Implementation

of Countywide Practice Manager

Representative Group; Exercising

Delegated Commissioning

Responsibilities; close working with

member practices.

Primary Care

Commissioning

Committee, Primary

Care Operational

Group, Risk and

Issues log.

Ongoing monitoring, appointments made within Senior Management of Primary Care

team, Investment to support unplanned admissions DES to practices, new ways of

working pilots, funding identified to support Primary Care initiatives. Event held 5th

November 2015 to commence discussions with member practices, now events

happening across localities on future of primary care.

T13

(was

Q3)

Risk around the specialised services for

children and young people with mental health

problems due to specialised commissioning

transferring to NHS England leading to

fragmentation of pathways.

Simon

Bilous/Adele

Jones

12 (3x4) 16 (4x4) Monitoring service provision with

local providers and feedback to Area

Team. Issue raised in CQC review

report.

Assurance from Area

Team

NHS England in process of procuring extra bed capacity nationally. But some cases are

still not being found appropriate provision in a timely way which can have an impact on

local systems with inappropriate admissions to GRH or Wotton Lawn.

Opportunities for co‐commissioning with NHS England are being explored.

Local work ongoing includes changing the service arrangements for crisis support and

psychiatric liaison including extending the age range to include u18s and u16s

respectively as part of overall Children's Mental Health Transformation Plan; and

developing additional options for care and support of young people in need of

accommodating in a crisis (Safe Places / Place of Safety).

Q4 Risk of failure to capture and ensure outcomes

from patient, carer and public feedback and

quality governance systems to inform

commissioning and contracting arrangements

which may result in failure to maintain and

improve the quality of services.

Marion Andrews‐

Evans, Mark

Walkingshaw,

Becky Parish

9 (3x3) 6 (2x3) Communications and Engagement

Strategy, 4Cs Policy and Procedure,

Provider Clinical Quality Review

Groups, HSOSC, Healthwatch

Gloucestershire (HWG) comments.

Commissioning for

Quality Report,

Outcome of

Engagement/Consulta

tion Reports, CPGs

and other programme

groups

Commissioning for Quality Report, Outcome of Engagement/Consultation Reports, CPGs

and other programme groups.

Risk Controls Assurances

Objective 1: Develop strong, high quality, clinically effective and innovative services.

Objective 2: Work with patients, carers and the public to inform decision making.

Objective 3: Transform services to meet the future needs of the population, through the most effective use of resources; ensuring the reduction of harm, waste and variation.

Page 1


Actions / Status


objectives


Risk

Ratings

(LxC)

Current

Risk

Ratings

(LxC)


Controls



C5 (Discharge) Risk that the number of medically

stable patients remaining in hospital exceeds

agreed target.

Maria Metherall 16 (4x4) 12 (3x4) GSRG, 7 day services countywide

group, ORCP schemes mitigated by

fortnightly delivery calls and clear

KPIs and milestones.

Performance Reports

and dashboards,

critical milestones

reviewed, regular

programme

stocktake.

SRG 4‐hour recovery plan reviewed and consolidated with focus on admission

avoidance and system‐wide flow. Monitoring and review to be undertaken through the

SRG.

C6 (Acute Care) Non‐delivery of the Constitution

standard for maximum wait of 4 hours within

the Emergency Department.

Maria Metherall 12 (3x4) 16 (4x4) GSRG, Weekly GHT, ECB, 7 day

service project board and steering

group. ORCP schemes mitigated by

fortnightly delivery calls and clear

KPIs and milestones.

Performance Reports

to Governing Body,

weekly situation

report, project status

updates.

SRG 4‐hour recovery plan reviewed and consolidated with focus on admission

avoidance and system‐wide flow. Monitoring and review to be undertaken through the

SRG.

C15 Failure to comply with national and local

access targets for planned care; including 2ww,

over 52ww, 62 day cancer target, diagnostic 6‐

week target, planned follow‐ups could result in

inadequate and/or delayed care.

Annemarie

Vicary

12 (3x4) 12 (3x4) Acute provider contracts, including

AQP.

Performance Reports

to Governing Body

Number of targets

not being met,

insufficient capacity

in planned care.

Insufficient planned care capacity to meet demand could result in increasing waiting

lists and inability to meet waiting time targets, impacting on the quality of local health

services.

A number of targets regularly not being met, including 62 day cancer target, 6 week

wait for diagnostics, and a small number of 52 week wait breaches have been reported.

Change fortnightly calls to weekly from October to monitor plans and trajectories.

Monthly access and performance meeting arranged to discuss progress. Recovery

action plans in place in a number of areas. Monthly communications being sent to GPs

regarding waiting times across providers to encourage informed choice. Waiting times

have been included on G‐Care as part of the referral process. Some patient transfers

underway for long waiters, although this is primarily in General Surgery and Urology.

Robust financial plan aligned to

commissioning strategy.

Budgets approved by

the Governing Body.

Monthly reporting to

CCG Governing Body.

Ongoing work to ensure financial commitments are affordable and CCG is achieving a

recurrent balance (at least quarterly). Work on 5 year financial plan underway

including growth estimates.

Robust contract management and

activity monitoring and validation

(particularly at GHFT)

Monthly performance

dashboard for larger

contracts with robust

out of county

contract monitoring

reflected within

performance reports.

Monthly performance meeting which reviews all contracts (including out of county)

together with Contract Boards and Finance & Information Groups for larger contracts.

Financial procedure being refreshed. Internal audit plan in

place and internal

audit reports and

recommendations to

be reported to Audit

Committee.

Procedures have been reviewed.

F11 ‐

F16

Failure to deliver financial targets. Cath Leech 12 (3x4) 12 (3x4)

Page 2


Actions / Status


objectives


Risk

Ratings

(LxC)

Current

Risk

Ratings

(LxC)


Controls



C26 There is a risk that the scale, complexity and

unavoidable time constraints associated with

the implementation of the agreed service

model for strengthened health and social care

integrated community teams across

Gloucestershire means that the financial

savings target allocated to this programme as

part of 2013/14 Annual Operation Plan and

prior to the completion of the case for change

and return of investment are not realised

along with the service objectives (given the

significant change in the model of service

delivery required).

Phil Jones 12 (3x4) 12 (3x4) ICT Programme Group, QIPP Board

Reports, GCCG Board Reports

Report to IGQC and

Governing Body

Implementation of

integrated case

management and

model; Delivery of

HIS functionality as

part of day to day

service. Finalised

financial model.

Impact of current DN

working on

programme

development.

Throughput of Rapid

Response cases.

There is a detailed action plan for improving the operational performance and rate of

patient referrals for Rapid Response e.g. the average number of Patients being seen,

treated and discharged from Rapid Response on a weekly basis was 52.04% (Target 60)

covering the period 30/08/2015 ‐06/03/2016. The Rapid Response referral activity

continues to be closely monitored and scrutinised by (i) ICT Performance & Delivery

Group (monthly meetings) & (ii) Rapid Response sub group entitled ‘Preventing Hospital

Admissions’ (weekly meetings) (iii) ICT Briefing sessions with ICT Programme Sponsor

(fortnightly meetings). At these meetings Rapid Response data generated via the clinical

data codes agreed is evaluated in detail together with (i) performance data relating to

the ‘System Wide’ KPI’s aligned to ICTs teams and (ii) the outcome of planned patient

case reviews. IT access issues relating to the new ICT Patient Case Review webpage

have been escalated and CSCSU have agreed to (i) transfer the webpage from CSCSU to

the GCCG network (ii) resolve specific access issues for GPs who are designated to

undertake the patient case reviews. The draft ICT Service Specification has been agreed

in principle with GCS. The associated schedules for this specification have been drafted

e.g. the first draft of an Occupational Therapy, Physiotherapy and Community Nursing

schedule have been produced and are currently being considered by GCS.

F8 Insufficient capacity and/or capability within

the CSU as a result of the proposed merger

could adversely affect the organisation's ability

to adequately support the CCG during the

transitional period.

Cath Leech 12 (3x4) 8 (2x4) Contract/service level agreement

signed between the CCG and CSU

specifying the services to be

delivered.

Monthly meetings

between the CCG and

the CSU to review

service delivery. CCG

service leads meet

with their

counterparts in the

CSU to review more

detailed aspects of

delivery.

Most services are now being provided in‐house and the remaining CSU services are

subject to a tender (lead provider framework) with any new arrangement being

implemented in 2017/18 at the earliest

A1 Failure to build positive relationships with the

local health community and other

commissioners could impact on joined‐up

service delivery and transformation.

Mary Hutton,

Andy Seymour

12 (3x4) 8 (2x4) Joint Commissioning posts, Joint

Commissioning Boards and

Executives in place between the

CCG and the Local Authority. System

vision agreed and Joining Up Your

Care implementation with key

members of the healthcare

community established. GSF

programme of work established to

deliver on system vision.

Performance reports Risk to partner

engagement due to

austerity measures

Continued engagement with all partners.

Objective 4: Build a sustainable and effective organisation, with robust governance arrangements throughout the organisation and localities.

Objective 5: Work together with our partners to develop and deliver ill health prevention and care strategies designed to improved the lives of patients, their families and carers.

Page 3


Actions / Status


objectives


Risk

Ratings

(LxC)

Current

Risk

Ratings

(LxC)


Controls



A2 Failure to build positive relationships with key

stakeholders (HCOSC, HWG) could impact on

implementation of service delivery and

transformation.

Mary Hutton,

Andy Seymour,

Becky Parish,

Anthony

Dallimore

12 (3x4) 8 (2x4) Attend HCOSC meetings. NHS

Reference Group 'No surprises'

discussions. Attend HWG Meetings.

Timely written briefing of

stakeholders. Joint Health and Well

Being Strategy agreed. Membership

of Health and Well Being Board.

C4Q reports,

Outcome of

Engagement/Consulta

tion reports, Written

stakeholder briefings

as part of integrated

communication plans

Communications and Engagement Strategy now approved. BCF being produced for

16/17. JCPE and JCPB continue to provide oversight. Health and Wellbeing Boards plans

established.

A3 Failure to build positive relationships with local

media could impact on the ability of the CCG

to promote engagement opportunities.

Anthony

Dallimore, Andy

Seymour, Mary

Hutton

12 (3x4) 8 (2x4) CCG Communication and

Engagement Strategy. Regular

meetings with editors. 'No Surprises'

briefing on key announcements.

Sponsorship/partners

hip agreements,

briefing

arrangements within

individual

communication plans.

Implementation of GCCG Communications and Engagement Strategy (Ongoing).

Q7 Lack of compliance with national targets for C

Difficile and MRSA could result in a lower

quality of care for some patients.

Teresa

Middleton, Karyn

Probert

12 (4x3) 6 (2x3) Countywide HCAI action plan.

