27 march 2014 13.00 - 16.00 boardrooms, becketts house ...€¦ · nhs redbridge clinical...

NHS Redbridge Clinical Commissioning Group Governing Body meeting

27 March 2014 13.00 - 16.00

Boardrooms, Becketts House

Item Time Lead Attached, verbal or to follow

1.0 1.1 1.2 1.3

Welcome, introductions and apologies Declaration of conflicts of interest Minutes of the meetings held on 30 January 2014 Matters/actions arising

1.00 Chair Chair Chair

Verbal Attached Attached

2.0 2.1 2.2

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

1.10 1.20

Chair CB

Attached Attached

3.0 3.1

Governing body assurance Governing body assurance framework

1.30

LM

Attached

4.0 4.1 4.2 4.3 4.4

Corporate strategy and planning Operating plan 5 year strategic plan Better Care Fund 2014/15 Budget

1.40 1.50 2.00 2.10

LM LM LM MS

Attached Attached Attached Attached

5.0 5.1

Service transformation and development QIPP report

2.20

LM

Attached

6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7

Quality and performance BHRUT update Francis report update Annual adult safeguarding report Patient experience report Finance and activity report Contracting report

2.30 2.40 2.50 3.00 3.10 3.20

CB JH JH KA MS MS

Attached Attached Attached Attached Attached Attached

7.0 7.1 7.2 7.3 7.4 7.5 7.6

Development/governance Policy on sponsorship and joint working with the pharmaceutical industry Constitution change Annual remuneration report Values and behaviours CSU contract Minutes of sub – committees and relevant fora:

• Executive committee • Audit and governance committee • Quality and Safety committee

3.30 3.35 3.40 3.45 3.50 4.00

SA SA KP SA MS Chair KP JH

Attached Attached Attached Attached Attached Attached Attached Attached

Item Time Lead Attached, verbal or to follow

• Finance and delivery committee • Patient engagement forum • Joint executive team committee

MM KA CB

Attached

8.0 AOB 4.05 Chair

Verbal

9.0 Questions from the public

10.0 Next meeting: 27 June 2014 The public are asked to indicate to the company secretary any points of enquiry or questions they would wish to address with the governing body at least three days before the meeting by e-mail to [email protected]

mailto:[email protected]

Register of interests 2013/14

Declaration of governing body member interests

Name Role Organisation Nature of interest

Dr Anil Mehta Chair Fullwell Cross Medical Centre Metropolitan Police

GP Principal Forensic Medical Examiner

Dr Sarah Heyes Clinical director The Shrubberies Medical Centre

GP Principal

Dr Muhammad Tahir

Clinical director Forest Edge practice, Hainault Health Centre Dagenham & Redbridge Football Club Redbridge CCG

GP Partner Club doctor GP with special interest in diabetes

Dr Mehul Mathukia

Clinical director Mathukia’s surgery

GP Partner

Dr Shabana Ali Clinical director Southdene Surgery North East London Foundation Trust

GP Partner GP with special interest in cardiology

Dr Samia Azeem

Clinical director Chadwell heath surgery Salaried GP

Dr Chidi Okorie Clinical director Ilford Lane Surgery

GP Partner (from 01/02/2013)


Partnership of East London Co-operative ProCivitas Ltd

GP Director and shareholder

Dr Syed Raza Clinical director Chadwell Heath surgery Salaried GP

Dr J. Sood Clinical director Newbury Group Practice Redbridge CCG Care UK (Barking and Dagenham) ESS

GP Partner GPwSI – Diabetes & Dermatology GPwSI – Diabetes & Dermatology GPwSI – Diabetes & Dermatology

Dr Heath Springer

Clinical director Redbridge CCG Redbridge LMC

GPwSI - Diabetes Vice chair GP Trainer/Educator

Ah-Fee Chan Secondary care consultant

North Middlesex University Hospital NHS Trust

Consultant in Anaesthetics and Intensive Care Medicine

Conor Burke Accountable officer Your business works (not trading) Redbridge college

Director Audit committee member

Louise Mitchell Chief operating officer Richard House Children’s Hospice

Former employee

Martin Sheldon Chief finance officer Novus Generation Limited

Director/shareholder


Somerset Sight Trustee Jacqui Himbury Nurse director Nursing & Midwifery Council Fitness to practice panellist

Khalil Ali Lay member

Brookside Junior School, Havering Chair of governing body

Kash Pandya Lay member Hillcroft College Surbiton

Ministry of Justice Essex Advisory Committee Health & Safety Executive Brentwood Citizen’s Advice Bureau Havering CCG Barking & Dagenham CCG University of Essex Her Majesty’s Inspector of Constabulary

Council Member and Audit Chair Lay Member Independent Audit Committee Member Advisor Lay Member Lay Member Independent member of Audit and Risk Committee Associate Inspector

Draft Redbridge Clinical Commissioning Group Governing Body Meeting 30 January 2014

1.00 - 4.00pm Boardrooms, Becketts House

Present: Dr Anil Mehta (AM) Clinical Director/Chair Dr Shabana Ali (SA) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Chidi Okorie (CO) Clinical Director Dr Jyoti Sood (JS) Clinical Director Dr Muhammed Tahir (MT) Clinical Director Dr Heath Springer (HS) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Dr Syed Raza (SR) Clinical Director Jacqui Himbury (JH) Director of Nursing Conor Burke (CB) Accountable Officer Martin Sheldon (MS) Chief Finance Officer Louise Mitchell (LM) Chief Operating Officer Kash Pandya (KP) Lay member – Governance Khalil Ali (KA) Lay member – PPI Ah-fee Chan (AFC) Secondary care consultant In Attendance: Sue Assar (SMA) Interim Director of Corporate Services Anne-Marie Keliris Company Secretary Vicky Hobart (VH) Director of Public Health Graham Simpson (GS) BHR Commissioning support Director CSU Cathy Turland (CT) Chair, Healthwatch Redbridge Apologies: Dr Samia Azeem (SA) Clinical Director John Powell Director of adult social services and housing

Item Action 1.0 Welcome and apologies

The Chair welcomed members to the meeting. Apologies for absence were received from Dr Samia Azeem and John Powell.

1.1 Declarations of conflicts of interest There were no additional conflicts of interest declared.

Item 1.2

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1.2 Minutes of the last meeting

The minutes of the meeting held on 20 September were agreed as a correct record.

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

2.0 Chair & Accountable Officer’s Reports

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

• Health & wellbeing board • CQC inspections and provider management • NHS strategic engagement • Member engagement • Financial allocation.

The governing body noted the report. 2.2 Chief Officer’s report The chief officer presented his report covering the following areas:

• BHRUT performance • CCG performance • CCG authorisation • CCG development • New appointments – Chief Finance Officer and Director of

primary care development • Health & wellbeing board update • King George hospital vision group update • Primary Ministers challenge fund • Meeting attendance.

The governing body noted the report.

3.0 Governing body assurance 3.1 Governing body assurance framework

LM presented a report which outlineds the key risks to the clinical commissioning group in achieving its corporate objectives that are identified in the governing body risk assurance framework. It was noted that although the key risks remain the same as reported in September 2013, the severity for some had changed, the risk associated with specialist commissioning had been de-escalated. The risk relating to BHRUT had increased due to special measures and continued poor performance with more detail being discussed later in the meeting. It was noted that information had been included on how risks had changed and where assurance on specific risks were given at

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committees of the governing body. KA referred to the backlog of CHC reviews and outstanding initial assessments, adding that whilst this has been described as presenting clinical and financial risks to the CCG, it should be noted that delays could lead to patient / carer dissatisfaction and complaints, and this should be taken into account when scoring and mitigating this risk. KP commended the framework but questioned if the risks could be more explicit on financial health. CB responded that the forecast is for an in year balanced position but technically the CCG do not have a financial risk this year. The Chair questioned if internal audit will be reviewing the GBAF on yearly basis. MS responded that this was normally a regular item in the internal audit work plan, and next year it will be reviewed again but will also include how risks appear and flow upwards into localities. MM questioned if the risk associated with the engagement of GP practices in commissioning process should be included. LM responded that risk was included at the beginning of the year, but this has now been downgraded due to the excellent engagement which has taken place. MM referred to innovative and radical work taking place in Somerset and Cornwall, CB responded that he would be interested in receiving more information on this and always welcomed suggestions of innovative ways of working. KA referred to the quality assurance process of care homes and commended JH for her work in this area, he questioned how the CCG be assured that if and when all nursing homes achieve the quality of care standards, this leads to measurable outcomes relating to improved patient experience, and reduced unnecessary trips to A&E. JH responded that the next stage to focus on will be the risk profile of nursing homes, adding that a report will be presented to the quality and safety committee. MS added that contracting of care homes has been moved to the CSU contracting team to ensure there is appropriate safeguarding in place. The governing body noted the report and that the recommendations from internal audit have been implemented to improve the process and effectiveness of the GBAF.

4.0 Corporate strategy and planning 4.1CSPP/Operating Plan

LM presented a report which provided an update on the

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development of the CCG strategic plan, operating plan and better care fund plan.

KA commented it was good to see so much emphasis on improving patient experience and involvement through the planning and delivery system locally. He questioned if there is any patient representation on the integrated care steering group for the 5 year strategy and the operating plan for this CCG. CB responded that the integrated care steering group was not a decision making group, adding that engagement on the plans the steering group considers had already taken place, and reports to the health and wellbeing board.

KA questioned if there had been any work on identifying the baselines for each of the seven system objectives, including those on patient experience of inpatients, in order to better inform the targets. LM responded that the seven objectives were driven nationally and the CCG knows where work is required to meet these.

KP questioned what the QIPP requirements are for the coming year. LM responded that for 14/15 £15.3 QIPP savings are required, adding that over 60% have been identified to date. KA commented that it would be mindful for the primary care improvement plan to also reflect patient views and experiences as indicated through the GP practices’ patient surveys.

The governing body noted the briefing, approved the proposal to

use the integrated care steering group to co-ordinate the strategic planning process on behalf of the collation/BHR system.

4.2 Contracting development process 14/15

MS presented a report which set out the current progress with the negotiation of the contracts for which the BHR CCGs are the host in the 2014/15 round. It was noted that the contracting process had been set up with baselines and quality indicators established for all contracts. He added that a shadow tariff for NELFT had been set for next year and a baseline offer had been made to BHRUT which would be a challenge to the Trust but felt the process had been good. It was also noted that the CCG were fully involved in negotiations with Barts Health. AFC questioned if block contracts were stopping, MS responded that there is work being undertaken to unpick service lines with the aim to complete this project by summer with this information being

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used for commissioning in the following year. SA questioned if this will also apply to contracts with Holly House and Spire Health. MS reported that a performance review of each contract based on quality/patient experience will be undertaken. KA questioned how confident are commissioners regarding the accuracy of the patient activity data that forms the basis for CCG commissioning and performance monitoring of acute trusts in particular. MS responded that quality of data had improved dramatically over the last year, adding that now the CCG were ASH accredited and guidance for the validation process had recently been received so further improvements were expected. It was also noted that BHRUT had moved to the new Medway data administration system. The governing body noted the report.

5.0 Service transformation and development 5.1 Trialling of community services

LM presented a report which provided an update on the progress of the development of a new model of intermediate care for the BHR health economy. KA welcomed the report and the excellent news about users very positive views of their care and the services in general but felt it was very important for any communications issues to be resolved quickly, particularly in view of the potential growth in referrals and transactions now, and into the future.

KP commented that he was unconvinced on value for money but looked forward to receiving the next report. CB agreed that double running risks will need to be reviewed. CT commented that the patient engagement event was very successful with lots of feedback received and thought it would be useful to run a follow-up event in May. She also suggested the need to review from the carers perspective. CB agreed to explore this further. MM reported that it had been discussed at a locality forum and on the whole members had been positive and welcomed the trial. The Chair agreed with the positive comments expressed. The governing body agreed to continue to commission the trial of CTT and IRS 2014/15 with a view to:

• reviewing the model in year following further evidence regarding service effectiveness and development of plans to improve links with social care;

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• finalising the proposed model of intermediate care in partnership with the local authority, and;

• consulting on any significant service changes for 2015/16.

5.2 Tier 3 weight management services LM presented a report which proposes that the BHR CCGs proceed to commission a tier 3 weight management service and prioritise this for investment in 2014/15. KA requested that an Equalities Impact Assessment on the new services be undertaken.

It was noted that a service gap had been identified which is common across a number CCGs, NHS England is leading a programme of work nationally and in London to review the weight management pathway. CB responded that the governing body are being asked to establish a tier 3 provision but understands that concerns have been raised because tiers 1 and 2 are fragmented and suggested that an organisation will need to lead this from April 2014.He has been raising this at every meeting with NHS England and will formally write to raise these concerns and find out how the backlog of patients will be resolved. The governing body approved the commissioning of a tier 3 weight management service and authorised the executive committee to sign off the service specification and budget. The governing bodyagreed to request that the health and wellbeing board review the adult obesity pathway.

CB

6.0 Quality and performance 6.1 Continuing healthcare (CHC)development plan and

assurance report JH presented a report which detailed the outcome of the continuing healthcare options appraisal that was undertaken to consider, build or share models that would enable CHC services to be stabilised and delivered in the immediate future to a high standard. It was noted that option 1, to build an internal CCG team, with capability and capacity to provide an assessment, brokerage and care management service was the option recommended to the governing body. KP supported option 1 but would like to understand the difference between this and option 2. MS responded that option 1 will be more cost effective, enable risks to be managed and a greater focus on quality and value for money.

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CT commented that this could have a major impact on disabled people when they reach CHC criteria from personal health budgets and asked the GB not make this a tick box exercise and ensure that patients are at the centre of any decisions that are made. The governing body noted the current position and assurance process and agreed to option 1 as the future delivery model for continuing healthcare services. 6.2 Urgent care board and winter resilience CB presented a report which provided a progress update on the urgent care board and winter resilience. It was noted that although the A&E target remains challenging, there has been significant progress in the implementation of projects to improve overall A&E performance. He added that there are 2 areas that need to be increasingly focused on including urgent care centre utilisation and primary care surge scheme, although this is still in its infancy. KA commented that assuming that the A&E targets and better utilisation of the UCCs are all achieved over this winter (which is still relatively mild), how will this be sustained year on year. CB responded that funds had been used to change how BHRUT operates and anticipates that there are enough funds in the system to enable further change but added that more focus is also needed on recruitment and retention within the Trust.

KA questioned if there will be an overall independent evaluation to assess effectiveness and impact on patient / public experience. CB responded that appendix 2 sets out investments which were considered at the urgent care board and will be monitored against performance indicators.

AFC questioned how long the urgent care board will continue. CB responded that the urgent care board is accountable to the integrated care coalition who will decide on its future.

The governing body noted the progress of the urgent care board and progress against the winter pressure funded schemes and its monitoring approach. 6.3 CQC and special measures at BHRUT CB presented a report which advised the governing body on the publication of the CQC inspection report of BHRUT and assure members on the action being taken to address key quality issues.

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CB highlighted the actions taken by the CCG within the report and it was noted that this was a very serious issue for the health economy. KA highlighted the effect on staff morale at the Trust since it had been placed in special measures and questioned what consideration is or has been given to support these people, bearing in mind that in their most recent national staff survey, a high percentage suggested that they would not recommend being treated at BHRUT. The chair responded that the Sir Ian Carruthers’ review did interview staff. CB added that the CCG needs to do all it can to help BHRUT to improve, and this will include exploring ways of improving primary care.It will be an opportunity for the CCG to change the current local system.

VH questioned what the process for BHRUT moving forward. CB responded that Trust will need to obtain approved from the Trust Development Agency for its improvement plan which will be embedded into contracts.

KP raised concern of the trust’s capacity to implement improvement plans, CB noted his concerns. The governing body noted the CQC report and the actions being taken by the Trust Development Agency and BHRUT under the ‘special measures’ framework. The governing body agreed to receive a further report on the trust improvement plan at its next meeting. 6.4 CQC at Barts Healthcare JH presented a report which advised the governing body on the publication of the CQC inspection report of Barts Health NHS Trust and assured members on the action being taken to address key quality issues. It was noted that warning notices had now been removed and the Trust response acknowledged the issues raised which were reviewed and immediate action taken. SA commented that there had been a high number of never events with 3 relating to patients at her own practice and questioned if these were increasing. JH responded that she would need to understand what these incidents were as she was unaware of any Redbridge never events and agreed to discuss this with SA outside of the meeting.

JH

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The governing body noted that the trust must submit a draft improvement plan by 7 February with a more detailed and comprehensive plan submitted by the end of February 2014. A second quality summit is planned for 6 February to further develop the improvement plan with partners and quality of services delivered will be continued to be monitored formally through the clinical quality review meetings. 6.5 Patient experience report KA presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:

• Complaints and MP/councillor queries • Commissioned services • Patient stories • Patient engagement forum • Healthwatch Redbridge report • Redbridge CVS report • Healthwatch Redbridge workshop • The development of the vision for King George Hospital • Seven Kings GP Surgery

KA expressed thanks to the Melvin Weinberg and Vivenne Nathan who had resigned as Chair and deputy Chair of the patient engagement forum. It was noted that a new chair will be elected in due course. KP highlighted the need to explore a way of presenting patient stories to the governing body. The governing body noted the report. 6.6 Finance and activity report MS presented the month 9 finance and activity report highlighting that the CCG did not achieve the planned year to date surplus of £2.19m by reporting a £9k surplus. He added that it is estimated at year end that the CCG will not achieve its 1% target surplus of £2.9m but will deliver a break even position. MS reported that the biggest financial risk was Barts Health contract with regard to the agreement of challenges and specialist commissioning activity that may not be attributed to the CCG. He added that a London wide project is reviewing the misattributions and meetings are currently ongoing with the provider to triangulate the position. It was also noted that the independent sector and continuing healthcare was above plan and there had been a level of over performance at Homerton hospital.

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MM commented that past criticism was that PCTs were too big and questioned if continuing healthcare over performance and the appointment of the director of primary care will impact on the CCG management costs. MS responded that these will not impact, adding that the organisation is developing in the right places. It was noted that the 10% drop in running costs which will come into effect in 15/16 will be a challenge, but CSU have been challenged to find savings each year. The governing body noted the report. 6.7 Contracting report MS presented a report which provided an update with the position on the 2013/14 contracts and highlighted quality issues that have been identified with the Redbridge CCG main providers for acute and community services. KA commented that it was unacceptable for the provider Trusts not to provide accurate and reliable information on patient activity, and this situation needs to be resolved as soon as possible. MS agreed and assured the governing body that he was taking action to challenge this. KP referred to appendix 1 and 2 report and expressed concern at the Barts Healthcare trend, noting that the CQC did not take this into account. MS responded and agreed that the CQC focused less on RTT performance. JH reported that the transfer of child protection from BHRUT to NELFT went smoothly. VH questioned how proactive and engaged are London cancer being. CB responded that a BHRUT collaborative cancer group had been formed which will focus on pathways in BHR and will liaise with WELC and London cancer colleagues as pathways start to change. The governing body noted the report.

7.0 Development/governance 7.1 Gifts and hospitality, whistle blowing, anti-fraud and

bribery policies SMA presented the policies for approval which had been reviewed by the remuneration and workforce committee KA commented that it would be useful to have a level of appreciation of these policies. SMA responded that this would be part of the communications plan.

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The governing body approved the policies. 7.2 CSU contract 2014/15 and beyond MS presented which provided an update on the progress of the current negotiations with CSU for corporate service in 2014/15, he added that negotiations had been good and more aligned to the CCG as a customer. GS commented that there had been challenges over the year but also improvements by learning around the operating model and that localised services work better. VH questioned if there will be access to data for JNSA purposes, LM agreed to discuss this outside the meeting. The governing body noted the report and agreed to receive a final report in March 2014. 7.3 OD plan progress report SMA presented a report which provided an update on progress and timescales for the production of the plans. The governing body noted the progress made and the timescales for the production of a comprehensive OD plan.

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

• Executive committee held on 15 October & 4 December 2013

• Audit and governance committee held on 12 November 2013 • Quality and safety committee held on 8 October 2013 & 9

January 2014 • Finance and delivery committee on 12 November 2013 • Patient engagement forum held on 8 October & 10

December 2013 • Joint executive team committee held on 3 October, 7

November & 3 December 2013.

LM

8.0 AOB There was no other business

9.0 Questions from the public Jon Abrahms, representing Redbridge concern for mental health addressed the governing body with the following questions:

1) What processes has the Board put in place for ensuring accessibility of governing body meeting minutes especially in light of the public sector equality duty and what processes

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are in place to ensure local residents and organisations are able to digest the information and make a meaningful contribution. SMA responded that minutes are available on the CCG website but agreed to investigate ways of ensuring these are easier to understand for all service users.

2) What are the commissioning intentions in respect of the

voluntary sector, for example, a contract relating to the Mental Health development worker which comes to an end in March 2014. What processes will the governing body put in place to ensure transparency and openness with regard to commissioning intentions. How is the governing body engaging with and consulting with local communities and organisations with regards to commissioning services in the voluntary sector. CO responded that the mental health development worker post is currently being reviewed and no decision has been made yet and a discussion will take place with the provider. He added that as a CCG we do part fund on a collaborative basis with our colleagues in the local authority so future joint commissioning arrangements will of course need to be discussed in partnership.

3) How is the governing body addressing the recommendations

contained in the NHS commissioned report. CO responded and noted that the focus group work led by Redbridge concern for mental health identified key areas for improvement and this has informed the 13/14 mental health contract and performance management, which has focused on understanding patient and carer experience of home treatment and inpatient services as well as overseeing improvements to access. He added that key areas relating to supporting people in crisis will continue to be the focus of the 14/15 contract and there is still more work to do, and the CCG clinical directors meetings with NELFT clinicians will continue to focus on improving primary/secondary interface.

10.0 Date of the next meeting

27 March 2014.

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Actions arising from the Redbridge Clinical Commissioning group Governing Body

30 January 2014 Part I Action reference Action required Lead Progress 5.2 Tier 3 weight management services

CB responded that the governing body are being asked to establish a tier 3 provision but understands the concerns being raised because tiers 1 and 2 are fragmented and suggested that an organisation will need to lead this from April 2014 and has been raising this at every meeting with NHS England and will formally write to raise these concerns and find out how the backlog of patients will be resolved. The governing body would request the health and wellbeing board review the adult obesity pathway.

LM/CB

CB has written to NHS England, a formal response is awaited. This is being progressed with Public Health colleagues at the local authority.

6.4 CQC at Barts Healthcare

SA commented that there had been a high number of never events with 3 relating to patients at her own practice and questioned if these were increasing. JH responded that she would need to understand what these incidents were as she was unaware of any Redbridge never events and agreed to discuss this with SA outside of the meeting.

JH Completed

7.2 CSU contract 2014/15 and beyond

LM agreed to discuss further with VH access to data for JSNA purposes.

LM Completed.

Item 1.3

www.southwark.gov.uk

To: NHS Redbridge Clinical Commissioning Group Governing Body From: Dr A Mehta, Chair Date: 27th March 2014 Subject: Chairman’s Report

Executive summary As we reach the end of our first year as a CCG I have had cause to reflect upon the significant achievements we have made and challenges that we have risen to in less than 12 months existence as a new organisation. This I believe is testimony to the staff that we have, the stakeholders that we work with and the robust Governance arrangements and infrastructure within which we operate. Without doubt, we continue to operate in a challenging NHS economy and we need to continue to focus all of our efforts and skills on striving to deliver the best as commissioners for the population of Redbridge. We must remember the good work that has been achieved thus far in 13/14 which we can build upon to meet our objectives in the coming year too. This report provides you with a summary of key activities that I have undertaken since our last meeting in January of this year along with a high level summary of some of the key areas of achievement for us as an organisation Recommendations

• The governing body is asked to note this progress report.

1.0 Purpose of the Report 1.1 To provide an update on my activities as Chair since the last meeting in January 2014.

2.0 Health and Wellbeing Board 2.1 We approved the DRAFT submission of the Better Care Fund template (BCF) at our most recent

HWBB. A progress report is included as part of today’s agenda. Our next HWBB will be held after our local council elections which take place in May. In the interim we will continue to work together as stakeholders to review the operating model of the Board itself.

3.0 Leadership Capacity and Capability 3.1 Since our last Governing Body meeting I have met individually with each of our Clinical Directors

to review their 13/14 personal objectives which align to our corporate objectives. I know that all CCG staff are currently meeting with their respective line managers to review their delivery over the past year and to begin to discuss their objectives for 14/15 which again will need to align to our organisational corporate objectives.

4.0 NHS Strategic engagement 4.1 I mentioned in my last report to you all that we have committed to determining our ‘vision’ for

primary care within this year which will be led by Dr Heath Springer Clinical Director working closely with colleagues, engagement groups and partners across the CCG. I am delighted to inform you that we held a very successful workshop with a range of stakeholders including providers, service users in the form of parents, Local Authorities and health commissioners with a specific focus on ‘ Children and Young people’ I know that our Chief Officer has made reference to this within his report for today . It is excellent to see the work of the CCG fully embracing such a wide variety of stakeholders and certainly service users as we ‘shape’ our future strategy.

5.0 Appointment of the Chair at BHRUT Maureen Dalziel has been appointed as Interim Chair of the Trust following the resignation of Sir Peter Dixon. Arrangements are being made for myself and Conor Burke to meet with Maureen so we can discuss the CCG’s plans and how the Trust’s improvement plans align with these. 6.0 Key areas of progress in 13/14 6.1 Today’s agenda will provide a greater level of detail regarding progress and key areas of challenge that impact the CCG. However I wanted to take this opportunity to share with you just some of the key highlights from my perspective as Chair with regard to significant achievement in our first year as a CCG .

• Demonstrated active clinical leadership within our contractual management arrangements

with providers – ensuring that delivery of quality of care and outcomes for our patients are at the heart of our commissioning arrangements.

• Strong focus on patient and public engagement with the establishment of our CCG engagement forum and Locality specific forums too

• We have risen to the challenge of the largest QIPP value that Redbridge has ever had (£20m in 13/14).

• We have reduced the number of outstanding authorisation conditions applied since April 2013.

7.0 Risk 7.1 There are no risks associated with this report. 8.0 Resources 8.1 There are no additional resources associated with this report. Louise Mitchell, Chief Operating Officer 18 March 2014

www.southwark.gov.uk

To: Meeting of the Redbridge Clinical Commissioning Group Governing Body From: Conor Burke, Chief Officer Date: 27 March 2014 Subject: Chief Officer’s Report

Executive summary This report provides an overview of key activities undertaken by the Chief Officer and the CCG since the last meeting.

Recommendations The governing body is asked to:

• Note the progress report

1.0 Purpose of the report 1.1 To provide an update on my activities since the last meeting in January 2014.

2.0 Barking, Havering and Redbridge University Hospital Trust (BHRUT) 2.1 Matthew Hopkins has recently been appointed as Chief Executive, replacing Averil Dongworth

who retires at the end of the month. I will be meeting with Matthew for the first time on 7 April. . An update on the improvement plan will be provided later on the agenda.

3.0 CCG performance 3.1 Monthly assurance meetings with NHS England (NHSE) continue with the most recent one held

on 17 March where we received positive feedback on our Operating Plan and Better Care Fund. Discussions also focused on contracting negotiation progress, finance and performance across a range of areas. NHSE were reassured and satisfied of our progress in these areas.

4.0 CCG Development 4.1 I was unfortunately unable to attend the Governing Body awayday on 13 February but have

received feedback that the session which focused on safeguarding, BHRUT special measures and strategic planning was useful to those that attended. The next session is scheduled for 8 May where the draft corporate objectives for 14/15 will be reviewed.

5.0 King George Hospital (KGH) Vision Group update 5.1 On 27 February the KGH Vision Group held a very successful and interactive workshop with

stakeholders including parents of service users, local authority staff and acute service paediatricians amongst others. There were a number of key emerging themes that included the need for better integration of services for children and young people, the need to co- locate services to make it easier for families to see a variety of support staff under one roof and the desire and need to improve communication across all stakeholders. Recommendations included the formation of a dedicated working group reporting to the KGH vision group and constituted of representatives from the stakeholders who attended the day to progress with the work.

6.0 Recent appointment 6.1 I am pleased to confirm Sarah See has started in her post as Director of Primary Care

Improvement.

7.0 Prime Ministers Challenge Fund: Extending Access to General Practice 7.1 Following a lot of hard work from officers and GPs on the bid that was submitted, we are still

awaiting feedback. We received a high level of support from partners and are hopeful of a positive outcome.

8.0 Meeting attendance 8.1 On 10 February, the Integrated Care Coalition (ICC) held a workshop to review progress with

implementing the agreed vision and agree priorities and alignment of the plans and how all partners will work together to deliver those plans. There was agreement that the vision, signed up to in 2012 still held true, however, there was recognition that further work was needed to define the cohort of patients that the system should focus on next to have the biggest impact. It was agreed that the CCGs would lead a piece of work to scope the population cohort and next steps. This proposal would then be considered by the system at the next ICC meeting. It was recognised that additional support/capacity was likely to be required to take this forward. It was also acknowledged that the BHRUT system improvement plan would need to reflect and be consistent with the system plan.

8.2 From 24 to 27 February I joined a Corporate Peer Challenge at Kirklees Council in Huddersfield. This focused on the Council’s role and approach to the health and wellbeing of Kirklees residents and how current partnership arrangements are working. It was a very positive and interesting experience and I will look to apply what I have learnt locally.

8.3 The Urgent Care Board met on 28 February and discussions focused on system wide performance and progress of winter monies. The next meeting on 28 March will focus on the BHRUT Improvement Plan.

8.4 On 11 March I attended the London Health and Care Leaders Forum, which was a collaboration

between NHS England (London), NHS Trust Development Authority, London Councils, London Clinical Commissioning Council, Public Health England and Monitor. The purpose of the event was to align leaders around the case for change and system priorities and to examine different models of leadership to enable transformational change in delivery and commissioning.

8.5 On 13 March at the London Chief Officers meeting, discussion focused on the draft Londonwide

primary care standards and how CCGs will work with NHSE to implement.

9.0 Equalities 9.1 There are no equalities implications arising from this report.

10.0 Risk 10.1 There are no risks arising from this report.

To: NHS Redbridge Clinical Commissioning Group Governing Body From: Louise Mitchell, chief operating officer Date: 27 March 2014 Subject: Governing body risk assurance framework report Executive summary This report outlines the key risks to the clinical commissioning group (CCG) in achieving its corporate objectives that have been escalated to the governing body assurance framework (GBAF). This report will also detail any risks that have been de-escalated from the GBAF. The key risks to the CCG, aligned to the corporate objectives, are as follows:

1. Inherited PCT continuing health care (CHC) assessment backlogs and delays 2. Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) emergency

care performance 3. Quality monitoring of care home concerns 4. Concerns with provider data 5. Transition of GP contracts to NHS England and delegation of unanticipated responsibilities.

There have been no significant changes to the GBAF since the report in January 2014; key risks have remained the same with some reduction in the risk ratings against CHC assessments and provider data. Recommendations The governing body is asked to: • Note and comment on the current risks escalated to the GBAF and levels of assurance in the

controls and mitigating actions being taken.

1.0 Purpose of the report 1.1 The purpose of the GBAF is to outline the strategic risks to the CCG in achieving its corporate

objectives and the controls in place to provide assurance. This report presents the current high level risks to the organisation detailed within the GBAF.

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

that internal control systems are appropriate and effective. 2.2 Risk management processes are well established at locality, borough and collaborative levels.

All registers are reviewed monthly with appropriate clinical and managerial staff. Reports are presented and discussed at a number of our committees, namely the executive, finance and delivery and audit and governance committees.

Item 3.

2.3 Based on criteria set out in the risk management framework and the current risk rating, significant risks are escalated from the borough risk register to the GBAF where appropriate. The strategic risks have been aligned to the corporate objectives and are shown in the GBAF and the summary at appendices 1 and 2.

3.0 Report content

The CCG risk register consists of risks that are local to the borough and risks that the CCG has in common with its collaborative partners, Barking and Dagenham and Havering CCGs. The register is reviewed as outlined above within the borough and the common risks are reviewed across the three CCGs via discussion at the joint management team meeting each month.

4.0 Current risks on the GBAF 4.1 There are five risks that have been escalated to the GBAF and remain the same as those

reported to the January meeting. Please refer to appendix 1 for the full details. These fall under three of the six corporate objectives (COBs) and are as follows:

COB 3: Continue to focus on the development and success of our new organisation – our members, governing body and staff. Risk 3.2: Operational pressures on CCG GP members due to the transition of GP contracts to NHS England and some issues with resolving issues affects focus on/delivery of QIPP. Delegation of unanticipated functions to CCGs from NHSE impacts on existing scarce CCG resources – staff and finance. Mitigation: Working closely with NHSE and establishing regular arrangement for two way dialogue on issues. The CCG is in close liaison with our CSU to identify contract management resource to manage the contracts in order to deliver QIPP. Joint meetings with NHSE primary care lead and improved engagement and communication with clusters. Risk 3.3: Commissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk Mitigation: We have issued instructions to the CSU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity. Where there is no contract we will develop an alternative validation process. Until the process is developed we will not pay the invoices. We have achieved accredited safe haven (ASH) status in October 2013. The new system is now being developed which will enable us to run patient level validations. COB 4: Improve the quality of care from all the services we commission Risk 4.1: Continuing health care assessments – ongoing backlog and delays Mitigation: The backlog is now cleared and the service is under more control but weekly monitoring continues by the management team. Weekly CHC risk log review by the senior management team. The clinical assessment services are being repatriated in-house from April 2014. The recruitment of additional clinical staff to undertake reviews and the transfer to CAPS clinical application services of all CHC patients has commenced.

Risk 4.2: Quality assurance of care in care homes – process for monitoring contracts not yet finalised. Mitigation: Escalation to CSU leads, nurse director and team working with CSU to prioritise and identify the process and nurse directorate meeting with care quality commission (CQC) and dealing with any immediate risks. The quality reporting metrics have now been finalised and are being implemented. There is a plan in place for local quality visits to all nursing care homes across BHR CCGs in conjunction with the local authority and Barking and Dagenham visits have commenced. COB 5: Failure to deliver quality improvement in urgent and emergency care at BHRUT. Risk 5.1: Continued concerns with urgent and emergency care at BHRUT - risks to patient care and viability of trust. Mitigation: BHRUT is being held to account through weekly performance monitoring meetings reporting to our CCG governing body, quality and safety committee and CCG executive committee and the final improvement plan due by 31 March. With the care quality commission inspection complete the Trust is now in ‘special measures’ and actions include - Improvement director appointed and started in January 2014 - Support from the TDA special measures director - Trust is buddied with a foundation trust for peer support - The urgent care board is leading work to support improvement

5.0 De-escalated risks from the GBAF There are no risks de-escalated for this report.

6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capital costs arising from this report.

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

7.0 Equalities 7.1 There are no equalities considerations arising from this report. 8.0 Risk 8.1 This paper relates directly to risk. The key risk to making this process work well is a lack of

engagement and over-complication. This is being mitigated by good support from the corporate team, closely linking with the borough teams. This report also links to the following GB paper(s) being presented at this March meeting:

• Risk ref. 5.1: Item 6.1 – BHRUT update provides an update on the key risks and how they are being mitigated.

Attachments:

1. Governing body assurance framework 2. Governing body assurance framework summary

Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 17 March 2014

of 9 3.1.2_Apendix 1&2_Redbridge GBAF & Summary March 2014_v0.2

Appendix 1 – NHS Redbridge CCG Local objective 3: Continue to focus on the development and success of our new organisation – our members, governing body and staff

Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)

Controls Assurances I = internal

E = external

Current risk

rating

Gaps Proposed

actions

Target Risk – 1/4/14 Control Assurance

3.2 LM

Issue: Changes in NHS system regarding primary care and concerns from practices regarding responsibilities and engagement with NHS England (NHSE), and proposed delegation of responsibilities to CCGs for a number of unanticipated areas. Risk: financial and operational pressures on practices associated with the transition of GP contracts to NHSE will impact adversely on practice engagement in QIPP delivery The key risk is that we will fail to deliver our QIPP plan as a result of the issues. Delegated responsibilities that are unplanned for, and without budget/ resources will add to pressure on current budgets and workforce.

Like

lihoo

d (3

) x

Impa

ct (5

) = S

ever

e 15

1. CCG assurance meetings with

NHS England (NHS E) where a number of concerns have been raised.

2. Discussion at London CCGs

Chief Officer meetings.

3. NHSE attendance at our joint executive meetings (JET).

4. Day to day support to CCG

practices with signposting to NHSE (or to CCG) dependent on responsibility.

5. NHS E primary care lead attends

Business senior management team meeting.

6. Cluster/locality and practice

engagement on QIPP schemes.

7. Chair’s briefing at protected learning events (PLE).

For all controls: Minutes and feedback from all meetings. (E & I) 7. CCG Chair’s briefing at

protected learning events (I)

Like

lihoo

d (3

) x Im

pact

(4) =

Med

ium

12

1. Joint meeting with

NHS E Primary Care Lead at senior level with the Chief Operating Officers across BHR CCGs for common issues

2. Minutes

and feedback from meetings.

Meetings initiated with NHS E primary care commissioning lead (by Feb 14) but contact remains via teleconference and NHS E assurance meetings. Our newly appointed Programme Director for Primary care Development will formalise meetings by end of April 2014.

Like

lihoo

d (1

) x Im

pact

(3) =

Low

3


R

isk

Ref

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed actions


3.3 MS

Commissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk

Like

lihoo

d (3

) x

Impa

ct (5

) = S

ever

e (1

5)

1. We have issued instructions to the CSU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity.

2. Where there is no contract we will

develop an alternative validation process and will not pay the invoices until the process is developed.

Issued formal contract notices, challenges and claims letters on existing contracts

Formally written to non-contracted activity providers if cannot provide validation information we will not pay the invoices

3. Agreed a quarterly close down

process with main providers BHRUT and NELFT

4. Project commenced to achieve

accredited safe haven (ASH) status which will enable us to receive patient identifiable data

5. Agreed process for non contract

invoicing developed and has commenced.

6. Setting up a controlled environment

for finance.

1. A regular weekly report is being

developed with the CSU to report on the progress. (I)

2. The audit committee will be

updated on performance to only pay validated invoices. (I)

3. Letter to the Trust proposing

agreement as have reached an acceptable year end position with BHRUT (I).

CFO will review the outcome of the 1st quarter for effectiveness. (I)

4. Achieved accredited safe

haven (ASH) status in October 2013 (E)

5. New documentation for the agreed process to ensure compliance with the information requirements received (contractual and non-contractual). (E)

6. Paper that describes how the

controlled environment will operate for presentation to the April Audit committee. (I)

Like

lihoo

d (2

) x

Impa

ct (3

) = H

igh

(6)

7. Redesign of our existing contractual invoice validation process in line with the received new documentation

8. The same

controls utilised for BHRUT have been used for Barts Health

7. A regular

report will be produced for the audit and governance committee to monitor progress

8. Have not yet

reached an acceptable year end position with Barts Health.

1. Develop/redesign

contractual validation process to enable us to receive patient identifiable data by 28 February 2014. This action became delayed due to the requirement to set up a controlled environment and will now be complete by end of April 2014.

2. Challenge

activity via service performance review meetings

3. CFO discussions

with the director of finance for Barts Health

Like

lihoo

d (1

) x

Impa

ct (3

) = L

ow (3

)


Collaborative objective 4: Improve the quality of care from all the services we commission

Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed

actions


4.1 JH

A backlog of continuing health care (CHC) reviews and outstanding initial assessments, inherited from the PCT, does present a clinical and financial risk to the CCG.

Like

lihoo

d (4

) x

Impa

ct (4

) = S

ever

e 16

1. Escalation to the CCG

accountable officer and managing director of the CCU

2. Detailed action plan signed off

by the CCG.

Additional team to deal with the business as usual work (care brokerage) managed by the BHR CCGs

CHC assurance framework developed Fortnightly reporting presented to the BHR CCGs Joint management team meeting

3. Extra resource to ensure the

project plan is implemented effectively

4. Governance and escalation

framework in place

1. Minutes of the fortnightly CHC

executive meetings (I) 2. Plan presented to our joint

management team (JMT) and quality and safety committee (Q&SC) (I)

3. Minutes of our finance and

delivery committee (I) 4. Minutes of the quality and

safety committee (I) For all controls: • Bi-monthly report to the

governing body (I) • Monthly report on progress,

issues and risks to the BHR CCGs audit and governance committee (I)

• Weekly reports showing

movement and progress to reduce the back log to Nurse Director (I)

Like

lihoo

d (3

) x Im

pact

(4) =

Sev

ere

12

5. Broadcare data requires further validation which is in progress

6. Review of the

financial impact via our commissioning support unit (CSU).

5. Daily updates from

the programme manager to the CCG Nurse

CCG undertaking validation audits of Broadcare records and accuracy

6. Minutes of contract

monitoring meetings (I)

The recommends from the external review to be implemented by 31 March 2014

Like

lihoo

d (1

) x

Impa

ct (2

) = L

ow 2


R

isk

Ref

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed actions


4.2 JH

Issue: Quality Assurance process of care homes (related to process of quality monitoring of all providers) Risk: as the CCG has not inherited a robust system for assuring quality of all providers the risk is that there is not a culture of sound monitoring. Li

kelih

ood

(3)

x Im

pact

(5) =

Sev

ere

(15)

1. Quality assurance framework

for self assessment developed 2. 6 weekly meetings between the

nurse director and the CQC regional manager

Monthly meetings between the deputy nurse director and CQC inspectors

3. Implement quality assurance

performance framework 4. Action plan developed to quality

assure care homes 5. Strengthened collaboration with

the local authority

1. Feedback intelligence from

nurse director meetings (I)

Self assessment tool submitted to CSU (E)

CSU analysis and report to BHR CCGs quality and safety committee (I)

2. Cross referencing with CQC

reports (E)

Alignment with quality surveillance groups (E)

3. JMT and Q&SC (I) 4. Summary report of serious

incidents presented to Q&SC (I) 5. Safeguarding adults board (E)

Like

lihoo

d (1

) x

Impa

ct (3

) = M

ediu

m (3

) 6. Hold quality

review meeting with individual provider where shown to be a ‘red outlier’ by the KIPs/Dashboard.

6. Minutes of the

quality review meetings with providers (I)

Like

lihoo

d (1

) x

Impa

ct (

3) =

Low

(3)


Collaborative objective 5: Improve the performance of urgent care and emergency care, with a particular focus at BHRUT

Ris

k R

ef

Lead

D

irect

or

Risk Description

Initial Risk

Rating (June 13)


E = external

Current risk

rating

Gaps Proposed

actions

Target Risk – 1/4/14

Control Assurance

5.1 AS

Failure to deliver quality improvement in urgent and emergency care at BHRUT could: 1. Threaten the

long-term validity of the Trust

2. Put patients at risk, cause reputational damage and delay the implementation of acute reconfiguration programmes

3. BHRUT raised potential overnight closure of KGH to address safety and resource issues at Queens Hospital

Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

(16)

1. Agreed BHRUT

improvement plan with TDA/ NHSE monitoring of the plan via the weekly emergency care standards performance group (ECSPG)

2. Tri-partite Panel (NHSE /

TDA / Monitor) reviews progress each week

3. Contractual meetings –

SPR / CQRM – and levers used fully

4. Monthly Strategic review meetings with senior leadership for overarching assurance and escalation of risk

5. Urgent Care Board focused on six priorities for action, A&E recruitment, 7 days working, urgent care centres, joint discharge, primary care support and frail elders

6. Winter plan agreed with additional resource invested on priority areas

7. Daily Dashboard reviewed by CCG during winter

1. Minutes of the weekly

ECSPG (E)

2. Minutes of Tri-Partite Panel escalation meetings (E)

3. Minutes of contractual

meetings – SPR / CQRM (I)

4. Minutes of strategic

review meeting (I) 5. Minutes of the monthly

urgent care board (I) 6. Daily and Weekly

performance reports (I) 7. Update to March GB on

progress (I)

Like

lihoo

d (5

) x

Impa

ct (

4) =

Sev

ere

(20)

1. Special Measures governance, arrangements and support to be finalised by end of March 2014

1. Improvement Plan, associated governance and performance trajectory

Continued liaison with NHS England and TDA to agree arrangements and leading role for CCG Turnaround Director appointed with engagement with partners and stakeholders on the draft plan to allow end of March sign-off

Like

lihoo

d (4

) x

Impa

ct (

3) =

Hig

h (1

2)


NB: Item 6.1 – BHRUT update relates specifically to this risk and provides an update on the key risks and how they are being mitigated. De-escalated risk: None Key: Lead Directors MS – Martin Sheldon, Chief finance officer SM – Sharon Morrow, chief operating officer AS – Alan Steward, chief operating officer JH – Jacqui Himbury, Nurse Director


Appendix 2

NHS Redbridge CCG Governing Body Assurance Framework - Overall Summary

Lead

GBAF Ref. Risk Description

Initial Risk Rating

(June 2013)

Current risk Rating End Year Forecast Target risk

level September 2013

January 2014

March 2014 This time Last Time

MS

3.1 (4)

De-escalated in January: Central allocation funding issue / specialised commissioning unexplained changes to the LSG calculations resulting in potential additional financial pressure to CCG

Possible (3) x Severe (5) = Extreme (15)

Possible (3) x Severe (5) = High (15)

Rare (1) x Moderate (3) = Low (3)




LM 3.2 (21)

Financial and operational pressures on practices associated with the transition of GP contracts to NHSE will impact adversely on practice engagement in QIPP delivery. The key risk is that we will fail to deliver our QIPP plan as a result of the issues.



Possible (3) x Minor (2) = Medium (6)

Possible (3) x Major (4) = High (12)




MS 3.3 (22)



Likely (4) x Severe (5) = Extreme (20

Possible (3) x Moderate (3) = High (9)

Possible (3) x Minor (2) = Medium (6)




JH 4.1 (2)

A backlog of continuing health care reviews and outstanding initial assessments, inherited from the PCT, does present a clinical and financial risk to the CCG.

Likely (4) x Major (4) = Severe (16)




Unlikely (2) x Minor (2)= Medium (4)


Rare (1) x Minor (2) = Low (2)

JH 4.2 (10)

Assurance process of care homes (related to process of quality monitoring of all providers) as the CCG has not inherited a robust system for assuring quality of all providers the risk is that there is not a culture of sound monitoring.








AS 5.1 (13)

Failure to deliver quality improvement in urgent and emergency care at BHRUT



Likely (4) x Severe (5) = Extreme (20)

Likely (4) x Severe (5) = Extreme (20)




NB: risk register reference is denoted in brackets ( )

Risk Summary Number

Total risks last report 5 New risks added 0


Risks de-escalated this report 0 Total GBAF risk this report 5


How to interpret the CCG governing body assurance framework (GBAF):

Risk refThis is a risk identifier attributed to the risk by the CCG risk lead

Lead directorThis is the executive lead with responsibility for:- managing the risks to the corporate objectives and- liaising with the risk lead to ensure the GBAF is up to dateReporting to the CCG governing body or other committee on progress

Risk ratings:The risk rating is derived from conversation between the lead director (or nominated deputy) and the risk lead. The risk score is calculated using the risk grading matrix. There are three types of risk rating used in the CCG GBAF.- initial risk rating: this grades the risk as if there were no remedial measures in place. This is called the ‘inherent risk’. - current risk rating: this grades the risk taking into account the remedial measures. The remedial measures should aim to 1, reduce the likelihood of the risk materialising, 2, reduce the impact of the risk if it does happen and 3, reduce both.- target risk rating: this is the level of risk that the CCG is prepared to accept and the level of risk that must be aimed for.

Risk descriptionFor each risk note down:Who can be harmed and how can they be harmed if the risk materialises.Areas to consider are: harm/injury, objectives, claims or litigation, service disruption, staffing and competence, morale, financial, external assessment and adverse media interest

ControlsWhat is being done to reduce the likelihood and severity of the risk.One specific risk may be mitigated by a number of controls

AssuranceAssurances are inevitably ‘bits of paper’ that act as evidence the controls are in place. Examples include:Job descriptions /organisation chartsRegular reportsContracts / service level agreementsPolicies and proceduresMinutes / agendas / terms of reference

Gaps in controlsWhat more can be done to control the risk and what controls could be improvedGaps in assuranceWhat associated documentation will demonstrate that the controls are in place?

Proposed actionsWhere gaps have been identified, list the actions required to put them into place. Ensure they have a named lead and target date

Risk Ref

Lead Director

Risk Description

Initial Risk

Rating (June 13)

Controls Assurances Current

risk rating

Gaps Proposed

actions

Target Risk – 1/4/1

4

Control Assurance

3.3 MS


15 • Our current control is we have issued instructions to the CSU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity.

• Where there is no contract we will develop an alternative validation process. Until the process is developed we will not pay the invoices.

• A regular weekly report is being developed with the CSU to report on the progress.

• The audit committee will be updated on performance to only pay validated invoices.

15 • A detailed process for non contract invoicing requires urgent development.

• A regular report will be produced for the audit and governance committee

• Develop new validation process

3

1

To: NHS Redbridge CCG governing body From: Louise Mitchell, Chief Operating Officer Date: 27th March 2014 Subject: Update on the Redbridge CCG Operating Plan submission 2014/15 Executive summary

The NHS planning guidance ‘Everyone Counts: Planning for patients 2014/15 to 2018/19’ was issued on 19th December 2013 and requires CCGs to submit a balanced financial plan, a two-year Operating Plan (at CCG Level) and a five-year Strategic Plan (BHR system wide). The deadline for a draft Operating Plan was 14th February, with the final being required by 4th April. The Strategic Plan is not due in draft until 4th April and the final version by 20th June. The draft Operating Plan was submitted on time by Redbridge CCG to NHS England on Friday 14th February 2014. The drafts comprised a number of planning, finance, activity and performance templates that were presented to and approved by the last CCG governing body meeting in January . The final submission of the Operating Plan is due on Friday 4th April 2014. Work is being undertaken towards finalising the templates that are required, as set out in this report. Due to tight timescales and meeting dates, final draft Operating Plan cannot be taken to the March governing body meeting in time. Therefore, subject to the formal delegation by the Governing Body today, final approval and sign off will be made by the Accountable Officer in consultation with the CCG Chair. Recommendations The governing body is asked to: • Note the update provided by this report • Agree to delegate authority to the Accountable Officer (in consultation with the CCG Chair) for sign

off of the Operating Plan prior to 4th April submission deadline

1.0 Purpose of the report 1.1 The purpose of this report is to update the governing body prior to final submission of the

Operating Plan to NHS England by Redbridge CCG, and to seek agreement to delegate authority to the Accountable Officer for final sign off of plans.

2.0 Introduction 2.1 Each year commissioners are required to set out their strategic and operational plans for the

forthcoming years in line with financial allocations and central planning guidance. The NHS planning guidance ‘Everyone Counts: Planning for patients 2014/15 to 2018/19’ was issued on 19th December 2013. This identified the requirements for a balanced financial plan, a two-year Operating Plan (at CCG Level) and a five-year Strategic Plan (BHR system wide).

2.2 The draft Operating Plan submission deadline was 14th February and included the following documents set out below. The drafts were taken to and approved by the CCG governing body and Redbridge Health and Wellbeing Board in January and February respectively. • Operating Plan planning template

This includes self-certification questions about the NHS Constitution, provider CIPS and HCAIs; baselines and targets for our outcome ambitions; quality premium measures; and A&E activity. Separate explanatory notes were also included about how trajectories have been set and narrative against self-certifications.

• Operating Plan Financial Plan 2014/15-2018/19

This includes planning assumptions, QIPP, contracts, risk, investment, revenue, cash, capital and Better Care Fund expenditure. A surplus / deficit reconciliation was also provided.

• Provider / commissioner planning template This sets out forecast activity in each month of 2014/15 and 2015/16 against a number of measures, including elective admissions, non-elective, outpatient attendances and referrals.

• Better Care Fund (BCF) Finance template

This contains a summary of the funding that the CCG and local authority will each put into the BCF and what schemes this will fund in year 1 and year 2. It also sets out the national and local outcomes metrics (baselines and targets).

• Covering note

This highlights any areas that were incomplete at draft submission that will be addressed prior to final submission on 4th April. These include:

o From the Operating Plan: Number of C. Difficile infections (we are awaiting national guidance on the baseline for this)

o From the BCF: Local measure on carers (an appropriate metric is being developed with the local authority to capture this important workstream)

o From the BCF: User experience metric (we are awaiting announcement of the national metric for this being developed by NHS England)

2.3 The five-year Strategic Plan is due for draft submission on 4th April and final submission on 20th

June. There is a separate report on the agenda. 3.0 Submission of the Operating Plan 3.1 The draft Operating Plan was submitted by Redbridge CCG on time to NHS England on Friday

14th February 2014.

3.2 Feedback on the draft was received from NHS England on Friday 28th February 2014. To summarise the feedback, NHS England advised:

“Our [NHS England’s] analysis of activity trajectories raised some concerns in regards to the work being done to manage demand. For each of the activity measures we need to understand the current growth, assumptions over the next two years and the actions being taken to manage growth. In relation to the self certification, we will discuss red and amber ratings to understand the extent to which the operational plan will address key planning requirements over the two years”

3.3 Some more detailed financial queries were also raised. In response to this, section 4 sets out

the next steps for how the CCG and local authority will finalise a robust submission to NHS England within the required timescales of 4th April.

4.0 Next steps towards final submission 4.1 The final submission of the Operating Plan is due on Friday 4 April 2014. Since submitting the

draft and receiving the feedback, the next steps are already in progress and include:

• Finalising our QIPP Plan for 2014/15 and ensuring the finance and activity templates reflect how we will achieve the required level of savings

• Responding to the queries made by NHS England in their feedback of 28th February

• Finalising detail of the performance metrics and ensuring they are robust

• Confirming the self-certification responses and ensuring these give enough information to

reviewers

4.2 The CCG governing body is asked to agree that, once the draft templates covering the narrative of plans, financial benefits and investments, self-certifications, performance metrics and covering note are completed, the Accountable Officer (in consultation with the CCG Chair) has delegated authority to approve these for submission on 4 April.

5.0 Resources/investment 5.1 There are no resource implications arising from this report.


7.0 Risk 7.1 The risks associated with submission of the final Operating Plan to NHS England by 4th April

2014 are low.

Author: Louise Mitchell COO NHS Redbridge CCG Date: 17th March 2014 Additional template submissions The Operating Plan submissions were shared at the last Governing Body meeting in DRAFT format. Amended versions for submission on 4th April are being developed at the time of writing and are subject to formal approval of the AO in consultation with the Chair given approval of the recommendation at today’s governing Body. Attachments are included with this paper are the current version of templates submitted in DRAFT on 14th February.

Response collection: Self Certification questions/Quality Premium yes/no questions, Operating Plan submission 2014/15

Please note: the information below is provided solely to stimulate discussion and is not to be considered a recommendation or final position for submission.

