Meeting in Public of the Camden CCG Governing Body Wednesday 14 March 2018 14:00 - 16.00

PART I

AGENDA

Item Title Presenter Action Paper Time Page 1. Introduction1.1 Apologies for Absence Dr Neel Gupta Note Verbal 14.00 -

1.2 Declarations of Interest Dr Neel Gupta Note 1.2 14.01 3

1.3 Declarations of Gifts and Hospitality Dr Neel Gupta Note 1.3 14.03 -

1.4 Minutes of the Previous Meeting Dr Neel Gupta Approve 1.4 14.05 7

1.5 Action Log Dr Neel Gupta Note 1.5 14.07 15

2. Questions from the Public -

Members of the public have the opportunity to ask questions. These must relate to items that are on the agenda for this meeting and should take no longer than three minutes per person.

3. Chair, Accountable Officer, Patient and Quality Reports3.1 Chair’s Report Dr Neel Gupta Note 3.1 14.15 17

3.2 Accountable Officer’s Report Helen Pettersen

Approve 3.2 14.25 21

3.3 The Patient Voice Report Kathy Elliott Note 3.3 14.35 25

3.4 Quality and Clinical Effectiveness Report Charlotte Cooley

Note 3.4 14.40 31

4. Strategy4.1 PMS Update Sally

MacKinnon Note 4.1 14.45 39

4.2 Musculoskeletal Service Update Dr Matthew Clark

Note 4.2 14.55 65

4.3 Analysis of Non-elective Admissions Delyth Ford Note 4.3 15.05 71

5. Finance and Performance5.1 Budget 2018/19 Report Simon

Goodwin Note 5.1 15.15 83

5.2 Finance Report Simon Goodwin

Note 5.2 15.25 95

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5.3 Performance Report Richard Cartwright

Note 5.3 15.35 105

6. Governance

6.1 Board Assurance Framework Richard Strang Note 6.1 15.45 125

6.2 NCL Joint Commissioning Committee Terms of Reference

Helen Pettersen

Approval 6.2 15.50 139

7. Committee Reports – For information only

15.55

7.1 Finance, Performance and QIPP Committee

Dr Birgit Curtis Note 7.1 155

7.2 Integrated Commissioning Committee

Dr Matthew Clark

Note 7.2 159

7.3 Localities Report

Dr Jonathan Levy

Note 7.3 163

7.4 Procurement Committee Kathy Elliott

Note 7.4 167

7.5 Health and Wellbeing Board Dr Julie Billett Note 7.5 171

8. Any other Business

9. Date of Next Meeting: 9 May 2018

REGISTER OF INTERESTS A register of members’ interests is available on the Camden CCG website

http://www.camdenccg.nhs.uk

A conflict of interest is defined as “a set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or

assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold”.

Managing conflicts of interests in the NHS: Guidance for staff and organisations 2017.

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Declared From Updated

Fina

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Non

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Prof

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Inte

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Non

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Pers

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Swiss Cottage Surgery Yes Yes No Direct Owner and GP Partner 16/12/2016 01/07/2007 13/6/2017Haverstock Healthcare Ltd Yes Yes No Direct Swiss Cottage Surgery is a shareholder 16/12/2016 01/07/2007 13/6/2017Swiss Cottage Private General Practice Yes Yes No Direct Owner and Shareholder 16/12/2016 01/01/2016 13/6/2017CHE Neighbourhood Yes Yes No Direct Swiss Cottage Surgery is affiliated to this neighbourhood 16/12/2016 01/08/2016 13/6/2017Cadence Minerals PLC Yes No No Direct Shareholder 16/12/2016 01/07/2014 13/6/2017Docmartin Residential Yes No No Direct Owner shareholder of property investment company 18/02/2017 13/6/2017Children's Trust Partnership No Yes No Indirect CCG Representative 16/12/2016 01/07/2014 13/6/2017North Camden Zone No Yes No Indirect CCG Representative 16/12/2016 01/07/2015 13/6/2017Camden Youth Foundation No Yes No Indirect CCG Representative 16/12/2016 01/08/2016 13/6/2017Central Health Evolution Limited Yes Yes No Direct Shareholder and Founding Member 22/03/2017 13/6/2017Hampstead Group Practice Yes Yes No Direct Nurse Practitioner 18/07/2017Haverstock Healthcare Limited Yes Yes No Direct Works at out of hours hub at weekend 18/07/2017Camden LMC No Yes No Direct Practice Nurse Representative, Not voting, observer role 18/07/2017Royal College of Nursing No Yes No Direct Member 18/07/2017City University Yes Yes No Direct Honourary lecturer for nursing and midwifery 29/09/2017West Hampstead Medical Centre Yes Yes No Direct GP Partner 14/12/2016 01/11/2012 05/07/2017Haverstock Healthcare Ltd Yes Yes No Direct West Hampstead Medical Centre is a shareholder 14/12/2016 01/11/2012 05/07/2017KCA Architects No No Yes Indirect Company Secretary and husband is a Director 14/12/2016 01/01/1998 05/07/2017Central Health Evolution Limited Yes Yes No Direct Shareholder 22/03/2017 05/07/2017Prince of Wales Group Practice Yes Yes No Direct Practice Manager 13/12/2016 12/06/2017SanKtus Welfare Project - Welfare Charity No No Yes Direct Treasurer 13/12/2016 12/06/2017

Dr Neel Gupta Elected GP and GB Chair The Keats Group Practice Yes Yes No Direct Salaried Employee 15/11/2016 01/08/2011 14/8/2017

James Wigg and Queens Crescent Practices Yes Yes No Direct GP Partner 15/11/2016 01/09/2015 12/06/2017Haverstock Healthcare Ltd Yes Yes No Direct Shareholder in GP Federation 15/11/2016 01/09/2015 12/06/2017Hampstead Group Partner Yes Yes No Direct Partner 29/11/2016 14/06/2017Haverstock Healthcare Ltd Yes Yes No Direct Shareholder in GP Federation 29/11/2016 14/06/2017CCAS Assessor Yes Yes No Direct GP Assessor 29/11/2016 14/06/2017UCLH Council of Governors No Yes No Indirect Camden CCG rep on UCLH Council of Governers 01/03/2018 13/06/2017Bloomsbury Surgery Yes Yes No Direct GP Partner 13/06/2017 13/06/2017Central Health Evolution Limited Yes Yes No Direct GP Practice is a Member 13/06/2017 13/06/2017CCAS Assessor Yes Yes No Direct 2-4 sessions per month 13/06/2017 23/8/2017

Parliament Hill Medical Centre Yes Yes No DirectSalaried Employee. The partners at Parliament Hill Medical Centre are shareholders of Haverstock Health. 11/07/2017

Care UK, HMP Pentonville Yes Yes No Direct Salaried GP (1 day per week) 11/07/2017

Public Health England No No Yes IndirectPartner, Mr Peter Graham is a civil servant and works at Public Health England as a partnership marketing manager. 11/07/2017

Nature of InterestDeclared Interest- (Name of the organisation and nature of business)Name

Position (s) held- i.e. Governing Body, Member practice,

Employee or other

Date of InterestType of Interest

Is the interest direct or indirect?

Elected Voting Members

Jonathan Duffy Elected Practice Manager

Dr Jonathan Levy Elected GP Representative

Dr Sarah Morgan

Dr Kevan Ritchie Elected GP Representative

Dr Martin Abbas Elected GP Representative

Dr Birgit Curtis Elected GP Representative

Elected GP Representative

Elected Practice NurseCharlotte Cooley

Dr Philip Taylor Elected GP Representative

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Director of Public Health Camden and IslingtonYes Yes No Direct Salaried Employee 15/11/2016 01/02/2013 12/06/2017Vice-chair of London Association of Directors of Public Health No Yes No Direct 15/11/2016 01/01/2014 12/06/2017Lewisham and Greenwich NHS Trust Yes Yes No Direct Paediatric Registrar 15/11/2016 01/03/2013 12/06/2017Welbodi Partnership - registered UK Charity No No Yes Direct Board Member 15/11/2016 08/08/2008 12/06/2017

Kings College London No No No Indirect

Wife is a research fellow which is funded by the NHS National Institute of Health Research and Tommy's Charitable Trust 15/11/2016 01/10/2014 12/06/2017

Nursing and Midwifery Council No Yes No Direct Registrant Panellist for the Conduct and Competence Panels 16/11/2016 01/02/2013 12/06/2017The Order of St John Priory Group for Greater London No No Yes Direct Member 29/03/2017 12/06/2017Caversham Group Practice No Yes No Direct Member of the Patient Participation Group 12/12/2016 13/06/2017Kaeconsulting - independent consultancy Yes No No Direct Owner/Director 12/12/2016 13/06/2017UK Public Health Register (UKPHR) No Yes No Direct Assessor and Chair of the Registration Panel 12/12/2016 13/06/2017Faculty of Public Health No Yes No Direct Member 12/12/2016 13/06/2017PHAST - public health consultancy No Yes No Direct Associate 12/12/2016 13/06/2017

Simon Goodwin Chief Finance Officer, NCL CCGs East London NHS Foundation Trust Yes No No Indirect Wife is a senior manager 14/06/2017 14/06/2017

Helen PettersenAccountable Officer, NCL CCGs and NCL STP Convenor No declared interests Nil return 05/04/2017

Richard Strang Lay Member Tavistock and Portman NHS Foundation Trust No Yes Yes Direct Former Non-Executive Director 31/07/2017

Young Foundation Yes Yes No Direct Chief Executive Officer 09/08/2017

Member of the House of Lords Yes Yes No DirectBaroness Thornton - Labour and Co-operative Member From 1.11.2017: Opposition spokesperson for Health 09/08/2017 23/07/1998 1/11/2017

London School of Economics No Yes Yes Direct Emeritus Governor 09/08/2017

Social Enterprise UK No Yes Yes Direct Patron 09/08/2017

Healthcare and Assistive Technology Society No Yes Yes Direct Chair of the Advisory Panel and Patron 09/08/2017

Cabinet Member for Health and Adult Social Care Yes Yes No Direct Councillor, Camden Borough Council 02/10/2017St Michael's Primary School No Yes No Direct Governor of St Michael's Primary School 02/10.2017Unison No Yes No Direct Union Member 02/10/2017Camden LMC No Yes No Direct Chair 20/09/2016 18/06/2017

Camden, Barnet and Brent GP Practices Yes Yes No DirectLocum GP working across multiple GP practices and GP Appraiser (paid work) 18/01/2017 18/06/2017

Medical Women's Federation No Yes No Direct Trustee - unpaid 18/01/2017 18/06/2017UK General Practitioners Committee Yes Yes No Direct Elected Member - paid honoraria for attendance 18/01/2017 18/06/2017

NHS Digital Yes Yes No Indirect

Husband is a member of an advisory panel for e-Consult and is currently seconded to NHS Digital as a national medical director clinical fellow 18/01/2017 18/06/2017

Pulse Live Conferences Yes Yes No Direct Speaker - paid honoraria 18/01/2017 18/06/2017

Medical Student OSCE examiner Yes Yes No Direct Paid for work completed 18/01/2017 18/06/2017

Simone Hensby Voluntary Sector Representative Voluntary Action Camden Yes Yes No Direct Executive Director 19/12/2016 18/06/2017

Camden Patient & Public Engagement Group No Yes Yes Direct Chair 16/08/2017 14/08/2017

Non-Voting Members

Appointed Voting Members

Julie Billett Public Health Representative

Dr Mathew Clark Secondary Care Doctor

Kathy Elliott

Glenys Thornton Lay Member

Dr Farah Jameel LMC Observer

Patricia Callaghan Health and Wellbeing Board Observer

Lay Member

Jane Davis OBE Registered Nurse

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Adelaide Medical Centre No Yes Yes Direct Chair of Patient Participation Group 16/08/2017

Universal Offer Delivery Group No Yes Yes Direct CPPEG Patient Representative 27/09/2017London Borough of Camden Yes Yes No Direct Director of Integrated Commissioning 23/11/2016 13/06/2017Camden Schools Project Ltd Yes Yes No Direct Director 23/11/2016 13/06/2017Camden BSF SPV Ltd Yes Yes No Direct Director 23/11/2016 13/06/2017Camden SPV Holdings Ltd Yes Yes No Direct Director 23/11/2016 13/06/2017Camden Healthwatch No Yes No Direct Chair 29/06/2017 12/07/2017Chomley Garden Surgery Practice No Yes No Direct Patient Participation Group Representative 06/01/2016 12/07/2017UK National Thalassemia and Sickle Cell Group (NHS England) No Yes No Direct Lay Member 06/01/2016 12/07/2017Ambassador Little Village Charity No No Yes Direct 12/07/2017 12/07/2017Camden Reach Pregnancy Project Yes Yes No Direct Project Coordinator 12/07/2017 12/07/2017London Antenatal Screening Programme No Yes No Direct Lay Member representative 12/07/2017 12/07/2017

Rebecca Booker Deputy Chief Finance Officer No interests declared Nil return 18/10/2017Mike Cooke Chief Executive No interests declared Nil return 21/11/2016 28/06/2017Sally MacKinnon Transformation Programme Director Change the Record Management Consultancy No No Yes Indirect Executive Director. Company owned by husband David

MacKinnon 25/11/2016 01/10/2014 20/06/2017Meena Mahil Interim Director of Primary Care

and Community CommissioningOptologie Ltd Yes No No Direct

Director 02/02/2018 02/02/2018 02/02/2018Sarah Mansuralli Chief Operating Officer No interests declared Nil return 12/06/2017 12/06/2017Jennifer Murray-Robertson

Director of Commissioning and Contracting

No interests declared Nil return 02/02/2018 02/02/2018 02/02/2018

Ian Porter Director of Corporate Services No interests declared Nil return 14/11/2016 16/06/2017Neeshma Shah Director of Quality and Clinical

EffectivenessIndependent consultant Yes Yes No Direct Occasional ad hoc consultancy work on sole trader basis on

subject matter relating to medicine, the pharmacy profession and the health and social care landscape 25/11/2016 24/04/2013 18/06/2017

Saloni Thakrar Healthwatch Representative

Richard Lewin Local Authority Representative

Patient RepresentativeHilary Lance

Attendees

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CAMDEN CLINICAL COMMISSIONING GROUP GOVERNING BODY Minutes of the Meeting held on Wednesday, 15 January 2018 at 2pm

Mary Ward House Conference and Exhibition Centre

5-7 Tavistock Place, London WC1H 9SN.

Present: Elected Voting Members: Dr Neel Gupta Chair Dr Martin Abbas Elected GP Representative Dr Birgit Curtis Elected GP Representative Dr Jonathan Duffy Elected Practice Manager Dr Jonathan Levy Elected GP Representative Dr Sarah Morgan Elected GP Representative Dr Philip Taylor Elected GP Representative Appointed Voting Members: Dr Matthew Clark Secondary Care Doctor Simon Goodwin Chief Finance Officer, NCL CCGs Helen Pettersen Accountable Officer, NCL CCGs Richard Strang Lay Member Glenys Thornton Lay Member Non-Voting Members: Simone Hensby Voluntary Sector Representative Hilary Lance Patient Representative Richard Lewin Local Authority Representative, London Borough of Camden (LBC) Councillor Richard Olszewski Health and Wellbeing Board, London Borough of Camden Saloni Thackar Healthwatch Representative In Attendance: Rebecca Booker Deputy Chief Finance Officer, Camden CCG Carolyn Cullen Interim Board Secretary, Camden CCG (Minutes) Charlotte Mullins Director of Sustainable Insights Partnerships, Camden Jennifer Murray-Robertson Director of Commissioning and Contracting David Stout Senior Programme Director (Item 3.1 only) Steve Burak Member of the Public

1. Introduction

1.1 Apologies for Absence 1.1.1 Apologies were received from Charlotte Cooley, Jane Davis, OBE, Kathy Elliott, Sally Dilini

Kalupahare, Sally Mackinnon, Sarah Mansuralli and Dr Kevan Ritchie. 1.2 Declaration of Interest 1.2.1 The Register of Interests was considered. There were no new declarations of interest. 1.3 Declarations of Gifts and Hospitality 1.3.1 There were no declarations of gifts and hospitality.

1.4 Minutes of the Meeting held on 8 November 2017

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1.4.1 The Governing Body considered the minutes of the meeting held on 8 November 2017 and no points of accuracy were raised.

1.4.2 The Governing Body agreed that the minutes of the meeting held on 13 September 2017 were a true record.

1.5 Action Log 1.5.1 The Governing Body considered the updates on the actions arising from the previous meeting.

Item 4 8 November 2017: Neel Gupta updated the Governing Body as regards to the GP at Hand Service and the concerns of the CCG including the risk of destabilising local general practice. A further update will be given to the March 2018 after further liaison with the LMC (Local Medical Committee).

1.5.2 The Governing Body agreed to note the Action Log.

2. Chair, Accountable Officer, Patient and Quality Reports

2.1 Chair’s Report 2.1.1 The Chair highlighted recent successes in national awards. Camden CCG/Orion Health had

won the Tech Project of the Year (Heath Technology Newspaper Awards) and the Camden GP Website had won the award for the best public sector website at the User Experience UK Awards. Camden CCG also received a ‘good rating’ for patient and public engagement work from NHS England. The CCG is saying goodbye to Gordon Houliston Assistant Director of Primary Care, Charlotte Mullins Director of Sustainable Insights and Delyth Ford Head of Sustainable Insights. The Chair thanked them for their dedicated work for Camden.

2.1.2 The Governing Body agreed to note the Chair’s Report. 2.2 Accountable Officer’s Report 2.2.1 Helen Pettersen welcomed Jennifer Murray-Robertson, Director of Commissioning and

Contracting to Camden CCG and announced that Sarah McDonnell had been appointed to the role of Director of Primary Care/Deputy Chief Operating Officer. Sarah will take up her post of 28th May 2018. Meena Mahil has been appointed interim Director of Primary Care.

2.2.2 A Transition Steering Group to oversee the transfer of commissioning functions from the

Council to the CCG has been established and the Continuing Healthcare (CHC) and Delayed Transfers of Care (DTOC) teams successfully transferred on 11 December 2017. The adult community commissioning function will also transfer to the CCG on the 31 January 2018.

2.2.3 Helen Pettersen highlighted recent initiatives to mitigate winter pressure:

• Discharge to Access pathway launched to undertake continuing healthcare needs

assessed in the community, rather than in hospital • £626,000 of additional funding for UCLH and the Camden and Islington NHS

Foundation Trusts • An additional 2,900 GP appointments during extended hours each month through

extended access services. 2.2.4 Helen Pettersen informed the meeting that a proposal to redevelop the St Pancras Hospital site

will be put out to public consultation once firm plans are in place. The CCG will be working very closely with Camden Council on the approach to consultation and with local residents, partners and stakeholders.

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2.2.5 Simon Goodwin informed the meeting that a tendering exercise for a Health Information

Exchange (HIE) is currently taking place. The results of the procurement will be reported to the March 2018 Governing Body meeting but Chair’s Action will be required for Camden CCG to proceed with the procurement in the interim. Action 1: Neel Gupta to report back to the March 2018 Governing Body meeting the results of the procurement for the Health Information Exchange (HIE) system.

2.2.6 The Chair invited comments:

a) Concern was expressed as to how patients will be engaged with the roll out of any new Health Information System in Camden

b) The impact of winter pressure at the Royal Free London was raised, particularly regarding the cancellation of elective surgery; it was made clear that the cancellation notice only referred to January 2018

c) Work is being undertaken with Camden & Islington NHS Foundation Trust regarding the development at St Pancras Hospital; Islington CCG is the lead commissioner for Camden & Islington NHS Foundation Trust and will lead the consultation process and planning.

2.2.7 The Chair asked for a vote on the approval of Chair’s action; and the following was approved

with no votes against or abstentions:

2.2.8 The Governing Body agreed to grant Chair’s Action to Neel Gupta to act on behalf of Camden CCG in the procurement of the Health Information Exchange

The Governing Body noted the Accountable Officer’s Report.

2.3 The Patient Voice Report

2.3.1 Glenys Thornton introduced the Patient Voice Report. Since the last Governing Body meeting

one Camden Patient and Public Engagement Group (CPPEG) operational meeting and one public meeting had been held. Issues raised included:

a) St Pancras Hospital development b) GP extended access c) Changes to the Musculoskeletal services d) Long Term Conditions Strategy e) National General Practice Survey f) Raising awareness of Camden Council’s Camden 2025 Plan.

2.3.2 Hillary Lance followed on with two short patient stories. An older female patient, was referred

by a neurologist at Queens Square for a follow-up up MRI scan. When the patient arrived at Queen Square the patient was taken aback to find the scan was to be done in a mobile unit not run by the hospital. The patient had the following to say:

• the van was cramped and not clean • the patient was able to observe another patient in the scanner • lockers were too small to take all belongings and items had to be left in a side room • before the scan the paper covering on the bed was replaced but the head area was not

wiped down • the scan equipment was claustrophobic and not as pleasant as previous scanners

experienced at Queens Square • However staff were pleasant and doing their best.

The second patient story concerned a patient who has cancer, who had transferred to UCLH. While the chemotherapy was unpleasant this patient had nothing but praise for the clinical care and personalised nursing care she had received.

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2.3.3 The Chair invited comments: The work of Camden Patient and Public engagement group (CPPEG) was commended by the

Governing Body as valuable and it was noted that the work of CPPEG had proved significant in the award of “Good” for patient and public engagement assessment by NHS England.

2.3.4 The Governing Body agreed to note the Patient Voice Report. 2.4 Quality and Clinical Effectiveness Report 2.4.1 Philip Taylor introduced the above report and drew attention to the following:

• UCLH had begun implementation of the National Early Warning Score (NEWS) system

which is designed to detect rapid deterioration of patients in A&E and is very helpful for the identification of sepsis

• Four more Never Events had been reported at the Royal Free London. Barnet CCG, as lead commissioner, is undertaking a thematic analysis of the incidents

• Current process for applying Deprivation of Liberty (DoL) by Central and North West London NHS Foundation Trust had been identified as not robust. The Trust has launched an investigation

• The Care Quality Commission undertook a re-inspection of Camden & Islington NHS Foundation before Christmas; their report and scores are not yet available.

2.4.2 The Chair invited comments:

a) There are not only four Never Events at the Royal Free London reported this month but

a total of eight Never Events since the start of the financial year; the work by Barnet CCG on analysing the root cause analysis of each of the Never Events is to be circulated to Governing Body members when available Action 2: Neeshma Shah to update the Governing Body once the Lead Commissioner has considered the outcome of the review of the Never Events by the Royal Free London

b) It was known that Central and North West London NHS Foundation Trust are not in compliance as regards their Statutory and Mandatory Training.

2.4.3 The Governing Body agreed to note the Quality and Clinical Effectiveness Report. 3. Strategy 3.1 Proposal to take in-house a range of Commissioning Support Unit Services

3.1.1 David Stout introduced the report which set out a proposal to take in-house a range of services

from North East London Commissioning Support Unit (NELSU) to the five CCGs across North Central London. The proposal has been developed subsequent to a review of current service provision in the light of new management arrangements for the five NCL CCGs and the development of the NCL Sustainability and Transformation Partnership (STP). David Stout stated that to minimise the period of uncertainty for staff, these changes should be implemented as soon as possible without compromising due process. Therefore Camden CCG Governing Body is asked to support the proposed approach and to give approval for notice to be given to NELCSU of the CCGs intention to bring services in-house.

3.1.2 The Chair asked for comments and Governing Body members stated they were supportive of the proposal.

3.1.3 The Governing Body agreed to support the proposed approach and gave approval for notice to be given to NELCSU of the CCG’s intention to bring services in-house.

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4. Finance and Performance 4.1 Finance and QIPP Report 4.1.1 Simon Goodwin introduced the Finance and QIPP report, which set out the CCG’s financial

position at the end of month 8 (November 2017) and gives the latest position with regarding delivery of the 2017/18 QIPP.

4.1.2 Simon Goodwin highlighted:

• At the end of month 8 the CCG is forecast to meet its control total of £414.7m for the financial year 2017/18 The CCG will meet its control total by the use of reserves and contingencies

• There has been a small decrease in acute over performance from £4.8m in month 7 to £4.5m in month 8. Acute over performance relates to £2.8m at the Royal Free London, £1m at UCLH and £1m at Imperial Healthcare Trust

• The main driver for acute sector over performance is non-elective expenditure; which was £5.9m at month 8

• The non-acute sector is forecasting an end of year over performance of £2.3m at the end of month 8. The main areas of over performance are: Continuing Heath Care (£0.9m), Primary Care Prescribing (£0.7m), Children’s Services (£0.4m), Mental Health Services (£0.2m) and Learning Disabilities (£0.1m)

• The total QIPP plan is £18.1m; currently the CCG is projecting an underperformance of £1.5m. A recovery plan for £2.8m has been put in place to manage this risk.

4.1.3 The Chair invited comments:

a) Questions were raised regarding the over performance by Imperial College Healthcare NHS Trust; it was explained that Camden CCG is now attending the Associate meetings at Imperial and their performance is being kept under close review

b) Questions were raised regarding the increased number of non-elective admissions. It was agreed that a deep dive into non-elective admissions would be presented to the March 2018 Governing Body Action 3: Charlotte Mullins to provide a deep dive into non-elective admissions for the March 2018 Governing Body meeting

c) Questions were raised on how the patient voice is heard in the identification and sign off of QIPP schemes and there was a request for a patient facing narrative explaining the 2018/19 QIPP plan in plain English.

4.1.4 The Governing Body agreed to note the Finance Report. 4.2 Performance Report 4.2.1 Charlotte Mullins highlighted the key performance issues which included:

• Referral to Treatment (RTT), Cancer waiting times and A&E four hour waits as key

areas of concern for the CCG • In November 16 out of 22 London Trusts did not meet the A&E four wait 95% standard • In October both the Royal Free London and UCLH did not meet their RTT targets • However Cancer 62 day performance in Camden has improved significantly and the

CCG is close to reporting a compliant position • In October diagnostics standards were not met; this was largely driven by

underperformance at the Royal Free London.

4.2.2 The Chair invited comments:

a) The improvement to a compliant position on the 62 day Cancer performance target was welcomed

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b) Concern was expressed on the failure to meet the call waiting times by the NCL Urgent Care Out of Hours Provider in Quarters 2 and 3; this will be continued to be monitored and raised with the Provider

c) An explanation regarding underperformance regarding diagnostic standards at the Royal Free London to be given to the March 2018 Governing Body meeting Action 4: Charlotte Mullins to provide an explanation for the underperformance of diagnostic targets at the Royal Free London to the March 2018 Governing Body meeting.

4.2.3 The Governing Body agreed to note the contents of the Performance Report. 5. Governance 5.1 Board Assurance Framework 5.1.1 Richard Strang introduced the Board Assurance Framework (BAF) and confirmed that the Audit

Committee had that morning received a satisfactory internal audit report on the processes that underpin the production of the BAF.

5.1.2 Currently there are 13 risks on the BAF with one new risk added and one risk removed. The new risk is JCC 20 which is a risk to the delivery of the Referral to Treatment waiting time standard. This has been escalated from the NCL Joint Commissioning Committee. The CCG is continuing to work with UCLH and the Royal Free London to improve RTT performance via Remedial Action Plans.

5.1.3 The Governing Body agreed to note the Board Assurance Framework 5.2 Audit Committee in Common 5.2.1 Richard Strang introduced the above report which proposed the establishment of a North

Central London Audit Committee in Common. The benefits of an Audit Committee in Common are that it maximises strategic collaboration across North Central London Clinical Commissioning Groups and strengthens oversight and assurance of internal controls. A Committee in Common also reduces the amount of internal and external auditor resource needed and better deploys learning through information, knowledge and skills sharing and offers the opportunity to commission audit work across North Central London.

5.2.2 Simon Goodwin explained that it is not possible to establish a joint audit committee as each CCG is required to retain their own individual audit committee. However it is possible to hold individual CCG audit committees at the same time, in the same place with a common agenda and this is the proposal being put forward in this report. Such a Committee will be known as North Central London Audit Committee in Common.

5.2.3 Simon Goodwin informed the Governing Body that, at the current time, the North Central London Audit Committee in Common will comprise of all North Central London CCG audit committees with the exception of Barnet who will join at a later date.

5.2.4 The Chair invited comments: Governing Body members expressed that this was the right way to go, but that it was important to balance a Camden CCG audit programme with a North Central London programme.

5.2.5 The Chair asked for a vote; and the following was approved with no votes against or abstentions.

5.2.6 The Governing Body approved:

• The establishment of an North Central London Audit Committee in Common • The Terms of Reference for the North Central London Audit Committee in

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Common and the Camden Clinical Commissioning Group Audit Committee 6. Committee Reports 6.1 Finance, Performance and QIPP Committee 6.1.1 The above report was considered by the Governing Body. 6.1.2 The Governing Body agreed to note the Finance, Performance and QIPP Committee

Report 6.2 Integrated Commissioning Committee 6.2.1 The above report was considered by the Governing Body. 6.2.2 The Governing Body agreed to note the Integrated Commissioning Committee Report 6.3 Localities Report 6.3.1 The above report was considered by the Governing Body. 6.3.2 The Governing Body agreed to note the Localities Report 6.4 Procurement Committee 6.4.1 The above report was considered by the Governing Body. 6.4.2 The Governing Body agreed to note the Procurement Committee Report 6.5 NCL Primary Care in Common Committee 6.5.1 The above report was considered by the Governing Body. 6.5.2 The Governing Body agreed to note the NCL Primary Care in Common Committee

Report 7. Any Other Business 7.1 Draft March 2018 Meeting agenda 7.1.1 The Governing Body agreed to note the planned agenda items for the March 2018

Governing Body meeting. 8. Questions from the Public 8.1 Questions from Member of the Public 8.1.1 One member of the public attended and asked the following questions:

“In relation to the Board Assurance Framework, do you consider that there is a risk to system resilience in relation to acute hospitals not having sufficient nurses to care for patients because nurses cannot afford to live locally?” It was explained that acute hospitals are responsible for employing nurses so any risk regarding the sufficiency of nurses would be recorded on an acute hospital risk register. The local authority works closely with the main employers in the Borough to establish housing needs and is currently producing Camden 2025 which sets out Camden’s planning intentions.

“In relation to the Accountable Officer’s Report, will having groups of Clinical Commissioning

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Groups working to a single strategic plan help or hinder the development of Camden’s health services?” Having a strategic plan across all five boroughs will help to focus on what the health needs of the population are and how best they can be met. There are also opportunities as shown today as regards having an Audit Committee in Common to streamline services and make saving which can then be better deployed to frontline services.

8.3. There was no further business and the Chair closed the meeting at 16.15 pm.

These minutes are agreed to be a correct record of the Governing Body meeting of Camden Clinical Commissioning Group held on 15 January 2018

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

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CAMDEN CLINICAL COMMISSIONING GROUP GOVERNING BODY 2017/18 ACTION LOG - PART 1

Meeting Date

Action No.

Action Lead Deadline Update

15 January 1 Accountable Officers Report GB to be informed of the results of the procurement for the Health Information Exchange (HIE) system

Neel Gupta March 2018 The results of the procurement for the Health Information Exchange (HIE) system will be reported in Part II of this Governing Body.

15 January 2 Quality and Clinical Effectiveness Report The Governing Body to be updated once the Lead Commissioner has considered the outcome of the review of Never Events by the Royal Free London

Neeshma Shah March 2018 There were eight Never Events reported since April 2017 at the Royal Free London that were considered in the review. The key themes identified in the review of these focused on embedding the World Health Organisation (WHO) checklist, improved checks on the choice of devise, ensuring consistent staff understanding of the “count” policy in theatres, improving he access to medical photography across sites and services, and the availability of finger tourniquets. The Lead Commissioner is satisfied with the review and associated action plan.

15 January 3 Finance and QIPP Report A deep dive into the reasons for the increase in non-elective admissions to be undertaken for consideration at the March 2018 Governing Body meeting

Charlotte Mullins

March 2018 A report on Non-Elective Admissions is on this agenda.

15 January 4 Performance Report GB Members to receive an explanation for the underperformance of the Royal Free London in meeting its diagnostic targets.

Charlotte Mullins

March 2018 Sally Mackinnon will provide a verbal update at the 14 March 2018 Governing Body meeting.

8 November

1 Healthy London Partnership

GB to receive an update on the link with the STP in the next HLP report. Board Secretary to add to annual cycle of business.

Board Secretary

May 2018

15

8 November 4 GP at Hand Service On behalf of NCL write to NHS England about the on-line app which has been launched in West London to understand the reasons for the implementation of the new technology/approach and to point out the impact on commissioners.

Neel Gupta March 2018 Neel Gupta will provide an update as regards the GP at Hand Service following further liaison with the Local Medical Committee (LMC).

13

September 5 STP Programme Spend

GB to consider detailed STP programme spend and evidence of delivery/value for money at May 2018 meeting.

Helen Pettersen

May 2018

16

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Chair’s Report

Agenda Item 3.1 Date 02/03/2018

Committee Chair (where applicable)

Lead Director Dr Neel Gupta, Chair Tel/Email Neel.gupta@nhs.net Report Author Tel/Email GB Sponsor(s) (where applicable)

Tel/Email

Report Summary

The purpose of this report is to highlight the Chair’s business activities and to provide an update on key areas of work.

Purpose Information

Approval To note √

Decision

Recommendation The Governing Body is asked to note the content of this report.

Strategic Objectives Links

The Chair’s business activities are linked to all the CCG’s strategic objectives.

Identified Risks and Risk Management Actions

Where applicable any risks are identified within the report.

Conflicts of Interest

None

Resource Implications

Not applicable

Engagement

Engagement activities are contained within the report.

Equality Impact Analysis

There are no equality impacts arising from this report.

Report History and Key Decisions

The Chair’s Report is a standing item on the Governing Body agenda.

Next Steps None

Appendices

None

17

18

Chair’s report January to March 2018 1. Introduction

This is my regular written report to the Governing Body, updating on the business that I undertake on behalf of the CCG and highlighting key areas of work being progressed in the CCG. 2. Transfer of adults community commissioning Following the decision to transition adult community commissioning back to the CCG in November, I am pleased to report that work to achieve this has concluded. The Continuing HealthCare and Delayed Transfers of Care team transferred on 11th December, just ahead of the festive season. This enabled the CCG to support UCLH in managing winter demand through close joint working and having an onsite presence at the hospital over the holiday period. As part of the transfer arrangements, the CCG and Council have worked hard to mitigate the effect of any impact on service users and carers through a robust and seamless approach to transferring the services/contracts, which include: Establishing a contract task and finish group to ensure seamless transfer of actions

relating to commissioning and contract management of these services Increasing CCG dedicated leadership and capacity to assume responsibilities Timely stakeholder and provider communications sent in January providing contact

names and details of new CCG contract managers. Next steps include reviewing and refreshing S75 documentation in partnership with the Council to clarify arrangements for integrated commissioning arrangements, thereby enabling a stronger partnership going forward. We will also be introducing joint CCG and Council management of the remaining integrated commissioning teams, Mental Health/Learning Disabilities and Children’s from March 2018. 3. CCG Business Plan 2018/19 Following a series of very productive workshops, the Governing Body and the Executive Management Team (EMT) have finalised the CCG 2018-19 Business Plan, focused on a reduced number of critical priorities. The business plan is aligned to the QIPP Plan for 2018/19 and the Sustainability and Transformation Plan (STP) deliverables. The focus on ensuring financial sustainability is a key feature of all CCG plans for 2018/19 in order to regain a positive financial outlook which will support local control and autonomy of strategic commissioning decisions.

4. Key Meetings

A small number of CCG Governing Body members attended an informal Board to Board meeting with representatives from Islington CCG. The meeting focussed on areas of common interest and explored the benefits of collaborating on these. The meeting was positive and indicated that there were key areas where closer joint working would realise and enable multiple joint objectives being progressed and possibly accelerated. A further meeting is planned in three months.

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5. Celebrating Success

Camden CCG was rated as outstanding for its performance on the diabetes assessment framework, exceeding both the average performance nationally and across NCL CCGs. We ensured that:

• 100% of GP practices are compliant with the National Diabetes Audit • 43% of patients with type 2 diabetes are achieving all NICE recommended treatment

targets (NCL average 40%, England average 41%) • 20% of patients with type 2 diabetes who have been diagnosed for less than a year are

attending a structured education programme (NCL average 5%, England average 7%).

This is a significant achievement for the CCG after many years of focused work around diabetes in primary, community and secondary care and one that should be celebrated and acknowledged. Thank you to all staff, patients and clinicians who have made this significant improvement which will benefit patients with diabetes and their families/carers.

North Central London CCGs were assessed positively in the feedback received in February from the 2018/19 QIPP Planning Status Reviews undertaken by NHS England, designed to assure the completeness of planning documentation for proposed 2018/19 schemes

6. Staff Changes

The CCG has had a number of staff changes with the departure of Gordon Houliston in January and Charlotte Mullins in February. I’m pleased to advise that the Sustainable Insights Directorate will be ably led by Hasib Aftab (Assistant Director GP IT & Systems) until further developments aligned to the NCL Digital work stream and CCG Operating model are confirmed.

I’m also very pleased to welcome Meena Mahil who has joined us as interim Director of Primary and Community Commissioning. Meena will provide senior leadership to primary and community commissioning until Sarah McDonnell returns from sabbatical at the end of May 2018 to take up the substantive role of Director of Primary and Community Commissioning/Deputy Chief Operating Officer.

Neel Gupta Chair Camden Clinical Commissioning Group

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Camden Clinical Commissioning Group Governing Body Meeting 14th March 2018

Report Title Accountable Officer’s Report

Agenda Item 3.2 Date

Lead Director N/A

Tel/Email

Report Author Helen Pettersen, NCL Accountable Officer

Tel/Email h.pettersen@nhs.net

GB Sponsor(s) (where applicable)

Tel/Email

Report Summary The Accountable Officer’s Report highlights key issues for the Governing

Body’s consideration that are not covered elsewhere on the agenda.

Purpose (tick one only)

Information Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of this report.

Strategic Objectives Links

The Accountable Officer highlights a variety of issues within the report and these may link with all strategic objectives.

Identified Risks and Risk Management Actions

Where applicable any risks are identified within the report.

Conflicts of Interest

There are no conflicts of interest arising from this report.

Resource Implications

No direct implications, although each area described has resource implications for the CCG.

Engagement

Engagement activities are highlighted as appropriate.