Monthly monitoring of incidents of

C Difficile and MRSA. Countywide

HCAI Committee oversees action

plan implementation and monitors

progress.

Performance reports,

Bimonthly C Difficile

working group,

Strategic Countywide

HCAIs group.

Bi‐monthly Strategic Countywide Healthcare Acquired Infections (HCAIs) Group.

Ribotyping all C Difficile cases. Annual review of Countywide Antibiotic Formulary.

Bimonthly CCG C Difficile working group. Regular communications with all prescribers.

Involvement in sharing good practice with Area Team Workshop. Explore faecal

transplantation as a method to reduce relapse of C Diff in patients as per NICE

intervential procedures guidance (IPG) (March 2015).

C32 2015/16 Impact of Care Act 2014: 1)

Significantly reduced social care capacity

within ICTs associated with early assessment

and review for national eligibility criteria. 2)

Predicted increased demand on service

(information, advice & advocacy), focus on

early intervention and prevention and

promotion of independent advocacy. 3) GCC

new duties for managing provider failure and

other service interruptions. CQC new duties for

managing 'hard to replace' provider failure.

New arrangements with prisons, approved

premises and bail accommodation. 4) Equal

rights for carers ‐ assessments and duty to

meet assessed needs

Donna Miles 12 (3x4) 12 (3x4) Maintain regular monitoring of

performance/progress at quality

groups. Active participation from

joint commissioners into new

contractual arrangements, input

into market management (via

Commissioning Intentions /

safeguarding / compliance)

Reports to Governing

Body

NHS engaging fully with GCC Implementation Plan (March 2015)

Page 4


Actions / Status


objectives


Risk

Ratings

(LxC)

Current

Risk

Ratings

(LxC)


Controls



C33 Impact of Children & Families Act 2014: GCCG

new duties associated with assessment,

planning and provision of services for children

and young people up to age 25 who have

special educational needs and disabilities, and

their families. New provisions for these duties

to be challenged and potentially taken to

tribunal / tested by case law.

Simon Bilous 12 (3x4) 8 (2x4) Maintain regular monitoring of

performance/progress at quality

groups. Active participation from

joint commissioners into new

contractual arrangements, input

into market management (via

Commissioning Intentions /

safeguarding / compliance). Direct

engagement of provider services in

managing the new system and

supporting compliance.

Reports to Governing

Body

NHS engaging fully with GCC implementation plan. Interim champion arrangements

now replaced with formal commissioning and funding by the CCG of SEND Designated

Officer capacity in the 3 NHS Trusts and the CCG. Continued engagement of these

officers in the implementation programme.

F9 Lack of staff engagement and staff

development could limit the achievement of

financial balance.

All Directors 6 (2x3) 6 (2x3) Organisational Development Plan

progress reports.

Organisational

Development Plan

progress reports.

Organisational

development plan

update needed to

reflect new

information.

Appraisal process

needs to be

developed to fit the

organisation's needs.

Refresh of the Organisational Development Plan. Senior Manager's Group developing

an appraisal process (March 2015).

Objective 6: Develop strong leadership as commissioners at all levels of the organisation, including localities.

Page 5

Agenda Item 16

Governing Body

Meeting Date


Title Audit Committee Annual Report 2015/16

Executive Summary The report outlines the work of the Audit Committee during the financial year 2015/16.

Key Issues

The role of the Audit Committee is to critically review financial reporting and internal control principles, and to ensure an appropriate relationship is maintained with internal and external auditors. The report outlines details of this activity over the six meetings held.

Risk Issues: Original Risk: Residual Risk

The absence of an Audit Committee Annual Report could result in the Governing Body being insufficiently aware of the role and activities of the Committee. 6 (2x3) 3 (1x3)

Financial Impact There is no financial impact. Legal Issues (including NHS Constitution)

There are no legal issues associated with this report.


There is no impact on health inequalities.


There is no impact on equality and diversity.


There is no impact on sustainable development.


Not applicable.

Recommendation The Governing Body is asked to accept this report on the work of the Audit Committee as part of its overall governance and assurance programme for 2015/16.

Author Colin Greaves Designation Lay Member, Governance and Audit Committee

Chair Sponsoring Director (if not author)

Page 1 of 10

Agenda Item 16

Audit Committee Annual Report 2015/16

1. Introduction

1.1 The Health and Social Care Act 2012 set out the requirement for Clinical Commissioning Groups (CCGs) to establish an Audit Committee. This report, the third to the Governing Body, covers the work of the Audit Committee (the Committee) for the financial year 2015/16.

2. Membership

2.1 The membership of the Audit Committee during the year was:

Colin Greaves Chair – Lay Member Governance; Alan Elkin – Lay Member Patient Public Engagement; Valerie Webb – Lay Member Business; Dr Andrew Seymour – Deputy Clinical Chair; Dr Hein Le Roux – GP Stroud Locality.

3. The Function of the Audit Committee

3.1 The role of the Committee is to critically review the CCG’s financial reporting and internal control principles whilst ensuring that an appropriate relationship is maintained with both internal and external auditors. It is important that the Committee maintains an independent and objective view 3.2 The Audit Committee also fulfils the role of the Auditor Panel, as defined in the Local Audit and Accountability Act 2014. Details of the Auditor Panel are at Appendix 1.

4. Terms of reference

4.1 The Committee’s terms of reference were reviewed at the 29 September 2015 meeting. 4.2 The Committee’s terms of reference were revised by the Governing Body at the 26 November 2015 meeting in order to include, amongst other things, the role of the Auditor Panel.

Page 2 of 10

5. Meetings

5.1 The Audit Committee met on the following dates:

12 May 2015; 26 May 2015; 7 July 2015; 22 September 2015; 8 December 2015; 8 March 2016.

5.2 The external auditors, internal auditors and the Local Counter Fraud Service attended all of the meetings to which they were invited. The Chief Finance Officer and her deputy attended all meetings. The Associate Director of Corporate Governance attended five out of the six meetings held. A breakdown of meeting attendance is at Appendix 2 5.3 The Accountable Officer had an open invitation to attend all meetings. 5.4 The confirmed minutes of all the Audit Committee meetings were considered at the Governing Body meetings. 5.5 The Committee had a private meeting with the internal auditors on 15 June 2015. 5.6 The Committee had a private meeting with the external auditors on 14 July 2015. 5.7 There was an open invitation to the internal and external auditors and the Local Counter Fraud officer to make contact with the Chair of the Committee if they had any concerns.

6. Review of the Committee’s Work

6.1 The Committee had an annual work plan, which was updated during the year as additional issues were identified.

6.2 The Committee completed a self-assessment on 29 September 2015. A similar exercise is planned for September 2016.

7. Internal Audit 7.1 PricewaterhouseCoopers provides the internal audit service for the CCG. 7.2 The Internal Audit Annual Report for 2014/15 was presented at the Audit Committee meeting on 12 May 2015. The Head of Internal Audit’s annual opinion on the adequacy and effectiveness of the CCG’s framework of governance, risk management and control was that there were adequate and

Page 3 of 10

effective governance, risk management and control processes to enable the related risks to be managed and objectives to be met. 7.3 The internal audit work plan for 2015/16, which was based on a risk assessment for the organisation, was presented and agreed at the Audit Committee meeting on 7 July 2015. The audits undertaken in 2015/16 with their associated assessments are:

Business Continuity Process was rated high risk overall. This included one high risk, which related to the lack of either a business impact analysis or a critical functions analysis across the business teams. An action plan is in place to address both the high risk and the two associated medium risks;

Primary Care Co-commissioning – medium risk;

Personal Health Budgets – low risk;

Core Financial Systems – low risk;

Information Governance – low risk;

Clinical Records Management – medium risk;

Continuing Health Care was rated high risk overall. This included

two high risks: there were a number of instances of non-compliance with processes around a lack of ongoing case review; and Domiciliary Care Invoices did not match documentation on CareTrack;

Partnership Working – low risk;

Risk Management – low risk;

Corporate Governance – low risk.

There were areas of good practice noted in all reports issued.

7.4 A risk-based work plan for internal audit for 2016/17 was considered at the Audit Committee meeting on 8 March 2016. 7.5 South, Central and West Commissioning Support Unit (CSU) provides services to a number of CCGs. NHS England, which hosts the CSU, engaged Deloitte to prepare a report on internal controls for 2015/16. The only area tested, which is applicable to Gloucestershire CCG, is payroll. There were two areas identified within the report where the controls were not found to be operating in the way described. The CSU has developed an action plan to

Page 4 of 10

remedy these issues. The CCG’s internal auditors tested the payroll controls and found no evidence that incorrect payments had been made.

8. External Audit

8.1 The role of external audit is to give an opinion on the financial statements and issue a value for money conclusion. The external audit services are provided by Grant Thornton. 8.2 At the Audit Committee meeting on 26 May 15 Grant Thornton presented their audit conclusions for 2014/15:

Financial statements opinion – an unqualified opinion was provided on the financial statements, which give a true and fair view of the CCG's financial position as at 31 March 2015 and of the net operating costs recorded by the CCG for the year;

Regularity opinion – an unqualified regularity opinion was provided;

Value for money – an unqualified value for money conclusion was

provided.

8.3 Grant Thornton has provided update reports against the agreed work plan for 2015/16 and their draft assessments are due to be presented to the Committee at the meeting on 24 May 2016. Grant Thornton has also provided reports on emerging issues and developments; this has proved most helpful to both the Committee and the Executive.

9. Counter Fraud

9.1 The counter fraud service is provided by the Gloucestershire Hospital Foundation Trust and covers the following areas: preventing and detecting fraud; investigating fraud; and the creation of an anti-fraud culture. The annual plan was created following a risk assessment of the CCG. The Committee has received reports in all of the above areas and a draft annual report for 2015/16 was presented to the Audit Committee at the 8 March 2016 meeting. In addition, a risk-based draft work plan for 2016/17 was presented to the Audit Committee at the same meeting.

10. Other Assurance Functions

10.1 Through the receipt of regular reports the Audit Committee reviewed the management of the following:

Procurement decisions; Procurement Waiver of Standing Orders; Aged Debts;

Page 5 of 10

Debts Proposed for Write-off; Losses and Special Payments.

The Committee is satisfied that these areas are being appropriately managed. Any concerns on individual items were raised at the time and appropriate responses have been received

11. Governance

11.1 The Integrated Governance and Quality Committee ensures that the appropriate governance plans and mechanisms are in place for all areas other than financial governance, which is the responsibility of the Audit Committee

12. Annual Governance Statement

12.1 The Draft Annual Governance Statement for 2014/15 was reviewed by the Audit Committee at the 10 March 2015 meeting. The Annual Governance Statement was approved by the Governing Body at the 28 May 2015 meeting. 12.2 The Draft Annual Governance Statement for 2015/16 was reviewed by the Audit Committee at the 8 March 2016 meeting.