Section/Question Anticipated answer (if

known)

Justification for anticipated answer/ previous year narrative

(where available) Potential 2014/15 narrative

Self certification question i: Do your plans ensure that the performance standards in the NHS Constitution will be delivered throughout 2014/15 and 2015/16?

No The anticipated answer is based on BHRUT’s current and consistent failing of A&E and RTT targets, which could be considered a key contributor to Commissioners meeting the required performance standards.

Whilst there is a degree of confidence in the delivery of majority of the other indicators in the NHS Constitution, there remain significant challenges in achieving A&E and RTT performance standards. BHRUT Following a CQC visit in October 2013, it was announced in December 2013 that BHRUT would be placed in Special Measures. As part of this process there has been an increase in the level of external focus on BHRUT A&E, and a number of managerial changes within the Trust to try and address the concerns raised. Contract negotiations for 2014/15 have now commenced. As part of these discussions, the CCGs and CSU are developing both CQUIN and KPIs that cover A&E and UCC performance. Performance in relation to the RTT 18 Week pathways is currently non-compliant with the national standards. BHR CCGs are working with the trusts on how this can be managed. To support this the CCGs have asked BHRUT to produce enhanced monitoring processes to entail weekly monitoring of the waiting lists as well as more detailed information on the composition of patients on the waiting lists, including the number of patients who have chosen to wait beyond 18 weeks. This has been requested at specialty level. Barts Health Care The Trust year to date position on A&E All Types is 94.82%. Given the failure of meeting the A&E standard, Barts Health has been required to complete Exception Reports explaining how the Trust is going to improve performance, and attend Tripartite Escalation Meetings (along with the Commissioners and CSU) to explain the reasons for poor performance and

mitigating actions. Performance in relation to the TT 18 Week pathways is currently non-compliant with the national standards. Barts Health and the commissioning CCGs have developed an improvement plan for RTT that will clear the admitted backlog by the end of March, in all specialties (with the exception of Trauma & Orthopaedics) and clearance of the non-admitted backlog. A trajectory for RTT is being developed and will be finalised when RTT data validation has been completed.

Self certification question ii: Have you assured provider CIPs are deliverable without impacting on the quality and safety of patient care from 2014/15 until 2018/9?

No Whilst CCGs have an agreed process for assurance of provider CIPs, we must recognise that BHRUT have not (as at 24 Jan 2014) confirmed 2014/15 CIPs to Commissioners.

No; providers have not submitted CIPs for 2014/15 through to 2018/19. During 2013/14, CCGs established a process for gaining assurance regarding the Trust’s processes for developing and monitoring the quality impact of CIPs. For 2014/15, BHR CCGs will be looking to assure BHRUT, NELFT and Barts Health CIPs. We will be working with providers to ensure submission and sign off of CIPs by 31/3/2014.

Self certification question iii: Do you plan to manage HCAIs so that your local population have no cases of MRSA in 2014/15 and 2015/16?

Yes It is assumed that CCGs must agree that this will be managed so no cases occur. However, CCGs are asked to recognise that where registered patients are treated out of area (and/or as non contracted activity) that the same level of control over HCAI may not exist with out of area Providers.

For provider attributed cases of MRSA, we can confirm that plans are in place. During 2013/14, CCGs established a process for monitoring arrangements for BHRUT and NELFT. Monitoring arrangements included:

• Trusts notifying CCGs in real time when they identify a new Trust attributed MRSA;

• Trusts have provided assurance to CCGs via CQRMs that they undertake a root cause analysis for all Trust attributed cases; CCGs have also gained assurance via the nationally designed PIR process.

• Trusts report numbers of cases via submission of monthly dashboards to commissioners.

• Where Trusts exceed annual zero tolerance, BHR CCGs have established a process for implementing the national contract by issuing contract query letters; as part of this process, CCGs meet with the Trust within 10 working days of issuing the letter and

agree remedial action; agreed remedial action is reviewed and monitored by the CQRM.

During Q4 2013/14, BHR CCGs agreed with BHRUT & NELFT to set up a monthly joint meeting to discuss the infection prevention and control agenda. For CCG attributed cases of MRSA, we can confirm that plans are in place. During 2013/14, CCGs established a process for receiving and acting on notification of CCG attributed cases of MRSA. As part of this process, BHR CCGs undertake PIRs and update the DCS as per national requirements. As part of the monthly reporting, the CSU includes in the monthly Quality & Performance report information and commentary on cases of MRSA.

Quality premium question iv: Do you plan to meet the nationally set objective for the Friends and Family Test in 2014/15 and 2015/16?

Yes Information from CSU Quality Team to inform a response will follow.

We can confirm that plans are in place. CCGs are implementing the national FFT CQUIN; this will include an incentive to improve scores. During 2013/14, CCGs monitored compliance with the CQUIN at the CQRM with Trust. Compliance was also monitored via the CQUIN monitoring arrangements. As part of the monitoring, providers are asked to report on progress with increasing response rates and how they are acting on the feedback; the CQRM forward planner agreed with the Trust ensures there are regular discussions regarding how the Trust is using the feedback. The model for monitoring CQUIN which was established during 2013/14 will be used to monitor the 2014/15/16 national CQUIN. As part of the monthly reporting, the CSU includes in the monthly Quality & Performance report information and commentary FFT.

Quality premium question iv: Do you plan to meet the nationally set objective from 2014/15 until 2018/19 for improving the reporting of medication errors?

Yes BHR CCGs are committed to increasing the level of reporting of medication errors with a focus on BHRUT and NELFT; the former currently reporting a percentage of medication errors (as a proportion of all reported errors) commensurate with other large acute trusts and the latter currently reporting 4.4% of incidents as medication incidents, compared to 8.3% as an average for all other 55 Trusts in their NRLS Cluster. We are aiming to achieve increased levels of reporting by: 1) Alerting Lead Commissioners to the tools available on the NRLS website and requiring them to use the information supplied to determine where trusts are placed in relation to their peers and specialties. 2) Working with our specified providers to identify service areas where the level of reporting is below the average for the organisation itself and agreeing appropriate levels of improvement; recognising that NRLS can be used as the measurement tool for showing an increase in reporting of medication incidents (recognising the lag in data availability via this portal). 3) Discussing with our specified providers the possibility of using their own data for increased reporting levels (i.e. from risk management systems or internal recording systems).

Quality premium question iv: Where there are requirement for Quality Premium measures and/or planned levels of improvement to b agreed with the relevant Health and Wellbeing Board and NHS England Area Team, do you have their agreement to each of these?

Yes It is assumed that CCGs will confirm choices of measures/levels of improvement with HWBs (or members thereof) prior to submission of the Operating Plan. It is recognised that not all HWBs will meet between now (24th Jan) and the first submission date (14th Feb) but that HWBs will be given sight of the submission made at the next meeting after the 14th Feb submission.

Redbridge Operating Plan/BCF submission baseline/trajectory summary

Item Baseline figure Trajectory and rationale Outcomes ambitions 1 (E.A.1): Additional years of life from conditions amenable to healthcare (PYLL per 100,000)

2132.8 (rate) 3.3% reduction per year. This percentage challenges the CCG to maintain a reduction halfway between that required to reach the London average (1.3%) and the average rate of improvement seen by the CCG over the last four years (5.3%).

Outcomes ambitions 2 (E.A.2): Improving health related quality of life for people with LTCs (EQ-5D)

74.03 (rate) 1% increase over the five year period. This percentage challenges the CCG to maintain a reduction to bring them in line with ONS cluster peers.

Outcomes ambitions 3 (E.A.4): Reduction in emergency admissions (composite indicator)

2,067.5 (rate) CCG will aim to maintain it’s current (baseline) score for 14/15, then aim for a rate of improvement to bring it back to the current London average by 2018/19. This equals a 45 point reduction per annum from year 2 to year 5 (2% pa).

Outcomes ambitions 5 (E.A.5 ): Improving patient experience (hospital based care)

187.8 (rate) A 23.8 point reduction over the next five years (phased 3.8, 4, 4, 6, 6) to bring the CCG’s score to the CfV cluster average score.

Outcomes ambitions 6 (E.A.7): Improving patient experience (General Practice and GP OOHs)

11.6 (rate) A 2.3 point reduction over the next five years (phased in the same way as the hospital patient experience; so 0.37, 0.38, 0.38, 0.57, 0.57) to bring the CCG’s score to the CfV cluster average score.

Quality Premium measure i (E.A.1): Potential years of life lost from conditions amenable to healthcare (PYLL per 100,000)

2,112.6 (as above) forecast forward one year as per rationale (also

above)

N/A – single year figure only (which gets automatically drawn through from the previous PYLL ambition).

Quality Premium measure ii (E.A.4): Reduction in emergency admissions (composite indicator)

2,067.5 (as above) forecast forward one year as per rationale (also

above) and split into quarters

Analytics will provide a breakdown of NEL activity for the last four full quarters so the number can be broken down according to historical proportions (taking into account seasonality).

Quality Premium measure iii (E.A.3): IAPT - access rate

29099 people with depression or

anxiety with #’s

In 15/16 they project a 15% proportion; treating 4365 people with depression and anxiety ( raising from 771 in Qrtr 1 of 14/15 to a total of 4365 having received therapy by March 2015).

Quality Premium local priorities:

C2.2 A greater proportion of people aged 18 and over suffering from a long-term condition feeling supported to manage their condition

The CCG recognise that it is an area that is a reasonable margin away from the London and England averages with a steady rate of improvement which has the greatest likelihood of addressing the condition and links to the strategy around better management of patients with LTCs..

Other measures i (E.A.S.5): Number of C.Diff Infections in 2014/15

BHR POD Quality Team to set baseline and

trajectory

Other measures ii (E.A.S.1): Dementia diagnosis rate

55% A 14/15 diagnosis rate achieved from 1486 diagnosed by a prevalence of 2702. 15/16 achieves this from 1516 people diagnosed by a prevalence of 2757.

Other measures iii (E.A.S.2): IAPT recovery rate

50% 12.5% by baseline prevalence of 29099 is 3637. 50% of this is 1818 which is the anticipated recovery rate. For 15/16 beginning at 15% by the same prevalence rate should give 4364 which 50% is 2182..

BCF metric 3: Delayed transfers of care from hospital per 100,000 population (average per month)

186 (rate) – the average number of

DTOC days per 100,000 of

population per month in 12/13

A rate reduction of 18 points per annum for the two year period. This is below the statistically significant value but considers that the monthly DTOC day rate has not consistently decreased over the last 12 months.

BCF metric 4: Avoidable emergency admissions (composite measure)

162.1 (rate) – the average number of

avoidable emergency

admissions per 100,000 of

population per month in 12/13

A rate reduction of 2.3 points per annum for the two year period. This is below the statistically significant value but considers that the monthly EM admission rate has not consistently decreased over the last 12 months.

BCF metric 5: Patient / service user experience (for local measure)

CCG are choosing to use national measure (currently under development) therefore no

baseline/trajectory needs to be given.

BCF metric 6: Local measure

CCG still to choose

To: Meeting of the Redbridge CCG Governing Body

From: Louise Mitchell, Chief Operating Officer, NHS Redbridge CCG

Date: 27 March 2014

Subject: Draft 5 Year Strategic Plan

Executive summary

The purpose of this report is to update members of the Governing Body on:

• Development of the CCGs 5 Year Strategic Plan for the BHR system for comment

• Next steps for the planning process prior to submission of a draft plan to NHS England on the 4 April 2014.

Recommendations

The Governing Body is asked to:

• Comment on the draft CCGs 5 year Strategic Plan

• Note the next steps in the planning process

1.0 Purpose of the Report

The purpose of this report is to present the latest draft of the draft 5 Year Strategic Plan for BHR systems and provide the opportunity to comment on the plan prior to submission of the first draft to NHS England on 4 April 2014.

2.0 Background/Introduction

Everyone Counts: Planning for Patients 2014/15 – 2018/19 was released on 20 December 2013. It builds on the 2013/14 planning guidance and sets out a framework within which commissioners need to work with partners in local government and providers to develop strong, robust and ambitious 5 year plans to secure sustainable high quality care for all. This report and draft strategic plan builds on the planning process described in the paper presented to the last Governing Body meeting in January.

The Integrated Care Steering Group has been leading the development of the 5 year Strategic Planning process, as mandated by the Integrated Care Coalition.

3.0 The BHR Strategic Plan

The five year strategic plan comprises a high level system narrative ‘plan on a page’ and a more comprehensive ‘key lines of enquiry’ section which includes the system vision, enquiries around current position, improving quality outcomes, sustainability and improvement interventions.

3.1 The draft 5 Year Strategic Plan has been developed using the CCGs Operating Plan and the Better Care Fund plans to provide the foundations of the 5 year Strategic Plan. In addition to this, the development of the strategic plan has been discussed at the following forums:

• 10 February 2014: The Integrated Care Coalition workshop

• 13 February 2014: CCGs Governing Bodies away day

• 19 February 2014: Integrated Care Steering Group workshop

Outputs from the ‘Call to Action’ themes have also been considered and incorporated into development of the plan.

3.2 Next steps

The next steps for the draft 5 Year Strategic Plan is as follows:

• The Integrated Care Steering Group meeting on the 19 March will review and update the plan taking into account comments from the stakeholders.

• Chief Operating Officer’s are currently reviewing arrangements for the Health and Wellbeing Board to review and will update at the Governing Body meeting.

• Integrated Care Coalition to receive at its meeting on the 31 March for endorsement prior to submission of the draft on the 4 April.

• The final plan needs to be submitted on the 20 June 2014.

4.0 Resources/investment

There are no additional resource implications/revenue or capitals costs arising from this report.

5.0 Equalities

A fundamental element of the Strategic Plan is to reduce health inequalities and improve outcomes within and between communities over the next 5 years.

6.0 Risk

There are no risk implications arising from this report at this stage.

Attachments:

1. Draft Strategic Plan

2. Everyone Counts: Planning for Patients 2014/15 – 2018/19 can be accessed via the following link http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

Author: Emily Plane, Project Manager, Strategic Delivery

Date: 5 March 2014

Attachment 1: Draft Strategic Plan

Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups Strategic Plan draft submission Draft as at 28 February 2014

BHR strategic headline plan on a page

The BHR health economy is comprised of partners from Barking and Dagenham CCG, London borough of Barking and Dagenham, Havering CCG, London borough of Havering, Redbridge CCG, London borough of Redbridge, Barking, Havering and Redbridge University Hospitals Trust and North East London Foundation Trust; who have come together to agree, refine and implement the following vision: Improving health outcomes for local people through best value health care in partnership with the community.

System Objective 1 To reduce the number of years of life lost by 23%

Delivered through prevention and health promotion Programmes of work informed by local JSNAs and London wide preventative agenda. Target areas: obesity/dementia/reduce inequalities/diabetes/cardiovascular disease/cancer/smoking cessation/breastfeeding/alcohol and substance misuse

Overseen through the following governance arrangements

� Health and Wellbeing Boards (HWBB) oversee the process for strategic planning in each borough

� Integrated Care Coalition (ICC): an advisory group to HWBBs - bringing senior leaders together to build a sustainable health and social care system

� The coalition has two subgroups: o Integrated care steering group: development and

delivery of strategic plan o Urgent care board: improvement plan for urgent

care � All work streams have identified leads

System Objective 2 To improve health related quality of life for those with

1+ LTCs by 4%

Delivered through primary care improvement plan Providing new ways to access primary care and finding new ways to provide innovative services designed around the needs of the patient to reduce acute admission and A&E attendance and increase positive patient experience.

System Objective 3 To reduce avoidable time in hospital through integrated

care by 13%

Delivered through the integrated care strategy Seamless and integrated health and social care for local people. Continued implementation of local strategy putting the person at the centre of care provided by integrated teams

System Objective 4 To increase the percentage

of older people living independently following

discharge

Delivered through the acute re-configuration programme Reconfiguring local A&E and maternity services in order to improve the quality of care for local people; developing KGH as a centre of excellence for children’s and women's services and new and effective 24/7 Urgent Care Centres at Queens Hospital and King George Hospital (facilitated through the procurement of a high quality end to end urgent care service running through 2014/15); better co-ordination of services and pathways through collocation of services’ leading to enhanced experience for children and families.

Measured using the following success criteria

� All NHS organisations within the health economy report a financial surplus in 18/19 (under review)

� Local Authorities manage funding pressures � Delivery of the system objectives � No provider under enhanced regulatory scrutiny

due to performance concerns � Shared care records for all patients

System Objective 5 To reduce the percentage of

people reporting a poor experience of inpatient care

by12%

Delivered through planned care programme Building on the Health for North East London programme for planned care which will see an improvement in the clinical outcomes, patient satisfaction and a reduction in cancellations of scheduled elective care. Other developments include productivity improvements for MSK and ophthalmology pathways, service redesign for the diabetic pathway and re-procurement of the Independent Sector Treatment Centre.

System Objective 6 To reduce the percentage of

people reporting a poor experience of primary care

by 15%

Delivered through specialised commissioned services Commissioning to consistently deliver best outcomes and experience for patients, working with local stakeholders to develop integrated services and align priorities High level risks to be mitigated

� BHRUT quality and performance issues � Achieving financial targets � Building sustainable services and capacity in the

right place with scarce resources (financial and workforce including clinical leadership)

� Balancing increased patient expectation with improved outcomes at a time of less resource

Delivered through mental health service improvement plan Strategic Commissioning Framework for Mental Health being developed and will include completion of full roll-out of the access to psychological therapies programme by 2014/15 with the aim that at least 15% of adults with relevant disorders will have timely access to services

System Objective 7 To reduce hospital avoidable

deaths

Delivered through childrens services improvement plan Implementation of an Integrated Single Assessment process. Develop assessment process for children needing an EHC plan, Local Offer agreement to be confirmed and put children on EHC plans with cessation of ‘statement system’

Section Two | Key lines of enquiry (KLOE)

Segment Key Line of Enquiry Organisational Response Supported by

Submission details

System vision

Which organisation(s) are completing this submission?

The organisations completing this submission comprise of:

� Barking and Dagenham Clinical Commissioning Group

� Havering Clinical Commissioning Group

� Redbridge Clinical Commissioning Group

� London Borough Barking and Dagenham

� London Borough Havering

� London Borough Redbridge

� North East London Foundation Trust

� Barking Havering and Redbridge University Hospital Trust

The senior leaders from the above organisations have committed to work together as the Integrated Care Coalition to support the three Clinical Commissioning Groups (CCGs) and the three Local Authorities in commissioning integrated care and ensuring a sustainable health and social care system.

The Integrated Care Coalition (ICC) oversees the development of the 5 year strategic plan but has delegated formal authority to the Integrated Care Steering Group (ISCG) to co-ordinate on its behalf the production of the 5 year strategic plan.

ToR Integrated Care Coalition. Yellow font denotes specific reference to strategic planning

Adobe Acrobat Document

ToR Integrated Care Steering Group:


In case of enquiry, please provide a contact name and contact details

Ramesh Rajah

BHR CCGs, Programme Management Office

Tel: 0208 926 5327

Email: [email protected]

Jane Gateley

BHR CCGs, Director of Strategic Delivery

Tel: 0208 926 5136


Emily Plane

BHR CCGs, Project Manager – Strategic Delivery

Tel: 0208 822 3052


What is the vision for the system in five years’ time?

The vision for the BHR health economy is improving health outcomes for local people through best value health care in partnership with the community.

In 5 years time the BHRUT economy aims to improve health outcomes for local people by:

� reducing the number of years of life lost by 23%

� improving health related quality of life for those with 1+ LTCs by 4%

� reducing avoidable time in hospital through integrated care by 13%

� increasing the percentage of older people living independently following discharge (rate to be confirmed)

� reducing the percentage of people reporting a poor experience of inpatient care by12%

� reducing the percentage of people reporting a poor experience of primary care by 15%

� reducing the number of hospital avoidable deaths (rate to be confirmed)

In 5 years time patients will have better experiences of inpatient and primary care, will spend less avoidable time in hospital, will have a greater chance of living independently following discharge from hospital and will experience improved health related quality of life for those with one or more Long Term conditions.

Services will work together more closely, functioning as a more integrated

DRAFT BHR Plan on a Page.pdf

Borough teams will be reviewing trajectories and may be updated for the next submissions.

system delivering high quality health and social care to patients closer to home.

How does the vision include the six characteristics of a high quality and sustainable system and transformational service models highlighted in the guidance? Specifically:

1. Ensuring that citizens will be fully included in all aspects of service design and change, and that patients will be fully empowered in their own care

2. Wider primary care, provided at scale

3. A modern model of integrated care

4. Access to the highest quality urgent and emergency care

5. A step-change in the productivity of elective care

6. Specialised services concentrated in centres of excellence (as relevant to the

The vision for the BHR health economy characterises the six high quality and sustainable system and transformational service models through:

1. The responses from citizens to the local Call to Action events held in response to the NHSE challenge to ensure that future development of services is framed around the ‘I’ statements to ensure that what the patient wants is at the heart of service development going forward . Local citizens specifically stated that they wanted:

� better access to primary care

� partnership working with social care/integrated care

� improved hospital performance

� involvement of voluntary sector

� more support for carers

� improved patient engagement/communication

In addition, citizens have also contributed in the development of the following areas

� on-going patient experience evaluation for integrated care and community service developments.

� patient involvement is the design and development of the acute reconfiguration developments to ensure new services delivers improved performance, better outcomes and patient experience.

The following areas have been identified to support the prevention and health promotion programme:

� obesity

� dementia

� reduction in health inequalities

� diabetes

� cardiovascular disease

Details provided within the activity and financial templates which will be triangulated.

locality) � cancer

� smoking cessation

� breastfeeding

� alcohol and substance misuse

2. Providing new ways to access primary care and finding new ways to provide innovative services designed around the needs of the patient to reduce acute admission and A&E attendance and increase positive patient experience. These include:

� weekend access

� core hours plus

� 6-10pm appointments

� triage service

� primary care provider support

� dedicated registered list

� specialist expertise

� implementation of unified point of access

3. Implementation of the BHR Integrated Care Strategy designed to support and care for people in their homes or closer to home, shifting activity from acute to community (supporting acute reconfiguration plans), and in particular to locality settings. The strategy seeks to transform the relationship with individuals by placing them at the centre of delivery, driving improvements to the quality of experience and outcomes. In 5 years, Community services will have been remodelled (physical, mental and social) to support clusters of GPs (covering a population of up to 70,000 – check number) to enable more proactive management of the population. The focus will be on those with LTCs, high service users, and those vulnerable to decline.

4. Acute Reconfiguration programme building on Health for North East London work to reconfigure local A&E and maternity services in order to improve the care for the local people. This will be delivered by the procurement of a high quality end to end urgent care service that meets or exceeds the London Quality Standards. An element of this procurement will include a new and

effective 24/7 Urgent Care Centres at Queens Hospital and King George Hospital.

5. Delivered by building on the Health for North East London programme for plan care which should see an improvement in the clinical outcomes, patient satisfaction and a reduction in cancellations of scheduled elective care. Other developments include productivity improvements for MSK and ophthalmology pathways, service redesign for the diabetic pathway and a re-procurement of the Independent Sector Treatment Centre.

6. Specialised services narrative to be completed following discussion with Sue Sawyer.

How does the five year vision address the following aims:

a) Delivering a sustainable NHS for future generations?

b) Improving health outcomes in alignment with the seven ambitions

c) Reducing health inequalities?

A) From a resources perspective, what will the position be in five years’ time? Is this position risk assessed?

Two year financial projections on all boroughs have been completed and the five year plans are currently being finalised. All plans leading up to 2018/19 will be designed to deliver a surplus. The plans are currently being risk assessed to ensure sustainability.

B) The schemes / projects identified in the BCF / Operating Plan are consistent with those in the BHR system wide Integrated Care strategy. The schemes are linked to the 6 characteristics outlined on the plan on the page and mapped directly to the 7 ambition areas.

C) Each borough within the BHR economy has reviewed their baseline position for the seven ambitions targets and has planned five year reductions to align performance to equitable levels across the patch, as well as (where possible), closer to, or performing better against the national average. This is reducing health inequalities within the BHR system, which will make a significant change to the lives of patients living in the boroughs.

The supporting evidence to the right illustrates this shift towards equitable performance across the BHR economy.

BCF Schemes have been mapped to 7 outcome measures

BHR 5 year target projections.pdf

Who has signed up to the strategic vision? How have the health and wellbeing boards

The Integrated Care Coalition has endorsed the Strategic Vision.

The Integrated Care Coalition (including members of Health and Wellbeing Boards) were involved in development of the Strategic Plan, reviewing the draft

been involved in developing and signing off the plan?

plan 10 January 2014 and holding an Integrated Care Coalition workshop on 10 February where members reviewed progress and endorsed the vision.

A BHR CCGs Governing Body Away Day took place on 13 February 2014 where members reviewed the plan on a page which was then updated incorporating feedback.

The draft Operating and BCF plans submitted on the 14 February were reviewed and signed off by the Health and Wellbeing Board in each Borough on the following dates:

� Barking and Dagenham HWBB reviewed and approved on the 11 February 2014. The development of the BCF was overseen by the H&WB Integrated Care sub-group which has membership across health and social care as well as from key providers.

� Havering submission was agreed by the Havering Wellbeing Board at its formal meeting on Wednesday 12 February 2014. It was then subsequently the subject of an Executive Decision by Councillor Steven Kelly, Leader of the Council, Chair of the Health and Wellbeing Board and Portfolio Holder for Individuals on the 13th February 2014.

� Redbridge HWBB meeting – the draft plans were submitted on the 14 February subject to the HWBB review on the 17 February. The HWBB has now taken place and the draft plans were reviewed and agreed.

How does your plan for the Better Care Fund align/fit with your 5 year strategic vision?

Integrated Care Strategy initiatives are embedded in the Better Care Fund plans, with the focus in years one and two being on the following initiatives:

� Integrated Health Teams

� Community Treatment Teams / Intensive Rehabilitation Service

� Joint Assessment and Discharge Team

These are key enablers to deliver the 5 year strategic vision.

What key themes arose from the Call to Action engagement programme that have been used to shape the

To respond to the challenge of the NHSE Call to Action, each borough undertook a series of engagement events over the October to December 2013 period. These involved and covered a wide range of stakeholder groups. Following the sessions, the following themes were identified:

vision? � better access to primary care

� working in partnership with social care/integrated care

� improved hospital performance

� involvement of voluntary sector

� more support for carers

� improved patient engagement/communication

The feedback from the CTA engagement programmes have informed and assisted in the development of CCGs’ local and strategic five year plans for their respective populations.

Is there a clear ‘you said, we did’ framework in place to show those that engaged how their perspective and feedback has been included

We will report back to public and patients at our regular CCG Patient Engagement Forums (PEFs) with cascade down to the practice level, Practice Participation Groups (PPGs). This will be based on our identified themes from local Call To Action engagement as described above and how those themes helped shape our strategic plan.

Current position

Has an assessment of the current state been undertaken? Have opportunities and challenges been identified and agreed? Does this correlate to the Commissioning for Value packs and other benchmarking materials?

Yes, the Health for North East London programme of work (2009-2011) and Developing a Commissioning Strategy for Integrated Health & Social Care Services in Barking & Dagenham, Havering and Redbridge Strategic Outline Case (November 2012) included in-depth assessment of the current state of the BHR economy. Other assessment included the ‘Integrated Care in Barking & Dagenham, Havering and Redbridge Case for Change’ in 2012 which formed the foundation for development of the BHR Integrated Care Strategy.

Supporting Evidence:

� developing a Viable Acute Services Provider Landscape in North East London - INEL and ONEL Sector PCTs and acute trusts Case for Change (03 December 2008)

� decision making business case – December 2010

� August 2012: Integrated Care in Barking and Dagenham, Havering and Redbridge Case for Change

DMBC 021210 FINAL V1.0.pdf

NEL Case for change_v20b 081201.pdf

C4C.pdf

� November 2012: Developing a Commissioning Strategy for Integrated Health & Social Care Services in Barking & Dagenham, Havering and Redbridge Strategic Outline Case

The first draft submission also considered the JSNA and the Health and Wellbeing Strategy to identify and agree the priorities for each borough. In addition to this, each borough also undertook a review of the Commissioning for Value packs to understand the current benchmarked position against similar organisations in London and against statistical neighbours.

Following the analysis of the above sources, the schemes identified were mapped against the 7 ambitions areas to deliver the improvements required over the next 5 years.

DMBC 021210 FINAL V1.0.pdf

Do the objectives and interventions identified below take into consideration the current state?

BHR Better Care Fund Plans are directly informed by and build upon the Integrated Care in Barking and Dagenham, Havering and Redbridge Case for Change. Objectives and interventions identified have been developed following a review of the current state of the BHR economy. Ongoing patient engagement and review of performance feeds into service development.

Baselines for the 2 year BCF metrics and the 5 year operating plan trajectories take into account the current baseline performance.

Does the two year detailed operational plan submitted provide the necessary foundations to deliver the strategic vision described here?

BHR Better Care Fund Plans are directly informed by and build upon the Integrated Care Case for Change in Barking & Dagenham, Havering and Redbridge. Phase 1 and 2 of the strategy, which includes non acute bed quality / productivity improvements, development of the Community Treatment Team and the Intensive Rehab Service, has been delivered.

The foundations for the strategic vision is also based on the Acute reconfiguration programme to reduce the number of sites with emergency care provision, centralise the workforce, increase senior cover and improve quality of care for patients and deliver services that meet the London Quality standards.

Improving quality and outcomes

At the Unit of Planning level, what are the five year local outcome ambitions i.e. the aggregation of individual organisations contribution to the outcome ambitions?

Ambition area Metric Proposed

attainment in 18/19

To reduce the number of years of life lost

Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare (Adults, children and young people

To reduce the number of years of life lost by 23%

To improve health related quality of life for those with 1+ LTCs

Health related quality of life for people with long term conditions (sum of the weighted EQ-5D values)

To improve health related quality of life for those with 1+ LTCs by 4%

To reduce avoidable time in hospital through integrated care

Unplanned hospitalisation for chronic ambulatory care sensitive conditions

To reduce the number of avoidable hospital admissions by 13%

To increase the % of older people living independently following discharge

Number of people age 65+ discharged from hospital into reablement/rehabilitation services still at home after 91 days NB: No indicator available at CCG level to set quantifiable level of ambition against. However CCG plans on this ambition should be making explicit links to the related ambition as part the Better Care Fund, set for 2 years at Health & Wellbeing Board level

No indicator available at

CCG level to set

quantifiable level of

ambition against

To reduce the % of people reporting a poor experience of inpatient care

Patient experience of hospital care To reduce the % of people reporting a poor experience of inpatient care by12%

To reduce the % of people reporting a poor experience of primary care

Patient experience of GP services and GP Out of Hours service

To reduce the % of people reporting a poor experience of primary care by 15%

To reduce hospital avoidable deaths

Incidence of healthcare associated infection (MRSA and C.DIFF NB: Baseline data not yet available at CCG level to set quantifiable level of ambition against. However ‘case note review’ data will be available to measure progress on local plans in the next few years

Baseline data not yet

available at CCG level to

set quantifiable level of

ambition

Data analysis packs for each of the three BHR Boroughs detailing historic performance against each measure, trend analysis, position against national average and position against fellow BHR Boroughs.

How have the community and clinician views been considered when developing plans for improving outcomes and quantifiable ambitions?

The engagement process as part of the development of the BHR Integrated Care Strategy (which is the foundation for the Better Care Fund Plans) included engagement with clinicians and community stakeholders.

Clinicians were also actively involved in the H4NEL proposals through the Clinical Working Groups that were established to produce recommendations for the H4NEL programme.

Draft plans have been shared and reviewed with the Joint Executive Teams, the Integrated Care Coalition, and at Governing Body workshops; clinicians are key members of these groups and have fed into the development of the Strategic

Plan via these groups.

Clinical Directors have actively been involved in the development of plans at Borough levels.

What data, intelligence and local analysis were explored to support the development of plans for improving outcomes and quantifiable ambitions?

Developing a Commissioning Strategy for Integrated Health & Social Care Services in Barking & Dagenham, Havering and Redbridge Strategic Outline Case in 2012 reviewed a range of data and local analysis including the A&E attendance and emergency admissions as well as mapping of non acute beds in the community in order to support the development of the strategy.

The H4NEL Case for Change and business case undertaken in 2008/09 looked at a range of data / intelligence including

� growth in demand linked to projected population growth and changes in medical technology and patterns of care

� reductions in demand for hospital care linked to out of hospital care strategies and commissioning initiatives

� hospital productivity improvements

� activity flows are expected to be affected by the reconfiguration of services

Data analysis packs for each of the three BHR Boroughs detailing historic performance against each measure, trend analysis, position against national average and position against fellow BHR Boroughs and review and incorporation of JSNA recommendations for each of the three BHR Boroughs.

Redbridge baselines & trajectories.pdf

B&D Ambitions & BCF baselines & trajectories

Havering baselines trajectories narrative.pdf

How are the plans for improving outcomes and quantifiable ambitions aligned to local JSNAs?

The local JSNA / Health and Wellbeing Strategy have driven the identification of the quantifiable ambitions. The outcomes identified have been mapped to the JSNA and the 7 ambitions to ensure alignment and fit.

How have the Health and well-being boards been involved in setting the plans for improving outcomes?

H&WBB have played an active role in developing plans in each borough; H&WBB members part of Coalition with responsibility for the reviewing and signing off the Strategic Plan.

The draft BCF templates were signed off by HWBB

Members of the Health and Wellbeing Board have also been involved in the following forums

� integrated care coalition workshop

� BHR CCGs Governing Body Away Day

� integrated care steering group workshop

Sustainability Are the outcome ambitions included within the sustainability calculations? I.e. the cost of implementation has been evaluated and included in the resource plans moving forwards?

The outcome ambitions have been included as part of the sustainability calculations for the 2 and 5 year plans. The finance / QIPP plans for the next 2 years are being finalised. This will be then be used for agreeing the resource plans going forward for years 3-5.

Are assumptions made by the health economy consistent with the challenges identified in a Call to Action?

Yes, the key themes raised from local engagement were:

� better access to primary care – (See Primary Care [Intervention 2] in Improvement Interventions section of this template)

� linking with social care/integrated care – (See Integrated Care Programme [Intervention 3] in Improvement Interventions section of this template)

� improved hospital performance – (See Integrated Acute Reconfiguration [Intervention 4] in Improvement Interventions section of this template)

� involvement of voluntary sector – engagement of the public and patients in the design of pathways

� more support for carers – referenced as one of schemes in the Barking and Dagenham submission (Havering and Redbridge to clarify position)

� improved patient information / communication – relevant to all interventions of the BHR Strategic Plan

� service co-design with patients and voluntary sector – relevant to all interventions of the BHR Strategic Plan

Can the plan on a page The plan on a page outcome targets for the BHR economy can be identified

element be identified through examining the activity and financial projections covered in operational and financial templates?

through examining of the activity projections covered in the operational templates. A mapping exercise has been completed using the baseline and five year reduction targets for each of the BHR Boroughs to produce a consolidated summary position of the BHR target projections for the BHR strategic plan outcome measures (see supporting evidence).

Outcomes 4 and 7 are not covered in the activity projections in the operational template, as baseline data is not available. Ref - NHS England guidance document for commissioners ‘Setting 5-year ambitions for improving outcomes’ (Gateway reference: 00893) states, baseline data is not available for these outcomes.

CCGs however are reviewing local data to make explicit links to the related ambition as part the Better Care Fund.

Improvement interventions

Please list the material transformational interventions required to move from the current state and deliver the five year vision. For each transformational intervention, please describe the :

• Overall aims of the intervention and who is likely to be impacted by the intervention

• Expected outcome in quality, activity, cost and point of delivery terms e.g. the description of the large scale impact the project will have

• Investment costs (time, money,

Intervention One: Prevention and Health Promotion

Prevention and health promotion forms the foundation of our Strategic Plan schemes.

JSNAs have identified the following areas for targeting:

� reduction in obesity

� dementia: earlier identification and diagnosis of dementia to improve treatment

� reduction in health and social equalities

� diabetes: earlier identification and diagnosis of dementia to improve treatment

� cardiovascular disease

� improve early diagnosis of Cancer and treatment times

� targeted action to improve smoking cessation

� improve levels of Breastfeeding

� improved treatment of alcohol and substance misuse

The London wide elements of the plan is being progressed by Dr Kathie Binysh with borough public health leads. A meeting has been tentatively set for the 10 March to discuss.

workforce)

• Implementation timeline

• Enablers required for example medicines optimisation

• Barriers to success

• Confidence levels of implementation

The planning teams may find it helpful to consider the reports recently published or to be published imminently including commissioning for prevention, Any town health system and the report following the NHS Futures Summit.

Expected Outcome

� reduced numbers of patients attending A&E

� reduced health inequalities

� increase in patient Friends and Family test score

� reduced number of non elective emergency admissions

� reduction in the number of patients with multiple LTCs

Investment costs

� financial costs

� non-financial costs

Implementation timeline

� TBC

Enablers required

� stakeholder engagement is crucial

� innovative use of social media to raise awareness

Barriers to success

stakeholder engagement

� limited resource

Intervention two: Primary Care Improvement Plan

The Barking & Dagenham, Havering and Redbridge Primary Care Improvement Plan aims to allow local GPs to lead a system that educates patients, reduces unplanned attendance and reduces hospital admissions by:

� extending standard primary care provision

� providing easier access to clinical support prior to A&E

� supporting better planned care

Interventions required:

� weekend access

� core hours plus

� 6-10pm appointments

� triage service

� primary care provider support

� dedicated registered list

� specialist expertise

� implementation of unified point of access

Expected Outcome

� reduced numbers of patients attending A&E

� increase in patient Friends and Family test score

� reduced number of non elective emergency admissions

� number of patients supported by the complex care service

Investment costs

Implementation timeline: Formal project start/finish: 01.04.14 – 31.03.16

� scheme 1: Improved Access; 14.04.14 – 28.02.15

� scheme 2: Complex Care; 30.06.14 – 28.02.15

Barriers to success:

� finance – dependence on Prime Minister’s challenge fund bid to initiate this plan

� information Governance – linking IT system across different organisations

� engagement with key stakeholders

� 6 month timeframe to establish Unified point of access

Intervention three: BHR Integrated Care Programme

Following extensive public engagement the BHR economy published a case for change in August 2012. The resulting vision and strategy for integrated care has been developed with needs of people at its heart, helping them to live well, and independently, for as long as possible and empowering and supporting them to self care.

PERSON CENTRED CO-ORDINATED CARE: designing care around patients making sure that they receive the right care in the right place, at the right time, and ensuring that different services “talk” to each other, reducing inefficiencies in care

The strategy is to support and care for people in their homes or closer to home, shifting activity from acute to community (supporting acute reconfiguration plans), and in particular to locality settings. It seeks to transform the relationship with individuals by placing them at the centre of delivery, driving improvements to the quality of experience and outcomes.

5 year vision:

Community services will have been remodelled (physical, mental and social) to support clusters of GPs (covering a population of up to 70,000 – check number) to enable more proactive management of the population. The focus will be on those with LTCs, high service users, and those vulnerable to decline.

This may result in less demand for community beds, with resources transferred into multi disciplinary team based around GP practices supported by borough level community response teams.

Services will be jointly commissioned based on outcome measures and designed based on the principles set out in National Voices.

Characteristics of new service model:

� risk stratification of patients

� care planning across the comprehensive needs of individuals

� care co-ordination, with clarity on who is responsible for patients with each level of acuity, linking to established disease pathways as

appropriate , and end of life protocols as required

� a single point of access to the team for patients/service users and their carers through co-ordinators and a 24/7 number

� strong partnership and pathways with the voluntary sector.

� a Joint Assessment and Discharge Team will operate across the system to facilitate the safe return home of patients

Supported and enabled by:

� the Better Care Fund

� technology enabling information and data sharing

� aligned funding arrangements and incentives across the system including personal budgets and building on local Year of Care work

� frailty academy

Expected Outcome

� reduced A&E attendances and emergency admissions

� reduced admissions to residential and nursing care

� reduced delayed transfers of care

� effectiveness of re-ablement

� improved patient/user experience

� reduced % of hospital deaths

� shared care record

Investment costs

� financial costs


Implementation timeline:

� TBC


� building sustainable services and capacity in the right place with scarce

resources (financial and workforce including clinical leadership)

� service delivery across organisational boundaries

Confidence levels of implementation:

� TBC

Intervention four: Acute re-configuration programme

The Health for NE London programme aims to improve health services for local people. The key objectives are:

� urgent and emergency care – to be provided at 5 hospitals in NE London at Queens, Whipps Cross, The Royal London, Homerton and Newham, with urgent care being enhanced at all hospitals (A&E services are therefore transferring from King George Hospital)

� King George Hospital to provide 24/7 urgent care and short stay assessment and treatment services, including location of a GP practice at the polyclinic site

� maternity - to establish and relocate KGH maternity services on to Queens site

� planned care development; see separate planned care intervention below

Moving forward, implementation plans will take account of Sir Bruce Keogh’s recommendations for urgent and emergency care across England:

� providing better support for people to self-care

� helping people with urgent care needs to get the right advice in the right place, first time

� providing highly responsive urgent care services outside of hospital so people no longer choose to queue in A&E

� ensuring that those people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery

� connecting urgent and emergency care services so the overall system becomes more than just the sum of its parts

In 5 years time, service users will see

� a transformed Emergency Department at Queens Hospital with improved A&E quality of services

� a high quality end to end urgent care service that meets or exceeds the London Quality Standards. This will include a new and effective 24/7 Urgent Care Centres at Queens Hospital and King George Hospital.

� a centralised and expanded critical care services

� being treated by a centralised workforce with increased senior cover that will improve quality of care for patients to those that meet the London Quality standards.


� emergency department business case

� urgent care procurement

� maternity reconfiguration has been achieved by working closely with NE London providers. Full relocation of maternity services completed March 2013 following the sign off from NHS London.

� KGH vision - Delivered through the development of KGH as a centre of excellence for Women’s and Children’s services.

Expected Outcome

� to improve the A&E 4 hour performance

� to reduce avoidable emergency admissions

� to reduce the number of years of life lost

� to reduce the percentage of people reporting a poor experience of inpatient care

� to reduce acute inpatient length of stay

Investment costs

� financial costs



� December 2015


� risk that performance improvements on A&E target, LoS and bed reductions not delivered.

� possible slippages in the timelines due to delays in the process

� risk that UCC service model does not deliver the agreed utilisation rates.


� TBC

Intervention five: Planned Care Programme

The Barking & Dagenham, Havering and Redbridge Planned Care Programme aims to improve health services for local people by separating planned surgery pathway from emergency pathway, where appropriate.

Enabled through:

� moving planned surgery from Queen’s Hospital to King George Hospital except where there are benefits in co-locating services or clinical need

� productivity (MSK and Ophthalmology), service re-design (diabetic) and the re-procurement of the Independent Sector Treatment Centre.

Expected Outcome

� to reduce the number of years of life lost

� to increase the percentage of older people living independently following discharge

� to reduce the percentage of people reporting a poor experience of inpatient care

� to reduce hospital avoidable deaths

Investment costs

� financial costs



� TBC


� risk that performance improvements will not be delivered


� TBC

Intervention six: Specialised Commissioning Services

The vision for Specialised services commissioned is to consistently deliver best outcomes and experience for patients, within available resources


� compliance with service specifications

� consistent achievement of service standards

� benchmarked outcomes in London, England and internationally, identifying the best practice to emulate

� engage patients in service / pathway development and contract management

� through contract management, ensure patient feedback is heard and acted upon throughout providers commissioned

� co-commission with CCGs and Local Authorities

� develop and implement best practice patient pathways for individual services, ensuring they are incorporated into national service specifications

� understand the cost of services commissioned

� converge prices

� alignment of incentives

� contract management

Expected Outcome

� specialised services commissioned in London are consistently in the top decile for outcomes across all providers

� continually improve patient experience for each individual

� maintain the integrity of the care pathway for patients of specialised services

� contain the cost of specialised services through Quality, Innovation, Productivity and Prevention, in partnership with providers and other service commissioners

Investment costs

� financial costs



� TBC


� alignment with national specialised services strategy due to strategy developments working to different timelines

� resource capacity – improved matrix working and new ways of working

Confidence levels of implementation

� TBC

Sue Sawyer (NHSE specialised commissioning lead) to update for next version.

Intervention seven: Mental Health Services

A Strategic Commissioning Framework for Mental Health is currently being developed in response to “Closing the Gap: Priorities for essential change in mental health” which was published on January 2014. The framework is expected to be completed by June 2014 and will be jointly developed through the

mental health subgroups of the respective Health and Wellbeing Board.

The completion of the full roll-out of the access to psychological therapies programme by 2014/15 and that every CCG plan will include at least 15% of adults with relevant disorders having timely access to services is reflected within the Borough Operating Plans.

Intervention eight: Children’s Services

One of the key priorities being taken forward is the need to have an Integrated Single Assessment process with Education, Health and Care Plan (EHC) having similar status to the Statement of Special Educational. The key actions to be in place by September 2014 are:

� an assessment process for children needing an EHC plan.

� local offer (capturing the nature and scale of all services available)

agreement confirmed

� start to put children on to EHC plans and the cessation of the current

‘statement system’. National guidance expected soon will confirm

deadlines on when this should complete by.

The CCGs and the Local Authorities will be working in collaborative partnership arrangements to deliver the priority.

The CCGs and the Local Authorities will also be working together to deliver the Safeguarding and looked after children outcomes required in the Children and Families Bill.

Governance overview

What governance processes are in place to ensure future plans are developed in collaboration with key stakeholders including the local community?

The supporting evidence attached details the Governance Structures in place within the BHR economy to ensure future plans are developed in collaboration with key stakeholders.

This is underpinned by ongoing engagement with patients (via Patient Engagement Forums, as well as other methods of engagement such as periodical telephone interviews with patients accessing the Community Treatment Team and Intensive Rehab Service, the outcomes of which directly feed into ongoing service development).


Values and principles

Please outline how the values and principles are embedded in the planned implementation of the interventions

The Integrated Care Coalition are signed up to a set of articulated Values and Principles underpinning BCF (final version to be agreed at Integrated Care Coalition meeting on 31.03.14), Operating and Strategic Plans which are embedded in both organisations and programmes of work, promoting joint working.


To: Meeting of NHS Redbridge CCG Governing Body From: Louise Mitchell, Chief Operating Officer NHS Redbridge CCG Date: 27th March 2014 Subject: Better Care Fund Executive summary This paper provides:

• An update on the Better Care Fund plan - final submission due 4 April.

Recommendations The Governing Body is asked to:

• Approve the overall content of the Better Care Fund plan • Delegate final CCG sign off of submissions being made to LBR to the Accountable Officer

and Chief Finance Officer 1.0 Purpose of the Report

The purpose of the report is to update the Governing Body on the content of the Better Care Fund (BCF) due to be submitted in final form on 4 April.


Redbridge CCG is required by NHS England to submit a two year Better Care Fund (BCF) plan in partnership with the Local Authority. The Governing Body received an update on this requirement in January. The Health and Wellbeing Board signed off the Better Care Fund draft plan at its February meeting and the first cut submissions of both plans were made on 14 February. Final submission is required on 4th April. At its meeting in Feburary,the H&WB approved delegated authority to named officers within the LA and CCG to approve the final version of the submission in the absence of a convened HWBB prior to 4th April. Initial feedback from NHSE following their review and analysis of our draft submission formally confirmed that NHSE are confident that any concerns raised in the review will be addressed by 4th April.

3.0 Better Care Fund The Better Care Fund was announced in June 2013 as part of the 2013 Spending Round. The

Fund provides an opportunity for the Council and the Clinical Commissioning Group to work together to transform local services so that people are provided with better care and support to enable the achievement of health and social care outcomes and accelerate the progress towards integration. In partnership between the CCG and Local Authority a total of six schemes have been identified to align with the BCF vision for Redbridge. These schemes are listed below;

Scheme 1: Seven Day social care provision in hospital and discharge management

Scheme 2: Prevention and Early intervention and self care Self Care

Scheme 3: Transforming Nursing and Care home commissioning

Scheme 4: Supporting Integration, including IT

Scheme 5: Care and Support reform

Scheme 6: Transforming End of Life Care.

In their entirety the schemes cover the following agreed principles:

Help people self – manage and provide peer support working in partnership with voluntary, community and long – term condition groups.

Invest in developing personalised health and care budgets working with patients and service users and frontline professionals to empower people to make informed decisions around their care. Implement routine patient satisfaction surveying from GP practices to enable the capture and tracking of the experience of care Reduce delayed discharges through investment in and strengthening of 7 day social care provision in hospitals Integration of NHS and social care systems around the NHS number to ensure that frontline professionals and ultimately all patients and service users, have access to all o fhte records and information that they need. Undertake a full review of the use of technology to support primary and secondary prevention, enable self management , improve customer experience and access, and free up professional resources to focus on individuals in greatest need. GPs will be a the centre of organising an coordinating peoples care. Our systems will enable not hinder the provision of integrated care,. Our providers will assume joint accountability for achieving a persons outcomes and goals and will be required to show how this delivers efficiencies across the system,

Further summary details of each of these schemes are provided in the template attached as appendix 2.

4.0 Health and Wellbeing Board

The Better Care Fund plan will be revised by Senior officers from LBR and CCG via the Joint working Group established in partnership. The final version of the template will be approved from a CCG perspective by the AO and CFO pending delegation of authority by today’s Governing Body with subsequent formal HWBB sign off as delegated to officers at the 17th February meeting.


The financial implications are detailed in Attachment 1.

6.0 Equalities There are no specific equalities implications arising from this report.

7.0 Risk

Key risks to date have focused on risk to submission. The Joint BCF Partnership forum for Redbridge agreed at its meeting on 12th March to review all risks associated with Delivery of the scheme and to work in partnership to identify the mitigating actions required.

Attachments:

1. Better Care Fund metrics template 2. Copy of the revised template detailing schemes 3. Identified Risks

Author: Louise Mitchell – Chief Operating Officer NHS Redbridge CCG Date: 17th March 2014

Better Care Fund planning template – Part 1 Please note, there are two parts to the template. Part 2 is in Excel and contains metrics and finance. Both parts must be completed as part of your Better Care Fund Submission. Plans are to be submitted to the relevant NHS England Area Team and Local government representative, as well as copied to: [email protected] To find your relevant Area Team and local government representative, and for additional support, guidance and contact details, please see the Better Care Fund pages on the NHS England or LGA websites. 1) PLAN DETAILS a) Summary of Plan

Local Authority London Borough of Redbridge Clinical Commissioning Groups Redbridge CCG Boundary Differences Co-terminus (limited exceptions) Date agreed at Health and Well-Being Board: 1st April 2014

Date submitted: April 2014

Minimum required value of BCF pooled budget: 2014/15 £0.930 million

2015/16 £17.549 million

Total agreed value of pooled budget: 2014/15 £8.503 million

2015/16 £17.549 million b) Authorisation and signoff

Signed on behalf of the Clinical Commissioning Group By Dr Anil Mehta Position Chair Date Signed on behalf of the Clinical Commissioning Group By Louise Mitchell


Position Chief Operating Officer Date Signed on behalf of the Council By John Powell Position Director of Adult Social Services & Housing Date Signed on behalf of the Health and Wellbeing Board By Chair of Health and Wellbeing Board Cllr Shoaib Patel Date c) Service provider engagement Please describe how health and social care providers have been involved in the development of this plan, and the extent to which they are party to it There are number of existing programmes, including provider forums undertaken by Redbridge CCG and Redbridge Council with health providers, social care providers and other voluntary and community sector providers which has involved providers about the main aspects of this plan, mainly the integrated care direction across health and social care.

Some health care and social care providers have already been engaged through the development of commissioning intentions, market events and contract negotiations.

The local community and mental health services provider, North East London Foundation Trust (NELFT) and the acute provider, Barking and Dagenham, Havering and Redbridge University NHS Hospitals Trust (BHRUT) are members of the Barking and Dagenham, Havering and Redbridge (BHR) Integrated Care Coalition (ICC). The ICC is the local health and social care vehicle for driving forward the 5 year strategic plan, so providers are engaged through this and in the BHR Integrated Care Steering Group in setting the overall strategic direction within which the BCF is being developed.

The health and wellbeing board has members from social and health provider sector who have been part of the development of health and wellbeing strategy and this fits in well with the intention to develop BCF vision further.

Joint engagement plans are being developed between CCG and the Council for provider engagement as part of finalising our Better Care Fund (BCF) plan.

As an example, the local care/nursing home and home care providers forum on the 26th of February 2014 was used to brief the social care providers about BCF plan, and we will continue to hold these BCF sessions. Local Authority is already developing a Market Position statement, which further details commissioning intentions and outcomes we aim to achieve and this embeds the vision we have for an integrated service across health and social care through the use of BCF. There is a proposal to host a joint service providers (including from voluntary, community, Foundation Trust and independent social, health care, housing providers, including

micro-providers) event by May 2014 planned by the CCG and Redbridge Council.

d) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan, and the extent to which they are party to it Our vision for whole system integration continues to engage and empower patient, service users and public to have their say on what services they want and how they would want it to achieve their personal outcomes.

Through patient and service user workshops, interviews and surveys across Redbridge, we know that people want services that looks at their needs holistically and help them to self-direct their support as much as possible. We also know that people do not necessarily want to know whether it is health or social care service; they would rather want support at the right time, in the right way, without delay. They want their care to be delivered by people and organisations who show dignity, compassion and respect at all times.

Redbridge has CCG Patient and Public Involvement lay members, representatives from HealthWatch and from service user and carer groups to ensure that the patient perspective is reflected in all our programmes as they develop. The CCG has a borough-wide Patient Engagement Forum with membership drawn from the four localities (GP practices assigned to one of four clusters). These locality groups are formed by PPG chairs from the practices and they nominate four representatives for the borough group.

At a borough and CCG level, service users and carers are involved in developing person centred services; and service users from our Integrated Care Management teams have contributed to the organisation, National Voices about their views recently.

Our Health and Wellbeing Board will be exploring the possibility of adopting the National Voices approach, involving service users in identifying local measures of success.

Redbridge CCG and Council are developing online resources in local authority and local NHS websites to ensure that we are open and transparent with the member of public about the development of the BCF vision and plan for Redbridge. There will be opportunities as detailed above for members of public who will be both briefed and will be consulted on the development of BCF plan.

e) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition. Document or information title Synopsis and links Integration Pioneer application Redbridge Adult Social Services and Redbridge

CCG applied unsuccessfully to become an integrated pioneer showing that (even before

the BCF proposal) we have a shared vision for integrated health and social care in Redbridge.

Health for NEL Strategic change programme across North East London to re-configure hospital services and develop integrated care.

JSNA Joint local authority and CCG assessments of the health needs of a local population in order to improve the physical, social and mental health well-being of individuals and communities in Redbridge.

H&WB Strategy The Joint Health and Wellbeing Strategy sets out the priorities and actions which the Health and Wellbeing Board are planning to carry out until in Redbridge.