Equality Impact Analysis

There are no equality impacts arising from this report.

Report History This report is a standing item on the Governing Body agenda.

Next Steps None

Appendices None

21

1. Introduction

This report provides an update on the key activities that the senior team and I have been involved in since the last Governing Body meeting.

2. Camden CCG operating model A revised Operating Model for the CCG, which sets out the functions that each directorate will be responsible for, and the supporting rationale was approved by the Governing Body in November and shared with staff in December 2017 for comment. Following this, Directors have been working through the capacity and skill mix required to deliver the functions within their respective Directorates. To support this programme of work, during the period of January 2018 and February 2018, Directors with support from Finance and Human Resources undertook to ensure reconciliation and alignment between the current organisational structures, staffing establishment data and financial budgets to develop the sub structures of each directorate. The majority of changes in the revised Operating Model underpin the need to strengthen the CCG’s core commissioning resources across acute, adults’ community and primary care and to embed substantive resources within the CCG to support QIPP transformation and delivery team. The operating model and sub structures will be subject to further staff engagement prior to implementation. The implementation phase will be overseen by the CCG’s Executive Management team and monitored against an implementation plan that aims to conclude by June 2018.

3. Winter planning

Despite continuous pressure on local hospitals over the winter months the system has been resilient and continued to manage overall patient demand. This is a testament to the impact and resilience of both in and out of hospital services to manage surges in demand and increased acuity of patients. A number of initiatives and plans were put in place at a local level to improve the urgent and emergency care pathway for patients which included: • Additional primary care capacity through extended access hubs • Introduction of Emergency Department streaming and redirection to primary care hubs • Increased support by our community and mental health providers and social services teams to

prevent hospital admissions where possible by supporting people at home and helping support efficient patient discharges

• Onsite presence by CCG teams to improve patient flow and progress discharges to more appropriate settings of care

This winter, we have seen excellent examples of system working across acute and non acute services to manage winter demand in a manner that ensures care is provided in the most appropriate setting and by the right professionals, whether this be at home, in community settings or in the hospital. There has been continued focus on the CCG’s Continuing Healthcare (CHC) and Delayed Transfers of Care (DTOC) teams to reduce the number of DTOCs and increase the number of CHC assessments being undertaken in the community as well as putting in place local escalation plans to ensure that the system flow is maintained during periods of peak demand. This has been the subject of considerable scrutiny by regulators and the CCG have developed a CHC improvement plan in response to this. A lessons learnt programme will commence to assess the winter planning process and outcomes in 2017/18. This will include a review of how additional winter funding was utilised, and recommendations for change for 2018/19.

4. Continuing Health Care Over the past year, the national focus on Continuing Health Care (CHC) performance has intensified and this is likely to further increase over the next few months. NHS England have indicated that they see transformation as being key in ensuring CHC services are fit for purpose for future needs of the local population whilst achieving nationally set performance targets. They have also stipulated that

22

they want to work with one Senior Responsible Officer for CHC for North Central London CCGs. Kay Matthews, Barnet CCG Chief Operating Officer is undertaking this strategic role on behalf of the 5 NCL CCGs. The responsibility for providing CHC will remain with the individual CCGs. In addition to this, Jenny Goodridge, Barnet CCG Director of Quality and Clinical Services will lead a project to review CHC clinical services across NCL with a view to establishing a consistent approach to service delivery. Becky Booker, Camden CCG Deputy Director of Finance will concurrently lead a review of the finance and business requirements of CHC services across NCL.

5. NCL Corporate Services

I am pleased to announce that following successful consultation with staff, the NCL corporate services proposal commenced implementation in early January 2018. I am also very pleased to advise that Ian Porter has been appointed Director of NCL Corporate Services. Following his appointment, Ian has been implementing the corporate services proposals and ensuring the review recommendations are achieved through a structure that is equitable across CCGs and fit for purpose.

6. Planning Guidance for 2018/19

The NHS Planning Guidance for 2018/19 was released at the beginning of February. A number of items are included that will impact on local commissioners and providers, including the expectations around NHS constitutional performance standards:

• that above 90% is achieved against the A&E standard by September 2018 • that the majority of providers achieve 95% against the A&E standard by March 2019 • that there is a reduction in the number of 52 week waiters by 50% by March 2019 and

number of incompletes (i.e. waiting list) to be no higher at March 2019 than March 2018 level These issues are being taken into account during the contract negotiations that are taking place for 2018/19. The planning guidance also stipulated that final agreement on contract values needs to take place by 23rd March 2018.

7. Contract Award – Internal Audit and Counter-Fraud Services The procurement process for the above concluded and recommended the award of the Internal Audit and Counter Fraud Services contract to RSM Risk Assurance Services (the NCL CCGs’ current provider of internal audit and counter fraud services). RSM presented the highest scoring bid submission and are therefore recommended for re-appointment.

8. Commissioning Support Unit Services

Following agreement at the five NCL CCG Governing Bodies in January 2018, we issued a notice letter to NELCSU of our intention to take in-house contract management (POD MDT) services and acute medicines management services. The next step is to submit a business case to NHS England for approval. TUPE consultation with the staff who will transfer will commence once we have received approval from NHS England. We held our first Governing Body Sub-Group meeting on 22 February. This sub-group is designed to give assurance to Governing Bodies that the process we are following is robust. At the first meeting we reviewed the project plan and risk register. The Sub-Group agreed that we should ensure that the business case to take these services back in-house is also approved by the individual governing bodies prior to commencing TUPE consultation through an agreed sign-off process or through delegated decision-making to the sub-group.

9. Contract Award – Internal Audit and Counter-Fraud Services

The procurement process has now concluded for the award of the Internal Audit and Counter Fraud Services contract. The contract award is to provide services to the CCGs in NCL along with WELC (Waltham Forest, Newham, Tower Hamlets, City & Hackney) and BHR (Barking & Dagenham, Havering, Redbridge). The award is for a period of 3-years with an optional extension of 2 years. The evaluation criteria used in the procurement process was:

23

• Technical (Quality) – 60% • Commercial (Cost) – 40%

The procurement process was fair, transparent and conducted in accordance with legislation. RSM Risk Assurance Services (the NCL CCGs’ current provider of internal audit and counter fraud services) presented the highest scoring bid submission and are therefore recommended for appointment. The appointment offers economies of scale to all of the CCGs in scope and represents best value for money. In order to enable RSM to commence audit planning for 2018/19 a Chair’s Action under section 3.9 of the Constitution was sought in February 2018 to approve the re-appointment of RSM on behalf of the Governing Body. The process was conducted in accordance with the provisions of the Constitution. This action was also supported by the Chair of the Audit Committee. The Governing Body is asked to ratify the decision taken under Chair’s Action.

10. Information Governance (IG) Update

Camden CCG is on course to achieve its target ‘level two’ IG Toolkit submission. At the time of writing, the evidence for the submission is being uploaded and quality-assured, prior to it being submitted by the 31 March 2018 deadline. The final submission will be signed-off by Neel Gupta (in his capacity as Caldecott Guardian) and Ian Porter (in his capacity as Senior Information Risk Officer).

Finally, with the departure of Charlotte Mullins, Director of Sustainable Insights, at the end of February; the role of the SIRO (Senior Information Risk Owner) will transfer to Ian Porter, Director of Corporate Services, NCL. Helen Pettersen Accountable Officer Barnet, Camden, Enfield, Haringey and Islington CCGs

24

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Patient Voice Report

Agenda Item 3.3 Date 14.03.2018

Committee Chair (where applicable)

Not Applicable

Lead Director Ian Porter, Director of Corporate Services

Tel/Email ian.porter@nhs.net

Report Author Martin Emery, Deputy Head of Engagement & Francesca McNeil, Head of Communications and Engagement

Tel/Email martin.emery@nhs.net francesca.mcneil@nhs.net

GB Sponsor(s) (where applicable)

Kathy Elliott, Lay Governing Body member responsible for Patient and Public Engagement

Tel/Email kathy.elliott1@nhs.net

Report Summary

This paper gives a synopsis of the patient and public engagement activity undertaken since the previous Governing Body meeting.

Purpose

Information

Approval To note X

Decision

Recommendation The Governing Body is asked to note the content of the report.

Strategic Objectives Links

Objective E: Work jointly with the people and patients of Camden to shape the services we commission

Identified Risks and Risk Management Actions

Not Applicable

Conflicts of Interest

Not Applicable

Resource Implications

Not Applicable

Engagement

Engagement documented in report.

Equality Impact Analysis

No equality impact assessment is required for this report.

Report History and Key Decisions

The Patient Voice is reported to the Governing Body on a Bi-monthly basis

Next Steps Not Applicable

Appendices

Not Applicable

25

The Patient Voice Report (March 2018)

This paper covers work undertaken over the past two months, relating to: 1. Camden Patient and Public Engagement Group (CPPEG) 2. Business Plan Objective E: Work jointly with the people and patients of Camden to shape the services we commission. 1. Camden Patient & Public Engagement Group (CPPEG) Since the last Governing Body meeting the CCG has held one CPPEG operational meeting and one open public meeting. Key themes and issues arising are described below. 1.1 CPPEG operational meeting (06/11/2017) CCG Committee reports CPPEG committee representative reports and the Governing Body Patient Voice report were discussed, approved and disseminated to PPGs for information, which can be accessed here. Primary Care Investment Vanessa Cooke, Primary Care Senior Commissioning Manager gave an overview of primary care investment. In summary, overall investment in primary care in 2018/19 is being maintained and the proposal is being refined after listening to feedback from the Local Medical Committee, neighbourhood and federation leads. CPPEG members welcomed the opportunity to comment in advance of final approval and appreciated the sensitivities of change for some practices. CPPEG members asked that money is not diverted from direct patient care in general practice to support the development of the neighbourhoods and federations. Vanessa agreed to forward the primary care investment paper once all the general practices have had the opportunity to comment. Care Navigation and Social Prescribing Presenter: Philip Darby, Adult Strategic Commissioner, London Borough of Camden gave an overview of the current status of care navigation and social prescribing in Camden. The presentation is here. In summary, 4 providers currently deliver services (Care Navigators, CAB Information and Advice, Health Inequalities Hub and Wish+). The services were reviewed between August – December 2017. The review found that there was some overlap as the services were commissioned separately and did not align to the outcomes of the Local Care Strategy or offer best value for money. In conclusion it is proposed that a single point of access for social prescribing is set up in Camden, improving access to services. All local services will be able to refer to the social prescribers, improving awareness and access to the service. CPPEG members welcomed the presentation and the proposal for a single point of access, reduced duplication of service and the aspiration for greater equality of service. It was agreed that a commissioner would return to CPPEG in the summer to report on progress made with care navigation and social prescribing. CPPEG Elections Martin Emery, Communications and Engagement Team gave an overview of the upcoming CPPEG elections for PPG representations in the North (4 vacancies) and West (3 vacancies) Localities. In summary, you are eligible to become a General Practice Patient Participation Group (PPG) member of CPPEG if you are: a member of your practice PPG; and have attended at least one practice PPG meeting in the past 12 months; or are participating in your practice PPG via email/the internet. PPG members can submit their nominations from 9:00 Tuesday 13 February to 23:59 on Friday 2nd March. Only PPG members can vote and voting takes place from 9:00 Thursday 8th March to 23:59 on Thursday 5th April. Martin Emery, will announce the results on Monday 9th April. You Said We Did CPPEG committee report: CPPEG committee reports approved. Primary Care Investment: CPPEG members welcomed the presentation

Camden CCG has: Disseminated reports to PPGs via the monthly PPG newsletter and made available on CPPEG webpage. Camden will: Disseminate the approved proposal to CPPEG and PPGs once the local medical committee,

26

and the opportunity to give comment on the proposal. Care Navigation and Social Prescribing: CPPEG members welcomed the update and being the opportunity to give comment.

neighbourhood and federation leads have had opportunity to comment. Camden has: Disseminated the presentation to PPGs and made it available on CPPEG webpage. Camden CCG will: Invite a commissioning representatives to a future operational meeting to update CPPEG on progress made with care navigation and social prescribing.

1.2 CPPEG open meeting (06/02/2018) CPPEG open meetings occur bi-monthly and allow an opportunity for members of the public to hear about and engage with the work of the CCG. The February open meeting was attended by 32 members of the public. Presentation 1: Admission Avoidance using the Rapid Response Team The presentation by Thomas Dowle, Clinical and Operational Lead Camden Rapid Access Services (Rapid Response, REDS and PACE) Central and North West London NHS Foundation Trust (CNWL) can be viewed here. The main messages from the presentation were as follows: Camden Rapids service is a multi-disciplinary team comprising of senior nurses and

occupational therapists, physiotherapists, a therapy practitioner and pharmacy provision. The team is managed by two clinical nursing leads. There is also access to a dietician and psychologist as needed.

Rapid Response Admission Avoidance (RRAA): This service prevents unplanned avoidable admissions or readmission to hospital by providing care for people in their home, including in residential and nursing placements. The service supports those patients having an urgent and immediate medical crisis that, if not treated by the Rapid Response team, would require admission to hospital. The team operates from 8am to 9pm, 7 days a week.

82% of referrals result in avoided admission: 74 referrals and 61 admissions avoided per month (average).

Accepts referrals from a wide range of sources: (58% GPs, 10% other community services, 10% from acute hospitals, 5% London Ambulance Service and others).

The attendees welcomed the presentation of the benefits that the service brings to patients. Attendees also welcomed the plans to maximise referral rates from general practices and improve links with Camden Carers Service. Presentation 2: Annual Health Checks – Learning Disabilities The presentation by Dulwinder Jandu, Strategic Commissioner - Learning Disabilities, can be viewed here . The main messages from the presentation reported that Camden CCG is a top 10 performing CCG across England (source: MyNHS – January 2017) and during 2016/17, Camden GPs provided an annual health check to 62% of their register. This was increased 7% from 2015/16. An action plan is in place to achieve 79% of the register by 2020. Attendees welcomed the success to date and noted the plan to achieve the 79% target. Presentation 3: Medicines Management Consultations The presentation given by Dr Philip Taylor, GP, Parliament Hill Medical Centre/Camden CCG & Rachael Clark, Head of Medicines Management, Camden CCG can be viewed here. The main messages informed attendees of the current NHS England national guidance and consultations: Guidance for CCGs on items which should not be routinely prescribed in primary care. Consultation on proposals for commissioning guidance on conditions for which over the counter

items should not routinely be prescribed in primary care. Attendees welcomed the presentation and the opportunity to give feedback to the national consultations. Concerns were expressed in relation to financial challenges for disabled people and people from deprived backgrounds. Hard copies and online access to surveys were disseminated to attendees to complete and return to NHS England and the date for a public meeting (Monday 5 March 2018, 14:00-16:00, Carnation Hotels, 15 Montague Street, London, WC1B 5BJ) was disseminated.

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Presentation 4: CPPEG and PPG Forum Forward Planner: The presentation given by Martin Emery, Communications and Engagement Team, can be viewed here. The presentation outlined the forward planner for 2018-19. You Said We Did Admission Avoidance using the Rapid Response Team: Attendees welcomed the presentation and success of the service in providing healthcare closer to home. Questions from the public Do all patients have access to the services offered by the rapid access team? Are all general practices referring to the service? Annual Health Checks – Learning Disabilities: Attendees welcomed that the CCG is one of the top 10 performers in England. Medicines Management Consultations: Attendees welcomed the presentation and the opportunities to get involved and give feedback.

Camden CCG have: Disseminated the presentation to PPGs and the public via the PPG newsletter and website. Response to questions from the public: In the meeting information was given about the criteria for the service, and that they aim to ensure information and access to the service is available to all professionals, carers and patients who could benefit. The GB lay member followed up with a meeting to review and understand about different levels of referral between general practices. The service shared up to date information about referrals, and explained that they have undertaken visits to practices to explain the service and agree how to work together. The Rapid Response Team welcomed the interest from patients, and agreed to contact the practices with low referrals to better understand the reasons. They also were interested in learning from a local service that has achieved referrals from all practices. It was an important opportunity to update the service on changes in general practices. Information will be made available to all PPGs about the service, and the service welcomed requests for additional information. The difference this made: PPGs (and other patient representatives) are more aware of the service, and able to support their practice with ensuring access to everyone who could benefit from the service. There is a renewed effort to communicate with practices and tackle any barriers to all patients who can benefit from the service getting high quality care in their home. Camden CCG has: Disseminated the presentation to PPGs and the public via the PPG newsletter and public website. The CCG continues to collaborate with Healthwatch Camden and LMC in providing support sessions for General Practices whereby registrations forms and annual health check letters are tailored to meet the needs of individual practices. The difference this made: Patients with learning disabilities are getting information in a more accessible format meeting their needs. Camden CCG have: Disseminated the presentation and opportunity to give feedback via social media (twitter) the PPG Newsletter and public website.

2. Business Plan Objective E: Work jointly with the people and patients of Camden to shape the services we commission The following summarises other key engagement activity undertaken by the CCG over the last two months to support Objective E:

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Acute Day Units (Mental Health) Consultation (Jules Thorn unit on the St Pancras Hospital site and at Daleham Gardens unit in Belsize Park) The Communications and Engagement team supported the Mental Health Commissioning Leads with the public consultation ending on Wednesday 10 January 2018. You can read the outcome report by clicking here. It was clear from the response to the consultation that the balance of opinion felt that the Jules Thorn unit was the preferred acute day unit to remain open for a number of reasons summarised in the analysis of consultation results. This supports a CCG decision to proceed with this option which we intend to implement from 30 April 2018. The outcome report outlines 12 actions that we will strengthen the change. These include: Camden & Islington Foundation Trust and Camden CCG will monitor the usage of Jules Thorn

unit in the future and will take action to ensure that it retains sufficient capacity to address the needs of the borough.

Camden & Islington Foundation Trust to develop referral criteria and processes between the Jules Thorn unit and the Highgate Day Centre and to ensure that Highgate Day Centre’s free 12 week service is well publicised.

Both acute day units will discuss with patients the impact of changes and provide spaces to discuss this. Individual plans will be made with any patient with particular concerns.

The full 12 actions are available in the report. The outcome report has been disseminated to the public who were involved in the consultation and will also be disseminated to PPGs via the PPG newsletter, social media and made available on the public website. Medicines Management – NHS England Consultation The Communications and Engagement team is supporting the Medicine Management team in promoting the public consultation on reducing prescribing of over-the-counter (OTC) medicine for minor and short-term health concerns which could save the NHS £136 million a year and encourage more people to self-care. For additional information click here. A list of 33 minor health concerns has been identified by a national joint clinical working group which are either self-limiting or suitable for self-care. Vitamins / minerals and probiotics have also been included as items of low clinical effectiveness which are of high cost to the NHS. The consultation is open until 14 March 2018 Equality Delivery Scheme 2 pre-grading workshop with community interest groups. The Communications & Engagement team supported the Equality and Diversity Manager in hosting 2 grading workshops with local community groups asking them to grade us in relation to Outcome Goal 1: Better health outcomes for all Outcome Goal 2: Improved patient access and experience Local Groups that were contacted to assist us with the grading included: Healthwatch Camden, Voluntary Action Camden, Camden Disability Action, Camden Lesbian, Gay, Bisexual and Transgender Forum, Age UK Camden, Camden Carers Service, Parents Advisory Board, CPPEG, Bengali Workers Association, Hopscotch. Mental Health Service Group and the Chinese Community Centre. The range of feedback received to date was positive. The 3 areas that the community groups reviewed the CCG on where, end of life care, annual health checks for learning disability patients and minding the gap. Camden General Practice Extended Access The Communications and Engagement team is supporting AT Medics to raise awareness with the public and PPGs in relation to the provision and location of the new services via our public website, social media and newsletters. National General Practice Survey The Communications and Engagement team is supporting the Primary Care team by raising public awareness of the national survey (1 Jan - 31 Mar 2018) via our website, social media and PPG newsletter. Patient Participation Group Forum The Communications & Engagement team is supporting the Primary Care team and Children’s and Family Commissioning team in developing the agenda for the next forum meeting (Tuesday 10 April). The focus of the forum will provide an update on:

Primary Care Investment GP Neighbourhoods updates on (delivery of services and patient engagement plans) &

29

Children’s and Family Commissioning teams – delivering the Local Care Strategy and STP plans.

“Camden 2025” The Communications & Engagement team is supporting the council to raising awareness of the opportunity for audiences to contribute the development of their ‘Camden 2025’ plan. The plan will set updated priorities for 2018 up to 2025, to make Camden a better place for everyone to live by 2025. Deaf Awareness Training – Camden General Practices The Communications & Engagement team is working with a local service user to facilitate free deaf awareness training for practice staff - with 10 practices trained to date. Feedback from clinical and administrative staff has been exceedingly positive. Accessible Information Standard (AIS) – Camden General Practices The CCG (via the Communications & Engagement team), Healthwatch Camden and Camden LMC are partnering to offer practices support to meet AIS requirements. Healthwatch Camden have 22 practice visits scheduled to date. This work is not only helping practices to meet Accessible Information Standards but is ensuring that patients with a learning disability are receiving information (annual health check letters) in an appropriate format. Our thanks is owed to Healthwatch Camden for providing this resource. Camden Musculoskeletal (MSK) Director Interviews at University College London Hospitals (UCLH) Successful Interviews were held in February for a Patient Director post who will champion the patient experience in MSK services. A representative from the Communications and Engagement team sat on the interview panel with the MSK Clinical Lead at UCLH. The Communications and Engagement Team have also supported MSK project managers in recruiting patients for a focus group to review a newer version of the Camden MSK Service website to ensure that it has the right content and functionality. 3.0 Looking ahead The following activity is currently planned for March/April 2018: Monday 6th March – CPPEG Operational Meeting Monday 9th April – CPPEG Election Results Announcement (North and West Localities) Tuesday 10 April - PPG Forum Meeting

Through 2018, the Communications and Engagement team will look at how we: Can best support commissioners to share information transparently with residents about service

changes or consultations under consideration Link commissioning decisions being taken at a North Central London (STP or Joint Commissioning

Committee) level into our local Camden patent and public engagement activity and communication channels.

Include examples of the impact that patient and public engagement work has on commissioning plans and decisions in future Patient Voice reports, which Lay Member Kathy Elliott will highlight (linked to NHS England Assurance Rating feedback on Domain D).

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Camden Clinical Commissioning Governing Body 14 March 2018

Report title Quality and Clinical Effectiveness Report

Agenda item 3.4 Date 28 February 2018

CCG Clinical Lead

Charlotte Cooley Tel/Email charlottecooley@nhs.net

Lead director Neeshma Shah Tel/Email Neeshma.shah@nhs.net

Report author Quality and Safety team Tel/Email qands.camdenccg@nhs.net

Report summary This report provides a summary of key quality, safety and clinical effectiveness

information for Camden CCG. Areas to highlight to the Governing Body are: UCLH UCLH provided assurance on the Trust wide implementation of the Introduction, Situation, Background, Assessment, Recommend, Decision (ISBARD) communication tool. This tool assist clinical staff to make clear and effective escalations and is for use in handovers. Despite not meeting some of the targets within the constitutional standards, UCLH have assured commissioners that patients have not suffered any clinical harm as a result of the longer waits. UCLH is also undertaking Improving Care Rounds (ICRs) and we will report the outcome of these in the next report. RFL Three more Never Events have been reported since the last report to this committee. Barnet CCG as lead commissioner, in conjunction with NHSE and NHSI, have undertaken a review of all Surgical Never Events on 30 January 2018. RFL continue to undertake clinical harm reviews to provide assurance on the impact of breaching constitutional targets. Concerns were raised by Camden GPs relating to delays in reporting of diagnostic test results, and these have been escalated to the lead commissioner. At the time of writing this was due to be discussed at the February CQRG. CIFT The CQC undertook a re-inspection of CIFT on week commencing 4th December 2017. Initial verbal feedback has been positive with no enforcement notices, the CQC noted cultural changes and improvements within the Trust. Commissioners were updated on the progress of actions relating to two NHSE mental health serious incident investigations. T&P Concerns have been raised regarding the lack of compliance regarding Adult Safeguarding training and the lack of safeguarding referrals for several months. Medicines Management The circumstances beyond the CCG’s control affecting the delivery of QIPP, and an update on the NHS England consultations.

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Purpose

Information Approval To note Decision

Recommendation The Governing Body is asked to NOTE the content of this report, and to read in conjunction with the CCG’s annual safeguarding children report.

Strategic objectives links

Objective A: Commission the delivery of NHS Constitutional rights and pledges Objective B: Improve the quality and safety of commissioned services Objective C: Improve health outcomes, address inequalities and achieve parity of esteem

Identified risks and risk management actions

Provider management of quality and safety issues affecting patient care and experience. These are being managed through regular clinical quality review (CQR) meetings and regular liaison with respective provider leads.

Resource implications

Competent and appropriately resourced CCG teams

Equality impact analysis

An equality impact assessment has not been conducted on this document as it is a summary report and record of the key outcomes of the Quality and Safety Committee meeting.

Report history This report is a summary report of the work of the QSC. Next steps None. Appendices None. Glossary ATAIN Avoiding Term Admissions to Neonatal units CHR Clinical Harm Review CQC Care Quality Commission CQRG Clinical Quality Review Group CIFT Camden and Islington NHS Foundation Trust CYP Children and Young People DNA Did Not Attend DoLS Deprivation of Safeguard Liberties ED Emergency Department LBC London Borough of Camden MCA Mental Capacity Act MDT Multidisciplinary Team MSUK Marie Stopes United Kingdom NCL North Central London NE Never Event NEWS National Early Warning Scores NHSE NHS England NHSI NHS Improvement NHSR NHS Resolution NRLS National Reporting and Learning System TOPS Termination of Pregnancy Services QSC Quality and Safety Committee RFL Royal Free London Foundation Trust RTT Referral to Treatment SI Serious incidents SJE St John and St Elizabeth STP Sustainability & Transformation Partnership T&P Tavistock and Portman NHS Foundation Trust UCLH University College London Hospital NHS Foundation Trust

√

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Executive summary This report provides an update on Provider quality and safety, medicines management and the CCG’s statutory duties under safeguarding children and vulnerable adults. The CCG’s Quality and Safety Committee (QSC) received reports from Termination of Pregnancy Services (TOPS), Camden Children and Young People Atopy services, North Central London (NCL) Maternity Report, Care Home and Care Agency Quality Assurance Report, Hospice Report, Infection Prevention and Control (IPC) Report, Primary Care Extended Access Report, Prevent Delivery Plan, Modern Day Slavery CCG Statement, Quality Surveillance Group, and the Camden Medicines Management Committee. The Quality and Clinical Effectiveness Risk Register is reviewed monthly. Key points and actions from these reports and discussions are noted below. University College Hospital London (UCLH) UCLH provided assurance on the Trust wide implementation of the Introduction, Situation, Background, Assessment, Recommend, Decision (ISBARD) communication tool. This communication tool have been developed to assist clinical staff to make clear and effective escalations and for use in handovers. This compliments the implementation of the updated National Early Warning Scores (NEWS), which was reported to the Governing Body in January 2018. Reducing harm from unrecognised deterioration is a key patient safety priority for the Trust, as outlined in their 2016/17 Quality Account. Clinical Harm Reviews (CHRs) continue to be undertaken by the Trust on patients who have breached the Referral to Treatment (RTT), and 62 day cancer targets. There have been no incidents of harm associated with waiting times reported to date. UCLH have also been successful in reducing the number of third and fourth degree tears, through a programme of training and development for midwives and medical staff. Royal Free London (RFL)

The Trust have reported three Never Events (NE) since the last report to the Camden CCG Governing Body – two of which relate to retained foreign objects, and the third whereby a patient was connected to an airflow meter rather than an oxygen flow meter.

Barnet CCG in their role as lead commissioner, had requested a review of all Surgical Never Events. This was undertaken on 30 January 2018, a full report on into the findings will be published. The Trust have taken the following immediate actions in response to these incidents and oversight will be maintained through the monthly Clinical Quality Review Group (CQRG) meetings:

• A Task and Finish Group has been established, chaired by Clinical Lead for Safer Surgery and Medical Director for Chase Farm Hospital. This group are reviewing all Never Events which have occurred over the previous two years to identify trends, themes and further learning. It is anticipated that this review will help to establish whether learning identified in the earlier Never Events had been embedded.

• NHSI, NHSE and the CCG representatives were all satisfied that the trust has been transparent about the areas for improvement, has robust senior level oversight (including from non-executive directors), has engagement from clinicians at all levels and has a clear plan for improvement.

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Clinical Harm Reviews (CHRs) continue to be undertaken by the Trust on patients who have breached the Referral to Treatment (RTT), and 62 day cancer targets. There have been no incidents of harm associated with waiting times reported to date.

Camden and Islington Foundation Trust (CIFT) The Care Quality Commission (CQC) carried out a re-inspection during the week commencing 4th December 2017, following their inspection in February 2017. Initial verbal feedback has been positive with no enforcement notices, the CQC noted cultural changes and improvements within the Trust. Once the inspection report is published further updates will be provided. The Trust provided an update on progress against their action plan in relation to a Mental Health Serious Incident (SI) involving Mr T. The action plan was signed off at the meeting that took place on 11th December 2017 with CIFT and Islington CCG. The Trust’s Chief Operating Officer and Director of Nursing have verbalised their assurance to Islington and Camden CCGs that all areas identified within the action plan have been completed. The Trust will be required to provide assurance that actions have been embedded and are sustained. Islington CCG confirmed that they have viewed all the required evidence. NHS England have published their investigation into another mental health SI (Mr G) on 25 January 2018. The Trust is working with the Commissioners to ensure that the required evidence is presented as part of the action plan. Further meetings are taking place outside the CQRG. Tavistock and Portman NHS Foundation Trust (T&P) The CCGs Designated Nurse for Adult Safeguarding has raised concerns regarding the lack of compliance with adult safeguarding training. The Trust have not made any safeguarding referrals for several months, which is causing concern due to the vulnerability of the people accessing these services. The substantive post for safeguarding is currently vacant. These issues are being addressed with the Trust and will be monitored through the CQRG. Termination of Pregnancy Services (TOPS) The committee received an update report on Marie Stopes UK’s (MSUK) progress in implementing their improvement plan to address the breach identified by the CQC in relation to Regulation 17: Governance, following the previous report to this committee in October 2017. MSUK and CCG London Commissioners and Quality and Safety Leads are working in partnership to support MSUK to address the Regulation 17 Improvement Plan, and to ensure the improvement and sustainability of services in London. Meetings have been scheduled to take place with MSUK during February and May 2018, to review the implementation of actions and monitor the work undertaken to address the actions identified in the plan. Camden Children and Young People Atopy Services The Head of Integrated Children’s Commissioning provided an inaugural report for this service to the committee in January 2018. This Atopy nurse specialist led service became operational in July 2017, supporting the care needs and management for children with asthma and eczema within primary care settings. The service supports patients that would otherwise have been referred to secondary care and will now be managed in the community, considering all atopic conditions in one appointment.

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Weekly clinics are hosted across five GP surgeries, offering 30 minute appointments to Children and Young People (CYP) and their families. These appointments are an opportunity to undertake assessment, develop a management plan, and to provide education and support. The community atopy nursing service is the first phase of developing a system wide service. It is anticipated that the service will deliver improvements in consistency and quality of care in the community. The other intended outcome is a reduction attendance within the Emergency Departments (ED), outpatients and primary care through better control and access to timelier specialist input closer to home. North Central London (NCL) Maternity Report An update in relation to maternity services across NCL was received from the NCL head of maternity commissioning. The maternity transformation programme plan has been put in place during 2017-18 and is currently being monitored through the STP and NHS England (NHSE). NCL is one of seven early adopters for the National Maternity Review, Better Births. Key outcomes are for providers to work together to deliver safer care, improved experience through greater personalisation and to provide greater continuity of care. A plan to achieve this has been submitted to NHSE in October 2017 with a further refresh submitted on 31 January 2018. The CQC national maternity survey was published on 30th January 2018. This survey represents the experience of women who had their babies in England during February 2017. Scores are broken down into 3 areas – labour and birth, staff response during labour and care in hospital following birth. Scores for UCLH and Royal Free overall were similar to those in the previous survey undertaken in 2015. UCLH scored better on average than other Trusts in involving partners in the care of women during labour and birth. As part of the safer maternity care initiative the Secretary of State has expressed that stillbirths, neonatal deaths, maternal deaths and brain injuries should be halved by 2030. This target is in the process of being changed to 50% by 2025, reflective of the work already undertaken by Providers and Commissioners. NHS Resolution (NHSR) aims to incentivise delivery of best practice through a link to the Clinical Negligence Scheme for Trusts (CNST). In order to qualify for (at least) 10% rebate in maternity CNST contributions for 2018/19, Trusts will be measured against 10 criteria: 1. Use of the National Perinatal Mortality Review Tool to review perinatal deaths. 2. Submitting data to the Maternity Services Data Set to the required standard. 3. Demonstrating transitional care facilities are in place and operational to support implementation of the Avoiding Term Admissions into Neonatal units (ATAIN) programme. 4. Demonstrating an effective system of medical workforce planning. 5. Demonstrating an effective system of midwifery workforce planning. 6. Demonstrating compliance with the four elements of the Saving Babies’ Lives Care Bundle. 7. Demonstrating a patient feedback mechanism for maternity services, such as the Maternity Voices Partnership forum, and regularly acting on feedback. 8. Evidencing that 90% of each maternity staff group have attended an in-house multi-professional maternity emergencies training session within the last training year. 9. Demonstrating that trust safety champions are meeting bi-monthly with board level champions to escalate locally identified issues. 10. Reporting 100% of qualifying 2017/18 incidents under NHS Resolution Early Notification scheme.

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Maternity units are currently undertaking a gap analysis against these 10 criteria, developing an action plan to be signed off by Trust boards and submitted to NHSR by 29 June 2018. Reports will be made available to the next CQRG subgroups and subsequently to the main CQRGs. Care Home and Care Agency Quality Assurance Report All care homes in the borough have a ‘Good’ rating with the CQC. The QSC were informed of a number of Safeguarding concerns at St. John’s Wood Care Home in relation poor standard of care, neglect, unprofessional practice and nursing care management. The London Borough of Camden (LBC) Quality Assurance Team have been collating feedback from social workers, family and residents to identifying trends and common issues. The previous improvement plan was closed on the basis that the home had taken appropriate action; however, further new concerns have been raised and close monitoring of this service is required until the next CQC inspection. The next CQC visit is expected to take place in April 2018. LBC Quality Assurance Team have planned an unannounced site visit on the 9th February 2018. The outcome of this site visit will be reported to the QSC. Hospices Report The committee had previously requested for assurances regarding staff training and knowledge regarding the Mental Capacity Act (MCA) and Deprivation of Liberties Safeguards (DoLs). The CQC inspected St John’s and Elizabeth Hospice (SJE) in October and were assured that staff have received training and demonstrated awareness of their roles and responsibilities in relation to the MCA and DoLS. Marie Curie have some challenges relating to their nursing workforce. At present this is being mitigated by the use of bank staff that have worked at Marie Curie before Both Hospices declared incidents with the bulk of these related to medication, including controlled drugs, followed by pressure ulcers, some inherited and some acquired. Primary Care Extended Access Report The QSC received an update of the quality and safety of this service which is being delivered by AT Medics since 01 December 2017. One vaccination related incident has been identified through a complaint. This has been reported to the National reporting and Learning System (NRLS). The patient safety team at NHSE have reviewed this incident and have advised that it does not meet the criteria to be classified as a Serious Incident and should be investigated locally within the practice. The service is performing well overall against contractual requirements with average increased utilisation rates and lower Did Not Attend (DNA) rates for some hubs, though there remain some outstanding issues on policies being in place at the time of reporting. Camden CCG Prevent Delivery Plan The Designated Nurse for Safeguarding Adults provided an overview of the above plan to the committee in January. Although CCGs are not specifically captured in the Prevent or Channel Duty they have responsibilities as a result of their role within the health system. The NHS Standard Contract 2017/18 outlines specific Prevent requirements under the safeguarding and safety namely section SC32 Safeguarding, Mental Capacity and Prevent. As commissioners of services

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from NHS Trust and Foundation Trusts, CCGs have the responsibility of oversight and performance management of the implementation of the Prevent Duty. As part of the NHS CCG Assurance Framework, CCGs are required to demonstrate they are well led organisations which include ensuring statutory duties and NHS performance requirements are met. NHS England will seek assurance from CCGs regarding how they undertake and deliver on these requirements. Camden CCG can demonstrate robust governance systems are in place for safeguarding, providing internal and wider system assurance that the Prevent duty is being implemented. This is established through the provision of annual and quarterly safeguarding reports to the Quality and Safety Committee and the quarterly Prevent Return from providers. Modern Day Slavery CCG Statement 2017/19 Modern slavery is the recruitment, movement, harbouring or receiving of children, women or men through the use of force, coercion, abuse of vulnerability, deception or other means for the purpose of exploitation. Individuals may be trafficked into, out of or within the UK, and they may be trafficked for a number of reasons including sexual exploitation, forced labour, domestic servitude and organ harvesting. The Designated Nurse for Safeguarding Adults, presented the CCGs statement to the QSC in January. Camden CCG recognises the requirement of supporting the Government's objective to eradicate modern slavery and human trafficking and the significant role it has to play in both combating it and supporting victims. NHS England have requested that organisations publish a statement on their public facing websites to support this. Our overall approach will be governed by compliance with legislative and regulatory requirements and the maintenance and development of good practice in the fields of contracting and employment. All of our contracting and commissioning staff have mandatory safeguarding training which includes awareness on Modern Slavery. During 2017/19 as part of our commissioning assurance process we will request evidence via the NHS contract schedule from all our providers in regards to their plans and arrangements to prevent slavery in their activities and supply chain. Camden Medicines Management Committee (CMMC)

The CMMC’s focus at the February 2018 meeting was on the forecasted financial challenges to Camden’s prescribing budget; the QIPP programme for prescribing for 2018/19; and the NHS England Consultations.

The Committee was apprised of a number of risks and cost pressures affecting the budget, hardest hitting amongst them being the unexpected in year rise in prices of certain medicines when ‘no cheaper stock option’ (NCSO) is available. A recent BMJ article named Camden as a borough that is affected nationally, with the current NCSO cost pressure in Camden noted as £1m (as at 30 Nov 2017), whereas the NCSO cost pressure for the entirety of 2016/17 was £105,852. These are pressures which cannot be offset, and will impact on the delivery of the Medicines Optimisation QIPP plan savings (currently this is flagged as amber).