13. Annual Accounts

13.1 The year-end reports and accounts for 2014/15 were considered by the Committee on 26 May 2015 and approved at the extraordinary Governing Body meeting on 28 May 2015. 13.2 International Accounting Standard requires management to assess, as part of the annual accounts preparation process, the CCG’s ability to continue as a going concern. A paper on this issue was presented at the Audit Committee meeting on 12 May 2015 and the Committee confirmed that the CCG was a going concern. 13.3 The year-end reports and accounts for 2015/16 will be considered by the Committee on 24 May 2016 before being recommended for approval at the Governing Body meeting on 26 May 2016.

14. Co-operation

14.1 The Committee is grateful to the CCG staff, the CSU staff, Gloucestershire Local Counter Fraud Service, Grant Thornton; and PricewaterhouseCoopers for their positive and constructive approach in discussions and reporting.

Page 6 of 10

15. Conclusion

15.1 The Audit Committee can confirm the following:

The risk management systems in the CCG are adequate and allow the Governing Body to understand the appropriate management of those risks.

There are no areas of significant duplication or omission in the

systems of governance in the CCG that have come to the Committee’s attention.

The draft Annual Governance Statement for 2014/15 is consistent

with the Committee’s views on the CCG’s system of internal control and that it supports the Governing Body’s approval of the Statement.

The basis for the above opinion is drawn from evidence highlighted in paragraphs 5 to 13 and from discussion and debate in the Committee.

16. Recommendation

16.1 The Governing Body is asked to accept this report on the work of the Audit Committee as part of its overall governance and assurance programme for 2015/16.

Colin Greaves Chair of Gloucestershire CCG Audit Committee 2 May 2016

Page 7 of 10

APPENDIX 1

AUDITOR PANEL 1. Introduction

1.1 The Local Audit and Accountability Act 2014 introduced significant changes to the local public audit regime in England by replacing centralised arrangements for appointing external auditors to CCGs with a system that allowed each body to make its own appointment. 1.2 From 2017/18, CCGs must have an auditor panel to advise the Governing Body on the appointment of their external auditors. As the 2017/18 appointment must be made by 31 December 2016, the auditor panel needed to be in place early in 2016. Audit Committees are able to fulfil the role of the auditor panel. 1.3 At the 26 November 2015 meeting the CCG Governing Body approved the Audit Committee to fulfil the role of the Auditor Panel.

2. Membership

2.1 The membership of the Auditor Panel during the year was:

Colin Greaves Chair – Lay Member Governance; Alan Elkin – Lay Member Patient Public Engagement; Valerie Webb – Lay Member Business; Dr Andrew Seymour – Deputy Clinical Chair; Dr Hein Le Roux – GP Stroud Locality

3. The Function of the Auditor Panel

3.1 The role of the Panel is to advise the Governing Body on:

The selection, appointment and removal of the CCG’s external auditors;

The maintenance of an independent relationship with the appointed

external auditor;

The purchase of ‘non-audit services’ from the external auditor. 4. Terms of reference

4.1 The Auditor Panel’s terms of reference were approved at the Governing Body meeting on the 26 November 2015.

Page 8 of 10

5. Meetings

5.1 The inaugural Auditor Panel meeting was held on 8 March 2016. A breakdown of meeting attendance is at Appendix 3.

6. Review of the Committee’s Work

6.1 The process for the procurement of external auditors was discussed at the 8 March 2016 meeting.

Page 9 of 10

APPENDIX 2

AUDIT COMMITTEE ATTENDANCE

12th

May 26th May

7th Jul

22nd Sep

8th Dec

8th Mar

Colin Greaves Lay Member √ √ √ √ √ √ Alan Elkin Lay Member √ √ √ √ √ √ Valerie Webb Lay Member √ √ √ √ √ √ Dr Andy Seymour Dep Clinical Chair √ √ √ √ Dr Hein Le Roux GP Stroud Locality √ √ √ √

Paul Dalton PwC √ √ √ Lyn Pamment PwC √ Rebecca Robinson PwC √ Natalie Tarr PwC √ √ Liz Cave Grant Thornton √ √ √ Roy Edwards Grant Thornton √ Ashley Allen Grant Thornton √ Laura Hallez Grant Thornton √ √ √ Sallie Cheung Counter Fraud Off √ √ Lee Sheridan Counter Fraud Off √ √ √ Mary Hutton Accountable Officer √ √ Cath Leech CFO √ √ √ √ √ √ Andrew Beard Dep CFO √ √ √ √ √ √ Rupert Boex Financial

Accountant √

Alan Potter Assoc Dir Corp Gov √ √ √ √ √

In accordance with the Audit Committee’s Terms of Reference other members of CCG staff attended on an as required basis.

Page 10 of 10

APPENDIX 3

AUDITOR PANEL ATTENDANCE

8th

Mar Colin Greaves Lay Member √ Alan Elkin Lay Member √ Valerie Webb Lay Member √ Dr Andy Seymour Dep Clinical Chair √ Dr Hein Le Roux GP Stroud Locality √

Cath Leech CFO √ Alan Potter Assoc Dir Corp Gov √

Page 1 of 1

Governing Body



Title Integrated Governance and Quality Committee (IGQC) minutes

Executive Summary The attached minutes provide a record of the IGQC meeting held on the 3rd March 2016.

Key Issues

The following principal issues were discussed:

Patient’s Story; Experience and Engagement Report Quality Report; CQC Inspection Report; Risk Register; Assurance Framework; Policies; and Information Governance update.


Not applicable

Financial Impact Not applicable


Not applicable


None


None


None


Not applicable

Recommendation The Governing Body is requested to note these minutes which are provided for information.

Author Alan Potter Designation Associate Director of Corporate Governance Sponsoring Director (if not author)

Julie Clatworthy IGQC Chair and Registered Nurse

Agenda Item 17

Page 1 of 19

Integrated Governance and Quality Committee (IGQC)

Minutes of the meeting held on Thursday 3rd March 2016, Board Room, Sanger House

Present: Julie Clatworthy JC Chair Dr Charles Buckley CBu GP – Stroud Locality Dr Caroline Bennett CBe GP – North Cotswold Marion Andrews-Evans MAE Executive Nurse and Quality Lead Alan Elkin AE Lay Member – Patient and Public

Engagement Colin Greaves CG Lay Member – Governance Mary Hutton MH Accountable Officer Dr Tristan Lench (part meeting)

TL GP – Forest of Dean Locality

Dr Helen Miller HM Clinical Chair Sarah Scott SS Director of Public Health, GCC Mark Walkingshaw MW Director of Commissioning

Implementation In Attendance: Caroline Smith (Item 5 and 6)

CS Senior Manager Engagement and Inclusion

Jules Ford (Item 5) JF Cultural Commissioning Project Manager

Richard Thorn (Item 11) RT Commissioning Manager - Planned Care

Cate White CW Project and Business Manager Quality Team

Fazila Tagari FT Board Administrator

1. Apologies for Absence 1.1 Apologies were received from Cath Leech. 2. Declarations of Interest 2.1 There were no declarations of interest received.

Page 2 of 19

3. Minutes of the meeting held on 17th December 2015 3.1 The minutes of the meeting were accepted as a true

and correct record, subject to the following amendments:

Section 7.7 to be amended to read ‘CBu highlighted that the Drugs and Alcohol and Healthy Lifestyle service was out for consultation and urged members to contribute to understand the impact on healthcare’.

4. Matters Arising 4.1 IGQC139 and IGQC140 Sustainable Development

Policy MAE advised that the feedback had been forwarded to Georgina Smith. However, it was noted that her employment contract was being terminated by GCS and that the CCG were negotiating an independent contractor agreement with Georgina.

4.2 IGQC141 Risk Register

Risk No Q5 relating to prescribing costs was re-assessed and being monitored through the performance report. Item Closed.

4.3 IGQC143 Experience and Engagement Report

MAE informed members that there had been progress with the discharge performance and felt that this should not be included within the Risk Register. Item Closed.

4.4 IGQC145 Experience and Engagement Report

The communication materials regarding the JUYI project was circulated to members on the 17th December 2015. Item Closed.

4.5 IGQC147 Quality Report

MAE advised that the details regarding pressure ulcers was provided on Section 11.4 of the Quality Report and noted that these were split by localities. It was advised that three Grade 3 pressure ulcers were reported and that these had been community acquired. MAE

Page 3 of 19

provided assurance that these were being monitored by the Quality Team. Item Closed.


The Suicide Prevention Annual Report was circulated on the 12th February 2016. Item Closed.


MAE explained the process of the revalidation procedure that she had undertaken. MAE advised that she had written a reflective piece regarding the process in the practice nurse newsletter. Item Closed.

4.8 IGQC152 and IGQC153 Child Death Overview Panel

Annual Report The comments regarding the ambiguity of the report had been forwarded to the team. Item Closed.

4.9 IGQC154 Risk Register

MW confirmed that the action relating to Risk No C16 regarding AQP contracts can be completed. Item Closed.

5. Patient’s Story - Self-Care (Diabetes); Cultural

Commissioning Programme

5.1 JF provided a presentation relating to the Cultural

Commissioning Programme (CCP) and a patient’s story relating to the self-care (diabetes) programme.

5.2 JF advised that the CCP was a key enabling project

within the healthy individuals programme with the aim to raise awareness amongst public service commissioners of the benefits which arts and culture can bring to people’s health and wellbeing.

5.3 The presentation covered:

background; alignment with other key programmes; a stepped model; and CCP grants programme.

Page 4 of 19

5.4 JF indicated that there was a growing concern with teenagers not appropriately managing their medications for diabetes and that poor management often lead to surgical interventions. JF advised that the focus was to increase awareness between teenagers.

5.5 CS advised that the programme was recently rolled out

and had not been implemented during the filming of the video highlighting the use of Art Space, Cinderford and the use of co-production. It was proposed that this was revisited post implementation.

5.6 MH requested that the logos of partner organisations

were included within the video. CS

5.7 CBu queried the opportunities available for engaging

with teenage boys and was advised that there was a project using computer gaming software packages and music based programme.

5.8 RECOMMENDATION: The Committee noted the

presentation.

6. Experience and Engagement Report 6.1 CS introduced the report which provided an overview

of key experience and engagement activity undertaken by the CCG during Quarters 3 of 2015/16. The report was taken as read.

6.2 CS updated members on the latest data from the

Friends and Family Test (FFT) for Primary Care and highlighted that this was still a challenging area. CS drew attention to Section 3.6 of the report which stated that where response rates were very low, the validity of the statistical data was reduced. It was noted that the Primary Care Team would be working with the practices in order to develop this further going forward. CS also advised that this was being discussed at a Practice Participation Group meeting in order to raise awareness. AE felt that there was not sufficient patient experience value to be gained from the FFT and that the focus should be to coordinate an internal reporting

Page 5 of 19

process. 6.3 CG highlighted that IGQC were not responsible for

reviewing the information bus charging arrangements and that this was a function of the Core Team to consider.