Integrated Care Strategy Integrated Care Strategy – BHR ICC BHR ICC OBC for integrated care BHR ICC OBC for Reconfiguring the non-acute bed base (November 2012) Reprovision programme to implement Integrated Health teams

Ernst & Young strategic document for the three borough (BHR) Integrated Care Coalition. Business cases with options for re-provision of community services following reconfiguration of the non-acute bed base. An ongoing programme to optimise the delivery of integrated community services in Redbridge and across BHR.

LTC Year of Care pilot site Redbridge is one of the seven ‘Year of Care’ pilot for long-term conditions management which results in a yearly tariff. We have completed two years of this pilot phase and have learned and implemented the foundations required for successfully implementing this work. The pilot has enabled us to further our health and social care integration in Redbridge.

2013/14 Commissioning Strategy Plan (CSP) and Quality, Innovation, Productivity and Prevention (QIPP) plan 2014/15 Commissioning Intentions

Redbridge CCG agreed one-year plans setting out strategy to deliver against national planning guidance, “Everyone Counts: Planning for Patients 2013/14” and for achieving financial balance through its QIPP work programme.

2014-16 CCG Operating Plan (draft) 2014-19 BHR CCGs strategic plan (draft)

The two-year operating plan for the CCG for the period 2014-16 is currently in development. The five-year strategy for the BHR CCGs is also currently in development.

7 day working plan Is incorporated in our overall integrated care arrangements.

Joint Commissioning Intentions from Public Health, Adult Social Services, Redbridge CCG

Redbridge CCG, Adult Social Services and public health have provided their individual commissioning intentions and are currently developing a joint intention covering all three sectors.

Other supporting strategies Telecare strategy Carers strategy

2) VISION AND SCHEMES a) Vision for health and care services Please describe the vision for health and social care services for this community for 2018/19.

• What changes will have been delivered in the pattern and configuration of services over the next five years?

• What difference will this make to patient and service user outcomes? Our Vision for our community for 2018/19 is: ‘’To commission and ensure delivery of a first class health and care service for our residents – faster access to advice and information, care and support, better services, better outcomes and better health & wellbeing’’ In Redbridge, in the next five years: We want person centred care for our people provided in a fully integrated way. We truly believe that if we are person-centred, everything else will fall in place; We want more people to:

• Be active and self-manage their health; • Be able to access support, contribute to and be part of a vibrant community; • Use telecare, telehealth and other assistive technology • Use their health and care budgets to buy and shape their support the way they

want

We want our local public and other services to look at people’s strengths and how to sustain them for longer; We want to pool monies between health and social care and explore possibilities of pooling resources with other council departments; We want primary care, within a stronger, better networked structure based on the existing locality configuration, to be at the core of the community offer for our people; We want more people to be supported in the community rather than in acute settings, unless it is essential, with better clinical and social outcomes, improved safety and user experience; We want to develop and implement joint-commissioning mechanisms that looks to commission ‘one lead provider’ with ‘outcomes’ clearly described and all agencies involved made accountable for the same throughout the person’s journey through the health and social care system; We want to achieve financial efficiencies and re-invest in public health, reablement and other preventative early intervention services; We want to learn from and implement innovative approaches from lower and middle income countries where great outcomes for people have been achieved at relatively less cost;

We want to reflect increasing use of the internet and smartphones to harness advanced web technologies for promoting self-care and providing advice and information to the residence of Redbridge in a faster and more creative way. Patient and service user outcomes: By 2018, patient and service user will have one care and support plan; will be able to have personal care and health budget or direct payment to self-direct their care and health; will be able to liaise with one named co-ordinator at anytime; will be able to direct their care to achieve their personal goals with or without support from the local authority or local health service. To help explain how more integrated services can help local people maintain their independence and quality of life and to make this more personal, a number of anonymised case studies have been built up from real-life examples of integrated service provision across BHR.

“Jack”, for example, is a 55-year-old male living at home with COPD. He visits his GP frequently about his condition because he does not feel confident managing his condition alone, Before the implementation of the Community Treatment Team (CTT), when he experiences an exacerbation of his COPD he calls ‘999’ and is taken by ambulance to Queen’s Hospital where he spends two days under observation before being discharged home. Two weeks later, he repeats this following another exacerbation and has another two days in hospital. With the availability of the CTT, now Jack calls their number and they come to his home to give treatment. “Amy”, an 86 year old living along at home who is hypertensive, suffers from rheumatoid arthritis and is showing early signs of dementia, provides an example of home rehab. Previously, she has fallen down the stairs at home and a neighbour has called ‘999’. Amy spends three weeks in Queen’s before being discharged to an inpatient rehab bed, where she spends another four weeks. Unfortunately, while there she contracts a UTI which staff notice is having a significant impact on her memory. They feel it is unsafe for her return home and she is discharged to a care home. With the availability of Intensive Rehabilitation Service at home (IRS), when she falls and an ambulance is called, while she spends a similar length of time in the acute hospital, she is referred to the IRS team and a home rehab package is agreed post-discharge. This is designed to allow her to get back into her old routine while continually to live independently. Given the pattern of falls and her medical condition, she is also referred to the Integrated Case Management (ICM) service for ongoing planned care. b) Aims and objectives Please describe your overall aims and objectives for integrated care and provide information on how the fund will secure improved outcomes in health and care in your area. Suggested points to cover:

• What are the aims and objectives of your integrated system? • How will you measure these aims and objectives? • What measures of health gain will you apply to your population?

We want to maximise our joint potential to enable residents and patients within Redbridge to receive the best quality of care services available. To achieve this, we will place the emphasis on

personalised service and choice within a preventative, integrated approach that prioritises care in people's homes and communities first. Aims

Our aims are:

To join or co-ordinate various services commissioned by health and social care to ensure that it supports patients and services users seamlessly in a person-centred manner so that the person is in a position to achieve his/her best personal outcomes.

This will be done by:

• co-coordinating around individuals and targeted to their specific needs;

• improving the experience of care, with the right services available in the right place at the right time;

• improving outcomes, reducing premature mortality and reducing morbidity;

• maximising independence by providing more support at home and in the community, and by empowering people to manage their own health and wellbeing;

• avoiding unnecessary admissions to hospitals and care homes through proactive and joined up case management, and enable people rapidly to regain their independence after episodes of ill-health.

We recognise that this journey will involve further significant changes to the way in which services are designed and delivered, but that journey is now underway.

From 2015, we aim to have the following (note: some of these are already in place or in development):,

• CCG and Social Care commissioners will be commissioning and procuring jointly, focused on improving outcomes for individuals within our communities

• Our community providers are already implementing new models of service delivery, driven by clinical staff on the ground, and integrated with our broader health and wellbeing strategies. This will involve a single approach to assessing and meeting the needs of individuals in their homes and communities, with seamless delivery of health and care functions. This includes building on the Integrated Case Management service, provided jointly by the local NHS community trust and LBR social care for individuals identified primarily by general practice through risk profiling, to develop an Integrated Health Team with an urgent, Community Treatment Team (rapid response) intervention service (CTT) and Intensive Rehabilitation Service (IRS).

• Our GP practices are already divided into four localities which are supporting their local communities and four Integrated Health Teams (IHT) will configure on the same geographic basis. Community, social care services and specialist mental and physical health services are already organised and will be further strengthened to work effectively with these networks, enabling GPs to ensure their patients are getting the very best person-centred care.

We will deliver on the new provisions of GMS, including the requirements of the unplanned admissions DES, designed to place the GP at the heart of the care planning for patients at risk of an emergency admission.

We will be investing in person-centred co-ordinated care that promotes a holistic view of individual needs and works with people to empower them and enable them to stay as independent as possible.

This means ensuring there is a good quality care plan in place commissioned to deliver on the required support and outcomes envisaged in each and every plan. Through ICM, their patients will all have electronic care plans and crisis plans, accessible in local A&Es for clinical staff through the Health Analytics system.

By improving individual health and wellbeing, and access to home and community based services, we will relieve pressures on our acute services and help to eliminate the costs that arise from failures to provide adequate help to those at greatest risk of deterioration. In parallel, the 7 day social care provision will help us to eliminate delayed transfers of care.

Through enhanced preventative and community independence functions, we aim to reduce the volume of emergency and planned care activity in hospitals, together with the number of residential and nursing care placements and improved support in the community and in the home.

We will measure our aims and objectives for integrated care by doing the following:

• Through our collaborative approach across health and social care, our GP practices provide the opportunity for care and support providers to all use the same patient and service user record; the BCF will help ensure this happens by joining up Health and Social Care data across Redbridge, linked via the NHS number. We will guarantee that individual information is shared in an appropriate and timely way to maximise safeguarding, wellbeing and user experience; and aggregated to allow effective identification and management of need and outcomes across our health and care economy as a whole.

• Introduce customer satisfaction surveying for those with one or more long-term conditions, already done for Integrated care management (ICM) users looking holistically at their experience of care.

• Leverage investments in data warehousing, data mining, including total activity and cost data across health and social care for individuals and whole segments of our population. We are developing interoperability between all systems to provide both real time information and managerial analytics.

Furthermore, these objectives will be measured by way of overall aspirations against the national outcome measures as set out in Appendix B (BCF Part 2). In essence we expect to see from the planned changes the following;

1. A reduction in delayed transfers of care.

2. A reduction in avoidable unplanned admissions.

3. Improving the effectiveness of our re-ablement services (hospital discharge reablement)

so that we continue to ensure upper quartile performance and to develop and measure the improvement in people going through community reablement (to be finalised).

4. Reducing the number of people who are admitted to residential or nursing home placements.

5. Improved patient and service user experience (metric to be developed at National level).

6. Reducing the number of injuries due to falls in people aged 65.

7. Supporting more people to achieve individual outcomes through Redbridge First Response scheme (ReFRS) whose referrals come from non-clinical needs identified through various partners (including General Practices) (to be inserted into final plan).

Appendix B describes how we expect these changes to impact on key performance measures, with further local measures to be developed as part of the finalisation of this plan. c) Description of planned changes Please provide an overview of the schemes and changes covered by your joint work programme, including:

• The key success factors including an outline of processes, end points and time frames for delivery

• How you will ensure other related activity will align, including the JSNA, JHWS, CCG commissioning plan/s and Local Authority plan/s for social care

The planned changes we have proposed are detailed below. They form the basis of our aim for integrated services. We understand that these changes are only possible if we are able to get our patients, service users, public and providers to work together to co-produce the vision we all share. To effect the change, the CCG and local authority commissioners are committed to working together to create a marketplace and by working with existing health and social care providers ensure that this happens at scale and at pace.

Local joint commissioning intentions are being developed which encompasses the following:

• People will be empowered to direct their care and support, and to receive the care they need in their homes or local community.

• Identify the population (through LTC year of Care pilot and Integrated Care Management) that will most benefit from integrated commissioning and provision; the outcomes for these populations; the budgets that will be contributed and the whole care payment that will be made for each person requiring care; the performance management and governance arrangements to ensure effective delivery of this care.

• Local health and care providers, and associated public, private and voluntary and community sector groups, co-designing the care models that will deliver these outcomes; transitioning resources into these models to deliver the outcomes required; ensuring governance and organisational arrangements are in place to manage these resources; agreeing the process for managing risks and savings achieved through improving

outcomes; establishing information flows to support delivery;

We have refined our BCF schemes further during the first week of March 2014 by consolidating into six schemes, which thematically aligns with out BCF vision with the respective services under each scheme. The services, the monies involved, the outcomes expected and the metrics used to measure are all detailed in the Appendix B (Part 2 template):

BCF 01- 7 day social care provision in hospital & discharge management

BCF02 –Prevention and Early Intervention and Self-Care

BCF 03 -Transforming Nursing and care home commissioning

BCF -04 - Supporting Integration, including IT

BCF 05 - Care and Support reform

BCF 06 – Transforming end of life care

The schemes cover the following principles:

• Help people self-manage and provide peer support working in partnership with voluntary, community and long-term conditions groups.

• Invest in developing personalised health and care budgets working with patients and service users and frontline professionals to empower people to make informed decisions around their care.

• Implement routine patient satisfaction surveying from GP Practices to enable the capture and tracking of the experience of care.

• Invest in reablement through approach to Community Independence, reducing hospital admissions and nursing and residential care costs.

• Reduce Delayed Discharges through investment in and strengthen 7 day social care provision in hospitals.

• Integrate NHS and social care systems around the NHS Number to ensure that frontline professionals, and ultimately all patients and service users, have access to all of the records and information they need.

• Undertake a full review of the use of technology to support primary and secondary prevention, enable self-management, improve customer experience and access, and free up professional resources to focus on individuals in greatest need. GPs will be at the centre of organising and coordinating people's care.

We will use the BCF to:

• Roll out the Whole Systems Integrated Care model building on existing care planning, care co ordination, risk stratification and multi-disciplinary teams developed through ICM teams.

• Invest in 7 day GP access in each locality and deliver on the new provision of the GMS.

Our systems will enable and not hinder the provision of integrated care. Our providers will

assume joint accountability for achieving a person's outcomes and goals and will be required to show how this delivers efficiencies across the system.

We will use the BCF to:

• Establish a Joint Integration Team working across the local authority and CCG to support the implementation of integrated commissioning of health and social care.

• Review all existing services, including services commissioned under existing section 256 agreement, to ensure they represent VFM and re-procure services where necessary to enable integrated working.

• Create a joint Nursing and Care Home Commissioning Team focused on improving outcomes through transforming the quality, consistency and co-ordination of care across the nursing and care homes in Redbridge.

An overview of the overall timeline is provided below: January – July 2014

• Development of joint commissioning intentions to support the greater co-ordination and

integration of priority services, including in relation to community health and adult social care.

• Develop locality integration plans that set out the scope of our plans for integrated care, including target population, desired outcomes and budgets available, as well as providers’ responses.

• Prepare the detailed specifications and plans for joint commissioning and provision in 2014/15 as per the priority areas outlined above.

July 2014 – March 2015

• Planning to implement concepts developed during co-design phase to achieve our objectives.

• Evaluate financial impact of possible models on different providers and on total cost to commissioners.

• Develop our next iteration of the joint commissioning plan in line with local needs and the Whole Systems approach.

From April 2015 We will be ensuring closer collaboration with the other boroughs in Outer North East London in co-designing approaches to integrating care. This is designed to ensure shared providers have a consistent approach from their different commissioners, and that we are proactively sharing learning across borough boundaries. Our plans are aggregated into the Integration Coalition in order to accelerate learning and joint planning. The Integrated Coalition provides oversight to this process, as described in the governance section below; with each borough Health & Wellbeing Board taking the lead in

approving local joint commissioning plans, especially where the shared acute/hospital bases are involved. d) Implications for the acute sector Set out the implications of the plan on the delivery of NHS services including clearly identifying where any NHS savings will be realised and the risk of the savings not being realised. You must clearly quantify the impact on NHS service delivery targets including in the scenario of the required savings not materialising. The details of this response must be developed with the relevant NHS providers. Commissioning intentions were issued by the CCG in autumn 2013 and have been shared with providers and inform contract negotiations for 2014/15. They are designed to meet the vision of improving health and health outcomes for local people through clinical commissioning of sustainable, safe high quality local service and have been mapped to the seven strategic plan ambitions:

• Securing additional years of life for the people of Redbridge with treatable mental and physical health conditions

• Improving health related quality of life for people with LTCs including MH • Reducing the amount of time people spend avoidably in hospital through better and

more integrated care in the community, outside of hospital • Increasing the proportion of older people living at home following discharge from hospital • Increasing the number of people having a positive experience of hospital care • Increasing the number of people (MH and physical conditions) having a positive

experience of care outside hospital in general practice and community • Making significant progress towards eliminating avoidable deaths in our hospitals caused

by problems in care

And the five NHS outcome domains which, in common with the Adult social care outcome domains, are also mapped to our Better Care Fund. The CCG commissioning intentions cover the following areas:

• Urgent care • Planned care • Integrated care • Maternity • Mental health and disabilities • Primary care • Paediatrics • End of life • Cancer

The principle for shifting care from hospital to a community setting is well-established within the local health economy and informs the planning assumptions for providers as has been the case in 2013/14. For the purposes of the Redbridge Better Care Fund, the CCG will quantify:

• Reductions in emergency admissions based on the impact of Integrated Case Management (ICM);

• Project the full year effect of the piloted Community Treatment Team, which has been approved by the CCG Governing Body to continue through 2014/15, and incorporate its anticipated impact in reducing emergency admissions;

• Project the full year effect of the Intensive Rehabilitation at home service on the community bed base, based on the impact of the current pilot phase; TBD

• Community Long Term Condition (LTC) services to be reviewed in line with integrated care services and improved primary care;

• Improved co-ordination of End of Life (EOL) Care via Integrated health teams; • Improved quality of care for nursing home residents, based on the Integrated Health

team approach, a closer working relationship with CTT and findings from the current ICM+ pilot;

• Patients receiving continuing care to be offered personal health budgets in line with national guidance;

• Improved pathways for patients with chronic conditions and cancer which bypass A&E • A BHR-wide primary care strategy and development plan, which will include a BHR-wide

application to the Prime Minister’s Access Challenge Fund for pilot status; primary care development to include factoring in the implications for acute services of local implementation of seven day working in primary care and the impact of the new unplanned admissions DES;

• Improved co-ordination End of Life (EOL) Care via Integrated health teams, increased community nursing levels and local implementation of the Gold Standard Framework with more than 90% of Redbridge general practices now undertaking GSF training;

• Develop a joint commissioning strategy for people with learning disabilities and challenging behaviour and progress joint commissioning arrangements in line with the Winterbourne Concordat;

• Dementia: Review memory service to ensure sufficient capacity for local need and alignment with National Dementia strategy and best practice; supported in 2014/15 with continuation of the Dementia Directed Enhanced Service (DES). This is designed to support early detection and from April 2014 will incorporate advance care planning with patients as a performance measure (the DES is provided by more than 90% of Redbridge general practices).

NHS Providers affected by these items within the CCG Commissioning Intentions are: Barking, Havering and Redbridge University NHS Trust; North East London Foundation NHS Trust; Barts Healthcare NHS Foundation Trust; and general practice. The local authority Adult social services commissioning intentions cover the following themes broadly. Number of services commissioned by the Adult Social Services supports the move from care and support offered in acute health settings to peoples own home or in the community in a place of their choice; e.g, extra care setting, sheltered housing schemes, supported living etc. Universal Information; Some of the services such as Information and Advice, Advocacy contracts, including grants for community development or for promoting innovation through voluntary and community organisations will facilitate people to live independently in their own home without care or support, as long as possible. Social Capital

Some of the voluntary sector organisations and faith based organisations, already provide peer support, timebanking concepts as part of using the local community. Prevention and Early Intervention Services such as ReFRS (Redbridge First Response Service) is already looking at joining up public health, adult social services and the health care by addressing the ‘causes of causes’. Following an initial pilot with selected general practices, GP referral into ReFRS is now being rolled out across all practices. The Community reablement service provided through independent sector is also supporting the need for care packages and in reducing hospital admissions. Redbridge Lifeline and visiting support service is another example of prevention and early intervention. Integrated community equipment service has also supported people to live independently using assistive equipment and technology in their own homes. Choice and Control Redbridge Adult Social Services has good take up of direct payment services and the use of individual service funds (ISF) in a unique way has supported the take up of personal budgets. e) Governance Please provide details of the arrangements are in place for oversight and governance for progress and outcomes The monitoring of progress and delivery will be overseen by the following groups, configured across three boroughs and involving partners across health and social care and within the London Borough of Redbridge. The BHR-wide strategic groups involve local authorities, CCGs and major service providers across the three boroughs. The Joint Health and Social Care Group reports to the Integrated Care Coalition and is the main planning group for the Better Care Fund. This group also includes NHS England participation. Oversight and governance within the borough is through the Health and Well Being Board, with the Redbridge Joint Commissioning Partnership group (RJCP) reporting to the Board. The CCG Governing Body sets the strategic direction for the CCG, provides oversight and is ultimately responsible for CCG delivery against the organisational objectives. The Executive meets more regularly and takes a more direct role in ensuring CCG delivers against its plan. BHR-wide collaborative strategic groups

• BHR Integrated Care Coalition • BHR Joint Health and Social Care Group • BHR Urgent Care Board

The BHR groups have been designated as the lead forum for coordinating and managing Better Care Fund planning across the three boroughs. London Borough of Redbridge

• Redbridge Health and Well Being Board • Redbridge Joint Commissioning Partnership

Redbridge CCG • Governing Body • Redbridge Executive

3) NATIONAL CONDITIONS a) Protecting social care services Please outline your agreed local definition of protecting adult social care services. To ensure that any use of the BCF to re-design social care services does not have adverse impact on Adult Social Care in its ability to sustain the current spend on services Please explain how local social care services will be protected within your plans. Funding currently allocated under the Social Care to Benefit Health grant has been used to enable the local authority to sustain the current level of eligibility criteria and to provide timely assessment, care management and review and commissioned services to clients who have substantial or critical needs and information and signposting to those who are not FACS eligible. This will need to be sustained, if not increased, within the funding allocations for 2014/15 and beyond if this level of offer is to be maintained, both in order to deliver 7 day services and in particular as the new Social Care Bill requires additional assessments to be undertaken for people who did not previously access Social Services.

It is proposed that additional resources will be invested in social care to deliver enhanced rehabilitation / reablement services which will reduce hospital readmissions and admissions to residential and nursing home care.

b) 7 day services to support discharge Please provide evidence of strategic commitment to providing seven-day health and social care services across the local health economy at a joint leadership level (Joint Health and Wellbeing Strategy). Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends.

Seven day service already implemented across health and social care across Redbridge and BHR University Hospital Trust and Barts Health under the project ‘Improving Continuity of Care and Implementing 7 day working across the Health Economy’. Winter funding has been used within the BHR health economy to facilitate 7 day services in health and social care. This enables partners to assess what additional capacity is required to develop an ongoing 7 day offer and to evaluate how successful the approach is to facilitating discharges and avoiding unnecessary admissions. For Redbridge, this has supported the a pilot phase for extending the coverage of the BHR Community Treatment Team into Redbridge, with a community presence in the borough and a new acute hub based at the King George’s Hospital A&E, Goodmayes. This is a multidisciplinary team that works both in the community and alongside A&E in Queen’s and King George’s Hospital (with reciprocal arrangements in place at Whipps Cross Hospital for the 25-30% of Redbridge residents that predominantly use that hospital). The team operates between 8am and 10pm, seven days a week.

Further work is also being undertaken to understand the Adult Social Care Customer Journey, including interfaces with health providers to enable timely assessment and transfer, with 7 day services in social care will be considered as part of this work.

c) Data sharing Please confirm that you are using the NHS Number as the primary identifier for correspondence across all health and care services. We confirm that we are using the NHS Number as the primary identifier. All health services use the NHS number as the primary identifier and the Social services match on NHS number is currently around 80%.

If you are not currently using the NHS Number as primary identifier for correspondence please confirm your commitment that this will be in place and when by N/A Please confirm that you are committed to adopting systems that are based upon Open APIs (Application Programming Interface) and Open Standards (i.e. secure email standards, interoperability standards (ITK))

We are committed to adopting systems based upon Open APIs and Open Standards.

We already use:

• System One, INPS Vision, EMIS Web and Microtest are the GP clinical computer systems currently in use in the 46 general practices in Redbridge which allows service users and clinicians to view information and add data to their records;

• Carefirst 6, a software solution to provide a range of services and content to social care, while allowing the involvement of health care partners.

To enable cross-boundary working, we will improve interfaces between systems. Further, we are creating a data warehouse through the Health Analytics system that aggregates data from

different sources into a consistent format. This will provide one view over the whole systems of health and social care, and allow queries and analyses to take place across multiple, separate systems. Also, it will improve data quality by identifying gaps or inconsistent record.

Please confirm that you are committed to ensuring that the appropriate IG Controls will be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit requirements, professional clinical practise and in particular requirements set out in Caldicott 2. All of this will take place within our Information Governance framework, and we are committed to maintaining five rules in health and social care to ensure than patient and service user confidentiality is maintained. The rules are:

• Confidential information about service users or patients should be treated confidentially and respectfully

• Members of a care team should share confidential information when it is needed for the safe and effective care of an individual

• Information that is shared for the benefit of the community should be anonymised • An individual’s right to object to the sharing of confidential information about them

should be respected • Organisations should put policies, procedures and systems in place to ensure the

confidentiality rules are followed

d) Joint assessment and accountable lead professional Please confirm that local people at high risk of hospital admission have an agreed accountable lead professional and that health and social care use a joint process to assess risk, plan care and allocate a lead professional. Please specify what proportion of the adult population are identified as at high risk of hospital admission, what approach to risk stratification you have used to identify them, and what proportion of individuals at risk have a joint care plan and accountable professional. The Integrated Care Management team provides a multidisciplinary service for people in Redbridge who are at high risk of hospital admission. The lead professionals are community matrons working alongside individual GPs with social work, occupational health and mental health professionals as part of the integrated team. Redbridge Adult Social Services provides support through its Access and Wellbeing Team, which also supports community reablement. The joint learning disability team in Cranbrook Road and mental health team based in Goodmayes are also examples of multi-disciplinary teams which are linked to the integrated care managed teams. The risk profiling tool used in Redbridge is provided by Health Analytics. This uses a composite of 77 different indicators to form a baseline at borough and individual practice level of those most at risk of admission. The top 1% is the principle cohort used for assessing suitablility for Integrated Case Management and referral. There are currently 2,659 people identified as part of this top 1%. People being case managed by this service will all have a care plan and an accountable professional for their care.

4) RISKS Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers Likelihood

Impact

1- Catastrophic 2 - Critical 3- Marginal 4 – Negligible

Ref Risk Mitigating Actions Risk Rating

1. Externally imposed deadlines are in place. Timescales for developing BCF plan to be submitted by 4th April 2014.

Redbridge Adult Social Services and Redbridge CCG are working on Resources have been identified to ensure the deadlines are achieved

C2

2 BHRUT quality and performance issues- the local hospital trust faces substantial challenges to deliver quality care and financial sustainability. The intention to reduce expenditure on acute care will further impact upon the Trusts financial model.

Performance management, the effective implementation of local community based services such as Community Treatment Teams, Intensive Rehabilitation Service etc; contract management and implementation of deliverable through Urgent Care board are to support the release of efficiencies from acute settings.

C2

3 Meaningful engagement with stakeholders, users and carers given the tight externally imposed timescales

Every opportunity is being identified to engage with key stakeholders. Future engagement activities about BCF and whole systems integration have been jointly planned

C2

4 Changing Redbridge population demographics, social deprivation and the nascent state of some of the community based integrated

Set and manage deliverables, including outcomes and being pragmatic in the approach and empowering professionals on the front line of health and social care (and IT systems) to work seamlessly across

C2

A –Very High B – High C - Significant D -Low E – Very Low F – Almost impossible

services might not produce the required outcomes as planned by the time period projected

health and local government through a good governance structure is expected to help BCF plans

5 The Care Bill when enacted will result in LB Redbridge spending significant amounts of monies on those eligible for social care, including the costs involved in setting up and managing care accounts. LBR, at the moment is working on quantifying the costs.

In order for any future costs to social care due to the Care Bill (and subsequently, the Care Act) being sustainable, fair allocation to LB Redbridge is expected from the BCF and other routes, without which it will be very difficult to meet the demands created as a result of Care Bill. An impact assessment exercise will be undertaken locally.

A2

5

Appendix B – This Appendix 2 is the Part 2 of the BCF template that details the investment, schemes and services, their outcomes and associated metrics

Appendix 3 Key risks and contingencies - Better Care Fund

Key risks to the success of the BCF programme are outlined below with proposed contingencies to mitigate potential impact and review and reporting arrangements.

Ref Risks: Review and reporting points:

Review date and required actions:

R1: Current resources/ investment not maintained by partners

To be addressed through risk share as part of broader BCF pooled budget. Plan delivers increased investment over period.

Established within risk share agreement and review by HWBB sub group.

R2: Given the additional burdens of the Care Bill Investment cannot be secured and capacity of LA to maintain current services is compromised impacting upon plan delivery.

As yet there is insufficient clarity as to how the Care Bill burden is to be funded. it is recognised by the CCG and the Council that this presents a financial risk to the local health and social care economy and cost modelling is currently underway. More detailed work will be undertaken from April to develop the risk management strategy as a schedule of the S.75 which will set out the responsibility of partners in managing financial and operational risks and arrangements for shared risk management.

Established within risk management strategy between the CCG and the Council.

Ref Risks: Review and reporting points:

Review date and required actions:

R3: Performance against required outcomes is not achieved

Guidance now provides for peer review and support to areas rather than withholding of funding. We have also carefully considered the targets within our BCF plan to ensure that these are measurable and achievable providing both a level of ambition and sustainability over the life of the plan. There is also sufficient linkage with CCGs 5 year strategic plan.

Monthly reporting to Executive committee and HWBB Sub-group: BCF partnership Steering Group for Redbridge Engagement with NHS England and Local Government Association in our review of progress to seek necessary support as may be required.

R4: BHRUTs quality and performance issues. As a part of our local system the local hospital trust faces substantial challenges to deliver quality care and financial sustainability. The intention to reduce expenditure on acute care will further impact upon the Trusts financial model.

CCG have quality and performance contract management arrangements in place. We are also closely engaged with the Trusts improvement plan, ensuring that BCF steps such as those of 7 day working positively impact upon the management of acute resources. Oversight is also supported through the governance of the Urgent Care Board and our system plan.

Monthly review through Urgent Care Board and system plan reporting arrangements.

This template is to be used for part 2 of HWB BCF plans and replaces the original template available on the NHS England BCF webpage. The new version contains more information in the metrics section and is locked in order to assist in the NHS England assurance process . This new template should be used for submitting final BCF plans for the 4th April The three tabs containing tables have been protected so that the structure can not be modified in a way that will impede the collation of all HWB plans. However, for the finance tables whole rows can still be inserted by right clicking on the row number to the left of the sheet and clicking 'insert'.

BCF Planning Template Finance - Summary DRAFT

DRAFT 4.3.4_bcf-plan-temp-update - Redbridge 20-3-14

OrganisationHolds the pooled budget? (Y/N)

Spending on BCF schemes in 14/15 /£

Minimum contribution (15/16)

/£

Actual contribution

(15/16) /£London Borough of Redbridge £ 6,485,000 £ 1,517,000 £ 1,517,000 Redbridge CCG £ 2,018,000 £ 16,032,000 £ 16,032,000

BCF Total 8,503,000£ 17,549,000£ 17,549,000£

Contingency plan: 2015/16 Ongoing

28000 56000

175000 350000

0 0

0 0

0 0

0 0

150000 600000

150000 600000

0 0

0 0

25000 100000

25000 100000Outcome 6 (Injuries due to falls)

Planned savings (if targets fully achieved)Maximum support needed for other services (if targets not achieved)

Finance - Summary

Approximately 25% of the BCF is paid for improving outcomes. If the planned improvements are not achieved, some of this funding may need to be used to alleviate the pressure on other services. Please outline your plan for maintaining services if planned improvements are not achieved.

BCF 01 - If the demand for 7 day services (social care) and reducing delayed discharges increases so that the planned improvements are not achieved, the following will be done: 1) There will be close working with (including performance management) the acute providers to ensure that the increase in demand is managed consistently by using the Community independence route effectively and/or flexing available resources required (for example, winter pressures funding) to manage the demand for an agreed period until the demand eases to a manageable level. (The exact details are to be decided at later stage); BCF 02 - Incorporating telecare, telehealth, use of assistive technology, use of peer support and advocacy are expected to improve outcomes, particularly as there is huge untapped potential to integrate these services with local general practice. If individual evaluation of these services do not contribute to improvement in this particular scheme, then re-evaluation of individual services will be undertaken to effect improvement. Preventative, early intervention services and community independence need to be looked together as there are many services within these schemes. If planned improvements are not achieved, acute services and institutional care (residential, nursing home care) outcomes and metrics will be negatively impacted as people might be using these services more. BCF 03 - If there are no improvements in the expected number of reductions in residential/nursing home placements and/or to support living for various service categories (LD, MH, OP) etc due to increased demographic and other pressures, including due to the implications of the care and support bill and/or due to the new demand created by the integrated care teams in the community, then some additional resources in commissioning and social work are to be looked at to maintain services. BCF 04 - If planned improvements are not achieved there will be a need to ensure continuity of services to revert to legacy systems for a period until new integration processes, systems, including ITsystems are to be re-evaluated. BCF 05 - If the demand relating to Care Act (when the bill is enacted) in Redbridge exceeds the demands predicted and the associated costs when implemented, resources, including financial will have to be found from other initiatives to ensure the sustainability of this schem. BCF06 - If improvements in end of life care is not realised, a re-evaluation of the pathway needs to be undertaken with any performance management for provider services robustly undertaken during the improvement planning,

For each contributing organisation, please list any spending on BCF schemes in 2014/15 and the minimum and actual contributions to the Better Care Fund pooled budget in 2015/16. It is important that these figures match those in the plan details of planning template part 1 . Please insert extra rows if necessary

Outcome 1 (Permanent Admissions)


Outcome 2 (Rehabilitation)


Outcome 3 (Delayed Transfers of Care)


Outcome 4 (Avoidable emergency admissions)


Outcome 5 (Patient / User Experience)


BCF Planning Template Finance - Schemes DRAFT


BCF Investment Lead provider

Recurrent /£ Non-recurrent /£ Recurrent /£ Non-recurrent /£ Recurrent /£ Non-recurrent /£ Recurrent /£ Non-recurrent /£

BCF 01 Strengthening 7 day social care provision in hospitals and discharge management LBR/CCG

£ 418,000 £ - £ 463,000 £ -

BCF 02 Prevention & Early Intervention and Self-Care LBR/CCG

£ 3,777,000 £ - £ 52,500 £ 5,007,000 £ - £ 210,000

BCF 03 Nursing and Care Home Commissioning LBR

£ 529,000 £ - £ 49,000 £ 1,863,000 £ - £ 168,000

BCF 04 Supporting Integration, includiong IT LBR

£ 1,190,000 £ - £ 101,500 £ 4,647,000 £ - £ 378,000

BCF 05 Care and Support Reform LBR £ 1,090,000 £ - £ 3,923,000 £ -

BCF 06 Transforming Pallative Care LBR

£ 129,000 £ - £ 129,000 £ -

Capital LBR £ - £ 1,370,000 £ - £ 1,517,000 Total £ 7,133,000 £ 1,370,000 £ 203,000 £ - £ 16,032,000 £ 1,517,000 £ 756,000 £ -

2014/15 spend 2014/15 benefits 2015/16 spend 2015/16 benefits

Please list the individual schemes on which you plan to spend the Better Care Fund, including any investment in 2014/15. Please add rows to the table if necessary.

BCF Planning Template Outcomes & Metrics DRAFT


Outcomes and metrics

If planning is being undertaken at multiple HWB level please include details of which HWBs this covers and submit a separate version of the metric template both for each HWB and for the multiple-HWB combined

N/A

Metric 1: Permanent admissions to residential / nursing homes can be obtained from Care First 6 and Abacus IT systems Metric 2: Proportion of people at home after 91 days of rehabilitation and / or reablement has to obtained from Intermediate Care Team data and Care First 6 system used by LBR. Metric 3: NELCSU have undertaken to complete the data analysis required for this metric for the ten CCGs that it provides commissioning support services for in North and East London. A DTOC dataset has been received from NHS England and data for the last full financial year, 2012/13, selected as the most appropriate baseline. using the ready reckoner a performance target has then been made against which Redbridge can be assessed. The improvement target has been reviewed by LB of Redbridge and Redbridge CGG and recommended to HWBB. Metric 4: NELCSU have undertaken to complete the data analysis required for this metric for the ten CCGs that it provides commissioning support services for in North and East London. The emergency admissions dataset has been received from NHS England and data for the last full financial year, 2012/13, selected as the most appropriate baseline. using the ready reckoner a performance target has then been made against which Redbridge can be assessed.. The improvement target has been reviewed by LB of Redbridge and Redbridge CGG and recommended to HWBB Metric 5: TBD Metric 6: Public health outcomes framework data on injuries due to falls was last published for 2011/12 and, therefore, an earlier financial year has been selected for the baseline. Reference to the current JSNA and the borough's public health priorities can also be confirmed.

The national metric has been selected, so awaiting its release.

For each metric, please provide details of the assurance process underpinning the agreement of the performance plans

Please provide details of how your BCF plans will enable you to achieve the metric targets, and how you will monitor and measure achievement

For the patient experience metric, either existing or newly developed local metrics or a national metric (currently under development) can be used for October 2015 payment. Please see the technical guidance for further detail. If you are using a local metric please provide details of the expected outcomes and benefits and how these will be measured, and include the relevant details in the table below

BCF 01- (Outcome Metrics 3 and 5) Benefits: There is reduction in delayed discharges attributable to both health and social care separately, Discharge planning coordinated and planned with the individual in a person-centred way; BCF 02 (Outcome Metrics 2,4 and 5) Benefits: More people are able to self-care by having access to telecare, telehealth and assistive technology in their own homes. More people have the opportunity for advocacy and peer support services.Increase in number of people needing community reablement, Number of people having Falls reduces, Number of people at home after 91 days of Community reablement, Outcomes for people due to Advocacy services being available. BCF 03 - (Outcome Metrics 1, 4, 5, 6) Benefits: People have the choice, capacity and capabilityto live in a non-institutional setting; people are able to maintain their independence and control for as long as possible. BCF 04 - (Outcome Metrics 1, 4, 5, ) Benefits: Seamless pathway for people; less duplication across services; people are followed rather than their conditions, NHS number is the primary identifier and it is easy to see at any point of time the current care and support status for a user/patient; reduction in duplication of too many IT systems, People are supported in the community and have choice, independence and control over their lives. Those identified as being most at-risk of hospital admission will be able to access integrated health and social care support to enable them to maintain their health and independence. BCF 05 - (Outcomes Metrics TBD) Benefits: TBD BCF 06 - (Outcome Metrics 5) Benefits: People have the opportunity to be supported at the end of their lives and are able to retain dignity and respect until the very end.

BCF Planning Template Outcomes & Metrics 2 DRAFT


Please complete all pink cells:

Metrics Baseline*Performance

underpinning April 2015 payment

Performance underpinning October

2015 paymentMetric Value 320.0 254.0Numerator 110 90Denominator 34365 35481

( Apr 2012 - Mar 2013 ) ( Apr 2014 - Mar 2015 )Metric Value 0.82 0.86Numerator 265 292Denominator 325 338

( Apr 2012 - Mar 2013 ) ( Apr 2014 - Mar 2015 )

Metric Value 186.0 168.0 149.4Numerator 4771 3308 1998Denominator 212700 218795 222894

(April 2012 - March 2013) Apr - Dec 2014 (9 months)

Jan - Jun 2015 (6 months)


(April 2012 - March 2013) Apr - Sep 2014 (6 months)

Oct 2014 - Mar 2015(6 months)

(State time period and select no. of months)

(State time period and select no. of months)


(April 2011 - March 2012)

Permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population

N/A

Outcomes and metrics

Local measure Injuries due to falls in people aged 65 and over

Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation servicesNB. This should correspond to the published figures which are based on a 3 month period i.e. they should not be converted to average annual figures. The metric can be entered either as a % or as a figure e.g. 75% (0.75) or 75.0

N/A

Delayed transfers of care (delayed days) from hospital per 100,000 population (average per month)

NB. The numerator should either be the average monthly count or the appropriate total count for the time period

Avoidable emergency admissions per 100,000 population (average per month)

NB. The numerator should either be the average monthly count or the appropriate total count for the time period

Patient / service user experience For local measure, please list actual measure to be used. This does not need to be completed if the national metric (under development) is to be used N/A

To: NHS Redbridge CCG Governing Body From: Martin Sheldon, Chief Financial Officer, BHR CCGs Date: 27 March 2014 Subject: Budget Framework 2014/15 EXECUTIVE SUMMARY The purpose of this report is to present the 2014/15 revenue and capital budgets to the CCG for approval. The revenue budget is consistent with the operating plan and has been produced and reviewed by the CSU and approved by the Chief Operating Officers, Director of Finance and individual budget holders. The budget sets out a planned surplus for the CCG of £3.01m in line with their statutory duty. INTRODUCTION The CCG is currently planning to achieve a breakeven position in 2013/14. However, it faces ongoing financial challenges in order to achieve a 1% surplus in 2014/15, as NHS England is changing the way in which funding levels for local health services are calculated. The changes are aimed to help ensure that funding matches the needs of local populations. The CCG will receive a funding increase of 4.79% in 2014/15 moving Redbridge CCG closer to their target allocation. Other emerging risks are Specialised Commissioning, the CCG is expecting to receive a further £3.10m of funding relating to the specialist commissioning transfer that was agreed and received in the current financial year. The full funding impact of changes in Specialised Commissioning responsibilities are yet to be finalised. Also there is a national requirement for a Retrospective Continuing Care claims risk share. NHS England are proposing further restrictions on the use of Non Recurrent funds. Action plans will be required to mitigate these emerging risks. The CCG’s running cost budget will increase marginally to £7.03m in 2014/15 but receive an approximate 10% reduction to £6.40m in 2015/16. PLANNING GUIDELINES The NHS England planning guidance set out the following targets.

Surplus Policy Each commissioning organisation should plan to make a cumulative surplus at the end of 2014/15 of at least 1% of revenue, including any historic surplus carried forward from 2013/14. The maximum expected level of the national surplus drawdown will be finalised with NHS England and this has been included within the operating plan submission. A key measure of financial resilience of an organisation is the recurrent, or underlying, financial position after stripping out non-recurrent income and expenditure. Managing Risk It is important to ensure that the approach to risk management provides flexibility whilst providing sufficient mitigations against financial risks. These include:

• risk pooling between clinical commissioning groups; • policy for 2.5% of income to be set aside and spent non-recurrently in 2014/15

with 1% in subsequent years; and • contingencies of 0.5%.

Planning Assumptions Clinical commissioning groups should plan for an underlying growth in demand based upon both demographic and non-demographic changes. The running cost allowance for clinical commissioning groups in 2014/15 has been set in line with the total overall national allocation of £24.73 per head of population. The national provider efficiency requirement for 2014/15 tariff setting is 4%. This is offset against estimated provider cost inflation of 2.5 percent. This gives a net tariff adjustment of -1.5%, which is also the base assumption for discussions on price for services outside the scope of the mandatory tariff. The 30% marginal tariff for non-elective admissions continues. However, this is subject to further flexibility and negotiation with providers. Commissioners should budget for all admissions at 100% tariff. NHS England Area Teams will administer the 70% balance for local investment in relevant demand management schemes, jointly owned by commissioners and providers. Decisions on how to spend this resource will be undertaken by NHS England Area Teams in partnership with clinical commissioning groups.

In summary these key financial requirements are:

• 4.79% nominal uplift to Clinical Commissioning Group allocations.

• 4% efficiency assumption within national tariffs made up of a 2.5% non-funding of inflation and a 1.5% price reduction

• A requirement on Clinical Commissioning Groups to produce a plan including: 0.5% reserve 1% surplus in-year 1% recurrent surplus. 2.5% non-recurrent investment

The resource available to the CCG is summarised below. Opening Resources 2014-15 £'000 Recurrent Programme Baseline Allocation 277,702 Growth Uplift 13,290 Anticipated Adjustments 3,096 Programme Resources 294,088 Running Costs Allocation 7,032 Total Resources 2014-15 301,120 Opening Budget Envelopes and Financial Targets for 2014-15 At this stage appropriate budget negotiating envelopes have been drawn up locally, including input from our CSU acute and non-acute contracting teams, and meetings with NHS Trusts are in progress and agreement must be reached on all NHS contracts by 31 March at the latest. Specialised Commissioning are refining their criteria for commissioning services and the final impact of this is yet to be finalised across England, we are working with the current assessment of the impact on local CCG acute contract values. An update will be provided to the CCG governing body when the full impact is known. NHS England has introduced a needs-based funding formula and this has resulted in Redbridge CCG receiving a 4.79% funding increase in 2014/15, which is higher than the overall NHS England CCG allocations increase of 2.13%. As Redbridge CCG’s funding is 6.02% below the target allocation, it is anticipated that future differential funding increases will move it closer to target. In order to achieve a balanced budget position, including making a 1% surplus, the CCG currently needs a net QIPP programme of £15.33m in total.

Opening Budget Envelopes 2014-15 £'000 Acute BHRUT 72,801 Barts Healthcare 50,796 Other Associate Trusts incl LAS 35,008 Other Acute 13,900 Total Acute 172,505 Non Acute NELFT Mental Health Contract 20,840 Other Mental Health 8,198 NELFT Community Services 19,390 Other Community Services 3,350 Continuing Care 16,163 Other Healthcare Purchased 13,301 Total Non Acute 81,243 Primary Care Prescribing 34,012 Non Core Primary Care 1,805 Primary Care Total 35,817 CCG Running Costs 7,032 CCG 0.5% Contingency 1,508 Corporate/Reserves Total 8,540 Total Expenditure 298,106 Revenue Resource Limit 301,120 1% Surplus 3,014 The above figures include non-recurrent allocations for:

• CQUIN quality improvement measures (£5.36m), which represent an addition of 2.5% to NHS Contracts. One fifth of this value (0.5% of overall contract value) is to be linked to the national CQUIN goals, where these apply.

• Return of 2013-14 surplus (£0) • 2.5% headroom

QIPP Programme for 2014-15 The CCG has determined that it will need a net QIPP saving programme of £15.33m. The table below summarises the main areas where risk rated QIPP savings are planned. QIPP Programme 2014-15 £'000 Transactional Productivity and Contractual Efficiency Savings Planned Care 1,721 Mental Health Services 995 Community Services 322 Prescribing 2,500 Other Schemes 11 Transformational Service Re-design and Pathway Changes OP Redirection 768 Diagnostics (Pathology/Radiology/Cardiology) 784 ICM/CTT 500 Emergency Admissions/Acute Contract 4,141 Other Commissioner To be Identified 3,589 Total QIPP Savings 15,331 Reserves and Risk Mitigation The CCG has had significant cost pressures to deal with in the past few years, most significantly the growth in acute activity. The current envelopes include an assumption of £3.65m being set aside for acute growth, 2013-14 outturn, demographic growth and meeting Referral to Treat targets (RTT). Mental health and client group contracts are managing within their envelopes in 13-14, but significant service change is planned for 14-15 to deliver the QIPP savings. Prescribing has delivered significant savings to date, and is expected to continue in 14-15, both as a result of national price changes, and excellent local work by our medicines management team. Other previous high risk areas such as the primary care contracts have now transferred to the NHS England and other bodies, so we will no longer hold the risk for these areas. However, traditionally the majority of risk has materialised around the areas the CCG remains accountable for, particularly acute services and any transfers in commissioning responsibility to/from other bodies. Other emerging risks are Specialised Commissioning, the full funding impact of changes in Specialised Commissioning responsibilities are yet to be finalised. Also there is a national requirement for a Retrospective Continuing Care claims risk share. NHS England are proposing further restrictions on the use of Non Recurrent funds. Action plans will be required to mitigate these emerging risks.

The table below shows the reserves for Redbridge CCG. Planned Reserves for 2013-14 £'000 2.5% Non recurrent funds 7,540 0.5% General contingency 1,508 Re-admissions Credit 0 Total Reserves 9,048 CCG Running Costs CCG running costs have been reviewed with the CCG and will be contained within the allocation of £7.03m. Capital Budget The capital budget has been set at £1.0m to cover Corporate IT and NELFT Disengagement. Forward Look to 2015-16 onwards The Operating Framework for 2014-15 onwards was published in December 2013. This states the expectation that CCG’s will move up to a 1% annual surplus each year from 2014-15 onwards. The new NHS England allocations formula has been introduced in 2014-15 and this will give lower overall growth uplift in future years. Taken together, these issues represent an increased level of risk to achieve targets from 14-15 onwards, and it is expected that the level of QIPP required will remain a significant challenge in future years. Recommendations 1. The CCG are asked to approve the budgetary framework for 2014-15. 2. The CCG are asked to delegate authority for contract negotiations, to the Chief Officer, Chief Financial Officer and CCG Chair, to allow these to be concluded by the deadline of 31st March. They will take account of the advice from clinical members of the committee who are engaged in the negotiations.

APPENDIX – Operating Plan Financial Summary NHS Redbridge CCG 08N Contents Quality Checks

Financial Position

Revenue Resource Limit£ 000 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19Recurrent 287,742 301,125 318,443 329,498 340,543 351,741Non-Recurrent 10,282 (5) 3,014 3,219 3,329 3,441Total 298,024 301,120 321,457 332,717 343,872 355,182

Income and ExpenditureAcute 182,334 172,505 181,913 186,099 192,006 197,577Mental Health 30,450 29,038 29,704 30,500 31,380 32,256Community 21,856 22,740 23,927 25,680 26,533 27,371Continuing Care 15,284 16,163 17,067 18,409 19,892 21,473Primary Care 36,523 35,817 35,364 36,473 37,589 38,761Other Programme 3,206 13,301 22,255 24,093 24,777 25,815Total Programme Costs 289,653 289,566 310,229 321,255 332,177 343,253

Running Costs 6,940 7,032 6,400 6,468 6,534 6,597

Contingency 1,431 1,508 1,609 1,665 1,721 1,778

Total Costs 298,024 298,106 318,238 329,387 340,431 351,628

£ 000 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19Surplus/(Deficit) In-Year Movement (2,919) 3,014 205 111 112 113Surplus/(Deficit) Cumulative 0 3,014 3,219 3,329 3,441 3,554Surplus/(Deficit) % 0.00% 1.00% 1.00% 1.00% 1.00% 1.00%Surplus (RAG) AMBER GREEN GREEN GREEN GREEN GREEN

Net Risk/Headroom (2,984) 210 1,665 1,946 2,121Risk Adjusted Surplus/(Deficit) Cumulative 30 3,429 4,994 5,387 5,675Risk Adjusted Surplus/(Deficit) % 0.01% 1.07% 1.50% 1.57% 1.60%Risk Adjusted Surplus/(Deficit) (RAG) AMBER GREEN GREEN GREEN GREEN

Underlying position - Surplus/ (Deficit) Cumulative (5,044) 4,415 6,024 7,982 10,619 14,331Underlying position - Surplus/ (Deficit) % -1.75% 1.47% 1.89% 2.42% 3.12% 4.07%

Contingency 1,431 1,508 1,609 1,665 1,721 1,778Contingency % 0.5% 0.5% 0.5% 0.5% 0.5% 0.5%Contingency (RAG) GREEN GREEN GREEN GREEN GREEN

Notified Running Cost Allocation 6,940 7,033 6,401 6,468 6,534 6,597Running Cost 6,940 7,032 6,400 6,468 6,534 6,597Under / (Overspend) 0 1 1 0 0 0Running Costs (RAG) GREEN GREEN GREEN GREEN GREEN GREENPopulation Size (000) 278 284 290 296 301 306Spend per head (£) 25.00 24.73 22.07 21.88 21.70 21.53

Key Planning Assumptions2014/15 2015/16 2016/17 2017/18 2018/19

Notified Allocation Change (£'000) 3,096 20,337 11,260 11,156 11,310Notified Allocation Change (%) 4.65% 4.05% 3.47% 3.35% 3.29%Tariff Change - Acute (%) -1.50% -1.50% -1.00% -0.60% -0.60%Tariff Change - Non Acute (%) -1.80% -1.80% -1.00% -0.60% -0.60%Demographic Growth (%) 2.04% 1.95% 1.87% 1.81% 1.75%Non Demographic Growth - Acute (%) 2.46% 2.55% 2.63% 2.69% 2.75%Non Demographic Growth - CHC (%) 1.00% 1.00% 1.00% 1.00% 1.00%Non Demographic Growth - Prescribing (%) 5.00% 5.00% 5.00% 5.00% 5.00%Non Demographic Growth - Other Non Acute (%) 1.40% 1.40% 1.40% 1.40% 1.40%

Net QIPP Savings£ 000 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19Recurrent (inclusive of full year effect) 15,600 15,331 11,128 5,735 5,911 5,931Non-Recurrent - - - - -Total 15,600 15,331 11,128 5,735 5,911 5,931% of Notified Resource 5.23% 5.09% 3.46% 1.72% 1.72% 1.67%% Unidentified -23.41% -24.41% -23.80% -23.90% -24.56%

Non Recurrent Requirement£ 000 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19Value 7,352 3,120 3,230 3,340 3,451Agreed plans in place 1,455 3,038 3,230 3,340 3,451Difference - 5,897 82 (0) (0) (0)

To: NHS Redbridge CCG Governing Body From: Louise Mitchell Chief Operating Officer Date: 27th March 2014 Subject: QIPP 14/15 Planning progress update Executive summary The identified financial value of the QIPP for Redbridge CCG for 14/15 is £15.3m. This report provides an overarching summary of the identified schemes for 14/15 both from an investment and savings perspective. Savings currently identified equate to a total value of £12.5m subject to the caveats noted below. NHSE have made provision for additional resource to be made available to the CCG to support the identification of additional plans to secure at a minimum the delivery of the full value in year. The report provides an assessment of risk associated with each of the schemed identified to date from a planning perspective; delivery will commence from April 1st from an accounting perspective. The schemes identified align to the budget report full value of £15.3m .The Governing Body is advised that the schemes are still to be considered as a work in progress and savings are subject to final contractual sign off with key providers and full analysis of supporting data for innovation schemes. All schemes requiring investment will be subject to formal governance procedures for authorisation prior to service commencement. Each scheme will have an identified Clinical Lead (Clinical Director) and designated Officer lead from within the CCG staff team. Delivery and monitoring of all schemes will be subject to the same robust arrangements that were in place for 14/15 with regular reporting of progress and mitigation of risk raised though the Executive Committee. Recommendations The governing body is asked to: • Note the progress report setting out the summary of 14/5 QIPP schemes which is attached in the

form of a Candlestick report. • Receive a further report detailing progress against delivery commencing April 1st 2014 at

subsequent Governing Body meetings.


1.1 This report provides an update for members with regard to the progress and risks to planning

Redbridge CCG’s QIPP Plan for 20145/14. The report is for information and members are asked to note the progress.


2.1 The value of the QIPP for Redbridge for 2014 /15 has been identified as £15.3m. Despite its lower value than the £20m QIPP for 13/14 it still poses a significant challenge and is to be viewed in the context of the overarching financial position for the CCG. This report specifically addresses the ‘planning’ phase of QIPP schemes as opposed to the delivery phase which will commence from April 1st.

2.2 Each of the QIPP schemes will be subject to a Quality Impact Assessment and will focus on continued provision of quality services for the population of Redbridge.

2.3 Many of the schemes identified illustrate a continuity of schemes that have been successful during 2013/14 and are known to have capacity to bring continued efficiency over a longer period of time. New opportunity schemes have been identified through a process of benchmarking our activity against other comparable organisations and through analysis of best practice from a clinical perspective; this is particularly notable both within unplanned care and medicines management productivity opportunities.

2.4 Public and user views have been reflected in some of the schemes already identified by way of active user engagement for example ; the provision of Community Treatment services and Integrated Case Management to enable individuals to receive quality care closer to home and out of hospital.