Delivery of the prescribing QIPP plan is through the Prescribing Quality Scheme (PQS), which will deliver both improvements in clinical quality and financial efficiencies. Practices will be able to sign up to the 2018-19 PQS when the annual practice prescribing visits start in April 2018.

The implementation of the NHS England guidance on items that should not be routinely prescribed in primary care was discussed by the Committee, including engagement plan and collaboration with the NCL Implementation Group.

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The response to the national consultation launched by NHS England on “Conditions For Which Over The Counter Items Should Not Routinely Be Prescribed In Primary Care” was discussed by the Committee. The CCG is currently involved in a range of engagement activities with patient groups and stakeholders, with support from the CCG’s communication team. Careful consideration will need to be given to ensure that particular groups of people are not disproportionately affected, and that principles of best practice clinical prescribing are followed. The Medicines Management and Communications & Engagement Teams will collate views and engagement feedback in order to submit a response on behalf of Camden CCG. The commissioning guidance is due to be issued by NHS England in April 2018.

In addition, further to an assessment of quality, safety, clinical effectiveness, cost efficiency and evidence base: the following guidelines were approved:

• Palliative Care in Adults - Guidance for Primary Care • North Central London Sustainability and Transformation Plan (NCL STP) Urology Pathways &

Camden CCG Prescribing Guidance for Lower Urinary Tract Symptoms (LUTS) due to Benign Prostatic Hyperplasia (BPH)

• Management of Menopause in Primary Care – Hormone Replacement Therapy (HRT) Products Flowchart

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Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Camden PMS Update

Agenda Item 4.1 Date 14 March

2018 Committee Chair (where applicable)

Na

Lead Director Sally MacKinnon Transformation Director

Tel/Email sally.mackinnon1@nhs.net

Report Author Sally Mackinnon & Nic Ince Tel/Email GB Sponsor(s) (where applicable)

Kevan Ritchie Kathy Elliott

Tel/Email kevanritchie@nhs.net kathy.elliott1@nhs.net

Report Summary

The attached report provides an update on the PMS review process.

Purpose (tick one box only) [See note 6]

Information

Approval To note X

Decision

Recommendation N/A

Strategic Objectives Links

The PMS redistribution process will contribute to the following strategic objectives of the CCG:

• Improve the quality and safety of commissioned services • Improve health outcomes address inequalities and achieve parity of

esteem • Integrate and enable local services to deliver the right care in the right

setting at the right time • Involve member practices and commissioning partners in the key

commissioning decisions

Identified Risks and Risk Management Actions

The full range of risks considered in the full report 3 significant risks identified as moderate are:

1) Relevant practices will not sign up to the new agreement – mitigating

actions: the lead director has visited all PMS practices and there is no indication from any of the practices that this is likely to occur, similarly engagement through the local PMS oversight group is ongoing to ensure the CCG maintains a dialogue with all practices.

2) Practices may not deliver against the agreed PMS Premium specification in the Locally Enhanced Service (LES) – mitigating actions: the requirement for practices to produce a plan against the spec in year 1 and the Quality Improvement Support Team (QIST) will also be able to support implementation work going forward

3) 2 practices have indicated they may not be able to continue once the transition is made. One of these has given notice of handing in their contract. – mitigating actions: ongoing communications between the

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practices concerned and the NHSE contract team/Primary Care Director at the CCG. LMC support being provided direct to practices.

Conflicts of Interest

All final decisions are taken at NCS Primary Care Co-Commissioning Committee. Local Camden Procurement Committee (chaired by Kathy Elliott lay member of GB) has also overseen the PMS proposals.

Resource Implications

The full PMS premium is worth £3.4 million per annum this is the amount that is being transitioned from 15 to the full 34 practices in Camden over the next 4 years into a LES agreement.

Engagement

There has been extensive consultation and engagement with PMS/GMS/APMS practices across Camden through the locality meetings, the Local PMS Reinvestment group also includes 8 practice representatives. In addition the Transformation director and her team have met with all the PMS practices individually.

Equality Impact Analysis

Equality Impact Assessments will be conducted throughout 2018/9 once we are clear which PMS services will be changed by the practices to accommodate the implementation of the contract variations.

Report History and Key Decisions

This update has been shared with the Camden Executive Management team. Ongoing updates have been provided to clinical sponsors and the chair. The local PMS Reinvestment Group, NCL PMS group and the Primary Care Committee in Common have also been regularly updated on the progress of this work. CPPEG have also had a briefing.

Next Steps The PMS and LES contracts will be issued in the week starting the 5th March and practices will be given 3 months to sign up but the revised contract terms will start on the 1st April 2018 as agreed with NHSE. Financial payments to practices will not change until all contracts are signed locally and for Camden we anticipate this will happen in June 2019.

Appendices

Appendix 1 - NCL Transition Framework for PMS practices Appendix 2 – PMS Local Disputes process

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Introduction

The PMS review is a process of transferring the PMS premium currently being paid to 15 PMS practices in Camden to all 34 practices in the area against an agreed specification for service delivery. The total value of this investment is approx. £3.4 million and will be redistributed according to list size over the next 4 years as agreed by the NCL Primary care Co-commissioning Committee. Using a recent weighted list size figure (274,082) this provides an approximate per patient figure as of April 2017 of £12.6 per patient which will be released over the 4 years.

Progress Update

There have been a number of governance stages to pass before we were in a position to make the PMS contract offer to all practices in Camden. These have included the following:

1) A local PMS commission agreed with all practices across Camden identifying the nature and scope of a suitable commission against the PMS monies. This was done through the local PMS reinvestment group which included: 8 local GP representatives (who linked back to the wider practice population), primary care clinical leads and lay member, CPPEG representatives, non-conflicted GP, LMC and CCG officers (Chaired by the Director of Transformation).

2) A local assessment of the impact on practice sustainability – this was done both through the local PMS reinvestment group but more specifically through individual visits to practices by the Director of Transformation and a project manager from the transformation team. These visits provided an opportunity to present broad financials for the full transition period to the practices involved and discuss the impact on their practice. 2 practices indicated that they felt the change could make their business unstable and one of these has now given notice to hand in their contract by the end of August 2018. These practices have been visited by primary care and the NHSE contracts team continues to discuss options going forward.

3) A NCL agreement on the nature of the transition support we could offer practices – this was agreed through the NCL PMS group as a four year framework with some practices getting less if the proportion of their PMS against their total income was proportionately smaller. Two Camden practices only get 2 years transition monies but the remainder get 4 years. See Appendix 1 for the Transition framework that has been agreed across NCL CCGs.

4) NCL agreement on the proposed commission – This was different for each of the CCGs in NCL. Camden received early approval from the NCL PMS oversight committee and final ratification from the Primary Care Co-commissioning committee in November 2017.

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5) NHSE and LMC assurance on the commissioning intentions – Following submission of the specification (now available on the GP website) the specification was assured by NHSE and the LMC in November 2017. (See Appendix 3)

6) LMC comments on the offer letter to Camden PMS practices – following submission in December this was returned with some comments and suggestions in January 2018. Two substantive points arose: 1) LMC suggested we adopt a local PMS dispute process to link into the national dispute process already available. They recommended one that had already been assured by them from SE London and this was subsequently agreed by the CCG Executive Management team (See Appendix 2.) 2) That LMC would like to see our local LES contract before it is issued to practices. This was issued to the LMC for their consideration.

7) Send out a contractual offer letter to PMS practices

A letter asking practices to submit their practice details for the purposes of populating the new PMS contracts and giving details of the proposed commission and their transition monies/ financials over the relevant transition period was sent in February and has now been completed by relevant practices.

8) Agree a financial schedule with NHSE for PMS related payments to practices

The LMC and NHSE have agreed that all practices will have 3 months to consider the contracts and associated commission and sign up to: a) the new PMS contract -which will detail the transition and extraction of PMS premium over the agreed period for all PMS practices and b) the associated LES - will set out the service requirements and the practice specific resource each practice in Camden will be paid to deliver. The payments will reflect this fact and the adjustments to payments will only be made following practice signing up to the new contracts in June 2018.

Next Steps:

Send out contracts for signature to all practices in Camden PMS practices will receive a new updated PMS contract. All practices will receive the LES for the local PMS Premium commission to be signed and returned to the CCG at the same time. (estimated dispatch week of March 5th 2018). Initiate year one implementation Engage with all practices about the planning requirements of the PMS premium in

2018/19 to ensure they full understand the requirements and are able to action this as soon as possible in the relevant financial year.

Risk Analysis

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The following risks have been identified going forward and the associated mitigating action are summarised below:

RISK MITIGATING ACTIONS RESPONSIBLE LEAD 1. Some practices may become unsustainable following the redistribution of the PMS monies

a) Meeting with all PMS practices their partners and Transformation director to assess risk b) Practices at risk referred to NHSE contracts team and LMC for support c) Meetings with LMC and NHSE contracts team separately

a) and b) Transformation Director c) Director of Primary Care & Community

2. PMS practices may not sign up to the new PMS contract or the associated PMS Premium

a) Ongoing dialogue with: NHSE, LMC, Local PMS Reinvestment group, NCL PMS Oversight group, GB sponsors, ET b) GP reps are in regular communication with their practices through neighbourhood and other meetings c) Individual meetings with PMS practices from Director of Transformation and project worker in the team

a) Director of Transformation b) GP PMS reps on Local PMS Reinvestment Group c) Director of Transformation

3. Practices may not deliver against the PMS Premium specification

a) The PMS Premium spec identifies the need to develop a practice based plan in year 1 to support practices to understand the commission and the impact on their patients and delivery b) Ongoing support for practices through the primary care team and QIST arrangements

a) Director of Transformation b) Director of Primary Care and Community

3. Patients may find the transition disruptive as PMS practices seek to rebase their PMS services to the LES contract specification and their new resource envelope

a) The PMS Premium spec identifies the need to develop a practice based plan in year 1 to support practices to identify the potential impact on their patients and consult with them appropriately b) Corporate engagement resource available to support practices undertake effective consultation and engagement work

a) Director of Primary care and Community

b) Director of Corporate Services

Recommendations

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Governing Body is asked to note:

a) Progress on the PMS and next steps b) The identified risks and actions being taken to mitigate those risks c) The NCL PMS transition process and Local PMS Dispute Resolution process as agreed

by the CCG Executive Management Team

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APPENDIX 1 – NCL PMS TRANSITION FRAMEWORK Category Threshold

reduction in PMS income

Transitional period Transition support

(% of current premium)

A <5% Nil Nil Nil Nil Nil B

5%-9% 2 years 90 40 Nil Nil

C

10%-15% 3 years 90 70 40 Nil

D

>15% 4 years 90% 70% 40% 20%

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APPENDIX 2 – LOCAL PMS DISPUTES PROCESS

PMS Review - Local Dispute Resolution Procedure

NCL CCGs - Camden

1 Introduction Where a contractor wishes to clarify or challenge any appropriate aspect of the local PMS contract offer, a 3-stage process will be implemented as summarised in section 2 below

2 Definitions

2.1 Pre-dispute procedure The procedure implemented where a contractor wishes to clarify or challenge a relevant aspect of the PMS Contract Offer (Ref section 3 below)

2.2 Local Dispute Resolution Procedure The procedure, which is the principal subject of this short paper and which is implemented where the Pre-Dispute procedure does not lead to the resolution of the matters raised under that procedure.

2.3 NHS Dispute Resolution Procedure The formal Dispute Resolution Procedure detailed in Schedule 6 of the national PMS contract

3 Matters appropriate to this Local Dispute Procedure 3.1 Any aspect of the PMS contract offer which has been developed locally may be the subject of a local

dispute 3.2 This procedure is not applicable to aspects of the contract which have been issued as part of the NHS

England national PMS Contract and which have not been modified locally.

4 Pre – Dispute Procedure 4.1 Where a contractor, on receipt of the PMS Contract documentation, identifies a matter which the

contractor wishes to clarify or challenge, the contractor will at the earliest opportunity inform the CCG in writing providing as much detail as possible.

4.2 The CCG Director of Primary Care and Community Commissioning/Deputy COO shall, on receipt of the request or challenge, respond in writing within no more than 5 working days or, where the contractor requests a face to face meeting, offer such a meeting to take place normally within 10 working days.

4.3 If, on receipt of a written response from the CCG, a Contractor wishes to have a face to face meeting, the Director of Primary Care and Community Commissioning/Deputy COO shall offer such a meeting to take place normally within 10 working days

4.4 Where it is not practicable to offer a meeting within 10 working days, the CCG will offer an appointment as soon as reasonably practicable and in any case within no more than 28 working days.

4.5 The CCG Director of Primary Care and Community Commissioning/Deputy COO and the Contractor will make all reasonable efforts within the contractual and statutory frameworks to resolve the issues raised.

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4.6 Representation from the LMC will be sought.

5 Local Dispute Resolution Procedure

5.1 Structure 5.1.1 The local dispute will be heard by Director of Primary Care and Community Commissioning/Deputy COO

of the relevant CCG. 5.1.2 The Contractor(s) shall have the right to be accompanied by an LMC representative or by another

appropriate (not legally qualified) person. 5.1.3 Where the matter raised relates to a clinical aspect of the contract and the Contractor is challenging the

clinical validity (as opposed to the organisational or financial consequences) of the matter raised, an appropriate senior clinician shall be invited to attend to provide clinical advice. This will be the non-conflicted primary care lead for the CCG or another non conflicted clinical lead on the Governing Body.

5.2 Process 5.2.1 Where the written information provided by the CCG Director of Primary Care and Community

Commissioning/Deputy COO or the face to face discussion with the CCG Director of Primary Care and Community Commissioning/Deputy COO does not lead to the resolution of the issues raised, the Local Disputes Resolution Procedure shall be implemented.

5.2.2 The contractor shall, either in writing or verbally at a face to face meeting, request that the commissioner record the issue as a dispute and implement the local procedure.

5.2.3 The CCG shall offer the contractors a meeting with the Director of Primary Care and Community Commissioning/Deputy COO as detailed in paragraph 5.1.1 above normally within no more than 10 working days from the request for implementation of the procedure.

5.2.4 Where the Contractor contends that the issue raised impacts unreasonably on the Contractor’s practice because of specific circumstances particular to that practice, the CCG may request that the CCG and Practice conduct an “Open Book” 1process to establish the reasonableness of the contractor’s challenge.

5.2.5 The Directors and the Contractors will make all reasonable efforts within the contractual and statutory frameworks to resolve the issues raised. This may necessitate more than a single meeting and neither party shall unreasonably refuse further meetings in these circumstances.

5.2.6 Normally, a maximum of three meetings, including an initial meeting with the Director of Primary Care and Community Commissioning/Deputy COO, should take place after which the dispute, if not resolved, shall be referred to the NHS Disputes procedure

6 NHS Dispute Resolution Procedure 6.1 Where the matters raised cannot be resolved within the CCG Local Resolution Procedure, the matter may

be referred by either party for determination in accordance with the NHS Dispute Resolution Procedure set out in paragraphs 2 to 12 (inclusive) of Schedule 6 of the PMS Contract.

7 Contractual Status during the Dispute Process 7.1 Where a contractor does not wish to accept the terms of the current PMS Offer pending dispute resolution

the existing contract terms shall continue to apply. 7.2 In the event of any contract dispute following signing of the new PMS contract, the contractual status of

the contractor remains unchanged until a determination of their dispute has been made.

1 Where financial hardship is being cited a practice will be asked to declare its full practice income and expenditure.

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APPENDIX 3 - ASSURED SPECIFICATION

SCHEDULE 2 – THE SERVICES

A. Service Specification

Service PMS Premium Allocation – Appointment Management (Same Day Demand) & Complex Care Needs

Commissioner Lead Camden CCG Provider Lead GP Practices in Camden Period 1st April 2018 to 31st March 2022

Contents 1. Introduction ................................................................................................................................... 12

2. Aims .............................................................................................................................................. 12

3. Scope ............................................................................................................................................ 12

4. Eligibility and Exclusion Criteria .................................................................................................... 14

5. Quality and Safety......................................................................................................................... 14

6. Service .......................................................................................................................................... 15

6.1 Year 1 (2018/19) ................................................................................................................... 16

6.2 Year 2 (2019/20) ................................................................................................................... 18

6.3 Year 3 (2020/21) ................................................................................................................... 18

6.4 Year 4 (2021/22) ................................................................................................................... 19

7. Monitoring and Payment Schedule ............................................................................................... 20

8. Supporting Information ................................................................................................................. 21

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1. Introduction The purpose of the PMS reinvestment exercise is to redistribute the PMS premium across all practices in Camden. The following proposals aim to build on the fact that the majority of PMS practices across Camden have already invested PMS monies in extending access for particular groups of patients notably; those with complex needs and or providing same day appointments for routine needs.

This service is designed to meet the needs of patients who place high levels of demand on primary or secondary care or are frequent attenders at the practice. The 2 target groups this resource will particularly benefit are patients with complex needs and those who present on the day for an appointment. This investment will improve the health outcomes and experience for both these patient groups, reduce inequalities, reduce pressure on secondary care and ensure cost-effective use of resources. It will also support the delivery of the Camden Local Care and NCL’s STP strategic aims of delivering care as close to home as possible and the primary care national mandate of delivering universal coverage.

Increasing numbers of patients have complex needs. This group of patients request the highest number of routine and emergency appointments and it is no longer possible to deal with all the issues in a routine ten minute appointment. This demand is therefore not being adequately met through core provision and this service will provide the capacity to adequately manage these patients outside of the current planned preventative provision. Same day demand similarly puts significant strain on practices systems and processes and by supporting practices to establish effective appointment management that provides sufficient capacity for same day appointments, the investment will improve and maintain effective access and enhance the patient experience. It is anticipated that this element of the resource will also encourage practices to use the full range of staff available in the practices to meet the range of demands consistent with the new models of care approach e.g. Pharmacists, Physician Associates, Nurses and Psychologists, subject to associated core funding remaining stable and future changes in consultation models taking place in agreement with the LMC. 2. Aims The key outcomes we are seeking to derive from this investment are:

a) Meeting the care needs of complex patients who frequently present at the practice and require longer appointments and whose health outcomes would benefit from improved continuity of care.

b) To ensure that all practices have an appointment management system that can effectively meet the range of needs of the population particularly same day demand.

3. Scope This proposal is aimed at individuals with complex care needs who may or may not be under the caseload management of the emerging integrated care teams, cases where intervention is required to support their increasing needs; promote independence and self-management; and/or slow down escalating need. It is difficult to address complex needs within the usual 10 minute GP appointment, the

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investment will establish a pathway where practices are able to offer appointments of 20 minute duration to deal with patients who have complex care needs. Complex care needs: are likely to include patients with complex or multiple problems who have two or more of the following types of challenges; long term conditions, combined medical and social problems, significant mental health issues not under secondary care, language barriers with difficulty communicating e.g. deaf and or English as a second language, recurrent anxieties about health leading to health seeking behaviour, discussions on patient and their carers needs, patients with medically unexplained symptoms and those with complex family needs. The capacity provided to support complex care needs will be focused on the patient’s agenda and not so much on single disease management. They will also aim to provide continuity of care for complex care patient groups. There is evidence to indicate that continuity reduces secondary care usage. A recent article in the BMJ concludes continuity is ‘associated with avoidable hospital admissions’i and a King’s Fund GP Inquiry indicates it ‘leads to increased satisfaction among patients and staff, reduced costs and better health outcomes’ii. To support the establishment of increased GP capacity for patients with complex care needs this service also provides practices with resource to provide better flow and throughput of patients particularly for on the day demand. It is estimated that 48%* of current appointments in Camden practices are on the day many of which will be minor ailments/injury. For example: Hardeep’s GP receives a discharge summary informing him that Hardeep has attended A&E with stomach pains. The GP sees from a view of his clinical record on CIDR that Hardeep has had five other similar attendances in the last year, and has had a number of investigations which have all been normal. The GP contacts Hardeep and they book a 20 minute complex care appointment to review his symptoms and investigations to date. They discuss whether other tests might be required and his GP also introduces the concept of unexplained physical symptoms. They arrange a further planned appointment and also a plan for getting in contact should his symptoms worsen.

On the day demand: One of the other target groups is patients presenting on the same day, some of these needs could be dealt with by the supporting health care practitioners in the practice e.g. prescribing nurses, health care assistants, Physician Associates, CPAs etc. The higher volume same day demands that will particularly benefit from an effective appointment management system is likely to include; fever and flu, URTI, respiratory tract infections, ear nose and throat, external eye, head neck and back, skin, women’s and children’s health, mental health and minor injury. This service will also link to the provision of complex care appointments. This service is focussed on ‘in hours’ appointments and access and does not include the Extended Access Service commissioned by Camden CCG. For example: Pauline brings her son for a same day appointment with the GP. He has learning difficulties and has developed an ear infection which has been causing him distress. In the course of this consultation, the GP hears that Pauline has been experiencing headaches, has been feeling very anxious, and is also concerned about her partner’s mental health. The GP books a 20 minute complex care

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appointment for Pauline later that week and has the time to hear more of Pauline’s story, and to agree a management plan

*Taken from a survey conducted in Camden of all practices in 2014 1BMJ 2017;356:j84. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. http://www.bmj.com/content/356/bmj.j84

1King’s Fund research paper. Continuity of care and the patient experience. https://www.kingsfund.org.uk/sites/files/kf/field/field_document/continuity-care-patient-experience-gp-inquiry-research-paper-mar11.pdf 4. Eligibility and Exclusion Criteria In order to provide for the Appointment Management (Same Day Demand) and Complex Care needs detailed in this specification, providers will need to be fully compliant with all requirements of core contracts (GMS, PMS or APMS). The Provider must comply with the CCGs quality alert processes, reporting and responding to quality alert investigations where necessary. Where the CCG believes a practice in not complying with the terms of the contract it should invoice a remedial notice according to the procedure laid out in the regulation. 5. Quality and Safety Practices making claims will be required to complete and submit reports in accordance with the submission schedule (see Section 7 – Activity submission and Payment schedule). All practices delivering the aforementioned services must provide assurance that they are compliant with all stipulations outlined in Section 4, ‘Eligibility and Exclusion Criteria’, ‘Eligibility criteria’ within each service, as well as the following: • The practice is registered with the Care Quality Commission (CQC). • The practice meets requirements of NHS England (NHSE) for the provision of Core, Additional

services and any related Directed Enhanced Service (DES) or National Enhanced Service (NES) that the practice are commissioned to deliver.

• Practices participating in the aforementioned services will comply with NICE guidance ‘Healthcare-associated infections: prevention and control in primary and community care’, March 2012 –updated February 2017. https://www.nice.org.uk/guidance/CG139

The Providers of the aforementioned services are to report any incidents, (including near misses, significant events, incidents and Serious Incidents [Sis]), relating to the services, on the National Reporting and Learning System (NRLS). Providers should use the NHSE incident reporting GP e-form and ensure the box is ticked for sharing with the CCG. https://gps.camdenccg.nhs.uk/practice-management/incident-reporting SIs must be reported within 24 hours following identification. The Providers of the aforementioned services shall report complaints and patient feedback relating to services to Camden CCG Quality & Safety Team via secure email: qands.camdenccg@nhs.net.

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The Providers shall ensure that the workforce delivering the aforementioned services meet the following requirements:

• All GPs on the Camden Performers List • Appropriately trained, qualified and competent staff in place to deliver the each Service

requirement. • Where applicable, clinical staff are trained and competent to work under relevant Patient Group

Directions (PGDs) or Patient Specific Directions (PSD). • Cold chain policies and procedures are in place and adhered to by staff members. • Infection Control policies and procedures are in place and adhered to by staff members. • Staff members are up to date with mandatory training, including appropriate level of Safeguarding

Children and Safeguarding Adults.

6. Service The focus of the service will be to provide effective management of patients with complex needs a secondary aim will be to support Camden practices to provide effective and consistent management of same day appointments. It is anticipated that addressing a portion of pressing daily demand will also free up some of the GP time to work more closely with and give more time to patients who have complex needs e.g. frail elderly, people who require interpreters or signers etc. Patients with complex needs will be identified by the practice using the criteria described in section 3 above. GP practices will know who these patients are and will be expected to use their judgement to determine eligibility for this service. Patients also have changing needs and practices will be aware of this. Patients may stop needing additional input and this too should be left to the judgment of the practice. When these patients request an appointment this would be facilitated to be a ‘complex needs’ 20 minute appointment. In summary we anticipate that the pathway will work as follows: Appointment management system dealing with Same Day demand • Each practice will establish a system to manage the full range of patient needs but particularly to

provide for on the day demand and throughput of patients. As part of this they will identify how they will support the full range of patient needs including both complex need patients (who require additional support in longer appointments) but also those with minor ailments and injuries and devise a process that is fit-for-purpose to deal with their patients’ needs.

Complex • Having identified patients with complex needs • GP spends time in an extended (20 minute appointment) with patient to assess need and identify

issues • GP and patient, using the principles of shared decision making, develop a treatment and management

plan The stages above will allow the GP to assess need and develop and agree a comprehensive management plan with the patient furthermore ensuring continuity of care by wherever possible using the same or

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named GP. This approach will maintain the GP as the coordinator of patient centred services and will help follow through on the agreed plans.

Service Aims

The aims of the service are: • Extending or maintaining same day appointments to free up GP time to also provide longer (20

minute) appointments for patients with complex care needs • To organise same day access in a way that reflects the needs of the patients a practice serves. For

example, same day access might be supported by a range of staff in practices (either individually or on a neighbourhood hub basis) consistent with new models of care being developed under the Camden Local Care Strategy

• The additional appointment allocation will be led by a GP to ensure effective clinical oversight but they will access a range of professionals (where possible) to match patient need with the most appropriate practice resource

• To benefit complex care need patients by offering longer appointments and continuity of care for example for high risk patients who have multiple health and care concerns, to improve population health outcomes and prevent avoidable hospital attendance and admissions.

The benefits will include:

• Using part of this resource to undertake more effective management of on the day demand; practices will be able to make the best use of their resources to meet the full spectrum of needs of their patient cohort

• Providing longer appointments for patients with complex care needs will provide more consistent, holistic care to patients with complex needs and better continuity of care

• More efficient use (where clinically appropriate) of the practice team and the skill mix provided by a multi-disciplinary team including: nurse practitioners, pharmacists, physiotherapists, CPNs, health care assistants, Physician Associates, preventative and self-care support etc. Collaborations of practices may well make use of their neighbourhood (CHIN) arrangements to ensure all practices have access to a wider group of supporting staff

6.1 Year 1 (2018/19) Service Objectives Year 1

During the first year of PMS transition (2018-19) practices will be asked to review their on the day appointment system and patient access to appointments. Identifying how the practice will monitor need and capacity and take action to address gaps in provision. As part of developing or adapting an existing approach; practices will consult with patients and staff attached to the practice.

Each practice will need to agree a plan that sets out their approach to providing appointments and particularly same day support and later in the implementation phasing how patients will access the complex care appointments (unless as a PMS practice you are already providing these services in which case you will need to review your capacity to continue to provide these services and quantify and describe any planned reduction or change you are proposing as part of your transition).

Practices will be asked to start their mobilisation plans from October 2018 and practices will be expected to have implemented a first phase appointment system that specifically addresses same day demand

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by the end of the financial year. Many of the PMS practices will already have this in place in which case they will be asked to evidence how it is being provided and how it will be maintained.

Data collected during the first six months will be used to develop an access model for the practice’s registered patients that will be shared with the Commissioners for agreement.

The practice’s access model will take in to account patient demographics and detail the specific number of consultations that should be provided for same day patients and those with complex needs as a minimum and include:

I. a full range of consultation methods according to clinical need, that can include but not limited to, telephone, e-mail, video-conferencing and face to face consultations at the GP practice

II. a range of consultation lengths e.g. longer 20min appointments for patients with complex needs e.g. long term conditions or those requiring home visits, interpreting support

III. detail of the practice’s workforce who will support the access model

IV. detail of how the practice will provide urgent/same day consultations in core hours

V. utilisation of the extended primary care services provided by AT Medics

Total Resource invested in year 1 – £345,317 (£1.26 pwp)

Quality and Performance Monitoring

Success will be measured by the practices being able to describe and confirm the following key deliverables:

• Produce a baseline of how many complex care 20 min appointments and same day appointments they were providing in 2018 taking a six month period in the calendar year 2018. This information should be used to inform the appointment system and (assuming it is available) will include the use of the national ‘Workload tool’ NHSE are proposing to use in all practices.

• Within 9 months of the start of the financial year, a plan setting out how they will either: I. transition from the full PMS premium in terms of service delivery against the specification

in Appendix 1 or II. gear up to use the PMS resource to provide the year on year deliverables in the

specification. All plans must use the plan template provided by the CCG. • Engagement with the practice patients on any proposed changes in appointment systems and or

services being proposed e.g. PMS reductions as well as any changes in the appointment system in GMS practices to deliver the same day demand and complex need appointments.

• By the end of the financial year 17/18 confirm that they are delivering the first phase of the appointment system that aims to effectively manage same day demand at the practice by year 5 when the full amount of funding is released.

• A register of services discontinued by the PMS practices. • Relevant Equalities impact assessments completed on any major service changes proposed to be

made. The CCG will:

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- Provide a ‘plan template’ for practices to set out: 1) how their appointment management system will work including dimensions i-v in the specification page 7 and 2) how complex care extended appointments will be delivered over the 4 year period

- Provide a ‘return template’ to confirm implementation of the appointment management system i.e. c) above

-Define in more detail how data will be extracted to support the KPIs

- Support practices to use the ‘NHSE Workforce tool’ assuming it is available in time to support this process 6.2 Year 2 (2019/20) Additional Service Objectives Year 2

In the second year of transition practices that do not already have them will start to provide extended appointments for patients with more complex care alongside embedding the same day appointments extending the scale of the latter to cover 30% of patients attached to the practice. Many of the PMS practices will already have these services in place in which case they will be asked to evidence how complex care appointments are already provided and how these will be maintained. Total Resource invested in year 2 (cumulative total) - £1,065,514 (£3.89 pwp)

Quality and Performance Monitoring

The following key deliverables and KPIs will become operational in year 2: • 30% (366 subject to minor adjustment in year 1) of the complex care appointments set out in

their practice plan (PMS practices may be planning a reduction during this period) and referred to in section 8 of the specification (2019-20)

• First phase of the appointment system implementation as per individual practice plans implemented (30% of resource invested)

• The number of appointments offered to patients with interpreting needs i.e. those with English as a second language and deaf patients unable to communicate effectively without an interpreter (measures every 6 months)

The CCG will provide:

- Data extraction for agreed KPIs by practice

6.3 Year 3 (2020/21) Additional Service Objectives Year 3

In year three complex care needs will be addressed more fully through widespread use of extended appointments and full use of a same day appointments as part of a wider appointment management system at scale. Total Resource invested in year 3 – £2,111,320 (£7.70 pwp)

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Quality and Performance Monitoring

The following key deliverables and KPIs will become operational in year 3: • 60% (732 subject to minor adjustment in year 1) extended appointments for people with

complex needs as detailed in the specification section 8 for year 2020-21 • Second phase of same day appointments being delivered as per the practice plan (60% of

resource invested) • The number of appointments offered to patients with interpreting needs i.e. those with English

as a second language and deaf patients unable to communicate effectively without an interpreter (measures every 6 months)

• Patient feedback on a) access and b) experience and c) ease of making an appointment (GP survey and FFT cards)

The CCG will provide:

- Data extraction for agreed KPIs by practice 6.4 Year 4 (2021/22) Additional Service Objectives Year 4

In year four, we will build upon the work undertaken in year three, addressing complex care needs through widespread use of extended appointments and full use of a same day appointments as part of a wider appointment management system at scale. Total Resource invested in year 4 - £2,782,246 (£10.15 pwp)

Quality and Performance Monitoring

The following deliverables and KPIs will become operational in year 4: • 80% (976 weekly subject to minor adjustment in year 1) extended appointments for people with

complex needs as detailed in the specification section 8 for year 2020-21 • Third phase of same day appointments being delivered as per the practice plan (80% of resource

invested) • The number of appointments offered to patients with interpreting needs i.e. those with English

as a second language and deaf patients unable to communicate effectively without an interpreter (measures every 6 months)

• Patient feedback on a) access and b) experience and c) ease of making an appointment (GP survey and FFT cards) contributing to the overview of impact

• Local staff survey to assess their understanding of impact on: patient care, work life balance, use of practice resources, work satisfaction.

The CCG will provide:

- Data extraction for agreed KPIs by practice

- An evaluation of the impact of the PMS investment to inform future commissioning

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Total Resource invested in following Transition (Year 5) - £3,453,172 (£12.60 pwp)

Quality and Performance Monitoring

• 100% (1220 weekly subject to minor adjustment in year 1) extended appointments for people with complex needs as detailed in the specification section 8 for year 2020-21

• Final phase of same day appointments being delivered as per the practice plan (100% of resource invested)

• 6 monthly monitoring data on same day appointment numbers and complex care extended appointments,

• The number of appointments offered to patients with interpreting needs i.e. those with English as a second language and deaf patients unable to communicate effectively without an interpreter (measures every 6 months)

• Patient feedback on a) access and b) experience and c) ease of making an appointment (GP survey and FFT cards)

• Local staff survey to assess their understanding of impact on: patient care, work life balance, use of practice resources, work satisfaction.

The CCG will provide:

- Data extraction for agreed KPIs by practice

7. Monitoring and Payment Schedule The total amount of funding to be reinvested in Camden following the transition period = £3,453 million. For the purposes of the specification, resource has been allocated accordingly following the transition period:

- Complex Care Appointments (66%) = £2,290,449 - On the Day Demand (33%) = £1,150,942

Payments will be made to individual practices and will occur in accordance with the following schedule:

- Quarter 1 = 40% - Quarter 3 = 40% (subject to KPI and key deliverables being achieved) - Quarter 4 = 20% (subject to achievement of Key Performance Indicators (KPIs) and key

deliverables being achieved) For further details of KPIs and deliverables please see Appendix 1. A practice based monitoring and payment schedule will be developed for each practice during year 1 that will be attached to their contract from year 2.

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8. Supporting Information Activity and Costs Activity and cost for Complex Care Appointments have been calculated using the assumptions outlined below:

- Total released funds for complex care appointments = £2,290,449 million for 274,082 patients on weighted population list size

- Total funds released per year is in line with the NCL transition model - Cost of GP for 3 hour clinical session = £325 - 1 x 20 minute appointment = £36

The table below demonstrates the number of complex case clinic appointments that each practice would be expected to provide per week (based on April 17 weighted list sizes). This will be adjusted annually to reflect list size changes. Final delivery targets will be negotiated in Year 1 using the following as a guide to the CCG expectations however some practice populations may not lend themselves to delivering this allocation and others may have a higher demand.

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Appendix 1. KPIs and Key Deliverables

Year 1 (18/19) Key Deliverables Description Submission/Extraction Date Due Monitoring Develop a plan setting out utilisation of resource within 9 months

Submission by practice using CCG template

September 2018 Primary Care Business As Usual Group

Produce a baseline of how many complex care and same day appointments provided (6 month period in 2018)

Submission by practice using CCG template

September 2018 Primary Care Business As Usual Group

Engagement with the practice patients on any proposed changes in appointment systems and or services being proposed

Submission by practice September 2018 Primary Care Business As Usual Group

Practices to deliver the first phase of the appointment system that aims to effectively manage all same day demand at the practice by year 3

Submission by practice September 2018 Primary Care Business As Usual Group

PMS practices to produce a register of services being discontinued

Submission by practice using CCG template

September 2018 Primary Care Business As Usual Group

Practices to conduct relevant Equalities impact assessments completed on any major service changes proposed to be made.

Submission by practice using CCG template

September 2018 Primary Care Business As Usual Group

Year 2 (19/20) Key Performance Indicators Description Submission/Extraction Date Due Monitoring Number of same day appointments offered

Extraction from clinical system

September 2019 March 2020

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

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Number of complex care appointments offered

Extraction from clinical system

September 2019 March 2020

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

The number of appointments offered to patients with interpreting needs i.e. those with English as a second language and deaf patients unable to communicate effectively without an interpreter

Extraction from clinical system

September 2019 March 2020

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

Year 3 (20/21) Key Performance Indicators Description Submission/Extraction Date Due Monitoring Number of same day appointments offered

Extraction from clinical system

September 2020 March 2021

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

Number of complex care appointments offered

Extraction from clinical system

September 2020 March 2021

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

The number of appointments offered to patients with interpreting needs i.e. those with English as a second language and deaf patients unable to communicate effectively without an interpreter

Extraction from clinical system

September 2020 March 2021

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

Patient feedback on a) access and b) experience and c) ease of making an appointment

NHS patient survey Friends and Family Test results

March 2021 Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

Year 4 (21/22) Key Performance Indicators Description Submission/Extraction Date Due Monitoring

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Number of same day appointments offered

Extraction from clinical system

September 2021 March 2022

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

Number of complex care appointments offered

Extraction from clinical system

September 2021 March 2022

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

The number of appointments offered to patients with interpreting needs i.e. those with English as a second language and deaf patients unable to communicate effectively without an interpreter

Extraction from clinical system

September 2021 March 2022

Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

Patient feedback on a) access and b) experience and c) ease of making an appointment

NHS patient survey Friends and Family Test results

March 2022 Dashboard shared with practices and reviewed by Primary Care Business As Usual Group

Staff survey to assess their understanding of impact on: patient care, work life balance, use of practice resources, work satisfaction

Submission by practice March 2022 Primary Care Business As Usual (BAU) Group

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Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Camden Musculoskeletal Service (MSK) Update

Agenda Item 4.2 Date 05/03/2018

Committee Chair (where applicable)

Lead Director Jennifer Murray-Robertson Tel/Email Jennifer.murray-robertson@nhs.net

Report Author Patrick Meaney Tel/Email Patrick.meaney@nhs.net GB Sponsor(s) (where applicable)

Matthew Clark Tel/Email Matthew.clark1@nhs.net

Report Summary

This report details the background to the commissioning of the new Camden musculoskeletal (Camden MSK) service and the progress made to date by UCLH, the lead provider, during Year 1 (17/18) of the contract. The new Camden MSK service is expected to provide a complete and integrated programme of care for patients suffering from musculoskeletal conditions that affect the joints, bones and muscles, and also include rarer autoimmune diseases and back pain.