6.4 JC felt that the report required further specifics which

demonstrated that there was a continuous improvement cycle and examples of what had changed as a result of the engagement work. CS advised that the report provided details regarding the work undertaken by the CCG. However, the CCG did not have the authority to access provider information in terms of patient experience and that the provider organisations were responsible for reporting this information. It was noted that there were issues with the reporting arrangement as it only provided quantitative information and not qualitative. MAE advised that Becky Parish would be liaising with Heather Beer from GHFT in order to discuss this further.

6.5 The Committee considered the CCG’s response to

Healthwatch Gloucestershire patient transport recommendations and actions in place.

6.6 MH advised that any new schemes should report on

patient experience at regular intervals as part of the project management process and that the Project Management Office (PMO) Team should lead on this.

6.7 The Committee emphasised the importance of patient

experience being supported by all involved in the CCG and was wider than the patient experience team.

6.8 The Committee noted the consistently good results of

the GP patient survey, and receiving assurance that the primary care team were following up poorer performing practices at lower end of the result ranges.


contents of this report, and wide ranging

Page 6 of 19

engagement work, including with partners and Healthwatch Gloucestershire.

7. Quality Report 7.1 MAE presented the Quality Report which provided

assurance to the Committee that quality and patient safety issues were given the appropriate priority and that there were clear actions to address them. The report was taken as read.

7.2 Members were informed that the report included the

Quality Dashboard which provided an overview of performance within the provider organisations.

7.3 MAE advised that the Terms of Reference for the

Clinical Effectiveness Group would be presented to the April 2016 IGQC meeting. It was noted that the Group was reviewing the Nice ‘Do Not Do’ recommendations and that the outcome from the review would be presented to the Priorities Committee.

7.4 MAE drew attention to Section 5 of the report which

outlined the Research and Development trials that had been submitted and approved.

7.5 MAE advised that a named GP for Safeguarding Adults

and Children was being recruited and noted that the role would be to provide support to the Serious Case Reviews, Adult Case Reviews and Domestic Homicide Reviews. It was also noted that role would be integral in supporting the development and delivery of effective safeguarding training to Primary Care. MAE advised that similar forums for dentists, pharmacists and ophthalmologists would be rolled out during 2016/2017.

7.6 JC queried if there was any information available on

the incidents occurring within primary care. MAE advised that there was not a requirement to record these and that generally numbers were low and noted that one incident had been reported within the last three years. MAE advised that GHFT, GCS had also enquired about a similar system to feedback on

Page 7 of 19

primary care services and that this was currently being explored. MAE stated that a Quality Report was being prepared for the Primary Care Commissioning Committee.

7.7 AE expressed concerns regarding the consistency of

reporting falls by providers. MAE advised that the criteria for reporting falls by GHFT were not aligned with other providers in the county and advised that GHFT would be reviewing its reporting process. MAE also advised that she had reviewed the internal Quality Reports for each provider where falls were comprehensively reported.

MAE

7.8 MAE informed members that there had been two Never

Events reported by GHFT. It was noted that one Never Event was subsequently confirmed as a near miss, and therefore, was not classified as a Never Event.

7.9 MAE updated members regarding the Southern Health

Mortality (Mazars) Review. The review looked at the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust, including investigations of unexpected deaths by the Board. MAE informed members that a meeting with providers was being convened to discuss if any lessons could be learnt and shared.

MAE

7.10 CBu requested further details regarding the serious

incident involving Gloucestershire Diabetic Eye Screening programme outlined in section 8.7 of the report. MAE agreed that she would circulate further details.

MAE

7.11 It was noted that Gloucestershire were one of the first

areas to implement the Learning Disability mortality reviews locally. JC enquired if there was an overview of the learning disability deaths in the performance metrics. MAE advised that this information was not readily available. CBu highlighted the work of the Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD) which was undertaken by Bristol and understood that

Page 8 of 19

Gloucestershire was involved with this project. 7.12 The work of the Transforming Care workstream was

highlighted at section 9.5 of the report and it was noted that Gloucestershire was seen as one of the leading areas to deliver this area of work. JC requested that further information regarding staffing issues should be detailed. It was agreed that this would be fedback.

MAE

7.13 JC enquired if there were any further details relating to

the audit of deaths at GHFT undertaken by their Medical Director in response to the summary hospital level mortality indicator rates (SHMI). CBe advised that this would be picked up at the May 2016 CQRG meeting.

7.14 Fractured Neck of Femur (NOF) mortality rates; GHFT

had received an external audit report by the Royal College of Surgeons (RCOS) and established Clinical Review Groups to identify and implement changes. The Committee awaited sight of the RCOS report and action plan when available.

7.15 MAE advised that there were increasing concerns

regarding the 4 hour Emergency Department performance. MAE advised that the inconsistencies in the performance were the key issue raised from the conference call with NHS England. JC suggested that an audit was undertaken at different intervals of the week in order to identify key causes. HM articulated that several root cause analysis had been undertaken and that key themes were not identified and that this could be due to fragmentation and lack of clear internal professional standards and uniform adoption across the system.

7.16 CBu enquired if there was any evidence to indicate that

there were poorer outcomes for patients if the 4 hour targets were not met and deliberated if this was a performance issue compared to a quality issue. MAE responded that national research had been undertaken to demonstrate this. CBu felt that an effective triage system was important in order to prioritise the critical

Page 9 of 19

patients irrespective of performance targets. 7.17 MAE informed members that a conference call was

held with NHS England to discuss the quality and safety implications of the 4 hour target for Gloucestershire Patients. MAE advised that there was no information currently available to evidence this impact. However, it was noted that there was a decrease in serious incidents and that the mortality rates were lower this year in comparison to the previous year. MAE also agreed that patients waiting in corridor were unacceptable in terms of patient experience point of view.

7.18 MAE advised that NHS England hosted a risk summit

on the 29th February 2016 relating to GHFT performance which was attended by CQC, Monitor, Healthwatch, key leads from partner organisation and the regional NHS England Directors. It was agreed that further analytics was collated on a regular basis which included patient experience, quality and safety.

7.19 MW provided an update regarding next steps and

advised that GHFT would be placed under investigation by Monitor and that an announcement was being issued imminently. It was noted that Monitor would be focusing a number of areas which included board overview and leadership effectiveness. MW advised that GHFT had appointed a new Improvement Director who had a good track record of performance improvement. CBe enquired if there was an opportunity for the new Director to be involved with the CCGs work and it was noted that this was being looked into.

7.20 MAE informed members regarding the mixed sex

breaches within GHFT recently and that historically no breaches had been reported since 2013. MAE advised that the reported 9 mixed sex accommodation breaches affecting 37 patients were reported from Critical Care and Acute Care Unit. It was assured that the privacy and dignity had been protected for all these patients.

Page 10 of 19

7.21 JC queried if the target relating to the reduction in the proportion of broad spectrum antibiotics prescribed in primary care by 10% would be achieved. CBu advised that the latest data indicated that there was good progress although there were still variations between practices which were being reviewed in order to improve performance.

7.22 JC highlighted the five deaths that were attributable to

C.Difficile and queried the improvements that had been made as a result of this. MAE stated that Karyn Probert, a senior manager in the Quality Team completed the Root Cause Analysis for these cases.

7.23 JC queried if an evaluation of the flu season had been

undertaken and it was noted that the data had been reviewed at the Primary Care CQRG. CBu highlighted that there were anomalies with the data provided. SS advised that a Countywide Immunisation Group had been established and suggested that she can produce a report on the work that had been undertaken by the Group and recommended that NHS England was invited to this meeting to update on the plans for the seasonal flu campaign in 2016/17.

SS

7.24 MAE reported that there had been approximately 3500

vaccines administered by pharmacists. MAE felt that a review on the reasons for patients choosing to visit pharmacists should be undertaken and it was considered that ease of access could be a key reason.

7.25 JC felt that the Quality Dashboard focused on provider

performance only and felt that other indicators should be included i.e. staff sickness, appraisals etc.


contents of this report.

8. CQC inspection Report - 2gether Trust 8.1 MAE presented an update on the CQC inspection

report of 2gether which was taken as read. It was noted that the Trust was rated as good overall which

Page 11 of 19

was highly regarded for a mental health organisation. 8.2 Members were informed that the Trust was rated as

outstanding in the following two areas; acute wards for adults of working age and

psychiatric intensive care units; and mental health crisis services and health-based

places of safety.

8.3 MAE advised that both of these services were able to

demonstrate excellent practice and innovation which went above the standards expected particularly when managing risks.

8.4 MAE advised that areas of concern were around the

level of use of seclusion in the learning disabilities inpatient units in Gloucestershire.

8.5 Members were informed that the issue in relation to the

older people services related to Herefordshire services.

8.6 The Committee requested that a formal letter of

congratulation was sent to 2gether. It was also suggested that this was highlighted at the next Governing Body meeting.

MAE


presentation.

9. Risk Register 9.1 MAE presented the Risk Register which provided

details of those risks identified by the responsible managers that currently face the CCG and which could affect the achievement of the organisational objectives.

9.2 The Risk Register comprised a total of 48 risks, five of

which were graded as ‘red’ as outlined in Appendix 1.

9.3 The Committee highlighted Risk No C15 relating to

compliance with national and local access targets for planned care and queried the progress of the risk

Page 12 of 19

following the last report. MW advised that the performance for the referral to treat targets were maintained although there were still underlying concerns around the 62 day cancer target and highlighted that this was the rationale for maintaining the risk at that level. MH suggested that the risk could be split into two.

9.4 The Committee reviewed the items for closure and

requested that Risk No T9 on Appendix 2 relating to inability of GHFT to gain re-accreditation of specialised services for specialised commissioning should not be deleted and be reviewed at the April meeting as the target risk had not been reached.

9.5 The Committee approved the addition of two new risks

which related to Risk No T11 regarding the financial cuts to Public Health budgets and Risk No C34 regarding the impact on discharges due to delays sourcing independent sector domiciliary care.

9.6 MW provided an update on Risk No C34 and advised

that the CCG was working closely with the Local Authority in order to source a market provider.

9.7 RECOMMENDATION: The Committee:

reviewed the paper and the attached Risk Register

approved the closure of the one risk (Risk No L7) detailed on Appendix 2; and

approved the addition of the two new risks detailed on Appendix 3.

10. Assurance Framework 10.1 MAE presented the Assurance Framework for 2015/16

which provided details of the assurances that will be received by the Governing Body regarding the achievement of the CCG’s Objectives and agreed the minor changes to the Assurance Framework format. The paper was taken as read.