2.5 All schemes are subject to formal approval through the governance arrangements in place for the CCG and will be subject to continuous monitoring of delivery and risks as has been in place during the current financial year.

2.6 The Governing Body will continue to receive a progress report detailing progress against delivery in year and risks associated with this..

3.0 Report Content 3.1 This report provides a summary of schemes identified to date with a risk rating

assessment of planning progress to date for each scheme. 4.0 Resources/investment 4.1 To date, an investment requirement of £1.3m identified to date to support the move of

care from hospital to community and therefore enable delivery of the full realisation of financial value reduction to the acute contract for BHRUT.

5.0 Equalities 5.1 Individual schemes will be subject to an impact assessment. As part of the formal

approval process evidence of such will be provided.

6.0 Risk 6.1 The current value of the risk associate with the plan is c £3m – this relates to

unidentified savings schemes. ( labelled as Pipeline and Innovation Schemes)

6.2 Additional resource identified by NHSE to support the planning phase of 14/15 QIPP is focused on the identification of schemes which will enable full delivery of QIPP in year at a minimum therefore enabling the plans for 14/15 to realise £15.3m once finalised.

Attachments: 1. Candlestick Planning Report 14/15 QIPP schemes NHS Redbridge CCG

Author: Louise Mitchell Date: 17th March 2014

QIPP Scheme Current Value£000k

ProgressRisk Rating (RAG)

Outpatient reduction 858a

Associate adjustments 336a

Diagnostics - pathology 148a

Diagnostics - radiology 434a

Diagnostics - cardiology 150g

POLCV 160g

ICM/ CTT 554g

Falls 285a

Frequent attenders 189a

A&E paeds 100a

Calprotectin 232a

Medicines management 2500a

Redbridge CCG 14/15 QIPP Planning Progress Summary

GPSI contracts 343g

Productivity measures 971a

MH contracts 225g

Community contracts 290g

Patient transport 100g

Non clinical SLA at WX 60a

NELFT - MH ISA benefit 300g

NELFT 1% CQUIN on community 410r

NELFT saving on MH 100g

Meadowcourt 250a

OOH 100g

A&E - linked to urgent care pathway 410a

EM admission saving 897a

Maternity charge adjustment 400a

Additional QIPP aligned to BHRUT 2014/15 agreement 3000a

Investment - OP and EM demand management -1300a

SUBTOTAL 12501

Schemes in development 2799

r

Total 15300

R= No plan identifed / rejectedA = Plan in progress / not completeG= Plan completed to full scheme value

Project approval? (Y/N)

2014/15 QIPP Redbridge

Investment

Outpatient FA reduction Moving to median referral rate for key specialties - T&O, Rheumatology, Ophthalmology, Diabetes, General Surgery

0.86 0.20 0.66 R C Marshall Dr Tahir

Community Diagnostics Reprovision of the Community Diagnostics contract. Savings achieved through, reduced activity and cost.

0.23 0.00 0.23 A C Marshall Dr Sood

Pathology demand managementReducing testing in line with benchmark and good practice guidelines

0.15 0.00 0.15 A C Marshall Dr Sood

Calprotectin Increased uptake of the Calprotectin Diagnostics to reduce Endoscopy activity

0.32 0.09 0.23 A G Gungor Dr Okorie

Contractual adjustments to out of area providersAdjusting for overperformance areas on non local providers - biggest adjustments are Moorfields and UCLH

0.34 0.00 0.34 A C Marshall TBC

POLCV Implementation of a revised POLCV policy for 2014/15

0.16 0.00 0.16 G C Marshall Dr Tahir

Patient transportReduction on cost of service and need to review criteria

0.10 0.00 0.10 G C Marshall Dr Tahir

Cardiac diagnosticsImplementation of a ECG Interpretation scheme in primary care, and implementation of SNP testing for heart failure

0.22 0.07 0.15 G G Gungor Dr Ali

Admission Avoidance Reduction of admissions, through ICM/CTT. 1.20 0.66 0.54 G S James Dr Mathukia

Admission Avoidance Reduction of admissions, through EOLC, Falls and reducing frequent attenders.

0.47 0.10 0.37 A C Marshall/G Gungor Dr Mathukia

Emergency admissions 0.90 0.30 0.60 A S James Dr Mathukia

A&E attendance reduction Reduction in A&E attendances from the "no investigation, no treatment" category for (i) paediatrics (ii) all attendances

0.51 0.20 0.31 A S James Dr Mathukia

OOH contract negotationSaving through reduction in duplication between OOH and 111

0.10 0.00 0.10 G S James Dr Raza

Medicines Management

Prescribing incentive schemeTo achieve additional medicines management saving opportunities through the use of primary care incentives

2.50 0.00 2.50 A Belinda Krishnek Dr Okories

Contract productivity - BHRUT & BH Contract efficiencies 0.97 0.00 0.97 A K Boettcher TBC

Contract productivity - NELFT Contract efficiencies 0.51 0.00 0.51 R K Boettcher TBC

Other contract negotiationMH providers; WX non clinical SLA; Meadow Court; Maternity charge adjustment

1.23 0.00 1.23 A K Boettcher TBC

CCG led schemes Budget review GPSI contracts/ MH ISA benefit 0.64 0.00 0.64 G K Boettcher TBC

BHRUT contract impact 3.00 0.50 2.50 A K Boettcher TBC

Total14.40 2.12 12.28

14/15 QIPP Target 15.3

Under-identified QIPP 3.02

Net QIPP Saving £m

Senior Lead

Contract Productivity - Acute & Community

Workstream Sub initiative

Planned Care

Project RAG

Unplanned Care

Gross saving Scheme description Clinical lead

G

A

R

Appropriate degree of project planning in place (project brief, milestones, actions, timelines) and milestones are being met / Risks identified with sufficient mitigating actions.

Project plan in place although some key steps are not sufficiently addressed / Risks, including quality impacts, identified but sufficient mitigating actions not in place.

Scheme remains conceptual/no evidence of project planning in place / There appear to be significant risks to financial delivery and insufficient mitigating actions in place.

To: Meeting of NHS Redbridge Clinical Commissioning Group Governing Body From: Conor Burke, Chief Accountable Officer Date: 27 March 2014 Subject: BHRUT Performance

Executive summary The CQC inspected the Trust from 14 - 17 October 2013 and held a Quality Summit on 17 December 2013 where the final reports were shared. It was also announced at the Quality Summit that the Trust was being placed in “Special Measures” as it was recognised given the scope and scale of the challenges faced by the Trust additional support was required. The Governing Body received a report in January describing the initial actions to be taken by local and national organisations to address the key issues identified within the CQC report. This report provides an update on recent developments and actions.


• Note the action being taken to date

• Agree to receive a further report on the Trust Improvement plan at its next meeting

1.0 Purpose of the Report 1.1 To provide an update to the Governing Body on developments and actions since

January with regards special measures and performance at BHRUT 2.0 Background/Introduction

2.1 The CQC inspected the trust from 14th -17th October 2013. It was also announced at

the Quality Summit that the trust were being placed in “Special Measures” as it was recognised that given the scope and scale of the challenges faced by the Trust additional support was required.

2.2 Given the scale and scope of the challenges faced by the Trust it was placed in special

measures by the CQC and TDA on the 18 December 2013. 2.3 The Governing Body received the CQC inspection report and findings at its January

meeting. 2.4 The Special Measures include:-

• The requirement for the Trust to develop an improvement plan. • That an organisational capability review be conducted by Sir Ian Carruthers on the

15 and 16 January 2014. • A Board to Board meeting in February • The TDA will appoint an Improvement Director. • The Trust will receive support from the TDA Special Measures Director. • The Trust is buddied with a Foundation Trust for peer support.

2.5 The CQC report and Special Measures makes little reference to the wider health and

social care system. However as the statutory bodies responsible for commissioning safe and sustainable health services across the BHR system, the CCGs have a fundamental role to play in this process.

3.0 CCG Action

3.1 The Chief Officer and Cheryl Coppell, LBH CEO have met with Alwen Williams, Director of Delivery & Development (London) TDA in January to discuss and agree arrangements for the development of the Trust improvement plan.

3.2 The Chief Officer has received a copy of the Trusts draft improvement plan and has had

a very positive meeting with the TDA’s Improvement Director and colleagues to agree how this will be further developed and finalised in April alongside and aligned with the BHR system wide strategic plan.

3.3 The CCGs continue to actively manage the Trust on contracted performance and quality

targets including the A&E 4hr wait. The CCGs have agreed a revised 4hr wait target recovery trajectory with the Trust to achieve 91% by the end of March. BHRUT are currently on track to achieve this.

3.4 The CCGs have made good progress negotiating 14/15 contracts that enable the Trust

to focus on service improvement. As the Trust and system improvement plans develop, we will ensure all agreed targets are aligned with and actively managed through related provider contracts.

3.5 Further and rapid development of primary care is critical to improving outcomes for local

people and the future of this health economy. The CCG has developed a primary care improvement plan and submitted a bid to resource this through the Prime Ministers Challenge Fund. We are awaiting feedback on our submission and in the meantime are reviewing which elements of the plan we intend to implement if the bid is unsuccessful.

3.6 The Chief Officer has initiated early discussions with local partners, NHS Improving

Quality and UCL Partners to begin to establish a BHR system wide leadership programme.

4.0 Resources/investment 4.1 The Trust will scope its investment/resource requirements as part of the development of

its improvement plan.

4.2 The CCG CFO has started to work with NHSE colleagues on our approach to

transitional funding which will be fundamental to delivering the required changes. 5.0 Equalities 5.1 The implementation of the Trust improvement plan will improve quality and reduce

health inequalities.

6.0 Risk 6.1 Patient quality and safety concerns continue. 6.2 The Trust may be placed into Special Administration should services not improve.

Author: Conor Burke, Chief Accountable Officer Date: 17th March 2014

To: Meeting of the Redbridge Commissioning Group Governing Body From: Jacqui Himbury, Nurse Director Date: 27 March 2014 Subject: Implementing the Recommendations of the Francis Report Executive summary This paper provides an update on the progress made to address and implement the Francis Report recommendations. How Redbridge Clinical Commissioning Group (CCG) and the NHS as a whole responds to this report is a critical test of its ability to make a real difference to improving patient safety and to caring for some of the people most at risk in society. The overarching lesson from events at Mid Staffordshire is that a fundamental culture change is needed to put people at the centre of the NHS. This is why Redbridge CCG has made a commitment to review and implement the Francis Report recommendations. The changes that are required to ensure that Redbridge CCG develops and fosters a culture of compassionate care in which patients are genuinely and consistently at the centre of everything we do cannot be managed or delivered through a discrete programme management approach. However, the CCG has made commitments to implement a number of specific early actions and changes arising from the Public Inquiry, and this paper focuses on progress of those actions. Recommendations The governing body is asked to: • Note the progress report and the action taken by the CCG to implement the recommendations to

date • Agree to next steps in section 4

1.0 Purpose of the Report 1.1 The nurse director was asked to develop an implementation plan in response to the Francis

Report recommendations at the meeting of the Governing Body in April 2013; this plan is detailed at Appendix 1.

1.2 This paper sets out detailed progress against the goals in the plan, which is the Barking & Dagenham, Havering and Redbridge (BHR) heath and care system wide response to the Francis Report. The CCG is the lead organisation for implementation of the plan.

1.3 This paper provides assurance to the Governing Body on the progress that Redbridge CCG is making to implement the Francis Report recommendations.

2.0 Background 2.1 The report of the Public Inquiry led by Robert Francis QC into Mid Staffordshire was published

on 6 February 2013. It told the story of the appalling suffering of many patients, primarily caused by a serious failure on the part of a Trust Board which did not listen sufficiently to its patients and staff or ensure the correction of deficiencies were brought to the Trust’s attention. It failed to tackle a culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. The report referred to the many checks and balances in the NHS system which should have prevented serious systemic failure of this sort but did not.

2.2 The report set out 290 recommendations but its overarching theme was clear: that a fundamental culture change is needed in the NHS to put patients first.

2.3 The government’s initial response to Francis, Patients First and Foremost, was published by the

Department of Health (DH) on 26 March 2013 on behalf of the health and care system. It set out how the NHS would begin to respond to Robert Francis’s challenge to make patients ‘the first and foremost consideration of the system and everyone who works in it’. It included a statement of common purpose, jointly developed and signed by a wide range of partners who share responsibility for patient care.

2.4 A more comprehensive response, entitled Hard Truths: the journey to putting patients first, was

published in November of the same year, which presented a detailed response to each recommendation, and set out new actions planned by the government, including requiring commissioners to make better use of patient safety information, such as detailed patient complaints data. The recommendations of both government responses were considered and reviewed during the development of our implementation plan,

3.0 Progress to date 3.1 A BHR system wide task and finish group (the group) was established in September 2013,

chaired by the Nurse Director and comprising members of BHR CCGs and Local Authorities. The group also sought the views of and engaged with providers, Lay members of the governing bodies, Healthwatch and Safeguarding Board Chairs to review the recommendations in detail, agree priorities for delivery and to develop an implementation plan. The group confirmed our commitment to work in partnership, recognising that changing culture in the health and care system can only be achieved with the continued of support the various organisations locally.

3.2 We recognise that success will require sustained action and leadership over a number of years. In this context, the table at Appendix 1 provides only a snapshot of progress. It sets out details of the actions agreed in the implementation plan for which the CCG is the lead organisation, or has a key role or responsibility. The table provides a progress report on each action and describes the further work required where appropriate.

3.3 During 2013/14 we have achieved:

• We have published our response to the Francis Report on our website • A quality assurance monitoring framework has been implemented for all our large and

medium size contracts • As a CCG we have welcomed patient and public feedback, have acknowledged service

difficulties where they exists and have worked and encouraged providers to do the same. • The sharing of quality and safeguarding information with our partners has alerted us to

potential quality concerns and enabled us to take immediate action • We have developed internal systems that enable the quality team to work with general

practitioners to follow up concerns raised during patient consultations

• Clinical directors actively participate in the Clinical Quality Review Meetings and this has strengthened our clinical contract management

3.4 Redbridge CG has made significant progress in implementing the Francis Report

recommendations over the past twelve months and continues to deliver to plan.

4.0 Next Steps 4.1 To continue to implement the agreed actions, with progress reviewed by the Quality and Safety

Committee in April 14.

4.2 To continue to implement all completed actions within our current commissioning system and daily activities, such as quality assurance walk round visits to departments in Barking, Havering, Redbridge University NHS Trust and North East London NHS Foundation Trust. This will ensure that quality and patient centred care underpins all that we do as a commissioning organisation.

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

The cost of implementing the Francis Report recommendations has been met from within existing resources.

6.0 Equalities 6.1 Delivery of the Francis Report system wide implementation plan will promote the values of the

NHS constitution and uphold the rights it confers on people; improve health outcomes; promote equality and reduce health inequalities; and make Redbridge CCG an excellent organisation so that we can work with patients, the public and our partners to deliver progress in all these areas.

7.0 Risk 7.1 The risks arising from this report are already fully captured within the governing body assurance

framework, which also confirms assurance controls and mitigating actions.

Attachments: 1. Appendix 1- Update on progress with the Actions for Redbridge CCG from the System

response to the Francis Report

Author: Jacqui Himbury, Nurse Director Date: 11 March 2014

Francis Report System Wide Implementation Action Plan Version 4.2 Author Jacqui Himbury Updated date: 19 March 2014

Francis Report Task & Finish Group

System Wide Implementation Plan

Week Commencing: 17 March 2014 RAG Key for monitoring progress Tasks and outcomes are completed

Tasks and outcomes are on track, milestones met but

not completed Tasks and outcomes have not been met or timescale

slipped

No update available

Goals Francis Recommendation Task Due Date Owner (s) Status RAG All organisations must publish their response to the Report and Recommendations

1 Prepare and publish a response to the Francis report on organisational websites. All organisations to prepare an annual report on the implementation of the Francis recommendations and to progress through internal governance mechanisms. Receive provider response to Francis Inquiry – BHRUT, NELFT, BH, PELC, Basildon University Hospital Trust. This should be included in the Quality Accounts

December 30 March 14 28 February 13

BDCCG Response now on the CCG website HCCG Response now on the CCG website RCCG Response now on the CCG website LBBD In progress

Update report on progress going to HWB 11 February 13

LBH In progress

LBR Progress reports programmed in for Health Scrutiny Committee

Contracts for services must be clear on minimum standards and be Francis compliant

8, 13, 14, 124, 125, 127, 129, 130, 131, 132, 135, 136, 137, 205, 245

Review all contracts & ensure Duty of Candour or an equivalent requirement is included. 2014/15 Duty of Candour strengthened in NHS Standard contract. Francis specifically referenced in the 14/15 contracts.

31 January 14

BDCCG Standard NHS contracts to be issued to all providers when new contracts issued.

HCCG Contract negotiation process ongoing. New contracts will be issued for 14/15

RCCG CSU to be asked to do this LBBD Public Health Contracts to have included as

appropriate on renewal

LBH This is a commissioning task and is in hand LBR DoC will be considered in the context of existing

frameworks for adult social care which includes ongoing working relationships with CQC and Safeguarding Adults Board

Ensure there is sufficient commissioning capacity to quality monitor and performance manage all contracts. Processes for identifying risks and emerging risks need to be clearly defined. This must include the appropriate escalation of risks

24 January 13

BDCCG The larger contracts have a formal quality and performance framework in place. Medium size contracts are now quality assured. Smaller contracts are being reviewed, quality indicators are being developed that act as an early warning system. For Care homes joint quality assurance visits are being completed by LBH and CCG. Strong links with the CQC have also been developed.

HCCG The larger contracts have a formal quality and performance framework in place and we have


quality assured medium size contracts. Smaller contracts are being reviewed, quality indicators are being developed that act as an early warning system. For Care homes, we undertake joint quality assurance visits with LBH and CCG.

RCCG There is capacity to manage – the governance structure is in place for all major contract management. Capacity issues have been identified with medium and smaller value contracts. This is on the risk register and plans are in place to mitigate the risks.

LBBD There is capacity to manage public health contracts

LBH There is capacity to manage contracts and this has been reviewed across all contracts. Quality performance governance frameworks are in place to monitor public health contracts such as school nursing, health visiting and sexual health services. CSU represent the CCG on the Quality and Suspension Committee. Provider performance is reviewed and monitored at this meeting.

LBR This has been reviewed and can be recorded as green.

Escalation and reference points are in place for addressing and managing poor performance

31 January 13

BDCCG Clinical quality review meetings and service performance review meetings are in place for major contracts. Contract management arrangements are being reviewed for some small contracts.

HCCG We use the Clinical Quality Review Meetings (CQRM) and Strategic Performance Review (SPR) meetings with our major providers to do this. We are reviewing the contract management arrangements for small providers.

RCCG This is done through the Clinical Quality Review Meetings (CQRM) and Strategic Performance Review (SPR) meetings. PELC has a combined meeting.

LBBD Performance mechanisms in place across council contracting

LBH This is addressed by the Quality and Suspension Board for all our contracts. Issues of concern are escalated to the Safeguarding Adults Board or LSCB. Winterbourne reviews of people with learning disabilities are undertaken and monitored through specific arrangements.

LBR Reviewed and complete Develop system wide integrated processes for tracking and reporting on patient experience and safety

12, 252, 253, 254 Systems & processes are in place for tracking poor performance. The sharing of information is through the safeguarding boards, Quality Surveillance Group, LD Partnership Boards and the local operational systems. All agencies to review effectiveness at keeping people safe.

31 December 13 14 March 14

BDCCG Complete HCCG Complete RCCG Complete LBBD Complete LBH Complete LBR Complete


Identify and close gaps in monitoring. To consider and collaborate with Frailty Academy. Incorporate work from delayed cancer diagnosis audit – primary and secondary care

28 February 14

BDCCG Collaborative cancer commissioning group established, which will focus on early diagnosis. Quality and Safety Committee responsible for tracking and reporting on patient experience and safety.

HCCG This is a focus at both CQRMs and Quality and Assurance Committee. We are supporting the Frailty Academy through a Lead Clinical Director for Care Homes and have encouraged two care homes leaders to join the Frailty Action Learning set.

RCCG This is done through the CQRMs. Gaps exists for smaller providers. Actions are in place to close the gaps

LBBD Public Health reviewed and fine LBH This is done jointly between Quality Team and

Safeguarding

LBR Reviewed and reported complete. Gaps identified and closed.

Collaborate on design of system-wide model to develop a Clinical Quality Board Consider other models and learn from best practice. Integrated social care and health models reviewed. Kings Fund and UCLP research also reviewed.

31 Mar 14 All Workshop held. Quality Improvement Board to be established to manage response across BHR economy. To go to ICC end of March

Develop process for tracking patient experience by primary care as referrers and commissioners of services. This is to develop a sustainable, shared, mature patient and service users safety culture across the entire health and care system.

123, 134, 135 Monitor patients receiving acute treatment. Clinical insights on quality of services is captured from front line staff in general practice Work with CSU on reporting framework to CCGs. To be monitored by the Quality and Safety Committee

28 March 14

BDCCG A formal system is in place, although this requires a review which will be completed at end of February 14

HCCG Plans are in place to implement a formal system of capturing real patient experience. The financial resourcing issues are in the process of being resolved.

RCCG This is done through a CQUIN, monitored by the CQRM. Still to develop a systematic process for capturing feedback and patient stories.

Develop internal systems to allow GP’s to track areas of concern

28 March 14

BDCCG Process in place for capturing practice feedback is through locality meetings and localities issues log.

HCCG We use our locality meetings to capture practice feedback and considering further how this can be developed into an early warning system across the local health economy.

RCCG This takes place through the 4 Locality Committee meetings

Ensure open and shared communication of up-held complaints

109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122

Consider processes required to obtain adequate consent

28 February 14

BDCCG CCG complaints policy in place. Review of consent policy in progress

HCCG RCCG This is detailed in contracts LBBD Public Health contracts where appropriate

consent is built in i.e. sexual health, healthy adults etc

LBH Normal practice LBR Public Health contracts: where appropriate

consent is built in i.e. sexual health, healthy adults etc.


Write to providers to formally enquire how they propose to implement these recommendations

12 February 14

BDCCG HCCG RCCG Contracting are drafting a letter template to send

to providers

LBBD Public Health contracts been built in for future contracting discussions

LBH LBR Discussion will be built into Public Health contract

monitoring discussions

Develop process for sharing upheld complaints when consent given

26 March 14

BDCCG HCCG RCCG LBBD Public Health being discussed locally and

nationally

LBH LBR Process for Public Health being discussed locally

and nationally

Revise LA Scrutiny process 145, 146, 147, 149, 150 Revise and implement local scrutiny processes 12 February 14

LBBD Complete LBH Via Quality and Suspension Board and

Safeguarding

LBR Complete To ensure active involvement of clinical leaders in performance management of quality and safety

2, 11 Clinical leaders to attend CQRM meetings to strengthen focus on clinical outcomes and triangulation of quality indicators

29 January 14

BDCCG Complete HCCG Complete RCCG Complete – Two Clinical Directors are members

of the Quality and Safety Committee

All patients in acute settings to have an identified consultant who is responsible for their care and to be seen by consultants

236, 238 Ensure acute and mental contracts contain this provision and that this is monitored through the CQRM’s

31 March 2014

BDCCG This is being discussed during the clinical contracting discussions and was discussed at the January CQRM.

HCCG This is within the BHRUT contract and for A&E is monitored through the Emergency Care Standards Group.

RCCG Barts Health contract is currently under discussion through the negotiation process

Culture and organisational development. Culture must be defined, understood and accepted by all staff who work within our organisations. This should then be continually reinforced by leadership, training, personal engagement and commitment. Have clear workforce plans for recruitment, retention and development of staff to create a positive culture

7, 126, 179, 180, 191, 194 Review existing workforce development plans and build on these plans in conjunction with Human Resources. Recruitment and retention must be specific actions

26 February 2014

BDCCG Initial governing body away day held to build concept of behaviour charter that puts the patient at the heart of all we do.

HCCG Output of governing body away day shared with all staff at organisational staff briefing

RCCG Check with CSU HR staff LBBD Borough based workforce plans being developed LBH Normal Practice LBR Normal practice

Examine how new vetting system impacts on recruitment and retention

26 February 14

BDCCG The safeguarding assurance committee is reviewing this working with corporate services

HCCG The safeguarding assurance committee is reviewing this working with corporate services

RCCG The safeguarding assurance committee is reviewing this working with corporate services

LBBD In progress LBH In progress LBR In progress

Develop effective shared governance for quality and safety that demonstrates our commitment to quality

11, 244 NHS England’s QSG to invite representatives from local authorities and Health Watch

NHS England

Complete

Identify system wide issues through intelligence sharing BHR GGS Strategically and operationally systems have


Nurse Director

been reviewed and changes made. Formal intelligence sharing now common practice.

Patient and Public Involvement and insights to ensure service user and patient feedback drives quality improvement.

Locally led conversations with patients, service users and their families and carers about “what matters to you”

Ongoing All Each agency to identify methods of communication working with communication leads

Patient vignettes to go to every governing body meeting to present a patient perspective of receiving care

Ongoing BHRCCG This was discussed at all governing body meetings in January and is being progressed working with PPE lay members of the governing body’s

Action Plan to be updated every fortnight after each meeting of the Task and Finish Group New actions to be agreed at Task and Finish group and added as needed

To: Meeting of the Redbridge Clinical Commissioning Group Governing Body From: Jacqui Himbury, Nurse Director Date: 25 March 2014 Subject: Safeguarding Adults Annual Report Executive summary The term ‘safeguarding adults’ covers everything that assists an adult vulnerable to abuse and neglect to live a life that is free from harm and which enables them to retain independence, well-being, dignity and choice. It is about preventing abuse and neglect, as well as promoting good practice for responding to concerns on a multi-agency basis. Whilst the responsibility for coordinating safeguarding adult’s arrangements lies with local authorities, effective safeguarding is based on collaboration, a local multi-agency approach and strong partnerships. Safeguarding is wide ranging, however this report focuses specifically on :

• The prevention of harm and abuse through provision of safe, effective and high quality are care • Effective responses to allegations of harm and abuse, responses that are in line with local

multi-agency procedures • Using learning to improve service to patients, their families and carers and members of the

public. Safeguarding adults from harm is one of the Clinical Commissioning Group’s (CCG) quality priorities which underpins and supports delivery of corporate objective: To improve the quality of care from all the services we commission Redbridge CCG have a commissioning responsibility to ensure the government approved safeguarding principles are applied in how we operate as an organisation and when working with our partners. This annual report details how the CCG fulfils their obligations. Safeguarding is also central to the quality of care and the NHS outcomes framework, particularly:

• Domain 4 - Ensuring people have a positive experience of care: and • Domain 5 -Treating and caring for people in a safe environment and protecting them from

avoidable harm. Recommendations The governing body is asked to: • Note the report and advise on any further actions required • To agree the recommendations for 2014/15 safeguarding adult priorities in section 6

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1.0 Purpose of the Report 1.1 To provide assurance that Redbridge CCG have complied, during 2013/14, with and will

continue to comply with the expected best evidence safeguarding standards as set out in: Role of the commissioners (2011); pan London policy and procedures to safeguard adults (2011); Safeguarding Vulnerable People in the Reformed NHS: Accountability and Assurance Framework (2013).

1.2 To provide an annual update to the Governing Body on the 2013/14 service developments for safeguarding adults and those at risk of harm.

1.3 As this is the first annual safeguarding adult’s report that Redbridge CCG Governing Body has received, it will inform members of the safeguarding adult responsibilities and how the organisation meets these responsibilities. This includes partnership working with the Safeguarding Adults Board (SAB).

1.4 Safeguarding services continued to be provided effectively through the transition and the Primary care Trust (PCT) handed over legacy documents to ensure continuity of effective service.

2.0 Introduction 2.1 Commissioners have responsibilities for commissioning high quality health care for all patients

within their defined boundary, including residents not registered with a general practitioner. We also have particular duties for those patients who are less able to protect themselves from harm, neglect or abuse, for example, due to impaired mental capacity.

2.2 Prior to establishment as a CCG we established systems for safeguarding adults, developed clear lines of accountability and governance arrangements and secured the expertise of a safeguarding lead professional. During 2013/14 we have further embedded and strengthened these arrangements, especially through partnership working with the Local Authority, Care Quality Commission and information sharing.

2.3 The Government’s policy objective continues to be to reduce the risk of significant harm to adults from abuse or other types of exploitation, whilst supporting individuals in maintaining control over their lives and making informed choices without coercion. Therefore all safeguarding arrangements must reflect the principles the Government has set out that provide an excellent foundation to achieve positive outcomes and experiences for people. The safeguarding adult principles are:

• Empowerment – presumption of person led decisions and informed consent • Prevention – it is better to take action before harm occurs • Protection – support and representation for those in greatest need • Proportionality – proportionate and least intrusive response appropriate to the risk

presented • Partnership – local solutions through services working with their communities • Accountability- and transparency in delivering safeguarding.

2.4 Safeguarding is also central to the quality of care and the NHS outcomes framework, particularly: • Domain 4 - Ensuring people have a positive experience of care. • Domain 5 -Treating and caring for people in a safe environment and protecting them from

avoidable harm. 3.0 Safeguarding arrangements and delivery 3.1 There is a joint Barking & Dagenham, Havering and Redbridge (BHR) CCGs safeguarding

assurance committee which will meet monthly during 2014/15. To purpose of the committee is to ensure that our safeguarding arrangements are constantly reviewed and that the CCGs are fulfilling their safeguarding functions. The committee is accountable to the quality and safety committee.

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3.2 A safeguarding adults report will be submitted to the assurance committee each month and will detail all the safeguarding adults’ issues, including the number of safeguarding alerts received and the CCG response.

3.3 The safeguarding assurance committee also assesses and manages the CCG’s safeguarding

risks, making recommendations for mitigating actions where required. 3.4 The Department of Health document Safeguarding Adults: The role of NHS commissioners

outlines six fundamental actions to ensure safeguarding is integral to all commissioning activity.

3.5 Six fundamental actions for safeguarding adults: • Use the safeguarding principles to shape strategic and operational safeguarding

arrangements. • Set safeguarding adults as a strategic objective in commissioning health care • Use integrated governance systems and processes for assurance to act on safeguarding

concerns in services • Work with the local Safeguarding Adults Board, patients and community partners to create

safeguards for patients • Provide leadership to safeguard adults across the health economy • Ensure accountability and use learning within the service and the partnership to bring

about improvement.

3.6 Redbridge CCG meets each of these actions by: 3.6.1 Use the safeguarding principles to shape strategic and operational safeguarding arrangements:

The chief operating officer and the nurse director are both members of the Safeguarding Adults’ Board and attended all meetings to influence and shape the strategic direction. The deputy nurse director is the nominated operational lead for safeguarding adults and meets regularly with the local authority safeguarding team to ensure effective working relationships are maintained and operational systems are aligned.

3.6.2 Set safeguarding adults as a strategic objective in commissioning health care:

Safeguarding is explicitly referenced as a deliverable function in the CCG operating plan and in service specifications with providers for 2014/15, and will continue to have a significant focus in future contracts and specifications as recommended by the Francis Report. Delivery is through the safeguarding lead and close working with providers and contractors. The safeguarding information requirements have been agreed with our provider services for contract year 2014/15. This means commissioners are able to monitor provider services on key requirements and hold them to account. Any concerns in the quality or performance can then be addressed formally with provider organisations through formal contractual processes.

3.6.3 Use integrated governance systems and processes for assurance to act on safeguarding concerns in services:

Over the past twelve months considerable progress has been made by the Deputy Nurse Director Safeguarding in strengthening the governance and operational process for safeguarding between the CCG and the London Borough of Redbridge. Social care safeguarding adult’s intake team now routinely informs the CCG of any safeguarding alerts that require a strategy meeting. The CCG ensures that an appropriate representative is present, which would usually be the operational lead. Close working continues until the concern has been resolved and the person is safe. Providers may also raise a safeguarding concern that can meet the serious incident (SI) criteria. This is monitored by the SI panel, which has safeguarding representation in adherence to our agreed process for the reporting and monitoring of all SI’s.

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The CCG is represented in all case conferences and strategy meetings when required, especially if a concern is raised about a service we commission or a patient we fund for NHS Continuing Health Care.

3.6.4 Work with the local Safeguarding Adults Board, patients and community partners to create safeguards for patients:

Redbridge CCG is an active member of the SAB and has good working relationships with partners. A self assessment was completed by all partners in June and reviewed in December 2013. This has informed the priorities for the board, and enables partners to challenge where gaps exist in order to strengthen safeguards for adults at risk of harm or neglect. The outcome of our self assessment demonstrates CCG areas of strength, but also areas where we need to focus on. Of the 43 indicators there are 33 areas rated green, 10 amber and no red areas. Things that we will focus on in the coming months are the training needs analysis and a robust induction programme for new staff that has a specific focus on safeguarding..

3.6.5 Provide leadership to safeguard adults across the health economy:

The Nurse Director is the executive lead on the governing body for safeguarding and is responsible for leading the continued development of a culture that ensures safeguarding is integral to all we do. Safeguarding adults is within the work plan agreed with providers for discussion and assurance at the clinical quality review meetings (CQRM). Redbridge CCG receives assurance from providers that demonstrates effective safeguard processes are in place to prevent harm and also to manage /minimise risks where harm has occurred. Organisational leadership and governance are areas of focus for assurance.

3.6.7 Ensure accountability and use learning within the service and the partnership to bring about

improvement. The CCG has worked collaboratively with the SAB over the past twelve months and has

effectively contributed to the setting and local achievement of SAB objectives. The CCG utilises the CQRM to routinely review information regarding safeguarding adult training, supervision and feedback from patients and carers about their experiences of care to assure how well any safeguarding concerns were addressed and learning that can be shared across the organisation in an open and transparent way.

4.0 Winterbourne view 4.1 The joint plan submitted by the local authority to NHSE and DH remains on track to deliver the

key objectives set out in the DH response to Winterbourne View. The CCG receives monthly assurance that all Redbridge patients in an assessment and treatment unit are being assessed regularly and an appropriate plan of care is in place.

5.0 Priorities 2013/14 5.1 The focus for 13/14 has been to ensure that our safeguarding arrangements comply with the

Government’s requirements, to further strengthen our partnership with the SAB and to raise organisational awareness of safeguarding as everybody’s business. All Redbridge CCG staff will have completed safeguarding adults’ awareness training by 31 March 14.

6.0 Recommendations 6.1 The governing body are asked to agree the following as adult safeguarding priorities for 2014/15:

• To review all published guidance (listed below in section 10) and ensure that the CCG is compliant with best practice and if any gaps are identified, to take action to close the gaps

• The safeguarding assurance committee t review and update all organisational safeguarding polices, and once approved, make these available to staff on the intranet

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• To continue to strengthen our work as a partner organisation on the SAB and participate in the working groups when requested

• To continue operational working with the safeguarding named professionals in provider organisations to ensure that safeguarding adult arrangements across the health economy are robust and that an early warning system is formalised

• To formally agree operational safeguarding arrangements (including the ongoing quality assurance of community care providers) with LBR

• To review the safeguarding adult arrangements when the Care Bill 13/14 is passed. 7.0 Resources/investment 7.1 Failures of care are costly for the NHS as well as the patient. Safeguarding adults is a

significant factor in reducing costs incurred in avoidable harm, avoidable admissions, delayed and unsafe discharges.

7.2 This report does not have any additional resource requirements. There may be additional resource requirements identified as part of the review of the Care Bill 13/14.

8.0 Equalities 8.1 The continued development and strengthening of our safeguarding arrangements will promote

the values of the NHS constitution and uphold the rights it confers on people; improve health outcomes; promote equality and reduce health inequalities; and make Redbridge CCG an excellent organisation so that we can work with patients, the public and our partners to continue to protect vulnerable adults from abuse or neglect.

9.0 Risks 9.1 Operationally the CCG has one adult safeguarding lead working across the BHR CCG’s. Over

the past twelve months as our safeguarding arrangements have become more effective, there have been occasions when resources are stretched. To mitigate this risk additional nursing support has been sourced to support the quality assurance monitoring of care homes. All care home quality assurance visits will be completed by the end of Q1 14/15. The additional resource will also enable continued attendance at all safeguarding forums. This will enable capacity to attend key safeguarding adult forums.

9.2 The Care Bill 13/14 has yet to receive Royal Assent. This is a Bill to reform the law relating to care and support for adult and the law relating to support for carers, to make provision about safeguarding adults from abuse or neglect and to make provision about care standards. The Bill will bring together care and social support for adults with clear accountabilities and responsibilities. There will be a need for CCGs to identify and ensure that resources are available for each requirement appropriate to CCGs. It is anticipated that this will be a similar resource as currently provided for children’s safeguarding.

10 Referenced documents 10.1 All documents referenced in this report can be found at:

Safeguarding adults: role of the commissioners (2011) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215715/dh_125036.pdf Protecting adults at risk: London multi-agency policy and procedures to safeguard adults from abuse (2011) http://www.scie.org.uk/publications/reports/report39.pdf Safeguarding Vulnerable People in the Reformed NHS: Accountability and Assurance Framework (2013). http://www.england.nhs.uk/wp-content/uploads/2013/03/safeguarding-vulnerable-people.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215715/dh_125036.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215715/dh_125036.pdf

http://www.scie.org.uk/publications/reports/report39.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/03/safeguarding-vulnerable-people.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/03/safeguarding-vulnerable-people.pdf

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Author: Diane Jones: Deputy Nurse Director Date: 13 March 2014

To: NHS Redbridge Clinical Commissioning Group Governing (CCG) Body From: Khalil Ali, lay member (PPI) Date: 27 March 2014 Subject: Patient experience report Executive summary As part of the Redbridge Clinical Commissioning Group’s (Redbridge CCG) focus on ensuring that patient experience of services is considered throughout all that we do, this paper provides a summary of feedback and insight available since the last meeting. Recommendations: The governing body is asked to:

• Note that the Redbridge CCG is working in collaboration with partner organisations and the Council of Voluntary Sector

• Note the further development of the CCG Patient Engagement Forum (PEF) • Note the success of the Children’s Services Workshop • Note positive development relating to the patients’ stories • Note engagement of the Redbridge CCG in the Life Study programme

1.0 Purpose of the report 1.1 To provide a summary of the various feedback that has come through to the CCG

from patients and stakeholders. 2.0 Complaints and MP/councillor queries 2.1 In quarter three there were three complaints in total; one was received directly from

the complainant and two via MPs.

2.2 The first complaint related to the process of supplying a piece of equipment required for the patient care and arrangements prior to the hospital discharge. This complaint is still open and the patient was advised that the deadline for the response had to be extended because of the complexity of the concerns raised.

2.3 The second complaint (received via an MP) related to difficulties obtaining a

diagnosis and treatment for a child over a number of years. This complaint is still open and the CCG response will be a joint response with the North East London Foundation Trust (NELFT) and Barking, Havering and Redbridge University Trust (BHRUT).

2.4 Third complaint (also received via an MP) consisted of two concerns; one was

relating to the length of time waiting for physiotherapy, so the patient had to pay for the private treatment. The other issue was about patient being offered only one choice through Choose and Book and a lengthy wait for the appointment. This complaint is still open because of the complexity.

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2.5 The CCG also considers the trends on complaints with all our providers. Any

common issues, one of exceptions or other matters are discussed with the organisations concerned through our regular quarterly monitoring meetings with them.

2.6 In quarter three there were six new complaints received by North East London Clinical Support Unit (NEL CSU) plus one BHRUT/Whipps Cross complaint which was re-opened from Quarter 2 of 2013/14.

2.7 The concerns raised in those complaints were: communication relating to IVF

treatment options, difficulty obtaining orthopaedic appointment, being unable to obtain immediate bereavement counselling, waiting time for the operation, alleged poor care and treatment provided at King George hospital, difficulty in contacting out of hours dental service.

2.8 The re-opened (BHRUT/Whipps Cross) complaint was graded as high risk, four were

graded as low risk and two were rated as medium risk. They are all closed complaints now apart from one medium graded complaint at Barts Health (waiting time for the operation), which is still open.

3.0 Patient stories 3.1 A new ‘virtual’ email action group had been established by the CCG’s Patient and

Public (PPE) Advisor. The main aim of this group is to communicate with colleagues from all three boroughs and to discuss the best ways of collecting patients’ stories.

3.2 The PPE Advisor discussed how to collect and communicate patients’ stories received by Redbridge Council of Voluntary Sector (CVS). Health Partnerships Manager, Swati Vyas, has sent several stories to the PPE Advisor, including a report from Redbridge Disability Consortium and Redbridge Centre for Independent and Inclusive Living titled ‘Response to Redbridge CVS request for patient experiences of using local health services’. Key messages from this report were: The needs of some black and minority ethnic (BME) communities are still not being met. There are barriers in terms of access to mental health services as well as in the provision of culturally appropriate and tailored assessments and treatment programmes. Many service users identified communication skills as the most important factor when seeking support in crisis. People wanted someone to talk to, to be listened to, and to be treated with empathy, compassion and respect.

3.3 Patient story 1: Good experience with 111 NHS service: A member of the public

had a good experience using the 111 service on two occasions; once when her father-in-law had a chest pain and was sent an ambulance. On another occasion, her daughter was unwell and unable to get a GP appointment. Following a telephone discussion with the 111 service, the operator of the 111 service contacted the GP surgery and an appointment for her daughter was arranged within ten minutes.

3.4 Patient story 2: Poor communication between a GP and the hospital: A patient had a hip replacement scheduled for the beginning of the month. A pre-assessment was done by the cardiologist prior to the operation and the report was sent to the patient GP. By the

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time the GP forwarded the cardiologist’s report to the hospital, the date of the operation was gone, so another date had to be arranged. The learning from this experience was that the communication between the hospital and the GP needs to be streamlined better in order to reduce and stop any delays. This would enable patients to receive their treatment on time.

3.5 On Monday, 24 February 2014 the PPE Advisor had carried out a joint visit with the

CVS to Uniting Friends, a charity in Redbridge that supports people with learning disabilities. It had been agreed to invite two members (who are also patients and service users of the local health services) to participate in the Discovery Interviews which will be organised in March 2014. Feedback from this PPE activity will be reported to the Governing Body at the next meeting.

4.0 CCG Patient Engagement Forum (PEF) 4.1 The new Patient Engagement Forum (PEF) held its first meeting on 18 February

2014. Four representatives from each Patient Participation Group (PPG) locality are represented on the PEF. Redbridge CCG COO and Clinical Lead for PPE both attended the meeting. Two representatives from the Young People’s Forum in Redbridge also attended and have been selected as permanent members at the PEF; Redbridge Council of Voluntary Sector (CVS) and Redbridge Healthwatch are also members of the Forum. More representation will be sought, especially mental health service users, BME representatives and people with learning disabilities. A charity, Uniting Friends, which supports people with learning disabilities, has been approached to appoint two of their members to attend the meetings. Terms of reference has been adopted from the previous Forum but will be revised. The election of a new Chair and a Vice-Chair is on its way and two applications have been received, so far. The voting will be via ballot box on Thursday, 13 March 2014 (before the start of the PEF Workshop)

4.2 A workshop: “What does a good engagement looks like?” was held on Thursday, 13 March 2014 in Becketts House. It was attended by PEF members and associate stakeholders who are represented on the Forum. Feedback from this PPE activity will be reported to the Governing Body at the next meeting.

5.0 A patient’s survey- Anticoagulation Service in Redbridge at BHRUT 5.1 A short questionnaire has been given to patients who attend the clinic at BHRUT.

The main aim of the survey is to find out about their experience using the services and how they feel about the changes being implemented to the service. 100 questionnaires have been given to patients by clinic staff and the PPE Advisor will help analyse this survey. The results of this survey will be included in the next lay member’s report.

6.0 Redbridge Council of Voluntary Sector (CVS) and other community work 6.1 PPE Advisor and Khalil Ali visited the CVS in Redbridge on 4 March 2014 and

attended a feedback session with the representatives from the community groups Khalil had visited last year. Seven organisations were present and the session lasted an hour and a half. The PPE Advisor gave a presentation “An update from Redbridge CCG”. Several questions were asked. PPE Advisor and Khalil will discuss those questions with senior managers. Feedback from the CCG will be sent to the Redbridge CVS who will pass it onto the relevant voluntary organisation who attended the meeting. There is a potential for this group to become a Voluntary and Community Sector (VCS) Forum in Redbridge. The meetings will be organised by the Redbridge CCG. All attendees and the host, CVS Redbridge, expressed an interest

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to continue with the meetings of this group, which would be organised on quarterly basis.

6.2 Khalil Ali and the PPE Advisor commenced visits to community groups in February

2014. This is a continuation of the community work Khalil had started with the previous PPE Advisor. The visits have been scheduled in advance with the support of the Redbridge CVS. February visits included the Uniting Friends, the charity that supports people with learning disabilities and the community feedback session described above. More visits are planned for March 2014. The following groups will be visited: Senior Citizens Club, Redbridge Stroke Association and Redbridge Stroke Club and Redbridge Asian Mandal. The main aim of the visits is to provide feedback from the CCG. It is also envisaged that those visits will bring the voluntary sector and the CCG closer and develop a more effective working partnership.

7.0 Life Study 7.1 BHR CCGs were approached by University College London (UCL) Institute for Child

Health to participate in the Life Study project which is a national research project. The overarching vision is to develop a UK wide large scale cohort study – called Life Study – which will provide information relevant to the improvement of the lives, health and well-being of children, both now and in the future. This cohort will provide a rich and internationally unique longitudinal resource of data, environmental and biological samples that can be used to address future questions and hypotheses regarding early life origins of disease, health, well-being and development. They will collect information on up to 90,000 children across England, Scotland, Wales and Northern Ireland. Women and their partners will be invited to take part during pregnancy, or soon after birth, and they and their new baby will be seen either at specially commissioned Life Study centres on three occasions during pregnancy and the first year of the baby’s life, or in their own homes when the baby is about six months old with a further contact at 12 months by post, web or telephone. The intention is to observe the children and their families throughout childhood and into adult life as with previous UK birth cohort studies. All three boroughs, Havering, Redbridge and Barking and Dagenham, have been selected by the research team because of the multicultural background of the residents and its diversity.

8.0 Resources/investment 8.1 There was an expense for the refreshments for the PEF Workshop held on 13 March

2014 and the cost of a tape recorder to carry out Discovery Interviews. The resources for this costing have been covered by the budget.

9.0 Equalities 9.1 The work on engagement in Redbridge, through the CCG’s Engagement Forum structure, and through collaboration with patients, the voluntary sector and other key stakeholders will contribute to reducing inequalities in access to healthcare. 10.0 Risk 10.1 No key risks were identified from this report.

Author: Boba Rangelov, Patient and Public Engagement Advisor, BHR CCGs Date: March 2014

To: Redbridge CCG Governing Body From: Martin Sheldon, Chief Finance Officer Date: 27 March 2014 Subject: Finance Reporting Month 11 Executive Summary

As at the end of February (Month 11) the CCG did not achieve the planned year to date surplus but delivered a £11k surplus, a £2,673k adverse variance. The forecast for the year end is that the CCG will not achieve its overall surplus of £2.9m, but will deliver a break-even position as agreed at Month 6. The main drivers to the position are overspends within Acute contracts and continuing care, which are partially offset by under spends within primary care and the use of reserves / contingency.

There is significant year to date pressure within acute contracts with year to date over performance of £5.2m. Most of the variance relates to the three highest value contracts. These are Barts Health contract (£3.9m), BHRUT (£0.7m) and Homerton (£0.7m). A number of claims and challenges have been raised against acute contracts; a risk assessed position of the likely outcome of these claims is included within the year to date and Predicted Year End Value outturn financial position. BHRUT submitted activity data within the required deadline. However, the Trust implemented a new PAS at the end of November which has made accurate month end reporting difficult. To mitigate the risk of this to both organisations, the CCG Chief Finance Officer and the Trust Director of Finance have been in discussion about the likely year end outturn. The settlement agreed between the CCGs and Trust is a fixed year-end position of £14m over plan. The Redbridge CCG share of the settlement is £1.329m. The Lead Commissioner has reached agreement with Barts Health Trust on the 2013/14 contract however BHR CCGs have not agreed the contract until the Q1 position has been finalised and agreed. The WELC POD is currently in the process of agreeing quarters 1 and 2 with the Trust. The analysis of data and the application of claims, penalties and productivity measures suggest that there is an over spend in quarter 1 for Redbridge CCG. However, it has been proposed that the CCG will pay at Heads of Terms for quarter 1. This has been reflected in the reported position. The quarter 2 reconciliation suggests a small under spend for Redbridge CCG. Once the final quarter 2 figure is agreed the reported position will be adjusted to reflect this. The QIPP projects at month 11 are £2.023m below plan. The borough team are working to address this variance.

Some of the CCG reserves (For example the 0.5% contingency) have been utilised within the year to date position to partially offset some of the acute overspends. However a number of risks remain:

Key financial risks

1. BHRUT - The CCG and Trust have agreed a year settlement of £14m across all NEL CCGs. The CCG view is that the £14m is inclusive of all activity undertaken on behalf of the parties to the contract. The Trust has written requesting additional funding for the GP courier transport service for blood. The CCG view is that this is included in the settlement figure and this has been communicated back to the Trust. The cash has been drawn down to pay the Trust with a final date of payment of 20th March 2014. Failure to meet this payment date will mean that the payment cannot be made to the Trust in this financial year without their agreement.

2. Barts Health Contract – Significant levels of over performance has been built into the reported position. A risk remains with regard to the agreement of challenges and specialist commissioning activity that may not have been attributed to the CCGs. A London wide project is reviewing the misattributions and meetings are currently ongoing with the Provider to triangulate the position.

3. Adjustments to the Financial Position – There are a range of financial adjustment made to the reported financial position for the two largest contracts; these adjustments are not currently agreed by the trusts. The CCGs are in discussion with BHRUT and Barts Health about the year end and quarter 1 and 2 closedown. The basis of any agreement reached will impact in the future reported position.

4. Associate Contracts – A large number of smaller associate contracts have been signed off this month however there still remains a few unsigned; the value of the unsigned contracts is £0.9m. Until the contracts are signed the CCG has taken a decision to withhold the payment of CQUIN.

5. NCA’s Invoices – There is a large number of NCA invoices that remain un-validated and unpaid. The NCA budget has been adjusted to remove the element of budget relating to specialist activity. Until the invoice backlog is cleared there is a risk that the reported position is either over stated or under stated. There is a risk that the reported position contains an element of specialist costs. Additionally there is lack of clarity about whether CCGs should be charged for Walk in Centres, Urgent Care Centres and Minor Injury Units. There is a plan in place to clear the invoices at a rate of £500k per week across the 3 CCG’s,

6. The potential for other volume related costs, acute activity Continuing Health Care/individual placements packages. Mitigations include robust contract management, winter planning project implementation and CHC review process underway and action higher than anticipated plans in place.


Agree the financial position and the actions being undertaken to manage the key risks.

Finance and Activity Report Purpose of the Report The purpose of this report is to brief the Governing Body on the financial risks inherent as at 14th March 2014 and report on the overall financial position for financial year 2013/14. Resource limit The CCG has an anticipated resource limit of £298,911k. The changes to this month’s anticipated adjustments include Central Programme funding from NHS England of £20k Funding for Personal Health Budget rollout and £10k Support to planning funding for CCG’s. The resource limit for 2014-15 has recently been announced and shows a £13.2m, or 4.79%, increase on the recurrent funding for Redbridge CCG. Cash Draw Down The CCG is required to draw down cash from the DoH on a monthly basis to pay invoices and staff salaries. To date £217,914k of a full year predicted year end value of £247,214k has been drawn down. The CCG is showing the predicted year end value as utilising all cash made available, this is in Appendix 1.

The closing cash position as at 28th February 2014 was £4,059k. A summary of Predicted Year End Value receipts and payments for the year is provided for information at Appendix 2.

The cash to income and expenditure reconciliation at appendix 5 reconciles the actual cash received and paid out by the organisation to the total charge within the income and expenditure account.

Throughout February the CCG continued to operate within its expected cash envelope and was not overdrawn on any of its bank accounts at any time. The CCG is working closely with the CSU to ensure accurate and robust cash predicted year end values are in place, and that there continues to be appropriate cash and treasury safeguards.

Opening Resources 2013-14 £'000

Recurrent Programme Baseline Allocation 286,196Growth Uplift 6,583Anticipated Adjustments -808Programme Resources 291,971Running Costs Allocation 6,940Total Resources 2013-14 298,911

Redbridge CCG

Monthly Reported Position The CCG revenue financial position is summarised in the table below. A more detailed summary can be viewed in Appendix 4. Total expenditure year to date for Redbridge CCG is overspending by £2,673k and this has resulted in the Predicted Year End Value remaining at breakeven. Acute contracts The total acute budget is £161,963k in month 11.

The year to date performance shows an over spend against budget of £5,155k with an anticipated Predicted Year End Value over spend of £6,541k.