Purpose

Information

Approval To note x

Decision

Recommendation The CCG Commissioning Team and North East London Commissioning Support Unit (NELCSU) will continue to adopt a collaborative & supportive approach with UCLH to reflect that Year 1 of the Contract was to focus on the transition over of existing MSK services in a phased manner to ensure minimal impact to patients. Commissioning staff and NELCSU are currently working closely with UCLH to help ensure the necessary electronic patient record platform (known as EMIS) and e-referral infrastructure is set-up and ready to be tested in March further to deployment at start of April in order that UCLH can transition all of the existing MSK services in Camden over to a Single Point of Access (SPoA) by the end of April 18. The CCG Clinical Director, Director of Contracting & Commissioning and CCG Clinical Lead for MSK will continue their ongoing dialogue with UCLH MSK team and escalate any further concerns or risks via the Camden Chief Operating Officer (COO) and Governing Body Chair. The CCG will seek approval on any changes to the performance related measures in Year 2 from the Integrated Commissioning Committee (ICC). The CCG with support from NELCSU will take a stricter contract monitoring approach in from Year 2 to reflect that UCLH will be expected to have transitioned over all the MSK services and finalised all its subcontracting arrangements with the other MSK providers by the end of April 2018. The standard NHS contract levers and penalties will also be capable of being applied from Year 2 onwards.

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Strategic Objectives Links

The new clinical model for Camden MSK aims to provide: • a single point of access (SPoA), triage, referral and case management for

patients, carers and referrers (including patient self-referral). A Multi Disciplinary Team oversees this as well as the wrap around liaison for patients, GPs and provider clinicians;

• a full range of clinically integrated MSK Services including specialist ambulatory care, imaging and specialist inpatients services;

• patient choice for specialist services and bearing the cost of such procedures should the patient chose to go outside Camden MSK supply chain;

• ensuring coordination, clinical education, and sharing of data with services related to the MSK programme but not forming a part of Camden MSK (e.g. psychology support, lifestyle services, and general practice);

• resources for patient self-management and education (including digital services)

Identified Risks and Risk Management Actions

All risks are managed through regular operational and contract meeting with the lead provider

Conflicts of Interest

N/A

Resource Implications

Resources allocated as part of the contract management, commissioning and clinical engagement with the lead provider (UCLH) and other MSK providers in Camden.

Engagement

Part of Mobilisation process of the service

Equality Impact Analysis

N/A

Report History and Key Decisions

N/A

Next Steps The CCG Commissioning Team and NELCSU will continue to adopt a collaborative & supportive approach with UCLH to reflect that Year 1 of the Contract was to focus on the transition over of existing MSK services in a phased manner to ensure minimal impact to patients.

Appendices

N/A

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Camden Musculoskeletal Service (MSK) Update

This report details the background to the commissioning of the new Camden MSK service and the progress made to date by UCLH, the lead provider, during Year 1 (17/18) of the contract:

Background to the recommissioning of MSK Services in Camden

In 2015/2016 Camden CCG decided to re-commission MSK service provision in Camden. Extensive consultation of patients and other stakeholders resulted in a single integrated model covering the entire service. Funding is through a fixed block contract with a performance related component which supports the bringing together of all of the services required to improve outcomes. The services will be commissioned based on their ability to deliver certain outcomes for patients and the population.

The new clinical model for Camden MSK aims to provide:

• a single point of access, triage, referral and case management for patients, carers and referrers (including patient self-referral). An extensive MDT oversees this as well as the wrap around liaison for patients, GPs and provider clinicians;

• a full range of clinically integrated MSK Services including specialist ambulatory care, imaging and specialist inpatients services;

• patient choice for specialist services and bearing the cost of such procedures should the patient chose to go outside Camden MSK supply chain;

• ensuring coordination, clinical education, and sharing of data with services related to the MSK programme but not forming a part of Camden MSK (e.g. psychology support, lifestyle services, and general practice);

• resources for patient self-management and education (including digital services)

UCLH submitted a successful bid to implement a new Camden MSK service. They are the lead provider but agreed to work in partnership with the Royal Free, Connect Health, Haverstock Healthcare and CNWL. In addition, the partnership is also in close discussion with the Royal National Orthopaedic Hospital (RNOH) and Whittington Health as other key providers of MSK services in Camden.

New Contract Model

The contract is a fixed block contract with performance related component and UCLH, as the Lead Accountable Provider, have responsibility for co-ordinating the delivery of MSK services across the whole MSK pathway in Camden.

Successful delivery of these outcomes is linked to a performance related component under the Contract which represents 10% (1.4m) of the total annual capped budget £14.2m in Year 2 increasing to 20% (£2.8m) for Years 3-5. This Local Incentive Scheme is contingent on UCLH undertaking the necessary baselining exercise in Year 1 in order that the metrics in relation to each of the outcomes can be agreed with the CCG by the start of Year2 and further adjusted/stretched in subsequent years. Collaborative Working

The principals of the new model is that commissioners and providers work together across an entire pathway to maximise health gain at an individual and population level. To achieve this requires the ability to look at value and health gain with enough granularity. Through a new system of coding and data flow into GP records, the service will have access to a level of information that has not been achieved anywhere else in the NHS. The

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contract also requires joint working between GP neighbourhoods and the MSK provider. This has the potential to create a template for integration as well as an accountable care organisation.

UCLH EMIS

UCLH have contracted an EMIS IT specialist to build a new EMIS instance for Camden MSK to allow a dedicated UCLH admin team to manage all MSK referrals from 2 April 2018. GPIT have provided considerable support to assist UCLH with the scoping and build of the new MSK EMIS, templates, process flows, referral forms and discharge summary templates. A significant amount of advice and input has also been provided by the CCG commissioning team and CCG clinical MSK lead to ensure the most relevant read codes are included in the EMIS templates to aid completion by service users (i.e. admin, MDT, GP and clinicians) and to allow richer and more consistent data collection on the Camden MSK services and population needs. The EMIS build is on course to complete in early March thereafter UCLH will have a 3-4 week window to test the new EMIS instance and train a dedicated MSK admin & MDT teams to use the system in conjunction with the new SPoA before deployment across Camden during April’18.

Communications

The UCLH MSK team have committed to improve the level of communications provided to patients, GPs and other stakeholders in the run-up to the Camden wide launch of the new SPoA in April and after. UCLH are now attending locality meetings, visiting GP practices and attending CPPEG to provide more updates on the new MSK service and to request feedback. Recent feedback from patients and clinicians expressed confusion around the CIMS abbreviation. It was agreed further to consultation with the CCG Comms team that CIMS abbreviation be replaced with ‘Camden MSK’. The part-time Patient Director position has now been recruited and should help further improve the level of comms and engagement with patient groups in the future. UCLH have launched a new and informative patient focused website for Camden MSK:

http://www.uclh.nhs.uk/msk/Pages/CamdenMSK.aspx

Staffing

UCLH experienced some delays in the recruitment of a Programme Lead to their MSK operational team. The postholder has been in post since Nov’17 and since then UCLH have made better progress on outstanding tasks and actions. UCLH have committed to the transition of all of the existing MSK services into the new Single Point of Access (SPoA) by the end of April 2018. Contracts & Reporting

UCLH have struggled to formalise their subcontract arrangements with the other MSK providers (i.e. Connect Health, Whittington, RNOH & BCOM. However, their subcontract (£3.25m) with the RFL has now been signed and UCLH aiming to formalise subcontracting arrangements with the other MSK providers asap.

UCLH are not currently providing a sufficient level of reporting. NELCSU and the CCG Q&S team are currently escalating this issue via the monthly Camden MSK contract review group meetings in order that UCLH provide monthly activity and Q&S reporting from Year 2.

Finance (inc NCA)

NELCSU will continue to monitor the MSK activity and spend including the NCA across all NCL contracts and advise the CCG of any financial adjustments. However, UCLH are responsible as the Lead Provider for Camden MSK for managing and paying for all Camden MSK activity within the yearly capped budget of the £14.2m contract over the next 5 years. This includes any the Non Contract Activity (NCA) for Camden MSK. The CCG has agreed a risk share agreement with UCLH in relation to the NCA. The CCG is currently retaining £1.9m in relation to this risk share for the Year 1 NCA.

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GP Pilot

UCLH have undertaken a pilot in 3-4 Camden GP practices to test the new MSK referral form and SPoA. However, due to technical issues and an insufficient number of Extended Scope Physiotherapists (ESP/APP) posts a Camden wide launch will not be possible before the end of Year 1 of the MSK contract. There is an urgent need to now review the patient level experience to identify and correct any issues.

Year 1 Baselining and Outcomes setting for Year 2

UCLH is currently undertaking a baselining exercise in order that targets and thresholds for the outcomes measures can be set for Year 2. However, UCLH has indicated that as some of the baselining is limited to the 3-4 GP practices in the MSK pilot there will not be a sufficient baseline for the two Quality of Life improvement indicators (EQ5D & MSK-HQ). Accordingly, the CCG Clinical Director, CCG clinical lead for MSK and Commissioning Team are currently in discussions with UCLH to determine whether during Year 2 some of the performance related monies assigned to these two indicators would be better invested in an QIST led initiative for Camden MSK to facilitate greater feedback and engagement with primary care; greater use of the SPoA for Camden MSK; and provide an opportunity to review patient level data across the Neighbourhoods to better identify patterns and any potential outliers. It is hoped that this will also facilitate a more integrated approach for MSK in Camden and provide a clearer focus on population health gain while being a possible template for an ACO model for MSK in the future.

CCG Commissioning Strategy

The CCG Commissioning Team and NELCSU will continue to adopt a collaborative & supportive approach with UCLH to reflect that Year 1 of the Contract was to focus on the transition over of existing MSK services in a phased manner to ensure minimal impact to patients. Commissioning staff and NELCSU are currently working closely with UCLH to help ensure the necessary EMIS and e-referral infrastructure is ready to be tested in March and then deployed at start of April in order that UCLH can transition all of the existing MSK services in Camden over to the SPoA by the end of April 18.

The CCG Clinical Director, Director of Contracting & Commissioning and CCG Clinical Lead for MSK will continue their ongoing dialogue with UCLH MSK team and escalate any further concerns or risks via the Camden COO and GB Chair.

The CCG will seek approval on any changes to the performance related measures in Year 2 from the ICC.

The CCG with support from NELCSU will take a stricter contract monitoring approach in from Year 2 to reflect that UCLH will be expected to have transitioned over all the MSK services and finalised all its subcontracting arrangements with the other MSK providers by the end of April 2018. The standard NHS contract levers will also be capable of being applied from Year 2 onwards.

STP Commissioning Strategy

The Camden team have engaged with the STP MSK board and there has been agreement to move to adopt the Camden model. This will enable the providers to look at greater uniformity in terms of things like data flow, discharge letters etc. Having one way of working for most of the patients seen by providers makes this much more likely to succeed.

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Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Insights around Non Electives

Agenda Item 4.3 Date 14.03.2018

Committee Chair (where applicable)

Dr Birgit Curtis

Lead Director Charlotte Mullins Tel/Email charlotte.mullins@nhs.net Report Author Charlotte Mullins & Delyth Ford Tel/Email charlotte.mullins@nhs.net GB Sponsor(s) (where applicable)

Dr Birgit Curtis Tel/Email birgit.curtis@nhs.net

Report Summary

This report looks in detail at the Non Elective pressures facing Camden. Where small increases in activity are associated with significant financial over performance. It takes a whole system look at what is known around non-elective activity. It looks at the increasing trend of non-elective activity alongside stable and decreasing demand drivers of A&E and London Ambulance Service. The impact of HRG4+ has been an increase in unit cost for non-elective activity, this unit cost continues to increase driven in part by an increase in the depth of coding used by providers. However different levels of impact is seen between providers. Information from clinical staff indicates that acuity is not significantly increasing. Increase in Non-Elective activity year on year is lower than expected for total population growth, however increases in activity for the over 60 population is significantly higher than population growth. This could be driven by pathways such as the Evergreen model, which has provided additional capacity that would impact this population group. Putting all these factors together builds the picture behind the non-elective over performance and suggests that there is a combination of issues that is driving significant increases in the cost of non-elective activity. It is only partially driven by demand and acuity.

Purpose

Information √

Approval To note Decision

Recommendation For this paper to be shared with the NCL Joint Commissioning Committee.

Strategic Objectives Links

Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for money services.

Identified Risks and Risk

None

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Management Actions Conflicts of Interest

None

Resource Implications

Resource required for further analysis

Engagement

FP&Q Committee

Equality Impact Analysis

N/A

Report History and Key Decisions

Presented and discussed at FP&Q Committee 28/02/2018 where decision was made to share at the next Governing Body meeting.

Next Steps N/A

Appendices

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Insights around Non Electives

Camden Non Elective Utilisation

Produced by Sustainable Insights,

Camden CCG

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Introduction

The purpose of this report is to understand inmore depth non elective activity (and costs) in thecontext of significant cost pressures and stableA&E and London Ambulance Service demand torealise whether demand for Non Elective activityhas increased and the factors driving this.

The focus for these insights will be acute contractbaseline rather than the CCG Operating Plan.Over performance for Non Elective activity wasreported at the Finance, Performance and QIPPmeeting in January, the value associated with thisover performance from the contract at month 9 is£6.3m. Feedback from the main acute providersis this extra cost relates to the increased acuity ofthe patients receiving treatment.

To be able to understand with confidence in thewhite noise of data whether demand for non-elective activity is increasing the CCG needs toconsider the construction of the contract plan inrelation to outturn, demographic growth,reduction for QIPP and other non-demographicfactors.

Construction of 2017/18 Contract Plan

The following chart provides a top level view ofCamden Non elective activity; outturn (the yearend position) and contract plan to understandwhether sufficient demand was commissionedoriginally.

15/16 OT 16/17 PLAN 16/17 OT

17/18 PLAN 17/18 FOT

UCLH 7,874

7,475

9,346

9,075

9,786

Royal Free 6,220

6,387

5,968

5,699

6,091

Imperial 922

1,023

995

1,206

Other 1,607

1,641

1,617

1,691

Total 16,390

17,978

17,386

18,774

Source: CSU SLAM, excluding excess bed days

The figures contained within the UCLH line havewitnessed a step change in activity as new caremodels have been developed, therefore a like forlike trend is difficult as the new care models haveinflated the recording of activity.

The following bridge analysis supporting theconstruction of the contracts enables the CCG todistinguish between demand and technicaladjustments and the impact these factors have onvariance from plan for Royal Free and UCLH.

Bridge Analysis illustrating the technicalconstruction of the contractThese are illustrated in Appendices 1 & 2. Thisillustrates that there has been more growth atUCLH than Royal Free. However new care modelshave been introduced.

Figure 2: Royal Free Activity Bridge (see appendix 1)

Figure 1: Activity outturnFigure 3: UCLH Activity Bridge (see appendix 1)

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Understanding the drivers of financial over performance?

The focus of the following analysis is to understandthe financial over performance by provider.

Month 9 showed the following forecasted variancefrom financial plan for Non Electives;

UCLH £2.5m +Royal Free £3.1m +Imperial £0.9m +Other £0.2m –Total £6.3m

HRG4+ introduced a cost pressure forcommissioners, as illustrated by the table below.HRG4+ introduced more granularity forcomplications which can be influenced by deepercoding.

Figure 4 below shows the increase in unit pricebetween 16/17 & 17/18 prices for UCLH. Latestinformation shows that unit cost has increasedduring the financial year.

This shows for Non Elective to commission thesame amount of 16/17 activity at 17/18 priceswould cost an additional £1.4m just at UCLHalone.

Additional money for HRG4+ had been allocated tothe CCG, however the increasing unit costsobserved indicates that the impact of HRG4+ wasgreater that the allocation. Different providershave seen impact of differing proportions with theRoyal Free seeing increases in the cost of non-elective out of sync with the relatively smallincrease in activity.

What is happening in the system?A wider perspective than contract monitoring is needed to understand what is happening in thesystem. The following infographic illustrates the demand in the Camden system.

Data flowing through the system does not provide a consistent narrative to explain the costpressures.

UCLH has a conversion rate of 22%, this compares with the Royal Free of 20.7% and London at 17.4%

Source: CSU Data

Data Set Activity Cost Unit Price Change2016/17 @ 16/17 rules and tariff 9,341 £13,443,941 £1,4392016/17 @ 17/18 rules and tariff 9,373 £14,824,455 £1,582 9.89%2017/18 YTD @ 17/18 rules and tariff 6,581 £10,276,977 £1,562 -1.26%2017/18 FOT @ 17/18 rules and tariff 9,872 £15,419,283

Figure 4: UCLH Activity costs

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Demand and Population Growth

Non- Elective activity has grown at a slowerrate than population growth over the last 3years for the total population, however whenlooking at the population cohort over 60 andover 75 the data shows an increase greaterthan population growth. The populationfigures have been taken from the most recentPractice population figures (Jan 2018).

LOS: Across Camden zero length of stays havedecreased whilst there has been an increase inlonger length of stay admissions.

People & Activity

This section considers the demographics of the peoplegenerating this activity or ‘transactions’ with the acuteproviders. The contract lens views transactions only,local data has been used to understand populationsegment behaviour.

Under 60sDemand for this group is stable in terms of the numberof people seeking non elective care and the number of‘transactions’ undertaken in a hospital setting. Thispicture is consistent for UCLH, Royal Free & Imperial.

60-74The number of people admitted non electively hasincreased as has the number of transactions.

Over 75sThe number of people being admitted is increasing forthis cohort at a rate higher than expected for thispopulation segment. The number of people beingadmitted is increasing for all Lengths of Stay butparticularly for those LOS > 4 days, this would beimpacted by delayed transfer of care.

The above (Appendix 3) is an illustration of the impactnew pathways or capacity can have on the contract. Forexample reducing the LOS in rehab increases thecapacity allowing more ‘transactions’ to take place.When introducing more pathways or care models theimpact on the contract needs to be considered.

Figure 5: Actual activity versus expected activity

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Are the increased costs driven by increased acuity?Is this better recording? Or Neither?

Feedback from the Trusts is increased costs are drivenby increased acuity.

HRG4+ introduces more granularity to understandwhether this is driven by deeper coding in thediagnostic fields this is presented by the mainproviders. This is shown in more detail in Appendix 4.

This analysis shows that the over 60 & 75s have seen an increase in coding.

Outputs from the comparison of contractual & clinical information?Two GPs reviewed a sample of emergency data fortheir practice. The small sample yieldedinconsistent results; some patients were attractinghigher complication codes in the contractual datafor which there was limited clinical evidence tosupport.

Market ShareThere is a view that market share has changed for NCLhowever at a Camden level the increase in marketshare at UCLH is driven by increased activity not ashift from another provider. Therefore the increase atUCLH is not as a result of a reduction of activity at theother providers.

Delayed Transfer of CarePerformance to December shows a deterioratingposition compared with previous years, this positionwill impact the length of stay of patients. From thedata it is not possible to determine whether this isbecause of increased acuity. However feedback fromthe DTOC team confirms there has been nodemographic change to this cohort over time, and theneeds of this cohort have not become more complex.

Discharge destinations for the over 75s do not showsignificant change with the vast majority returning totheir usual place of residence.

Figure 6: Average ICD10 diagnostic coding (see appendix 4)

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Conclusion

To understand the drivers for the financial over performance this paper has attempted todistinguish between demand driven and technical over performance.

• The data shows that non elective activity for the over 60s has grown significantly more thanpopulation growth. It should not be presumed that this ‘growth’ is a cause of increased acuity.

• Increased through put and the lowering of the clinical threshold in the system could accountfor this increase. Local data shows conversion rates are not increasing.

• The financial impact of the perceived growth in the older segment has been compounded bythe application of deeper coding for this cohort as illustrated in appendix 4.

• For the whole population despite the non elective activity increasing at a slower rate thanpopulation growth, financially significant increases are seen due to the introduction of HRG4+.

Data flowing through the system does not provide a consistent view of the pressures the CCG iswitnessing on the contracts. A system wide understanding needs to be developed to provide acomprehensive view of what is happening in the system, this would provide the foundation for apopulation health management approach giving a view of people and pathways and not justactivity and finance.

To ensure the right effort is focused in the right area to deliver QIPP consistent triangulation of allassured data sources is required.

Recommendations

1. Replicate this exercise for all NCL CCGs to understand the impact of the introduction of HRG4+across a wider footprint and for this paper to be shared with the NCL Joint Committee.

2. Activity & Finance and People & Pathways need to be considered in partnership whenconstructing and monitoring plans.

3. When implementing new pathways technical adjustments and data flows to contracts need tobe understood for inflationary impact.

4. Contract performance can not be viewed in isolation, an understanding of the system andcross impacts needs to be developed.

5. Consider the acute contracts as a further QIPP opportunity and rebalance the emphasis of theQIPP planning.

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Appendix 1 – Royal Free Contract Bridge in Spells

Appendix 2 – UCLH Contract Bridge in Spells

79

Appendix 3 – System flow hypothesis

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Appendix 4 – Coding Trend by Trust

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82

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Budget Setting 2018/19

Agenda Item 5.1 Date 14.03.18

Committee Chair (where applicable)

Lead Director Simon Goodwin, Chief Finance Officer

Tel/Email Simon.Goodwin@haringeyccg.nhs.uk

Report Author Becky Booker, Deputy Director of Finance Officer

Tel/Email r.booker@nhs.net

GB Sponsor(s) (where applicable)

Dr Birgit Curtis, Finance, Performance & QIPP Committee Chair

Tel/Email birgitcurtis@nhs.net

Report Summary

The report summarises the CCG’s Financial Plan for 2018/19. Included in the report is:- Summary of the NHSE Planning guidelines Key Dates for the Financial Plan 2017/18 underlying position Summary of the 2018/19 QIPP Assumptions behind the plan 2018/19 Budget Potential 2018/19 budget Risks

Purpose (tick one box only)

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of this report.

Strategic Objectives Links

Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for money services.

Identified Risks and Risk Management Actions

This report sets out the financial risks and potential opportunities for the 2018/19 Budget.

Conflicts of Interest

None

Resource Implications

The paper sets out the resources available to the CCG for 2018/19.

Engagement

Not applicable for the purpose of this report.

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Equality Impact Analysis

This report has been written in accordance with the provisions of the Equality Act 2010.

Report History and Key Decisions

The Governing Body receives regular Finance and QIPP updates.

Next Steps The final budget will be presented to Governing Body for approval at a subsequent meeting.

Appendices

None

84

Budget Setting2018-19

85

Camden CCGBudget setting 2018/19

Contents:

Planning guidance summary 3

Timelines 4

2017/18 Underlying Position 5

2018/19 QIPP Programmes 6

2018/19 Assumptions 7

2018/19 Budget 8

2018/19 Budget Risk 9

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Planning guidance - summary

Context

• The NHS already has two-year contracts and improvement priorities set for the period 2017/19, therefore whilst 2018/19 will be arefresh of plans already prepared, Camden CCG are reviewing all budgets from a bottom up perspective.

Headlines for NHS England

• £1.6bn additional NHS revenue funding in 2018/19

• £540m funding made available for Mental Health and Primary Care core frontline services by the Dept. of Health & Social Care (DHSC). Details on how this will be allocated are not yet available

• Resources for CCGs increased by a total of £1.4bn.

Key points

• £600m added to CCG allocations (£94m for London).

• Introduction of new £400m Commissioner Sustainability Fund (London not a beneficiary)

• Planning requirement for CCGs to underspend 0.5% of allocations lifted for 18/19 – realising a benefit of £370m (approx. £59m for London).

• The requirement to use a further 0.5% of CCGs’ allocations solely for non-recurrent purposes has also been lifted.

• Cat M generic drugs clawback will not continue in 2018/19. There will therefore be a benefit to CCGs in 18/19.

• £650 million will be added to the £1.8 billion Provider Sustainability Fund

• Accountable Care Systems (ACS) rebranded to Integrated Care Systems (ICS)

• Non-recurrent STP funding to continue into 18/19

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Timelines

Below are the key dates for budget planning & presentation

Item Date

Draft budget presented to FPQ 28 February 2018Draft 2018/19 Organisational Operating Plans submitted 8 March 2018Budget paper presented to Governing Body 14 March 2018National deadline for signing 2018/19 contract variations & contracts 23 March 2018Budget presentation to ICC 28 March 2018Governing Body session on budget detail 11 April 20182018/19 Winter Demand & Capacity Plans submitted 30 April 2018

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2017/18 Underlying Position

The CCGs underlying position once contractual changes are accounted for is a deficit of £7.73m compared to a FOT of £0m (break-even)

1 2 3 4 5 6

Remove non-recurrent allocations and expenditure as per planning guidance

1

ADD: • Prior year (16/17) accruals of £2.02m• No Cheaper Stock Obtainable (NCSO)

prescribing costs of £1.24m• LESS corporate efficiencies

2

LESS: non-recurrent is estimated at £2.25m. The majority of QIPP delivered is expected to be recurrent,

3

ADD: CCGs from 18/19 are no longer required to hold 0.5% of the budget uncommitted for the national risk reserve.

4

LESS: The non-recurrent benefit from the contractual marginal rates received in 17/18.

5

Underlying position is mainly driven by:• Non recurrent QIPP• Use of Non recurrent resources to

offset over-performance

6

1

589

2018/19 QIPP ProgrammesThe QIPP target is currently planned at £27.6m. This may be subject to revision. The below table summaries this plan. The notably increase in QIPP requirement is mainly due to the CCGs 18/19 growth allocation of circa 0.1%.

QIPP Programme (£m)

The total gross QIPP plan is £27.6m. Included are £1.6m of investment costs to achieve net QIPP of £26m

The QIPP programmes are a combination of STP and local initiatives

Area Gross Investment NetCare Closer to Home 2.2 (0.8) 1.4Urgent & Emergency Care 5.4 (0.4) 5.0Planned Care 5.0 (0.4) 4.6Other Acute - - -Acute 12.6 (1.6) 11.0Mental Health 2.6 - 2.6Prescribing 0.7 - 0.7Community 2.1 - 2.1Continuing Healthcare (CHC) 0.8 - 0.8Non-acute 6.3 - 6.3Other 8.7 - 8.7Total 27.6 (1.6) 26.0

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2018/19 Assumptions

Camden CCG have formulated their assumptions driven by national guidance and historical experience. Please note that this may be subject to change.

Area Assumption Value Rationale

Growth 3% Based on prior year assumptions and compared to figures set out in national guidance which equate to c3%

Tariff 0.80%National tariff increase of 0.1% plus allowance for the impact of CNST which has been modelled to average 0.7% across the acute profile

QIPP £12.6m Gross QIPP savings planned

Growth 2.1% In excess of the wider STP assumptions of around 1.5% to allow for baseline catch-up and investment

Tariff 0.10% As per national tariff guidelinesGrowth 1.4% Demographic growth only (non-demo included in price change)

Tariff 5% Based on historical experience of pressures in prescribing costs based on new products

Growth 0.00% Growth to be updated at next iteration of budget (£2.5m included in Recurrent costs to consider this increase)

Tariff 0.00% Tariff as per NHSE guidelinesNon Acute QIPP QIPP £15m Gross QIPP savings plannedContingency Contingency £2m 0.5% of allocation

STP STP resource £0 Assumed any incremental STP resource such as programme management is met by likely reduction in HLP contributions

Allocation Allocation £3.7m Per published guidance, £0.8m in delegated budgets, £2.8m in general CCG baseline and running costs

Risks Risk range of £5.4m - £17.9m across a range of services

Acute

Non-acute

Prescribing

Continuing care

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2018/19 Budget

1 32 8 9764 5

1. 2017/18 recurrent underlying position £7.73m

2. Inflation 0.8% on all expenditure excluding Prescribing. Prescribing inflation 5%.

3. Growth assumed in planning process4. Increase in recurrent allocation,

baseline5. QIPP investment6. Non recurrent (NR) paramedic

rebranding allocation £0.3m7. NR spend STP, Healthy London

Partnership, London levies8. NR spend9. Net QIPP spend £26m10. Subject to NHSE approval £2m

drawdown funding to be allocated

10

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2018/19 Budget Risk

We have calculated a risk range over and above our 2018/19 budget profile and identified mitigations. This is dependant upon a number of factors and will be updated during the budgeting exercise and contract sign off processes.

Opportunities

• Acute – contract baseline negotiations with providers. Marginal rate agreements in place for 18/19

• Continuing Healthcare – action plan in place to improve quality and minimise financial risk.

• Prescribing – planning efficiencies in other prescribing areas.• Primary Care Delegated Commissioning - consideration in financial planning • Other QIPP risks – proactive management of QIPP schemes including

identification of pipeline schemes

AreaAcute - overperformance 1.3 - 4.3Acute QIPP Risks 0.0 - 3.9Continuing Healthcare - additional activity 0.8 - 2.5Prescribing - new drugs / NCSO 0.5 - 1.7Primary Care Delegated Comissioning 1.1 - 3.1Non Acute QIPP Risks 1.9 - 2.4

Total 5.4 17.9

Risk Range (£'m)

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Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Finance Report - Month 10 – 2017/18

Agenda Item 5.2 Date 14.03.18

Committee Chair (where applicable)

Lead Director Simon Goodwin, Chief Finance Officer

Tel/Email Simon.Goodwin@haringeyccg.nhs.uk

Report Author Becky Booker, Deputy Director of Finance Officer

Tel/Email r.booker@nhs.net

GB Sponsor(s) (where applicable)

Dr Birgit Curtis, Finance, Performance & QIPP Committee Chair

Tel/Email birgitcurtis@nhs.net

Report Summary

The report sets out the Camden CCG Financial & QIPP Position as at Month 10 being January 2018

Purpose (tick one box only)

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of this report.

Strategic Objectives Links

Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for money services.

Identified Risks and Risk Management Actions

This report sets out the financial risks and mitigations for 2017/18.

Conflicts of Interest

None

Resource Implications

This report sets out the CCG’s Financial Position as at January 2018, together with the forecasted spend for the year. At month 10 the CCG is forecast to meet its control total of £415.9m for financial year 2017/18. Within this, the CCG is forecasting over-performance of £6.4m. Over-performance is contained within the CCGs control total by use of contingencies and non-recurrent reserves.

Engagement

Not applicable for the purpose of this report.

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Equality Impact Analysis

This report has been written in accordance with the provisions of the Equality Act 2010.

Report History and Key Decisions

The Governing Body receives regular Finance and QIPP updates.

Next Steps Continued oversight by the Finance, Performance and QIPP Committee.

Appendices

None

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Camden Clinical Commissioning Group (CCG)

Finance Report: 1 April 2017 to 30 January 2018 (Month 10) 1. Introduction 1.1 This paper presents to the Finance, Performance and QIPP (FPQ) Committee the Camden Clinical

Commissioning Group financial performance as at month 10, January 2018. 2. Executive Summary 2.1 The month 10 financial performance can be summarised as follows: Table 1: Financial Performance Summary

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2.2 At month 10 the CCG is forecast to meet its control total of £415.8m for financial year 2017/18.

2.3 In month 10 the CCGs total expenditure budget increased by £0.3m from £415.5m to £415.9m. This

increase is due to the allocation of pass through funding.

2.4 The CCG is forecasting over-performance of £6.4m. The month 10 over-performance is due to:-

Table 2: Areas of over-performance

Month 10

Acute spend over-performance 3.2m

Non-Acute spend over-performance 2.5m

Primary care delegated commissioning cost pressure 1.5m

Investment programmes over-performance 0.1m

Less underspends in general overheads (0.9m)

Total 6.4m

2.5 Over-performance is contained within the CCGs control total by use of contingencies and non-recurrent reserves.

2.6 The most significant points to note include:-

• The main areas of over-performance in the acute trusts continue to be Royal Free £1.4m, Imperial £0.8m, and UCLH £0.7m

• The main point of delivery (POD) driver for over-performance in the acute sector is non-elective

expenditure, being £6.7m at month 10 (£6.3m at month 9).

• The non-acute sector is forecasting a year-end over-performance of £2.5m at month 10. This is an increase on the reported over-performance by £0.8m from £1.7m at month 9. The main driver for an increase in non-acute is no cheaper stock available (NCSO) costs

• The below points summarise the non-acute over-performance areas.

Continuing Health Care (CHC) £1.1m Primary Care Prescribing £0.5m Children Services £0.4m Mental Health Services £0.2m

• Financial risks and mitigations are detailed in section 10.

• The CCG control total has been met by use of reserves and contingencies that have been

released to offset over-performance.

3. Acute Expenditure 3.1 Acute contracts are forecast to overspend by £3.2m at year end. The current year to date overspend

is c£3.0m.

98

Table 3 below shows the acute spend per provider. Where appropriate the marginal rate on acute contracts has been applied.

Table 3: Acute Expenditure

3.2 Details of acute spend by point of delivery (POD) is detailed in tables 4 and 5 below. At POD level

the main drivers of over-performance continue to be non-electives, £6.7m and diagnostic imaging, £1.5m partly offset by under-performance within other PODs.

Table 4: Expenditure at POD Level

99

Table 5: Expenditure at POD Level by Trust

100

4. Non-Acute Expenditure Table 6: Non Acute Expenditure

4.1 At month 10 non-acute is forecasting an over-performance of £2.5m for the year. This is a £0.8m

increase in performance against the month 9 position of £1.7m. This is due to over-performance within Quality & Clinical Effectiveness resulting from an increase in forecast for No Cheaper Stock Obtainable (NCSO) drugs.

4.2 The main area of over-performance continues to be Continuing Healthcare which is forecast over-

performance against budget of £1.1m. 4.3 The other main pressure areas, as previously reported, continues to be Mental Health £0.2m and

Children’s Services £0.4m. 5. Delegated Primary Care Commissioning Expenditure 5.1 The below table 7 provides a summary of the delegated primary care commissioning budget to

expenditure. As at month 8 this service is reporting a cost pressure of £1.5m. Table 7: Delegated Primary Care Commissioning

6. Other Budgets 6.1 Investment programmes budgets of £8m, which includes programmes for Primary Care, Children

and Mental Health, are forecast to deliver a £0.1m overspend by the end of the financial year. 6.2 Running costs are forecast to deliver on target. These costs include the CSU contract, estates

charges and staffing.

101

7. QIPP 7.1 At month 10 the FOT is £16.51m, against annual QIPP plan of £18.14m. Consequently, we forecast

an underperformance £1.63m, primarily due to a shortfall in Acute Services QIPP. Table 8: QIPP Summary

8 Risks and Mitigations 8.1 The below table 9 provides details of the financial risks and mitigations as at month 10. Table 9: Risks and Mitigations

Risks - events that may happen which have not been built into expenditure plans

Full risk value

(£’000)

Probability of risk

realised

Potential risk value

(£’000)

QIPP slippage 2,760 60% 1,656 Acute contracts over performing 1,200 53% 640 Non-acute risks 857 100% 857 Continuing Healthcare 300 100% 300 TOTAL RISKS 5,117 3,453

Opportunities / Mitigations Full

mitigation value

(£,000)

Probability of

mitigation success

Expected mitigation

value (£,000)

Non-recurrent reserves* -2,857 100% -2,857

Use of CCG contingency -383 100% -383

NHSE Income -100 100% -100 Corporate efficiency -330 50% -165 TOTAL MITIGATION -3,670 -3,505

NET RISK / (HEADROOM) - Forecast likelihood of risks and mitigations being achieved -52

102

BEST CASE - No risks materialise and uncommitted reserves and contingency available -3,670

9 Summary 9.1 During 2017/18 the CCG is managing significant financial pressures. As at month 10 Camden CCG

has forecast to achieve its control total, through the use of non-recurrent reserves and contingencies. As detailed in section 8 above, there are a number of potential risks, outside of our reported position are currently mitigated. Any additional increases in over-performance may result in additional financial pressure.

103

104

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Integrated Performance Report

Agenda Item 5.3 Date 14.03.2018

Committee Chair (where applicable)

Lead Director Sally Mackinnon, Director of Transformation

Tel/Email sally.mackinnon1@nhs.net

Report Author Richard Cartwright, Head of Performance

Tel/Email rcartwright@nhs.net

GB Sponsor(s) Dr Birgit Curtis Tel/Email birgit.curtis@nhs.net Report Summary

The Integrated Performance Report reports on provide performance against the constitutional targets, financial performance, quality and outcomes

Purpose

Information

Approval To note √

Decision

Recommendation The Governing Body is asked to note the contents of the March 2018 Integrated Performance Report. The main areas of concern for the CCG are currently performance against the A&E 4 hour wait and the 62 day cancer targets and the RTT waiting time standards.

Strategic Objectives Links

Commission the delivery of NHS Constitution rights and pledges Improve the quality and safety of commissioned services

Identified Risks and Risk Management Actions

These are identified in the report

Conflicts of Interest

None

Resource Implications

Not applicable for the purpose of this report

Engagement

Not applicable for the purpose of this report

Equality Impact Analysis

Not applicable for the purpose of this report

Report History and Key Decisions

This report is a standing item on the Governing Body agenda

Next Steps None

Appendices

None

105

106

Integrated Performance ReportMarch 2018

107

1. Access 1.1 CCG Operating Plan Targets

Key messages:

• RTT, Cancer waiting times and A&E 4 hour waits are the key areas of concern and focus for theCCG.

• The CCG is reporting a non-compliant position for RTT due to underperformance at UCLH andRoyal Free. A RAP is in place at UCLH with compliance forecast for March 2018. Royal Free aredeveloping a RAP and performance is being managed by Barnet CCG and the NCL performanceteam.

• Following investigation, the CCG has not found an increase in demand that would havecontributed to RTT underperformance. The current issues faced by UCLH can be attributed toelongated pathways and not booking patients in order. Royal Free performance has beenimpacted by changes to the Trust’s reporting system, improvements to which IST aresupporting.

• The operating plan guidance for 2018/19 asks commissioners and providers to plan on thebasis that their RTT waiting list will be no higher in March 2019 than March 2018, and thisshould aim to be reduced.

• Ten Camden patients were waiting over 52 weeks in December 2017. These patients were atImperial (four) and the Royal Free (six).

• Camden achieved the 62 day cancer standard in December however remains non-compliantwith the standard year to date. Forecast underperformance at UCLH in January and Februarymeans that it is unlikely the CCG will achieve the standard overall in 2017/18.

• NCL has not received any transformation funding in 2017/18 due to non-compliance againstthe 62 day standard. NEL has however recently received £700k as a result of reporting acompliant position for some months. 62 day cancer performance has been made aprerequisite for accessing national cancer transformation funding for STPs. NCL is currentlyforecast to achieve the 62 day standard from June 2018.