Page 13 of 19

10.2 RECOMMENDATION: The Committee noted this paper and the attached Assurance Framework.

11. Clinical Policies for Approval 11.1 Effective Clinical Commissioning Policies 11.1.1 MW presented the Effective Clinical Commissioning

Policies (ECCP) and provided a background context underpinning the review to the policies on the current ECCP list.

11.1.2 The Committee were presented with a proposal for 8

policies which had been reviewed in the final stages of the review process.

11.1.3 MW advised that the majority of the policies had been

reviewed through the relevant Clinical Programme Groups (CPG). In a few cases where an active CPG did not exist, the initial review had been undertaken by a lead CCG GP in consultation with relevant specialists at GHFT, with the recommendations then being reviewed by the ECCP group.

11.1.4 The Committee reviewed the following policies where

amendments and additions were proposed. These were:

11.2 Knee Arthroscopy and Irrigation 11.2.1 CBe expressed concerns regarding the criteria

requirements. Members were informed that this was an existing policy which had been informed by best evidence.

11.2.2 MH suggested that the source of evidence was

confirmed and requested that MW established how many patients undergo this procedure per annum.

MW

11.2.3 MW highlighted that the review would prompt the policy

compliance process.

11.2.4 JC queried if an impact assessment had been

Page 14 of 19

undertaken and it was advised that this was not required as no changes had been proposed.

11.2.5 RECOMMENDATION: The Committee approved the

Policy.

11.3 The Committee reviewed the following policies where

major changes were proposed. These were:

11.4 Microwave or Laser Surgery for Benign Prostatic

Hyperplasia

11.4.1 RT advised that currently all procedures for microwave

and laser surgery were not routinely funded. The new policy proposed allowing Holmium Laser Enucleation of the Prostate on specific patients subject to Prior Approval, with the remaining forms of laser and microwave treatment being retained as Interventions Not Normally Funded (INNF).


Policy.

11.5 Removal of Bunions/Lesser Toe Deformity 11.5.1 RT advised that the Policy had been changed following

the advice received from the MSK CPG following a review of evidence. Key changes included the removal of the requirement for applying the conservative management techniques and appropriate footwear advice and the addition of criteria relating to bone infection.


Policy.

11.6 Primary Hip Replacement Surgery 11.6.1 RT advised that the key changes related to the removal

of the requirement for patient to have shown commitment to weight reduction through active participation in a weight management programme if the

Page 15 of 19

patients BMI is >30 with the addition of a reference to weight management.


Policy.

11.7 Primary Knee Replacement Surgery 11.7.1 RT advised that the key changes related to the removal

of the requirement for patient to have shown commitment to weight reduction through active participation in a weight management programme if the patients BMI is >30 with the addition of a reference to weight management.


Policy.

11.8 Hydroceles 11.8.1 RT advised that the proposal was to routinely fund

surgical referral for hydroceles for patients aged under 18 years of age.


Policy.

11.9 Botox for Hyperhidrosis 11.9.1 It was noted that this procedure was currently an INNF

and the proposal was to change this to Criteria Based Access with Prior Approval from the CCG. RT advised that it should only be used in severe cases where alternative treatments had failed.


Policy.

11.10 NICE ‘DO NOT DO’ List 11.10.1 RT advised that this was a new policy to clarify CCG

position that things on the NICE ‘DO NOT DO’ list are automatically considered to be INNFs.

Page 16 of 19


Policy.

11.11 Individual Funding Request (IFR) Policy 11.11.1 MW presented the updated IFR Policy and advised that

the policy had been reviewed in accordance with its planned review date with a small number of amendments.

11.11.2 JC requested that a reference was included in section

5.9.1 regarding the process for decisions which required an urgent review as the Policy currently stated that decisions following triage were communicated to the clinician within 10 days.

11.11.3 JC requested that the job title of the Chair for the IFR

Panel was specified.


Policy subject to the comments made above.

12. Policies for Approval 12.1 Joint Working with the Pharmaceutical Industry 12.1.2 This policy would inform and advise staff of their main

responsibilities when entering into joint working arrangements with the pharmaceutical industry.


Policy.

12.2 Training and Development policy (to include

Employer Supported Volunteering scheme)

12.2.1 MW presented this Policy and advised that it had been

developed by the CSU and reviewed by the Policy Working Group. IT was noted that the Policy was consistent with any relevant employment legislations.

Page 17 of 19

12.2.2 MW advised that the Training and Development Policy was to ensure that the organisation was resourced, at all times, with people who had the appropriate competence and experience to enable the organisation to achieve its purpose and meet future needs.

12.2.3 MAE highlighted that the Policy also included the

statement of commitment to the Employer Supported Volunteering scheme. JC queried if this was restricted to a particular activity and was advised that it should benefit the community within the Gloucestershire CCG remit. JC requested that an evaluation of the volunteering experience was undertaken.


Policy.

12.3 Maternity Leave 12.3.1 JC requested that the Maternity Policy was cross

referenced with the Adoption Leave Policy.


Policy subject to the comment made above.

12.4 Paternity Leave 12.4.1 JC drew attention to Section 1.3 of the Policy and

queried the statement regarding nominated carer and requested that this was clearly defined to explain what this covered.



12.5 Adoption Leave 12.5.1 JC requested that the Maternity Policy was cross

referenced with the Adoption Leave Policy.



Page 18 of 19

12.6 Policy Format and Approval Process 12.6.1 This Policy proposed that a common format and

approval structure for policies was adopted to reinforce corporate identity.


Policy.

12.7 Acceptable Use of IT 12.7.1 MH requested that this policy was deferred as it

required a comprehensive review.

12.7.2 RECOMMENDATION: The Committee deferred this

policy.

12.8 Business Continuity Strategy 12.8.1 JC requested that Section 5.1 stated who the

Accountable Emergency Officer was accountable to and requested that the job title was also specified.



13. Legacy Human Resources Policies 13.1 A review of the CCG Human Resources (HR) policies

had recently been undertaken by the CSU HR Team in liaison with the CCG Governance Team. As a result of this review, a number of former PCT policies that had been approved for adoption at the 2nd April 2013 Governing Body meeting, had been identified as no longer required.

13.2 RECOMMENDATION: The Committee approved the

deletion of policies included within Appendix 1 of the report.

14. Information Governance Update 14.1 The paper provided an update on the organisation’s

Page 19 of 19

information governance arrangements. The paper was taken as read.

14.2 It was noted that good progress was being made

against the IG Toolkit and the CCG was on track to achieve a strong level 2.

14.5 RECOMMENDATION: The Committee:

noted the notes from the Information Governance Group meeting; and

noted the contents of this report.

15. Any Other Business 15.1 JC advised that the contract for the Genomic

Medicines Centre had formally been signed and the programme had received capital funding of £540K from NHS England.

16. The meeting closed at 12.30pm. Date and time of next meeting: Thursday 21st April

2016 in the Board Room at 9am.

Page 1 of 1

Governing Body



Title Primary Care Commissioning Committee (PCCC) minutes

Executive Summary The attached minutes provide a record of the PCCC meeting held on the 28th January 2016.

Key Issues

The following principal issues were discussed:

applications to close branch surgeries; and Draft Primary Care Infrastructure Plan.


Not applicable



Not applicable


None


None


None


Not applicable


Author Alan Potter



Alan Elkin PCCC Chair and Lay Member

Agenda Item 18

Page 1 of 11 PCC Committee Minutes 28/01/16

Primary Care Commissioning Committee

Minutes of the Meeting held on Thursday 28th January 2016 in the Board Room, Sanger House, Gloucester GL3 4FE

1 Apologies for Absence 1.1 Apologies were received from Mary Hutton, Julie Clatworthy and Debra

Elliott.

Present: Alan Elkin AE Chair Marion Andrews-Evans MAE Executive Nurse and Quality Lead

Colin Greaves CG Lay Member - Governance

Helen Goodey HG Director of Locality Development and Primary Care

Cath Leech CL Chief Finance Officer Dr Andy Seymour AS Deputy Clinical Chair In attendance:

Jeanette Giles JG Head of Primary Care Contracting Teresa Middleton TM Deputy Director of Quality Becky Parish BP Associate Director Patient and Public

Engagement Rosi Shepherd RS Assistant Director of Nursing (Quality and

Safety), NHS England Nikki Holmes NH Head of Primary Care, NHS England

Cllr Dorcas Binns DB Chair of the Health and Wellbeing Board Anthony Dallimore AD Associate Director of Communications Barbara Piranty BPi Chief Executive of Healthwatch

Gloucestershire Andrew Hughes (Agenda Item 8)

AH Locality Implementation Manager

Alan Potter AP Associate Director of Corporate Governance

Fazila Tagari FT Board Administrator There were 2 members of public present.


2 Declarations of Interest 2.1 CG and BPi declared an interest in Agenda Item 5 as they were

registered patients at Crescent Bakery Surgery.

2.2 AS declared a general interest as a GP member. 3 Minutes of the Meeting held on Thursday 26th November 2015 3.1 The minutes were approved. 4 Matters Arising 4.1 24.09.2015 AI 5.8 – Springbank Procurement Update – NH

agreed that she would follow up the action in relation to forwarding the nurse led paediatric nurse model from Swindon.

4.2 26.11.2015 AI 5.15 – Review of PMS Services Contracts – HG

confirmed that Bartongate Surgery was classified within the 2nd most deprived area within Gloucestershire. Item Closed.

4.3 26.11.2015 AI 6.5 – Springbank APMS Contract KPI - HG advised

that the Healthy Living Centre were aware of the KPIs and were committed to partnership working arrangements. Item Closed.

4.4 26.11.2015 AI 7.5 – Standard Operating Procedures: Practice

Boundary Changes – HG advised that the appeals procedure process had been reviewed which took the national guidance into account. HG stated that the 2nd stage of the process required further consideration and advised that a local dispute resolution group was required to oversee the appeals process prior to progressing to the litigation stage (stage 3). Item Closed.

4.5 26.11.2015 AI 8.5 – Standard Operating Procedures: Application

to close a branch surgery – HG confirmed that the wording and sequencing of the process had been completed. Item Closed.

5 Application to close branch surgery at Hesters Way Healthy

Living Centre from Crescent Bakery Surgery


5.1 HG introduced this report and advised that Crescent Bakery Surgery, based at St George’s Place in Cheltenham, had applied for approval to close their branch surgery at the Hesters Way Healthy Living Centre in Cheltenham.

5.2 HG advised that the practice had been considering their future at

this branch surgery location for over a year, reducing sessions over time as servicing the branch had become more difficult for the practice which threatened their ability to remain sustainable at their main site.