The detail against individual contracts is shown in the table below:

Redbrige CCG Financial Position 2013/14

Month 11 February 2013

Commissioner Function Annual YTD YTD YTD Predicted Year PYEV

Allocation Budget Actual Variance End Value (PYEV) Variance

£000's £000's £000's £000's £000's £000's

Acute

Acute Clinical SLA 146,733 134,736 141,479 (6,743) 154,875 (8,142)Acute Other 30,083 27,228 25,639 1,588 28,481 1,601

Acute sub-total 176,815 161,964 167,119 (5,155) 183,356 (6,541)

Mental Health & LD 29,233 26,797 26,655 142 29,059 174Community Healthcare 21,481 19,690 19,862 (172) 21,741 (260)Continuing Care 13,637 12,501 14,563 (2,063) 15,887 (2,250)Programme Spend 9,459 7,773 3,383 4,390 3,456 6,003Services Provided in a Primary Care Setting 38,418 35,204 35,019 185 38,472 (54)

Healthcare Provision sub-total 112,227 101,965 99,482 2,482 108,615 3,613

CCG Running Costs 6,940 6,361 6,361 (0) 6,940 (0)

Running Costs 6,940 6,361 6,361 (0) 6,940 (0)

Total Expenditure 295,983 270,290 272,962 (2,673) 298,911 (2,928)

Resource Limit 298,911 272,974 272,974 0 298,911 0

Surplus/Deficit 2,928 2,684 11 (2,673) 0 (0)

Provider Annual YTD YTD YTD YTD YTD In month In month In month In Month FCOT FCOTAllocation Budget Actual Variance Variance Challenges Budget Actual Variance Movement Variance

£000's £000's £000's £000's % £000's £000's £000's £000's £000's £000's £000's

BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST 78,005 71,789 72,525 (736) -1% (883) 5,894 5,510 384 322 79,334 (1,329)BARTS HEALTH NHS TRUST 52,654 48,266 52,158 (3,892) -8% (913) 4,388 5,664 (1,276) (823) 57,165 (4,511)MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST 2,827 2,576 2,938 (362) -14% 0 236 296 (61) (56) 3,215 (388)UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 3,227 2,958 3,033 (75) -3% (20) 269 287 (18) (156) 3,313 (87)HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 1,844 1,681 2,387 (705) -42% 0 154 194 (40) 16 2,608 (764)GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 1,349 1,230 1,474 (243) -20% 0 112 161 (49) 4 1,611 (263)MID ESSEX HOSPITAL SERVICES NHS TRUST 1,107 1,015 1,226 (211) -21% 0 92 106 (14) 7 1,342 (235)THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST 795 728 796 (67) -9% 0 66 65 1 8 869 (74)ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST 985 897 994 (97) -11% 0 82 116 (34) (28) 1,088 (102)IMPERIAL 506 462 509 (47) -10% 0 42 21 21 25 557 (51)NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST 534 489 317 171 35% (1) 45 20 24 14 347 187ROYAL FREE HAMPSTEAD NHS TRUST 567 517 756 (238) -46% 0 47 76 (29) (14) 826 (259)GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS TRUST 558 512 606 (94) -18% 0 47 47 (1) 18 663 (105)KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 271 247 268 (20) -8% 0 23 (3) 26 25 293 (22)BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 217 199 163 35 18% 0 18 22 (4) 1 178 39THE WHITTINGTON HOSPITAL NHS TRUST 191 175 219 (43) -25% 0 16 24 (8) (10) 239 (48)CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 231 211 167 44 21% 0 19 15 4 (3) 183 47NORTH WEST LONDON HOSPITALS NHS TRUST 242 221 252 (31) -14% 0 20 19 1 3 275 (34)ST GEORGE'S HEALTHCARE NHS TRUST 135 115 128 (13) -11% 0 11 15 (4) (9) 140 (4)THE ROYAL MARSDEN NHS FOUNDATION TRUST 147 135 185 (50) -37% 0 12 (6) 19 45 213 (66)ROYAL BROMPTON AND HAREFIELD NHS FOUNDATION TRUST 169 154 220 (66) -43% 0 14 21 (7) (10) 241 (72)

0ACUTE CLINICAL SLA SUB-TOTAL 146,560 134,577 141,321 (6,743) -5% (1,818) 11,607 12,672 (1,065) (622) 154,702 -8,142

LONDON AMBULANCE SERVICE 8,261 7,573 7,573 (0) -0% 0 688 688 (0) (0) 8,261 0NCA'S 2,725 2,498 2,553 (55) -2% 0 227 237 (10) 10 2,785 (60)COMMUNITY SPECIALIST SERVICES 982 900 908 (8) -1% 0 82 82 (1) (9) 990 (8)URGENT CARE CENTRE 1,752 1,606 1,380 226 14% 0 146 162 (16) (0) 1,204 548INDEPENDENT SECTOR 7,349 6,736 7,708 (972) -14% 0 612 699 (86) 3 8,409 (1,060)ACUTE OTHER (INCL IFR) 369 338 328 10 3% 0 31 28 2 (23) 358 11SPECIALIST COMMISSIOING REDUCTION 2,171 1,990 0 1,990 100% 0 181 0 181 (267) 0 2,171WINTER PRESSURES 6,647 5,745 5,349 397 7% 0 428 329 99 0 6,647 0

ACUTE OTHER SUB-TOTAL 30,256 27,387 25,798 1,588 6% 0 2,395 2,226 169 (286) 28,654 1,601

TOTAL ACUTE 176,815 161,964 167,119 (5,155) -3% (1,818) 14,002 14,898 (896) (908) 183,356 (6,541)

Redbridge CCG Financial Position 2013/14

Month 11 February 2014

Key issues

BHRUT: The reported position shows an over spend of £736k in month 11 compared to a reported over spend of £1,120k in month 10. The movement has arisen as a result of ongoing negotiations with the Trust about the likely year end outturn. The Trust submitted activity data within the required deadline. However, the Trust implemented a new PAS at the end of November which has made accurate month end reporting difficult. To mitigate the risk of this to both organisations, the CCG Chief Finance Officer and the Trust Director of Finance have been in discussion about the likely year end outturn. The settlement agreed between the CCG and Trust is a fixed year end position of £14m over plan. The agreement reached is a full and final settlement of all invoices, with no additional funding available. Winter pressures funding is outside this agreement and will be dealt with separately. The split of the year end settlement between the NEL CCGs has been worked up based on the latest complete data set and reflects the CCGs differential attitudes to the pursuit of claims and contract penalties. The Redbridge share of the settlement is £1,329k. Barts Health: The Lead Commissioner has reached agreement with the Trust on the 2013/14 contract. However, BHR CCGs have not agreed the contract until the Q1 position has been finalised and agreed. The reported position shows an over spend of £3,892k compared to £2,616k in month 10. The position is based on the latest information received which is the month 10 (January) activity data. The reported position shows a significant swing compared to reporting in previous months. Analysis of the data suggests that there has been an increase in activity and spend in January across a range of specialties. Further detail will be given about this in the contracts report. The BHR team has raised a query with the WELC contract team about the current month movement, As in previous months the WELC CSU team lead on this contract and make a series of financial adjustments to the activity data. As with previous months the largest adjustments are for challenges, contract penalties, CQUIN, productivity, readmissions, incorrectly assigned activity (specialist and renal transplants) and the emergency threshold. Claims have been adjusted for quarters 1 and 2 for outstanding claims. For quarters 3 and 4 the WELC team based their adjustment on 75% of the automated claims generated in quarters 1 and 2. The level of claims has been amended in month 11 to a more realistic level. The total claims figure put through in month 11 is £913k. It has been assumed that the CQUIN payment to the Trust will be 91% of the target. The adjustments for productivity and readmissions reflect actuals to month 8 or 9 with an extrapolation for the remainder of the year. The emergency threshold adjustment is based on the Trust offer for quarter 1 and plan for the remainder of the financial year. Activity incorrectly assigned to the CCG contracts relates to specialist activity and renal transplants. The total predicted year end cost of this activity is £1,249k.

As with previous months the financial adjustments made to the cost of the data submitted are significant which means that this contract has a risk of financial volatility. An additional adjustment was made this month in respect of Trauma and Orthopaedic activity where the Trust charged 1,740 excess bed days in month. The impact of this was removed from the year to date and predicted year end position. The WELC POD is currently in the process of agreeing quarters 1 and 2 with the Trust. The analysis of data and the application of claims, penalties and productivity measures suggest that there is an over spend in quarter 1 for Redbridge CCG. However, it has been proposed that the CCG will pay at Heads of Terms for quarter 1. This has been reflected in the reported position. The quarter 2 reconciliation suggests a small under spend for Redbridge CCG. Once the final quarter 2 figure is agreed the reported position will be adjusted to reflect this. Other Acute Trusts: January activity data was received for all Trusts except the Whittington, Mid Essex and Basildon and Thurrock For these Trusts December activity data was used and extrapolated forward to month 11 and the year end. There were no budget adjustments made in month 11. This means that Homerton, UCLH, Royal Brompton, Royal Marsden, Royal Free, Great Ormond Street and North West London Hospital contracts are monitored against the CCG budget rather than the Trust version of the contract plan. Based on the current budget the contracts representing the biggest financial risk to Redbridge CCG at month 11 are the Royal Free (£238k over plan) and the Homerton contract (£705k over plan). The largest over spend at the Homerton (£140k) relates to IVF cycles. The reported position against these Trusts may change when the contracts are signed. Additionally Mid Essex is reporting a month 11 position of £211k over plan. This position is based on December activity data so may not reflect the current position. The main areas of over spend using this data is against the elective and outpatient procedure points of delivery. Further detail will be given about the variances against plan in the contract report. NCA’s: The backlog of NCA invoices are in the process of being cleared. The CSU has set a trajectory for invoice clearance, with a plan to clear £500k per week across the three BHR CCGs. This means that the invoice levels will be brought to a manageable level by May 2014. The CSU has agreed this procedure with the CCG. The backlog was built up over the first six months of the financial year. For the purposes of reporting invoices paid and those waiting for validation are accrued. Independent Sector: The contracts reported in this section are Care UK, In Health, Holly House, BMI and Spire Healthcare. The reported position has been based on data received to date with a

straight line used for the predicted year end value outturn. This budget is £972k over plan at month 11 with a predicted year end value of £1,060k. The main over spends are on the contracts with In Health, Holly House and Spire Healthcare. The reported position is based on the cost of the latest activity data. Winter Pressures: Budget has been phased to match expenditure paid and accrued to date. The total reported position shows expected spend at month 11 of £5,349k. The remainder of the budget is phased in to month 12 and will be released as invoices are received. Specialist Commissioning Reduction: The budget allocated to Redbridge CCG totals £2,171k. The budget has been phased across the remainder of the financial year, which results in a month 11 under spend of £1,990k and £2,171k under plan at year end. Acute risks and recommendations BHRUT: Risk – The CCG and Trust have agreed a year settlement of £14m across all NEL CCGs. The CCG view is that the £14m is inclusive of all activity undertaken on behalf of the parties to the contract. The Trust has written requesting additional funding for the GP courier transport service for blood. The CCG view is that this is included in the settlement figure and this has been communicated back to the Trust. The cash has been drawn down to pay the Trust with a final date of payment of 20th March 2014. Failure to meet this payment date will mean that the payment cannot be made to the Trust in this financial year without their agreement. Recommendation – The CSU have prepared a split of the £14m payment by CCG. The BHR POD team have shared this with the WELC and NCL team to get the agreement of the other CCG’s. It is recommended that the CSU asks the Trust to raise the appropriate invoices and that they are approved in time for the payment run on 20th March. Barts Health: Risk – There is a significant financial risk associated with this contract. The reported position has been consistently above plan and has worsened in month. There is a risk that the adjustments made to the contract have been overly ambitious and that the contract position worsens. The predicted year end value position is £4,511k over plan but the underlying data suggests that the predicted year end value position could be significantly higher. The year-end position isn’t agreed with the Trust and the CSU are still in discussion about quarters 1 and 2. There is a risk, therefore, that the reported year end position is different to the position currently reported. Recommendation – Further analysis of the main areas of over spend are detailed in the contracts report. It is recommended that the Barts Health contract team, CCG and Trust agree the final year end position. NCA’s: Risk – There are a large number of NCA invoices that remain un-validated and unpaid. The NCA budget has been adjusted to remove the element of budget relating to

specialist activity. Until the invoice backlog is cleared there is a risk that the reported position is either over stated or under stated. There is a risk that the reported position contains an element of specialist costs. Additionally there is lack of clarity about whether CCGs should be charged for Walk in Centres, Urgent Care Centres and Minor Injury Units. Recommendation – The CSU and CCG have agreed a NCA validation process. The CSU contracts team have started to clear the backlog of invoices in the system. Until the invoicing process for Walk in Centres, Urgent Care Centres and Minor Injury Units is agreed the invoices will remain on hold, although they will be accrued into the financial position to ensure the full cost is reflected. NCA spend will be closely monitored and the contracts team will notify the CCG of any emerging financial risks. Independent Sector: Risk – The reported position is based on activity to date and is showing an upward trend. The risk is that the month on month position continues to increase. Recommendation – The CSU Contracts and Finance team to carry out further analysis of the data to understand the drivers of spend and finesse the predicted year end position.

Healthcare Provision A summary analysis of year to date and Predicted Year End Value financial performance is provided as detailed in the table below: Service provided in a primary care setting:

GP Prescribing - The December data was available in February from the Prescription Pricing Authority (PPA) and this also includes a predicted year end value. The cash report from the Business Services Authority has also been received. Figures have also been finalised for December amounts against Non-Discretionary drugs and Centrally Held Drugs costs. For month 11 reporting (month 9 data) the moving average method has been used as per Medicines Management calculations.

The above has therefore resulted in a predicted value at year end of a £317k underspend being reported in the February position as per month 11 reporting. A cost pressure of £144k is predicted against Centrally Held Drugs costs and a further £16k against the Scriptswitch budget. Oxygen is predicted to be £32k under and Medicines Management Clinical £59k over

Healthcare Provision Annual Budget £000s

YTD Budget £000s

YTD Actual £000s

YTD Variance

£000s

In Month Budget £000s

In Month Actual £000s

In Month Variance

£000s

Predicted Year End

Value £000s

Predicted Year End Value

Variance £000sServices Provided in a Primary Care Setting 38,418 35,204 35,019 185 2,967 3,352 (385) 38,472 (54)Mental Health &LD 29,233 26,797 26,655 142 2,436 2,434 2 29,059 174Community Healthcare 21,481 19,690 19,860 (170) 1,790 1,934 (144) 21,741 (260)Continuing Care 13,637 12,501 14,563 (2,063) 1,136 1,741 (604) 15,887 (2,250)Programme Spend 9,459 7,773 3,385 4,388 1,848 66 1,782 3,456 6,003Healthcare Provision Total 112,228 101,965 99,482 2,482 10,178 9,526 652 108,615 3,613


Month 11 - 28th February 2014

Also included within this range is an underspend predicted against the Locally Enhanced Services budget of £50k, (this includes a year charge of £252k for the Pharmacy LES received from NHS England), and a WIC budget overspend of £180k. The WIC overspend has however been offset through the programme spend area as the CCG looks to finalise costs against UCCs, MIUs and WICs for 2013/14. The Who Pays? Guidance around these areas is not clear and with the IG issues still not resolved the predicted year end position is currently reflected across Acute, Programme Spend and Primary Care budgets. The Pharmacy LES change has been disputed with NHS England as the funding was not within the CCG allocations although the commissioning of the service is a CCG responsibility.

These items have resulted in an overall predicted year end variance of £54k overspend against Services Provided in a Primary Care Setting. Mental Health & LD: The reported position shows a month 11 underspend of £142k and a yearend variance of a £174k underspend. The predicted year end value is made up of a cost pressure of £226k against the Meadow court nursing home contract, £212k predicted overspend against NCAs and £32k predicted overspend against smaller miscellaneous . These are predicted to be offset by anticipated underspends against the Redbridge Community Housing budget of £117k, The North Essex Mental Health Trust contract of £140k, and against one to one nursing care of £49k, £35k against the Richmond Fellowship contract, £32k against Mental Health Act Assessment fees, £87k released from complex care budget, £35k against the ELFT complex care budget and £149k against the Servite House cost and volume contract due to a reduction in bed usage. Community Health Services: The position shows a month 11 reported overspend of £170k and a yearend predicted pressure of £260k. The predicted year end value is made up of a cost pressure of £495k against the contract variation with NELFT to appease winter pressures. This is offset against the winter pressures budget held within the acute area so is a cosmetic over spend. Further overperformance is also predicted against the unfunded Diabetes Service contract variation of £72k and another contract variation of £35k for CTT both with NELFT and £67k against the BPAS TOPs budget. Other services have produced a predicted year end variance of £406k under. This is made up of an unallocated budget of £221k, £40k against the Haven and Richard House budgets, £30k against Marie Stopes TOPS budget, £72k against Age UK due to a recharge to Redbridge Council and £43k against the St Joseph’s Hospice contract. Continuing Healthcare: In order to reach a predicted yearend position invoices received to date and anticipated costs from Council providers have been analysed and reviewed. This has resulted in the predicted year end position being forecast at £2,250k overspent. This year end predicted spend includes a disputed £147k staffing costs from NELFT. The Broadcare system, which is designed to support the reporting of continuing care, is currently being reviewed by the central NEL CSU continuing care team. A technician from Broadcare has also been engaged by the CSU to help with the review and reporting from the system.

So the work to cleanse the system is underway and regular meetings are being held between the CSU continuing care team and the BHR CCGs central management team. The invoice backlog has now been addressed and the two issues where very much interlinked. Programme Spend: Contains the CCGs reserves which are being used to offset the projected overspends in both acute and non-acute. A pressure of £229k is shown here against a non-clinical SLA held with Barts Health. This is being discussed with the provider and will form part of the 2014/15 contract round discussions.

Healthcare Provision risks and recommendations

Continuing Care: Risk: This area continues to be a concern and therefore a risk. Continuing care is historically a volatile area which has been susceptible to adverse variances.

Recommendation - The area continues to be closely monitored with all available tools utilised. The completion of the rectification work detailed above will further assist the understanding of the in year position and the predicted year end value.

Continuing care provision: Risk - A provision for previously un-assessed (retrospective) care claims was made in Redbridge PCT’s annual accounts. Latest notification from NHS England has stated that the provision, and related responsibilities against this, will be passed to Redbridge CCG in 2014/15. Therefore any costs incurred in 2013/14 will be paid by NHS England. Full clarity around this and the impacts on 2014/15 is being sort and it is expected full guidance will be issued shortly. Ongoing costs against successful retrospective claims will also need to be closely monitored and factored into this year’s forecasts and future years planning. A provision will also need to be made to cover any retrospective claims that may be received in future years relating to 2013/14. Cost and volume contracts: These areas are 111, Out of hours, Walk in Centres (WICs) and Termination of Pregnancies (TOPs). Currently the 111 service is under performing and a small claw back could be due if this trend continues. Over and under spends predicted within the TOPs and WIC budgets are detailed above. Due to information governance issues and confusion caused by the Who Pays? Guidance the recharging of WIC services hosted by Redbridge CCG has not occurred so far in 2013/14. Redbridge CCG also has the Broad Street WIC within its boundaries but the contract is an APMS contract held by NHS England with The Practice, so the host arrangements and therefore recharging mechanism, for this are also less than clear. Recommendation - Solutions to information governance issues are continued to be sort from NHS England. This will enable the risks, particularly around WICs, to be identified and mitigating plans, if required, can be put in place as soon as possible. The CCG also needs to take a view of the impact of the finalised Who Pays? Guidance on the recharging of services once the IG issues are resolved.

NHS England – Payment Responsibility: A number of issues around who should pay, or seek reimbursement, for services remain outstanding with NHS England. These are primary care interpreting, Pharmacy LES and Walk In Centres. Recommendation – that these issues are resolved as quickly as possible to allow the predicted year end position to be finalised, and therefore stabilised, as soon as possible.

Running Costs

Redbridge CCG is currently showing a breakeven position against plan. Corporate non-pay budgets have been split as per the CCG request.

QIPP

Cost Centre DescriptionAnnual

Allocation in £000's

YTD Budget £000's

M11 Ledger YTD Actual

Costs £000's

M11 Accruals

£000's

YTD Total £000's

YTD Variance

£000's

In Month Budget £000's

In Month Actual £000's

In Month Accruals

£000's

In Month Total

£000's

In Month Variance

£000's

In Month Movement

£000's

Predicted Year End

Value £000's

Predicted Year End Value

Variance £000's

CEO/ Board Office 345 316 346 -58 288 28 29 59 16 76 -47 -84 265 80Chair and Non Execs 378 346 374 -5 369 -23 31 41 -2 38 -7 -2 415 -37Clinical Support 75 69 0 34 34 35 6 0 3 3 3 0 37 38Corporate Costs & Services 586 537 588 101 689 -152 49 84 -7 77 -28 -1 657 -71Finance 769 705 371 258 629 76 64 129 -146 -17 81 95 803 -34Innovation Fund 99 91 87 -19 68 23 8 16 -9 7 1 -1 78 21Nursing Directorate 45 42 113 -71 42 0 4 -26 30 4 0 0 45 0Operations Management 726 665 612 11 624 41 60 55 7 63 -2 -10 694 31Recharges 3,851 3,530 3,871 -323 3,548 -18 321 0 323 323 -2 0 3,871 -20Strategy & Development 67 61 89 -19 70 -9 6 21 -16 6 0 2 74 -8Total Running costs 6,940 6,361 6,452 -91 6,361 0 578 380 198 579 0 -1 6,940 0

Redbridge CCG

Statement of CCG Running Costs

Position as at 28th February 2014

10

QIPP schemes - by commissioner function Full year YTD YTD YTD In month In month In month

saving target saving target actual savings variance saving target actual savings Variance£000's £000's £000's £000's £000's £000's £000's

AcuteOutpatient Demand Management 1,110 888 897 9 111 145 34Community OP Services (reducing OP tariffs) 50 33 0 -33 8 0 -8Diagnostic Demand Management 200 142 28 -114 17 -4 -20Cardiology Testing 150 107 0 -107 21 0 -21POLCV new policy roll-out & awareness 130 101 0 -101 13 0 -13Innovation 100 80 0 -80 10 0 -10Pathology 100 60 0 -60 20 0 -20Ophthalmology pathway redesign 100 78 0 -78 11 0 -11Integrated Case Management (ICM) 580 489 384 -105 56 66 10Integrated Case Management plus 350 279 0 -279 35 0 -35Intensive service users 200 160 0 -160 20 0 -20Reducing excess bed days 50 30 128 98 10 96 86Admission avoidance & reduced LoS for emergency adm 200 156 0 -156 22 0 -22Managing Urgent Care - GP Access & Paeds A&E Att Reduction 350 280 0 -280 35 0 -35Medicines Management 1,450 1,264 1,124 -140 93 395 302Medicines Management - Acute Budgets 50 44 44 0 3 3 0BHRUT Productivity Measures 1,200 1,000 1,000 0 100 100 0Barts Health Productivity, Risk Share & Validation Arrangements 3,870 3,225 3,225 0 323 323 0Acute Reconfiguration - A&E and Urgent Care Centres 180 144 203 59 18 23 5Well Babies Coding & Adj for Coding Challenges 2012/13 180 150 150 0 15 15 0

Acute scheme sub-total 10,600 8,709 7,182 -1,528 942 1,161 220

Non-AcuteCommunity Services Development 630 525 525 0 53 53 0Community Treatment Team 200 133 0 -133 33 0 -33Contract Novation: Local Authority 700 583 583 0 58 58 0Contract Novation: Termination of Pregnancy Service 80 67 67 0 7 7 0Contract Novation: GPs with Special Interests (GPwSI) 120 100 100 0 10 10 0Continuing Care (CHC) Reduced Price 250 208 0 -208 21 0 -21Other Contract Efficiency 1,220 1,017 1,017 0 102 102 0NELFT - Community Services Efficiencies 250 208 208 0 21 21 0NELFT - Mental Health Efficiencies 500 417 417 0 42 42 0Green Lodge 80 67 67 0 7 7 0Mental Health - savings on voids at Meadow Court 200 167 167 0 17 17 0Mental Health - Contracts 140 117 117 0 12 12 0Mental Health - Voiceability Contract 60 50 50 0 5 5 0Pipeline projects 460 153 0 -153 153 0 -153Mental Health - Anxiety Care Contract 20 17 17 0 2 2 0Palliative Care - St Joseph contract 90 75 75 0 8 8 0

Non-Acute scheme sub-total 5,000 3,903 3,408 -495 548 341 -208

Total position 15,600 12,613 10,590 -2,023 1,490 1,502 12

Redbridge CCG QIPP Financial Position 2013/14

Month 10

Redbridge CCG has achieved £10.59m of £12.61m QIPP savings required to M10 - 84% of the targeted total. The QIPP project total is shown at £15.6m on the Candlestick report. This includes new schemes that are being developed to cover QIPP slippage and the QIPP target remains at £15m. Performance is below target for: • POLCV new policy roll-out and awareness which has created nil savings YTD. A review of the savings target suggests that it was set unrealistically high and is unlikely to achieve any savings in-year. • ICM/ICM+ • Intensive Service Users. New Information Governance guidelines do not permit access to patient level information. Health Analytics is anticipated to offer this in November, following which the project can commence and be appropriately measured and reported. • Managing Urgent Care - GP Access and Paeds A&E attendances for which a nil saving is reported against. The CCG is focussing on the winter surge primary care access scheme as a means to mitigate the shortfall. • CHC reduced price - existing CHC providers are not agreeing to meet the AQP price; therefore no savings have been made. • Medicines Management, although their trajectory is front-loaded, and the team remain confident they will recover to target. • Diagnostic Demand Management - Savings have again dropped slightly in M10 Performance is on/above target for the following QIPP projects: • Outpatient Demand Management, Contract Novation, BHRUT Productivity measures • Acute Reconfiguration, Community Services Development • Barts Health Productivity. Whilst considered to a 'Blue' (guaranteed savings) scheme, this continues to be included in this report until the SLA is confirmed and signed. • Medicines Management acute budgets, Reducing Excess Bed Days The following scheme is not yet scheduled to deliver a saving: • Cardiology Testing, POLCV The following schemes are still in development: •Pathology, Pipeline projects The following schemes are no longer being pursued in 2013/14 so are no longer detailed in this project-per-page report: • Ophthalmology pathway redesign, Community outpatient services and Innovation

Statement of financial position The statement of financial position (SoFP) summarises the CCG’s assets, liabilities and tax payers’ equity at a specific point in time. The CCG’s statement of financial position as at 28th February 2014 can be seen at Appendix 1. The Redbridge CCG SoFP currently shows a negative non-current asset value of £119k with a Predicted Year End Value position of £285k positive. This is due to an expected depreciation charge to month nine of non-current assets which have not yet been transferred to the CCG as part of the legacy balance transfer from Primary Care Trusts. The predicted year end value position takes into account expected transferred Net Book Value of assets from legacy organisations and the predicted year end value of the depreciation charge.

The cash and cash equivalent balance within the statement of financial position as at 28th February 2014 was £3,787k. This was £272k less than the cash position shown within the actual cash and predicted year end value cash position (Appendix 2) due to the release of a bacs run on 27th February which cleared the bank account on 3rd March. The statement of financial position shows the general ledger balance based upon un-cleared cash items, whereas the actual cash and the predicted year end value cash position only shows cleared items. Trade and other payables totalling £36,585k include £24,417k worth of outstanding invoices to NHS and Non NHS organisations, as well as £12,168k worth of net manual adjustments most noticeably £5,087k in terms of prescribing which contribute to the estimated financial position as at 28th February 2014. The Predicted Year End Value of closing balances are based upon expected working capital balances including one quarters worth of predicted year end over performance to NHS Providers, as well as 50% in year utilisation of the retrospective continuing health care provision being transferred from legacy organisations. Invoice payment performance measure – Better Payment Practice Code (BPPC) The BPPC requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. A summary of the year to date results can be found at Appendix 3. BPPC figures for the CCG as at the end of January show that 72.3% was achieved on the number of invoices paid and 93.2% was achieved on the value of invoices against the target of 95% on both indicators. The CCG is working closely with the CSU to ensure all valid invoices are being cleared in line with this target. Financial Summary As at the end of February (Month 11) the CCG did not achieve the planned year to date surplus but delivered a £11k surplus, a £2,673k adverse variance. The forecast for the year end is that the CCG will not achieve its overall surplus of £2.9m, but will deliver a break-even position as agreed at month 6. The main drivers to the position are overspends within Acute contracts and continuing care, which are partially offset by under spends within primary care and the use of reserves / contingency.

The handover of legacy issues from Redbridge CCG is currently ongoing and the full financial impact of this will not be understood until it is completed. A further update will be provided next month. Due to the reported acute overspend the use of reserves has been required to deliver the current Predicted Year End Value position. The year to date position at month 11 highlights a £1.03m QIPP variance, which will need to be recovered to enable the full £15.6m QIPP programme to be delivered. The CCG is undertaking a number of actions to impact the financial position. However it should be noted that the latest information shows that the CCG is funded £33m below target and the financial position must be viewed in this context.

Appendix 1

Appendix 2

Appendix 3

Appendix 4

Commissioner Function Annual YTD YTD YTD In month In month In month In Month Predicted Year Predicted Year

Allocation Budget Actual Variance Budget Actual Variance Movement End Value End Value Variance£000's £000's £000's £000's £000's £000's £000's £000's £000's £000's

Acute Healthcare

Acute Commissioning 146,733 134,736 141,479 (6,743) 11,622 12,687 (1,065) (622) 154,875 (8,142)Acute Commissioning Other 14,103 12,580 11,279 1,301 1,049 1,003 46 (439) 13,116 986Urgent Care 1,752 1,606 1,380 226 146 162 (16) 0 1,204 548High Cost Drugs 120 110 118 (8) 10 9 1 (8) 129 (9)Ambulance Services 8,261 7,573 7,573 (0) 688 688 (0) 0 8,261 0Clinical Assessment and Treatment Centres 3,122 2,862 2,737 125 260 112 149 151 2,986 136NCA 2,725 2,498 2,553 (55) 227 237 (10) 10 2,785 (60)

Acute sub-total Acute sub-total 176,815 161,964 167,119 (5,155) 14,002 14,898 (896) (908) 183,356 (6,541)

Mental Health & LD

Mental Health Contracts 22,864 20,959 20,783 175 1,905 1,936 (31) (51) 22,673 191Mental Health Services Other 6,369 5,838 5,872 (33) 531 498 33 30 6,386 (17)Learning Difficulties 0 0 0 0 0 0 0 0 0 0

Mental Health 29,233 26,797 26,655 142 2,436 2,434 2 (21) 29,059 174

Community Helathcare

Community Services 20,253 18,565 18,800 (234) 1,688 1,824 (137) (93) 20,581 (328)Hospices 494 453 390 62 41 50 (9) (112) 426 68Wheel chair service 734 673 673 (0) 61 61 (0) 0 734 0

Community 21,481 19,690 19,862 (172) 1,790 1,936 (146) (206) 21,741 (260)

Continuing Healthcare

CHC Adult 11,652 10,681 12,077 (1,396) 971 1,331 (360) (416) 13,657 (2,005)CHC Adult Full Fund Pers Hlth Bud 0 0 257 (257) 0 23 (23) 0 280 (280)CHC Children 371 340 881 (540) 31 173 (142) 90 587 (216)Funded Nursing Care 1,614 1,479 1,349 130 135 213 (79) (132) 1,363 251

Continuing Healthcare Sub-total 13,637 12,501 14,563 (2,063) 1,136 1,741 (604) (458) 15,887 (2,250)

Programme Spend

Commissioning - Non Acute 643 589 951 (362) 54 140 (87) (59) 1,033 (390)Reserves - Commissioning (0) (0) 9 (10) (0) 5 (5) (5) 0 (0)Counselling Services 0 (0) (0) 0 (74) (74) (0) (1) (0) 0Safeguarding 89 82 70 12 82 70 12 12 89 0GP IT/Levies 0 0 (0) 0 0 (0) 0 (0) 0 0Non recurrent programmes 141 129 302 (172) 12 39 (27) (28) 322 (181)Programmes Projects 5,723 4,348 107 4,241 1,537 15 1,522 1,804 (107) 5,830Reablement 810 743 637 105 68 58 10 0 695 115NHS 111 458 420 431 (11) 38 38 (0) (0) 469 (11)NHS Prop.Co 1,595 1,462 875 587 133 (229) 362 407 955 640

Programme Spend Sub-total 9,459 7,773 3,383 4,390 1,848 64 1,784 2,130 3,456 6,003

Services Provided in a Primary Care Setting

Out of Hours 1,635 1,499 1,499 (0) 136 136 0 0 1,635 (0)Commissioning Schemes 501 459 304 155 42 21 21 14 558 (57)Primary Care Payments 319 292 258 35 27 89 (62) 80 269 50Medicines Management 221 203 276 (74) 18 45 (27) (46) 280 (59)Primary Care GP IT 716 656 656 0 60 60 0 (0) 779 (63)GP Prescribing 35,026 32,095 32,026 69 2,685 3,002 (317) (585) 34,951 75

Services Provided in a Primary Care Setting sub-total 38,418 35,204 35,019 185 2,967 3,352 (385) (538) 38,472 (54)

Sub-total Healthcare provision 289,043 263,928 266,601 (2,673) 24,180 24,424 (244) (2) 291,971 (2,928)

Corporate and non healthcare costs

CCG Running Costs 6,940 6,361 6,361 (0) 578 579 (0) (1) 6,940 (0)CCG Levies 0 (0) (0) (0) (0) 0 (0) (0) 0 0GP IT 0 0 (0) 0 0 (0) 0 0 0 0

Corporate and non healthcare costs Sub-total 6,940 6,361 6,361 (0) 578 579 (0) (1) 6,940 (0)

Gross Expenditure 295,983 270,290 272,962 (2,673) 24,759 25,003 (244) (3) 298,911 (2,928)


Month 11 - 28th February 2014

Appendix 5

To: Redbridge CCG Governing Body

From: Martin Sheldon, Chief Financial Officer

Author: NELCSU BHR POD

Date: 27 March 2014

Subject: Contract Report Executive Summary

The purpose of this report is to brief the Governing Body on the contract performance as at M11 (February 2014) for the four main providers of Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS Trust (BH), North East London Foundation Trust (NELFT), PELC and contracts for whom the CCG are an associate.

Overall financial performance of these four main contracts against plan is above plan performance of £5.045mm Year to Date (YTD), with a predicted year end variance of £6.370m (based on the adjusted position). Both acute providers are over performing although on a percentage of contract value basis the largest over performance relates to Barts Health NHS Trust (BH). Drivers of over performance vary between the two main acute providers, Barking, Havering

and Redbridge University Hospitals NHS Trust (BHRUT) and Barts Health (BH). The main

area where expenditure is highest above plan at BHRUT is planned admissions and at BH

emergency services.

This report provides information based on the Provider raw data (SLAM) and the adjustments made to that position (which have been agreed with the CCG) to give the assessed position. For BHRUT, the CCG Chief Finance Officer and the Trust Director of Finance have been in discussion about the likely year end outturn in order to mitigate risks attached to the implementation of a new Patient Administration System at the end of November which has made accurate month end reporting difficult. The settlement agreed between the CCG and Trust is a fixed year end position of £14m over plan, with the Redbridge share of the settlement being £1,329k. Challenges and queries are being raised where appropriate and there is a quarterly reconciliation process being undertaken with each Trust. These are expected to at least partially mitigate the above plan costs to date. Performance against standards and contractual quality requirements is showing that one red RAG rating is in place for at least one area in each standard and for the A&E standard performance is predominantly red rated across both acute Providers. There are breaches of specific requirements or standards that are identified within the report. Where these have occurred contract mechanisms have been applied to address the performance issue and where appropriate penalties are being applied. Details of the particular areas of concern are highlighted in the summary for each provider and full performance details are provided in the appendices to this report.

Recommendations

The Redbridge CCG Governing Body is asked to:

To note and discuss the current position for each of the four main contracts and

associates;

To agree any further actions to be taken in respect of managing the contracts and

mitigating the risk of over performance;

Note any risks that are to be added to the Governing Body Assurance Framework

To note the implementation of mitigation actions.

CONTENTS

1.0 Purpose of the Report 3

2.0 Background/Introduction 3

2.1 Overview for Provider Contracts 3

3.0 YTD Overview (£000,%) (Over)/Under Spend 4

3.1 YTD Adjustments 4

3.2 YTD Performance 5

3.3 Monthly Provider Performance (raw data) 5

3.4 Predicted Year End Position 6

4.0 Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) - Contract

Summary 6

4.1 Commentary 7

4.2 POD Analysis 7

4.5 Financial Mitigations 10

5.0 Barts Health NHS Trust (BH) - Contract Summary 11

5.1 Commentary 11

5.2 POD Analysis 12

5.3 Contractual Performance Summary 13

5.4 National Quality Requirements 13

5.5 Financial Mitigations 14

6.0 North East London Foundation Trust (NELFT) - Contracts Summary (Mental Health and

Community Services.) 15

6.1 Overview 15

6.2 Mental Health Contract (£22.2m) 15

6.3 Community Services Contract Redbridge (£19m) 16

7.0 PELC - Contract Summary 18

8.0 Continuing Health Care (CHC) 19

9.0 Summary of Associate Clinical Services Contracts 20

9.1 Associate Contracts Summary 20

9.2 Signed Contracts 20

9.3 Unsigned Contracts 21

9.4 Commentary 21

10.0 2014/15 Associate Contracts – Offer Status 22

10.1 BHRUT 23

10.2 Barts Health 24

11.0 Appendices 25

1.0 Purpose of the Report The purpose of this report is to brief the Governing Body on the contract performance Year to Date (YTD) as at M11 (February 2014). 2.0 Background/Introduction The following section describes the basis of the contract values and the reporting methodology used throughout this report. 2.1 Overview for Provider Contracts

2.1.1 Contract Value Methodology: BHRUT The contract value is based on the 2012/13 M6 Freeze reported activity and finance data for the Trust net of challenges extrapolated to full year effect and then net of NHS England (NHSE)/Local Authority (LA) transfers. QIPP deductions were made with no growth applied. No additional capacity was purchased in respect to planned Referral to Treatment (RTT) backlog clearance programmes. 2.1.2 Contract Value Methodology: BH The contract value is based on 2012/13 actual outturn with agreed adjustments, net of NHSE/LA transfers. No QIPP deductions were made however growth was applied. No additional capacity was purchased in respect to planned RTT backlog clearance programmes. 2.1.3 Adjustments and Predicted Year End Outturn Methodology for 2013/14 -

BHRUT The Trust submitted activity data within the required deadline. However, the Trust implemented a new PAS at the end of November which has made accurate month end reporting difficult. To mitigate the risk of this to both organisations, the CCG Chief Finance Officer and the Trust Director of Finance have been in discussion about the likely year end outturn. The settlement agreed between the CCG and Trust is a fixed year end position of £14m over plan. The agreement reached is a full and final settlement of all invoices, with no additional funding available. Winter pressures funding is outside this agreement and will be dealt with separately. The split of the year end settlement between the NEL CCGs has been worked up based on the latest complete data set and reflects the CCGs differential attitudes to the pursuit of claims and contract penalties. The Redbridge share of the settlement is £1,329k. 2.1.4 Adjustments and Predicted Year End Outturn Methodology for 2013/14 –

BH The predicted year end value outturn is calculated using the predicted year end value data generated by NELIE. This is based on a straight line, calendar days or working days depending on the type of activity. The adjustments made to the M11 position are also made to the predicted year end value position. As in previous months the WELC CSU team lead on this contract and make a series of financial adjustments to the activity data. As with previous months the largest adjustments are for challenges, contract penalties, CQUIN, productivity, readmissions, incorrectly assigned activity (specialist and renal transplants) and the emergency threshold.

Claims have been adjusted for Q1 and Q2 for outstanding claims. For Q3 and Q4 the WELC team based their adjustment on 75% of the automated claims generated in Q1 and Q2. The level of claims has been amended in month 11 to a more realistic level. It has been assumed that the CQUIN payment to the Trust will be 91% of the target. The adjustments for productivity and readmissions reflect actuals to M8 or 9 with an extrapolation for the remainder of the year. The emergency threshold adjustment is based on the Trust offer for Q1 and plan for the remainder of the financial year. Activity incorrectly assigned to the CCG contracts relates to specialist activity and renal transplants. The WELC POD is currently in the process of agreeing Q1 and Q2 with the Trust and clarity has been sought on the year-end process to be followed. 2.1.5 Drivers of Predicted Year End Over-performance Misallocations of activity between NHS England and the CCGs are being resolved via a triangulation process with participation from all commissioners and the Trusts concerned. For BHRUT the misallocation is being addressed with limited impact on the contract. The process for Barts Health is still ongoing. Much of the predicted year end overperformance at BHRUT is driven by planned care and the antenatal pathway. QIPP plans are loaded on to the latter half of the year for BHRUT, so where there are concerns about non-delivery, this will contribute to over performance. Overperformance at Barts Health is largely driven by emergency care.

2.1.6 Provider Performance

Analysis of the movement in the BHRUT position is limited because of the data issues due to the PAS implementation. Barts Health reported activity figures are subject to the usual data quality and accuracy concerns.

Other acute contracts are not all yet agreed as the offers include NHSE activity transfer values that are at variance to CCG assumed values. These variances should reduce as these final negotiations conclude.

2.1.7 Actions to Address Performance Position

Additional challenges have now been raised with all Providers. PbR and pricing queries are being raised with Providers and work is underway to address key areas of specialist attribution queries.

3.0 YTD Overview (£000,%) (Over)/Under Spend Note: For reporting purposes the convention adopted is that an over performance is described as a negative value (i.e. (£196k) is a £196k above plan performance). The tables below identify the total adjustments that have been made to the provider raw reported activity and finance data. These adjustments reflect the changes that are made to the provider reported figures resulting from challenges raised, productivity metric adjustments and performance penalties etc., which result in the final values that are presented in the Budget Report. The raw figures are used here as this is the data used to analyse provider performance. Details of the adjustments that have been applied are identified in the Budget Report. 3.1 YTD Adjustments The table below shows the YTD position based on the Provider’s actual position (SLAM), the total of the adjustments made and the reported budget (ledger) position.

3.2 YTD Performance The information below identifies the financial performance against expected contract plan levels for each provider post the application of any contract penalties, challenges or other adjustments.

YTD performance for four main contracts (contained within the table above) for Redbridge CCG shows an overall predicted year end overspend of £6.370m. This takes into account the year end position being agreed for BHRUT 3.3 Monthly Provider Performance (raw data) The chart below shows the monthly financial performance by Provider for each month of the year to date using the raw SLAM data i.e. prior to any financial adjustments being made. This identifies that the BHRUT plans are broadly representative of the levels of activity expected in year although the overall performance is under expected levels. The position for BH is more volatile, not least due to the data reporting issues being experienced and in particular for December and January where there has been a significant amount of change due to the omission of Geriatric Medicine activity in the M9 data and a significant amount of excess bed days for Trauma and Orthopaedics in M10 (which has been challenged). NELFT and PELC are block contracts therefore no variation is shown. N.B. Data was not available in M1 and that caution should be used in respect of M2 and M3 due to the embedding of new reporting systems.

Provider

YTD

Actual

YTD

Adjustments

YTD

Adjusted

Actual in

Budget

Report

£'000 £'000 £'000

BHRUT 74,310 (1,785) 72,525

Barts Health 60,201 (8,043) 52,158

NELFT 38,334 - 38,334

PELC 3,704 - 3,704

Redbridge CCG

February (M11)

Provider YTD Plan

YTD (Over)

/ under

spend

Full Year

Plan

FOT

(Over) /

Under

spend

£'000 £'000 £'000 £'000

BHRUT 71,789 (736) 78,005 (1,329)

Barts Health 48,266 (3,892) 52,654 (4,511)

NELFT 37,850 (484) 41,291 (603)

PELC 3,771 67 4,114 73

Total 161,677 (5,045) 176,064 (6,370)

Redbridge CCG

February (M11)

3.4 Predicted Year End Position The Predicted Year End Position is £6.370m above budget. This has been based on a

series of financial adjustments which are detailed further in the Budget Report.

4.0 Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) - Contract Summary

The figures in the table and graph below are based on the Finance and Activity Tables provided by the NELCSU Finance Team. The reported position shows an over spend of £736k in month 11 compared to a reported over spend of £1,120k in month 10. The movement has arisen as a result of ongoing negotiations with the Trust about the likely year end outturn. The Trust submitted activity data within the required deadline, however, the Trust implemented a new PAS at the end of November which has made accurate month end reporting difficult. To mitigate the risk of this to both organisations, the CCG Chief Finance Officer and the Trust Director of Finance have been in discussion about the likely year end outturn. The settlement agreed between the CCG and Trust is a fixed year end position of £14m over plan. The agreement reached is a full and final settlement of all invoices, with no additional funding available. Winter pressures funding is outside this agreement and will be dealt with separately. The split of the year end settlement between the NEL CCGs has been worked up based on the latest complete data set and reflects the CCGs differential attitudes to the pursuit of claims and contract penalties. The Redbridge share of the settlement is £1,329k.

YTD

Variance Accid

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Em

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attendances

Adult

Critic

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Adm

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Em

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Excess b

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Excess B

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ransport

Hig

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525 (496) 139 106 244 129 0 (450) (8) (8) 11 (300) (204) (186) (290) (193) (149)

Redbridge CCG Financial Position M11

(600)

(400)

(200)

0

200

400

600

4.1 Commentary After risk assessed adjustments for mitigations, agreed with the CCG, the BHRUT contract is performing above the contract value. Detail on these mitigations can be found in section 4.5. The predicted year-end position is £1.329m above plan. Under delivery of QIPP is a key risk to achieving the planned financial values set in the contract. Activity planned care and outpatient appointments is a potential risk given concerns on under reporting in these areas. Emergency activity has also shown signs of increasing, however all financial risk will be addressed in agreeing a year end position. Contract process is being followed in respect of the financial closedown, with a settlement letter for a year end position being sent to the Trust. Penalties are being levied for performance breaches and joint actions set out to understand and address variances in activity levels. Further actions are being addressed through the Service Performance Review Group and appropriate escalation processes. Adjustments will be made to the mitigated financial position once these items are resolved. 4.2 POD Analysis

4.2.1 Planned Admissions and Daycases

Activity consists of Day Case (DC), Planned Admissions, Regular Day Attenders and the related Excess Bed Days

The top 5 areas where YTD spend has been worse than expected are:

4.2.2 Emergency Admissions

Activity consists of Emergency Admissions, Non-Elective Non-Emergency and the related Excess Bed Days. The top 5 areas where YTD spend has been worse than expected are:

4.2.3 Outpatients

The Outpatient POD consists for first and follow–up attendances, non-face to face activity and outpatient procedures. The top 5 areas where YTD spend has been worse than expected are:

4.2.4 Maternity

The antenatal maternity pathway expenditure YTD is £4.530m, an overperformance of £300k. A range of checks are being run, including checks on the potential for double bookings across Trusts and both a clinical and non-clinical check of coding practice. Two briefing papers have been produced setting out the position for both BHRUT and BH in terms of Maternity Deliveries.

4.3 Contractual Performance Summary A summary of the achievements and issues in relation to BHRUT during December and January (where data is available) are set out below, the full Provider Scorecard is available at Appendix 1.

4.3.1 Referral to Treatment (RTT) Waiting Times.

Due to problems with reporting BHRUT have not submitted December and January RTT returns. The overall CCG position cannot be reported. The most up-to-date position is for November.

4.3.2 Diagnostics Test Waiting Times

Diagnostic waiting times were achieved at 99.4% at BHRUT.

4.3.3 A&E Waits

BHRUT continues to underperform on the A&E target, YTD position @ January is 88.8% (All Types). Queens remains below the standard, YTD position @ January is 84.5%. King George is above the standard YTD 95.4%.

4.3.4 Cancer Waits

The Trust failed to meet the 2 week GP referral for breast symptoms standard for December for the seventh month this year. The 62 day GP referral cancer wait standard was not met in December, this is the sixth month in a row the Trust has not met this standard. The Trust failed the 2 week GP referral standard for the first time this year.

4.3.5 Mixed Sex Accommodation (MSA)

In January 2014, BHRUT reported 2 further MSA cases, bringing the YTD total to 95.

4.3.6 Summary Hospital Mortality Indicator (SHMI)

Summary Hospital Mortality Indicator (SHMI). Trust wide SHMI score 98.5 – at Trust level it is positively noted that this is below 100 (i.e. overall there are less deaths than expected); however, at disease level, it is noted that there are more deaths than expected for a number of diseases.

4.3.7 Venous Thromboembolism

The Trust has achieved a level of 95.2% in November.

4.3.8 Cancelled Operations

In quarter three BHRUT cancelled 3 elective patients at short notice, who were not re-booked in 28 days.

4.4 National Quality Requirements

4.4.1 MRSA

Up to the end of October 2013, no MRSA cases had been reported in 2013/14. BHRUT reported one MRSA in November and a second in December 2013. The PIRs concluded both were not ‘true’ bacteraemia’s (i.e. the patients were not affected), but that the samples were contaminated, indicating issues with blood sampling techniques. Contract query letters were issued and have since been closed. BHR CCGs Deputy Nurse Director has set up a monthly Joint Infection Prevention and Control group with BHRUT and NELFT membership; a function of this group will be to monitor implementation of action plans following PIRs and RCAs.

4.4.2 Clostridium Difficile

Zero C. Diff cases reported for BHRUT in December. Total validated cases YTD (up to 31/12/2014) = 18; taking into account un-validated (i.e. Trust data) data (up to 02/03/2014), BHRUT remains within their annual tolerance of 40 cases. C.Diff tolerance for 2014/15 has been set at no more than 37 cases.

4.4.3 RTT Waits over 52 weeks

There were no patients waiting over 52 weeks on incomplete pathways at the end of January at BHRUT.

4.4.4 Ambulance Handovers

There were no over 60 minute handover breaches in January at BHRUT. The number of reported 30 minute handovers has increased significantly in January. 15 minute handover performance remains a cause for concern at both sites, 40% at Queens and 49.2% at KGH.

4.4.5 Never Events and Serious Incidents

Grade 2 Serious Incidents: During 2013/14, BHRUT has reported one Never Event - Wrong Site Surgery-April 2013); and two maternal deaths (April 2013 and December 2013). CCGs and CSU met with the Trust in March to review SI status and management; Trust agreed to take forward agreed actions.

4.4.6 Friends and Family Test (FFT)

Response rates: Trust Board and Commissioners were informed of a drop in the number of surveys handed out to patients during December 2013. Against a 15% Trust-wide Aggregate response rate target, BHRUT achieved national CQUIN target

(aggregate response rate A&E and Inpatient): Q1 = 18.84%; Q2 = 22.59%; Q3 = 26.06% Scores: In summary, BHRUT continues to receive good scores for Inpatient care; A&E: BHRUT has remained in the lowest ‘ranked’ five Trusts since April 2013 (April – July, ‘ranked’ in the lowest five; Aug – Sept, ‘ranked’ in the lowest two; Oct to Dec, ‘ranked’ as the lowest scoring A&E dept); whilst the scores are on an improving trajectory, data indicates other Trusts are improving at a faster rate. Summary of key actions: Email sent to all wards/depts. reminding them of the importance of handing out & encouraging return of discharge surveys; Deputy DoN is meeting with Matrons & Senior Sisters / Charge Nurses for all areas RAG rated red. Improvement actions include the appointment of Patient Experience Facilitators who meet with wards to help them analyse local patient feedback and identify further actions. Specifically within A&E, other action include production of a booklet for patients on what to expect whilst in the A&E dept; piloting a system of providing hourly verbal updates on waiting times at QH for UCC & Paeds.

4.4.7 CQC

The CQC visited BHRUT during week commencing 14 October 2013 under Professor Sir Mike Richards new hospital inspection programme. The Trust has written a draft improvement plan; commissioners expect to receive a copy of the draft in March 2014.

4.4.8 Quality of Services

CCGs have raised concerns regarding the quality of Radiology and Ophthalmology services and cancellation of Outpatient services. A Radiology Working Group has been set up and will provide a forum for focused discussions regarding quality of radiology services.

4.5 Financial Mitigations

Challenges are raised each month where there are perceived inaccuracies in the information provided by the Trust. These are raised and responded in accordance with the monthly claims timetable. Any unresolved claims at the end of each month are retained and money withheld until the underlying issue has been resolved or the claim is addressed as part of a quarterly reconciliation exercise. Performance penalties are applied each month in respect of breaches where a financial penalty is defined in the contract. These penalties are included in the quarterly reconciliation process. Remedial action plans are in place as a consequence of the Deep Dive meetings with the CCG that have been taking place and these are being developed to address performance issues as they arise. Performance against the agreed CQUIN targets in the contract is assessed and any financial penalty or benefit applied as required. A summary of the mitigations applied is shown below. Please note, these adjustments are included within the adjustments contained within the tables above and there are a number of other areas e.g. emergency threshold that are not included within this table.

5.0 Barts Health NHS Trust (BH) - Contract Summary

The Lead Commissioner has reached agreement with the Trust on the 2013/14 contract however BHR CCGs have not agreed the contract until the Q1 position has been finalised and agreed. The figures in the table and graph below are based on the Finance and Activity Tables provided by the NELCSU Finance Team.

5.1 Commentary After adjustments for mitigations, agreed with the CCG, the contract is over performing by £3.892m YTD for Redbridge CCG. Detail on these mitigations can be found in section 5.5. The predicted year-end position is £4.511m above budget. . The main areas of over-expenditure relate to Emergency services, namely Non Elective Non-Emergency (Maternity deliveries are captured within this POD), Emergency Admissions and Critical Care. For Redbridge CCG maternity deliveries are above planned levels at BH, although there is below plan performance at BHRUT. As noted above, formal queries are raised with the Trust via the monthly Claims process and are addressed through the Technical Sub Group (TSG) and will be picked up, as necessary as part of the quarterly reconciliation process.

Value M8

(£000's)

Claims 858

Performance Penalties 237

CQUIN Withholding 653

Total 1,748

Contract Mitigation Values

YTD Variance A&

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Cri

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(52) (2,099) (208) (4,469) 186 (4,824) (170) (162) (420) (1,753) 2,797 (706) (405) (10) 155 790


(6,000)

(5,000)

(4,000)

(3,000)

(2,000)

(1,000)

0

1,000

2,000

3,000

4,000

5.2 POD Analysis

5.2.1 Emergency Admissions

Activity consists of Non-Elective, Non-Elective Non-Emergency and the related Excess Bed Days. The top 5 areas where YTD spend has been worse than expected are:

Cardiology is again in the top 5 areas and is consistently above plan across all BHR CCGs at M11.

5.2.2 Outpatients

The various elements of Outpatient activity are set out within the chart above, however the specialties with the greatest above plan performance are shown in the table below:

There is no plan for Clinical Haematology or Endocrinology outpatient activity and this is currently being investigated as part of the SCG misattribution work ongoing across the NELCSU CCGs. Allied Health Professional activity has increased since M8 and is a proposed service development for 2014/15.

5.2.3 Maternity

In terms of the Maternity pathway, YTD this is better than plan by £2.797m. A range of checks are being run, including checks on the potential for double bookings across Trusts.

5.2.4 Planned Admissions and Daycases

Activity consists of Day Case (DC), Elective, Regular Day Attenders and the related Excess Bed Days. The top 5 areas where YTD spend has been worse than expected are:

Specialty YTD Price PlanYTD Price

Actual

YTD Price

Variance

YTD Activity

Plan

YTD Activity

Actual

YTD Activity

Variance

Geriatric Medicine £1,887,387 £3,380,140 (£1,492,754) 2,160 2,345 (185)

Cardiology £409,600 £914,812 (£505,212) 213 348 (135)

Medical Oncology £0 £194,162 (£194,162) 0 63 (63)

Vascular Surgery £88,646 £155,206 (£66,560) 39 71 (32)

Urology £114,931 £158,867 (£43,936) 60 90 (29)


Emergency Admisions


Actual

YTD Price

Variance

YTD Activity

Plan

YTD Activity

Actual

YTD Activity

Variance

Cardiology £1,040,998 £1,501,626 (£460,628) 642 658 (16)

Trauma & Orthopaedics £2,237,804 £2,679,342 (£441,538) 963 2,842 (1,879)

Interventional Radiology £49,382 £126,493 (£77,112) 33 88 (55)

Medical Oncology £1,249 £63,751 (£62,502) 3 146 (143)

Vascular Surgery £51,339 £107,379 (£56,041) 26 54 (28)


Planned Admissions and Daycases


Actual

YTD Price

Variance

YTD Activity

Plan

YTD Activity

Actual

YTD Activity

Variance

Nephrology £2,376 £469,718 (£467,342) 21 2,812 (2,791)

Clinical Haematology £0 £343,490 (£343,490) 0 2,083 (2,083)

Allied Health Professional Episode £0 £118,296 (£118,296) 0 6,257 (6,257)

Endocrinology £0 £114,169 (£114,169) 0 834 (834)

Breast Surgery £28,229 £124,854 (£96,625) 214 880 (667)


Outpatient Attendances by Specialty

Cardiology and Vascular Surgery were also in the top 5 areas last month.