• In January 2018, 18 of 22 London Trusts did not achieve the 95% standard. Despite thisLondon was ranked 1st of the four regions for the month, and Camden A&E performance isreflective of the regional and national position.

• The CCG developed a comprehensive winter plan, with priority actions identified within therefreshed UCLH RAP. Assurance around the impact of winter planning is being provided toNHSE and NHSI through a weekly joint teleconference. The RAP and winter planning will beproactively managed via the new A&E delivery board which will now be jointly chaired byCamden CCG and UCLH.

Camden CCG 2017/18 Performance Scorecard

Target/Threshold

RTT Incomplete Pathways within 18 Weeks 92% Dec-17 91.4% 91.9% RTT 52+ week waiters 0 Dec-17 10 71

Diagnostics Diagnostics - 6+ week waiters 99% Dec-17 99.2% 98.8% A&E 4 Hour Waits 95% Jan-18 86.6% 88.3% Delayed Transfers of Care - Acute - Dec-17 464 3205 Delayed Transfers of Care - Non-Acute - Dec-17 310 1972

Total delayed days per 100,000 18+ population - Dec-17 373 n/a

2 week wait 93% Dec-17 98.0% 96.0%

2 week wait breast symptomatic 93% Dec-17 95.9% 95.0% 31 day 1st definitive treatment 96% Dec-17 98.0% 97.7% 31 day 1st subsequent treatment - surg. 94% Dec-17 75.0% 85.1% 31 day 1st subsequent treatment - chemo. 98% Dec-17 100.0% 100.0% 31 day 1st subsequent treatment - radio. 94% Dec-17 100.0% 98.7% 62 day standard 85% Dec-17 87.5% 83.1% 62 day standard - screening 90% Dec-17 66.7% 83.4% 62 day standard - upgrade No Target Dec-17 100.0% 95.2%

Mixed Sex Mixed Sex Accommodation Breaches 0 Dec-17 7 50 MRSA Reported Cases (CCG Assigned) 0 Dec-17 0 2 C.Difficile Reported Cases Dec-17 6 53 new LAS Metric Category 1 (Life Threatening - 7 minute response t ime target - mean) 7 minute Dec-17 00:07:27 n/a n/a n/anew LAS Metric Category 2 (Emergencies - 18 minute response t ime target - mean) 18 minute Dec-17 00:26:58 tbc tbc tbcnew LAS Metric Category 3 (Urgent - 120 minute response t ime target - 90th Percent ile) 120 minute Dec-17 03:41:46 tbc tbc tbcnew LAS Metric Category 4 (Less Urgent - 180 minute mean response t ime target - 90th Percent ile) 180 minute Dec-17 03:21:55 tbc tbc tbc

CPA Follow-ups 95% 2017/18 Q3 92.4% 94.9% IAPT Access 1.25% Oct-17 1.3% 1.4% IAPT Recovery Rates (NB national data presented) 50% Oct-17 48.0% 48.9% 6 Weeks IAPT Waiting Times 75% Oct-17 88.0% 88.1% 18 Weeks IAPT Waiting Times 95% Oct-17 99.0% 99.3% Dementia Diagnosis Rate 67% Dec-17 88.1% 88.1% Psychosis (EIP) - 2 Week Wait, NICE approved package 50% Dec-17 75.0% 84.6% Eating Disorders Waiting Times (4Wk Routine) 95% 2017/18 Q3 80.0% 89.3% Eating Disorders Waiting Times (1Wk Urgent) 95% 2017/18 Q3 100.0% 100.0% New children and young people receiving treatment from NHS funded community services 30% 2017/18 Q2 Await MHSDS

V2 data, tbc Await MHSDS V2 data, tbc

Individual children and young people receiving treatment by NHS funded community services 30% 2017/18 Q2 Await MHSDS

V2 data, tbc Await MHSDS V2 data, tbc

Utilisation of e-RS booking50% (April 2017)80% (Oct 2017) Nov-17 42.0% 41.3%

Wheelchair Service RTT Childrens Wheelchairs within 18 Weeks 100% 2017/18 Q3 80.0% 97.8%

PHBs per 100,000 GP registered pop.11.23 (2017/18 Q1) 2017/18 Q1 16 n/a

Indicator Type

Camden DTOCs (days)

Cancer - 2 week

Reporting Period

Annual

RTT

New LAS Metrics (North Central)

Mental Health

A&E

e-RS

Personal Health Budgets

Cancer - 31 day

Cancer - 62 day

HCAI

Camden CCG - Current month Trend Camden CCG -

YTD Trend

108

1. Access1.2 Provider Access Targets

London A&E Performance18 of 22 Trusts did not achieve the 95% standard in January. London was ranked 1st of the four regions for the month.

NCL A&E performance

RTT• An RTT recovery plan is in place at UCLH which has been reviewed and

agreed by the CCG, and the Trust is currently forecasting compliance withthe RTT standard from March 2018. Specialty level recovery trajectories arebeing closely monitored by the CCG and the issue managed in accordancewith the CCG’s performance management framework.

• Royal Free are developing a RAP and performance is being managed byBarnet CCG and the NCL performance team.

A&E• Strengthened governance will be provided to the Camden/UCLH system

through the new A&E Delivery Board.• The RAP and the CCG’s winter plan have been aligned to provide one action

plan across the whole system, with RAG statuses to be reviewed and managed through the A&E Delivery Board.

• UCLH reported a 12 hour breach in A&E in January which was attributed to insufficient CAMHS PICU bed capacity in London, and nationally. CAMHS is a nationally commissioned service and this has been escalated to NHSE via the CCG’s Quality team.

• The operating plan guidance for 2018/19 states that:• Performance against the four-hour A&E standard should be at or

above 90% in September 2018• Achieve the 95% standard for the month of March 2019• Improve performance each quarter compared to the same quarter

the prior year in order to qualify for STF payments

CancerBoth UCLH and Royal Free are reporting strong performance across all cancertargets with the exception of 62 day waiting times. RAPs are in place and beingregularly refreshed in line with guidance from IST. Significant work has beendone across the sector to improve cancer performance and accelerate inter-trust transfer pathways.UCLH are forecasting compliance with the 62 day standard from June 2018.Royal Free are forecasting continued compliance with the standard throughout2018.

UCLH and Royal Free 2017/18 Scorecard Royal Free YTD

Target/Threshold

Reporting Period Performance Trend Performance Trend Performance Trend Performance Trend

RTT Incomplete Pathways 92% Dec-17 90.7% 91.5% 86.7% 89.6%

RTT 52+ week waiters 0 Dec-17 2 21 45 214

Diagnostics Diagnostics - 6+ week waiters 99% Dec-17 99.2% 99.3% 98.9% 99.1%

A&E 4 Hour Waits 95% Jan-18 86.1% 88.4% 84.0% 84.8%

A&E 12 Hour Waits 0 Jan-18 1 2 0 0

Delayed Transfers of Care (days) - Trust level - Dec-17 1054 6896 689 8179

Delayed days per occupied beds % 2.5% Dec-17 7.9% 6.7% 10.9% 10.2%

2 week wait 93% Dec-17 96.0% 95.2% 94.1% 93.9%

2 week wait breast symptomatic 93% Dec-17 94.1% 93.8% 93.8% 93.8%

31 day 1st definitive treatment 96% Dec-17 96.6% 95.3% 98.9% 98.2%

31 day 1st subsequent treatment - surg. 94% Dec-17 97.3% 95.8% 97.4% 97.6%

31 day 1st subsequent treatment - chemo 98% Dec-17 100.0% 100.0% 100.0% 100.0%

31 day 1st subsequent treatment - radio 94% Dec-17 100.0% 99.7% 100.0% 100.0%

62 day standard 85% Dec-17 79.9% 73.8% 89.6% 85.9%

62 day standard - screening 90% Dec-17 66.7% 71.0% 85.3% 89.0%

62 day standard - upgrade 90% (UCLH) Dec-17 86.3% 83.7% 91.8% 90.8%

Mixed Sex Mixed Sex Accommodation Breaches 0 Dec-17 42 272 33 297

Cancelled Ops for non-clinical reasons rebooked >28 days 100% 2017/18 Q3 91.4% 91.6% 97.4% 88.7%

Urgent operation cancelled for the 2nd time 0 Dec-17 0 0 0 0

MRSA Reported Cases (Trust assigned) 0 Dec-17 0 1 0 3

C.Difficile Reported Cases Dec-17 2 46 8 62

Handover time over 30min of arrival 0 Dec-17 259 2058 168 1494

Handover time over 60min of arrival 0 Dec-17 59 339 106 908

% of Data recorded electronically 90% Dec-17 90.2% 92.8% 88.0% 87.9%

VTE VTE Risk Assessed Admissions 95% Sep-17 94.6% 95.7% 95.1% 96.6%

SHMI Summary Level Hospital Mortality Indicator <100

July 2016 to June 2017 76.1 n/a 87.8 n/a

Cancelled Ops

HCAI-

Ambulance Handover

A&E

DTOCs

Cancer - 2 week

Cancer - 62 day

Cancer - 31 day

RTT

UCLH UCLH YTD Royal Free

Indicator Type

Nov-17 Dec-17 Jan-18

LONDON #REF! 89.6% 87.1% 87.6% 89.5% 89.7% 17.3% 38

# delays > 12 hrs in current month

13 month performance

Performance (against 95% standard)

Current 12 month rolling perf

% A&E attendances admitted (12

month rolling)

Previous 12 month

rolling perf

NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST 82.0% 72.6% 75.5% 79.2% 81.7% 19.2% 0ROYAL FREE LONDON NHS FOUNDATION TRUST 87.8% 83.7% 86.1% 87.9% 86.8% 21.1% 0THE WHITTINGTON HOSPITAL NHS TRUST 91.3% 86.5% 86.5% 86.5% 90.0% 17.5% 0UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 85.5% 86.6% 86.1% 87.7% 88.6% 21.3% 1

109

1. Access1.3 Demand Management

Extended AccessAT Medics took over the full extended access contract on 1st December 2017, and early indications are that utilisation rates have improved significantly. This can be attributed to:- There are now four hubs operational- One hub operates seven days per week- A full data sharing agreement is now in place meaning patient data from the source practice can now be seen- NHS 111 is now able to book directly into extended access slots

The service provider, AT Medics, is implementing an agreed communications and engagement plan with oversight by the CCG. Messaging focuses on the new direct booking route for patients: a dedicated phone number, open 8-8 seven days a week.

Communication activity includes: • practice training, focusing on those with lowest historical referral rates. • digital and print advertising in practices, pharmacies, libraries and leisure centres• targeted leaflet drops to households• outdoor advertising (primarily on bus stop poster sites from 16th January 2017)• social media updates • editorial in the Camden Magazine (council publication delivered to all Camden households in February 2017) • advertising in local media (Camden New Journal and Ham and High)• content in CCG partner websites, social media and publications.

This activity is being reinforced by a four-week London-wide extended access campaign by the Healthy London Partnership in Dec/Jan.

Extended Access utilisation: Haverstock Health Extended Access utilisation: AT Medics

110

1. Access1.4 DTOCs and CHC performance against trajectory

DTOC Performance against target for JanuaryTarget = 10.73 monthly average daily delaysPerformance for January = 17.9

Continuing Healthcare Target < 15% of assessments in the acute settingPerformance for December = 40%

All NHS Continuing Healthcare assessments completed within 28daysTarget 100%Performance for December = 100%

Month Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Target Total Days 15.8 14.46 13.53 11.93 10.73 10.73 10.73 10.73 10.73

Total number of patients 42 42 40 41 51 59 76

Total Days - Actual 17.1 15.66 15.71 20.5 22.0 23.29 17.9

NHS Attributable (target) 6.85 6.85 7.07 7.02 7.05 7.05 7.05 7.05 7.05

NHS Attributable - Actual 6.61 7.13 6.94 10.77 11.37 10.19 8.74

Unify

Average daily cases/days of Delayed Transfers of Care - NHS Attributable

6.61 7.97 6.09 8.9 13.2 10.7

ASC Attributable (target) 8.95 7.6 6.46 4.91 3.68 3.68 3.68 3.68 3.68

ASC Attributable - Actual 10.48 8.53 8.77 9.73 10.53 12.52 8.16

Unify

Average daily cases/days of Delayed Transfers of Care - ASC Attributable

10.48 8.90 9.55 10.00 10.5 13.7

Attributable to both (ASC & NHS) No target N/A N/A N/A N/A N/A 0.58 1.0

0

50

100

150

200

250

300Camden Local Authority Delayed Discharge reasons (Number of delayed days)

A) COMPLETION OF ASSESSMENT B) PUBLIC FUNDING

C) WAITING FURTHER NHS NON-ACUTE CARE DI) AWAITING RESIDENTIAL HOME PLACEMENT OR AVAILABILITY

DII) AWAITING NURSING HOME PLACEMENT OR AVAILABILITY E) AWAITING CARE PACKAGE IN OWN HOME

F) AWAITING COMMUNITY EQUIPMENT AND ADAPTIONS G) PATIENT OR FAMILY CHOICE

H) DISPUTES I) HOUSING - PATIENTS NOT COVERED BY NHS AND COMMUNITY CARE ACT

• January saw an increase in the number of patients delayed however delays were overallshorter.

• The Star Chamber and UCLH weekly director meetings have been effective in reducing thelength of delays.

• Discharge to assess pathways 0 to 3 are operational across both acute trusts.• There is a designated Pathway 3 Discharge to nurse in post. Recruitment is underway for a

social worker to join the nurse which will ensure assessments are undertaken jointly and in a timely way.

The majority of NHS delays are waiting further NHS Care which includes rehab (at St Pancras &specialist rehab) and patients agreed for NHS Continuing Healthcare (CHC).For adult social care the main reasons for delays are for patients waiting placements and carepackages.

Q1 2017/18Actual

Percentage of CHC decision support tool

assessments (taken from total number of Non-Fast

Track assessments) to take place in the acute

hospital setting

57.89%Target 30%

Actual 41.2%Target 25%

Actual 33.3%Target 21%

Actual 41.2%Target 18%

Actual 42.9%Target 15%

Actual 40.0%Target 15% Target 15%

Feb-18 Mar-18Sep-17 Oct-17 Nov-17 Dec-17 Jan-18

111

1. Access1.4 Delayed Transfer Of Care (DTOCs)

• A new executive led meeting has been set up at UCLH to manage DTOCs.• Discharge teams now operate on the wards ensuring patients are discharged promptly.• The CUR tool is now operational identifying medically optimised patients.• STAR chamber meets weekly and a new process is in place with social care colleagues which covers

cross border patients.

• Barnet CCG continue to lead on DTOC meetings for Royal Free, which are held twice each day to expediteearly discharges and free up bed capacity in acute setting.

• STAR chamber meets weekly and a new process is in place with social care colleagues which covers cross border patients.

0

200

400

600

800

1000

1200

Royal Free Delayed days by responsible organisation

NHS

Social Care

NHS and Social Care

0

100

200

300

400

500

600

700

800

UCLH Delayed days by responsible organisation

NHS

Social Care

NHS and Social Care

Waiting further NHS Non-Acute care

Patient or family choice

Awaiting for completion of assessment

Awaiting residential home placement or availability

Awaiting completion of assessment

Awaiting nursing home placement or availability

Awaiting care package in own home

Awaiting community equipment and adaptions

Awaiting public funding

Completion of assessment

Housing - Patients not covered by nhs and community care act

Disputes

Public funding

UCLH Delayed days by reason - December 2017

Waiting further NHS Non-Acute care

Patient or family choice

Awaiting care package in own home

Awaiting nursing home placement or availability

Awaiting residential home placement or availability

Awaiting community equipment and adaptions

Housing - Patients not covered by nhs and community care act

Awaiting for completion of assessment

Awaiting public funding

Disputes

Awaiting completion of assessment

Completion of assessment

Royal Free Delayed days by reason - December 2017

112

1. Access1.5 CNWL community services access targets

Key messages:• The only major deterioration in KPIs in January was related to

District Nursing attendance at GP meetings (90% in Jan vs. 95% in December), although this does not have a specific target attached to it.

• The podiatry targets for quarterly audit of percentage ofpatients with improved function and self-management, andpercentage of patients with a care plan at discharge werereported below target at the January CRG meeting. CNWLare reviewing performance in detail with the service tounderstand the issues in more detail and are due to reportback at the next CRG.

Performance across all indicators is discussed and managed atthe regular CNWL CRG meetings, attended by the IntegratedCommissioning team and CSU.

113

1. Access1.6 NCL Integrated Urgent Care Service (IUC) Performance against Quality and Performance KPIs

National 111 Key Metrics week ending 11th FebruarySource: NHSE weekly performance pack

Benchmarking data for w/e 11th February shows that LCW did not perform favourably against London or England for the calls answered in 60 seconds or calls abandoned metrics.

Integrated Urgent Care (IUC) Service – Source: LCW dataThere were 27,082 calls to the NCL IUC service in December 2017.

The following pilots have been extended until the end of February 2018:• Enhanced access for Care Homes• LAS crews to an IUC Clinician and• Enhanced access to Rapid Response Teams

This pilot processed 1,351 calls during December 2017.

The NCL-wide service continues to achieve well above the nationally mandated target of 30% of all calls to IUCbeing handled by a clinician. Current performance is above 60%. The NHS111 Online pilot which commenced inFebruary 2017 has been extended to July 2018.

The table below shows service performance from April to December 2017. Performance has shown an uplift of 4%on previous month. Call waiting time continues to be impacted by rostering issues and shortfall in WTE. Workforceplan progressing to trajectory.

% of calls answered in 60

seconds

% of calls abandoned after

30 seconds% of calls triaged

% of calls where a call back was

offered

% of call backs within 10 minutes

England 70.8% 6.3% 87.4% 15.5% 39.0%

Care UK 69.8% 6.0% 82.1% 17.2% 48.3%

LAS 79.9% 2.2% 82.3% 14.5% 47.3%

LCW 62.2% 9.6% 100.0% 5.1% 38.6%

PELC 80.3% 4.4% 84.2% 8.5% 59.4%

Vocare 72.4% 6.4% 83.6% 15.3% 51.7%

LONDON 73.4% 5.7% 86.3% 11.7% 50.0%

MIDLANDS 64.9% 7.2% 87.0% 17.7% 35.5%

NORTH 76.5% 6.3% 88.2% 14.4% 33.2%

SOUTH EAST 65.0% 7.9% 87.1% 14.2% 44.8%

SOUTH WEST 72.8% 4.4% 88.4% 18.2% 51.8%114

2. Commissioned Services Register Monitoring

SummaryThe Commissioned Services Register is comprised of a list of contracts that Camden CCG wholly or partly funds. The Register provides monthly oversight of these contracts, broken down into spend and performance, for the purposes of contract monitoring and informed decision-making regarding their future or maintenance.This month (Feb ’18) the focus is on those contracts with a high attention level whose overall RAG status is Red or Amber.

Highlights• UCLH – Acute Hospital Services: There is an over-performance of £1.6m, with the largest pressures continuing to be in non-elective, outpatients and drugs & devices. This is subject to both STP and Marginal

rate adjustments which will be added for Hard Close.• Royal Free – Acute Hospital Services: There is an over-performance of £7.2m, an unfavourable movement of £159k from previous month. This is driven largely in PTS, drugs & devices, non-elective and elective.

This is offset by positive in-month movement in diagnostic imaging and outpatients. Due to counting and coding changes made RFL a period of cost neutrality where commissioners are not expected to pay for additional costs is generated by these changes. Escalated items from Q1 reconciliation have now been agreed with remaining issues being worked through with the claims team.

• UCLH – MSK Services: Issues around implementation of contracting and reporting arrangements, quality & safety reporting and activity & finance reporting continue. The MSK adjustment has been made to the RFL acute contract. Outstanding Q&S reporting and template will be escalated at the CRM in Feb ’18. CCG & CSU will challenge on the NCA risk share and In Health baseline contract in order to identify potential Q4 17/18 savings.

• Whittington Hospital – Acute Hospital Services: There is an over-performance of £9k in M10, an unfavourable movement of £56k from previous month. This is driven largely to non-elective (£120k), elective (£60k) and A&E (£17k). This is offset by underperformance in other (£115k) and critical care (£47k). YTD and FOT positions are uncorrelated due to adjustments made for claims and challenges as agreed in Q1 reconciliation where the impact of A&E coding change is only relevant to Q1 and Q2 and not extrapolated into the FOT.

• Whittington Health – Adult & Children Community Services: An options appraisal has been developed and work completed to assess the impact of decommissioning on each service line. Recommendations were made to ICC that some (tissue viability, nutrition & dietetics and bladder & bowel) but not all services are decommissioned. Cross border arrangements would need to remain in place for adult services. CCG have outlined preference to delay termination of contracts and the decision was put on hold until management of adult services has been transferred. Early discussions have commenced on the recommendations amongst the new primary care & community commissioners. A meeting with Whittington Health took place in Jan ’18 to further discuss outstanding issues. A further paper with recommendations will be presented to EMT.

115

Royal Free LondonSerious Incidents (SI) and Never EventsThe Trust have reported eight Never Events since April 2017. These have been reported asSerious Incidents and are currently under investigation in line with the 2015 NHS SeriousIncident Framework. Barnet CCG as lead commissioner requested a thematic from these cases to bepresented to CQRG in January 2018, to identify themes and learning issues from these eight NeverEvents.An on-site visit was undertaken by NHSI, NHSE and the CCG representatives on 30 January 2018 whowere satisfied that the trust was fully open about the areas for improvement. There is evidence of robustsenior level oversight (including from non-executive directors), engagement from clinicians at all levelsand there is a clear plan for improvement.Thematic review findings.1. A lack of Local Safety Standards for Invasive Procedures (LocSSIP) implementation across all

departments, where invasive procedures are carried out e.g. Radiology.2. A LocSSIP is to be developed for use within the Interventional Radiology Department at Barnet

Hospital for all invasive procedures.3. The current Trust ‘Site and Side Marking Policy’ is to be reviewed and updated, to include additional

guidance as to which specific procedures in interventional radiology require site marking.4. A review of the placement of whiteboards in theatres at the Royal Free Hospital to be undertaken, to

ensure that they are positioned in the most appropriate place in the theatre.5. More work is needed to further develop LocSSIPs across all hospital sites and departments. It is

estimated that there are approximately 80 departments across the Trust where invasive proceduresoccur, where LocSSIPs are required. The Group chief medical officer and chief nurse are meeting withthe site medical directors in January to scope this programme.

Progress against these actions will be monitored at CQRG.

3. Quality3.1 Serious Incidents (SIs) & Never Events

UCLHSerious Incidents (SI)Assurances regarding organisational wide learning following SI investigations, were provided to theClinical Quality Review Group (CQRG) meeting on 06 February 2018.

Next steps:1. When the outstanding individual NE investigation reports and the overview report are completed, there will another on-site visit to review the action plans and evidence of implementation.2. The trust will set out to Barnet CCG, NHS England and NHS Improvement how it intends to embed Human Factors principles and practices in its culture, systems and processes. This may entail commissioning external expertise.3. There will be a further detailed report required for the February CQRG and further arrangements for monitoring will be developed based on progress with implementation of plans.

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3. Quality3.2 Complaints and Friends & Family Test

UCLHComplaintsCapacity within the complaints team has continued toimpact on response rates within Medical specialities,there are local plans in place to mitigate against this.Friends and Family Test (FFT)FFT scores and response rates have remained steady.

Royal Free LondonComplaintsClinical treatment and communication remain theprimary focus of complaints received by the Trust, asreported to CQRG on 30 January 2018.

Friends and Family TestThere was a decline in the numbers of positive responses reported in December. The Trust were unable to explain this at CQRG in January.

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4. Activity4.1 QIPP Plan 2017/19 - Executive Summary

Overview & Progress

The purpose of this paper is to provide the committee with an update of the QIPP plan at Month 10 of 17/18.

The CCG submitted it’s monthly report to NHSE with a YTD position of £11.97m against a plan of £14.16m. This represents 84% delivery, an overall CCG RAG rating of amber and negative variance of £2.19m. In month variance is mainly neutral.

Based on current highlight reports from commissioners the CCG is reporting a Forecast Outturn for QIPP of £16.51m against a plan of £18.14m, representing 91% delivery. At January 2018, various risks remain for delivery of Q4 schemes totaling £1.05m.

Commissioners continue follow up actions to deliver these targets via engagement with Trusts and other NCL commissioners or identifying other mitigating QIPP to reduce any impact on non-delivery as described on slide 5 in this presentation.

This reports also provides an update of the 2018/19 planning round including the current NCL/STP timetable for contract negotiations. In addition the CCG has now received planning guidance and is working towards operating plan submissions in March. Key issues included within this report highlight contract growth options and potential key QIPP schemes to be incorporated within acute contract negotiations.

QIPP Position

Split of QIPP FOT for 17/18 by RAG status (£,000):

Keys Risks

The main risk remains the pace of change to implement new models of care in-year. Although the CCG is reporting 55% of it’s plan closed (blue), this is disproportionately related to contract efficiencies and budgets. The majority of QIPP lines rated as Red are associated to transformation and STP work streams with start dates now adjusted for Q4 delivery. Teams are currently working on priority transformation schemes to ensure robust delivery in the last quarter of 17/18.

2350 576

3636

9948

1577

Red Amber Green Blue Gap

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4. Activity4.1 QIPP Plan 2017/19 - Status

Non-IFSE Return Summary

The CCG submitted its month 10 QIPP position to NHSE with a YTD position of £11.97mrepresenting a negative variance of £2.19m. This is a decrease of £17k in the adverse effectagainst plan highlighting slippage in transformation projects vs the QIPP profile.

Overall Camden is reporting a FOT position of £16.51m with minimal slippage since M9. Thefollowing slide includes a variance report highlighting movements since the previous month.

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5. Finance

Overview As at month 10 the CCG is forecast to meet its control total of £415.9m as at the end of the 2017-18 financial year.

Within this the CCG is forecasting over-performance of £6.4m. This over-performance is due to,

Acute spend over-performance £3.2mNon-acute spend over-performance £2.5mPrimary care delegated commissioning cost pressure £1.5mInvestment programmes cost pressure £0.1mLess underspends in general overheads (0.9m)

Over-performance is contained within the CCGs control total by use of contingencies and non-recurrent reserves.

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6. Improvement & Assessment Framework6.2 2017/18 Dashboard

The IAF dashboard, published by NHSE at the end ofNovember 2017, covers indicators located in fourdomains: Better Health, Better Care, Sustainabilityand Leadership.

Indicators that the CCG appears in the bottom quartile forEngland:

NB work is being undertaken to understand thediscrepancies between local and national IAPT data.Local data suggests that the CCG has met the recoveryrate standard for six of the last seven months.

Indicators that the CCG appears in the top quartile forEngland:

NHS Camden CCGBetter Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend

R 102a % 10-11 classified overweight /2013/14 to 2015/16 35.5% 5/11 143/207 R 121a High quality care - acute 17-18 Q1 57 9/11 151/207

103a Diabetes patients who achieve 2015-16 42.4% 1/11 37/207 R 121b High quality care - primary care17-18 Q1 65 5/11 137/207

103b Attendance of structured educ 2014 19.1% 1/11 17/207 R 121c High quality care - adult social 17-18 Q1 65 2/11 9/207

R 104a Injuries from falls in people 65 16-17 Q4 2,388 8/11 175/207 122a Cancers diagnosed at early sta 2015 54.2% 3/11 61/207

R 105b Personal health budgets 17-18 Q1 16 3/11 67/207 122b Cancer 62 days of referral to tr16-17 Q4 82.2% 5/11 96/207

R 106a Inequality Chronic - ACS & UCS16-17 Q4 2,360 6/11 133/207 122c One-year survival from all canc2014 71.1% 4/11 50/207

R 107a AMR: appropriate prescribing 2017 06 0.606 1/11 1/207 R 122d Cancer patient experience 2016 8.6 9/11 148/207

R 107b AMR: Broad spectrum prescrib2017 06 9.4% 5/11 130/207 R 123a IAPT recovery rate 2017 06 47.3% 10/11 167/207

108a Quality of life of carers (not available) R 123b IAPT Access 2017 07 3.4% 2/11 38/207

Sustainability Period CCG Peers England Trend R 123c EIP 2 week referral 2017 08 85.8% 3/11 49/207

R 141b In-year financial performance 17-18 Q1 Amber #N/A #N/A 123d MH - CYP mental health (not available)

R 144a Utilisation of the NHS e-referra 2017 06 41.7% 6/11 141/207 123f MH - OAP (not available)

Leadership Period CCG Peers England Trend 123e MH - Crisis care and liaison (not available)

R 162a Probity and corporate governa17-18 Q1 Fully Compliant #N/A #N/A R 124a LD - reliance on specialist IP ca 17-18 Q1 58 8/11 114/207

163a Staff engagement index 2016 3.83 4/11 48/207 124b LD - annual health check 2015-16 54.9% 1/11 10/207

163b Progress against WRES 2016 0.20 11/11 206/207 124c Completeness of the GP learning disability register (not available)

164a Working relationship effective 16-17 59.80 11/11 185/207 R 125d Maternal smoking at delivery 17-18 Q1 4.5% 3/11 22/207

166a CCG compliance with standards of public and patient participation (not available) 125a Neonatal mortality and stillbir2015 5.1 8/11 132/207

R 165a Quality of CCG leadership 17-18 Q1 Green #N/A #N/A 125b Experience of maternity service2015 76.4 8/11 169/207

Key 125c Choices in maternity services 2015 67.7 4/11 51/207

Worst quartile in England R 126a Dementia diagnosis rate 2017 08 87.6% 2/11 4/207

Best quartile in England 126b Dementia post diagnostic supp2015-16 80.0% 6/11 66/207

Interquartile range R 127b Emergency admissions for UCS 16-17 Q4 2,268 5/11 96/207

R 127c A&E admission, transfer, disch 2017 09 87.1% 8/11 137/207

R 127e Delayed transfers of care per 1 2017 08 9.3 3/11 63/207

R 127f Hospital bed use following em 16-17 Q4 439.3 4/11 33/207

105c % of deaths with 3+ emergency admissions in last three months of life (not available)

R 128b Patient experience of GP servic2017 83.8% 5/11 130/207

128c Primary care access (not available)

R 128d Primary care workforce 2017 03 1.00 3/11 91/207

R 129a 18 week RTT 2017 08 90.8% 6/11 106/207

130a 7 DS - achievement of standards (not available)R 131a % NHS CHC assesments taking 16-17 Q4 68.4% 2/11 19/207

132a Sepsis awareness (not available)

Good

Note: There is no data for NHS Manchester CCG (14L) for the following indictors: 121a, 121b, 121c, 122c, 122d, 124a, 125b, 125c, 126b, 130a, 141b, 163a, 163b, 164a & 165a

2016/17 Year End Rating:

Diabetes patients who achieved NICE targetsAttendance of structured education courseAMR: appropriate prescribingStaff engagement indexHigh quality care - adult social careOne-year survival from all cancersIAPT AccessEIP 2 week referralLD - annual health checkMaternal smoking at deliveryChoices in maternity servicesDementia diagnosis rateHospital bed use following emerg admission% NHS CHC assesments taking place in acute hospital setting

Injuries from falls in people 65yrs +Progress against WRESWorking relationship effectivenessIAPT recovery rateExperience of maternity services

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CCG leads are assigned to each of the QualityPremium indicators and actions in place to assist withdelivery of the targets.

To gain access to Quality Premium funds, CCGsmust also pass the following two gateways:

1. Quality Gateway - no cases of serious qualityfailures at a local provider where CCG is notconsidered to have made appropriate,proportionate response with its partners toresolve failures. Payments will be discretionaryand subject to CCG assurance process criteriain relation to quality failures where gateway isnot achieved.

2. Financial Gateway - operate in a mannerconsistent with Managing Public Money; doesnot incur unplanned deficit in 2017/18, orrequire unplanned support to avoid unplanneddeficit; and does not incur a qualified auditreport in respect of 2017/18.

7. Quality Premium7.2 2017/18 Quality Premium

Measure Target Latest DataQuality Premium allocation

MaximumAvailable

Performance Risk Rating

Early Cancer Diagnosis 4% point improvementORAt least 60% diagnosed at stage 1 & 2

44.1% (2013)45.8% (2014) 54.2% (2015)

17% £227,165

GP Access and Experience 85% of respondents who said they had a good experience of making an appointmentOR3 percentage point increase from July 2017

79.4% (2015)83.0% (2016)71% (2017)

17% £227,165

Continuing Healthcare Part a) in more than 80% of cases with a positive NHS CHC Checklist, the NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the ChecklistPart b) less than 15% of all full NHS CHC assessments take place in an acute hospital setting.

Part a) 91% (Q1 2017/18) Part b) 58% (Q1 2017/18)

17% £227,165

Mental Health Total number of bed days relating to out of area placements to have reduced by 33%

tbc 17% £227,165

Bloodstream Infections 2017/18 Part a) 10% reduction (or greater) in all E coli BSIPart b)b1 - 10% reduction (or greater) in the Trimethoprim: Nitrofurantoinprescribing ratiob2 - 10% reduction (or greater) in the number of trimethoprim itemsprescribed to patients aged 70 years or greaterPart c)items per STAR-PU must be equal to or below 1.161 items per STAR-PU

Part a) 185(Jan - Dec 2016)Part b1) 0.954(Jun 15 -May 16)Part b2) 1936(Jan - Dec 2016)Part c) 0.61(Mar 2017)

17% £227,165

Local indicator: The percentage of people waiting 6 or more weeks for a colonoscopy.

93.2% 98.3% (Dec 2017) 15% £200,440

NHS Constitution requirement Target Latest Data WeightingWeight Value

Performance Risk Rating

Maximum 18 weeks from referral to treatment – incomplete standard.

STF/ Op Plans for Q4 17/18 - 92% 91.9%(Dec 2017 YTD)

25% £334,066

Maximum four hour waits in A&E departments - standard.

STF/ Op Plans for Q4 17/18 - 95% 88.3%(Jan 2018 YTD)

25% £334,066

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer.

STF/ Op Plans for Q4 17/18 - 85% 83.1%(Dec 2017 YTD)

25% £334,066

Ambulance response - new ambulance response targets were introduced from 31/10/17.

Awaiting clarification on new response targets impact on Quality Premium

tbc 25% £334,066 tbc

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2018/19 is the second year of a two year planning cycle. The 2018/19 plan submission will be a refresh of plans already prepared.NHS England and NHS Improvement published the 2018/19 operating plan refresh guidance on 2 February 2018. This guidance described the framework, planning assumptions, next step priorities and expectations of deliverables on refreshed plans Commissioners and Providers plans for 2018/19. Nationally CCGs are required to submit draft plans by 8th March 2018 and final board or governing body approved plans by 30th April 2018. Locally NHS England have asked organisations in London to submit draft plans by 1st March 2018.The planning leads for each of the North Central London (NCL) CCGs have been working with the CSU to define the methodology for creating the activity forecast outturn and alignment of this with contracting discussions at the financial activity modelling group (FAM).