5.3 HG advised that the report outlined the process following the

receipt of the application for branch closure and noted that the process followed was in accordance with the Standard Operating Procedure which was previously signed off at the November 2015 PCCC meeting. HG advised that the report also outlined the feedback from the consultation process.

5.4 Members noted that the branch surgery offered minimal level of

service provision currently (two GP sessions per week) and did not provide nursing support.

5.5 HG advised that patients would continue to have access to

services at the main surgery site and would have a choice of other local primary care providers, including St Catherine’s who run their branch surgery at Hesters Way Healthy Living Centre five days a week. It was confirmed that St Catherine’s remain committed to provide this provision.

5.6 It was also noted that Springbank Surgery had expressed an

interest to provide services from the Healthy Living Centre and the particulars regarding this would need to be worked through taking into account other possible interested parties via a competitive process.

5.7 DB drew attention to Section 5.1.2 of the report regarding the

concerns raised around accessibility to the main surgery site. HG advised that AH would be presenting the Primary Care Infrastructure Plan and highlighted that the CCG was working with practices to develop a new surgery site(s) to accommodate up to 5 practices. It was noted that this proposal involved Crescent


Bakery Surgery, Berkeley Place, Yorkleigh Surgery, Royal Crescent and Overton Park.

5.8 JG advised that the CCG would be working with the practice to

ensure that patients were informed of local transport options to Crescent Bakery’s main site.

5.9 AE requested that the impact on the older demographic group

was reviewed as part of the consultations process. BP advised that managing the consultation process was the practice’s responsibility and the CCG acts as an advisory role and that guidance could include sample size, target audience etc.

5.10 RESOLUTION:

The Committee (CG abstained from voting): considered the recommendation from the Primary Care

Operational Group meeting of 26 January 2016; approved the request to close Crescent Bakery’s

branch surgery at Hesters Way Healthy Living Centre; and

agreed that a further report updating members on the arrangements for the provision of service within Hesters Way Living Centre.

6 Application to close branch surgeries in Hawkesbury Upton

and Wickwar from Culverhay Surgery

6.1 Agenda Item 6 and 7 were discussed concurrently as both items

were interlinked. HG advised that these were two separate contracts, although they operated branch surgeries at the same location.

6.2 HG advised that the practices had submitted applications to close

these branch surgeries following a consultation period with their patients who live in the Wickwar and Hawkesbury Upton areas.

6.3 It was noted that the principal reason for the application related to

the impact of the poor quality of the two premises which compromised the capacity to provide a high standard of care, notably in respect of the non-compliance with Care Quality Commission (CQC) requirements regarding infection control.


6.4 HG advised that the practice was bordered by South

Gloucestershire and that any alternative surgeries would be based in South Gloucestershire.

6.5 DB drew attention to section 3.5 of the report in relation to the

consultation and noted that the Health and Wellbeing Board was yet to be consulted. HG advised that timing issues were primarily the reason for this and that the schedule of meetings would be embedded as part of the process going forward. DB stated that the Board did not require comprehensive information and that an email or note would suffice in order to keep members informed.

6.6 CG highlighted that the branch surgeries were actually located in

South Gloucestershire (and not on the border as specified at section 6.4 above).

6.7 AD provided an update regarding communications acknowledging

that these practices were situated within South Gloucestershire and noted that the CCG were supporting the practices in managing the communication process.

6.8 AE enquired about the arrangements for the community transport

provision and queried if they were supported by the county or district council as it was recognised that these were central to transporting patients who had difficulties accessing the surgeries. BP indicated that there were a range of options in place which included local authority funded and volunteers services. Members also noted that these services were fully utilised by the community.

6.9 AE queried if discussions with the councils should be initiated as it

was felt that the continued support of those services would be essential to those affected by the changes particularly the older patients. GJ highlighted that the number of patients attending the branch surgery was minimal and noted that those patients also travelled to the main surgery and that the increase in the use of transport should not be significant. HG articulated that the practice was committed to undertaking home visits for frail and housebound patients where medically appropriate.


6.10 AE expressed concerns regarding progressing towards a final decision particularly as the Health and Wellbeing Board was not formally consulted with. DB (representative of the Board) confirmed that there should be no concerns and noted that an email would suffice for future reference.

6.11 HG proposed that a brief presentation regarding the work of the

Primary Care Commissioning Committee was presented to the Health and Wellbeing Board. DB welcomed this proposal.

6.12 CG felt that it would be useful to receive feedback on the

implementation and suggested that an update was provided in six months.

HG

6.13 BP suggested that the Primary Care report prepared for the

Health and Overview and Scrutiny Committee was forwarded to the Health and Wellbeing Board.

BP

6.14 TM highlighted that there were typographical errors within the

Quality and Sustainability Impact Assessment that were issued and tabled the correct documents. It was also advised that the website would be appropriately updated.

6.15 RESOLUTION: The Committee:

considered the recommendation from the Primary Care Operational Group meeting of 26 January 2016; and

approved the request to close Culverhay’s two branch surgeries.

7 Application to close branch surgeries in Hawkesbury Upton

and Wickwar from The Chipping Surgery

7.1 This item was covered under Agenda Item 6 and both topics

were discussed concurrently.

7.2 RESOLUTION: The Committee:

considered the recommendation from the Primary Care Operational Group meeting of 26 January 2016; and

approved the request to close Chipping’s two branch surgeries.


8 Draft Primary Care Infrastructure Plan 8.1 AH introduced the five year draft Primary Care Infrastructure Plan

for 2016 which outlined where investment was anticipated to be made in either, new, or extended buildings.

8.2 AH advised that the Plan was divided into two sections which

were: where are we and where do we need to be; and how are we going to get to where we need to be.

8.3 AH advised that he was working to the 2031 timeline which was

aimed to align with local authorities strategies on housing.

8.4 It was proposed that a population and place based approach was

used to plan how and where services should be developed. It was proposed that the CCG would map the current five year Joining Up Your Care proposals against a population approach.

8.5 AH informed members about the current challenges of the

existing estate and noted that a quarter of practices were significantly smaller than current recommended sizes. AH stated that taking into account future population growth, the proportion of practices in buildings that would be significantly smaller than current recommended sizes would increase to one third.

8.6 AH provided a brief update on key sections within the report.

These included: The Current State

primary care buildings in Gloucestershire; conditions and suitability of current state; current financial expenditure; current committed developments; and summary and challenges;

The Primary Care Infrastructure Plan

methodology, approach and assumptions; strategic priorities; and proposed locality developments


Delivery

business case processes; use of the Primary Care Transformation Fund; engagement and stakeholder involvement; fees assumptions; financial revenue investment profile; governance and decision making and approvals; risks and risk management; and key programme timelines

8.7 AH stated that the conditions and functional suitability of the

building would be key factors in determining priorities for premises development. AE queried if parking would be an element considered and it was advised that this would be considered under space utilisation and noted that negotiations with the Local Authority were actively undertaken acknowledging however, that planning policies promoted the use of green space. AE felt that the environmental policy should be called into question as it should consider the needs of patients and in particular distances that patients had to travel to their surgery.

8.8 AE enquired if funding from the Section 106 can be used towards

the cost of the development. AH advised that several schemes where funding was being secured were part of the negotiation with the Council.

8.9 AE queried the level of involvement from the Localities as part of

the decision making process and it was advised that the plan had been discussed at each of the locality meetings. Furthermore, this had been discussed with the practices and at Protected Learning Time events.

8.10 AE asked if there was any feedback received from the Primary

Care Operational Group (PCOG) and the development session meeting and it was noted that the final comments were still awaited. AH highlighted that a LMC representative had attended a PCOG meeting and was supportive of the proposals. AH also highlighted that a few of the practices have indicated that the size of their practices were smaller than identified.


8.11 AS drew attention to Appendix 1a of the report and highlighted that there were only 77 practices listed and queried if the additional practices would be subsequently listed. AH advised of the rationale underpinning the document and noted that the excluded practices did not have any developments in the pipeline and agreed that he would include these for completeness.

8.12 CG expressed concerns regarding the document as it focused on

short term proposals and felt that the scope should be extended beyond 2021. AH responded that this was a medium term plan and that the decisions were aimed to benefit the future generations. It was also noted that buildings would be constructed to a standard that would be suitable for long term use. CG recommended that a reference should be made to the longer term plans.

8.13 HG commended AH for his work in completing this plan within the

prescribed deadline. HG highlighted that this was presented at a Patient and Participation Group (PPG) event where there were representatives from 32 practices who were fully engaged with the process.

8.14 HG stated that this work formed part of the overall Primary Care

Strategy which should be presented at the March 2016 Committee meeting and advised that the Strategy would outline the future direction of travel.

8.15 CL articulated that this plan was contingent on the funding

received from the Primary Care Transformation bid and other key resources including Section 106 agreements and that these should be key enablers in driving this further forward.

8.16 DB noted that there have been no financial assumptions made on

some proposals, and asked if this could be included as an estimate as part of the Primary Care Transformation Fund. AH agreed that he could make assumptions although these would be estimates.

8.17 DB questioned the process of determining the internal floor space

and explored if this could be increased. It was advised that there were requirements regarding the maximum dimensions allowed


for a practice list size and noted that NHS England had also produced internal guidance.

8.18 AE queried the implications for the practices raising 1/3 of the

capital to fund the developments as 67% can only be obtained from the Transformation Fund. AH considered that if robust proposals were developed, then the key factor would be deliverability within three years. NH advised that the guidance was still awaited and that it would be difficult to assess the process without this although it was understood that some schemes could be funded by third parties. Members noted that third party developments contained risks as well as benefits.

8.19 BPi expressed concerns regarding accessibility for the aging

population living in rural areas and queried how the potential impact would be assessed and if this would be built into the process. AH felt that branch closures would be the biggest issue for accessibility and was not likely to be a major issue for new developments as these would be built to benefit the local population and took into account a number of factors although recognising that this needed to be balanced. AH advised that it was anticipated that a full engagement process would be undertaken including a review of access and travel plans and an assessment of the impact on patients. BP advised that the CCG were proposing to work with the PPGs including other stakeholders at an early stage of the communication process.

8.20 The Committee agreed to delegate the responsibility to CL, MH

and AE in order to formally approve the Primary Care Transformation bid submission.

8.21 AE requested that this item was ordered as the top of the agenda

going forward. FT

8.22 RESOLUTION: The Committee considered the contents of the

draft plan and noted that a finalised version would be presented at the March 2016 meeting.

9 Any Other Business 9.1 CG suggested that a self-assessment was undertaken to reflect AE


on the role as a Committee in order to improve on processes and identify areas for development where further training was required.

9.2 RS suggested that she can forward copies of Quality reports

produced for other Committees and it was noted that the Integrated Governance and Quality Committee (IGQC) was responsible for monitoring quality.