5.3 Contractual Performance Summary A copy of the Provider Scorecard for BH is attached at Appendix 2. A summary of the achievements and issues in relation to Barts Health during December and January (where data is available) are set out below.

5.3.1 Referral to Treatment (RTT) Waiting Times In December Barts Health was under the waiting time standard for Admitted (82.5%), Non-Admitted (93.7%) and Incomplete (85.8%).

5.3.2 Diagnostic Waiting Times Diagnostic waiting times were achieved at 99.6%.

5.3.3 A&E Waits Barts Health achieved the All Types standard in January with performance at 94.4%, the YTD position is 94.80%. Whipps Cross performance for January was 94.7% with a YTD position of 93.8%.

5.3.4 Cancer Waits All cancer waiting times were achieved in December with the exception of the 62 Day GP urgent referral at 81%, the year to date position is above the standard at 86%.

5.3.5 Mixed Sex Accommodation (MSA) Barts Health had 32 breaches in January 2013, of which 23 occurred at The Royal London and 9 at Newham.

5.3.6 Venous Thromboembolism The Trust continues to achieve the target to undertake a VTE risk assessment, with performance at 96.4% in November.

5.4 National Quality Requirements 5.4.1 RTT Waits over 52 weeks There were 54 patients waiting over 52 weeks on incomplete pathways at the end of January at Barts Health, 2 were from Barking and Dagenham CCG, 2 were from Havering CCG and 5 were from Redbridge CCG.

5.4.2 Ambulance Handovers There was one 60 minute handover breach reported in January at Barts Health at Whipps Cross. Whipps Cross Hospital failed the KPI 1 15 minute handover with (44.7%).

5.4.3 Serious Incidents Barts Health reported 70 SIs in January, this is the highest number of SIs since its formation in April 2013, which is a positive trend and could indicate improved clinical governance processes. There were 87 overdue SI reports in January which is a slight increase on previous months. CCGs and CSU are working with Barts to improve this position. Of the 70 SIs reported two of these were Never Events, this brings the total number of Never Events reported YTD at Barts to 10 Never Events. The Never Events in January 2014 related to: 1 wrong site surgery at The Royal London Hospital (incorrect surgery of lumbar spine); 1 misplaced NG tube at Newham Hospital.

5.4.4 Infection Control There have been 10 MRSA bacteraemia cases reported YTD (26/02/14) provisional figures indicate that of these there have been 3 MRSA cases at Whipps Cross. Barts Health has had 77 C Diff cases YTD (26/02/14) which is above their annual tolerance of 75 cases. 23 of these cases related to Whipps Cross.

5.4.5 Friends and Family Test (FFT) The overall performance for Barts Health in December was 12.53% (combined inpatient and A&E). This is a marked deterioration from the November (17.09%) and October (19.34%) performance. It appears that this may be due to difficulties in uploading the information on to Unify as Barts Health have a provisional figure different from the one reported. We are awaiting confirmation of the figures and a resolution to this issue which is also impacting upon the data provided for the maternity FFT roll out. 5.4.6 CQC The Care Quality Commission carried out inspections at Barts Health in early November. The CQC visited all sites. The three enforcement notices at Whipps Cross were lifted. However 15 compliance actions were issued, these related to: Royal London: 5 – Staffing (1); Records (1); equipment (1); care and welfare (1 treatment, 1 surgical procedures); Whipps Cross: 4 – care and welfare (1 – range of areas surgical, maternity, diagnostic screening); environment (1); equipment (1) ; complaints (1); Newham: 3 – medicines management (1); assessing and monitoring of service provision (1); care and welfare (1); St Barts: 2 – Staffing (numbers and skill mix) (1); nutritional needs (1); London Chest: 1 – Care and welfare.

5.5 Financial Mitigations Challenges are raised each month where there are perceived inaccuracies in the information provided by the Trust. These are raised and responded to in the monthly claims timetable. Any unresolved claims at the end of each month are retained and money withheld until the underlying issue has been resolved, or the claim is addressed as part of a quarterly reconciliation exercise. Performance penalties are applied each month in respect of breaches where a financial penalty is defined in the contract. These penalties are included in the quarterly reconciliation process. Remedial action plans are in place as a consequence of the Deep Dive meetings that have been taking place and these are being developed to address performance issues as they arise. Performance against the agreed CQUIN targets in the contract is assessed and any financial penalty or benefit applied as required. A summary of the mitigations applied is shown below. Please note, these adjustments are included within the adjustments contained within the tables above but there are also a number of other areas not listed out specifically in this table e.g. Emergency Threshold. It should also be noted that due to the poor data quality issues being experienced with the BH contract, it is not possible to quantify all of the challenges being raised and as such this table only includes those elements which can be quantified at the current time.

The CCGs and WELC POD are currently in the process of agreeing Q1 and Q2 with the Trust. This will be reflected in the reported position once agreement has been reached with the Trust. Clarity has also been sought on the approach to be taken to year-end.

6.0 North East London Foundation Trust (NELFT) - Contracts Summary (Mental

Health and Community Services.)

6.1 Overview

The NELFT block contracts are on budget at M11.

Quarter 3 performance data was presented to SPR on 24th February 2014 and will be fully

validated and closed down for sign-off at SPR on 24th March.

6.2 Mental Health Contract (£22.2m)

Mental Health Tariff (PBR) Summary reports on cluster activity, themes and accuracy now being provided to SPR. Areas for improvement identified with required actions agreed. Price per cluster, including assessment price is now also available and is being refreshed monthly as cluster and clinical activity data accuracy improves. The Mental Health Tariff MOU has been sent to CCGs’ AO and CFO and is in the process for sign-off. Q3 SDIP clustering exceptions report is now available, with actions agreed to improve accuracy. NELFT have provided a cost for out of scope services, and will report this as non- tariff services lines by month 11. Audit underway to understand the circumstances of cases referred to MH services, assessed, and not clustered (returned to primary care) to clarify referral pathways and potential inefficiencies.

There was also a presentation at the February CQRM from NELFT on its findings from an audit that was part of the action plan relating to the MsB Homicide enquiry. The audit had focused on access teams across the Trust. There had been concerns raised in the MsB report that MsB was not managed subject to CPA. It was therefore agreed the audit needed to be undertaken to assess if there were patients who required CPA who were not currently being managed with CPA. The audit involved 200 clients from across the 4 AATs, with approximately 50 from each of the Boroughs (Barking & Dagenham, Havering, Redbridge and Waltham Forest). The audit reviewed the criteria for placing someone on CPA. A caseload review of these clients followed to check whether they met the criteria for CPA. On average 25% of clients meet the criteria for CPA, but were being managed outside this framework. NELFT explained that when extrapolated this could amount to at least 600 patients across the 4 boroughs that should be managed within the community recovery teams and not within the access teams. CCGs voiced their concerns about the risks associated with the findings of the audit, and were not assured by the responses from NELFT. Following a further review of the audit outside of the CQRM, BHR

Value M11

(£000's)

Claims 913

Performance Penalties 410

CQUIN Withholding 118

Total 1,441

Redbridge CCG

Contract Mitigation Values

CCGs consider the potential risks to be high enough to warrant further action, and a plan of action is being requested from NELFT. This was also discussed at SpR.

Issues with access to mental health services have been identified across the BHR teams. NELFT presented an action plan to the December CQRM developed in response to concerns raised by GPs. The action plan was due to be completed by 31/12/2013. The Trust gave a presentation to the February CQRM to demonstrate the outcome of the implementation of the action plan. CCGs seeking further assurance. A quality visit to the Havering Access and Assessment Team was undertaken by CCGs (BHR and WF) on 7 March 2014. Results from this visit are currently being analysed.

NELFT Q3 reports have been received and presented to SPR on 24 February. There are no KPI failures requiring financial penalty.

NELFT MH Q3 SDIP progress reports have been received. Generally good progress although the CSU has been seeking various items of additional stronger evidence from NELFT.

NELFT MH Q3 CQUINs initial analysis indicating one possible part failure. This still being validated with NELFT.

IAPT procurement process in Redbridge and Havering is complete with the contracts to be awarded to NELFT. Transition arrangements are in progress.

6.3 Community Services Contract Redbridge (£19m) Managing Winter Pressures (funding via NHS England expected surplus for the current financial year - distributed among local communities based on the number of people they serve)

Contract Variation for 11 ‘winter pressure beds’ agreed and signed off by CCGs and NELFT with beds in place until end March 2014;

An additional 8 beds have been placed on standby to ensure back-up is available if required;

Contract Variation for additional CHC and CTT resources agreed between NELFT and BHR CCGs; and

NELFT not displaying any areas of poor performance or concern on daily sit-rep to support BHRUT during winter period.

Q3 Closedown Position

Quarter 3 closedown position was considered at SPR on 24th February with closedown sign-off due at SPR on 24th March;

No major areas of service performance concern;

Poor GP response to NELFT GP Satisfaction Questionnaire (CQUIN). Lead Clinical Director for NELFT SPR (Dr. Kumar) has written to GPs in support of returns for Q4.

NELFT required to submit further data on patient satisfaction questionnaires to validate Patient Satisfaction CQUIN;

ICM Caseload Target has been met for Q3 (NELFT has provided validation report for Commissioners). If the Q4 target for ICM is met then £67,184 currently withheld for not meeting target in Q1 and Q2 would be released to NELFT.

6.4 Clinical Quality Note: The information provided below is sourced from national data sources and Trust Board reports.

Care Programme Approach (CPA) Audit

NELFT reported to Feb CQRM that following an audit of 200 patients across the 4 CCGs, they have identified the need to undertake a rapid and focused piece of work to provide assurance that all patients currently under the Access & Assessment Team (A&AT) who need to be on a Care Programme Approach (CPA) are actually on a CPA; progress update to be provided to March CQRM. Access to Mental Health Services: Access & Assessment Services Action Plan

NELFT Associate Medical Director provided a presentation to Feb CQRM. Reason for issues within A&AT - a combination of the following: Low staffing resources; Increased rate of referrals; Interface issues between teams; Criteria for accepting patients into CRT – variable; Staff sickness; Variation in GPs acceptance of appropriate discharges from AAT. Action plan in place; update to be provided to April CQRM.

Clostridium Difficile

Against a 2013/14 annual tolerance of zero, as at 28/02/2014, NELFT reported a total of 7 cases. RCAS completed for all cases. CCGs issued and has since a contract query. BHR CCGs Deputy Nurse Director has set up a monthly Joint Infection Prevention and Control group with BHRUT and NELFT membership; a function of this group will be to monitor implementation of action plans following PIRs and RCAs.

Serious Incidents

Total overdue: As at 28/02/2014, there were 30 overdue SIs (2 by more than 6 months; 10 by 3-6 months; 18 by 0-3 months); whilst this was 6 less overdue reports than as at 30/01/2014, during Feb NELFT submitted a total of 38 reports. NELFT submitted a recovery trajectory for submission of the 36 overdue cases reported in Jan 2014: as at Feb CQRM, reports already submitted to CCGs/CSU: 10; To be submitted by: 28/02/14: 10; 28/03/14: 14; 30/04/14: 2 – an update has been

requested for the March (19th

) CQRM.

SI Action plans: Trust has changed internal reporting – from Feb 2014, overdue action plans are reported at CCG level: December data reported to Feb CQRM: B&D: 50% overdue; Havering: 0% overdue; Redbridge: 33% overdue (2 out of 6); WF: 64% overdue (7 out of 11) – Dec dashboard exception report flagged to Trust Board overdue SI action plans as one of the top 3 clinical risk areas . Trust continues to monitor action plans internally. Safeguarding

Safeguarding Adults: CCGs took assurance from the Deloittes audit in November 2013 which provided ‘substantial assurance’ regarding safeguarding adult processes; this is an improvement from the 2012 audit which provided ‘limited assurance’.

Adult (Level 1 & MCA/DOLs) and Child Safeguarding training (Levels 1-3) – Target 85% (presented to Feb CQRM)

Adult safeguarding training: B&D: 391 staff /502 total staff=77.89% (down from 81%); Havering: 852/1134=75.13% (down from 77%); Redbridge: 580/764=75.92% (down from 77%); WF: 1031/1339=77.0% (down from 79%).

Child safeguarding training: Target as per Safeguarding Intercollelgic Document=80%; Trust internal target=85%

Level 1: with exception of Havering (194/238 staff=81.51%), B&D, Redbridge & WF achieved Trust target;

Level 2: Havering missed the external & internal target (624/794=78.59%); Whilst not meeting the internal target, the following met the external target: B&D: 200/249=81.21%; Havering: 624/794=78.59%; Redbridge: 324/390=83.08%; WF: 824/976=84.43%.

Level 3: only Havering (84/89=94.38%) achieved internal & external targets (B&D: 81.21%; Redbridge: 73.36%; WF: 79.43%).

Access to child protection supervision in WF flagged to Trust Board as one of the top 3 clinical risk areas on the Dec dashboards. Safeguarding training (Levels 1-3) and supervision

NELFT provides a running total for safeguarding training figures to CQRM which provides assurance to the Director of Nursing regarding month on month improvements in training levels.

Adult safeguarding training: B&D: 81%; Havering: 77%; Redbridge: 77%; WF: 79% - NELFT has advised commissioners to view this data with some caution – the Trust has recently moved to Borough leadership and are working through reporting lines on EST – this means that at present some teams are not sitting with the correct Borough and this may have a ‘significant’ impact on the reported percentage. Figures are reported one month in arrears.

Child safeguarding training: Level 1: with exception of Havering (81.51%), B&D, Redbridge & WF achieved target; Level 2: not achieved in all 4 CCG areas (B&D: 80.32%; Havering: 78.59%; Redbridge: 83.03%; WF: 84.43%); Level 3: only Havering achieved the target (B&D: 81.2%; Redbridge: 73.3%; WF: 79.4%).

7.0 PELC - Contract Summary

7.1 Overview

The PELC contract covers UCC at Whipps Cross and King George Hospital (KGH), GP Out

of Hours (OOH) and 111.

Overall PELC’s performance has been within or very close to the contracted target but on

occasions, where it has fallen below 95% for calls answered within 60 seconds, or the call

abondment rate has been more than 5%, PELC have been required to submit an exception

report, explaining the reasons for deterioration in performance and mitigation to ensure

continuity of safe, quality service. PELC has reported mobilising other resources, including

supervisors and clinical directors, to ensure patient safety was not put at risk when the call

demand has surged

A daily SITREP on 111 performance, staffing and demand instigated during winter readiness

period is continuing to ensure a more rigorous daily performance management regime and

PELC’s performance is included in daily dash board report produced by the CSU

Performance team.

The remedial action plan submitted by PELC has been considered and feedback will be

provided. The outcome from the investigation will be included in 2014/15 contracts. The

second phase of investigation has begun and the PELC staff and working doctors have been

written to by the Chair of Redbridge CCG, Dr Anil Mehta, giving opportunity to the staff to

contribute to the investigation and raise any concerns with regards to the allegations made

by PELC working doctors by Friday 7 March 2014. The interviews scheduled to be

conducted on 14 March 2014.

CQC has completed the inspection of OOH service. PELC have been given positive verbal

feedback and have been advised that the completion of full report will take some time. A

team from NAO has met with the COO and Deputy Director of Contracts with regards to their

research of OOH services.

7.2 Urgent Care Centre (UCC)

The KGH UCC activities have underperformed by 14.18% against the planned activity, which was increased by 11,000 attendances (37%) in 2013/14. The activity against plan is being rigorously monitored to ensure increased targets are met. The overall number of patient at KGH UCC has increased compared to 12/13 for the corresponding period. However the overall aim of achieving 50% of appropriate attendances being directed through the UCC is not being met. PELC have been asked to come up with proposals to improve the uptake and increase the patient numbers. Walk in patients to UCC continues to perform well against target with no significant risks.

7.3 111

In M11 the 111 service achieved 69.97% of the planned activities level. The activities have not achieved the planned level largely because the planned national campaign to promote 111 has not been driven through. 15% of the 111 contract value is linked KPIs. These KPIs are banded and the provider will be entitled to full payment only if achieves the maximum target.

7.4 Out of Hours (OOH)

The OOH performance for the month of January was poor but was marginally better than December and PELC failed to meet the required targets on a number of KPIs. PELC has been asked to address the issues and assure commissioners that the safety and quality of service will be maintained at all times. The 2013/14 plan is based on 2012/13 outturn figures. There has been an overall reduction in activities in 2013/14 for the comparable period from 2012/13, which is likely to be a result of the impact of the 111 initiative as it was anticipated during the modelling of 111.

7.5 Contract Negotiations

PELC have provided a response for 111 to the HOT and have provided the counter financial

offers for OOH and UCC.

The Clinical Contract Quality has met to discuss the clinical matters including Francis

recommendations and further meeting is planned to finalise the quality metrics for inclusion

in the contract. The KPIs and DQUIP has been reviewed and a copy will be shared with

PLEC.

8.0 Continuing Health Care (CHC)

The CHC project group led by Jacqui Himbury (Director of Nursing, BHR CCGs) continues its work to develop the CHC pathway and address quality requirements. NELFT are proceeding with reviews of the backlog of CHC patients.

The contract for the clinical assessment team is now with NELFT for their consideration, further negotiation is continuing to achieve agreement on the contract but commissioners are pressing for this to be completed before concluding financial reimbursement to NELFT on the CHC work completed to date.

9.0 Summary of Associate Clinical Services Contracts Further detail can be found in Financial and activity report Month 11.

9.1 Associate Contracts Summary

9.2 Signed Contracts

Total NumberContract Value / Envelope

Value

2013/14 Predicted Year

End Position as at M11

£000s £000s

Signed Contracts 15 £12,252 £14,246

Signed - value not agreed 1 £576 £826

Unsigned Contracts 3 £1,998 £3,062

Total 19 £14,826 £18,134

Redbridge CCG

Associate Contract Summary (excluding Barts Health)

Provider Name Contract Value


End Position

£000s £000s

Moorfields £2,827 £3,215

UCLH £2,302 £3,313

Guy's And St Thomas's £1,349 £1,611

Mid Essex £1,107 £1,342

RNOH £985 £1,088

Princess Alexandra £795 £869

GOSH £555 £663

North Middlesex £534 £347

Imperial £506 £557

King's £271 £293

North West London £248 £208

Chelsea & Westminster £231 £183

Basildon & Thurrock £217 £178

The Whittington £191 £239St George's £135 £140

Total £12,252 £14,246

Redbridge CCG

Signed Associate Contracts

9.3 Unsigned Contracts

9.4 Commentary 9.4.1 Signed contracts

Guy’s and St Thomas’: Year to date expenditure remains significantly over plan. This is being driven by Elective, Non-Elective and High Cost Drugs. Trauma and Orthopaedics, Plastic Surgery and ENT are dominating the worse than planned spending in Elective Care. Furthermore, Plastic Surgery, Trauma and Orthopaedics and Vascular surgery are driving higher than planned emergency activity

Moorfields: Day Cases are now the largest contributor to expenditure worse than planned. Outpatient Procedure activity is significantly over plan for the year to date with a corresponding overspend in Outpatient activity for both new and follow up appointments. There is also a drug overspend due to the treatment of AMD with Lucentis.

Mid Essex: The year-end position remains worse than planned for 2013/14. Elective Care is the most significant contributor to the spend being worse than expected, driven by Plastic Surgery. Other areas worse than planned are Outpatient Procedures and Day Cases. Plastic Surgery continues to account for the overspend, due to higher than expected expenditure on Hand Procedures and Skin therapies and Mastectomy with Breast Reconstruction.

Princess Alexandra Hospital: Year to date expenditure continues to be worse than planned. Maternity is large factor in spending being worse than planned. In addition Elective Care spending in Trauma and Orthopaedics, General Surgery and Gastroenterology are worse than planned.

GOSH: The trust expenditure is worse than planned for the year to date. This can be attributed to Elective and Non-Elective care. The largest overspends are in Non-Elective care and day cases. Plastic Surgery, Haematology and Urology are the largest contributors to spending being higher than planned.

Provider Name

Latest Trust Offer to

CCGCCG Envelope Value


End Position

£000s £000s £000s

The Royal Free £926 £576 £826

Total £926 £576 £826

Redbridge CCG

Signed Associate Contracts - value not agreed

Provider Name

Latest Trust Offer to

CCGCCG Envelope Value


End Position

£000s £000s £000s

The Homerton £2,130 £1,752 £2,608

Royal Brompton £159 £99 £241

The Royal Marsden £139 £147 £213

Total £2,428 £1,998 £3,062

Redbridge CCG

Unsigned Associate Contracts

UCLH. The 13/14 contract documentation has now been signed by the Trust and Host Commissioner. The contract value was agreed prior to the Specialist Commissioning reconciliation process, during which it was found that the contract envelope was understated. The annual plan includes funding for activity that was misattributed to Specialist Commissioning. In month variance reported, is due to the change in budget envelope to reflect adjusted annual allocation, the value of which is in line with current levels of activity. There is higher than planned activity in Non-Elective, Elective, Day Cases and across outpatients. The largest contributing specialties are Urology, Gastroenterology and Trauma and Orthopaedics.

Royal Free: Host commissioner has now signed contract, tare still to be agreed. The latest Trust offer has been received and sent to CCG’s for review. Therefore, plans are indicative. Day Case, Non-Elective Activity and Drugs are driving spending worse than planned.

9.4.2 Unsigned contracts Particular delays are being experienced in agreeing contracts with providers where NHSE is a significant commissioner. For Redbridge, these include the Royal Marsden and Royal Brompton. A brief update on the position for each of the contracts which remain unsigned is as follows:

Homerton: The Heads of Terms have now been signed. An agreement on contract baselines is still being investigated between the CCG and Trust. Outpatient productivity metrics proposed by the Commissioners are still disputed by the trust. Day Case spending is over plan due to worse than expected Respiratory Medicine, General Surgery and Urology. There is also worse than planned Outpatient Follow Ups activity for Maternity, Gynaecology and Paediatrics. Non-Elective Non-Emergency spend is worse than planned for Obstetrics and Neonatology. Other main underlying cost pressures are noted against IVF activity.

Royal Brompton: Overall contract not yet agreed with host. The Redbridge offer is above budget but in line with the forecasted year end position. Day Cases are among the largest contributors to expenditure.

Royal Marsden: Contract close to agreement with the amendment of a zero financial envelope for Havering still pending.

10.0 2014/15 Associate Contracts – Offer Status

Trust Name Type of offer

Barnet and Chase Farm CSU Constructed Offer Received

Basildon & Thurrock Trust offer Received

Chelsea & Westminster -

GOSH -

Guy's And St Thomas's Trust offer Received, presented to CCGs,

counter offer issued 14/3/14

Imperial -

King's Trust offer Received and accepted by CCG

LAS Trust proposed contract value with CCG for

consideration.

Mid Essex -

Moorfields CSU Constructed Offer Accepted by CCG –

waiting counter offer from Trust.

North Middlesex CSU Constructed Offer Received

North West London -

Princess Alexandra Trust offer Received

RNOH CSU Constructed Offer Received

Royal Brompton Trust Offer Received

St George's Trust Offer Received

The Homerton -

The Royal Free CSU Constructed Offer Received

The Royal Marsden -

The Whittington CSU Constructed Offer Received

UCLH CSU Constructed Offer Received

10.1 BHRUT

10.1.1 Governance A meeting structure has been agreed, with fortnightly Contract Setting meetings between the CCGs / CSU and the Trust. There are clinical and financial sub groups reporting into this group. In addition, there is a CCG/CSU internal Contract Negotiation meeting which reports into an overall CCG Contract Steering Group which is chaired by the CCG Chief Financial Officer. This group is responsible for setting the direction and strategy for all contract negotiations. 10.1.2 Performance Measures

CQUINs: Meetings on CQUINs have been held throughout January, February

and March with a final list being worked through with the Trust

KPIs: A draft list of KPIs has been circulated to Trust. Financial penalties and

incentives are being considered

10.1.3 Finance and Technical issues

Baseline setting: The starting point of M6 SLAM Freeze (unadjusted) has been

agreed with the Trust. The Trusts and Commissioners have shared respective

baselines as parts of the process to agree Heads of Terms with a fixed price value

identified for agreement.

Productivity metrics: The metrics have been shared both with CCG clinical leads and

the Trust

10.2 Barts Health 10.2.1 Governance A meeting structure has been agreed, with fortnightly Internal Contract Negotiation meetings between the CCGs and CSU which reports into an overall CCG Contract Steering Group which is chaired by the CCG Chief Financial Officer. This group is responsible for setting the direction and strategy for all contract negotiations. In terms of contract negotiation meetings with the Trust, the BHR CCGs CFO is part of the team who have now met with BH on a number of occasions.

10.2.2 Performance Measures - CQUINs Two meetings were scheduled to have taken place week commencing 10 March 2014 with the Quality Leads to agree the strategy however to date this work is progressing well. 10.2.3 Performance Measures – KPIs The 3rd Session of the KPI negotiations took place on 6 March 2014. Around 80% of the KPI’s have been agreed. However, there are actions and discussions on the remainder that are being progressed. The Cancer KPIs have been agreed in principle with Barts Health and the Cancer Commissioner is currently awaiting written confirmation of this agreement. 10.2.4 Finance and Technical Issues - Baseline setting: The CSU has received Barts Health 1st cut 2014/15 baseline by summary and the matching backing data. The gap has been reduced to £16.9m. Key issues that remain relate to Non Elective activity (Haematology & Medical Oncology differences currently being queried with NHSE/SCG), Rehabilitation, General Medicine, Critical Care and Maternity (duplicate bookings). 10.2.5 Contract Documentation The WELC POD of the NEL CSU will lead on contract documentation and there is a detailed project plan in place which is monitored twice weekly to ensure sustained progress/escalation as necessary.

11.0 Appendices

Appendix 1 BHRUT Provider Scorecard

Appendix 2 BH Provider Scorecard

Appendix 3 BH RTT Update

Appendix 1

BHRUT Provider Scorecard

Appendix 2

Barts Health Provider Scorecard

Unify Submission for Barts Health and Redbridge CCG: January 2014

Admitted

SITE UNIFY SPECIALTY UNDER 18 OVER 18 TOTAL PERF %

BLT CARDIOLOGY 29 0 29 100.00%

BLT CARDIOTHORACIC SURGERY 9 2 11 81.82%

BLT DERMATOLOGY 1 0 1 100.00%

BLT ENT 3 0 3 100.00%

BLT GASTROENTEROLOGY 7 0 7 100.00%

BLT GENERAL SURGERY 3 1 4 75.00%

BLT GYNAECOLOGY 1 1 2 50.00%

BLT OPHTHALMOLOGY 3 1 4 75.00%

BLT ORAL SURGERY 5 10 15 33.33%

BLT OTHER 56 12 68 82.35%

BLT PLASTIC SURGERY 6 1 7 85.71%

BLT TRAUMA & ORTHOPAEDICS 1 5 6 16.67%

BLT UROLOGY 6 3 9 66.67%

NUH GENERAL SURGERY 2 0 2 100.00%

NUH GYNAECOLOGY 3 0 3 100.00%

NUH TRAUMA & ORTHOPAEDICS 5 0 5 100.00%

NUH UROLOGY 2 0 2 100.00%

WX ENT 18 9 27 66.67%

WX GASTROENTEROLOGY 1 0 1 100.00%

WX GENERAL SURGERY 13 14 27 48.15%

WX GYNAECOLOGY 16 1 17 94.12%

WX OPHTHALMOLOGY 92 21 113 81.42%

WX OTHER 9 14 23 39.13%

WX RHEUMATOLOGY 2 0 2 100.00%

WX TRAUMA & ORTHOPAEDICS 28 29 57 49.12%

WX UROLOGY 21 5 26 80.77%

GRAND TOTAL 342 129 471 72.61%

Non-Admitted





BLT ENT 12 0 12 100.00%


BLT GENERAL MEDICINE 4 1 5 80.00%



BLT NEUROLOGY 13 5 18 72.22%

BLT NEUROSURGERY 6 1 7 85.71%


BLT OTHER 177 23 200 88.50%


BLT RESPIRATORY MEDICINE 8 1 9 88.89%

BLT RHEUMATOLOGY 10 0 10 100.00%


BLT UROLOGY 4 1 5 80.00%

NUH CARDIOLOGY 6 0 6 100.00%

NUH ENT 7 0 7 100.00%

NUH GASTROENTEROLOGY 5 0 5 100.00%



NUH NEUROLOGY 1 0 1 100.00%

NUH OPHTHALMOLOGY 3 0 3 100.00%

NUH OTHER 9 0 9 100.00%

NUH RESPIRATORY MEDICINE 1 0 1 100.00%


WX CARDIOLOGY 63 0 63 100.00%

WX DERMATOLOGY 98 5 103 95.15%

WX ENT 55 2 57 96.49%



WX GERIATRIC MEDICINE 2 0 2 100.00%


WX NEUROLOGY 22 4 26 84.62%


WX OTHER 265 8 273 97.07%

WX PLASTIC SURGERY 8 0 8 100.00%

WX RESPIRATORY MEDICINE 25 0 25 100.00%



WX UROLOGY 41 2 43 95.35%

GRAND TOTAL 1,344 110 1,454 92.43%

Incomplete





BLT ENT 23 7 30 76.67%


BLT GENERAL MEDICINE 4 1 5 80.00%



BLT NEUROLOGY 55 3 58 94.83%

BLT NEUROSURGERY 41 1 42 97.62%


BLT OTHER 780 108 888 87.84%


BLT RESPIRATORY MEDICINE 50 3 53 94.34%

BLT RHEUMATOLOGY 24 0 24 100.00%


BLT UROLOGY 40 11 51 78.43%

NUH CARDIOLOGY 13 1 14 92.86%

NUH GASTROENTEROLOGY 5 0 5 100.00%


NUH GERIATRIC MEDICINE 2 0 2 100.00%


NUH NEUROLOGY 1 0 1 100.00%

NUH OPHTHALMOLOGY 10 0 10 100.00%

NUH OTHER 42 5 47 89.36%

NUH RESPIRATORY MEDICINE 9 0 9 100.00%


NUH UROLOGY 10 1 11 90.91%

WX CARDIOLOGY 217 17 234 92.74%

WX DERMATOLOGY 281 35 316 88.92%

WX ENT 217 16 233 93.13%


WX GENERAL MEDICINE 2 1 3 66.67%


WX GERIATRIC MEDICINE 7 0 7 100.00%


WX NEUROLOGY 80 3 83 96.39%


WX OTHER 793 72 865 91.68%

WX PLASTIC SURGERY 16 0 16 100.00%

WX RESPIRATORY MEDICINE 52 16 68 76.47%



WX UROLOGY 246 14 260 94.62%

GRAND TOTAL 5,603 747 6,350 88.24%

Barts Health

Month Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

18 Weeks Admitted 90.10% 88.60% 85.30% 84.40% 82.70% 82.00% 81.70% 76.90% 82.50% 75.70%

18 Weeks Non-Admitted 95.70% 96.00% 95.10% 96.10% 96.00% 94.60% 92.40% 91.90% 93.70% 91.30%

18 Weeks Incomplete 92.00% 91.90% 88.50% 84.30% 84.70% 84.40% 84.40% 84.30% 85.80% 86.80%

Barts And The London


18 Weeks Admitted 88.20% 87.40% 84.60% 86.50% 82.10% 83.60% 83.70% 77.60% 78.80% 75.60%



Newham


18 Weeks Admitted 94.70% 90.60% 90.80% 91.50% 95.10% 90.00% 90.30% 88.40% 90.10% 90.10%



Whipps Cross


18 Weeks Admitted 91.30% 89.80% 84.20% 78.50% 78.70% 75.20% 74.10% 71.40% 86.80% 70.60%



The performance table on the left shows the Trust’s performance against the three 18 week RTT standards at a Barts Health level, as well as at individual legacy Trust level, as reported

to Unify. The 3 tables below show performance at a CCG level for each of the 3 performance

standards, broken down by site and specialty.

Appendix 3

Unify Submission for Barts Health and Redbridge CCG: January 2014

Commentary: Barts Health has given a commitment that we will clear our backlog by the end of Q1 2014-2015, except for the speciality of Trauma and Orthopaedics. We continue to manage our backlog of patients, treating those with the longest waits in strict chronological order alongside patients with urgent health care needs. We highlighted in January, that moving forward, this would mean that our admitted and non-admitted 18 week performance figures would, temporarily, worsen. This expected dip in performance at Trust level is what we are now seeing in January’s data. It shows the impact of long-waiting patients being booked into outpatient capacity, as well as day case and in-patient theatre slots. This has reduced, as predicted, both our admitted and non-admitted 18 week performance for January as we focus, primarily, on reducing the number of patients who have waited longer than 18 weeks for treatment. What we also predicted was that as those two measures dropped, the number of patients waiting over 18 weeks for treatment would reduce. That is reflected in January’s performance data which shows that the number of patients on an incomplete pathway i.e. waiting for treatment has improved. January’s figures show that incomplete pathways for patients waiting over 18 weeks has dropped from 10,216 patients in December 2013 to 9,142 in January 2014. The Trust will continue to focus on the longest-waiting patients to ensure they are booked, dated and treated. To monitor the direction of travel and to ensure compliance by the end of Q1 for all specialities excluding trauma and orthopaedics, the Trust is using a variety of data sources. These include a weekly detailed 18 week data pack with speciality-level waiting times data and a set of challenging key performance indicators, as well as rigorous weekly audits to confirm that all clinical capacity is being used effectively. We are reassured that we are moving in the right direction by the latest data, and further encouraged to see that activity levels for all patients are not being adversely affected by the proactive steps being taken to reduce the number of patients waiting longer than 18 weeks for treatment. Redbridge CCG commentary: The majority of Redbridge CCG patients are treated / waiting at Whipps Cross Hospital. January performance at Whipps Cross demonstrated the expected drop in admitted pathway performance, an increase in non-admitted performance, and a decrease in incomplete performance. Whipps Cross has a significant number of compliant specialties which may account for the increase in non-admitted performance and the decrease in incomplete performance. However, we are ensuring that all patients at Whipps Cross are being booked in strict chronological order for both outpatient appointments and surgical procedures.

Unify Submission for Barts Health and Redbridge CCG: January 2014 - 52 week breaches

Commentary: The Trust reported 85 patients waiting longer than 52 weeks for treatment as of the end of January 2014. This is clearly unacceptable. The majority of these breaches (64) are in Trauma and Orthopaedics which remains the Trust's most challenged specialty. At the point of completing this CCG report, 45 patients had been treated or discharged and this number increases daily as patients are progressed through their pathways to ensure that they are treated as quickly as possible. The Trust recognises that enhanced training for staff in 18 weeks is a priority, and the need for this is further evident in this return as 11 patients were found to have had a clock stop incorrectly applied to their 18 week pathway and were waiting for their first definitive treatment. These patients are now being managed through their pathways to ensure that they receive the care they need. The Trust applies strict criteria to support clock stop events; discharging a patient after repeated 'did not attend' episodes for example, or discharging a patient after repeated efforts to offer them a date for an outpatient appointment, or a date for their elective surgery. Where there is no evidence of communication with the patient and their GP to this effect, the patient is considered to be waiting for treatment. Fourteen of the breaches could not be supported with clear, auditable evidence that the patient had been discharged back to their GP. Our managers have been reminded of the need to ensure that these types of clock stops are clearly communicated to the patient and their GP. The Trust has previously struggled with data quality issues which have contributed to our position, but is confident that there is now accurate data for all patients waiting over 40 weeks for treatment. This information is being used to identify all of those patients who will have been waiting over a year in February and March to ensure that they are dated, progressed and treated as an absolute priority. Daily reports on these patients have been established with rapid escalation to ensure that patients are being treated appropriately. This will continue to drive strict chronological booking of patients into all available capacity. All of the over 52 week patients will be assessed for clinical harm as they are treated or discharged. This is a key part of the clinical harm process the Trust is following. The Trust remains committed to eliminating all 52 week breaches from March 2014. Redbridge CCG commentary Redbridge CCG had 5 breaches in January. Of these, 2 have been treated or discharged. The remaining 3 patients all have a confirmed next event. The clinical harm process is now underway for all of the 52 week breaches. NB: Should any additional information be required on these patients, we would be happy to provide it.

CCG No. of patients

08V - NHS TOWER HAMLETS CCG 34

08M - NHS NEWHAM CCG 14

07T - NHS CITY AND HACKNEY CCG 10

08N - NHS REDBRIDGE CCG 5

08W - NHS WALTHAM FOREST CCG 4

07L - NHS BARKING AND DAGENHAM CCG 2

08D - NHS HARINGEY CCG 2

08F - NHS HAVERING CCG 2

08H - NHS ISLINGTON CCG 2

06K - NHS EAST AND NORTH HERTFORDSHIRE 1

06N - NHS HERTS VALLEYS CCG 1

06Q - NHS MID ESSEX CCG 1

07N - NHS BEXLEY CCG 1

07V - NHS CROYDON CCG 1

08A - NHS GREENWICH CCG 1

08K - NHS LAMBETH CCG 1

09A - NHS CENTRAL LONDON (WESTMINSTER) 1

09C - NHS ASHFORD CCG 1

09W - NHS MEDWAY CCG 1

Total 85

08N - NHS REDBRIDGE CCG 5

110 - TRAUMA & ORTHOPAEDICS 3

160 - PLASTIC SURGERY 1

105 - HEPATOBILIARY & PANCREATIC SURGERY 1

To: Meeting of the Redbridge Governing Body From: Sue Assar, Interim Director of Corporate Services Date: 25 March 2014 Subject: Policy on sponsorship and joint working with the pharmaceutical industry

1.0 Purpose of the Report 1.1 To obtain Governing Body approval of the attached policy. This policy applies to all CCG

employees, members of the Governing Body, its committees, working groups and any person working on behalf of the CCG e.g. agency staff.

2.0 Background/Introduction 2.1 The APC has produced a draft policy covering sponsorship and working with the pharmaceutical

industry for adoption by the CCGs. The committee has consulted with the LMCs and the document has also been reviewed and amended by the Audit and Governance committee its February meeting. The Audit and Governance Committee agreed that the policy should come to the Governing Bodies for final approval. It also agreed to review the sponsorship register at its July meeting to assess how this is working.

3.0 Report Content 3.1 The final draft policy is attached to this report for formal approval.

The policy does not apply to member practices. Should member practices wish to adopt it; this can be reflected in the final version of the policy.

Executive summary The policy on sponsorship and joint working with the pharmaceutical industry has been developed by the Area Prescribing Committee (APC) for the three CCGs. It complements the policy on gifts and hospitality approved at the January Governing Body meeting. The policy has been reviewed by the Audit and Governance Committee and the Local Medical Committees (LMCs) have been consulted on its content. The policy now requires formal approval by each of the Governing Bodies. Once approved the policy will be individualised for each of the CCGs. Currently the policy does not apply to member practices. Should member practices wish to adopt it this can be reflected in the final version of the policy.

Recommendations The Governing Body is asked to approve the policy on sponsorship and joint working with the pharmaceutical industry

Once approved the policy will be individualised for each CCG

4.0 Resources/investment 4.1 There are no resource implications.

5.0 Equalities 5.1 There are no equalities implications associated with this policy.

6.0 Risk 6.1 The CCG’s governance arrangements will be less robust without this policy in place

Attachments:

Author: Sue Assar, Interim Director of Corporate Services Date: 14 March 2014

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NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG Policy on Sponsorship and Joint Working with the

Pharmaceutical Industry

1. Background

This policy sets out the NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG (the “CCGs”) policy on the management of Sponsorship and Joint Working with the Pharmaceutical Industry. It applies to all “CCG Staff” ("Staff") whether directly working for the CCGs or on secondment to/from other organisations. The term “Staff” includes CCG Governing Body members and members of any committee of the Governing Body who shall comply with this policy whilst exercising functions of the CCG. This policy sets out best practice advice on Sponsorship and Joint Working with the Pharmaceutical Industry. The CCGs recommend that the principles of this policy and the GMC Good Medical Practice Guidance are adhered to by their respective member practices to govern their dealings with the pharmaceutical industry.

NHS organisations are increasingly being offered commercial sponsorship, particularly from the pharmaceutical industry. The Department of Health issued guidance relating to joint working between the NHS and pharmaceutical industry in January 2008 and this policy has been developed by taking into account this guidance. The policy requires all NHS bodies and GPs to adhere to the core values of accountability, probity and openness when dealing with the pharmaceutical industry. The general principles of this policy also apply to sponsorship and joint working with other industry sectors. The Governing Bodies of the CCGs are determined to ensure that the CCGs inspire confidence and trust amongst patients, Staff, partners, funders and suppliers by demonstrating integrity and avoiding any potential or real situations of undue bias or influence in the decision-making of the board or Staff. Prior approval is required before any Sponsorship or Joint Working arrangements are made. The procedure attached as Appendix 1 should be followed. When considering sponsorship and joint working arrangements, all Staff must follow and comply with, amongst other things:

this Policy;

the procedure for obtaining approval of sponsorship and joint working as set out in Appendix 1;

the summary of advice for healthcare professionals meeting with pharmaceutical representatives as set out in Appendix 5;

the DH’s Best Practice Guidance on Joint Working between the NHS and the Pharmaceutical Industry and Other Commercial Organisations;

the Standards of Business Conduct for NHS Staff (see Appendix 3 for summary);

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Commercial Sponsorship – Ethical Standards for the NHS;

their CCG Standards of Business Conduct and Managing Conflicts of Interests Policies;

the code of any relevant professional body e.g. GMC, GPhC, NMC etc;

the ABPI Code of Professional Conduct; and

the ABPI Code of Practice for the Pharmaceutical Industry (see http://www.abpi.org.uk).

Any application for sponsorship and joint working must be made using the approval form set out in Appendix 2. Further, when seeking sponsorship, the template letters set out in Appendix 4 must be used. 2. Definitions The pharmaceutical industry includes:

Companies, partnerships or individuals involved in the manufacture, sale, promotion or supply of medicinal products subject to the licensing provisions of the Medicines Act.

Companies, partnerships or individuals involved in the manufacture, sale, promotion or supply of medical devices, appliances, dressings, and nutritional supplements which are used in the treatment of patients within the NHS.

Trade associations representing companies involved with such products.

Companies, partnerships or individuals who are directly concerned with research, development or marketing of a medicinal product that is being considered by, or would be influenced by, decisions taken by the CCGs or one of their sub-committees or groups.

Pharmaceutical industry related industries, including companies, partnerships or individuals directly concerned with enterprises that may be positively or adversely affected by decisions taken by the CCGs or one of their sub-committees or groups.

Sponsorship is defined in NHS guidance as funding provided to the NHS from an

external commercial source, whether in cash, goods, services, or other benefits in

kind. This includes funding of all or part of the costs of a member of Staff, Staff

training, training of primary care contractors and their Staff, pharmaceuticals, medical

devices, dressings, nutritional supplements, equipment, meeting rooms, costs

associated with meetings, meals, gifts, hospitality, hotel and transport costs,

provision of free services (speakers etc), buildings or premises. Primary care rebate

schemes (PCRS) which are contractual arrangements offered by pharmaceutical

companies, or third party companies, which offer financial rebates on GP prescribing

expenditure for particular branded medicine(s) also apply. Further, Staff should be

aware that any medicine should only be agreed for use within a rebate scheme if it is

believed to be appropriate for a defined cohort of patients within a population. The

detailed content of PCRS’ offered to primary care organisations will differ between

schemes. Any rebate scheme must be compatible with the effective, efficient and

economic use of NHS resources.

http://www.abpi.org.uk/

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This list is not exhaustive. Any other benefits, goods or services that would otherwise

be funded through NHS resources could potentially be caught by the sponsorship

rules.

Joint working is where, for the benefit of patients, organisations pool skills, experience and/or resources for the joint development and implementation of patient centred projects and share a commitment to successful delivery. Joint working agreements and management arrangements are conducted in an open and transparent manner. Joint working differs from sponsorship where organisations simply provide funds for a specific event or work programme. 3. Philosophy underpinning the relationship with the pharmaceutical industry.

It is acknowledged that there is an interdependent relationship between the Pharmaceutical industry and the NHS.

There is a clear demarcation between the research/healthcare development interests and the marketing operations of the companies involved.

There are benefits to exploring and developing the relationships with the pharmaceutical industry for the benefit of the people of NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG within a clear ethical framework.

There is a need for the pharmaceutical industry to maintain profitability and promote specific drugs, and the needs of the NHS to ensure evidence based decision-making, value for money and equity.

It is recognised that ethical members of the pharmaceutical industry hold a clear desire to improve health and healthcare as well as maintain profitability.

There is a clear requirement for the pharmaceutical industry to promote its products in an ethical manner to the prescribing practitioners within the CCGs.

4. Principles for sponsorship and joint working Prior to applying for / accepting sponsorship or joint working, consider whether existing NHS resources normally accessed by the CCGs will suffice for the proposed purpose – e.g. use of NHS buildings and facilities, local / NHS speakers and other available NHS resources. When considering sponsorship and joint working, the following principles must be followed:

Joint projects with the pharmaceutical industry must:

o be for the benefit of the service users of CCG commissioned services; o fully respect and safeguard confidential patient information;

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o promote and enhance equitable access to evidence based high quality healthcare for the service users of CCG commissioned services;

o promote evidence-based medicine and support only those drugs and treatments that have an acceptable evidence-base and which have local formulary approval where applicable.

Offers of sponsorship from the pharmaceutical industry to support projects that are contrary to CCG strategic priorities will not be accepted.

The implications for the CCGs, BHR Health and Social Care Community, and other key stakeholders, of any proposal will be considered prior to approving the joint working project.

The continuity of any services funded through sponsorship or joint working must be fully considered before entering into any arrangements.

Where sponsorship or joint working is being sought, the opportunity to participate should be offered to an appropriate range of companies within the pharmaceutical industry and comply with procurement guidance.

All sponsorship must be assessed using the Approval of Sponsorship and Joint Working procedure (Appendix 1) application for approval (Appendix 2) and approval documented before commencement of the sponsorship or joint working.

Joint working may be pursued with any interested company of good standing within the pharmaceutical industry regardless of their size.

All relationships with the pharmaceutical industry must be handled in an open and transparent manner as befits a publicly funded body.

Sponsorship cannot be accepted for projects that have the prime objective of increasing the usage of a specific brand of pharmaceutical or other product.

The focus needs to be on:

o developing long term relationships with the pharmaceutical industry and undertaking joint projects with companies which have a proven history of ethical and productive joint working; and

o supporting sponsorship and joint working that develop the expertise and capabilities of the Staff and organisations within NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG Health and Social Care Community so as to provide high quality care for the service users of CCG commissioned services.

All sponsorship and joint working projects and associated materials must comply with the current Association of the British Pharmaceutical Industry (ABPI) code of practice, whether or not the sponsor is a member of the ABPI.

Any learning or products (protocols, guidelines, intellectual property etc) developed through joint working will be the property of the CCGs unless

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specifically agreed otherwise in a signed contract with the sponsor(s), and may be shared with other NHS organisations. Consideration will be given to supporting the dissemination of lessons learned from joint working, but the CCGs must retain the right of approval of associated literature and material.

5. When sponsorship can be considered Sponsorship will be considered for the following:

Audit work;

Research;

Publications;

Training and other educational resources;

Provision of facilities (i.e. for meetings, seminars and training);

Provision of free services (i.e. speakers). For example:

Pharmaceutical companies often sponsor clinical trials.

Some companies offer management and organisational development training. It would be preferable to approach several companies to consider the options available.

Sponsorship cannot be accepted for:

Pharmaceuticals, diagnostics, appliances or equipment which may influence a change in prescribing behaviour;

Direct funding of CCG Staff posts. For example:

The provision of free pharmaceutical starter packs by companies is not permitted as this promotes prescribing of a particular product and compromises purchasing decisions (e.g. maternity neo-natal packs).

6. Dos and Don’ts

Sponsorship dealings should not create inappropriate links or images of the CCGs in the minds of purchasers, patients or the general public. For example, sponsoring organisations should not be permitted to use the names of the CCGs (including logos) or their employees or services to infer endorsements of products or activities of the organisation, without explicit agreement from the CCGs.

Sponsoring organisations should not be promoting their products through the CCG work they are supporting by direct advertisement (except by promotional stands as appropriate at sponsored meetings).

Sponsorship arrangements which may allow non-NHS personnel access to confidential information, such as patient records, must follow ABPI code of practice.

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IF IN DOUBT, DECLARE IT! Appendix 4 of each CCG’s Standards of Business Conduct and Managing Policy require declarations to be made in respect of gifts / hospitality / sponsorship (not matter how small) in the register contained in Appendix 4. Declarations vary and typically include:

o Gifts; o Event attendance including travel; o Speakers at events; o Article writing; o Membership of advisory panels of pharmaceutical companies; o Funded questionnaires; o Close family members employed by a relevant organisation.

DO NOT accept any: o Inducements; o Inappropriate hospitality; o Gifts of a value (actual or perceived) greater than £25 without approval

from an executive director of the relevant CCG. Further, all such gifts must be logged in Appendix 4 of the relevant CCG’s Standards of Business Conduct Policies. Except for attendance at scientific meetings, conferences, promotional or other meetings, it is best practice (although, not policy) for Staff not to accept gifts of any value which bear a logo of a non-NHS company name or product. These may be deemed to be promotional and not in keeping with the image of the CCGs. Such gifts may include: pens, note-pads, mouse mats, mugs, calendars and calculators for example;

o Medicines management pharmaceutical industry support that has not been approved by BHR CCGs medicines management team.

DO NOT: o Unfairly advantage one competitor over another or show favouritism in

awarding contracts; o Permit company representatives to sit in on meetings where BHR

CCGs business is discussed unless specifically part of a previously agreed agenda item;

o Misuse or make available ‘commercial in confidence’ information. 7. The ABPI Code of Practice for the Pharmaceutical Industry Staff should adhere to the Code at all times and be aware of the following (as prescribed by the Code):

Companies must not provide hospitality to the NHS and healthcare professionals except in association with scientific meetings, promotional meetings, scientific congresses and other such meetings and training.

Meetings must be held in appropriate venues conducive to the main purpose of the event.

Hospitality must be strictly limited to the main purpose of the event and must be secondary to the purpose of the meeting - i.e. subsistence only. The level of subsistence must be appropriate and proportionate and must not exceed that level which the relevant CCG would have paid itself.

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Hospitality is limited to refreshments, accommodation, reasonable travel expenses and genuine registration fees.

When attending scientific meetings, conferences, promotional or other meetings, Staff can be provided with inexpensive notebooks, pens and pencils for use at that meeting. These must not bear the name of any medicine but may bear the name of the company providing them. No other gift or benefit or pecuniary advantage can be offered by the companies as an inducement to prescribe, supply, administer or recommend, buy or sell any medicine.

If any Staff involved in sponsorship or joint working arrangements with the pharmaceutical industry believe that a company has breached the Code, they should refuse the gift / hospitality / sponsorship and report their complaint to the Director of the Prescription Medicines Code of Practice Authority (further details of this can be found in the Code: http://www.abpi.org.uk). 8. Written Agreements – Joint Working and Sponsorship Any joint working / sponsorship between a company and any of the CCGs should be set out in writing – in the form of a legal agreement. The agreement should define the exact nature and scope of the joint working / sponsorship, together with any time frame. The agreement should deliver the following points:

The intended benefit to patients is clear;

All parties are clear about the other’s expectations of the arrangement;

The arrangements provide the best value services for the resources available;

Clinical and ethical issues around treatment choices are clarified;

Clinical and financial outcome measures and monitoring arrangements have been established;

Confidentiality and data protection are maintained;

Opt-out clauses are included so that either party can terminate the arrangement if it is not providing the desired outcomes or good value for money;

Work is agreed on a project basis with consideration given as to how the project will be managed and by whom;

Sponsorship must not compromise purchasing decisions or direct supply from a particular source and this must be made explicit in the agreement;

Sponsorship does not imply endorsement of the product by the organisation and there should be no promotion of products other than that agreed in writing in advance;

Sponsorship will not be accepted for meetings associated with the core business of the CCGs e.g. CCG Board Meetings.

The legal agreement(s) should be suitably robust. This may require advice from the relevant CCG’s legal advisors. A copy of the agreement(s) must be given to the CCG’s Head of Corporate Affairs.

http://www.abpi.org.uk/

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9. Governance All sponsorship and joint working arrangements with the pharmaceutical industry will be subject to scrutiny by the Audit Committee of the relevant CCG. 10. Research If a joint working project with the pharmaceutical industry concerns research, this falls outside the scope of this policy. Participants should refer to the CCG Governance lead for local process for Research or to the National Research Ethics service http://www.nres.npsa.nhs.uk 11. Application to Sub – Committees The provisions of this policy apply to any sub-committee and each member of a subcommittee established by NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG. 12. Policy implementation and review All existing members of the CCG will be provided with a copy of this policy and it will form part of the induction checklist for new members. The policy will be reviewed at least annually to ensure it is consistent with emerging guidance on the responsibilities and governance of CCGs and reflects the current law. References: 1. ABPI Code of Conduct for the Pharmaceutical Industry 2012

http://pmcpa.org.uk/files/ABPI%20Code%202012.pdf

2. Department of Health – Commercial Sponsorship – Ethical Standards in the NHS, Nov 2000

3. Department of Health – Best Practice Guidance on Joint Working between the NHS and the Pharmaceutical Industry, 2008 http://www.networks.nhs.uk/nhs-networks/joint-working-nhs-pharmaceutical/documents/dh_082569.pdf

4. GMC Good Medical Practice Guidelines 2013 http://www.gmc-uk.org/static/documents/content/GMP_2013.pdf_51447599.pdf

5. London Procurement Programme – rebate schemes http://www.lpp.nhs.uk/news_item.asp?fldID=45

http://pmcpa.org.uk/files/ABPI%20Code%202012.pdf

http://www.networks.nhs.uk/nhs-networks/joint-working-nhs-pharmaceutical/documents/dh_082569.pdf

http://www.networks.nhs.uk/nhs-networks/joint-working-nhs-pharmaceutical/documents/dh_082569.pdf

http://www.gmc-uk.org/static/documents/content/GMP_2013.pdf_51447599.pdf

http://www.lpp.nhs.uk/news_item.asp?fldID=45

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Acknowledgments In development of the policy work was adapted from the following:

NHS Crawley CCG, NHS Horsham and Mid Sussex CCG Policy on Sponsorship and Joint Working, February 2013

NHS Dorset NHS Bournemouth and Poole Medicines Code Chapter 21 Working With The Pharmaceutical Industry, January 2012 Solicitor and In House Counsel for BHR CCGs and Hempsons Solicitors

www.hempsons.co.uk

Author Oge Chesa, Deputy Chief Pharmacist BHR CCGs June 2013 Approved by BHR CCGs Area Prescribing sub-Committees, February 2014

http://www.hempsons.co.uk/

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Appendix 1: Procedure for the Approval of Sponsorship and Joint Working This procedure provides the framework to seek approval of sponsorship and joint working with the pharmaceutical industry. Please refer to the main Policy document for clarification of definitions used. 1. Scope

This procedure applies to sponsorship and joint working arrangements whether alone or in conjunction with other NHS organisations, where any funding (actual or in kind) is provided by the pharmaceutical industry.