Key points to note from the planning guidance are outlined below:

Key area Points to note• Removal of the requirement for CCGs to underspend 0.5 per cent of their allocations for 2018/19• Removal of the requirement for a further 0.5 per cent to be spent non-recurrently• Additional £600 million for CCG allocations in 2018/19• A further £650 million will be added to the Provider Sustainability and Transformation Fund• Additional investment will be reflected in 2018/19 provider control totals. 30% of the fund will be linked to A&E performance• Providers who accept their control totals will continue to be exempt from the application of certain agreed performance sanctions• Contract to extend this exemption to all national performance sanctions, except mixed-sex accommodation, cancelled operations, healthcare associated infections and duty of candour. NHS Improvement will continue to ensure performance is at acceptable levels against all national standards• Additional £354 million capital for property and estates investment. Allocations for this funding have not yet been confirmed. STPs and providers should not plan on the basis of receiving this additional funding• STP capital will be contingent on STPs having an estates and capital plan that sets out how individual organisations will work together to deploy the funding to support integrated service models, share assets and dispose or un- or under-used estate• The two-year tariff remains in place for next year The guidance described the following set of assumptions• Local systems are expected to continue to implement the priority efficiency programmes within the ten-point efficiency plan• CCGs will receive the remaining period of temporary benefit from changes made to Category M generic drug prices.• CCGs should consider how to locally implement guidance on 18 ineffective and low clinical value medicines• CCGs will continue to work with the NHS England Continuing Healthcare and QIPP programmes• There will be no additional winter funding in 2018/19• Systems will need to demonstrate that winter plans are embedded in both system and individual organisation operating plans• Each system needs to produce a separate winter demand and capacity plan• Guidance for winter demand and capacity plans will be available by March 2018

Winter demand and capacity

Financial framework for commissioners

Financial framework for providers

Capital and estates

National tariff

Key area Points to note• Allocations allow for a 2.3% growth in non-elective admissions and a 1.1% growth in A&E attendances• Expected roll forward of the goal of ensuring aggregate performance against the four-hour target of 90 per cent for September 2018, with the majority of providers achieving 95 per cent for March 2019 and a return to overall adherence to the 95 per cent standard during 2019• Plans should demonstrate how commissioners and providers will complete the implementation of the integrated urgent care strategy• All providers and commissioners should work together to reduce length of stay• Community providers will be invited to participate in a new local incentive scheme where savings from acute excess bed day costs can be reinvested to expand community and intermediate care• £210 million CCG Quality Premium incentive funding contingent on performance on moderating demand for emergency care• Allocations now allow for improvements in the volume of elective surgery and improvements in waits over 52 weeks• Commissioners and providers are asked to plan on the basis that their RTT waiting list will be no higher in March 2019 than March 2018, and should aim to reduce it• National numbers of patients waiting over 52 weeks should be halved by March 2019• Provider plans will need to consider the capacity required to deliver growth in elective and non-elective activity• Integrated care systems (previously known as accountable care systems) will continue to be rolled out voluntarily• All ICSs will work within a system control total, with flexibility to vary individual control totals. ICSs are encouraged to adopt a fully system- based approach to the PSF and CSF• All ICSs will be required to operate under system control total incentive structures by 2019/20, but there will be some flexibility on this in 2018/19. Systems adopting this structure will have a more autonomous regulatory relationship with NHS England and NHSI• STPs that wish to join the ICS programme should confirm expressions of interest with their regional team. NHS England will aim for applications to be reviewed by March 18• All systems are expected to engage with patients, the public, their democratic representatives and other community partners• NHS England will shortly publish an update to the 2017/19 CQUIN guidance

Integrated system working

CQUIN

Emergency care

Referral to treatment times

8. 2018/19 Planning guidance

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9. Glossary

Abbreviation Full Term Description2WW Two Week Wait cancer standard Cancer waiting times standardA&E Accident and Emergency Hospital emergency departmentCCAS Camden Clinical Assessment Service CCG referral management serviceCSU Commissioning Support Unit Provides commissioning support functions to CCGsCWT Cancer Waiting Times Set of indicators measuring cancer performanceDTOC Delayed Transfer of Care When an adult inpatient is ready to be discharged from hospital but this is delayedEIP Early Intervention in Psychosis Access standard - 50% of patients should be treated within 2 weeks of referralIAF Improvement and Assessment Framework Set of indicators on which CCG performance is assessedIAPT Improving Access to Psychological Therapies Programme for treating people with depression and anxiety disorders.MAR Monthly Activity Return Central activity data return QIPP Quality, Innovation, Productivity and Prevention Programme to improve quality of care while making efficiency savingsRAG Red, Amber Green Colour coded rating based on performanceRAP Remedial Action Plan Recovery plan to bring performance back to complianceRTT Referral to Treatment target NHS constitution target to start consultant-led non-emergency treatment within 18 weeks of referralSI Serious Incident A serious event that warrants using additional resources to mount a comprehensive responseSTF Sustainability and Transformation Fund Funding to acute trusts based on delivery of quarterly milestonesSUS Secondary Uses Service Repository for healthcare data

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Camden Clinical Commissioning Group Governing Body Meeting on 14 March 2018

Report Title Board Assurance Framework

Agenda Item 6.1 Date 6th March 2018

Lead Director Ian Porter,

Director of Corporate Services Tel/Email ian.porter3@nhs.net

Report Author Andrew Spicer, NCL Head of Governance and Risk

Tel/Email Andrew.spicer1@nhs.net

GB Sponsor(s) (where applicable)

Richard Strang, Lay Member Tel/Email richard.strang@nhs.net

Report Summary

The Board Assurance Framework (‘BAF’) captures the most serious risks identified as threatening the achievement of the CCG’s eight strategic objectives. The BAF includes some NCL wide risks escalated from the NCL Joint Commissioning Committee which takes a wider pan-NCL perspective. These are clearly set out as risks from an NCL perspective. In response to feedback from the January 2018 Governing Body meeting the local CCG risks and the NCL Joint Commissioning Committee risks have been clearly labelled. Number of risks There are 13 risks on the BAF. Five are from a Local perspective and 8 are from an NCL perspective. Key Highlights- Local Perspective Risk 362- System Resilience (Threat): Work is continuing to mitigate this risk. However, due to the level of challenge the Target Risk Score has increased from 8 to 12. Risk 382 - Failure to deliver the QIPP plan Forecast Out Turn for 17/18 (Threat): The risk title has been amended to better reflect the risk. The CCG is currently underperforming against its QIPP target by £1.6m. Contingency plans are in place to mitigate this risk. The Target Risk Score has decreased from 16 to 9 reflecting increased confidence in the risk mitigations. Risk 434 - Delivery of Cancer 62 Day Waiting Time Standard (Threat): The Performance Team continues to work with providers to meet the standard. UCL Hospitals is predicting recovery of the standard by the end of March 2018. Risk 432 - Increased costs due to acute over-performance (Threat): The CCG is pursuing contractual remedies for inappropriate charging beyond the standard challenges. There are on-going challenges regarding quarter 2 which are being addressed. Risk 432 - Failure to deliver a robust QIPP plan for 2018/19 (Threat): This risk complements risk 382. The CCG is developing a robust QIPP plan for 2018/19 in line with national planning guidance which was issued in January 2018. Weekly QIPP meetings are being held to take forward the 2018-19 QIPP plan and local providers are being engaged.

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Key Highlights- NCL Joint Commissioning Committee Risk JCC 1- Delivery of Cancer 62-day waiting time standard (Threat): The CCGs meets with providers fortnightly on recovering the trajectories. The standard was delivered for NCL in December 2017 but with UCLH the recovery plan received by them defers recovery of the standard from March 2018 to June 2018. Internal pathways are expected to be compliant by April 2018. Risk JCC 13- Ensuring that management of winter pressures supports recovery of waiting time standards for A&E and cancer and protects capacity for elective pathways (Threat): The NCL approach to escalation has been agreed in principle with NHS England and all A&E delivery boards have agreed escalation protocols to respond to surges in pressures and/or demand. In addition, provider mutual aid plans have been developed to free up clinical time from elective care pathways to support emergency patient flows. Risk JCC 20- Delivery of referral-to-treatment (RTT) waiting time standard (Threat): The CCGs are continuing to work with UCLH and Royal Free London on delivery of remedial action plans and on sustainability. Royal Free London submitted an updated Remedial Action Plan in March 2018 and the development of activity plans for 2018/19 is underway taking into account national planning guidance that waiting lists should be maintained at current levels as a minimum. NCL Risk Register A new NCL Risk Register has been developed which captures the key pan NCL risks that are not captured by our other risk registers. The NCL Risk Register contains ten risks which include NCL and STP risks. For example:

• Delivery of the Transformation Agenda; • Sustainability of Fragile Service; • Recruitment and Retention of a High Performing Workforce.

The NCL Risk Register will be reviewed regularly by the NCL Senior Management Team, the STP PMO and the assurance process will be overseen by the NCL audit committees.

Purpose

Information

Approval To note

Decision

Recommendation The Governing Body is asked to review the risks and provide feedback on the updated BAF.

Strategic Objectives Links

The BAF focuses on risks relating to the strategic objectives of the CCG: • Commission the delivery of NHS constitutional rights and pledges • Improve the quality and safety of commissioned services • Improve health outcomes, address inequalities and achieve parity of esteem • Integrate and enable local services to deliver the right care in the right setting

at the right time • Work jointly with the people and patients of Camden to shape the services

we commission • Involve member practices and commissioning partners in key commissioning

decisions • Maintain financial stability and ensure sustainability through robust planning

and commissioning of value-for- money services Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce.

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Identified Risks and Risk Management Actions

The BAF is a risk management document which is presented at every Governing Body report. It is available to members of the public on the CCG’s website.

Conflicts of Interest

None identified.

Resource Implications

Updating of the BAF is the responsibility of each risk owner and their respective directorates. The Governance Team helps to support this by providing monitoring, guidance and advice.

Engagement

Not applicable for the purpose of this report.

Equality Impact Analysis

This report was written in accordance with the provisions of the Equality Act 2010.

Report History

The BAF was last reviewed by the Governing Body on 17th January 2018. Risks are kept under review by committees of the Governing Body and risk owners.

Next Steps To continue to manage risk across the organisation in a robust way.

Appendices

The following is attached: 1. BAF; 2. BAF Heat Map; 3. Risk Scoring Key; 4. NCL Risk Register.

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ID Director Objectives Risk Controls in Place Evidence of ControlsOverall Effectiveness of Controls in Place

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Jennifer Murray-Robertson,Director of Commissioning and Contracts

Commission the delivery of NHS Constitutional rights and pledges

TITLE: System Resilience (Threat)

CAUSE: There may be insufficient capacity within the system

EFFECT: Which may lead to the risk that the system may be unable to cope with changes and increases of activity at times of high demand, such as the winter time.

IMPACT: This may lead to performance issues in A&E (UCLH), referral to treatment targets, and elective care which may impact on patient care. The CCG may also suffer reputational damage.

C1. An A&E delivery board has been established which has executive level representation from key providers in the system.C2. A&E Delivery Board has developed a 'Heat Map' dashboard which monitors key parts of the system to highlight any issues in terms of capacity and/or performance.C3. With key providers, and using funding available to the A&E Delivery Board, agreed which parts of the system would benefit from increased capacity or efficiency changes. C4. Continued monitoring of the action plan (RAP) against agreed outcome measures.C5. A North Central London ('NCL') wide review of how winter went across NCL took place on 6th April 2017 to share lessons learned.C6. The A&E Delivery Board submitted plans to NHS England for winter 2017/18 based on experiences and pressures in 2016/17.C7. Community Bed Review completed.

C1. A&E Delivery Board papers (meets monthly)C2. Heat Map discussed at each A&E Delivery Board meetingC3. Bids submitted and considered at the A&E Delivery BoardC4. Monitored through the monthly UCLH performance meetingC5. Notes from the workshop.C6. Winter planC7. Outcome from review.

AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk

4 4 16

Very High

A1. Have in place Weekend Hub Access to give increased access to GP services.A2. Access to Extended Hours service.A3. Put senior CCG support into place at UCLH to support increased patient flow and DTOCs.A4. Combine remdiat action plans across CCG and UCLH to form a single joint RAP

A1. Currently in place, reprovision exercise has been completed to enhance utilisation.A2.Currently in place, reprovision exercise has been completed to enhance utilisation.A3. Senior CCG support present in Trust to support directly from w.c 2/1 to be continued at Trust request during peak periodsA4. First draft single RAP being developed for March AEDB

A1. Completed.A2. Completed 31/12/2017.A3. Completed. live from 02.01.201.A4. 31.03.2018.

RISK TARGET INCREASED FROM 8 to 12 4 3 12

High

434

Jennifer Murray-Robertson, Director of Commissioning and Contracts

Commission the delivery of NHS constitutional rights and pledges

TITLE: Delivery of Cancer 62-day waiting time standard (Threat)

Cause: Performance against the 62 day waiting time standard at UCLH is impacted by whole system performance, particularly late inter-trust transfers.

Effect: There is a risk that the Trust may be unable to cope with the level of demand.

Impact: This may result in patients not receiving treatment within 62 days.

C1. Regular performance meetings with providers and strengthened CCG performance management process in place.C2. Use of contractual leavers where applicable.C3. RAPs being implemented and monitored.C4. North Central London ('NCL') cancer governance arrangements established to cover both performance and transformation.C5. Improvement trajectory agreed with NHS England and NHS Improvement.C6. 38 day transfer protocol in place for inter-provider transfers from district general hospitals to tertiary services with the 38 day standard compatible with treatment commencing within 62 days.

C1. Meeting papers and notes.C2. CPN issued.C3. RAPs monitored at the monthly performance meetingC4. Transfer protocol document.C5. TrajectoryC6. Transfer protocol.

AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk

4 4 16

Very High

A1. Continue to work with providers on delivering the trajectories.A2. Continue to work with providers to ensure sustainable delivery and includes work through the cancer vanguard.A3. UCLH recovery of the 62 day standard by end of March 2018.

A1. Meeting with providers on a monthly basis and ensuring their plans are consistent with agreed trajectories.A2. Meeting with providers on a monthly basis.A3. Currently on track for delivery. Dec validated data reviewed at CRG showed compliance, but noted that January 2018 and February 2018 will not as an expected part of the recovery trajectory

A1. Meetings are held continuously on a monthly basis.A2. Meetings are held continuously on a monthly basis.A3. 31.03.2018

4 3 12

High

High

Very High

A1. Monitor and adjust QIPP plans and activity relating to 2017-18 QIPP Schemes to meet Forecast Out Turn.

A2. Deputy Director Finance developed and implement a financial recovery plan to offset potential unmitigated financial risks

A1. Bi-weekly QIPP planning meetings and QIPP Challenge Panel meetings in place. These monitor progress and challenge on underpfromance. A2. Action completed. Financial Recovery Plan in place.

A1. 31.03.2018A2. 28.02.18

3

NHS Camden Clinical Commissioning Group- BAF Risks From A Local Perspective

382

Sally MacKinnon- Director of Transformation, Planning and Delivery

Maintain financial stability and ensure sustainability through robust planning and commissioning of value for money services

TITLE: Failure to deliver the QIPP plan Forecast Out Turn for 17/18 (Threat) CAUSE: If the CCG fails to deliver a robust QIPP plan for 2017/18 that meets NHS mandated control totals.

EFFECT: There is a risk that the CCG will not have a balanced budget for 2017-18 and not meet NHS England control totals.

IMPACT: This may result in the CCG being placed into Directions/special measures by NHS England, destabilisation of the CCG, destabilisation of local providers, a wider negative impact on the NCL health economy, patients and loss of influence of quality of patient care.

C1. Finance, Performance, Quality Committee reviews and approves the overall financial plan including QIPP plan. C2 Currently going through a review of avoidable spend, assigning priorities to spend areas with a view to reducing or ceasing low priority spend.C3. QIPP Exec lead and Manager to support the QIPP Programme are in role.C4. QIPP Planning started in September 2016.C5. Governing Body direction on lower priority spend areas for savings obtained.C6. Root and branch review of all spend across the organisation completed.C7. Deloitte review of QIPP successfully completedC8. PMO taking a strengthened role in QIPP.C9. Contractual arrangements with acute providers in place.C10. Clinical and manager leads in place for each area of QIPP scheme.C11. QIPP Challenge Panel established to oversee operational delivery of QIPP.C12. Camden CCG is part of the NCL STP which has shared responsibility to ensure financial stability. This includes commissioners and providers.C13. Contingency plans in place for QIPP under performance.

C1. Minutes and papers of the Finance, Performance and QIPP Committee.C2. Papers and e-mails.C3. Employment contracts.C4. QIPP Plan and monthly update on progress, minutes of meetings and meeting reports.C5. Governing Body forum note.C6. Updated financial assessment.C7. Deloitte feedback and agreed actions.C8. PMO reports.C9. Contracts with acute providers.C10. Employment contracts.C11. Meeting notes and papers.C12. A NCL STP Finance and Activity Modelling meeting occurs every two weeks to ensure NCL remains on track with QIPP delivery.C13. Papers and plans.

AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk

5 4 20 3 9

129

ID Director Objectives Risk Controls in Place Evidence of ControlsOverall Effectiveness of Controls in Place

Cons

eque

nce

(cur

rent

)Li

kelih

ood

(cur

rent

)

Ratin

g (c

urre

nt)

Risk

leve

l (c

urre

nt)

Actions Update on Actions Action Competion Date

Cons

eque

nce

(Tar

get)

Like

lihoo

d (T

arge

t)

Ratin

g (T

arge

t)

Risk

leve

l (Ta

rget

)

432

Jennifer Murray-Robertson,Director of Commissioning and Contracts

Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for- money services

TITLE: Increased costs due to acute over-performance (Threat)

Cause: if expenditure on acute contracts exceeds planned contract baselines

Effect: Increased acute expenditure leading to requirement for additional in-year and future QIPP delivery

Impact: recovery plan and additional in-year and future QIPP requirements. may impact on delivering a balanced control total. May increase baseline acute costs in 18-19

C1. Signed contracts in place for 2017/18 and 2018/19C2. Contracts include marginal rate payments/deductions for variances from plan and 3% growth (higher than historic growth trends) C3. Contract management framework in place with providersC4. Issue of contract notices in line with contact provisionsC5.. Mobilisation of STP and QIPP plans (see JCC10)C6. North Central London Finance and Activity Modelling (FAM) Group, with commissioner and provider membership. that oversees system financial positionC7. Work on alternative contract forms to support the Sustainability and Transformation Plan (STP) through the Acute Contract Modelling Group (with commissioner and provider membership)C8. Monthly finance and performance monitoring of acute contracts

C1. Signed contractsC2. Signed contractsC3. Meeting minutes and papersC4. Contract documentation and correspondence including remedial action plansC5. See JCC10C6. Meeting minutes and papersC7. Meeting minutes and papersC8. Finance & Performance reporting

AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk

5 4 20

Very High

A1. Develop, in co-production, with providers, proposals for alternative contract forms for hospital providersA2. Pursue all contractual remedies for inappropriate charging beyond standard challenges. These include PoLCE (incorporating RLHIM), 30-day readmission threshold at local trust, application of access policy, and coding notification issues at a neighbouring trust.A3. Conduct independent analysis of reconciliation between data sources to validate charging in specific areas

A1. Consideration of models used elsewhere - Aligned Incentive Contract in Bolton; Accountable Care models. This work is being developed with the STP throughout 2018.A2. This work has commenced and partially completed. There are some on-going challenges regarding quarter 2 which are being addressed.A3. This work was reported to Finance, Performance and QIPP committee 25th October 2017 and the Committee continues to maintain oversight of overperformance risks. CSU deeper dive carried out with FU queries to be investigated. Small audit by single GP of RFH case mix coding against clinical notes now underway supported by Care Insights team. This action is completed.

A1. 31.12.18.A2. 31.3.18.A3. 25.10.17.

4 4 16

Very High

431

Sally MacKinnon- Director of Transformation, Planning and Delivery

Maintain financial stability and ensure sustainability through robust planning and commissioning of value for money services

TITLE: Failure to produce a deliverable and robust QIPP plan for 2018/19 (Threat) CAUSE: If the CCG fails to produce and deliver a robust QIPP plan for 2018/19 that meets NHS mandated control totals.

EFFECT: There is a risk that the CCG will not have a balanced budget for 2018-19 and not meet NHS England control totals.

IMPACT: This may result in the CCCG being placed into Directions/special measures by NHS England, destabilisation of the CCG, destabilisation of local providers, a wider negative impact on the NCL health economy and loss of influence of quality of patient care.

C1. QIPP Workshop is providing clinical input into the development of the 2018/19 QIPP plan. C2. Finance and Performance Committee reviews and approves the overall financial plan including the QIPP plan. C3 Currently going through a review of avoidable spend, assigning priorities to spend areas with a view to reducing or ceasing low priority spend.C4. QIPP Exec lead and Manager to support the QIPP Programme is in role.C5. QIPP Planning started in September 2017.C6. Obtained from Governing Body direction on lower priority spend areas for savings.C7. Root and branch review of all spend across the organisation completed.C8. Consistent NCL approach to planning .C9. PMO taking a strengthened role in QIPP.C10. Governing Body direction on lower priority spend areas obtained.C11. Contractual arrangements with acute providers in place.C12. Clinical and manager leads in place for each area of QIPP.C13. QIPP Challenge Panel established to oversee operational delivery of QIPP.C14. Camden CCG is part of the NCL STP which has shared responsibility to ensure financial stability. This includes commissioners and providers.C15. Robust QIPP planning process in place.

C1. Minutes and papers of the QIpp Workshop and QIPP challenge panelC2. Minutes and papers of the Finance and Performance Quality Committee;C3. Minutes and papers of the QIPP Challenge Panel and Finance, Performance and Quality Committee.C4. Contract of Service/Job description Director.C5. Minutes of meetings and meeting reports.C6. Governing Body forum note.C7. Updated financial assessment.C8. NCL QIPP & planning meetings.C9. PMO reports.C10. Minutes of workshop.C11. Contracts with acute providers.C12. QIPP registerC13. Meeting notes and papers.C14. Papers and minutes of meetings.C15. Papers and minutes of meetings.

AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk

5 4 20

Very High

A1. NCL Financial Planning to develop 18/19 QIPP targetsA2. Initial QIPP targets schemes identified and PIDs developedA3. QIPP NHSE QIPP Assurance meetingA4. STP QIPP PIDs to be discussed with providers A5. Work underway to meet unidentified QIPP of circa 2mA6. Refresh QIPP plan on an ongoing basis as more detailed schemes are developed

A1. Work is continuing on this.A2. PIDs are being updated in line with 2018-19 financial planning.A3. Successfully completed and assurance given.A4. QIPP into 18/19 contract work ongoing. Local provider meeting being planned for March 2018.A5. Weekly QIPP meeting in place which is taking forward the 18/19 QIPP plan and overseeing delivery. This includes the development of pipeline schemes to meet QIPP gap.A6. Planning guidance issued January 2018. Financial planning underway including the impact of guidance on QIPP target.

A1. 31.03.2018A2. 31.03.2018A3. 22.12.17A4. 31.03.2018A5. 31.03.2018A6. 31.01.2018

4 4 16

High

130

North Central London CCG Risk Register as at April 2018

ID Director Objective Risk Controls in place Evidence of Controls

Overall Strength of Controls in

Place

Consequence (C

urrent)Likelihood (C

urrent)R

ating (Current)

Risk level (C

urrent)

Actions Update on Actions Action Completion Date

Consequence (Target)Likelihood (Target)

Rating (Target)

Risk level (Target)

JCC 1Paul Sinden, NCL Director of

Performance and Acute Commissioning

62 Days Waiting Time Standard is Met

Delivery of Cancer 62-day waiting time standard (Threat)

Cause: There may be insufficient capacity within the system, and inefficiencies along pathways in particular for inter-provider transfers.

Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events.

Impact: This may result in people not receiving treatment within 62 days with potential adverse impact on their health outcome.

C1. North Central London ('NCL') cancer governance arrangements established to cover both performance and transformation.C2. Improvement trajectory agreed with NHS England and NHS Improvement.C3. Remedial Action Plans in place with providers that are not meeting the 62 day standard. Updated plan received from Royal Free London.C4. 38 day transfer protocol in place for inter-provider transfers from district general hospitals to tertiary services with the 38 day standard compatible with treatment commencing within 62 days.C5. Trajectory agreed with providers to meet the 38-day standard for transfers of careC6. Recovery plan received from UCLH, with overall compliance by June 2018 and compliance on internal pathways by April 2018

C1. Meeting papers and notes.C2. Plans and trajectories in place with providers to allow NCL to meet the standard overall. Backlog analysis indicates reduction towards sustainable level. Progress most marked at Royal Free London in October and November. C3. Plans. C4. Transfer protocol document.C5. Provider trajectoriesC6. Provider recovery plan

Average

4 4 16

Very High

A1. Continue to work with providers on delivering the trajectories.A2. Continue to work with providers to ensure sustainable delivery and includes work through the cancer vanguard.A3. NCL recovery of the 62 day standard by December 2017.A4. UCLH recovery of the 62 day standard by end of March 2018 and is consistent with system recovery by December 2017. Updated recovery plan required from the Trust.

A1. Provider meetings continue on a fortnightly basis on recovering the trajectories. A2. Cancer vanguard meetings in place with provider and commissioner representation which meet monthly.A3. NCL delivered the standard in December 2017 but further work is required for sustainability. This work is being undertaken and is reflected in action A4.A4. UCLH recovery plan received but defers recovery to June 2018 from expected recovery by March 2018. Internal pathways are expected to be compliant by April 2018.

A1. 30.06.2018A2. 30.06.2018A3. 30.06.2018A4. 30.06.2018

3 4 12

High

JCC 2Paul Sinden, NCL Director of

Performance and Acute Commissioning

A&E 4 Hour Time Waiting Standard is Met

Delivery of four-hour waiting time standard for A&E (Threat)

Cause: There may be insufficient capacity across hospital and community services to meet peaks in emergency care demand.

Effect: There is a risk that people will spend more than four hours within emergency departments before receiving definitive treatment or be located in the wrong part of the system due to pressures along the emergency care pathway.

Impact: This may result in people experiencing delays in treatment, admission to a hospital bed and/or discharge back into the community.

C1. A&E Delivery Boards established and meet monthly which have executive level representation from key providers and commissioners in the systemC2. A&E Delivery Boards are informed by dashboards that monitor key parts of the system to highlight any issues in terms of capacity and/or performance.C3. With key providers, and using resilience funding available A&E Delivery Boards have agreed which parts of the system would benefit from increased capacity or efficiency changes. C4. Continued monitoring of the plan (i.e. initiatives) against agreed outcome measures by A&E Delivery Boards.C5. Funding is targeted to support the remedial action plans (RAPs) agreed with UCLH. C6. A North Central London (NCL) wide review of how winter went across NCL took place on 6th April 2017 to share lessons learnt.C7. All A&E Delivery Boards submitted plans to NHS England for winter 2017/18 based on experiences and pressures in 2016/17

C1. Meeting papers and notes.C2. Meeting papers and dashboards.C3. Remedial Action Plans, meeting papers and notes.C4. Meeting papers, notes and dashboards.C5. Plans to utilise winter resilience monies.C6. Report.C7. Plans

Weak

4 4 16

Very High

A1 . Develop a demand and capacity plan for both hospital and community services for 2018-19.A2. Implement STP initiatives.A3. Develop mutual aid plans for January 2018 to meet peaks in demand.

A1. A&E Delivery Boards are developing system wide demand and capacity plans. It is expected this will be delivered by 30th April 2018.A2. Action completed.A3. Action completed.

A1. 30.04.2018A2. 31.12.2017A3. 31.01.2018

3 4 12

High

JCC 10Paul Sinden, NCL Director of

Performance and Acute Commissioning

Effective mobilisation of Sustainability and

Transformation (STP) plans and CCG QIPP

plans to ensure contracts remain within resource

envelopes

Mobilisation of STP and QIPP plans (Threat)

Cause: if we do not ensure that STP and QIPP plans are delivered in accordance with planning assumptions

Effect: There is a risk that contracts will not be delivered within resource envelopes for 2017/18

Impact: This may result in delays to service changes, higher contract baselines for 2018/19 than anticipated in financial plans for CCGs, and a wider system financial gap.

C1. Signed contracts in place for 2017/18 and 2018/19C2. Contract frameworks in place with each provider including Local Delivery Teams to support the STPC3. In-year contract variances subject to marginal rates rather than full tariff adjustments C4. Collaborative arrangements in place through Finance and Activity Modelling (FAM) Group as part of STP governance frameworkC5. Sustainability and Transformation Plan governance and supporting work streams with commissioner and provider membership in placeC6. Development of schemes for 2018/19 underway. Project initiation documents shared with providers for planned care, care closer to home, and urgent and emergency care

C1. Signed contractsC2. Meeting minutes and papersC3. Signed contractsC4. Meeting minutes and papersC5. Meeting papersC6. Meeting papers and project initiation documents

Average

4 4 16

Very High

A1. Finalise proposals to increase support for STP work streams A2. Progress the work of the acute contract modelling group to consider alternative contract forms

A1. In-housing of NELCSU to provide greater support and capacity for delivery of STP interventions is underway.A2. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19.

A1. 01.07.2018.A2. 01.07.2018

4 3 12

High

NCL Joint Commissioning Committee- BAF Risks From A Pan NCL Perspective

131

ID Director Objective Risk Controls in place Evidence of Controls

Overall Strength of Controls in

Place

Consequence (C

urrent)Likelihood (C

urrent)R

ating (Current)

Risk level (C

urrent)

Actions Update on Actions Action Completion Date

Consequence (Target)Likelihood (Target)

Rating (Target)

Risk level (Target)

JCC11Paul Sinden, NCL Director of

Performance and Acute Commissioning

Management of acute contracts to ensure

contracts are delivered within contact baselines

(CCG resource envelopes)

Managing acute contracts within contract baselines (Threat)

Cause: if expenditure on acute contracts exceeds planned contract baselines

Effect: There is a risk that CCGs will not meet their financial duties and/or investment is withheld to support delivery of the Sustainability and Transformation Plan

Impact: This may result in delays to investing in primary care and community capacity and perpetuate the risk over performance on acute hospital contracts

C1. Signed contracts in place for 2017/18 and 2018/19C2. Contracts include marginal rate payments/deductions for variances from plan and 3% growth (higher than historic growth trends) C3. Contract management framework in place with providersC4. Issue of contract notices in line with contact provisionsC5.. Mobilisation of STP and QIPP plans (see JCC10)C6. North Central London Finance and Activity Modelling (FAM) Group, with commissioner and provider membership. that oversees system financial positionC7. Work on alternative contract forms to support the Sustainability and Transformation Plan (STP) through the Acute Contract Modelling Group (with commissioner and provider membership)C8. Quarter one reconciliation agreed with providers as a precursor to establishing the opening contract baseline for 2018/19C9. Agreement of treatment of disputed items with Royal Free London in 2017/18 reached

C1. Signed contractsC2. Signed contractsC3. Meeting minutes and papersC4. Contract documentation and correspondence including remedial action plansC5. See JCC10C6. Meeting minutes and papersC7. Meeting minutes and papersC8. Meeting minutes and papers

Average

4 4 16

Very high

A1. Develop and sign-off system intentions for 2018/19A2. Develop, in co-production, with providers, proposals for alternative contract forms for hospital providersA3. Development of planning assumptions for 2018/19 with providers.

A1. Action completed. System intentions issued to providers. A2. Consideration of models used elsewhere - Aligned Incentive Contract in Bolton; Accountable Care models. Work has commenced on this and is continuing.A3. Planning assumptions are being developed through STP finance meetings following publication of national planning guidance.

A1. 30.09.2017A2. 01.07.2018A3. 23.03.2018

4 3 12

High

JCC 13Paul Sinden, NCL Director of

Performance and Acute Commissioning

Management of winter pressures to support

recovery of A&E waiting time standard and protect

capacity for delivery of cancer and referral-to-treatment waiting time

standards

Ensuring that management of winter pressures supports recovery of waiting time standards for A&E and cancer and protects capacity for elective pathways (Threat)

Cause: if we are unable to manage non-elective flows within planned hospital and community capacity to meet winter pressures

Effect: There is a risk that patients may receive sub-optimal care and long waiting times leading to the local system missing waiting time standards for A&E and referral-to-treatment. Historically capacity to meet cancer waiting time standards has been successfully ring-fenced.

Impact: Patients may remain in inpatient placements longer than anticipated as community care packages are developed.

C1. Establishment of A&E Delivery Boards with representation across health and care system C2. Establishment of NCL Urgent and Emergency Care (UEC) BoardC3. STP work streams for urgent and emergency care established for long-term sustainability.C4. Winter plans for 2017/18 prepared by each A&E Delivery BoardC5. Recovery plans submitted by each A&E Delivery Board to regain A&E four-hour waiting time standardC6. See JCC2 - recovery of A&E four-hour waiting time standardC7. Supplementary winter plans submitted by each A&E Delivery Board to NHS England and NHS Improvement in December 2017

C1. Meeting papers and minutes from A&E Delivery BoardsC2. Meeting papers and minutes from UEC Board .C3. Work streams plans and QIPP monitoring reportsC4. Plans submitted and reports/dashboards monitoring progress.C5. Plans submitted and reports/dashboards monitoring progress.C6. See JCC2C7. Funding confirmation for priority supplementary schemes from NHS England

Average

4 5 20

Very high

A1. Agree escalation process for NCL with NHS England and NHS Improvement A2. Hold winter workshop on 27 SeptemberA3. Identification of further recover plans through winter workshop and A&E Delivery BoardsA4. Provider mutual aid plans developed for January 2018 to free up clinical time from elective care pathways to support emergency patient flows A5. Each A&E deliver board to complete an after action review process for winter 2017-18.A6. Plans for winter 2018-19 to be submitted to NHS England by end of April 2018.

A1. Action completed. NCL approach to escalation agreed in principle with NHS England. All A&E Delivery Boards have agreed escalation protocols to respond to surges in pressure and/or demand A2. Action completed. Actions from winter workshop were actioned through A&E Delivery Boards A3. Additional plans submitted by A&E deliver boards in December 2017.A4. Action completed. A5. Work is progressing on this.A6. Work is progressing on this.

A1. 13.10.2017A2. 30.11.2017A3. 31.12.2017A4. 31.01.2018A5. 31.03.2018A6. 30.04.2018.

4 4 16

Very high

JCC 14Paul Sinden, NCL Director of

Performance and Acute Commissioning

Mobilising STP schemes that shifts activity away

from acute providers in a way that allows those providers to release

capacity and costs, and thereby reduce overall

system costs

STP and local plans target the shift of care from hospital into community settings, to reduce the overall system financial deficit this needs to be done in a way that allows hospital providers to reduce capacity and costs. This risk follows on from the initial risk of mobilising STP and local plans in JCC10 (Threat)

Cause: if we are unable to shift care from hospital to community settings that allow providers to make a step-change in capacity

Effect: There is a risk that hospital providers are left with stranded costs and we do not reduce overall system costs

Impact: STP and local interventions do not help reduce the system financial deficit in the anticipated way.

C1. Signed contracts for 2017/18 and 2018/19 that include the impact of STP interventionsC2. System intentions for 2018/19 that seek to align intentions across CCGS so we commission at scaleC3. Agreement of approach to planning round for 2018/19 with providers through STP finance meetings. Contract baselines for 2018/19 to include the impact of STP interventions. C4. Work with providers on alternative contract forms to support STP delivery, with the work informed by provider cost profiles.C5. STP Finance meetings with commissioners and providers that has a common understanding of financial position in NCL systemC6. STP interventions for 2018/19 developed and shared with providers

C1. Contract documentationC2. NCL Systems Intentions letterC3. Meeting paper and notes.C4. Meeting papers and notes. C5. Meeting papers and notesC6. Meeting papers and project initiation documents.

Average

4 4 16

Very high

A1. Work streams development of STP plans for 2018/19.A2. Agree option for setting contract baselines for 2018/19.A3. Negotiation of contract baselines for 2018/19 incorporating 2017/18 plan/outturn, growth and impact of interventions.A4. Agree models for alternative contract forms to be shadow run in 2018/19A5. Create finance and activity schedules that support the shadow running od the alternative contract forms.

A1. Plans submitted to STP finance group in November 2017.A2. Options being refreshed following issue of national planning guidance.A3. Negotiations are underway with completion targeted in line with national timetable.A4. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19.A5. Open book approach to provider cost profiles agreed and work is underway to provide the information.

A1. 30.11.2017A2. 23.03.2018A3. 23.03.2018A4. 01.07.2018A5. 01.07.2018

3 3 9

High

JCC 18Paul Sinden, NCL Director of

Performance and Acute Commissioning

Reducing the system financial deficit in line with

planning assumptions

NCL is a system in deficit. One of the aims of our Sustainability and Transformation Plan is to deliver financial recovery and maintain and sustainable health and care system. The STP sets out the challenges to financial recovery from demographic and demand trends. (Threat)

Cause: if our plans do not deliver financial balance

Effect: There is a risk that additional savings plans will need to be developed that have a greater impact on service delivery and access than current plans, and the local system comes under greater scrutiny from regulators.

Impact: Delivery of our STP developments is slowed down and impact reduced. Greater local resource is taken up with assurance processes

C1. STP finance meeting established that has a common view of system deficit C2. Collaborative approach to contracting round for 2017/18 and 2018/19 C3. Work on alternative contract forms for future years to support cost reductionC4. Monthly reporting cycle and monitoringC5. Working groups established for areas of pressure and with scope for cost reduction - estates, continuing healthcare, demand management etc.C6. Iterative CCG QIPP plans

C1. Meeting papers and minutes from STP finance group C2. Contract documentation; notes from STP finance group.C3. Notes from acute contract modelling groupC4. ReportsC5. Meeting notesC6. Reports.

Average

4 5 20

Very high

A1. Finalise quarter one reconciliation process to identify opportunities for year-end settlementsA2. Continue to identify further savings opportunities A3. 2081/19 planning round to set contract baselines for 2018/19A4. Greater alignment of CCG QIPP and provider cost improvement programmes (CIP) for 2018/19

A1. Action completed. A2. Work is on-going. Opportunities are being developed through STP finance group and locally by CCGs A3. Process for planning round agreed through STP finance group and work is on-going.A4. QIPP/CIP meeting held in January 2018.

A1. 31.01.2018A2. 31.03.2018A3. 23.03.2018A4. 31.01.2018

4 4 16

Very high

132

ID Director Objective Risk Controls in place Evidence of Controls

Overall Strength of Controls in

Place

Consequence (C

urrent)Likelihood (C

urrent)R

ating (Current)

Risk level (C

urrent)

Actions Update on Actions Action Completion Date

Consequence (Target)Likelihood (Target)

Rating (Target)

Risk level (Target)

JCC 20Paul Sinden, NCL Director of

Performance and Acute Commissioning

18-week referral-to-treatment waiting time

standard is met

Delivery of referral-to-treatment (RTT) waiting time standard (Threat)

Cause: There may be insufficient capacity within the system, and inefficiencies along pathways.

Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events.

Impact: This may result in people not receiving treatment within 18 weeks of referral from their GP with potential adverse impact on their health outcome.

C1. Contract governance arrangements established to cover performance.C2. Remedial action plan agreed with UCLH. C3. Planned Care work stream considering demand management schemes to support RTT delivery including Clinical Advice and Navigation. C4. Remedial action plan received from Royal Free London but with recovery of the waiting time standard targeted by August 2018. CCGs and NHS Improvement are challenging the Trust for a faster recovery.

C1. Meeting papers and notes.C2. Agreed remedial action plan C3. STP Project Initiation Documents (PIDs)C4. Draft remedial action plan

Average

4 4 16

Very High

A1. Continue to work with UCLH and Royal Free London on delivery of remedial action plansA2. Continue to work with providers to ensure sustainable delivery including work through the STPA3. Develop activity plans for 2018/19 for sustainable deliveryA4. Develop tariff arrangements for Clinical Advice and Navigation.

A1. Updated Remedial Action Plan received from Royal Free London in March 2018. Continuing to monitor remedial action plans through contract meetings. A2. Action completed. Development of planned care initiatives for 2018/19 are completed. A3. Development of activity plans for 2018/19 underway taking into account national planning guidance that waiting lists should be maintained at current levels as a minimum.A4. Draft tariff agreed by commissioners which will be shared with providers.

A1. 31.03.2018A2. 30.11.2017A3. 23.03.2018A4. 23.03.2018.

3 3 9

High

133

BAF Risk Heat Map

2 3 4 5

3

4

5

Consequence

Likelihood

2

1

1

434

434

382

Current Risk Score: Target Risk Score:x x

382

362

362

JCC 1

JCC 1

JCC 2

JCC 2

JCC 10

JCC 10

JCC 11

JCC 20

JCC 13JCC 13

JCC 14

JCC 14

JCC 18

JCC 18

432

431

431

432

JCC 20JCC 11

134

Risk Scoring Key This document sets out the key scoring methodology for risks and risk management.