10 The meeting closed at 12:40. 11 Date and Time of next meeting: Thursday 31st March 2016 in

the Board Room at Sanger House.

Minutes Approved by Gloucestershire Clinical Commissioning Group Primary Care Commissioning Committee:

Signed (Chair):____________________ Date:_____________

Page 1 of 2

Governing Body



Title Priorities Committee minutes

Executive Summary The attached minutes provide a record of the Priorities Committee meetings held on the 4th February and the 10th March 2016.

Key Issues

The February meeting considered the following areas:

Draft Financial Plan 2016/17; Activity Plan 2016/17; Proposed QIPP Schedule 2016/17; and Prioritisation Weightings.

The March meeting considered:

Outline Business Cases; Resilience Funding 2016/17; Mental Health schemes; and Disinvestment.


Not applicable



Not applicable


None


None


None


Not applicable

Agenda Item 19

Page 2 of 2


Author Alan Potter



Dr Andy Seymour Clinical Chair

Page 1 of 8

Gloucestershire Clinical Commissioning Group

Minutes of the Priorities Committee held at 1.00 p.m.

on Thursday 4 February 2016 in the Board Room, Sanger House

1. Apologies for absence 1.1 Apologies were noted from Cath Leech (CL), Alan Elkin (AE),

Present: Dr Helen Miller (HM) Clinical Chair Dr Andrew Seymour (AS) Deputy Clinical Chair Mary Hutton (MH) Accountable Officer Andrew Beard (AB) Deputy Chief Finance Officer Dr Tristan Lench (TL) GP Liaison Lead - Forest Locality Colin Greaves (CG) Lay Member - Governance Dr Charles Buckley (CBu) GP Liaison Lead - Stroud & Berkeley Vale

Locality Mark Walkingshaw (MW) Director, Commissioning Implementation Dr Jeremy Welch (JW) GP Liaison Lead – Tewkesbury Locality Dr Caroline Bennett (CBe) GP Liaison Lead - North Cotswolds Locality Julie Clatworthy (JC) Registered Nurse Helen Goodey (HG) Director of Locality Development and Primary

Care Ellen Rule (ER) Director of Transformation and Service

Redesign Dr Hein Le Roux (HLR)part GP Liaison Lead - Stroud and Berkeley Vale

Locality Dr Will Haynes (WH) GP Liaison Lead - Gloucester City Locality Dr Sadaf Haque (SH) GP Liaison Lead - Cheltenham Locality Marion Andrews-Evans (MAE)

Executive Nurse and Quality Lead

Valerie Webb (VW) Lay Member - Business Raju Reddy (RR) Secondary Care Doctor Dr Malcolm Gerald (MGe)part GP Liaison Lead – South Cotswolds Locality In Attendance: Alan Potter (AP) Associate Director of Corporate Governance Zoe Barnes (ZB) Corporate Governance Support Officer Sarah Hammond (SHa) Jeremy Gough (JG) Chris Bell (CBl) Sadie Trout (ST)

Head of Information and Performance Business Intelligence Finance Manager Programme Manager Programme Manager

Page 2 of 8

Joanna Davies (JD), Sarah Scott (SS) and Margaret Willcox (MWi). 2. Declarations of Interest 2.1 All GPs declared an interest in the decisions of some of the

business cases as some would relate to their General Medical Services (GMS) contracts.

3. Minutes of the Meeting held on the 8 October 2015 3.1 CG requested that the titles of Governing Body members were

consistently recorded throughout all minutes. 3.2 The minutes were approved as an accurate record. 4. Matters Arising 4.1 All items from the 8 October 2015 were carried forward to the

March Priorities Committee. 5. Draft Financial Plan 2016/17

20160204_2016-17 draft finance plan v2.

5.1 AB presented the First Draft Financial Plan via PowerPoint presentation noting the financial and operational plan considerations of transparency across the community, financial balance across the system, agreed set of risks and mitigations and impact of the wider footprint.

5.2 HM queried if transparency was happening across the community

by providers. AB advised that it was however there had been slow progress.

5.3 It was noted that the First Draft Financial Plan deadline was the 8th

February 2016. 5.4 AB outlined the CCG allocation over the next 5 years to 2020/21

and that all but a small amount has already been committed.

5.5 AB discussed the business rules and noted: Surplus of 1% Headroom of 1% which must be uncommitted at the start of

Page 3 of 8

the year and there is discussion as to how this may be released throughout the year

Contingency 0.5% Minimum Better Care Fund (BCF) included Invest in Mental Health CCG must remain within running costs Surplus position planned Tariff – as per national tariff Acute demand growth 1.6% QIPP to be set at 18m – discussion whether this was realistic Pan-organisation conversations Continuing Health Care (CHC) risk pool had added extra

pressure The CCG was currently unsure how the headroom would be

released throughout the year Mental Health equal to allocation growth

5.6 It was noted and agreed that the CCG must be realistic around the

achievement of the QIPP schemes. 5.7 AB described the cost pressures and investments and outlined:

National priorities Local priorities Activity demands and population growth

5.8 JW queried if in year costs could come out of the headroom. AB

advised that the CCG was not certain that it could access the headroom at this point.

5.9 The Committee discussed the balancing of the budget at national

and local levels. MH advised that the potential to commit against headroom and contingency funds would be discussed further with NHS England (NHSE).

5.10

AB discussed the current draft activity growth assumptions including:

Prescribing Placements and CHC Hospices

Page 4 of 8

5.10.1 CBu queried what the difference between growth and price rises were and AB advised that growth in the volume impact while price reflects actual price change.

5.11 The investments were outlined and AB advised that the CCG were

looking at the requirements for next year and outlined the four main areas in the plan at the moment:

Resilience funds Mental Health – parity of esteem Healthy individuals Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT)

5.12 An overview of GHNHSFT was given and the following points

highlighted:

Baseline issues - Assumes - Cross border, impact outside of this - Impact of tariff changes

HLR joined the meeting at this point. 5.12.1 CG queried where Primary Care allocation was and AB confirmed

that it was included but was not a pressure or growth. Activity Plan 2016/17 5.13 SHa discussed the proposed changes to baseline and noted the

Non PbR (payment by results) pressure. SHa outlined the following from the PowerPoint:

Elective growth - review of long and short term referral trends - Meetings with GHFT divisional teams - Formal review of trends

Outpatient assumptions, all are currently pre QIPP Elective activity assumptions

- Newly recorded activity reductions to be on top of growth - Change of setting - All are pre QIPP

5.13.1 SHa explained the newly recorded activity further and it was advised that MH and MW were in discussions with GHFT regarding

Page 5 of 8

what is new activity and what isn’t. MW added that a process needs to be followed around coding and an audit programme was in place. CBe informed members that coding of co-morbidities was increasing.

5.14 SHa described the breakdown of growth and the growth

assumptions. It was advised that the CCG must plan for national activity models on a ‘comply or explain’ basis and the models were yet to be released.

Proposed QIPP schedule 2016/17 5.15 JG discussed the first draft QIPP plan and outlined the key steps

around the development of the programme, and noted the next steps:

Understand the potential opportunities indicated by benchmarking

Savings programme will need to be tested for time profile and full year effect

Review business cases to evaluate those with most potential Review Clinical Programme Group (CPG) work plans Review other transactional QIPP proposals

Discussion Points 5.16 CG noted that the QIPP target had not moved in four years

however the allocation had gone up and that other CCGs were setting QIPP at 4%.

5.17 5.18

JC queried if Right Care recommendations were considered and it was confirmed these were picked up and variation issues would also be picked up. ER noted that the benchmark numbers would need to be tested.

MGe joined the meeting at this point. 6. Prioritisation weightings for 2016/17 6.1 ER gave an overview of the process and approach to prioritising

and noted:

Programme leads had put together Outline Business Cases (OBCs) which were available on the Hub

Page 6 of 8

Weightings in the matrix are proposed and could be adjusted following comments if required

6.2 ER requested comments from the Committee on the approach

outlined and the documents forwarded prior to the meeting and none were received.

6.3 ER advised that the percentage weightings could be put into the

table before the next Priorities Committee and then the Committee would be asked to give their individual scores.

6.4 The summary spreadsheet including the schemes was discussed

and the 5 OBCs including QIPP were talked through in further detail. MH informed members that there was intelligent testing behind the investment and savings figures.

6.5 CBu queried if there was a de-prioritisation list in addition to

priorities as this was equally as important under the current climate. The Committee agreed with this point and ER confirmed that pathways around clinical programmes would be reviewed to look at areas where funding could be ceased.

6.6 JC raised concerns that there was no evidence within OBCs to

outline quality and outcomes information. ER advised that the OBCs were snapshot documents and that more information and work was available in addition. ER accepted that the level of information and the timescales were challenging however decisions must be made in March.

6.7 CBu noted issues around pathway compliance and engagement

within the system. MW advised that there was QIPP risk share in contracts with provider organisations. HM reiterated that the Priorities Committee should be about de-prioritising aswell as prioritising.

6.8 The Committee made a number of points regarding the business

cases and the prioritisation process.

6.8.1 HLR noted that the term ‘flow’ was being used more regularly but that this term was actually a science.

6.8.2 CG recommended that if business cases can’t deliver savings they

should not be considered. AS highlighted the matrix which includes

Page 7 of 8

cost effectiveness and suggested that perhaps this should be reviewed.

6.8.3 JC advised that linking to quality will improve cost saving and that

this was proven practise. 6.8.4 CBe requested that information regarding the overall picture of the

work of the CPGs was provided i.e. out of the budget what is being requested. This would enable better decision making.

6.8.5 ER agreed with the suggestion to review the matrix and advised

that the programme briefs would be made available on the Hub for the Committee to review in more detail prior to decision making at the next meeting.

6.8.6 CBu suggested looking at whole spend instead of marginal spend. 6.8.7 MH advised that there were Clinicians on the ground at present

looking at the pathways which would bring forward ideas about what does not need to be funded.

6.8.8 WH drew attention to the recurrent savings on the spreadsheet and

queried if these had been given a sense check. ER informed the Committee that the numbers were not put in until they were tested.

7. Any Other Business 7.1 MH informed the Committee that a formal decision was required to

continue the funding of Social Prescribing in Gloucestershire. The members discussed their views and it was agreed that a full evaluation would be forwarded to the Governing Body meeting and an agreement made to commit for a further year, with an evaluation after 6 months. It was advised that an evaluation report was already under development to be finalised in August 2016. It was agreed this would be confirmed with Helen Edwards.

7.2 MH highlighted the proposal to transfer responsibility for the

administration of the West of England AHSN to the Royal United Hospitals Bath Foundation Trust and advised that the CCG was invited to attend an extraordinary meeting on the 28th February 2016 to discuss this further. MH requested any comments on this issue to be forwarded to her.