All sponsorship and joint working arrangements must have a lead personnel who is responsible for overseeing the sponsorship or joint working, and ensuring compliance with the policy.

Where there are linked events or joint working arrangements, the lead personnel should group these within the same application.

2. Process 2.1 Applications with an external funding value of any value

2.1.1. The lead personnel must complete and sign the Application for Sponsorship and Joint Working Approval form below, and submit it to the responsible manager for approval.

2.1.2. The responsible manager should ensure that the application fully complies with the Policy on Sponsorship and Joint Working before giving approval.

2.1.3. Following approval, the lead personnel will be able to take forward the

arrangements as detailed in their application. No significant amendments to the arrangements may be made after approval.

2.1.4. The completed form should be sent to the Finance team for Barking and

Dagenham, Havering and Redbridge CCGs. The details will be logged and the application will be presented for information at the Audit Committees for Barking and Dagenham CCG and Havering CCG and Redbridge CCG

3. Governance 3.1 The CCG Governance lead will be responsible for maintaining a Sponsorship

Register detailing all sponsorship applications (above £25), and the decisions regarding approval.

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3.2 A quarterly report to the 3 Audit and Governance Committees will be produced giving details of all applications which have been received, and the decisions taken.

3.3 In the event of disagreement or dispute the matter will be referred to the Chair of

the Audit and Governance Committees for decision. Any queries regarding this procedure should be directed to the Chief Finance Officer for Barking and Dagenham, Havering and Redbridge CCGs.

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Appendix 2: Application for Sponsorship and Joint Working Approval form In accordance with NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG policy on Sponsorship and Joint Working this form should be received from the pharmaceutical industry as applying for authorisation to proceed with sponsorship.

Tick

Sponsorship of NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG educational meetings

Attendance at Sponsored meetings/acceptance of gifts

Sponsorship of joint projects

Other ...please specify

Details of proposed sponsorship: (please continue on separate sheet if necessary)

What are the expected benefits of this sponsorship?

What is the estimated value of this sponsorship: If exact value is unknown please give details at a later date.

Budget code that any income will be paid into:

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Applicants Details I confirm that this request complies with NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG policy on Sponsorship and Joint Working

Name: Signature:

Position: Date:

Contact details:

Approval Details I confirm that this request complies with NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG policy on Sponsorship and Joint Working and approve this request

Name: Signature:

Position: Date:

Copies of this completed and signed form must be retained by

Applicant

Responsible manager approving request

Governance / Finance personnel to provide an overview to the audit committee of all sponsorship received within NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG

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Appendix 3: The Standards of Business Conduct for NHS Staff - Summary NHS Staff are expected to

Ensure that the interests of patients remain paramount at all times;

Be impartial and honest in the conduct of their official business;

Use the public funds entrusted to them to the best advantage of the service, always ensuring value for money

It is also the responsibility of Staff to ensure that they do not:

Abuse their official position for personal gain or to benefit their family and friends;

Seek to advantage or further private business or other interests, in the course of their official duties.

In implementing these principles Staff should comply with policies on:

Gifts and Hospitality

Declaration of interests In addition: Individual Staff must not seek or accept preferential rates or benefits in kind for private transactions carried out with companies with which they have had, or may have, official dealings on behalf of their NHS employer. All Staff who are in contact with suppliers and contractors (including external consultants) and in particular those Staff who are authorised to sign Purchase Orders, or place contracts for goods, materials or services are expected to adhere to the NHS Procurement Guide for Health Services, European Procurement Directives and the Regulations that implement them in the UK and set out the law on public procurement. Invitations to potential contractors to tender for NHS business should include a notice warning tenderers of the consequence of engaging in any corrupt practices involving employees of public bodies. NHS employers should ensure that no special favour is shown to current or former employees or their close relatives or associates in awarding contracts to private businesses run by them or employing them in a senior or relevant capacity. Staff should be particularly careful of using, or making public, internal information of a “commercial in-confidence” nature, particularly if its disclosure would prejudice the principle of a procurement system based on fair competition

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Appendix 4: excerpt from NHS BHR CCGs Standards of Business Conduct and Managing Conflicts of

Interest Policy

Declaration of interests for members/employees template

NHS (name...............) Clinical Commissioning Group

Member / employee/ governing body member / committee or sub-committee member

(including committees and sub-committees of the governing body) [delete as

appropriate] declaration form: financial and other interests

This form is required to be completed in accordance with the CCG’s Constitution and section

14O of The National Health Service Act 2006.

Notes:

Each clinical commissioning group (CCG) must make arrangements to ensure that the persons mentioned above declare any interest which may lead to a conflict with the interests of the CCG and the public for whom they commission services in relation to a decision to be made by the CCG.

A declaration must be made of any interest likely to lead to a conflict or potential conflict as soon as the individual becomes aware of it, and within 28 days.

If any assistance is required in order to complete this form, then the individual should contact Rod McEwen, Legal and Governance Adviser (In-house Counsel and Solicitor) - [email protected].

The completed form should be sent by both email and signed hard copy to Anne-Marie Keliris, Company Secretary – [email protected] and by post to BHR CCGs, 5th Floor, Becketts House, 2-14 Ilford Hill, Ilford, IG1 2QX

Any changes to interests declared must also be registered within 28 days by completing and submitting a new declaration form.

The register will be published on the CCG’s website.

Any individual – and in particular members and employees of the CCG - must provide sufficient detail of the interest, and the potential for conflict with the interests of the CCG and the public for whom they commission services, to enable a lay person to understand the implications and why the interest needs to be registered.

If there is any doubt as to whether or not a conflict of interests could arise, a declaration of the interest must be made.

Interests that must be declared (whether such interests are those of the individual

themselves or of a family member (including, but not limited to: wife, husband, civil partner,

partner, in-laws, parent, child, sibling, aunt, uncle, cousin), close friend or other acquaintance

of the individual e.g. business partner include:

roles and responsibilities held within member practices;

directorships, including non-executive directorships, held in private companies or PLCs;

ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG;

shareholdings (more than 5%) of companies in the field of health and social care;

a position of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care;

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



16 | P a g e

research funding/grants that may be received by the individual or any organisation in which they have an interest or role;

any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or actions in their role within the CCG.

If there is any doubt as to whether or not an interest is relevant, a declaration of the interest

must be made.

Declaration:

Name:

Position within or

relationship with,

the CCG:

Interests:

Type of Interest Details of the

company/organisation where

appropriate (full name, address

and nature of the business)

including the date that I became

aware of the interest

(if no interest to declare please

state ‘none’)

Personal interest or that of

a family member, close

friend or other

acquaintance?

(if no interest to declare

please state ‘none’)

Roles and

responsibilities

held within

member practices

Directorships,

including non-

executive

directorships, held

in private

companies or PLCs

Ownership or part-

ownership of

private companies,

businesses or

consultancies

likely or possibly

seeking to do

business with the

CCG

Shareholdings

(more than 5%) of

companies in the

17 | P a g e








state ‘none’)



friend or other

acquaintance?



field of health and

social care

Positions of

authority in an

organisation (e.g.

charity or voluntary

organisation) in the

field of health and

social care

Any connection

with a voluntary or

other organisation

contracting for

NHS services

Research

funding/grants that

may be received by

the individual or

any organisation

they have an

interest or role in

Other specific

interests?

Any other role or

relationship which

the public could

perceive would

impair or otherwise

influence the

individual’s

judgement or

actions in their role

18 | P a g e








state ‘none’)



friend or other

acquaintance?



within the CCG

To the best of my knowledge and belief, the above information is complete and correct. I

undertake to update as necessary the information provided and to review the accuracy of the

information provided regularly and no longer than annually. I give my consent for the

information to be used for the purposes described in the CCG’s Constitution and published

accordingly.

Signed:

Date:

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Appendix 5: Suggested Sponsorship Letters Letter 1 – Request for sponsorship

<letterhead>

Dear

…………….. is/are arranging an education meeting.

<Give details of event>

In accordance with the NHS Barking and Dagenham CCG and NHS Havering CCG and NHS Redbridge CCG policy on Sponsorship and Joint Working I am writing to a number of companies to ask if you would like to sponsor this event. Sponsorship will be in the form of having a Promotional Stand which will be visited by delegates during breaks in the programme. Sponsors will not have access to the main educational event. If you would like further information please contact the Medicines Management Team 0208 822 3076/3074.

The programme for the event will note your sponsorship but will not promote any product.

The cost of having a Stand is £ XXX.

If you would be interested in having a stand at this meeting please contact ….

Letter 2 - Confirmation letter

Dear Thank you for agreeing to sponsor <details of event>

I confirm the following details <time, venues of event>

You will have a Promotional Stand, which will be visited by delegates during breaks in the programme, to promote company products.

The cost of having a Stand is £ XXX. Please send a cheque payable to XXXX, to XXX by XXXX /or arrange to pay this amount to the venue management (your contact is......) [delete as appropriate].

The programme for the event will note your sponsorship but will not promote any product.

I would like to take this opportunity to thank you for your input into this event and look forward to a productive session.

Yours sincerely

<name> <title> <telephone number> <email>

20 | P a g e

Appendix 6: Advice for Health Care Professionals Meeting with Pharmaceutical Representatives

See representatives by appointment only

Choose only to see those representatives whose product interest you and confine the interview to that product

Take charge of the interview. Do not hear out a rehearsed sales routine but

Ask for independent published evidence from reputable peer reviewed journals. BEWARE ‘Data on file’ references (ask why the information has not been published?), abstracts, supplements and reports from conferences (peer review processes may not be applied as rigorously as for full articles).

Avoid promotional brochures. BEWARE unpublished material, misleading graphs and selective quotations.

Ignore anecdotal ‘evidence’ such that a medical ‘celebrity’ is prescribing

the product. Contact the Medicines Management Team if you want to check out whether Consultant X is using the product.

Consider how the new drug compares to existing therapy in the following areas

Do not accept samples of medical products.

Be aware that Pharmaceutical Companies provide advertising material as they

have evidence that it leads to increased use of their products. An independent

group, ’No Free Lunch’ promotes awareness of the effects of the Pharmaceutical

Industry. For further information visit http://www.nofreelunch.org/

Representatives should not sit in on meetings where CCG business is being

discussed

Do not accept pharmaceutical industry support that has not been approved by

BHR CCGs medicines management team

Safety } Tolerability } Efficacy } Price }

Good quality, reliable data should

show the new drug to be better on at least one of these steps for it to be considered further.

http://www.nofreelunch.org/

To: Meeting of the Governing Body From: Rod McEwen, in house solicitor Date: 27 March 2014meeting Subject: Formal calling of a General Meeting of the Members’ Committee for the 14 May 2014

and to note and recommend to the General Meeting of the Members’ Committee the proposed amendments to the Constitution.

Executive summary Following discussions at the Executive Committee on 24 February 2014 it had been intended that the proposed amendments to the Constitution would be presented to the General Meeting of the Members’ Committee on the 19 March for their consideration.. However in governance terms, it is considered good practice for the proposed amendments to be first noted and if appropriate recommended by the Governing Body before they are presented to the Members’ Committee for approval. In the circumstances therefore the Governing Body is asked to resolve to call a General Meeting of the Members’ Committee for the 14 May 2014. It is also asked to consider and recommend to the General Meeting of the Members’ Committee the proposed amendments to the Constitution.

Recommendations The Governing Body resolves to call the General Meeting for the 14 May 2014 and to recommend the proposed amendments to the Constitution to the General Meeting of the Members’ Committee.


The purpose of the report is to ask the Governing Body to resolve to call a General

Meeting of the Members’ Committee for 14 May 2014 and to set out the proposed amendments to

the 1.1 Constitution to be put to that meeting for consideration..


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All clinical commissioning groups are obliged to have a written Constitution. The

Constitution 2.1 provides that the Governing Body may call a General Meeting at any time.

3.0 Report Content Process

It had been intended that the proposed amendments to the Constitution would be presented to the General Meeting of the Members’ Committee on the 19 March. These amendments had been noted at the Executive Committee on 24 February. However, it is considered good practice in governance terms for the proposed amendments to be also noted and if appropriate recommended by the Governing Body before the proposed amendments are presented to the Members’ Committee for approval. In the circumstances therefore the Governing Body is asked to resolve to call a General Meeting of the Members’ Committee for the 14 May 2014 and for the Governing Body to consider and recommend to the General Meeting of the Members’ Committee the proposed amendments to the Constitution. This has been agreed with the Members’ iat the Members’ Committee Meeting that which took place on 19 March. Vires The Governing Body is able to call a General Meeting of the Members’ Committee under clause 3.1.1 of Appendix C of the Constitution. 21 days notice must be given of the General Meeting. The Governing Body may discuss and make proposals on those decisions/duties which are reserved to the Members’ Committee and when the Chair arranges for the papers and the agenda to be distributed he is entitled to propose that the Members’ Committee agree the resolution amending the Constitution. Proposed Amendments The Governing Body is asked to note that since the current Constitution was drafted some areas which require clarification and/or amendment to give effect to DH guidance have been noted and it is now proposed to amend the Constitution. The Members’ Committee have also proposed a change to the decision making process at General Meetings so that matters for decisions at General Meetings are no longer decided on a weighted voting system relating to registered list size votes but on a one vote per Practice Representative basis. All amendments to the Constitution require the agreement of the Members’ Committee of the CCG and thereafter require an application to be made to NHS England. NHS England are currently considering applications for amendments only twice per year, and require applications to be made to them by 1 June or by 1 November in each year. It is proposed that the application is made to NHS England by 1 June and as such therefore the Members’ Committee will be asked to give their agreement to the amendments at the General Meeting which is to take place on 14 May 2014.

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The proposed amendments are set out below.

NHS Redbridge CCG

Material Changes:

Page,

Paragraph Change made Effect of change

5, 1.6 The constitution will be reviewed by the Group every twelve months.

There will be an obligation for the Group to review the constitution once every year.

7, 3.3.1 The words ‘and proxy’ have been removed.

There are sufficient provisions within the Constitution which relate to the appointment of a proxy. The wording here is unnecessary.

15, 6.6.1-6.6.2

Any reference to a Deputy Chair of the Member’s Committee has been deleted.

An additional sentence has been added allowing the Deputy Chair of the Governing Body to act for the Chair of the Members’ Committee where the Chair is unable to act.

There will not be a Deputy Chair of the Members’ Committee.

15, 6.6.3 The words ‘the Governing Body’ have been removed.

The inclusion has no practical effect and as such, has been removed.

15, 6.6.5 Additional wording has been inserted.

There will be an obligation for the Members’ Committee to meet twice every financial year; that being the NHS financial year which runs from 1 April to 31 March.

17, 6.8.1 Reference is now made to the Governing Body delivering any functions which are not reserved or delegated and the words "to the CCG membership" have been deleted.

This is a drafting point and clarifies that the Governing Body delivers any functions which are not otherwise reserved or delegated.

18, 6.8.4 b)

We have proposed adding a provision in, to reflect

This amendment is by way of clarification and reflects the legal position.

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the legal position that only members of the Governing Body may be members of the Remuneration and Workforce Committee.

18, 6.8.4 c), d), and e)

We have provided more details on the committees.

This is by way of clarification

19, 6.8.7 We propose adding the words "(except the Remuneration and Workforce Committee)" so as to make clear that this clause 6.8.7 does not apply to the Remuneration and Workforce Committee, on which only governing body members can sit.

This amendment is by way of clarification and reflects the legal position.

19, 6.8.7 d)

We have added Lay members who are aged 18 or over, reside in the Area and are not disqualified under Schedule 5 of the CCG Regulations.

We have suggested this amendment so that lay members are able to sit on committees other than the audit committee and the remuneration and workforce committee.

30, 9.11 We have added a clause as to whistle blowing.

NHS England has recommended that this clause as to whistle blowing is inserted. The clause simply confirms that there is nothing in the constitution which prevents whistle blowing.

Appendix B

We have added the locality description to the members.

43, 2.5 g) The words "where notice is given by the Clinical Director" have been added.

This is to confirm this is the notice period when notice is given by the clinical director but that otherwise where the clinical director is removed from office this takes effect immediately.

44, 2.6 f) The words "where notice is given by the Chair" have been added.

This is to confirm this is the notice period when notice is given by the Chair but that otherwise where the chair is removed from office this takes effect immediately.

45, 2.7 (g)

The words "3 months where notice is given by the Deputy Chair" have been added.

This is to confirm this is the notice period when notice is given by the deputy chair but that otherwise where the deputy chair is no longer a member of the governing body or no longer meets the eligibility criteria this takes effect

immediately. 46,2.10 f) The words "if

notice is given by the Lay Member" have been added.

This is to confirm this is the notice period when notice is given by the lay member but that otherwise where the lay member is removed from office this takes effect immediately.

47,2.11 f) The words "if notice is given by the secondary care specialist" have been added.

This is to confirm this is the notice period when notice is given by the secondary care specialist but that otherwise where the secondary care specialist is removed from office this takes effect immediately.

49,3.1.5 The requirement to give notice of General Meetings on the CCG’s website and at the CCG’s offices and to give notice to the auditor, local Healthwatch and the chair of the HWB of general meetings of such meetings has been moved so as to apply to Annual General Meetings and appears at 3.9.6 (page 53).

These notice requirements should apply to the AGM as the AGM is a public meeting whereas the General Meetings of the Members’ Committee are held in private (unless the Members Committee considers it should be held in public).

51, 3.6 3.6.2 and 3.6.3 have been replaced with a provision that each Practice Representative shall have one vote. There is a consequential change in the wording of 3.6.3.

The voting rights of Practice Representatives will be changed from one vote per 2000 patients on the registered list size to each Practice Representative having one vote.

53, 3.9.1 (a)

The word ‘financial’ has been added.

There is an obligation for the Members’ Committee to hold an AGM once in each financial year, that being between 1 April and 31 March.

61, 8.1.1 Additional wording has been added.

These amendments are designed to clarify that the Group can appoint its own committees; and the Governing Body can appoint its own committees. This is a drafting point and there is no substantial difference.


This is designed to clarify that the Group will determine the terms of reference for its committees; and the governing body the terms of reference for its committees.


This is designed to clarify that the Group can approve the appointments to its committees; and the Governing Body can approve the appointments to its committees.

63, 11.1.1

"Governing Body" has replaced "Group".

The proposed amendment is to make the Governing Body approve policies which apply to staff employed by the CCG.

68, 6 the Governing Body

We have deleted the reference to the terms and conditions.

The remuneration committee will determine the terms and conditions of employment of employees of the CCG and the terms of service of persons providing services to the group (other than the pay, which the governing body must determine or delegate).

72, b) We have deleted the words "determining the annual salary awards."

The remuneration committee is unable to so determine as this is a function of the governing body.

72, f) Additional wording has been added.

The remuneration committee will determine the terms and conditions of employment of employees of the CCG and the terms of service of persons providing services to the group (other than the pay, which the governing body must determine or delegate).

73, Q and S, F and D, and Joint executive committee

Additional wording has been added.

These amendments are designed to address the fact that these committees have now been established.

Immaterial Changes:

Footnotes have been removed throughout. Formatting changes and changes to paragraph references have been made at various places throughout for consistency.


It is proposed that Christian Dingwall of Hempsons solicitors attend the General Meeting of the

Members’ Committee on 14 May 2014 to answer any questions which may be raised on the

4.1 proposed amendments. Rod McEwen will also be present.

4.2 The cost will be met from the existing legal budget.


6.0 Risk 6.1 None identified.

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Attachments: 1. Proposed version of the Constitution.

An electronic copy will be made available to committee members and a hard copy will be available at the meeting.

Author:: Rod McEwen, legal and governance adviser Date: 11 March 2014

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NHS Redbridge CLINICAL COMMISSIONING GROUP

CONSTITUTION

2

[Page left intentionally blank]

1

CONTENTS

Part Description Page

Foreword 3

1 Introduction and Commencement 4

1.1 Name 4

1.2 Statutory framework 4

1.3 Status of this constitution 4

1.4 Amendment and variation of this constitution 4

2 Area Covered 6

3 Membership 7

3.1 Membership of the Clinical Commissioning Group 7

3.2 Eligibility 7

3.3 Practice Representatives 7

4 Mission, Values and Aims 8

4.1 Mission, Values and Aims 8

4.2 Principles of good governance 8

4.3 Accountability 9

5 Functions 10

5.1 Functions 10

5.2 General duties 10

5.3 Public involvement 11

5.4 General financial duties 12

5.5 Other relevant regulations, directions and documents 12

5.6 Arrangements by the Group to comply with its functions 12

6 Decision Making: The Governing Structure 14

6.1 Authority to act 14

6.2 Scheme of reservation and delegation 14

6.3 General 14

6.4 Committees of the Group 15

7 Roles and Responsibilities 21

7.1 Practice representatives 21

7.2 Clinical Directors 21

7.3 Other GPs or primary care health professionals 21

7.4 All members of the Group’s Governing Body 22

7.5 The Chair of the Governing Body 22

7.6 The deputy Chair of the Governing Body 23

7.7 Role of the accountable officer 23

7.8 Role of the Chief Finance Officer 23

7.9 Joint appointments with other organisations 24

7.10 Responsibilities of Members to the Group 24

7.11 Responsibilities of the Group to Members 24

8 Standards of Business Conduct and Managing Conflicts of Interest 25

2

Part Description Page

8.1 Standards of business conduct 25

8.2 Conflicts of interest 25

8.3 Declaring and registering interests 26

8.4 Managing conflicts of interest: general 26

8.5 Managing conflicts of interest: contractors and people who provide services to the Group

29

8.6 Transparency in procuring services 29

9 The Group as Employer 30

10 Transparency, Ways of Working and Standing Orders 31

10.1 General 31

10.2 Standing orders 31

Appendix Description Page

A Definitions of Key Descriptions used in this Constitution 32

B List of Member Practices 34

C Standing Orders 37

D Scheme of Reservation and Delegation 62

E Prime Financial Policies 72

F The Nolan Principles 83

G The Seven Key Principles of the NHS Constitution 84

3

Foreword

The Constitution sets out the arrangements made by NHS Redbridge Clinical Commissioning Group (the Group) to meet its responsibilities for commissioning care for the people for whom it is responsible. It describes the governing principles, rules and procedures that the Group has established to ensure probity and accountability in the day to day running of the clinical commissioning Group; to ensure that decisions are taken in an open and transparent way and that the interests of patients and the public remain central to the goals of the Group. The Constitution includes:

the name of the Group

the membership of the Group

the area of the Group

the arrangements for the discharge of the Group’s functions and those of its Governing Body

the procedure to be followed by the Group and its Governing Body in making decisions and securing transparency in its decision making

arrangements for discharging the Group’s duties in relation to registers of interests and managing conflicts of interests

arrangements for securing the involvement of persons who are, or may be, provided with services commissioned by the Group in certain aspects of those commissioning arrangements and the principles that underpin these.

The Constitution applies to the following, all of whom are required to adhere to it as a condition of their appointment:

the Group’s member practices

the Group’s employees

individuals working on behalf of the Group and

anyone who is a member of the Group’s Governing Body (including the Governing Body’s audit and remuneration committees)

anyone who is a member of any other committee(s) or sub-committees established by the Group or its Governing Body

4

1 INTRODUCTION AND COMMENCEMENT

1.1 Name

1.1.1 The name of this clinical commissioning group is NHS Redbridge Clinical Commissioning Group (the Group).

1.2 Statutory Framework

1.2.1 The Group is established under the 2006 Act (as amended by the 2012 Act). It is a statutory body which has the function of commissioning services for the purposes of the health service in England and is an NHS body for the purposes of the 2006 Act. The duties of the Group to commission certain health services are set out in section 3 of the 2006 Act, as amended by section 13 of the 2012 Act, and the regulations made under that provision.

1.2.2 The NHS Commissioning Board will undertake an annual assessment of the Group. It has powers to intervene in the Group where it is satisfied that a Group is failing or has failed to discharge any of its functions or that there is a significant risk that it will fail to do so.

1.2.3 The Group is a clinically led membership organisation made up of general practices. The Group’s Members are responsible for determining its governing arrangements, which are set out in this Constitution.

1.3 Status of this Constitution

1.3.1 This Constitution is made between the Group’s Members and has effect from the date when the NHS Commissioning Board established the Group. The Constitution is published on the Group’s website.

1.3.2 The Constitution will also be available upon request by making an application to the Group’s principal place of business, the details of which will be published on the Group’s website.

1.4 Amendment and Variation of this Constitution

1.4.1 This Constitution can only be varied in two circumstances.

a) where the Group applies to the NHS Commissioning Board and that application is granted; or

b) where in the circumstances set out in legislation the NHS Commissioning

Board varies the Group’s constitution other than on application by the Group.

5

1.5 The Group shall have a dispute resolution policy. 1.6 The Constitution will be reviewed by the Group no less than every twelve months.

6

2 AREA COVERED

2.1 The geographical area (the Area) covered by the Group is coterminous with the

London Borough of Redbridge as shown on the map at Clause 2.3.

2.2 The Area is divided into 4 geographic areas called Seven Kings Locality, Fairlop Locality, Wanstead and Woodford Locality, and Loxford and Cranbrook Locality (each a Locality and together the Localities) as shown on the map Clause 2.3.

2.3 Map referred to in Clauses 2.1 and 2.3 is as follows:

7

3 MEMBERSHIP

3.1 Membership of the Clinical Commissioning Group

3.1.1 Appendix B of this Constitution lists the Members of the Group.

3.1.2 Each Member is allocated to a Locality as listed in Appendix B.

3.2 Eligibility

3.2.1 Providers of primary medical services to a registered list of patients under a General Medical Services (GMS), Personal Medical Services (PMS) or Alternative Provider Medical Services (APMS) contract, will be eligible to apply for membership of this Group.

3.2.2 Subject to the agreement of the NHS Commissioning Board, a Member will cease to be a member of the Group if it ceases to meet the eligibility criteria set out in paragraph 3.2.1.

3.2.3 If a Member wishes to apply to leave the Group, the Member will give to the Group not less than 12 months written notice expiring on 31 March in a year following the year in which the notice is given. Any such application will be subject to the agreement of the NHS Commissioning Board.

3.3 Practice Representatives

3.3.1 Each Member will be required to nominate a Practice Representative and proxy of that Member who is either a GP partner or a salaried GP or other healthcare professional. Each Member shall notify the Governing Body of the name of its Practice Representative in writing. Each Member may remove and replace its Practice Representative at any time and from time to time, by notice in writing to the Governing Body. It is for each Member to decide how its Practice Representative is appointed, draw up any terms of office, including the grounds for removal from office and to decide on any notice period.

3.3.2 Each Practice Representative shall represent the Member that has appointed it at meetings of the Members’ Committee in accordance with the Standing Orders at Appendix C.

8

4 MISSION, VISION AND AIMS

4.1 Mission, Values and Aims

4.1.1 The Group’s vision is to improve the quality of care for patients and residents in Redbridge by working with partners and patients, making most efficient use of NHS resources.

4.1.2 The Group shall publish a statement setting out its mission, values and aims in its annual commissioning plan (“Statement of Mission, Values and Aims”).

4.1.3 The Governing Body shall review its Statement of Mission, Values and Aims

each year, as part of the process of producing the commissioning plan for the following year, and shall decide whether any changes are appropriate.

4.1.4 A copy of the Group’s Statement of Mission, Value and Aims, from time to time,

shall be published on its website. 4.2 Principles of Good Governance

4.2.1 In accordance with section 14L(2)(b) of the 2006 Act, the Group will at all times

observe “such generally accepted principles of good governance” in the way it conducts its business. These include:

a) the highest standards of propriety involving impartiality, integrity and objectivity in

relation to the stewardship of public funds, the management of the organisation and the conduct of its business;

b) The Good Governance Standard for Public Services; c) the standards of behaviour published by the Committee on Standards in Public

Life (1995) known as the ‘Nolan Principles’ d) the seven key principles of the NHS Constitution; e) the Equality Act 2010; and

f) Standards for members of NHS Boards and CCG governing bodies in England.

4.3 Accountability

4.3.1 The Group will demonstrate its accountability to its members, local people,

stakeholders and the NHS Commissioning Board in a number of ways, including by:

a) publishing its constitution; b) appointing independent lay members and non GP clinicians to its Governing

Body;

9

c) holding meetings of its Governing Body in public (except where the Group

considers that it would not be in the public interest in relation to all or part of a meeting);

d) publishing annually a commissioning plan and associated commissioning

strategies;

e) complying with local authority health related overview and scrutiny requirements; f) meeting annually in public to publish and present its annual report (which must be

published);

g) producing annual accounts in respect of each financial year which must be externally audited;

h) having a published and clear complaints process; i) complying with the Freedom of Information Act 2000; j) providing information to the NHS Commissioning Board as required; and

k) working with Healthwatch.

4.3.2 In addition to these statutory requirements, the Group will demonstrate its

accountability by:

a) Partnership working through the Health and Wellbeing Board; b) Establishing a Patient Engagement Forum;

c) Publishing a communications and engagement strategy; and d) Engaging with the LMC.

4.3.3 The Governing Body of the Group will throughout each year have an ongoing role in reviewing the Group’s governance arrangements to ensure that the Group continues to reflect the principles of good governance.

5 Functions

5.1 Functions

5.1.1 The Group’s functions include:

a) commissioning certain health services (where the NHS Commissioning Board is not under a duty to do so) that meet the reasonable needs of:

i) all people registered with Member GP practices, and

10

ii) people who are usually resident within the Area and are not registered with a member of any clinical commissioning Group;

b) commissioning emergency care for anyone present in the Group’s Area;

c) paying its employees’ remuneration, fees and allowances in accordance with the determinations made by its Governing Body and determining any other terms and conditions of service of the Group’s employees; and

d) determining the remuneration and travelling or other allowances of members of its Governing Body.

5.1.2 In discharging its functions the Group will:

a) act, when exercising its functions to commission health services, consistently with the discharge by the Secretary of State and the NHS Commissioning Board of their duty to promote a comprehensive health service and with the objectives and requirements placed on the NHS Commissioning Board through the mandate published by the Secretary of State before the start of each financial year;

b) meet the public sector equality duty; and

c) work in partnership with its local authority to develop joint strategic needs assessments and joint health and wellbeing strategies

5.2 General Duties - in discharging its functions the Group will:

5.2.1 Promote awareness of, and act with a view to securing that health services are

provided in a way that promotes awareness of, and have regard to the NHS Constitution;

5.2.2 Act effectively, efficiently and economically;

5.2.3 Act with a view to securing continuous improvement to the quality of services;

5.2.4 Assist and support the NHS Commissioning Board in relation to the Governing Body’s duty to improve the quality of primary medical services;

5.2.5 Have regard to the need to reduce inequalities;

5.2.6 Promote the involvement of patients, their carers and representatives in decisions about their healthcare;

5.2.7 Act with a view to enabling patients to make choices;

5.2.8 Obtain appropriate advice from persons who, taken together, have a broad range of professional expertise in healthcare and public health;

5.2.9 Promote innovation;

5.2.10 Promote research and the use of research;

11

5.2.11 Have regard to the need to promote education and training for persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England so as to assist the Secretary of State for Health in the discharge of his related duty; and

5.2.12 Act with a view to promoting integration of both health services with other health services and health services with health-related and social care services where the Group considers that this would improve the quality of services or reduce inequalities..

5.3 Public involvement – in discharging its functions the Group will:

5.3.1 comply with its duty to secure public involvement in the planning, development and consideration of proposals for changes and decisions affecting the operation of commissioning arrangements.

5.3.2 follow the principles set out below in implementing its arrangements to comply with its duty to secure public involvement:

a) adapting engagement activities to meet the specific needs of the different patient Groups and communities;

b) publishing information about health services on the Group’s website and through other media; and

c) the Group will monitor and report its compliance against this statement of principles through the annual report.

5.4 General Financial Duties – the Group will perform its functions so as to:

5.4.1 Ensure its expenditure does not exceed the aggregate of its allotments for the financial year;

5.4.2 Ensure its use of resources (both its capital resource use and revenue resource use) does not exceed the amount specified by the NHS Commissioning Board for the financial year;

5.4.3 Take account of any directions issued by the NHS Commissioning Board, in respect of specified types of resource use in a financial year, to ensure the Group does not exceed an amount specified by the NHS Commissioning Board; and

5.4.4 Publish an explanation of how the Group spent any payment in respect of quality made to it by the NHS Commissioning Board.

5.5 Other Relevant Regulations, Directions and Documents

5.5.1 The Group will a) comply with all relevant regulations;

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b) comply with directions issued by the Secretary of State for Health or the NHS Commissioning Board; and

c) take account, as appropriate, of documents issued by the NHS

Commissioning Board.

5.5.2 The Group will develop and implement the necessary systems and processes to comply with these regulations and directions, documenting them as necessary in this Constitution, its scheme of reservation and delegation and other relevant Group policies and procedures.

5.6 Arrangements by the Group to comply with its functions. The Group will

exercise the functions set out in Part 5 of this Constitution by:

5.6.1 delegating responsibility for their performance to the Governing Body, its committees and subcommittees which shall act in accordance with this Constitution, the Standing Orders and the Scheme of Delegation and Reservation;

5.6.2 acting in accordance with the Group’s Statement of Policy for Compliance with General, Financial, Partnership Working and Public Sector Equality Duties that the Governing Body will adopt, keep under review and update for the Group; and

5.6.3 monitoring delivery of the duties through the Group’s reporting mechanisms.

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6 DECISION MAKING: THE GOVERNING STRUCTURE

6.1 Authority to act

6.1.1 The Group is accountable for exercising the statutory functions of the Group. It

has granted authority to act on its behalf to:

a) any of its members;

b) its Governing Body;

c) employees;

d) a committee or sub-committee of the Group.

6.1.2 The extent of the authority to act of the respective bodies and individuals

depends on the powers delegated to them by the Group as expressed through:

a) this Constitution

b) the Group’s scheme of reservation and delegation; and

c) for committees, their terms of reference.

6.2 Scheme of Reservation and Delegation

6.2.1 The Group’s scheme of reservation and delegation sets out:

a) those decisions that are reserved for the membership as a whole;

b) those decisions that are the responsibilities of its Governing Body (and its committees), the Group’s committees and sub-committees, individual members and employees.

6.2.2 The Group remains accountable for all of its functions, including those that it has

delegated. 6.3 General

6.3.1 In discharging functions of the Group that have been delegated to them, its

committees, Governing Body and its committees, and individuals must :

a) comply with the Group’s Constitution including but not limited to its principles of good governance;

b) operate in accordance with the Group’s scheme of reservation and delegation;

c) comply with the Group’s standing orders;

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d) comply with the Group’s arrangements for discharging its statutory duties; and

e) where appropriate, ensure that Members have had the opportunity to contribute to the Group’s decision making process.

6.3.2 When discharging their delegated functions, committees, sub-committees and

joint committees must also operate in accordance with their approved terms of reference.

6.3.3 Where delegated responsibilities are being discharged collaboratively, the joint

(collaborative) arrangements must:

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

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

c) specify under which clinical commissioning group’s scheme of reservation and delegation and supporting policies the collaborative working arrangements will operate;

d) specify how the risks associated with the collaborative working arrangement will be managed between the respective parties;

e) identify how disputes will be resolved and the steps required to terminate the working arrangements; and

f) specify how decisions are communicated to the collaborative partners. 6.4 Committees of the Group

6.4.1 The Group shall have the following committees:

(a) Members’ Committee

(b) Seven Kings Locality Committee

(c) Fairlop Locality Committee

(d) Wanstead and Woodford Locality Committee

(e) Loxford and Cranbrook Locality Committee

6.4.2 The Group may, on or after its establishment, appoint such other committees as it considers appropriate.

6.4.3 A committee or sub-committee of the Group may consist of or include persons other than Members or employees of the Group.

6.5 Locality Committees

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6.5.1 The membership of each Locality Committee shall comprise the named practice clinical lead and Practice Representatives of the Members who are allocated to the relevant Locality in accordance with the table at Appendix B.

6.5.2 The Chair of each Locality Committee shall be the elected voting Clinical Director from that Locality.

6.5.3 Each Locality Committee shall regulate its proceedings in accordance with its terms of reference.

6.6 The Members’ Committee

6.6.1 The Members’ Committee shall comprise the Practice Representatives from time to time, the Accountable Officer, the Chief Operating Officer, and the Chair of the Governing Body and the Deputy Chair of the Governing Body.

6.6.2 The Chair and the Deputy Chair of the Governing Body shall respectively be the Chair and Deputy Chair of the Members’ Committee. The Deputy Chair of the Governing Body shall act for the Chair of the Members’ Committee where the Chair is unable to act.

6.6.3 Subject to the 2006 Act, the Governing Body shall perform or delegate all those functions of the Group which have not been delegated to:

a) the Governing Body;

b)a) any committee or subcommittee of the Group;

c)b) any Member of the Group; or

d)c) any employee;

under this Constitution or otherwise.

6.6.4 The Members’ Committee shall regulate their proceedings in accordance with the Standing Orders at Appendix C.

6.6.5 The Members’ Committee shall meet at least twice in each financial year in accordance with the Standing Orders at Appendix C. once per annum.

6.6.6 All decisions taken in good faith at a meeting of any committee or subcommittee shall be valid even if there is any vacancy in its membership or it is discovered subsequently that there was a defect in the calling of the meeting, or the appointment of a member attending the meeting.

6.6.7 An individual shall be ineligible for appointment to or shall otherwise be disqualified from membership of a committee or subcommittee if is he or she is a person who is disqualified from membership of a clinical commissioning group’s Governing Body under Schedule 5 of the National Health Service (Clinical Commissioning Groups) Regulations 2012.

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6.6.8 The Members’ Committee may appoint such subcommittees as it considers may be appropriate but other committees will only be able to establish their own sub-committees, to assist them in discharging their respective responsibilities, if this responsibility has been delegated to them by the Group or the committee they are accountable to.

6.7 Joint Arrangements

6.7.1 The Group may enter into joint arrangements with one or more other clinical

commissioning groups as it considers may be appropriate.

6.7.2 If the Group establishes joint arrangements with one or more clinical commissioning groups, it proposes to comply with the following key principles: a) The CCGs should collaborate where there is clear collective benefit. These

benefits may include maximising commissioning influence, achieving consistency in relation to the approach to shared principal providers of secondary care, mental health and specialist community services, and the promotion of best practice for primary care services (but not the performance management of primary care). There is also clear benefit from sharing scarce commissioning resources (commissioning support and some key development resources);

b) Each CCG is separately accountable for its functions including service delivery and performance. The process of collaboration is not intended to and will not dilute responsibilities within each organisation for decision making on change and the delivery of results. The collaborative process is there to develop joint proposals for change but not for taking decisions on implementation; and

c) Each area of collaboration requires validation and active support from each

CCG. The areas of collaboration should be led by entrusted clinical leaders with full support from each CCG and based on collective understanding of what will be done, why and when. Each area of collaboration with secure active representation from each CCG and have designated resource from commissioning support to ensure delivery of work.

6.7.3 The CCGs will put in place collaborative arrangements in accordance with any

guidance issued from time to time.

6.7.4 The Governing Body shall delegate responsibility to such Governing Body member as it considers appropriate for making decisions on its behalf within the joint arrangement.

6.7.5 The Group may establish joint committees with one or more local authorities as it considers may be appropriate.

6.8 The Governing Body

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6.8.1 Functions - the Governing Body has the following functions conferred on it by sections 14L(2) and (3) of the 2006 Act, inserted by section 25 the 2012 Act, together with any other functions connected with its main functions as may be specified in regulations or in this Constitution. The Governing Body may also have functions of the Group delegated to it by the Group. The Governing Body’s functions include:

a) ensuring that the Group has appropriate arrangements in place to exercise

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

b) determining the remuneration, fees and other allowances payable to

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

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

d) leading and setting the vision and strategy;

e) approving commissioning plans;

f) monitoring performance against plans;

g) providing assurance of strategic risk;

h) reviewing the CCG Conflict of Interest register; and

i) delivering any other functions that are not reserved or delegated to the CCG

membership, as set out in the Standing Orders.

6.8.2 Composition of the Governing Body –The Governing Body shall not have less than 16 members and comprises of:

a) Two GPs from each of the 4 Localities who shall be called “Clinical

Directors”, and an additional GP from any one Locality one of whom shall be the Chair of the Governing Body.

b) Two lay members:

(i) one to lead on audit, remuneration and conflict of interest matters, (ii) one to lead on patient and public participation matters;

c) One registered nurse;

d) One secondary care specialist doctor;

e) the accountable officer;

f) the Chief Finance Officer;

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g) The Chief Operating Officer

h) Two other individuals in attendance (non-voting):

(i) The Director of Public Health (ii) The Director of Adult Social Care, or nominated representative

6.8.3 Members of the Governing Body shall be appointed in accordance with the Standing Orders at Appendix C.

6.8.4 Committees of the Governing Body - the Governing Body shall at its first

meeting appoint the following committees: a) Audit and Governance Committee– the Audit and Governance Committee,

which is accountable to the Group’s Governing Body, shall provide the Governing Body with an independent and objective view of the Group’s financial systems, financial information and compliance with laws, regulations and directions governing the Group in so far as they relate to finance;

b) Remuneration and Workforce Committee– the Remuneration and

Workforce Committee, which is accountable to the Group’s Governing Body shall make recommendations to the Governing Body on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the Group and on determinations about allowances under any pension scheme that the Group may establish as an alternative to the NHS pension scheme. Only members of the Governing Body may be members of the Remuneration and Workforce Committee;

c) Executive Committee – the Executive Committee, which is accountable to

the Group’s Governing Body, will be responsible for managing CCG operational business such as monitoring the delivery of operating and business plans and ensuring mitigation of operational risks. The Executive Committee shall appoint the Joint Executive Sub-Committee as its sub-committee. The Joint Executive Sub-Committee is accountable to the Executive Committee and will be responsible for carrying out functions for the purpose of joint arrangements as agreed by the Group pursuant to Section 6.7 of this Constitution;

d) Quality and Safety Committee – the committee, which is accountable to the

Group’s Governing Body, will be responsible for managing quality assurance by the Group.

e) Finance and Delivery Committee – the committee, which is accountable to

the Group’s Governing Body, will be responsible for managing finance and delivery by the Group.

d)f) The Governing Body may appoint such other committees as it considers may be appropriate.

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6.8.5 The Governing Body shall approve and keep under review the Terms of Reference of its Committees, which shall include information about their membership.

6.8.6 The Audit Committee may include individuals who are not members of the Governing Body.

6.8.7 Other committees of the Governing Body (except the Remuneration and Workforce Committee) may include individuals who are not members of the Governing Body but are: a) Members, officers or governing body members of the Group or another

clinical commissioning group; b) Partners or employees of Members of the Group or another clinical

commissioning group; c) Officers of the NHS Commissioning Board; and d) Lay members who are aged 18 or over, reside in the Area and are not

disqualified under Schedule 5 of the CCG Regulations.

6.8.8 Committees of the Governing Body will only be able to establish their own sub-committees, to assist them in discharging their respective responsibilities, if this responsibility has been delegated to them by the Governing Body or the committee they are accountable to.

6.8.9 All decisions taken in good faith at a meeting of the Governing Body or any committee or subcommittee of it shall be valid even if there is any vacancy in its membership or it is discovered subsequently that there was a defect in the calling of the meeting, or the appointment of a member attending the meeting.

6.9 General

6.9.1 In discharging functions of the Group that have been delegated to them, its Committees (including any sub- or joint committees) and Governing Body (and its committees including any sub- or joint committees) must:

a) comply with the Group’s principles of good governance;

b) operate in accordance with the Group’s scheme of reservation and

delegation;

c) comply with the Group’s standing orders;

d) comply with the Group’s arrangements for discharging its statutory duties; and

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e) where appropriate, ensure that member practices have had the opportunity to contribute to the Group’s decision making process.

6.9.2 When a committee (including any sub- or joint committee) discharges delegated functions, it must also operate in accordance with its approved terms of reference.

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7 ROLES AND RESPONSIBILITIES

7.1 Practice Representatives

7.1.1 Each Practice Representative represents the views of the practice that has

appointed him/her and acts on behalf of that practice in matters relating to the Group.

7.1.2 The role of each Practice Representative is to:

a) attend and vote at General Meetings of the Members’ Committee, and the Annual General Meeting;

b) be the point of communication for the practice that has appointed him/her

for Group business; and c) deal with any issues in connection with the relevant practice’s membership

of the Group, as is more particularly set out in Appendix C.

7.2 Clinical Directors

7.2.1 The Clinical Directors are appointed to the membership of the Governing Body in line with the Standing Orders at Appendix C, by the Members’ Committee to represent the Members on the Governing Body and any committees to which they are appointed.

7.2.2 The role of the Clinical Directors as members of the Governing Body is to support the Governing Body and its committees in ensuring that the Group has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the principles of good governance and the Constitution of the Group. The Clinical Directors shall provide clinical leadership to the development and delivery of the Group’s commissioning and QIPP plans and ensure engagement of the Group’s membership in service redesign and commissioning strategy plans. One of the voting Clinical Directors will be appointed as the Chair of the Governing Body.

7.3 Other GP and Primary Care Health Professionals

7.3.1 In addition to the Practice Representatives identified in section 7.1 above, the

Group may identify from time to time a number of other GPs / primary care health professionals from member practices to support the work of the Group by providing clinical expertise and leadership in enabling the Group to discharge its functions and / or represent the Group rather than represent their own individual practices. These shall be known as Clinical Champions.

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7.4 All Members of the Group’s Governing Body

7.4.1 Guidance on the roles of members of the Group’s Governing Body is set out in a

separate document. In summary, each member of the Governing Body should share responsibility as part of a team to ensure that the Group exercises its functions effectively, efficiently and economically, with good governance and in accordance with the terms of this Constitution. Each brings their unique perspective, informed by their expertise and experience. The Governing Body members between them fulfil the requirements of the DoH “Clinical Commissioning Group Governing Body members; Role outlines, attributes and skills".

7.5 The Chair of the Governing Body

7.5.1 The Chair of the Governing Body shall be the Group’s Clinical Leader.

7.5.2 The role and responsibilities of the Chair of the Governing Body include:

a) leading the Governing Body, ensuring it remains continuously able to discharge its duties and responsibilities as set out in this constitution;

b) building and developing the Group’s Governing Body and its individual members;

c) ensuring that the Group has proper constitutional and governance arrangements in place;

d) ensuring that, through the appropriate support, information and evidence, the Governing Body is able to discharge its duties;

e) supporting the accountable officer in discharging the responsibilities of the organisation;

f) contributing to building a shared vision of the aims, values and culture of the organisation;

g) leading and influencing to achieve clinical and organisational change to enable the Group to deliver its commissioning responsibilities;

h) overseeing governance and particularly ensuring that the Governing Body and the wider Group behaves with the utmost transparency and responsiveness at all times;

i) ensuring that public and patients’ views are heard and their expectations understood and, where appropriate as far as reasonably possible, met; and

j) As the Clinical Leader of the Group, taking part in the NHS Commissioning

Assembly and leading in interactions with stakeholders including the NHS Commissioning Board.

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7.6 The Deputy Chair of the Governing Body

7.6.1 The deputy Chair of the Governing Body deputises for the Chair of the

Governing Body where he or she has a conflict of interest or is otherwise unable to act.

7.7 Role of the Accountable Officer

7.7.1 The Chief Officer shall be the Group’s accountable officer.

7.7.2 The role and responsibilities of the accountable officer include:

a) ensuring that the Group fulfils its duties to exercise its functions effectively,

efficiently and economically thus ensuring improvement in the quality of services and the health of the local population whilst maintaining value for money;

b) at all times ensuring that the regularity and propriety of expenditure is discharged, and that arrangements are put in place to ensure that good practice (as identified through such agencies as the Audit Commission and the National Audit Office) is embodied and that safeguarding of funds is ensured through effective financial and management systems; and

c) working closely with the Chair of the Governing Body, the accountable officer will ensure that proper constitutional, governance and development arrangements are put in place to assure the members (through the Governing Body) of the organisation’s ongoing capability and capacity to meet its duties and responsibilities. This will include arrangements for the ongoing development of its members and staff.

7.8 Role of the Chief Finance Officer

7.8.1 The Chief Finance Officer is a member of the Governing Body and is responsible

for providing financial advice to the Group and for supervising financial control and accounting systems

7.8.2 The role and responsibilities of the Chief Finance Officer include : a) being the Governing Body’s professional expert on finance and ensuring,

through robust systems and processes, the regularity and propriety of expenditure is fully discharged;

b) making appropriate arrangements to support, monitor on the Group’s finances;

c) overseeing robust audit and governance arrangements leading to propriety in the use of the Group’s resources;

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d) being able to advise the Governing Body on the effective, efficient and economic use of the Group’s allocation to remain within that allocation and deliver required financial targets and duties; and

e) producing the financial statements for audit and publication in accordance with the statutory requirements to demonstrate effective stewardship of public money and accountability to the NHS Commissioning Board;

7.9 Joint Appointments with other Organisations

7.9.1 The Group may agree joint appointments with other organisations as it considers

may be appropriate.

7.9.2 All joint appointments shall be supported by a memorandum of understanding between the organisations who are party to them.

7.10 Responsibilities of Members to the Group

7.10.1 It is the responsibility of Members of the Group to:

a) Agree to consult and take account of the views and interests of their employees regarding Group matters;

b) Agree to release staff as required to fulfil their obligations towards the

efficient and effective functioning of the Group; c) Provide financial information as required and make reasonable efforts to stay

in budget; and d) Have representation on committees as appropriate including the relevant

Locality Committee.

7.11 Responsibilities of the Group to Members

7.11.1 It is the responsibility of the Group to its Member to:

a) Visit each practice at least once per annum; b) Conduct a survey of practices annually to ensure practice details are kept up

to date and active representatives are nominated for each practice; c) Communicate regularly and thoroughly with practices as required, regarding

Group business and wider news affecting the Redbridge health economy; and

d) Notify Members of meetings of the Members’ Committees as and when the

need to call such meetings arises in accordance with the Standing Orders.

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8 STANDARDS OF BUSINESS CONDUCT AND MANAGING CONFLICTS OF INTEREST

8.1 Standards of Business Conduct

8.1.1 Employees, Members, members of committees and sub-committee of the Group

and members of the Governing Body (and its committees and sub committees) will at all times comply with this constitution and be aware of their responsibilities as outlined in it. They should act in good faith and in the interests of the Group and should follow the Seven Principles of Public Life, set out by the Committee on Standards in Public Life (the Nolan Principles) The Nolan Principles are incorporated into this constitution at Appendix F.

8.1.2 They must comply with the Group’s policy on business conduct, including the requirements set out in the policy for managing conflicts of interest. This policy will be available on the Group’s website.

8.1.3 Individuals contracted to work on behalf of the Group or otherwise providing

services or facilities to the Group will be made aware of their obligation with regard to declaring conflicts or potential conflicts of interest. This requirement will be written into their contract for services.

8.2 Conflicts of Interest

8.2.1 As required by section 14O of the 2006 Act, as inserted by section 25 of the

2012 Act, the Group will make arrangements to manage conflicts and potential conflicts of interest to ensure that decisions made by the Group will be taken and seen to be taken without any possibility of the influence of external or private interest.

8.2.2 Where an individual, i.e. an employee, Group member, member of the Governing Body, or a member of a committee or a sub-committee of the Group or its Governing Body has an interest, or becomes aware of an interest which could lead to a conflict of interests in the event of the Group considering an action or decision in relation to that interest, that must be considered as a potential conflict, and is subject to the provisions of this constitution.

8.2.3 A conflict of interest will include:

a) a direct pecuniary interest: where an individual may financially benefit from

the consequences of a commissioning decision (for example, as a provider of services); and/or

b) an indirect pecuniary interest: for example, where an individual is a partner,

member or shareholder in an organisation that will benefit financially from the consequences of a commissioning decision; and/or

c) a non-pecuniary interest: where an individual holds a non-remunerative or

not-for profit interest in an organisation, that will benefit from the consequences of a commissioning decision (for example, where an

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individual is a trustee of a voluntary provider that is bidding for a contract); and/or

d) a non-pecuniary personal benefit: where an individual may enjoy a qualitative

benefit from the consequence of a commissioning decision which cannot be given a monetary value (for example, a reconfiguration of hospital services which might result in the closure of a busy clinic next door to an individual’s house); and/or

e) where an individual is closely related to, or in a relationship, including

friendship, with an individual in the above categories.

8.2.4 If in doubt, the individual concerned should assume that a potential conflict of interest exists.

8.3 Declaring and Registering Interests

8.3.1 The Group will maintain one or more registers of the interests of:

a) the members of the Group; b) the members of its Governing Body;

c) the members of its committees or sub-committees and the committees or

sub-committees of its Governing Body; and

d) its employees. 8.3.2 The registers will be published on the Group’s website. 8.3.3 Individuals will declare any interest that they have, in relation to a decision to be

made in the exercise of the commissioning functions of the Group, in writing to the Governing Body, as soon as they are aware of it and in any event no later than 28 days after becoming aware.

8.3.4 Where an individual is unable to provide a declaration in writing, for example, if a

conflict becomes apparent in the course of a meeting, they will make an oral declaration before witnesses, and provide a written declaration as soon as possible thereafter.

8.3.5 The Governing Body will ensure that the register of interest is reviewed every

quarter, and updated as necessary.

8.4 Managing Conflicts of Interest: general

8.4.1 Individual members of the Group, the Governing Body, committees or sub-

committees, the committees or sub-committees of its Governing Body and employees will comply with the arrangements determined by the Group for managing conflicts or potential conflicts of interest.

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8.4.2 The Governing Body will ensure that for every interest declared, either in writing or by oral declaration, arrangements are in place to manage the conflict of interests or potential conflict of interests, to ensure the integrity of the Group’s decision making processes.

8.4.3 Arrangements for the management of conflicts of interest are to be determined

by the Governing Body and will include the requirement to put in writing to the relevant individual arrangements for managing the conflict of interests or potential conflicts of interests, within a week of declaration. The arrangements will confirm the following:

a) when an individual should withdraw from a specified activity, on a temporary

or permanent basis; and

b) monitoring of the specified activity undertaken by the individual, either by a line manager, colleague or other designated individual.

8.4.4 Where an interest has been declared, either in writing or by oral declaration, the

declarer will ensure that before participating in any activity connected with the Group’s exercise of its commissioning functions, they have received confirmation of the arrangements to manage the conflict of interest or potential conflict of interest from the Governing Body.

8.4.5 Where an individual member, employee or person providing services to the

Group is aware of an interest which:

a) has not been declared, either in the register or orally, they will declare this at the start of the meeting; or

b) has previously been declared, in relation to the scheduled or likely business of the meeting, the individual concerned will bring this to the attention of the Chair of the meeting, together with details of arrangements which have been confirmed for the management of the conflict of interests or potential conflict of interests.