1. Overall Strength of Controls in Place There are four levels of effectiveness: Level Criteria Zero The controls have no effect on controlling the risk. Weak The controls have a 1- 60% chance of successfully controlling the risk. Average The controls have a 61 – 79% chance of successfully controlling the risk Strong The controls have a 80%+ chance or higher of successfully controlling the risk

2. Risk Scoring This is separated into Consequence and Likelihood. Consequence Scale: Level of Impact on the Objective

Descriptor of Level of Impact on the Objective

Consequence for the Objective

Consequence Score

0 - 5% Very low impact Very Low 1 6 - 25% Low impact Low 2 26-50% Moderate impact Medium 3 51 – 75% High impact High 4 76%+ Very high impact Very High 5 Likelihood Scale: Level of Likelihood the Risk will Occur

Descriptor of Level of Likelihood the Risk will Occur

Likelihood the Risk will Occur

Likelihood Score

0 - 5% Highly unlikely to occur

Very Low 1

6 - 25% Unlikely to occur Low 2 26-50% Fairly likely to occur Medium 3 51 – 75% More likely to occur

than not High 4

76%+ Almost certainly will occur

Very High 5

135

3. Level of Risk and Priority Chart

This chart shows the level of risk a risk represents and sets out the priority which should be given to each risk:

LIKELIHOOD

CONSEQUENCE

Very Low (1)

Low (2)

Medium (3)

High (4)

Very High (5)

Very Low (1)

1 2 3 4 5

Low (2)

2 4 6 8 10

Medium (3)

3 6 9 12 15

High (4)

4 8 12 16 20

Very High (5)

5 10 15 20 25

1-3

Low Priority

4-6

Moderate Priority

8-12

High Priority

15-25

Very High Priority

136

NCL Risk Register March 2018

ID Director Objective Risk Controls in place Evidence of Controls

Overall Strength of Controls in

Place

Consequence

Likelihood (Current)

Rating (Current)

Risk level (Current)

Controls Needed Evidence of Controls Needed ActionsAction

Completion DateUpdate on Actions

Consequence

Likelihood (Target)

Rating (Target)

Risk level (Target)

NCL 1Will Huxter, NCL Director of Strategy

Successful delivery of the STP transformation agenda

Delivery of the Transformation Agenda (Threat)

Cause: If the STP does not have sufficient clinican and political support and suitable capacity and resources

Effect: There is a risk that the STP will not deliver the expect financial or quality benefits and that services are not appropriately integrated

Impact: This may result in a system wide financial deficit and deterioration in clinical quality which will negatively impact on patient care and reputational damage.

C1. Clinical leaders are in place across workstreams;C2. NCL wide Health and Care Cabinet established to oversee plans;C3. Recruitment to STP programme team is in progress;C4. QIPP Planning processes in NCL aligned with STP;C5. On-going senior enagement with local councillors and with the Joint Health and Overview Scrutiny CommitteeC6. STP programme infrastructure in place including programme board with senior representation from parter organisations and a sector wide finance group;C7. Robust planning process in place including regular reviews with NHS England and NHS Improvement;C8. Commissioning intentions;C9. Service business cases and project plans;C10. CCG commissioning teams and Provider teams in place;C11. Clinically led STP delivery plans in place.

C1. Terms of reference and project documentation;C2. Papers;C3. Job adverts and employment contracts;C4. Finance reports, CCG QIPP plans.C5. Meeting papers.C6. Terms of reference and meeting papers.C7. Programme delivery plans, notes and minutes from meetings;C8. Governing Body papers; C9. Business case and project plan papers;C10. Employment contracts;C11. Documents and papers.

Average

4 3 12

High

CN1. On-going work to link to new CCG operating models is in progress.CN2. Scope and develop provider focussed efficiency workplan;CN3. Complete recruitment to STP programme team.CN4. Strengthen Health and Care Cabinet and link back to partner organisationsCN5. Improve tracking of benefits across programmes.

CN1. Papers, Standing Operating Procedures;CN2. Provider focussed delivery plan;CN3. Employment contracts;CN4. Refreshed Terms of Reference and communications plans;CN5. Benefit tracker.

A1. Continue to work with CCGs on linking CCG operating models to STP plans.A2. Scope and develop provider focussed efficiency workplan;A3. Complete recruitment to STP programme team;A4. Revise terms of reference for Health and Care Cabinet;A5. Develop communications plan;A6. Develop new programme highlight reports containing benefits tracker.

A1. 14.02.2019A2. 01.04.2018;A3. 01.09.2018;A4. 30.05.2018;A5. 30.05.2018;A6. 30.05.2018

A1. Alignment on QIP is completed. Alignment on risk management has started.A2. SRO appointed and areas of scoping chosen;A3. 80% posts recruited to substantively;A4. Terms of reference under review;A5. Communication manager recruitment in progress;A6. A review of this is in progress.

4 2 8

High

NCL 2

Paul Sinden, Director of Performance and Acute Commissioning

Maintaining System Stability

Sustainability of Fragile Services (Threat)

Cause: If the STP does not recognise the need for system stability across services and providers

Effect: There is a risk that smaller and fragile services become unsustainable

Impact: This may result in disruption to patient services and system instability.

C1. NCL Joint Commissioning Committee in place which considers issues of system stability;C2. Relevant STP programme boards feed into service plans where appropriate;C3. CCGs have commissioning teams in place;C4. Governing Bodies focus on issues when they arise;C5. CCG commissioning intentions;C6. Commissioners feed into development of workstream plans.

C1. Terms of reference and committee papers;C2. Minutes and notes of programme board meetings;C3. Stuffing structure and employment contracts;C4. Governing Body and committee meeting papers and minutes;C5. Document;C6. Minutes and notes of programme board meetings.

Average

3 3 9

High

CN1. Strengthened oversight of totality of provider contracts: CN2. Centrally held registers of contracts in each CCG;CN3. Overview of fragile services

CN1. Completed register of contracts, named leads;CN2. Completed register of contracts;CN3. Notice from providers on service cessation for unsustainable services.

A1. Development of contract registersA2 Identification of fragile services

A1. 30.06.2018A2. 30.09.2018

A1. CCGs developing contract registers and identifying small contracts rolled forward year-on-yearA2. STP planned care workstream identifying fragile and at-risk services in providers

3 2 6

Moderate

NCL 3Simon Goodwin, NCL CCGs CFO

Development of an Effective STP Estates Strategy

Failure to Develop an Effective STP Estates Strategy

Cause: If the STP partners do not develop an effective estates strategy for the STP which takes into account the resources within the system and the current limitations of national legislation

Effect: There is a risk that the Estates Strategy does not deliver the most effective use of resources and impacts on services and staff

Impact: This may result in wasted resources, opportunity costs, reputational damage and difficulties in recruiting and retaining high quality staff.

C1. STP Estates Board established;C2. STP SRO appointed;C3. Working with STP partners, regulators and the London Estates Board to understand the key objectives.

C1. Terms of Reference, meeting papers and notes;C2. Employment contract;C3. E-mails, papers and notes.

Average

3 3 9

High

CN1. Recruit STP estates programme director to lead on the programme;C2. Develop STP estates strategyC3. Ensure appropriate link between STP Estates Board and NCL CCG Governing Bodies.

CN1. Employment contract;CN2. Estates Strategy paper;CN3. Governance chart, Governing Body papers and reports.

A1. Recruit STP estates programme director;A2. Develop draft STP estates strategy for engagement with key partners;A3. Establish appropriate governance arrangements for the STP Estates Board

A1. 01.09.2018;A2. 31.03.2018;A3. 31.03.2018

A1. Budget is in the process of being considered;A2. Work has started on this;A3. Work has started on this.

3 2 6

Moderate

NCL 4

Helen Pettersen, NCL CCGs Accountable Officer

Effective Engagement with Patients and the Public

Failure to Effectively Engage with Patients and the Public (Threat)

Cause: If the STP partner organisations do not effectively engage with patients and the public as part of the STP process

Effect: There is a risk that the STP process is not properly understood by patients, the public and their representatives causing them to disengage

Impact: This may result in service design not taking proper account of the needs of local people, reputational damage and a blcokage to integrated services.

C1. STP governance structure which includes significant clinical and public oversight;C2. Health and Well Being Boards;C3. Joint Health Overview and Scritiny Committee;C4. CCG Governing Bodies;C5. Provder Board of Directors and Council of Governors where appropriate;C6. Local Councils and Councillors;C7. NCL Advisory Board including councillors, Healthwarch and the Chairs of STP partner organisations;C8. Health and Care Cabinet with extensive clinical leadership;C9. CCGs and Providers have their own communications and engagement teams and local patient and public engagement mechanisms and meetings;C10. Named Communications Lead in each CCG.

C1. STP plan;C2. Papers and minutes of meetings;C3. Papers and minutes of meetings;C4. Papers and minutes of meetings;C5. Papers and minutes of meetings;C6. Papers and minutes of meetings;C7. Papers and minutes of meetings;C8. Papers and minutes of meetings;C9. Contracts of employment, meeting papers and notes;C10. Employment contracts.

Average

4 3 12

High

CN1. Recruit to Head of STP Communications role;CN2. STP communications and engagement plan;

CN1. Employment contract;CN2. Finalised STP communications and engagement plan.

A1. Recruit Head of STP Communications A2. Draft STP Communcations and Engagement Plan.

A1. 01.09.2018;A2. 30.05.2018

A1. Recruitment process is underway;A2. Head of ST Communications recruitment in progress.

4 2 8

High

NCL 5

Helen Pettersen, NCL CCGs Accountable Officer

Achievement of STP Year 2 Objectives

Purdah Period and the Impact of Local Elections (Threat)

Cause: If there is an inability for decision making at the local Councils due to the Purdah period or if there is signficant change of policial leadership and direction of travel due to local council elections in 2018

Effect: This is a risk that the Council cannot make key decisons as an STP partner organisation and/or that a change in personnel and policy within one of more local councils

Impact: This may result in a delay in the implemntation of the STP workstreams and/or the need to develop and strengthen new relationships to preservice continuity of delivery.

C1. Continued work with the Joint Health Oversight and Scrutiny Committee;C2. Continue to work with local authroity partner organisations;C3. Continue to work with and strengthen relationships with local councillors;C4. Continue to effectively engage.

C1. Papers and minutes of meetings;C2. Papers and minutes of meetings;C3. Papers and minutes of meetings;C4. Papers and minutes of meetings, communications, e-mails.

Average

4 3 12

High

CN1. An STP induction programmeCN2. Ensure clearer narrative between STP programmes and postive impact on local people;CN3. STP Communications and Engagement Plan;CN4. Quickly build relationships with new local councillors;CN5. Involve existing and new local councillors in on-going development of STP.

CN1. Register of attendance, induction pack;CN2. Communications;CN3. STP Communications and Engagement Plan document;CN4. E-mails and correspondence;CN5. E-mails, correspondence and papers.

A1. Create STP indiction pack;A2. Develop KPIs for workstreams which demonstrate positive impact on local people;A3. Draft STP Communcations and Engagement Plan;A4. Identify and make contact with new councillors after local elections in 2018;

A1. 03.05.2018;A2. 03.05.2018;A3. 30.05.2018;A4. 04.05.2018

A1. This work is due to begin;A2. This work is due to begin;A3. This in being developed;A4. This will be completed after the results of the local elections are announced.

3 3 9

High

NCL 6Will Huxter, NCL CCG Director of Strategy

Ensuring Effective Decision Making

Lack of Clarity on STP and NCL CCG Governance Arrangements (Threat)

Cause: If there is a lack of clarity on STP and NCL CCGs' governance arrangements;

Effect: There is a risk of confusions as to where decisions are made and that decisions are not made in the correctly or at all

Impact: This may result in decision freeze or in decisions being made ultra vires which may result in signficant delay in delivering integrated services due to an inability to act or legal challenge.

C1. STP Head of Programme Management in place;C2. Interim NCL Head of Governance and Risk in place for the NCL CCGs;C3. STP governance structure in place;C4. CCG and Provider organisations' governance structures in place;C5. STP website containing STP structure and minutes of STP Programme Delivery Board and Health and Care Cabinet meetings;C6. STP governance handbook in place.

C1. Employment contract;C2. Employment contract;C3. STP Plan, structure chart and papers and minutes of meetings;C4. Governance documentation, structure charts, papers and minutes of meetings;C5. Webiste;C6. Document.

Average

3 3 9

High

CN1. STP Communications and Engagement Plan;CN2. Recruit to Head of STP Communications role;CN3. A document clearly outlining STP governance and how it links with STP partners' governance structures;CN4. Recruitment to all governance and Board Secretary posts on NCL CCG Corporate Services structure.

CN1. STP Communications and Engagement Plan document;CN2. Employment contract;CN3. Governance document.CN4. Contracts of employment.

A1. Draft STP Communcations and Engagement Plan;A2. Recruit Head of STP Communications;A3. Create document setting out STP governance and how its links with STP partner organisations' governance structures.A4. Complete recruitment to NCL CCG Corporate Services governance roles.

A1. 30.05.2018;A2. 01.09.2018;A3. 30.04.2018A4. 30.06.2018

A1. This is being developed;A2. Recruitment process is underway;A3. This work is due to begin.A4. Board Secretaries recruitment completed. Other recruitment is progressing.

2 2 4

Moderate

NCL Risk Register

137

NCL 7Will Huxter, NCL CCG Director of Strategy

Delivery of the STP Digital Agenda

Failure to Deliver the Digital Agenda Across the STP (Threat)

Cause: If the STP partners do not deliver the digaital agenda across the STP;

Effect: There is a risk that the STP partners will not be able to deliver the Five Year Forward View and the underlying digital infrastructure such as integrated ditigal care records and will be unable to deliver the required QIPP savings

Impact: This may result in a negative impact on investments across the STP partners, a negaitve impact on the quality of patient care, reputational damage and an inability to meet the required national targets.

C1. Ditigal Programme Board in place;C2. Digital road map between STP partner organisations;C3. NCL GP IT Group in place;C4. NCL IG Group in place;C5. Health Information Exchange ('HIE') delivery plan being developed.

C1. Terms of Reference, meeting papers;C2. Terms of Reference, meeting papers;C3 Terms of Reference, meeting papers;C4. Terms of Reference, meeting papers;C5. Papers.

Average

4 3 12

High

CN1. STP Digital Strategy;CN2. Clear digital governance structure;CN3. Clear differentiation between commissioner and provider digital roles and responsibilities.

CN1. Digital Strategy paper;CN2. Digital governance structure paper;CN3. Agreement between STP partner orgsnisations showing clear responsibilities.

A1. Develop Digital Strategy;A2. Continue to develop HIE Delivery Plan;A3. Develop Digital governance structure;A4. Develop agreement between STP partners on responsibilities.

A1. 30.03.2019;A2. 01.06.2018;A3. 01.10.2018;A4. 01.06.2018

A1. This work is due to begin;A2. This work is being developed;A3. This work is being developed;A4. This work is due to begin.

3 2 6

Moderate

NCL 8

Ian Porter, NCL CCG Director of Corporatre Servces

Recruit and Retain a High Performing Workforce

Recruitment and Retention a High Performing Workforce (Threat)

Cause: If the NCL CCGs are unable to recruit and retain a high performing workforce;

Effect: The NCL CCGs will be unable to deliver their stategic objectives and operational goals;

Impact: This may result in a negivtive impact on the delivery of CCG workstreams, integrated care and patient services.

C1. STP is developing priorities for key clinical and staff providing care;C2. NCL CCG wide Senior Management Team in post;C3. Chief Operating Officer for each CCG in post;C4. Chief Operating Officers are recruiting to vacant posts on the establishment;C5. NCL SMT are fostering a culture of openness and transparency;C6. Executive leadership development is under way;C7. NHS Staff Survey and acting on the results;C8. NCL HR Team to support the NCL SMT and CCG Chief Operating Officers;C9. Recruiting to NCL HR roles;C10. NCL wide HR policies;C11. Increased focus on Organisational Development;C12. HR and OD groups operating locally in some CCGs and are being developed for all CCGs;C13, Equality, Diversity and Inclusion work is being developed across NCL;

C1. Papers;C2. Employment contracts;C3. Employment contracts;C4. Job adverts, employment contracts;C5. Papers, communications;C6. Papers;C7. Results paper and plans;C8. Employment contracts;C9. Job adverts and Job Descriptions;C10. Policy documents;C11. Papers, communications;C12. Meeting papers and notes;C13. Papers.

Strong

3 2 6

Moderate

CN1. Develop NCL Organisational Development strategy;CN2. Develop specific workforce strategy/plans for each CCG which includes talent management and succession planning;CN3. Develop organisational development strategic plan;CN4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ;CN5. Complete HR recruitment.

CN1. NCL Organisational Development strategy document; CN2. Strategy/plan documents;CN3. Strategic plan document;CN4. Equality, Diversity and Inclusion Strategy document;CN5. Employment contract.

A1. Develop NCL Organisational Development strategy;A2. Develop specific workforce strategies/plans for each CCG;A3. Develop organisational development strategic plan;A4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ;A5. Continue to recruit to HR and Organisational Developlment roles.

A1. 30.08.2018;A2. 30.08.2018;A3. 30.08.2018;A4. 30.05.2018;A5. 28.04.2018

A1. This work is due to begin;A2. This work is due to begin;A3. This work is due to begin;A4. This was is being developed;A5. Recruitment is being undertaken.

2 1 2

Low

NCL 9Simon Goodwin, NCL CCGs CFO

Achiement of Finance Balance Across NCL CCGs

Delivering Financial Balance Across NCL CCGs (Threat)

Cause: If the five CCGs in North Central London fail to deliver their QIPP targets and achieve financial balance by the end of the financial year

Effect: There is a risk that the NCL CCGs will fails to meet the collective NHS England control total.

Impact: This may result in one or more CCGs being placed under legal directions or special measures, destbilisation of one or more CCGs, a negative impact on the local health economy and loss of influence of quality of patient care.

C1. Each CCG has QIPP schemes in place and delivery plans;C2. QIPP planning and delivery is overseen and scrutinised by Governing Bodies and relevant committees;C3. NCL Senior Management Team are QIPP focussed;C4. QIPP managers are in role;C5. Deloitte review of QIPP completed;C6. CCGs working with providers through the STP to deliver QIPP savings;C7. Contractual levers and sanctions;C8. Addtional strategic QIPP capacity in place;C9. Single NCL CFO in place;C10. Financial planning undertaken at NCL level using consistent methology;C11. NCL finance leads meet on a monthly basis;C12. CCG Finance and Performance Committees (and equivalent)

C1. QIPP plans and papers;C2. Governing Body and committee papers and minutes;C3. Meeting papers, minutes and notes;C4. Contracts of employment;C5. Review outcomes document; C6. STP QIPP plans, meeting notes and minutes;C7. Contracts with providers;C8. Contract for services;C9. Employment contract;C10. Plans;C11. Papers;C12. Papers and minutes of meetings.

Average

4 4 16

Veery High

CN1. Develop and implement a 2018-19 budget to offset potential unmitigated financial risks within each CCG;CN2. Implement 2018-19 QIPP plans.

CN1. Agreed budgets and papers;CN2. In year QIPP moniroing reports.

A1. Develop and agree the 2018-19 budgets;A2. Implent 2018-19 QIPP plans.

A1. 31.03.2018;A2. 31.03.2019

A1. 2018-19 budget planning is underway;A2. This will start at the beginning of the 2018-19 financial year.

4 3 12

High

NCL 10

Paul Sinden,NCL Director of Performance and Acute Commissioning

Successful in-housing of the multi-disciplinary contract team from North East London Commissioning Support Unit (NELCSU)

CSU In-Housing of Services (Threat)

Cause: If we do not manage the in-housing of the contract team from NELCSU successfully

Effect: There is a risk that business continuity is disrupted which may have a significant negative impact on services, staffing, organisational stability, finance, performance, and contract delivery.

Impact: This may result in a reduction in contract delivery. an increase in costs, downturn in performance, reputational damage and a potential negative impact on patient services.

C1. Senior Management Team with a high degree of experience and expertise in CSU contracting.C2. Programme Director in place;C3. Working Group in place with Governing Body oversight;C4. Project Plan in place.C5. Contingency for additional support if needed.C6. Signed SLA in place for 2017/18 and 2018/19 as a baseline

C1. Employment contracts.C2. Service Agreement.C3. Minutes and papers of meetings.C4. Project plan document.C5. WAP Process.C6. Signed service level agreement

Strong

2 4 8

High

CN1. Business case for NHS England to be developed.CN2. Business case to be approved by NHS England.CN3. HR engagement process;CN4. Communications and engagement plan.

CN1. Business case a formal part of process to in-house CSU services.CN2. Approval from NHS England required before HR consultation process can begin.

A1. Continue to implement the project plan.A2. Draft the business case for NHS England.A3. Present the business case to NHS England.A4. Develop supporting HR engagement process to start on approval of business case by NHS EnglandA5. Development of communications and engagement plan to support the HR process

A1. 01.07.2018A2. 28.02.2018A3. 28.02.2018A4 28.02.2018A5. 31.03.2018

A1. Weekly project team meetings are held and going to plan;A2. Business case development has started.A3. Business case is on track for submission by target date.A4. Development of HR process underway.A5. Plan in development 1 2 2

Low

138

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title NCL Joint Commissioning Committee Terms

of Reference

Agenda Item 6.2 Date 14.03.2018

Committee Chair (where applicable)

Lead Director Helen Pettersen, Accountable Officer

Tel/Email helen.pettersen@nhs.net

Report Author Andrew Spicer, NCL Head of Governance and Risk

Tel/Email andrew.spicer@nhs.net

GB Sponsor(s) (where applicable)

Tel/Email

Report Summary

The Terms of Reference for the NCL CCG Joint Commissioning Committee have been updated to provide greater flexibility in the appointment of the Committee Chair and Committee Vice Chair. The update is made in the light of the Committee being Chaired by a CCG Lay Member representative in 2017/18 after an Independent Chair was not found following a recruitment process. The changes to Terms of Reference proposed allow for the Committee Chair to be appointed from either a CCG Lay Member representative or through the appointment of an Independent Chair should the Committee wish to pursue this option. The update also allows the appointment of a Committee Vice Chair from the remaining CCG Lay Member representatives. The approach was recommended to CCG Governing Bodies by the Joint Commissioning Committee at the meeting held on 1st February 2018.

Purpose Information

Approval √

To note Decision

Recommendation To approve the revised Terms of Reference and Standing Orders for the NCL Joint Commissioning Committee

Strategic Objectives Links

Ensure right care first time Deliver joined up care

Audit Trail The Terms of Reference for the NCL Joint Commissioning Committee and the roles of the independent clinical advisors were approved by each of the Governing Bodies in North Central London in November 2016 with some additional amendments being approved by Governing Bodies in January/February 2017 and July 2017. The NCL Joint Commissioning Committee further reviewed the Terms of Reference on 6th July 2017 after the Barnet CCG Governing Body meeting took place. A paper containing the amendments was presented to the other four NCL CCG Governing Body meetings in July 2017 and an additional paper was presented in July 2017 to

139

the Barnet CCG Chair. A report was brought to the September 2017 Governing Body meeting at which some points of clarification were sought.

Identified Risks and Risk Management Actions

The proposed revisions to the Terms of Reference help to maximise the opportunities and benefits of the five NCL CCGs working together to commission services for the benefit of patients.

Conflicts of Interest

None

Resource Implications

There are no resource implications arising from this report

Engagement

The amended Terms of Reference were reviewed on 6th July 2017 at the NCL Joint Commissioning Committee which includes lay members, Healthwatch and representatives from each of the five NCL London Boroughs.

Equality Impact Analysis

This report has been written in accordance with the Equality Act 2010

Next Steps None

Appendices

Terms of Reference Standing Orders

140

North Central London Joint Commissioning Committee

Terms of Reference

1. Introduction

These Terms of Reference set out the purpose, membership, remit and responsibilities of the North Central London Joint Commissioning Committee (‘Committee’).

2. Background

The National Health Service (‘NHS’) is facing unprecedented financial and clinical challenges including rising demand for services and a significant financial gap. System-wide solutions are required to address these challenges for the benefits of patients. In this regard the following organisations have agreed to work together to meet these challenges and jointly commission services where it is appropriate to do so:

• NHS Barnet Clinical Commissioning Group (‘Barnet CCG’); • NHS Camden Clinical Commissioning Group (‘Camden CCG’); • NHS Enfield Clinical Commissioning Group (‘Enfield CCG’); • NHS Haringey Clinical Commissioning Group (‘Haringey CCG’); • NHS Islington Clinical Commissioning Group (‘Islington CCG’).

The above Clinical Commissioning Groups are collectively referred to as the ‘NCL CCGs.’ These organisations have an informal history of some collaborative working, however, it is seen that the formation of this committee, as well as work conducted together as the health commissioners in the North Central London STP will formalise this collaborative working.

3. Purpose of the Committee

The Committee is a joint committee between Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG and Islington CCG to jointly commission goods and services as set out in section 4. For the people of the London Boroughs of Barnet, Camden, Enfield, Haringey and Islington.

4. Role of the Committee

The role of the Committee is to commission the following:

• All acute services including core contracts and other out of sector acute commissioning; • All learning disability contracting associated with the Transforming Care programme; • All integrated urgent care (including 111/ GP Out-of-Hours services) • Any specialised services not commissioned by NHS England.

For these services the Committee will oversee and make decision on the following commissioning functions:

• Approval of Business Cases and change requests • Needs assessment across NCL as informed by local strategies; • Planning service requirements; • Contracting and contract management; • Developing the provider landscape; • Setting and monitoring outcomes for providers; • Aligning incentives across the system; • Engagement with the public and key stakeholders where relevant such as NHS England and

the public; • Approval of decommissioning of services.

141

Each of the five NCL CCGs have delegated decision making on acute services to the Committee. Therefore, each of the individual CCG governing bodies will not make commissioning decisions on these services. To ensure that there is a strong link between pan NCL acute commissioning and individual CCG commissioning each CCG will feed into the Committee local care strategies and undertake local engagement of the public and key stakeholders where relevant and appropriate. This may include but is not limited to engagement on service change. The Committee’s role is supported by a statutory framework contained in section 6 below.

5. Quality and Safety

In performing its role, the Committee shall have due regard to any relevant quality and safety issues which may arise as agreed by Committee members.

6. Statutory Framework

The main statutory instrument is the NHS Act 2006 (as amended) with the key clauses being 13Z, 14Z3 and 14Z9. Section 13Z provides that:

• NHS England’s functions may be exercised jointly with a CCG or CCGs; • Functions exercised jointly in accordance with section 13Z may be exercised by a joint

committee of NHS England and the CCG or CCGs; • Arrangements made under section 13Z may be on such terms and conditions as may be agreed

between NHS England the CCG or CCGs. Section 14Z3 provides that:

• Two or more CCGs may exercise any of their commissioning functions jointly including by a joint committee of those CCGs;

• For the purposes of any arrangements made under this section a CCG may make payments, make the services of its employees or any other resources available to another CCG.

Section 14Z9 provides that:

• NHS England and one or more CCGs may make arrangements for any of the functions of the CCG under section 3 or 3A of the NHS Act or for any functions of the CCG(s) which are related to the exercise of those functions, to be exercised jointly by NHS England and the CCG(s);

• For functions exercised jointly in accordance with the section to be exercised by a Joint Committee of NHS England and the CCG(s);

• Arrangements under that section may be on such terms and conditions as may be agreed between NHS England and the CCG.

7. Membership

The Committee’s membership shall meet the requirement of each of the NCL CCG’s constitutions. The Committee shall comprise of the following voting members:

• The Chair of Barnet CCG; • The Chair of Camden CCG; • The Chair of Enfield CCG; • The Chair of Haringey CCG; • The Chair of Islington CCG; • A lay representative from Barnet CCG • A lay representative from Camden CCG; • A lay representative from Enfield CCG;

142

• A lay representative from Haringey CCG; • A lay representative from Islington CCG; • The NCL Accountable Officer; • The NCL Chief Financial Officer; • Three independent clinical advisors. One of whom must be a Secondary Care clinician and

one of who must be a nurse. The Committee shall comprise of the following non-voting members;

• An independent Chair where appointed; • Two Healthwatch representatives; • One Director of Public Health from one of the NCL London Boroughs; • A representative from London Borough of Barnet Council; • A representative from London Borough of Camden Council; • A representative from London Borough of Enfield Council; • A representative from London Borough of Haringey Council; • A representative from London Borough of Islington Council.

The list of named members and attendees is contained in Schedule 1. Committee members and non-voting attendees may nominate a deputy to represent them in their absence and make decisions on their behalf.

8. Chair and Vice Chair The Chair of the Committee shall be either an independent person or a lay member from an NCL CCG. Where the Chair is an independent person they shall ordinarily not be an officer, employee or office holder of any of the NCL CCGs except to the extent necessary to hold a contract for the role of independent Chair. The Committee shall have a Vice Chair. Where the Chair is unable to participate in a meeting or vote due to absence or a conflict of interest the Vice Chair may chair the meeting. The Vice Chair of the Committee shall be a lay member from an NCL CCG. Details of the Chair and Vice Chair are contained in Schedule 1.

9. Quorum

The quorum of the committee is 10 voting members (of whom 50% must be clinicians) The Committee must have present

a) Either the CCG Chair or lay representative from each CCG and b) At least one CCG Chair and one lay representative to be quorate.

If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements. If a clinician is conflicted the person temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements must be a clinician. If a meeting is not quorate the Chair may adjourn the meeting to permit the appointment or co-option of additional members if necessary. If the conflicted person is a Chair or lay member of a CCG the person temporarily appointed or co-opted onto the Committee must be from the same CCG as the conflicted person. The final decision as to the suitability of any person who is temporarily appointed or co-opted onto the Committee shall be made by the Committee’s Chair.

143

10. Voting

Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussions, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view. In the event of a vote, voting members of the Committee shall have one vote each with decisions being made in accordance with the provisions below. The Committee shall reach decisions by an 80% majority of votes of voting members present at a Committee meeting.

11. Decisions Decisions of the Committee shall be binding on each of the NCL CCGs.

12. Conflicts of Interest Conflicts of interest shall be dealt with in accordance with the NCL conflicts of interest policy. The NCL conflicts of interest policy is a document which is a master document containing the conflicts of interest policy agreed by all of the NCL CCGs together with a schedule setting out the local variations of each CCG.

13. Frequency of Committee Meetings

The Committee shall meet monthly or as otherwise agreed.

14. Meetings Held in Pubic

Meetings of the Committee shall be held in public unless the Committee resolves to exclude non-voting members and/or attendees and/or observers and/or the public from a meeting. In which case the meeting, in whole or part, may be held in private. Non-voting members, attendees, observers and the public may be excluded from all or part of a meeting whenever publicity would be prejudicial to the public interest by reason of:

• The confidential nature of the business to be transacted; or • The matter is commercially sensitive; or • The matter being discussed is part of an on-going investigation; or • Other special reason stated in the resolution and arising from the nature of that business or of

the proceedings; or • Any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended

or succeeded from time to time; or • General disturbance.

15. Secretary

The Committee shall have secretariat support. The secretariat function will be provided by the office of the NCL Accountable Officer.

16. Standing Orders

The Standing Orders for the Committee are contained in Schedule 2 and form part of these Terms of Reference. The Standing Orders must be adhered to.

17. Sub-Committees

The Committee may not delegate any of its powers to a committee or sub-committee. However, it may appoint committees to advise and assist the Committee in carrying out its role.

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18. Standards of Business Conduct

Committee members and any attendees or observers must maintain the highest standards of personal conduct and in this regard must comply with: 18.1.1 The law of England and Wales; 18.1.2 The NHS Constitution; 18.1.3 The Nolan Principles; 18.1.4 The standards of behaviour set out in each NCL CCG Constitution; 18.1.5. Any additional regulations or codes of practice relevant to the Committee.

19. Review of the Terms of Reference

These Terms of Reference shall be kept under review by the Committee to ensure that they meet the needs of the Committee and the NCL CCGs. Any changes to the Terms of Reference must be agreed by the governing bodies of the NCL CCGs in accordance with their Constitutions. These Terms of Reference shall be reviewed by the NCL CCGs annually in April of each year following the establishment of the Committee. Approved: Review:

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Schedule 1 - List of Members Voting Members The voting members of the Committee are as follows: Position Name

CCG Chair - Barnet CCG Dr Debbie Frost CCG Chair - Camden CCG Dr Caz Sayer CCG Chair - Enfield CCG Dr Mo Abedi CCG Chair - Haringey CCG Dr Peter Christian CCG Chair -Islington CCG Dr Jo Sauvage Lay member- Barnet CCG Ms Bernadette Conroy Lay member- Camden CCG Ms Kathy Elliott Lay member- Enfield CCG Ms Karen Trew Lay member- Haringey CCG Ms Catherine Herman Lay member- Islington CCG Ms Sorrel Brookes NCL Accountable Officer Ms Helen Pettersen NCL Chief Financial Officer Mr Simon Goodwin Independent clinician Dr Matthew Clark Independent clinician- Secondary Care Doctor Ms Sharon Seber

Independent clinician- Nurse Ms Angela Dempsey

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Non-Voting Members

The non-voting members of the Committee are as follows:

Position Name Title Independent Chair where appointed TBC Healthwatch representative Ms Sharon Grant Healthwatch representative Ms Parin Bahl One Director of Public Health from one of the NCL London Boroughs

Dr Jeanelle De-Gruchy

A representative from London Borough of Barnet Council Cllr Hugh Rayner

A representative from London Borough of Camden Council Cllr Pat Callaghan

A representative from London Borough of Enfield Council Cllr Alev Cazimoglu

A representative from London Borough of Haringey Council Cllr Jason Arthur

A representative from London Borough of Islington Council Cllr Janet Burgess

The roles referred to in the list of voting members and non-voting members above describe the members’ and non-voting members’ substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference.

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Chair and Vice of the Committee The Chair and Vice Chair of the Committee are as follows: Position Name Title Chair Ms Karen Trew Vice Chair TBC

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Standing Orders for the North Central London Joint Commissioning

Committee

1. Introduction 1.1 These Standing Orders apply to the North Central London Joint Commissioning Committee

(‘Committee’). 1.2 The Committee is a joint committee between the following organisations: 1.2.1 NHS Barnet Clinical Commissioning Group (‘Barnet CCG’); 1.2.2 NHS Camden Clinical Commissioning Group (‘Camden CCG’); 1.2.3 NHS Enfield Clinical Commissioning Group (‘Enfield CCG’); 1.2.4 NHS Haringey Clinical Commissioning Group (‘Haringey CCG’); 1.2.5 NHS Islington Clinical Commissioning Group (‘Islington CCG’). 1.3 In these Standing Orders the Clinical Commissioning Groups referred to at clauses 1.2.1 –

1.2.5 above are referred to as ‘NCL CCGs’. 1.4 The Committee’s purpose is to jointly commission goods and services for the people of the

London Boroughs of Barnet, Camden, Enfield, Haringey and Islington. 2. Terms of Reference 2.1 These Standing Orders form part of the Committee’s Terms of Reference and should be read

in conjunction with the Committee’s Terms of Reference. 3. Notice of Meetings 3.1 Notice of a Committee meeting shall be sent to all Committee members no less than 7 days

in advance of the meeting. 3.2 The meeting notice shall contain the date, time and location of the meeting. 3.3 Where Committee meetings are to be held in public the date, times and location of the

meetings will be published on each Committee members’ website. 4. Agendas and Circulation of Papers 4.1 Before each Committee meeting an agenda setting out the business of the meeting will be

sent to every Committee member no less than 7 days in advance of the meeting.

4.2 Before each Committee meeting the papers of the meeting will be sent to every Committee member no less than 7 days in advance of the meeting.

4.3 If a Committee member wishes to include an item on the agenda they must notify the Chair

via the Committee’s Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair but any request to add an item to the agenda must not be unreasonably refused.

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5. Quorum 5.1 The quorum for the Committee is ten voting members (of whom 50% must be clinicians). 5.2 The Committee must have present a) either the CCG Chair or lay representative from each

CCG and b) at least one CCG Chair and one lay representative to be quorate. 5.3. If any representative is conflicted on a particular item of business they will not count towards

the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements. If a clinician is conflicted the person temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements must be a clinician.

5.4 If a meeting is not quorate the Chair may adjourn the meeting to permit the appointment or co-option or additional members if necessary. If the conflicted person is a Chair or lay member of a CCG the person temporarily appointed or co-opted onto the Committee must be from the same CCG as the conflicted person. The final decision as to the suitability of any person who is temporarily appointed or co-opted onto the Committee shall be made by the Committee’s Chair.

6. Minutes 6.1 The minutes of the proceedings of a meeting shall be prepared by the Committee’s Secretariat

and submitted for agreement at the following Committee meeting.

7. Attendees and Observers 7.1 The Committee may call additional experts to attend meetings on a case by case basis to

inform discussions. 7.2 The Committee may invite or allow additional people to attend Committee meetings as

attendees. Attendees may present at Committee meetings and contribute to relevant Committee discussions but are not allowed to participate in any formal vote.

7.3 The Committee may invite or allow people to attend meetings as observers. Observers may

not present at Committee meetings, contribute to any Committee discussion or participate in any formal vote.

7.4 The Committee may invite or allow providers of health care services to attend meetings as

attendees or observers on a case by case basis at the Committee’s absolute discretion. 8. Meetings Held in Public 8.1 Meetings of the Committee shall be held in public unless the Committee resolves to exclude

the public from a meeting. In which case the meeting, in whole or part, may be held in private. The Committee may also exclude non-voting members, attendees and observers.

8.2 Non-voting members, attendees, observers and the public may be excluded from all or part of

a meeting at the Committee’s absolute discretion whenever publicity would be prejudicial to the public interest by reason of: 8.2.1 The confidential nature of the business to be transacted; or 8.2.2 The matter is commercially sensitive; or 8.2.3 The matter being discussed is part of an on-going investigation; or 8.2.4 Other special reason stated in the resolution and arising from the nature of that

business or of the proceedings; or

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8.2.5 Any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time; or

8.2.6 General disturbance.

8.3 It may be necessary for a person other than a voting member of the Committee to be present at a private Committee meeting to provide the Committee with expert and/or specialist advice and/or knowledge. The Committee may allow this at its absolute discretion without affecting the validity of any resolution determined in accordance with clauses 8.1 and 8.2 above.

8.4 The Committee may allow the Independent Chair where appointed or any other person or

persons to be present at a private Committee meeting at its absolute discretion without affecting the validity of any resolution determined in accordance with clauses 8.1 and 8.2 above.

8.5 For the avoidance of doubt Committee meetings are not public meetings. 8.6 The Chair may exclude any member of the public from a meeting if they interfere with the

proper conduct of that meeting.

9. Publishing and Reports from the Committee 9.1 Decisions of the Committee will be published by the NCL CCGs save as set out in clause 10

below. 9.2 The Committee will produce an executive summary report which will be presented to the NCL

CCG Governing Bodies for information as required.

10. Confidentiality 10.1 Members of the Committee shall respect confidentiality requirements as set out in these

Standing Orders. 10.2 Committee meetings may in whole or in part be held in private as per clause 8 above. Any

papers relating to these agenda items will also be excluded from the public domain. For any meeting or any part of a meeting held in private all members and/or attendees must treat the contents of the meeting and any relevant papers as strictly private and confidential.