Page 8 of 8

The meeting closed at 2:50pm. Date and time of next meeting: Thursday 3rd March 2016 at 2pm in the Boardroom at Sanger House. Circulation: GCCG Governing Body and attendees and at today’s meeting.

Page 1 of 8

Gloucestershire Clinical Commissioning Group

Minutes of the Priorities Committee held at 2.00 p.m.

on Thursday 10 March in the Board Room, Sanger House

1. Apologies for Absence 1.1 Apologies were noted as above.

Present: Dr Helen Miller (HM) Clinical Chair Andrew Beard (AB) Deputy Chief Finance Officer Dr Tristan Lench (TL) GP Liaison Lead - Forest Locality Colin Greaves (CG) Lay Member, Governance Dr Charles Buckley (CBu) GP Liaison Lead - Stroud & Berkeley Vale

Locality Mark Walkingshaw (MW) Director, Commissioning Implementation Dr Jeremy Welch (JW) GP Liaison Lead - Tewkesbury Locality Dr Caroline Bennett (CBe) GP Liaison Lead - North Cotswolds Locality Julie Clatworthy (JC) Registered Nurse Mary Hutton (MH) Accountable Officer Alan Elkin (AE) Lay Member, PPE Marion Andrews-Evans (MAE) Executive Nurse and Quality Lead Ellen Rule (ER) Director of Transformation and Service

Redesign Joanna Davies (JD) Lay Member, PPE Dr Will Haynes (WH) GP Liaison Lead - Gloucester City Locality Helen Goodey (HG) Director of Locality Development and Primary

Care Margaret Willcox (MWi) Director of Adult Social Care Apologies: Dr Andy Seymour (AS) Deputy Clinical Chair Cath Leech (CL) Chief Finance Officer Dr Sadaf Haque (SH) GP Liaison Lead - Cheltenham Dr Hein Le Roux (HLR) GP Liaison Lead – Stroud and Berkeley Vale Sarah Scott (SS) Director of Public Health, GCC Dr Raju Reddy (RR) Secondary Care Doctor In Attendance: Zoe Barnes (ZB) Corporate Governance Officer Sadie Trout (ST) Programme Manager Sarah Hammond (SHm) Head of Information and Performance

Page 2 of 8

2. Declarations of Interest 2.1 All GPs declared an interest in outline business cases relating to

Primary Care (6.6 and 6.8). 3. Minutes of the Meeting held on the 4 February 2016 3.1 The minutes were approved as an accurate record. 4. Matters Arising 4.1 8.10.2015 Item 5 – Acupuncture It was advised that

decommissioning had occurred in some places. JW was not present for this part of the meeting therefore it was agreed that this item would remain open for feedback from him. Item open.

4.2 8.10.2015 Item 6 – NOACs It was agreed that the three actions

relating to NOACs would be merged into one item and feedback brought to the next meeting. Item open.

4.3 The following matters were closed as actions had been completed:

4.2.2016 Item 6 – De-Prioritising 4.2.2016 Item 6.8.2 – Prioritisation Matrix 4.2.2016 Item 6.8.4 – CPGs information

5. Structured discussion of programmes and investments for

2016/17

Master Priorities Committee Presentati

5.1 ER presented the attached PowerPoint which was a detailed overview of the outline business cases and the approach to prioritisation.

5.2 AE noted that the summary of the approach was lacking within the

PowerPoint. 5.3 AB discussed finance and highlighted the key points from the

presentation:

2016/17 Draft budget Cost pressures

Page 3 of 8

Investments Budget – reserves Mental Health Inherent risks

5.4 CG queried the contingency and headroom. AB advised that this

was applied to Primary Care for delegated budgets. 5.5 CBu wondered if an evaluation of Choice + had been completed.

MW confirmed that this was being commissioned along with a review of the urgent care offer in each locality.

5.6 AE wondered how positive the CCG felt about building in growth in

QIPP shortfall. Helen Goodey joined the meeting at this point. 6. Outline Business Cases 6.1 ER outlined the approach to QIPP and gave an overview of the

schemes for discussion. ER advised that the scoring matrix for each scheme would be completed later by each Governing Body member for collating and feeding back.

6.2 Project number 3 – Healthy Coaching for Behavioural Change 6.2.1 MWi noted that the implementation of this project would need to be

evaluated. 6.2.2 JC queried if this should be included in Primary Care and WH

suggested that some of the work would be time consuming and staffing issues should be considered.

6.2.3 JC requested that quality and outcomes was included. 6.2.4 CG recommended that this project was included lower on the

priorities list as outcomes would be difficult to measure. ER explained the ‘checking’ process for business cases and advised that they would still need to be prioritised even if it was felt they were not viable.

6.2.5 It was summarised that this project was strategically positive

however capacity would be an issue and that there was a need to

Page 4 of 8

evaluate the implementation. 6.3 Project number 8 – Patient information and self-care website 6.3.1 It was advised that this would be promoted as part of the plan. 6.3.2 WH noted that helping patients to do things for themselves was

important. In addition, it was agreed that this would be an important piece of work with small investment which would be easy to evaluate.

6.4 Project number 13 - VCSE 6.4.1 Benchmarking was discussed and ER noted that this was difficult

however patients appeared to be benefitting from the service. 6.5 Project number 32 – Living with and beyond Cancer 6.5.1 It was noted that the Governing Body had agreed this programme in

principle previously however needed to agree it more formally. 6.6 Project number 36 – GP Education 6.6.1 The members discussed the possibility of capacity within the CCG

to deliver education. 6.6.2 It was agreed that the name of the project should be changed to

cover Primary Care in general within the OBC and that this was about education and training, not just education.

6.6.3 The GB accepted that implementation would be challenging if the

planning was not right. 6.7 Project number 4 – Healthy Habits, Healthy Communities 6.7.1 JC declared an interest in this project. 6.7.2 It was noted that this project should be prioritised higher due to the

potential impact. 6.8 Project number 37 – Primary Care Strategy

6.8.1 The Committee accepted that primary care strategy and

Page 5 of 8

improvement was imperative. It was advised that the strategy and workforce plan would give further information.

6.9 Project number 15 – Homeless Healthcare Team and potentially

violent patient service 6.9.1 The Committee discussed the growing need for support within this

area and investment was supported. 7. Resilience Funding 2016/17 7.1 ER highlighted slides 106 and 107 of the PowerPoint. 7.2 Discharge to assess was being considered separately because it

was a new scheme about enabling people to have more time spent with them at home.

7.3 It was agreed that further mapping of the process was needed and

then further information would be forwarded out to members. 8. Mental Health Schemes 8.1 Attention Deficit Hyperactivity Disorder (ADHD) 8.1.1 There were no comments on the ADHD scheme. 8.2 Personality Disorder Service (PDS) 8.2.1 MH advised that the CCG had submitted a bid for PDS and would

need to think about how this links in with the whole person approach and how it would work in practice.

8.2.2 MWi wanted to draw attention to how staff will be trained to deal

with people in the new service. 8.2.3 TL advised that this would be a small service which has arisen due

to a recommendation by 2Gether NHS Foundation Trust. 8.2.4 CBu suggested including training for the GP community as part of

the training and education project proposal (project number 36).

8.2.5 MH proposed that the service was supported however the OBC would need to be reviewed to be more comprehensive and this was

Page 6 of 8

agreed by the Committee. 8.3 Perinatal Mental Health (PMH) 8.3.1 It was noted that PMH was a national priority at present. 8.3.2 HM raised concerns that PMH needs to be joined up with the Health

Visiting teams. 8.4 Children’s Mental Health Transformation Plan 8.4.1 MH noted that the CCG was required to reflect where it considers

Mental Health schemes against the Children’s Mental Health plan and that further information needs to be brought back to a future meeting to discuss in more detail.

9. Disinvestment 9.1 ER advised that new opportunities for disinvestment were under

consideration and would be brought back to a future meeting. 9.2 CBu requested clarity on the process for de-prioritising and it was

confirmed that the same process would follow as prioritising and would be completed within the Priorities Committee.

10. Any Other Business 10.1 WH raised concerns that GPs were being asked to cover OOHs

shifts at short notice. CBe added that a conference call would be taking place with SWASFT next week. Reporting was requested on the target and numbers of staff per hour that are rostered onto shifts. It was noted that this was about gathering evidence and consideration of the knock on effects for safety of patients and staff.

10.2 WH queried the process for the approval of endometrial biopsies.

JC also requested assurance of the clinical governance arrangements. ER advised that the planned care team had taken this on and would be able to answer queries. MAE advised she had sign off responsibility however suggested that these would be better approved by a Doctor on the Governing Body (GB) rather than herself as Executive Nurse. It was agreed that something would be included in What’s New This Week.

Page 7 of 8

10.3 10.3.1

The process for the recruitment of the Clinical Chair was discussed and MH informed the GB that the comments received on the paper at the Development Session on 25 February had been incorporated. HM discussed her concerns around the number of sessions per week. HM advised that since the commencement of the CCG the role had evolved quite significantly therefore 5 sessions was not enough to complete the role effectively whilst maintaining a positive work life balance. The GB discussed this further and gave their views including:

The importance of maintaining the independence of the Clinical Chair

Considering against the sessions specified to be completed per week by the Deputy Clinical Chair

The Clinical Chair needs to spend enough time in practice to be able to be an ‘acting GP’ who represents the views of GPs and practices.

10.3.2 The GB voted on the number of sessions per week to be completed

by the Clinical Chair and therefore included within the job description and advert. The vote was for 6 sessions per week, with 1 virtual session (7 sessions, 3 days with 1 floating day). 16 voted in favour and 1 member abstained from the vote.

10.4 MH circulated a draft letter ‘Primary Care Clinical Leadership

Opportunities’ which was for views and comments from the GB prior to forwarding to members. The letter proposed approaches to taking forward testing and developing models of care following feedback from locality events and also outlined the request for a lead per locality to be identified.

10.4.1 CG noted that resources would be the next consideration afterward. 10.4.2 JC suggested that the language and governance was clear within

the letter to make sure this was easy to interpret. 10.4.3 WH queried the timeframe and wondered if it was too short for

localities to consider and to identify a lead (by 25 March). 10.4.4 AE summarised that the Governing Body accepted the concept in

principle however more detail was required. It was agreed that the

Page 8 of 8

letter would be circulated electronically for further comments. The meeting closed at 5:00pm. Date and time of next meeting: Thursday 19th May 2016 at 2pm in the Boardroom, Sanger House. Circulation: GCCG Governing Body and attendees and at today’s meeting

Documents

Governing Body Room, Sanger House, Brockworth, Gloucester ... · Governing Body Meeting to be held at 2pm on Thursday 26th May 2016 in the Board Room, Sanger House, Brockworth, Gloucester