10.3 Decisions of the Committee will be published except when decisions have been made in

private in accordance with clause 8 above. 11. Questions from the Public and Deputations 11.1 The Committee may receive questions from the public at its absolute discretion. 11.2 The Committee may receive, at its absolute discretion, Deputations from members of the

public or interested parties to make the Committee aware of a particular concern or concerns they have.

11.3 Any Deputations should be sent to the Committee secretariat who will pass it to the Chair for

consideration. 11.4 Any Deputations must be received by the Committee secretariat at least two calendar weeks

before a Committee meeting is due to take place to be eligible to be heard at that Committee meeting. Any Deputations not received within this time will not be eligible to be heard at that Committee meeting. However, on a strictly case by case basis there may be times where it

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would be highly beneficial to the Committee’s business to waive this requirement due to the relevance or content of the Deputations. In these circumstances the Chair may do so on a case by case basis and without setting any precedents of future or further waivers.

11.5 Any Deputations must take the form of a written request together with a statement setting out

what the Deputation is about. If any Deputation fails to set out this information it will be rejected.

11.6 Any Deputations which are not relevant to the Committee’s business will be rejected 11.7 The Chair may accept or reject any relevant and properly completed Deputations on a strictly

case by case basis at his/her absolute discretion and without setting any precedents for future or further decisions.

11.8 If a request is agreed the interested party and/or parties will be invited to a Committee meeting

where the Committee will consider the Deputation. 11.9 The Chair may decide how much time to allocate to any Deputations at his/her absolute

discretion on a case by case basis and without setting any precedents for future or further decisions on time allocated for Deputations.

11.10 Nothing in this section 11 shall limit, prohibit or otherwise restrict the Committee’s powers

contained in section 7 or 8 of these Standing Orders.

12. Committee Chair when Independent 12.1 The Chair of the Committee may be an independent person or a lay member from an NCL

CCG. Where the Chair is an independent person sections 12.2-12.3 below applies. 12.2 The Independent Chair will hold office for a period of three years commencing on the date of

appointment. The Independent Chair is eligible for re-appointment for a further term of three years subject to satisfactory performance.

12.3 The Independent Chair may be removed from office if: 12.3.1 They are not legally eligible to sit on a Governing Body committee;

12.3.2 A motion of no confidence is passed by simple majority of voting members present at a Committee meeting. The simple majority must include at least one representative from each of the NCL CCGs;

12.3.3 A motion of no confidence is passed by any NCL CCG Governing Body.

13. Standards of Business Conduct 13.1 Committee members and any attendees or observers must maintain the highest standards of

personal conduct and in this regard must comply with: 13.1.1 The law of England and Wales; 13.1.2 The NHS Constitution; 13.1.3 The Nolan Principles; 13.1.4 The standards of behaviour set out in each NCL CCG Constitution; 13.1.5 Any additional regulations or codes of practice relevant to the Committee. 14. Training and Information 14.1 It is the responsibility of each organisation referred to in section 1.2 above to ensure that their

representatives at the Committee are provided with appropriate training and information to allow them to exercise their responsibilities effectively.

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15. Withdrawal 15.1 The Governing Body of a participating Clinical Commissioning Group as listed in clause 1.2

above can decide to terminate their membership of the Committee upon giving 6 months’ written notice to all other organisations listed in clause 1.2 above with termination of their membership taking place on expiry of such notice.

16. Review of Standing Orders 16.1 These Standing Orders form part of the Committee’s Terms of Reference. They must be

reviewed in accordance with the provisions for review of the Terms of Reference contained in the Committee’s Terms of Reference.

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154

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Finance, Performance and QIPP

Committee Report

Agenda Item 7.1 Date 01/03/2018

Lead Director Simon Goodwin, NCL Chief Finance Officer

Tel/Email simon.goodwin1@nhs.net

Report Author Carolyn Cullen, Board Secretary (interim)

Tel/Email carolyn.cullen1@nhs.net

GB Sponsor(s)

Dr Birgit Curtis Tel/Email birgitcurtis@nhs.net

Report Summary

A summary report of the meeting on 31 January 2018

Purpose

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the report.

Strategic Objectives Links

This report links with the following strategic objectives: • Commission the delivery of NHS constitutional rights and pledges; • Improve health outcomes, address inequalities and achieve parity of esteem; • Maintain financial stability and ensure sustainability through robust planning

and commissioning of value-for- money services.

Identified Risks and Risk Management Actions

The Committee oversees performance and finance risks rated 12 or higher in line with the CCG’s standard risk management processes

Conflicts of Interest

There are no conflicts of interests arising from this report. The Committee identifies and manages conflicts of interests in line with CCG processes.

Resource Implications

None

Engagement

This summary report is shared with the Camden Public and Patient Engagement Group.

Equality Impact Analysis

There are no equality impacts arising from this work

Report History

The Finance and Performance Committee reports to each Governing Body Meeting.

Next Steps The Committee and QIPP Workshops will continue to meet as planned

Appendices

None

Name of committee: Finance and Performance and QIPP Committee

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Date of meeting: 31 January 2018 Issues discussed Finance Report: Month 9 In Summary:

• Over performance has risen from £4.5m to £4.7m in Month 9 • The main contributors of over performance in the acute sector continue to be the Royal Free

London £2.9m, UCLH £1m and Imperial £1m; the main driver for over performance is non-elective expenditure

• The non-acute sector is forecasting a year end over performance of £1.7m at Month 9. This is a favourable movement of £0.6m since Month 8

• Unmitigated financial risks at Month 9 are £2.9m, the updated recovery plan of £2.7m is in place to mitigate and further work is underway to find additional savings.

Finance Recovery Plan Actions in the Plan are to offset the potential unmitigated financial risks of £2.7m. At Month 9 £2m, or 43%, of the original plan of £4.6m has been delivered and reported. QIPP Report: Month 9 Progress and QIPP 2018/19 Update The Committee’s attention was drawn to the underachievement of £2.36m year to date of delivery of the 2017/18 QIPP. At the end of Quarter 3 Camden’s QIPP continues to forecast material savings for Quarter 4. QIPP schemes expected to deliver in Quarter 4 are integrated care teams, PoLCE and Primary Care @ the Front Door.

The Camden CCG QIPP for 2018/19 is £26m. This target comprises of 43% of savings from the acute sector and 57% of savings from non-acute budgets. NHS England has commenced an assurance process via Deloitte’s for all London CCGs. Each CCG is required to submit details of QIPP governance arrangements and PIDs for their top 10 QIPP schemes; the initial feedback from Deloitte was that Camden schemes were low to medium risk. Our CCG scored well in this governance review compared to other London CCGs. Integrated Performance Report The main areas of concern continue to be performance against the 62 day cancer and RTT waiting times standards and A&E performance. Attention was drawn to the impact of not achieving the 62 day cancer target. North East London has received £700k as a result of reporting a compliant position; North Central London, at the moment, will not qualify for such funding. As regards meeting the A&E target, strengthened governance will be provided through the new A&E Delivery Board. The Remedial Action Plan (RAP) and the Winter Plan have been aligned to provide one action plan across the whole system, to be managed through the A&E Delivery Board. End to End Data Process NEL CSU attended the Committee to present their paper on End to End Data Process. The Chair explained that the report had been requested to enable the Committee to understand data flows as the Committee wished to understand the roles and responsibilities between the Point of Delivery (POD) and the Central CSU team regarding data receipt, validation and data quality checks. A further report will come to the March Committee.

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Delayed Transfers of Care As at 1 January 2018 there were 17 delayed transfers of care; all of which were self-funding and placements were delayed due to relatives viewing available placements.

Issues for the Governing Body None. Decisions for the Governing Body None

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158

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Integrated Commissioning

Committee Report

Agenda Item 7.2 Date 01/03/2018

Lead Director Richard Lewin, Director of

Integrated Commissioning Tel/ Email

richard.lewin@camden.gov.uk

Report Author Carolyn Cullen Board Secretary (Interim)

Tel/ Email

carolyn.cullen1@nhs.net

GB Sponsor(s) (where applicable)

Dr Matthew Clark Tel/ Email

matthew.clark1@nhs.net

Report Summary This paper presents a summary of the Integrated Commissioning

Committee meetings held on

Purpose

Information Approval

To note

Decision

Recommendation The Governing Body is asked to note the Integrated Commissioning Committee Report.

Strategic Objectives Links

• Commission the delivery of NHS constitutional rights and pledges • Improve health outcomes, address inequalities and achieve parity of

esteem

Identified Risks and Risk Management actions

Any major risks are highlighted as part of this report.

Conflicts of Interest

There are no conflicts of interest arising from this report.

Resource Implications

None

Engagement

This summary report is shared with the Camden Public and Patient Engagement Group.

Equality Impact Analysis

There are no equality impacts arising from this report.

Report History The Committee reports to each Governing Body meeting.

Next Steps None

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Name of Committee: Integrated Commissioning Date of meeting: 24 January 2018 Issues discussed • Risk Report • Changes to the Health Visiting Primary Care Offer • Social Prescribing Services Review. Decisions Made: Risk Report The Committee conducted its quarterly review of the risk register. Current risks have been reviewed and updated and new risks added; there are currently 11 risks on the register with a score of 12 or greater. New risks include: neighbourhood proposed services, proposed changes to the Universal Offer in 2018/19 and Quality Improvement Support Teams 2018/19. A risk relating to Adult Social Care regarding the adequate supply and quality of commissioned services and the risk of market failure has been identified and will be reported to the February Committee. Changes to the Health Visiting Primary Care Offer Camden’s health visiting service is highly rated by the Care Quality Commission. The purpose of the review has been to spread best practice to all parts of the service. Specific changes proposed are: to strengthen meetings between GP practices and health visitors to ensure effective collaboration on the care and management of vulnerable children and to move the baby weighing clinics, currently provided by the health visiting service in GP practices, to children’s health centres. This move will provide a more equitable offer for families across Camden and a more efficient use of the limited health visiting resource. Social Prescribing Services Review Social Prescribing is a means of enabling GPs, nurses and other primary care professionals to refer people to a range of non-clinical services, many of which are run by the voluntary and community sector. The current service has been commissioned separately so a comprehensive review has been undertaken to prepare a specification for an integrated service. The new model will: establish a single point of access, Care Navigators will provide services for people with more complex needs, including case management for up to six weeks and volunteers will be recruited in each neighbourhood to support the delivery of social prescribing. A volunteer coordinator will be responsible for providing volunteers for the five neighbourhood areas.

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The Committee:

• Approved the new service model for social prescribing • Approved the decommissioning of current services • Agreed to seek procurement advice and devise a procurement timetable which will be

considered at the March Committee • Approved a waiver to extend the contract for the care navigators to provide a seamless

service while the procurement exercise takes place • Noted the intention to integrate mental health services into this service model in the

future • Agreed that the service specification, which should include key performance indicators,

be approved at the March Committee. Issues for the Governing Body: None to report.

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162

Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Locality Committees Report

Agenda Item 7.3 Date 01/03/2018

Lead Director Ian Porter, Director of

Corporate Services Tel/ Email

Ian.porter@nhs.net

Report Author Tori Awani Member Relations Manager

Tel/ Email

tori.awani@nhs.net

Report Summary

This paper is a summary report of Locality Committees held in January and February 2018

Purpose (tick one box only)

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of this report.

Strategic Objectives Links

Involve member practices and commissioning partners in key commissioning decisions.

Identified Risks and Risk Management Actions

There are no risks associated with this report.

Conflicts of Interest

None

Resource Implications

None

Engagement Not applicable for the purpose of this report Equality Impact Analysis

Not applicable for the purpose of this report

Report History The Locality Committees Report is presented at every Governing Body

meeting Next Steps None

Appendices None

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Camden CCG Locality Committees Report

1. Introduction One of the key ways that Camden CCG engages with its members is through Locality Committees. The South Locality Committee is chaired by Dr Jonathan Levy, the North by Dr Martin Abbas and the West by Dr Birgit Curtis. This report summarises the January and February 2018 committees. 2. January and February 2018 Locality Committees The following commissioning items were brought to all three Committees: Primary Care Investment 2018/19 and federation and neighbourhood investment updates were discussed at both the January and February localities by Vanessa Cooke, Senior Commissioning Manager and Kevan Ritchie, Governing Body representative and GP Lead for Primary Care. The proposal recommends changes to some Universal Offer service payments to release £150,000 to invest in new services which deliver QIPP savings. In addition, £280,000 of funding from previously underspent Universal Offer budgets was proposed to be spent on federation infrastructure. 2.1 Members requested clarity of indicative payment figures, and this was provided in February along with

modelling on the impact on practice income. Members would also appreciate a reconciliation of improved targets in relation to performance at the current Planned Care LCS

2.2 PMS Review Reinvestment was presented at the January Committees by Sally MacKinnon, Transformation Director. The review’s aim is to redistribute the PMS premium currently in 15 PMS practices in Camden. New contracts must be issued to the 15 PMS practices in Camden for implementation from April 2018 to all 34 practices across the area, against a shared service specification with light touch monitoring. Longer appointment times are being lightly monitored through a patient and staff survey embedded within the system. The specification requirements will increase proportionately reflecting the four year phasing of reinvestment of the PMS monies. Full mobilisation will begin in 2019/20. The LMC have agreed to a 3 month review period for practices to review and sign off the new contracts, payments will be backdated to reflect this. Members were reassured a one page communication leaflet has been produced by John Levite with support from Camden CCG, the team have also requested to attend future CPPEG meetings.

2.3 QIPP Update 2018-19: Becky Brooker, Deputy Finance Director, Harrison Spencer, QIPP Manager and

Trevor Myers Interim Director of Commissioning attended the January Locality Committees to give an update on Camden CCG’s QIPP status covering the following: 2017/18 Finance position, 2018/19 QIPP update, CCAS demand management QIPP for 2018/19. Improvements will be made via education and enhanced monitoring to provide GP Assessor assessment consistency. Full use of Camden Clinical Assessment Service (CCAS) was encouraged. CCAS enables other QIPPs – centralised booking of Minor Surgery DES appointments and provides the GP Referral Dashboard which allows GPs to review referral data at an individual level.

2.4 A New Model of Care Navigation and Social Prescribing: Philip Darby, Strategic Commissioner -Camden

Council, attended the January Committees to inform members. Camden CCG currently commission a number of services which provide social prescribing. The commissioned services were reviewed between August to December 2017 and the proposed new model will establish a single point of access for social prescribing in Camden. Member dialogue highlighted the lack of integrated care in relation to young patients, concerns around the CAB service being removed from practices, concerns about patients being directed to various inappropriate pathways and it was felt that to remove the service would negatively impact patient care. Phillip Darby reassured members that the service will be evolving into a Neighbourhood model and the current service will remain until August 2018. A phased reduced service will be available to support residents with non-complex cases between 1 April and 31 July. From 1 August

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to 30 September alternative services will be available until the new model goes live in October. 2.5 A dermatology and urology update was brought to the February localities by Dr. Sarah Morgan & Miro

Zvoc, Strategic Commissioner, to discuss the 10 urological conditions pathways, of which 8 pathways are being updated to ensure alignment across NCL and 2 new ones have been developed. They also provided updates on the progress of the Minor Surgery DES operating at 3 practices effectively and teledermatology on the STP work stream. In time, Dermalight (with iPod Touch) will be supplied to each practice with full training meaning that all future referrals would be sent with a photo thereby lessening pressure on the 2WW pathway.

2.6 Extended Access Consent Update: Michael Fox, Data Quality Lead - IT & Systems Team attended

February Committees to clarify the issues raised around patient consent and therefore access to the extended access service. Consent can be given and retracted at any point by the patient but it was highlighted that to access the service consent must be given to allow the GP access to the full patient records. GP IT is producing a patient friendly leaflet with input from CPPEG panel to further educate patients.

2.7 Rachael Clark Head of the Medicine Management team, Jyoti Gupta and Kristina Petrou, Senior

Prescribing Advisors from the Medicines Management team attended the February Committees to discuss the following:

NHS Consultation on Low Value Medicines: This national consultation addresses the use of 18 specific medicines and has now closed with the outcome published in December 2017. Some medicines have been suggested to be 'blacklisted' by the Department of Health and this decision is currently sitting with the Secretary of State NHS consultation on OTC Medicines: The Consultation on guidance for conditions for which Over the Counter items should not routinely be prescribed. NHSE are still at the consultation phase and possible consequences and impact are being discussed with local patient and other groups. It was highlighted to members that the consultation suggests GPs have the ability to exercise their clinical judgement should there be exceptional circumstances that warrant a deviation from self-care and if the product does not have an OTC license for its intended purpose e.g. paediatric use. The Minor Ailment Scheme: was briefly discussed where members expressed concerns that there is a risk that more patients will present to the GP/A&E for OTC medicines if adequate MAS are not in place. The locality was briefed on the changes proposed in the consultation on availability of gluten-free foods on prescription in primary care. The outcome of the consultation has been published along with a national presentation to restrict prescribing to gluten free bread and flour. Prescribing Quality Scheme (PQS): New indicators were briefly discussed as all practices were offered a visit from April 2018 to further review. Member enquiries relating to the use of FreeStyle Libre® for type 1 diabetics were addressed -NCL position statement stands, i.e. do not prescribe until further notice.

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3. Forward look

• March 2018 Locality Committees: Joint North and West: Thursday 15th, South: Wednesday 21st • Neel Gupta and Sarah Mansuralli are continuing to visit all Camden practices on a rolling basis. • The annual Counter Fraud and Bribery Training has been completed by all Camden practices • New patient referrals to the Team Around the Practice (TAP) service have been paused as there is a long

waiting list for new patients due to the current level of demand exceeding the service capacity. Members have highlighted the effectiveness of the service and have expressed their enthusiasm at the continuation of the service.

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Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Report of the Procurement

Committee

Agenda Item 7.4 Date 03/03/2018

Lead Director Rebecca Booker Chief Finance Officer, Camden CCG

Tel/ Email

Rebecca.booker@nhs.net

Report Author Carolyn Cullen Board Secretary (Interim)

Tel/ Email

Carolyn.cullen1@nhs.net

GB Sponsor(s) Kathy Elliott, Lay Member Tel/ Email

Kathy.elliott1@nhs.net

Report Summary

This report provides a summary of the issues considered by the Procurement Committee meetings held in November 2017 and February 2018.

Purpose

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the content of this report.

Strategic Objectives Links

Commission the delivery of NHS Constitutional rights and pledges

Identified Risks and Risk Management Actions

There are no identified risks arising from this report.

Conflicts of Interest

The Procurement Committee’s role is to: • Ensure conflicts of interest are managed; • Preserve the integrity of the CCG’s decision making processes and to • Ensure that the CCG’s decision making is not open to legal challenge.

Resource Implications

None.

Engagement

Not applicable for the purpose of this report.

Equality Impact Analysis

Not applicable for the purpose of this report.

Report History

The Governing Body receives regular reports from the Procurement Committee.

Next Steps None

Appendices

None

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Report of the Procurement Committee

Summary of the Meetings Held on 7 February 2018 and 15th November 2017.

The Procurement Committee (‘Committee’) (7th February) considered one item of business: Developing GP Federations in 2018/19. 1. Developing GP Federations in 2018/19

The Committee considered the proposed new contract to support the development of GP Federation(s). This will build on the neighbourhood working already being undertaken and will help secure the successful delivery of a range of new initiatives. A number of changes to the universal officer are also proposed. These changes do not require additional investment. Existing resources will be targeted to better achieve CCG priorities and release QIPP savings. Neighbourhoods will have outcomes. The approach for setting outcomes targets is:

• Neighbourhood outcomes will be developed by Neighbourhood leads involving clinicians and QIPP leads

• From this initial list of outcomes specific clinical outcomes will be identified along with performance metrics to measure success

• Each neighbourhood will have specific outcomes and targets • The decision on approving the methodology, and Neighbourhood outcomes and targets for

2018/19, will be taken by the Director of Primary Care and the Chief Operating Officer • The finalised outcomes and targets will be shared with neighbourhoods in early April 2018.

The recommended option for the procurement of the Development of GP Federation(s) is the capable provider route. This option complies with both the Public Contract Regulations 2015 and the NHS Regulations 2013. Primary care clinicians have been engaged in developing the service design and the resultant business case will be considered at the Integrated Commissioning Committee (ICC) on 21 February 2018. Clinicians delivering primary care services will be excluded from the decision made at the ICC. The final award of the contract will be taken by an independent procurement panel.

The Chair asked the Committee to consider the approvals required. The Chair then asked for a vote and the following was approved, subject to all the agreed actions being implemented, with no dissensions or abstentions:

• Approved the proposed procurement route for the at scale provider(s) • Approved the process for setting neighbourhood outcome targets • Approved the process for managing conflicts of interest.

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At the meeting on the 15th November, the Committee was asked to:

• Provide assurance that the PMS Investment proposal is free from bias and fair for all GP practices in Camden and that the money will be invested in accordance with the PMS contract criteria

• Provide assurance that the proposal is consistent with the primary care strategy for Camden and did not duplicate existing commissions in primary care

• Note NHS England/LMC’s assurance process for PMS investment • Sign off the PMS Specification.

The Committee:

• Agreed that the PMS Investment proposal was free from bias and fair to all GP practices in Camden and that the money will be invested in accordance with the PMS contract criteria. Also that the proposal is consistent with the primary care strategy for Camden which is based on the national agenda and that it will not duplicate existing contracts with primary care in Camden

• Noted the NHS England/LMC’s assurance process for PMS investment • Approved the PMS Specification.

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Camden Clinical Commissioning Group Governing Body Meeting 14 March 2018

Report Title Overview of Camden Health and Wellbeing Board Meeting (January 2018)

Agenda Item 7.5 Date 01/03/2018

Committee Chair (where applicable)

Lead Director Julie Billett, Director of Public Health

Tel/Email Julie.billett@islington.gov.uk

Report Author Daisy Beserve, Programme Manager

Tel/Email Daisy.beserve@camden.gov.uk

GB Sponsor(s) (where applicable)

Tel/Email

Report Summary

This report provides a summary of the most recent meeting of Camden’s Health and Wellbeing Board (January 2018).

Purpose (tick one box only)

Information

Approval To note

Decision

Recommendation The Governing Body is asked to note the contents of the report.

Strategic Objectives Links

This paper links to the following strategic objectives:- • ensure access to and the delivery of safe, effective and responsive services; • reduce inequalities and meet identified need; and • ensure maximum positive health impact within the resources available.

Identified Risks and Risk Management Actions

N/A

Conflicts of Interest

N/A

Resource Implications

N/A

Engagement

N/A

Equality Impact Analysis

No equality impact assessment is required for this report.

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Report History

This report provides the Governing Body with an overview of the Camden Health and Wellbeing Board’s agenda, discussions and decisions. The intention is to provide these reports to the Governing Body four times a year, broadly aligning to the Health and Wellbeing Board’s schedule of meetings.

Next Steps N/a

Appendices None

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Summary Report of Camden’s Health and Wellbeing Board Meeting held on 16th January 2018 1.0 Background The purpose of this report is to provide the Governing Body with a summary of the agenda items, discussions and actions agreed at the Camden Health and Wellbeing Board (HWBB) meeting on 16th January 2018. 2.0 Developing the Health and Wellbeing Board: Next steps The Board considered a report to help develop its thinking on its purpose and future priorities. The report followed on from the Board’s development session in November 2017, during which the Board reflected on its achievements to date and focus going forward. The concept of the Board as an ‘anchor of place’ for the local health and care system, moving away from overseeing a range of projects to a more strategic, system leadership role, resonated with members of the Board. Members agreed that the Board needed to take a lead role in facilitating the system level change required to tackle intractable population health and system issues. In line with this new role, the Board agreed to ‘healthy hearts’ – tackling cardiovascular disease – as its priority theme for 2018. Heart health is a cross-cutting theme that links to many of the priorities and objectives within the existing health and care strategies and plans. The Board will not simply look at CVD from a biomedical perspective but take a broader socio-ecological approach to improving heart health. The theme would also provide a lens through which to develop the Board’s system leadership role and engagement of wider stakeholders and partners. The Board will be having a workshop style session at its next meeting to discuss this theme further and help develop its work programme for 2018. The Board agreed to invite a range of other partners and community representatives, including the British Heart Foundation, local residents and businesses, NHS providers and community pharmacies to the meeting. Following on from this meeting, the Board will be hosting a health and care summit in May/June to further develop its system leadership role. 3.0 Reducing alcohol-related harm: thematic review The Board received an update on reducing alcohol-related harm – one of the five priorities of the Joint Health and Wellbeing Strategy – based on the three delivery plan themes of promotion, prevention and improvement. Some of the notable developments and successes include: an increased focus on alcohol awareness; strengthened partnership work around prevention; the establishment of a cross-council working group focused on improving outcomes for the street population; and effective treatment to support a reduction in hospital admissions for some of the most vulnerable drinkers. The latest available data showed that there has been a reduction in annual hospital admissions due to alcohol. However, the overall number of residents accessing treatment services for alcohol has reduced. Over the next 12 months a range of actions have been identified to build on existing work, these include: a focus on older drinkers (based on local and national evidence of growing need among older residents); greater engagement in services to identify those not accessing services, understanding the barriers to accessing treatment and address these; and offering frontline staff identification and brief advice (IBA) training to help reduce alcohol consumption across the population, with a particular focus on organisations and frontline staff who are in contact with middle aged and older drinkers.

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4.0 Safeguarding adults and children in Camden: A joint board approach Consideration was given to a report of the Independent Chairs of Camden Safeguarding Children Board (CSCB) and Camden Safeguarding Adults Partnership Board (SAPB). Safeguarding children and adults, and securing their health and wellbeing are intrinsically and inseparably linked. The annual report to the Health and Wellbeing Board was in recognition of the critical need to ensure effective mutual challenge and assurance between all three boards. The Chairs of both safeguarding boards noted the long tradition of effective partnership working in Camden, based on shared priorities, and stressed the importance of this to safeguarding local people. They highlighted opportunities for improvement going forward, including working closer with the voluntary and community sector. The Board congratulated the CSCB on the recent Ofsted inspection that had rated it as ‘Outstanding with effective partnership working, with a powerful example of the impact of partnership working on children and young people in Camden.’ The Board also noted that there was more work to be done to identify which groups were most at risk of social isolation and how to prevent this. People who were socially isolated were predisposed to being vulnerable. Homecare workers and district nurses were examples of the contacts that could help with identifying those who were socially isolated. Both safeguarding boards will try and capture the work they were already doing to address social isolation. 5.0 Overview of the Camden Clinical Commissioning Group and Council’s commissioning and strategic intentions for 2018/19 The Board received a joint report from the Director of Integrated Commissioning, Director of Public Health and the Chief Operating Officer of Camden Clinical Commissioning Group (CCCG). The report outlined a high level overview of the approach being taken by Camden CCG and Camden Council to develop and implement strategic commissioning plans and system intentions for 2018/2019. The strategic context and framework for the commissioning priorities are the new Camden Plan, Camden 2025 – the shared vision for the borough, the Health and Wellbeing Strategy, the Local Care Strategy, the Supporting People, Connecting Communities – Our plan for living and ageing well in Camden, the North Central London Sustainability and Transformation Plan and the NHS’s Next Steps on the Five Year Forward View. Key joint priorities across the Council and CCG include: supporting people at home; primary care neighbourhood development and supporting people in the community. 6.0 Date of the next Board meeting The next Camden Health and Wellbeing Board meeting is scheduled to take place on 13th March 2018. The main substantive item on the agenda is ‘Camden Healthy Hearts 2018’.

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GLOSSARY

Acronym Meaning A A&E Accident and Emergency ACHS Adult Community Health Services ADHD Attention Deficit Hyperactivity Disorder AHSNC Academic Health Science Networks and Centres ALB Arms’ Length Body AMR Anti-Microbial Resistance AMS Ancillary Medical Services AoMRC Academy of Medical Royal College APE Accountable Provider Entity APMS Any Provider Medical Services AQP Any Qualified Provider ASC Adult Social Care AWP Any Willing Provider B BAU Business As Usual BC Business Continuity BCDR Business Continuity and Disaster Recovery BCF Better Care Fund BEHMHT Barnet, Enfield and Haringey Mental Health Trust BMA British Medical Association BME Black and Minority Ethnic BNF British National Formulary C C2C Clinician to Clinician CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Services CAP Common Assurance Process CBT Cognitive Behavioural Therapy CC2H Care Closer to Home CCAS Camden Clinical Assessment Service CCG Clinical Commissioning Group CCU Critical Care Unit CDiff Clostridium Difficile CDF Cancer Drugs Fund CDS Commissioning Data Set CDU Clinical Decision Unit CEPN Community Education Provider Network CG Caldicott Guardian CHC Continuing Health Care CHP Camden Health Partnership CICS Camden Integrated Care Service CIDR Camden Integrated Digital Record CIFT Camden and Islington Foundation Trust CIP Cost Improvement Plans CIT Clinical Information Technology CKD Chronic Kidney Disease CLD Chronic Liver Disease CMHT Community Mental Health Team

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CMT Controlled Medical Terminology CNWL Central and North West London NHS Foundation Trust COPD Chronic Obstructive Pulmonary Disease CPPEG Camden Patient and Public Engagement Group CPRD Clinical Practice Research Datalink CQC Care Quality Commission CQN Contract Query Notice CQRG Clinical Quality Review Group CQUIN Commissioning for Quality and Innovation CSIPS Continuous Service Improvement Plans CSU Commissioning Support Unit D DBS Disclosure and Barring Service DES Directed Enhanced Service DH or DoH Department of Health DNA Did not attend DOAC Direct Oral Anticoagulants DOLS Deprivation of Liberty Safeguards DR Disaster Recovery DTOC Delayed Transfer Of Care (where patients are ready to

return home or transfer to another form of care but still occupy a hospital bed)

DVA Domestic Violence and Abuse E EA Equality Analysis E&D Equality and Diversity ED Emergency Department EDS Early Discharge Service (was REDS)

/ Equality Delivery System EMIS Electronic Management Information System EMT Executive Management Team EOLC End of Life Care EPR Electronic Patient Record ERR Enhanced Rapid Response (Lambeth) F F2F Face to Face F&P Finance & Performance FBC Full Business Case FE Frail and Elderly FFT Friends and Family Test FNC Funded Nursing Care FoI Freedom of Information FT Foundation Trust G GB Governing Body GDP Gross Domestic Product GMS General Medical Services GP General Practice (or General Practitioner)

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GPSU General Practice Support Unit H HASU Hyper Acute Stroke Unit HCA Health Care Assistant HCC Health Care Commission HEE Health Education England HHC/HHL Haverstock Healthcare Ltd HLP Healthy Living Pharmacy (Programme) HPA Health Protection Agency HPSS Health and Personal Social Services HSC Health Scrutiny Committee HSCIC Health and Social Care Information Centre HSSI Higher Severity Service Incident HVS Home Visiting Service HWBB Health and Wellbeing Board I IAPT Improving Access to Psychological Therapies ICAS Independent Complaints Advocacy Service ICAT Integrated Community Ageing Team (Islington) ICO Information Commissioner's Office iCOPE Camden and Islington Psychological Therapies ICP Integrated Care Pathway ICT Information and Communication Technology IDSVA Independent Domestic and Sexual Violence Adviser IFR Individual Funding Request IG Information Governance IHM Institute of Healthcare Management INR International Normalised Ratio IPC Integrated Personal Commissioning IPU Integrated Practice Unit IRIS Identification and Referral to Improve Safety ISBHaSC Information Standards Board for Health and Social Care ISIP Integrated Service Improvement Programme ISTC Independent Sector Treatment Centre ITF Integrated Transformational Fund ITT Invitation to Tender J JCC Joint Commissioning Committee JGPITC Joint GP IT Committee JSNA Joint Strategy Needs Assessment K KPI Key Performance Indicator L LAs Local Authority LAS London Ambulance Service LCS Locally Commissioned Service LES Locally Enhanced Service LGA Local Government Association LHB Local Health Board LHS Local Hospital Strategy LMC Local Medical Committee LSOA Lower Safer Output Access LSP Local Service Provider

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LTC Long Term Conditions M MARSG Multi-Agency Reablement Steering Group MASH Multi-Agency Safeguarding Hub MBSR Mindfulness Based Stress Reduction MCA Mental Capacity Act MCP Multispecialty Community Providers MDT Multi-Disciplinary Team MHAAT Mental Health Assessment and Advice Team MHRA Medicines and Healthcare products Regulatory Agency MRSA Methicillin Resistant Staphylococcus Aureus MSA Mixed Sex Accommodation MSK Musculoskeletal N N.A.P.P. National Association for Patient Participation NCL North Central London NCL JFC North Central London Joint Formulary Committee NCL MON North Central London Medicines Optimisation Network NCEL North Central and East London NE Never Event NEL CSU North East London Commissioning Support Unit NES National Enhanced Service NHSE National Health Service England NHS IQ NHS Improving Quality NIB National Information Board NICA National Integration Centre and Assurance NICE National Institute for Health and Care Excellence NIHR National Institute for Health Research NMP Non-Medical Prescribing NMUH North Middlesex University Hospital NP Nurse Practitioner NPSA National Patient Safety Agency NQB National Quality Board NRLS National Reporting & Learning System NSF National Service Framework O OBC Outline Business Case OBR Office for Budget Responsibility OCD Obsessional Compulsive Disorder OOH Out of Hours P PACE Post-Acute Care Enablement PACS Primary and Acute Care Systems PALS Patient Advice and Liaison Service PAS Patient Administration System PASA Purchasing and Supply Agency PBC Practice-Based Commissioning PC Primary Care PCT Primary Care Trust PCTF Primary Care Transition Fund PD Personality Disorder PDT Programme Delivery Team PGD Patient Group Directions

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PH Public Health PHB Personal Health Budget PHE Public Health England PID Person Identifiable Data/

Project Initiation Document PIL Patient Information Leaflet PIRU Policy Innovation Research Unit PM Practice Manager PMO Project Management Office PMS Primary Medical Services PN Practice Nurse PNA Pharmaceutical Needs Assessment PPE Patient and Public Engagement PPG Patient Participation Group PPI Patient and Public Involvement PQQ Pre-Qualification Questionnaire PQS Prescribing Quality Scheme PRC Programme Review Committee PREMS Patient Related Experience Measures PREVENT Part of the government’s counter-terrorism strategy PROMS Patient Related Outcome Measures PTL Patient Tracking List PTSD Post-Traumatic Stress Disorder Q Q&S Quality and Safety QAS Quality Alerts System QGG Quality Governance Group QIPP Quality, Innovation, Productivity and Prevention QM Quality Matters Newsletter QOF Quality Outcome Framework (Assessor Validation

Reports) QP Quality Premium QP(I) Quality Performance (Indicators) R R&R Rehabilitation and Recovery RACI Responsible Accountable Consulted Informed RAG Red Amber Green (a rating system for indicating the risk

status using the traffic light colours) RAID Rapid Assessment, Intervention and Discharge Service (a

mental health service) RAPIDS Rapid Response Admission Avoidance Service (a mental

health service) RAS Rapid Access Service RCP Royal College of Physicians RCGP Royal College of General Practitioners RCT Randomised Controlled Trials REDS Rapid Early Supported Discharge RFL Royal Free London NHS Foundation Trust consisting of

Barnet, Chase Farm and Royal Free Hospitals RFL DTC RFL - Drugs & Therapeutics Committee RNTNEH Royal National Throat Nose and Ear Hospital RRP Responsible Respiratory Prescribing Subgroup RTT Referral to Treatment

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S SBS Shared Business Services SCAS Assessment Service for Children with Autism SCG Shared Care Guideline SCR Serious Case Review SEND Special Educational Needs and Disabilities SFI Standing Financial Instructions SHA Strategic Health Authority SHMI Summary Hospital-level Mortality Indicator SHOT Serious Hazards of Transfusion SIGN Scottish Intercollegiate Guidelines Network SIs Statutory Instruments SI Serious Incident SLA Service Level Agreement SMI Service Measurement Index or Supplier Management

Inventory SMT Senior Management Team SOC Single Overriding Contract SPA Single Point of Access SPC Summary of Product Characteristics SPG Strategic Planning Group SPOR Single Point of Referral STEIS Strategic Executive Information System STP Sustainable Transformation Plan T TAP (Mental Health) Team Around the (GP) Practice TDA NHS Trust Development Authority TFT Thyroid Function Test TIA Transient ischaemic attack TOPS Termination of Pregnancy Service ToR Terms of Reference TREAT Triage and Rapid Elderly Assessment Team TSDO Transformation Strategy Delivery Office TTA Tablets to Take Away TUPE Transfer of undertaking protection of employment

regulations TWR Two-week referral U UCC Urgent Care Centre UCLH University College London Hospital UCLH UMC UCLH - Use of Medicines Committee UTC Urgent Treatment Centre V VBC Values Based Commissioning VSNAG Voluntary Sector National Advisory Group VTE Venous Thromboembolism W WEMWMS Warwick-Edinburgh Mental Health Wellbeing Scale WHO World Health Organisation

WRAP An interactive workshop undertaken by healthcare staff to raise awareness of PREVENT

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Carolyn Cullen Board Secretary

Dr Neel Gupta Chair

Helen Pettersen Accountable Officer

Sarah Mansuralli Chief Operating Officer

Kathy Elliott Vice Chair

Simon Goodwin Chief Finance Officer

Ian Porter NCL Director Corporate

Services

Dr Birgit Curtis GP

Dr Matthew Clark Secondary Care Clinician

Dr Martin Abbas GP

Dr Kevan Ritchie GP Dr Jonathan Levy GP

Richard Strang Lay Member

Glenys Thornton Lay Member

Jonathan Duffy Practice Manager

Dr Sarah Morgan GP

Jane Davis OBE Registered Nurse

Dr Philip Taylor GP

Charlotte Cooley Practice Nurse

Julie Billett Director of Public Health

Neeshma Shah Director Quality & Clinical

Effectiveness

Richard Lewin LA Representative

Saloni Thakrar Healthwatch

Representative

Hilary Lance Patient Representative

Simone Hensby Voluntary Action Camden

Dr Farah Jameel LMC Observer

Jennifer Murray Roberts Commissioning and Contracting Director

Richard Cartwright Head of Performance

Sally MacKinnon Transformation

Programme Director

Rebecca Booker Deputy Chief Finance

Officer

Table Plan - January 2018 Meeting

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