The Chair of the meeting will then determine how this should be managed and inform the member of their decision. Where no arrangements have been confirmed, the Chair of the meeting may require the individual to withdraw from the meeting or part of it. The individual will then comply with these arrangements, which must be recorded in the minutes of the meeting.

8.4.6 Where the Chair of any meeting of the Group, including committees, sub-

committees, or the Governing Body and the Governing Body’s committees and sub-committees, has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, they must make a declaration and the deputy Chair will act as Chair for the relevant part of the meeting. Where arrangements have been confirmed for the management of the conflict of interests or potential conflicts of interests in relation to the Chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the deputy Chair may require the Chair to withdraw from the meeting

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or part of it. Where there is no deputy Chair, the members of the meeting will select one.

8.4.7 Any declarations of interests, and arrangements agreed in any meeting of the

Group, committees or sub-committees, or the Governing Body, the Governing Body’s committees or sub-committees, will be recorded in the minutes.

8.4.8 Where more than 50% of the members of a meeting are required to withdraw

from a meeting or part of it, owing to the arrangements agreed for the management of conflicts of interests or potential conflicts of interests, the Chair (or deputy) will determine whether or not the discussion can proceed.

8.4.9 In making this decision the Chair will consider whether the meeting is quorate, in

accordance with the number and balance of membership set out in the Group’s standing orders. Where the meeting is not quorate, owing to the absence of certain members, the discussion will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the meeting, owing to the arrangements for managing conflicts of interest or potential conflicts of interests, the Chair of the meeting shall consult with the Governing Body on the action to be taken.

8.4.10 This may include:

a) requiring another of the Group’s committees or sub-committees, the Group’s

Governing Body or the Governing Body’s committees or sub-committees (as appropriate) which can be quorate to progress the item of business, or if this is not possible,

b) inviting on a temporary basis one or more of the following to make up the quorum (where these are permitted members of the Governing Body or committee / sub-committee in question) so that the Group can progress the item of business:

(i) a member of the Group who is an individual;

(ii) an individual appointed by a member to act on its behalf in the dealings

between it and the Group;

(iii) a member of a relevant Health and Wellbeing Governing Body;

(iv) a member of a Governing Body of another clinical commissioning group.

These arrangements must be recorded in the minutes.

8.4.11 In any transaction undertaken in support of the Group’s exercise of its

commissioning functions (including conversations between two or more individuals, e-mails, correspondence and other communications), individuals must ensure, where they are aware of an interest, that they conform to the arrangements confirmed for the management of that interest. Where an

29

individual has not had confirmation of arrangements for managing the interest, they must declare their interest at the earliest possible opportunity in the course of that transaction, and declare that interest as soon as possible thereafter. The individual must also inform either their line manager (in the case of employees), or the Governing Body of the transaction.

8.4.12 The Governing Body will take such steps as deemed appropriate, and request information deemed appropriate from individuals, to ensure that all conflicts of interest and potential conflicts of interest are declared

8.5 Managing Conflicts of Interest: contractors and people who provide

services to the Group

8.5.1 Anyone seeking information in relation to a procurement, or participating in a

procurement, or otherwise engaging with the Group in relation to the potential provision of services or facilities to the Group, will be required to make a declaration of any relevant conflict / potential conflict of interest.

8.5.2 Anyone contracted to provide services or facilities directly to the Group will be

subject to the same provisions of this constitution in relation to managing conflicts of interests. This requirement will be set out in the contract for their services.

8.6 Transparency in Procuring Services

8.6.1 The Group recognises the importance in making decisions about the services it

procures in a way that does not call into question the motives behind the procurement decision that has been made. The Group will procure services in a manner that is open, transparent, non-discriminatory and fair to all potential providers.

8.6.2 The Group will publish a Procurement Strategy approved by its Governing Body

which will ensure that:

a) all relevant clinicians (not just members of the Group) and potential providers, together with local members of the public, are engaged in the decision-making processes used to procure services;

b) service redesign and procurement processes are conducted in an open,

transparent, non-discriminatory and fair way 8.6.3 Copies of this Procurement Strategy will be available on the Group’s website.

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9 THE GROUP AS EMPLOYER

9.1 The Group recognises that its most valuable asset is its people. It will seek to

enhance their skills and experience and is committed to their development in all ways relevant to the work of the Group.

9.2 The Group will seek to set an example of best practice as an employer and is

committed to offering all staff equality of opportunity. It will ensure that its employment practices are designed to promote diversity and to treat all individuals equally.

9.3 The Group will ensure that it employs suitably qualified and experienced staff who will

discharge their responsibilities in accordance with the high standards expected of staff employed by the Group. All staff will be made aware of this constitution, the commissioning strategy and the relevant internal management and control systems which relate to their field of work.

9.4 The Group will maintain and publish policies and procedures (as appropriate) on the

recruitment and remuneration of staff to ensure it can recruit, retain and develop staff of an appropriate calibre. The Group will also maintain and publish policies on all aspects of human resources management, including grievance and disciplinary matters

9.5 The Group will ensure that its rules for recruitment and management of staff provide

for the appointment and advancement on merit on the basis of equal opportunity for all applicants and staff.

9.6 The Group will ensure that employees' behaviour reflects the values, aims and

principles set out above. 9.7 The Group will ensure that it complies with all aspects of employment law. 9.8 The Group will ensure that its employees have access to such expert advice and

training opportunities as they may require in order to exercise their responsibilities effectively.

9.9 The Group will adopt a Code of Conduct for staff and will maintain and promote

effective 'whistleblowing' procedures to ensure that concerned staff have means through which their concerns can be voiced

9.10 Copies of this Code of Conduct, together with the other policies and procedures

outlined in this chapter, will be available on the Group’s website. 9.11 The Group recognises and confirms that nothing in or referred to in this constitution

(including in relation to the issue of any press release or other public statement or disclosure) will prevent or inhibit the making of any protected disclosure (as defined in the Employment Rights Act 1996, as amended by the Public Interest Disclosure Act 1998) by any member of the Group, any member of its Governing Body, any member of any of its committees or sub-committees or the committees or sub-committees of its Governing Body, or any employee of the Group or of any of its Members, nor will it affect the rights of any worker (as defined in that Act) under that Act.

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10 TRANSPARENCY, WAYS OF WORKING AND STANDING ORDERS

10.1 General

10.1.1 The Group will publish annually a commissioning plan and an annual report,

presenting the Group’s annual report to a meeting in public.

10.1.2 Key communications issued by the Group, including the notices of procurements, public consultations, Governing Body meeting dates, times, venues, and certain papers will be published on the Group’s website.

10.1.3 The Group may use other means of communication, including circulating

information by post, or making information available in venues or services accessible to the public.

10.2 Standing Orders

10.2.1 This constitution is also informed by a number of documents which provide

further details on how the Group will operate. They are the Group’s:

a) Standing orders (Appendix C) – which sets out the arrangements for meetings and the appointment processes to elect the Group’s representatives and appoint to the Group’s committees, including the Governing Body;

b) Scheme of reservation and delegation (Appendix D) – which sets out

those decisions that are reserved for the membership as a whole and those decisions that are the responsibilities of the Group’s Governing Body, the Governing Body’s committees and sub-committees, the Group’s committees and sub-committees, individual members and employees;

c) Prime financial policies (Appendix E)– which sets out the arrangements

for managing the Group’s financial affairs.

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APPENDIX A DEFINITIONS OF KEY DESCRIPTIONS USED IN THIS CONSTITUTION

2006 Act National Health Service Act 2006

2012 Act Health and Social Care Act 2012 (this Act amends the 2006 Act)

Accountable officer

an individual, as defined under paragraph 12 of Schedule 1A of the 2006 Act (as inserted by Schedule 2 of the 2012 Act), appointed by the NHS Commissioning Board, with responsibility for ensuring the Group:

complies with its obligations under: o sections 14Q and 14R of the 2006 Act (as inserted by section

26 of the 2012 Act), o sections 223H to 223J of the 2006 Act (as inserted by section

27 of the 2012 Act), o paragraphs 17 to 19 of Schedule 1A of the NHS Act 2006 (as

inserted by Schedule 2 of the 2012 Act), and o any other provision of the 2006 Act (as amended by the 2012

Act) specified in a document published by the Governing Body for that purpose;

exercises its functions in a way which provides good value for money.

Area the geographical area that the Group has responsibility for, as

defined in Chapter 2 of this constitution

CCG Regulations The National Health Service (Clinical Commissioning Groups) Regulations 2012

Chair of the Governing Body

the individual appointed by the Group to act as Chair of the Governing Body

Chief finance officer

the qualified accountant employed by the Group with responsibility for financial strategy, financial management and financial governance

Chief Officer The Group’s most senior manager, being the Accountable Officer

Clinical commissioning Group

a body corporate established by the NHS Commissioning Board in accordance with Chapter A2 of Part 2 of the 2006 Act (as inserted by section 10 of the 2012 Act)

Clinical Leader the individual recognised by the Group as the leading clinician who represents the clinical voice of its Members, being the Chair of the Governing Body.

Committee a committee or sub-committee created and appointed by:

the membership of the Group

a committee / sub-committee created by a committee created

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/ appointed by the membership of the Group a committee / sub-committee created / appointed by the Governing Body

Financial year this usually runs from 1 April to 31 March, but under paragraph 17 of Schedule 1A of the 2006 Act (inserted by Schedule 2 of the 2012 Act), it can for the purposes of audit and accounts run from when a clinical commissioning Group is established until the following 31 March

Governing Body the body appointed under section 14L of the NHS Act 2006 (as inserted by section 25 of the 2012 Act), with the main function of ensuring that a clinical commissioning Group has made appropriate arrangements for ensuring that it complies with:

its obligations under section 14Q under the NHS Act 2006 (as inserted by section 26 of the 2012 Act), and

such generally accepted principles of good governance as are relevant to it.

Governing Body member

any member appointed to the Governing Body of the Group

Group NHS Redbridge Clinical Commissioning Group, whose constitution this is

Lay member LMC

a lay member of the Governing Body, appointed by the Group. A lay member is an individual who is not a member of the Group or a healthcare professional (i.e. an individual who is a member of a profession regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002) or as otherwise defined in regulations Local medical committee

Member a provider of primary medical services to a registered patient list, who is a members of this Group (see tables in Chapter 3 and Appendix B)

NHS Commissioning Board Practice representatives

the statutory body established under section 1H of the 2012 Act and also known as NHS England an individual appointed by a practice (who is a member of the Group) to act on its behalf in the dealings between it and the Group, under regulations made under section 89 or 94 of the 2006 Act (as amended by section 28 of the 2012 Act) or directions under section 98A of the 2006 Act (as inserted by section 49 of the 2012 Act)

Registers of registers a Group is required to maintain and make publicly available

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interests under section 14O of the 2006 Act (as inserted by section 25 of the 2012 Act), of the interests of:

the members of the Group;

the members of its Governing Body;

the members of its committees or sub-committees and committees or sub-committees of its Governing Body; and

its employees.

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APPENDIX B - LIST OF MEMBER PRACTICES

Practice Name Address

Spearpoint Surgery 1 Spearpoint Gardens, Aldborough Road North, IG2 7SX

Seven Kings

Goodmayes Medical Practice

595 Green Lane, Goodmayes, IG3 9RN

Seven Kings

The Palms Medical Centre

97-101 Netley Road, Newbury Park, IG2 7NW

Seven Kings

Grove Surgery 200-202 Chadwell Heath Lane, Chadwell Heath, RM6 4YU

Seven Kings

Chadwell Heath Surgery

72 Chadwell Heath Lane, Chadwell Heath, RM6 4AF

Seven Kings

Castleton Road Health Centre

19 Castleton Road, Goodmayes, IG3 9QW

Seven Kings

Newbury Group Practice

Newbury Park Health Centre, 40 Perrymans Farm Rd, IG2 7LE

Seven Kings

Paul's Surgery Seven Kings Health Centre, 1 Salisbury Road, IG3 8BG

Seven Kings

Seven Kings Practice Seven Kings Health Centre 1 Salisbury Road, IG3 8BG

Seven Kings

The Doctors House 40 Cameron Road, Seven Kings, IG3 8LF

Seven Kings

Goodmayes Medical Centre

4 Eastwood Road, Ilford, IG3 8XB Seven Kings

Ilford Medical Centre 61 Cleveland Road, Ilford, IG1 1EE

Cranbrook & Loxford

Mathukia's Surgery 281 Ilford Lane, Ilford, IG1 2SF

Cranbrook & Loxford

Oak Tree Medical Practice

273-275 Green Lane, Seven Kings, IG3 9TJ

Cranbrook & Loxford

The Practice Loxford PLC

Loxford Polyclinic, 417 Ilford Lane, Ilford, IG1 2SN

Cranbrook & Loxford

Ilford Lane Surgery 163-165 Ilford Lane, Ilford, IG1 2RS

Cranbrook & Loxford

The Elmhurst Practice The Health Centre, 114 High Road, Wanstead

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E18 2QS

Southdene Surgery George Lane, South Woodford, E18 1BD

Wanstead

The Shrubberies Medical Centre

12 The Shrubberies, South Woodford, E18 1BN

Wanstead

Glebelands Practice 2 Glebelands Avenue, South Woodford, E18 2AB

Wanstead

The Evergreen Practice

26 High Street, Wanstead, E11 2AQ

Wanstead

The Broadway Surgery 3 Broadway Gardens, Monkhams Avenue, IG8 0HF

Wanstead

Rydal 375 High Road, Woodford Green, IG8 9QJ

Wanstead

Ferndale Surgery 76 Snakes Lane East, Woodford Green, IG8 7QQ

Wanstead

Wanstead Place Surgery

45 Wanstead Place, Wanstead, E11 2SW

Wanstead

Queen Mary Practice The Health Centre, 114 High Road, E18 2QS

Wanstead

Roding Lane Surgery 2 Roding Lane North, Woodford Bridge, IG8 8NR

Wanstead

Clayhall Clinic 14 Clayhall Avenue, Clayhall, IG5 0LG

Wanstead

Aldersbrook Medical Centre

65 Aldersbrook Road, Manor Park, E12 5DL

Wanstead

Fencepiece Road Medical Centre

83 Fencepiece Road, Hainault, IG6 2NB

Fairlop

The Fullwell Avenue Surgery

272 Fullwell Avenue, Ilford, IG5 0SB

Fairlop

Heathcote Primary Care Centre

Heathcote Avenue, Clayhall, IG5 0QS

Fairlop

Hainault Surgery 34 New North Road, Hainault, IG6 2XG

Fairlop

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Fullwell Cross Medical Centre

1 Tomswood Hill, Barkingside, IG6 2HG

Fairlop

The Forest Edge Practice

Hainault Health Centre, Manford Way, IG7 4DF

Fairlop

The Willows Practice Hainault Health Centre, Manford Way, IG7 4DF

Fairlop

Eastern Avenue Medical Centre

167 Eastern Avenue, Ilford, IG4 5AW

Fairlop

Barkingside Medical Centre

700 Cranbrook Road, Barkingside, IG6 1HP

Fairlop

Gants Hill Medical Centre

63/65 Ethelbert Gardens, Ilford, IG2 6UW

Cranbrook & Loxford

The Drive Surgery 68 The Drive, Ilford, IG1 3HZ

Cranbrook & Loxford

Balfour Road Surgery 92 Balfour Road, Ilford, IG1 4JE

Cranbrook & Loxford

The Redbridge Surgery

49 Windermere Gardens, Redbridge, IG4 5BZ

Cranbrook & Loxford

The Courtland Surgery 62 Courtland Avenue, Ilford, IG1 3DP

Cranbrook & Loxford

Cranbrook Surgery 465 Cranbrook Road, Ilford, IG2 6EW

Cranbrook & Loxford

Granville Medical Centre

4 Granville Road, Ilford, IG1 0JY

Cranbrook & Loxford

St. Clements Surgery 38 Bathurst Road, Ilford, IG1 4LA

Cranbrook & Loxford

York Road Surgery 55 York Road, Ilford, IG1 3AF

Cranbrook & Loxford

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APPENDIX C – STANDING ORDERS

1. STATUTORY FRAMEWORK, STATUS AND DEFINITIONS

1.1. Introduction

1.1.1. These standing orders have been drawn up to regulate the proceedings of NHS Redbridge Clinical Commissioning Group (the Group) so that it can fulfil its obligations, including its functions set out in the 2006 Act and related regulations. They are effective from the date the Group is established.

1.1.2. The standing orders, together with the Group’s scheme of reservation and delegation and the Group’s prime financial policies, provide a procedural framework within which the Group discharges its business. They set out:

a) the arrangements for conducting the business of the Group;

b) the appointment of Practice Representatives;

c) the procedure to be followed at meetings of the Group, the Governing Body and any committees or sub-committees of the Group or the Governing Body;

d) the process to delegate powers; and

e) the declaration of interests and standards of conduct.

These arrangements must comply, and be consistent where applicable, with requirements set out in the 2006 Act and related regulations and take account as appropriate of any relevant guidance.

1.1.3. The standing orders, scheme of reservation and delegation and prime financial policies have effect as if incorporated into the Group’s Constitution. Members of the Group, employees, members of the Governing Body, members of the Governing Body’s committees and sub-committees, members of the Group’s committees and sub-committees and persons working on behalf of the Group should be aware of the existence of these documents and, where necessary, be familiar with their detailed provisions. Failure to comply with the standing orders, scheme of reservation and delegation and prime financial policies may be regarded as a disciplinary matter that could result in dismissal.

1.1.4. In these Standing Orders:

a) “attendance” includes physical attendance or, subject to the Chair’s agreement, participation by telephone or internet link provided that the link is audible and substantially free of interference.

b) “clear days’ notice” excludes the excludes the days on which the period begins and ends

c) “clear working days” means a day that is not a Saturday or Sunday, Christmas Day, Good Friday or any day that is a bank holiday under the

39

Banking and Financial Dealings Act 1971 and excludes the days on which the period begins and ends

d) “General Meeting" is any meeting of the Members’ Committee except an Annual General Meeting,

e) “the Group’s Area” is the Group’s Area as defined by its Constitution

f) "written notice" shall include notice by e mail where notice of receipt is received.

g) “Ordinary Resolution” means a resolution passed by a simple majority present and voting except where otherwise stated

h) “Special Resolution” means a resolution passed by a majority of not less than 60% present and voting except where otherwise stated

1.1.5. Where a Standing Order requires a resolution of the Governing Body or the Members’ Committee but does not specify what kind of resolution is required, what is required is an ordinary resolution unless the Standing Orders require a higher majority (or unanimity).

1.1.6. A resolution of the Governing Body or the Members’ Committee must be passed at a meeting of its members.

1.2. Schedule of matters reserved to the Group and the scheme of reservation and delegation

1.2.1. The 2006 Act provides the Group with powers to delegate the Group’s functions and those of the Governing Body to certain bodies (such as committees) and certain persons. The Group has decided that certain decisions may only be exercised by the Group in formal session. These decisions and also those delegated are contained in the Group’s scheme of reservation and delegation (see Appendix D).

1.2.2. Any of the following matters require the agreement of the Members’ Committee by a Special Resolution (and which to the extent constitute a change to the Constitution will require the consent of the NHS Commissioning Board)and no action can be taken by the Governing Body (except the calling of a general meeting at which such a resolution might be discussed) without its agreement:

a) Make recommendations to the NHS Commissioning Board for changes to the constitution of the Group;

b) Amend these Standing Orders and/or the Scheme of Delegation (which for the avoidance of doubt are part of the Constitution);

c) Change the nature of the business of the Group or do anything inconsistent with the mission, values and aims of the Group;

d) Use any other name than that specified in Clause 1.1 of the Constitution in relation to the activities of the Group;

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e) Merge, amalgamate or federate the Group with any other clinical commissioning Group;

f) Seek to remove any Member;

g) Reorganise the boundaries of or change the organisational structure of the Group.

1.2.3. These decisions and also those delegated are contained in the Group’s scheme of reservation and delegation (see Appendix D).

2. THE CLINICAL COMMISSIONING GROUP: COMPOSITION OF MEMBERSHIP, KEY ROLES AND APPOINTMENT PROCESS

2.1. Composition of membership

2.1.1. Chapter 3 and Appendix B of the Group’s Constitution provides details of the membership of the Group.

2.1.2. Chapter 6 of the Group’s Constitution provides details of the governing structure used in the Group’s decision-making processes, whilst Chapter 7 of the Constitution outlines certain key roles and responsibilities within the Group and its Governing Body, including the role of Practice Representatives.

2.2. Key Roles

2.2.1. Chapter 6 of the Group’s Constitution sets out the composition of the Group’s Governing Body whilst Chapter 7 of the Group’s Constitution identifies certain key roles and responsibilities within the Group and its Governing Body. These standing orders set out how the Group appoints individuals to these key roles.

2.3. Practice Representatives

Members shall appoint Practice Representatives in accordance with Clause 3.3 of the Constitution.

Each Member authorises their Practice Representative on the Members’ Committee to:

receive notice of, attend and vote at any meetings of the Members’ Committee, or sign any written resolution on behalf of that Member;

appoint a proxy, complete and return proxy cards, consent to short notice and consent to any other documents required to be signed by the Member;

deal with and give directions as to, documents, notices or other communications (in whatever form) arising by right of or received in connection with the Member’s membership of the Group.

41

to be an active link between the practice and the Group in discharging the Group’s functions. The Practice Representative should ensure the practice has a sound understanding of commissioning issues.

to attend and vote at meetings of the relevant Locality Committee (if the Group has localities) when these are held.

ensure that their practice supports the Group in meeting its statutory responsibilities and work with the Governing Body in this regard.

The Group (including the Governing Body) shall be entitled to treat any Practice Representative as having the continuing authority given to him under Clause 3.3 of the Constitution until it is notified of the removal of that Practice Representative in writing by the Member to the Governing Body (or an individual nominated by Governing Body) and any provision of this Constitution that requires delivery or notification to a Member shall be deemed to have been satisfied if delivery or notification is made to or served on the Practice Representative.

2.4. Appointment of members of the Governing Body

Members of the Governing Body shall be appointed in accordance with these Standing Orders save that the initial members of the Governing Body shall be as follows for their respective initial terms of office:

Position Member’s name

a) The Chair Dr Anil Mehta b) Clinical Director Dr Heath Springer c) Clinical Director Dr Sarah Heyes d) Clinical Director Dr Muhammad

Tahir e) Clinical Director Dr Shabana Ali f) Clinical Director Dr Chidi Okorie g) Clinical Director Dr Jyoti Sood h) Clinical Director Dr Mehul Mathukia i) Clinical Director (share)

Dr Samia Azeem

j) Clinical Director (share)

Dr Syed Raza…

k) Accountable Officer

Conor Burke

l) Chief Finance Officer

Martin Sheldon

m) Lay member Kash Pandya n) Lay member Khalil Ali

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o) Secondary care specialist

Dr Ah-Fee Chan

p) Independent nurse

Jacqui Himbury

q) Chief Operating Officer

Louise Mitchell

r) (non voting) Director of Public Health

Gladys Xavier

s) (non voting) Director of Adult Social Care

John Powell

2.5. Clinical Directors

Clinical Directors are subject to the following eligibility and appointment process:

a) Eligibility – A Clinical Director: shall be a Partner or salaried GP of a

Member and must have held ths position for not less than 12 months, with a minimum of 4 sessions of clinical work per week in the Locality for which he or she wishes to be elected;

b) Nominations and Appointment process – the following process shall be

undertaken should a vacancy arise

i) The role description shall be advertised to all Members’ practice partners and salaried GPs who meet the eligibility criteria provided for in a) above.

ii) Any such individual may be nominated in writing to the Accountable Officer by two persons who are Member practice partners or salaried GPs. At least one of those nominating the relevant individual must be from a different Member to the nominee.

iii) Any such nominee shall submit an application form to the assessment panel. The assessment panel shall not include any person who is an employee of the Group or a member of the Governing Body of the Group. The membership of the assessment panel shall be approved by the Governing Body of the Group as competent to fulfil the function required of it.

iv) The assessment panel shall assess and interview each nominee and make recommendations to the Group on the nominees’ suitability.

v) Following the conclusion of the process referred to above by the assessment panel, the nominees shall be subject to the following selection process.

vi) Each GP on the NHS Commissioning Board’s performers list who is eligible to vote as provided for below at 2.5 b) vii)in each Locality shall

43

elect two Clinical Directors to be members of the Governing Body, in accordance with the process described at Standing Orders 2.5 vii) to ix) below. In addition, where any Locality GP is elected to undertake the role of Chair of the Governing Body that Locality shall elect an additional Clinical Director to the Governing Body.

vii) Each GP on the NHS Commissioning Board’s performers list who works in a Member practice in the Locality for which the election is being held, for a minimum of four sessions a week, shall be able to cast one vote for each position for which an election is being held.

viii) If there is only one recommended nominee for each position, the GPs shall vote by a simple majority to approve or reject the recommendation.

ix) If there is more than one recommended nominee for each position, the GPs shall vote to appoint one of them. The nominee with the largest number of votes shall be appointed unless all the nominees are rejected.

x) Elections will be by means of secret ballot conducted by an independent and recognised election services organisation.

xi) The Practice Representatives for the Members in each Locality shall be responsible for reporting the outcome of each vote in their Locality to the Members’ Committee, at the first meeting of the Members’ Committee held subsequent to any vote. The Members’ Committee shall appoint the Clinical Directors to the Governing Body in accordance with the outcome of the vote.

c) If the post cannot be filled from among the eligible pool of GPs the Governing Body may extend the advertisement of the post to other practicing primary care clinicians within the Area and follow the process described in b i) – b v) above.

d) Term of office – 2 to 4 years as decided by the Governing Body.

e) Eligibility for reappointment – still meets the requirements set out at

Standing Orders 2.5 a), subject to serving a maximum of 2 consecutive terms of office.

f) Ineligibility and grounds for removal from office –

i) the Members’ Committee passes a Special Resolution for the removal of the Clinical Director;

ii) the Clinical Director is disqualified from membership of a CCG Governing Body under the CCG Regulations.

g) Notice period – 3 months where notice is given by the Clinical Director but

immediately if the Clinical Director is removed from office in accordance with paragraph f) above.

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2.6. Chair of the Governing Body

The Chair is subject to the following eligibility and appointment process:

a) Eligibility – The following persons shall be eligible to be the Chair: any of

the Clinical Directors who the Governing Body considers have received a satisfactory report from the national assessment centre of their competency for the role;

b) Appointment process – where more than one Clinical Director is eligible to

be appointed as the Chair of the Governing Body, each Clinical Director shall vote for the Clinical Director who they consider is the most competent to chair the Governing Body (but a Clinical Director shall not be able to vote for himself/ herself). The Clinical Director receiving the majority of the votes cast, on a simple majority basis, shall be appointed the Chair of the Governing Body. In the event of a tied vote, the Clinical Directors sharing the tied vote shall draw lots to determine which one of them will be the Chair.

c) Term of office – 4 years.

d) Eligibility for reappointment – remains a member of the Governing Body,

subject to serving a maximum term of office of 8 years in aggregate.

e) Ineligibility and grounds for removal from office – the Chair is no longer

a Clinical Director or is disqualified from membership of a clinical commissioning group Governing Body under the CCG Regulations.

f) Notice period – 3 months where notice is given by the Chair but

immediately if the Chair is removed from office in accordance with paragraph e) above.

2.7. Deputy Chair

The Deputy Chair is subject to the following eligibility and appointment process:

a) Nominations – any eligible member of the Governing Body may nominate

him- or herself

b) Eligibility – the Deputy Chair shall be a member of the Governing Body

and must be a lay person.

c) Appointment process – Majority vote of the Governing Body.

d) Term of office – annual renewal.

e) Eligibility for reappointment – remains a member of the Governing Body.

f) Ineligibility and grounds for removal from office – the Deputy Chair is

no longer a member of the Governing Body or no longer meets the eligibility criteria.

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g) Notice period – 3 months where notice is given by the Deputy Chair or

immediately if the Deputy Chair is no longer a member of the Governing Body or no longer meets the eligibility criteria at b) above.

2.8. Accountable Officer

The Accountable Officer is subject to the following eligibility and appointment process:

a) Eligibility – the following persons shall be eligible to be the Accountable

Officer: any person who the Governing Body considers has received a satisfactory report from the national assessment centre of their competency for the role.

b) Appointment process – the following process shall be undertaken should a

vacancy arise

i) The post will be advertised in accordance with good employment practice.

ii) Any applicant shall submit an application form to an externally appointed assessment board. The membership of the assessment board shall be approved by the Governing Body as competent to fulfil the function required of it.

iii) The assessment board shall assess the application of each applicant and interview each applicant and make recommendations to the Governing Body on each applicant’s suitability

iv) The Governing Body shall:

If there is only one recommended applicant to fill the post, vote by a simple majority to agree to nominate or reject the recommended applicant;

If there is more than one recommended applicant, vote to nominate one of them. The applicant with the largest number of votes shall be nominated for the office unless all the applicants are rejected.

v) The Governing Body shall recommend to the NHS National Commissioning Board that it should appoint its nominated candidate.

c) Term of office – the Accountable Officer’s term of office shall be stated in

his or her contract of employment or (if not an employee) terms of appointment.

d) Eligibility for reappointment – not applicable.

e) Ineligibility and grounds for removal from office –the Chief Officer is an

individual who is disqualified from membership of a clinical commissioning group Governing Body under the CCG Regulations and / or in accordance with his or her contract of employment.

46

f) Notice period – immediately if the Chief Officer is disqualified from

membership of a clinical commissioning group Governing Body under the CCG Regulations but otherwise the Chief Officer’s notice period shall be in accordance with his or her contract of employment (if any) and / or statutory employment rights (if any) or (if not an employee) terms of appointment.

2.9. Chief Finance Officer – appointment to be made by the Governing Body in accordance with law, guidance and good employment practice.

2.10. Lay Members

Lay Members are subject to the following eligibility and appointment process:

a) Eligibility – Lay members shall meet the requirements set out in the role

function and specification that the Governing Body shall approve.

b) Appointment process – when the role becomes vacant a job description

and person specification will be advertised widely followed by short-listing, testing and an interview. The interview panel shall include at least the Chair of the Governing Body, the Chair of the Governing Body of a neighbouring clinical commissioning Group and a member of the NHS Commissioning Board or a nominee with the appropriate expertise.

c) Term of office – the office holders will be appointed to the office for a period

of up to 3 years

d) Eligibility for reappointment – the criteria referred to at paragraph a)

above are still applicable, subject to serving a maximum term of office of 6 years

e) Ineligibility and grounds for removal from office –

i) the lay member is an individual who is excluded from being a lay member or is otherwise disqualified from membership of a CCG Governing Body under the CCG Regulations

ii) the Governing Body passes a Special Resolution for the removal of the Lay Member.

f) Notice period – 3 months if notice is given by the Lay Member but

immediately if the lay member is removed from office in accordance with paragraph e) above.

2.11. Secondary Care Specialist

The secondary care specialist is subject to the following eligibility and appointment process:

a) Eligibility – The secondary care specialist

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i) is a secondary care specialist within the meaning of the CCG Regulations and does not fall within regulation 12(1) of the CCG Regulations and

ii) shall meet the requirements of the role function and specification that the Governing Body shall approve.


and person specification will be advertised widely followed by short-listing, testing and an interview. The interview panel shall include at least the Chair of the Governing Body, the Chair of the Governing Body of a neighbouring clinical commissioning Group and a member of the NHS Commissioning Board or a nominee with the appropriate expertise.

c) Term of office – the secondary care specialist will be appointed to the office

for a period of up to 3 years

d) Eligibility for reappointment – the criteria referred to at paragraph a)

above are still applicable, subject to serving a maximum term of office of 9 years in aggregate.

e) Ineligibility and grounds for removal from office –

i) the secondary care specialist is an individual who is excluded from being a secondary care specialist or is otherwise disqualified from membership of a CCG Governing Body under the CCG Regulations

ii) the Governing Body passes a special resolution for the removal from office of the secondary care specialist.

f) Notice period – 3 months if notice is given by the secondary care consultant

but immediately if the secondary care consultant is removed from office in accordance with paragraph e) above.

2.12. Independent Nurse

The independent nurse subject to the following eligibility and appointment process:

a) Eligibility – The independent nurse

i) is a registered nurse who does not fall within regulation 12(1) of the CCG Regulations; and

ii) shall meet the requirements of the role function and specification that the Governing Body shall approve.


and person specification will be advertised widely followed by short-listing, testing and an interview. The interview panel shall include at least the Chair of the Governing Body, the Chair of the Governing Body of a neighbouring

48

clinical commissioning Group and a member of the NHS Commissioning Board or a nominee with the appropriate expertise.

c) Term of office – the independent nurse’s term of office shall be stated in his

or her contract of employment or (if not an employee) terms of appointment.

d) Eligibility for reappointment – not applicable.

e) Ineligibility and grounds for removal from office –the independent nurse

is an individual who is disqualified from membership of a clinical commissioning group Governing Body under the CCG Regulations and / or in accordance with his or her contract of employment.

f) Notice period – immediately if the independent nurse is disqualified from

membership of a clinical commissioning group Governing Body under the CCG Regulations but otherwise the independent nurse’s notice period shall be in accordance with his or her contract of employment (if any) and / or statutory employment rights (if any) or (if not an employee) terms of appointment.

2.13. Chief Operating Officer (voting member) – appointment to be made by the

Governing Body in accordance with good employment practice.

2.14. Director of Public Health (non-voting member) – appointment to be made by

the Governing Body.

2.15. Director of Adult Social Care (non-voting member) – appointment to be made

by the Governing Body.

2.16. Joint appointments.

2.16.1. Where more than one person is appointed jointly to a post on the Governing Body, those persons shall count for the purpose of the Constitution and these Standing Orders as one person.

2.16.2. Where the office of a member of the Governing Body is shared jointly by more than one person:

a) Either or both of those persons may attend or take part in meetings of the Governing Body;

b) If both are present at a meeting they should cast one vote if they agree;

c) In the case of disagreements no vote should be cast; and

d) The presence of either or both of those persons should count as the presence of one person for the purposes of Standing Order 4.34.3 Quorum.

3. MEETINGS OF THE MEMBERS’ COMMITTEE

3.1. Calling and Notice of General Meetings

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3.1.1. In addition to the Annual General Meeting of the Members’ Committee (referred to at 3.9 below), the Members Committee shall hold a General Meeting not less than once a year at such times and places as the Members’ Committee may determine.

3.1.2. The Governing Body or Practice Representatives together holding not less than 20% of the nominated voting rights allocated to the Practice Representatives may call a General Meeting at any time.

3.1.3. Every notice calling a General Meeting must specify the location, date and time of the meeting and the general nature of the business to be transacted. Every such notice must also contain any resolution which is proposed to be passed. A Practice Representative wanting a proposed resolution or item for discussion or placed on the agenda shall have such resolution or item placed on the agenda except where at the Chair’s discretion to do so would be unreasonable. For the avoidance of doubt the Governing Body may call a General Meeting to discuss and make proposals on those decisions/duties which are reserved to the Members’ Committee. The location must be publicly accessible premises within the Group’s Area.

3.1.4. The Governing Body or the Practice Representatives who call a General Meeting must give at least 21 clear days’ written notice of the meeting to all Practice Representatives and all members of the Governing Body.

3.1.5.On the calling of a General Meeting the Chair shall forthwith arrange to give notice of it:

a) at the offices of the Group and on the Group’s website; and

b) to the following local bodies directly via an appropriate mechanism: the Group’s auditor, the local Healthwatch for the Group’s Area and the Chair of the Health & Wellbeing Governing Body

3.1.6.3.1.5. The Chair may call an emergency General meeting at his or her discretion. The process set out above at 3.1.3 to 3.1.4 shall apply to such an emergency General meeting save for the time period specified therein.

3.2. Agenda and papers for General Meetings

3.2.1. The Chair shall arrange for the agenda and papers to be prepared for a General meeting.

3.2.2. The agenda and any papers for a General Meeting must be circulated at least 5 clear days prior to the General Meeting to each Practice Representative and each member of the Governing Body.

3.2.3. Any papers relating to items that are to be discussed in private at a General Meeting shall not be made public.

3.3. Attendance and Speaking at General Meetings

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3.3.1. A General Meeting shall be held in private except where the Members’ Committee decides that it would be in the public interest to permit members of the public to attend all or part of it. The Chair may also exclude any member of the public from a General Meeting if they are interfering with or preventing its proper conduct.

3.3.2. The Chair may make whatever arrangements he or she considers appropriate to enable those attending a General Meeting to listen and contribute including to exercise their rights to speak or vote.

3.3.3. Each Practice Representative, each Partner and each salaried GP of a Member and each member of the Governing Body may speak at a General Meeting.

3.3.4. Other attendees may ask questions by invitation of the Chair.

3.3.5. The accidental omission to give notice of a meeting to, or the non-receipt of notice of a meeting, agenda or papers by, any person entitled to receive notice shall not invalidate proceedings at that meeting.

3.4. Quorum

3.4.1. No business other than the appointment of the Chair of the meeting is to be transacted at a General Meeting if the persons attending do not constitute a quorum.

3.4.2. For a General Meeting to be quorate, the voting rights of the Practice Representatives (or their proxies) in attendance at a General Meeting shall equal or exceed 60% of the nominated voting rights allocated to Practice Representatives in any year.

3.5. Chairing of General Meetings

3.5.1. The Chair of the Governing Body shall Chair General Meetings if present. If not present the Deputy Chair shall Chair the General Meeting if present.

3.5.2. If the Chair and Deputy Chair are not present or are not present within 10 minutes of the time at which a General Meeting was due to start the Practice Representatives present at the meeting shall on a majority vote appoint one of themselves to Chair the meeting.

3.5.3. If the persons attending a General Meeting within half an hour of the time at which the meeting was due to start do not constitute a quorum, or if during a meeting a quorum ceases to be present, the Chair of the meeting must adjourn it.

3.5.4. The Chair of a quorate General Meeting may adjourn it if:

a) the meeting consents to an adjournment, or

b) it appears to the Chair of the meeting that an adjournment is necessary to ensure that the business of the meeting is conducted in an orderly manner.

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3.5.5. The Chair of a General Meeting must adjourn it if directed to do so by Practice Representatives holding a simple majority of the nominated voting rights allocated to the Practice Representatives present at the meeting.

3.5.6. When adjourning a General Meeting, the Chair of the meeting must:

a) either specify the time and place to which it is adjourned or state that it is to continue at a time and place to be fixed by the Governing Body; and

b) have regard to any directions as to the time and place of any adjournment which have been given by the meeting.

3.5.7. If the continuation of an adjourned meeting is to take place more than 14 days after it was adjourned, the Chair must give at least 14 clear days’ notice of it:

a) to the same persons to whom notice of a General Meeting is required to be given, and

b) containing the same information which such notice is required to contain.

3.5.8. At an adjourned General Meeting only that business that formed the business to be transacted at the original meeting can be transacted.

3.6. Decision Making at General Meetings

3.6.1. Matters for decision at a general meeting shall be decided by ordinary resolution unless these standing orders provide otherwise.

3.6.2. Each Practice Representative shall have nominated voting rights calculated on the basis of one vote per 2000 patients on their practice’s registered list of patients (rounded up or down to the nearest 1000), as submitted to the Group annually. Each Practice Representative shall have one vote

3.6.3. A Practice Representative should reflect the wishes of the Members who appointed him or her when casting his or her vote.

A Practice Representative may cast his or her votes as a block or separately but when doing so should reflect the wishes of the Member who appointed him or her.

3.6.4. Only the Practice Representatives (or their proxies) shall be entitled to vote at a General Meeting save that in the case of an equality of votes, the Chair of the meeting shall be entitled to a casting vote.

3.6.5. The decision of the Chair of the meeting on questions of order, relevancy and regularity and their interpretation of the constitution, standing orders, scheme of reservation and delegation and prime financial policies at the meeting, shall be final.

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3.7. Errors and disputes

3.7.1. No objection may be raised to the qualification of any person voting at a General Meeting except at the meeting or adjourned meeting at which the vote objected to is tendered, and every vote not disallowed at the meeting is valid.

3.7.2. Any such objection must be referred to the Chair of the meeting whose decision is final.

3.8. Content of proxy notices

3.8.1. Proxies may only validly be appointed by a notice in writing (a “proxy notice”) which:

a) states the name and address of the Practice Representative appointing the proxy;

b) identifies the person appointed to be that Practice Representative’s proxy and the General Meeting in relation to which that person is appointed;

c) is signed by or on behalf of the Practice Representative appointing the proxy, or is authenticated by the relevant Member; and

d) is delivered to the Governing Body in accordance with the Constitution and any instructions contained in the notice of the General Meeting to which they relate.

3.8.2. The Governing Body may require proxy notices to be delivered in a particular form, and may specify different forms for different purposes.

3.8.3. Proxy notices may specify how the proxy appointed under them is to vote (or that the proxy is to abstain from voting) on one or more resolutions.

3.8.4. Unless a proxy notice indicates otherwise, it must be treated as

a) allowing the person appointed under it as a proxy discretion as to how to vote on any ancillary or procedural resolutions put to the meeting; and

b) appointing that person as a proxy in relation to any adjournment of the General Meeting to which it relates as well as the meeting itself.

3.8.5. An appointment under a proxy notice may be revoked by delivering to the Governing Body a notice in writing given by or on behalf of the Practice Representative by whom or on whose behalf the proxy notice was given.

3.8.6. A notice revoking a proxy appointment only takes effect if it is delivered before the start of the meeting or adjourned meeting to which it relates.

3.8.7. If a proxy notice is not executed by the Practice Representative appointing the proxy, it must be accompanied by written evidence of the authority of the person who executed it to execute it on the relevant Member’s behalf.

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3.9. Annual General Meeting

3.9.1. The Members’ Committee shall hold an Annual General Meeting (AGM) of the Group:

a) once in each financial year provided that not more than 15 months shall elapse between the date of one Annual General Meeting and that of the next;

b) on a Business Day; and

c) at such a time and place as the Governing Body shall determine no later than September 30th of any year and in publicly accessible premises within the Group’s Area.

3.9.2. Minutes of the Annual General meeting will be a matter of public record

3.9.3. The matters to be discussed at the AGM shall be set out in the notice, and shall include the consideration and, if thought fit, approval of:

a) the Group accounts;

b) the Group Annual Report;

c) the Group Report on Public Involvement;

d) the Group Annual Plan;

e) the appointment of an external auditor;

f) the transaction of any other business included in the notice convening the meeting;

g) the appointment or approval of appointment of members to the Governing Body, where applicable.

3.9.4. The AGM shall be open to the public

3.9.5. Notice of the AGM will be published at least 28 clear days prior to the meeting.

3.9.6. On the calling of an Annual General Meeting the Chair shall forthwith arrange to give notice of it:

a) at the offices of the Group and on the Group’s website; and

b) to the following local bodies directly via an appropriate mechanism: the Group’s auditor, the local Healthwatch for the Group’s Area and the Chair of the Health & Wellbeing Governing Body.

3.9.6.3.9.7. Standing Orders 3.33.3 to 3.83.8 will apply to an Annual General Meeting.

3.10. Minutes




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3.10.1. The minutes of the proceedings of a General Meeting or Annual General meeting shall be drawn up and submitted for agreement at the next meeting where they shall be signed by the person presiding at it as a true record.

3.10.2. No discussion shall take place upon the minutes except upon their accuracy or where the person presiding at the meeting considers discussion appropriate.

4. MEETINGS OF THE GOVERNING BODY AND ITS COMMITTEES AND SUB-COMMITTEES

4.1. Calling and Notice of Governing Body Meetings

4.1.1. The Governing Body shall meet not less than 1 time a year at such times and places as the Governing Body may determine.

4.1.2. In addition to the meeting(s) referred to above at 4.1.1 the Chair may call a meeting of the Governing Body at any time.

4.1.3. One-third or more members of the Governing Body may requisition a meeting in writing. If the Chair refuses, or fails, to call a meeting within seven days of a requisition being presented, the members signing the requisition may forthwith call a meeting.

4.1.4. Written notice of a meeting of the Governing Body must be given to each member of the Governing Body and each Practice Representative at least 21 clear days before the meeting. The notice shall specify the date, time and venue of the meeting and it shall be published at the same time on the Group’s website.

4.1.5. The accidental omission to give notice of a meeting of the Governing Body to, or the non-receipt of notice of a meeting by, any person entitled to receive notice shall not invalidate proceedings of that meeting.

4.1.6. Agenda and Papers for Governing Body Meetings

4.1.7. The Chair and the Accountable Officer shall agree the agenda for a meeting of the Governing Body.

4.1.8. The agenda and any papers for a meeting of the Governing Body must be circulated to each member of the Governing Body at least 5 clear working days prior to the meeting. At the same time the agenda must be circulated to each Practice Representative and the agenda and papers must be published on the Group’s website.

4.1.9. Any papers relating to items that are to be discussed in private by the Governing Body shall not be made public.

4.2. Attendance and Speaking at Governing Body Meetings

4.2.1. The Governing Body shall meet in public except where it decides that it would not be in the public interest to permit members of the public to attend all or part

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of the meeting. The Chair may also exclude any member of the public from a meeting if they are interfering with or preventing its proper conduct.

4.2.2. The Chair may make whatever arrangements he or she considers appropriate to enable those attending a meeting of the Governing Body to listen and contribute including to exercise their rights to speak or vote.

4.2.3. If the Chair permits, members of the public and Practice Representatives will be allowed to ask questions at Governing Body meetings but will not be allowed to contribute to the discussion unless expressly invited to do so by the Chair.

4.2.4. The Governing Body may co-opt such other person(s) to attend all or any of its meetings, or part(s) of a meeting, in order to assist in its decision making and in its discharge of its functions as it sees fit. Any such person may speak and participate in debate but may not vote.

4.3. Quorum of Governing Body Meetings

4.3.1. The quorum of the Governing Body shall be 9 of its members of whom (subject to Standing Order 4.4.24.4.2) one is the Chair or Deputy Chair, another is the Accountable Officer or the Chief Finance Officer, and at least 3 others are Clinical Directors.

4.4. Chairing of Governing Body Meetings

4.4.1. At any meeting of Governing Body the Chair if present, shall preside. If the Chair is absent from the meeting, the Deputy Chair, if any and if present, shall preside.

4.4.2. If the Chair withdraws from a meeting temporarily on the grounds of a declared conflict of interest, then the Deputy Chair, if present, shall preside. If both the Chair and Deputy Chair withdraw from a meeting or are absent, then a member of the Governing Body, shall be chosen by the members present, or by a majority of them, and shall preside for so long as the Chair and/or Deputy Chair have withdrawn from the meeting.

4.4.3. The decision of the Chair of the meeting on questions of order, relevancy and regularity and their interpretation of the constitution, standing orders, scheme of reservation and delegation and prime financial policies at the meeting, shall be final.

4.5. Decision Making at Governing Body Meetings

4.5.1. The Governing Body shall normally look to make decisions by consensus.

4.5.2. If the need for a vote arises the following rules shall apply:

a) If the numbers of votes of those attending for or against a proposal are equal, the Chair of the Governing Body or other person Chairing the meeting has a casting vote.

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b) Any decision of the Governing Body must be decided by an ordinary resolution of those present and eligible to vote unless these Standing Orders otherwise prescribe that a special resolution is required.

c) Should a vote be taken the outcome of the vote, and any dissenting views, must be recorded in the minutes of the meeting.

4.6. Notice of Motions

4.6.1. Subject to the provision of Standing Orders 4.7.24.7.2 ‘Motions: Procedure at and during a meeting’ and 4.7.34.7.3 ‘Motions to Rescind a Resolution’, a member of the Governing Body wishing to move a motion shall send a written notice to the Chair.

4.6.2. The notice shall be delivered at least 14 clear days before the meeting. The Chair shall include in the agenda for the meeting all notices so received that are in order and permissible under governing regulations. This Standing Order shall not prevent any motion being withdrawn or moved without notice on any business mentioned on the agenda for the meeting.

4.7. Emergency Motions

4.7.1. Subject to the agreement of the Chair, and subject also to the provision of Standing Order 4.7.24.7.2 ‘Motions: Procedure at and during a meeting’, a member of the Governing Body may give written notice of an emergency motion after the issue of the notice of meeting and agenda, up to one hour before the time fixed for the meeting. The notice shall state the grounds of urgency. If in order, it shall be declared to the Governing Body at the commencement of the business of the meeting as an additional item included in the agenda. The Chair's decision to include the item shall be final.

4.7.2. Motions: Procedure at and during a meeting

a) Who may propose

A motion may be proposed by the Chair of the meeting or any member present. It must also be seconded by another member.

b) Contents of motions

The Chair may exclude from the debate at his discretion any such motion of which notice was not given on the notice summoning the meeting other than a motion relating to:

i) the reception of a report;

ii) consideration of any item of business before the Governing Body;

iii) the accuracy of minutes;

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iv) that the Governing Body proceed to next business;

v) that the Governing Body adjourn;

vi) that the question be now put.

c) Amendments to motions

i) A motion for amendment shall not be discussed unless it has been proposed and seconded.

ii) Amendments to motions shall be moved relevant to the motion, and shall not have the effect of negating the motion before the Governing Body.

iii) If there are a number of amendments, they shall be considered one at a time. When a motion has been amended, the amended motion shall become the substantive motion before the meeting, upon which any further amendment may be moved.

d) Rights of reply to motions

i) Amendments

The mover of an amendment may reply to the debate on their amendment immediately prior to the mover of the original motion, who shall have the right of reply at the close of debate on the amendment, but may not otherwise speak on it.

ii) Substantive/original motion

The member who proposed the substantive motion shall have a right of reply at the close of any debate on the motion.

e) Withdrawing a motion

A motion, or an amendment to a motion, may be withdrawn.

f) Motions once under debate

i) When a motion is under debate, no motion may be moved other than:

an amendment to the motion;

the adjournment of the discussion, or the meeting;

that the meeting proceed to the next business;

that the question should be now put;

the appointment of an 'ad hoc' committee to deal with a specific item of business;

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that a member be not further heard; and/or

a motion resolving to exclude the public, including the press (see Standing Order 4.2.1).

ii) In those cases where the motion is either that the meeting proceeds to the ‘next business’ or ‘that the question be now put’ in the interests of objectivity these should only be put forward by a member of the Governing Body who has not taken part in the debate and who is eligible to vote.

iii) If a motion to proceed to the next business or that the question be now put, is carried, the Chair should give the mover of the substantive motion under debate a right of reply, if not already exercised. The matter should then be put to the vote.

4.7.3. Motion to Rescind a Resolution

a) Notice of motion to rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the signature of the member who gives it and also the signature of three other members, and before considering any such motion of which notice shall have been given, the Governing Body may refer the matter to any appropriate Committee or the Chair or the Accountable Officer for recommendation.

b) When any such motion has been dealt with by the Governing Body it shall not be competent for any member other than the Chair to propose a motion to the same effect within six months. This Standing Order shall not apply to motions moved in pursuance of a report or recommendations of a Committee or the Accountable Officer.

4.8. Minutes

4.8.1. The minutes of the proceedings of a meeting shall be drawn up and submitted for agreement at the next meeting where they shall be signed by the person presiding at it as a true record.

4.8.2. No discussion shall take place upon the minutes except upon their accuracy or where the person presiding at the meeting considers discussion appropriate.

4.9. Petitions

4.9.1. Where a petition has been received by the Group at least 14 clear days before a meeting, the Chair of the Governing Body shall include the petition as an item for the agenda of the next meeting of the Governing Body.

4.10. Committees and Sub-Committees of the Governing Body

4.10.1. The Governing Body may arrange for any of its functions to be exercised on its behalf by any member of the Governing Body, any member of the Group who is an individual and not a member of the Governing Body, any employee or any

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committee or sub-committee of the Governing Body as it thinks fit, but the terms of any such delegation are set out in the Scheme of Delegation which are publically available; or by a specific instruction recorded in the minutes of a Governing Body meeting.

4.10.2. At any meeting of a committee or sub-committee of the Governing Body, the Chair of the relevant committee or sub-committee, if any and if present, shall preside. Any such committee shall have terms of reference and have at least one member of the Governing Body in attendance to be quorate. If the Chair is absent from the meeting, the deputy Chair, if any and if present, shall preside.

4.10.3. If the Chair is absent temporarily on the grounds of a declared conflict of interest the deputy Chair, if present, shall preside. If both the Chair and deputy Chair are absent, or are disqualified from participating, or there is neither a Chair or deputy a member of the committee or sub-committee respectively shall be chosen by the members present, or by a majority of them, and shall preside.

4.10.4. The provisions of these standing orders shall apply where relevant to the operation of the Governing Body, the Governing Body’s committees and sub-committee and all committees and sub-committees unless stated otherwise in the committee or sub-committee’s terms of reference.

4.10.5. Unless they are a member of a committee or sub-committee of the Governing Body, no member of the public or press, or of any other individual who is not a Practice Representative shall attend meetings of committees or sub-committees except by the express permission of the Chair of that committee or sub-committee

5. RECORD KEEPING

5.1. The Governing Body must keep and publish (excluding in relation to those meetings or parts of meetings from which the public are excluded under these Standing Orders):

a) Agreed minutes of all

i) Meetings of any committees of the Group including Annual General Meetings and General Meetings of the Members’ Committee; and

ii) Meetings of the Governing Body and any committee or sub-committee carrying out functions or powers on its behalf, and

b) A register of all Members and Practice Representatives.

5.2. Any minutes kept under Standing Order 5.15.1 shall

a) be made available or copied on request to any Member.

b) be sufficient evidence without further proof of the facts stated in such minutes

c) include:


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i) The names of persons present at the meeting;

ii) The decisions made at the meeting;

iii) Where appropriate the reasons for the decision.

5.3. No discussion shall take place on the agreed minutes of any meeting.

6. EMERGENCY POWERS AND URGENT DECISIONS

6.1. The Governing Body will delegate responsibility for emergency powers and urgent decisions (urgent action) to a Group of at least four members of the Governing Body that must include at least one from each of the following pairs of members:

a) The Chair or (if the Chair is unavailable when urgent action is required) Deputy-Chair of the Governing Body

b) The Accountable Officer or (if the Accountable Officer is unavailable when urgent action is required) the Chief Finance Officer; and

c) A Clinical Director.

6.2. The Chair or (if the Chair is unavailable when urgent action is required) Deputy-Chair will convene the Group either in person or by a virtual means.

6.3. The Chair or (if the Chair is unavailable when urgent action is required) Deputy-Chair will determine if an issue requires urgent action.

6.4. All urgent action will be reported to the Governing Body at its next meeting within the Chair’s report with an explanation of:

a) What the decision was

b) Why it was deemed an emergency or urgent decision; and

c) Who was in the Group convened to make the decision for ratification.

6.5. A record of matters discussed during the meeting shall be kept. These records shall be made available to the Governing Body’s audit and probity committee for review of the reasonableness of the decision to take urgent action.

7. SUSPENSION OF STANDING ORDERS

7.1. Except where it would contravene any statutory provision or any direction made by the Secretary of State for Health or the NHS Commissioning Board, the Governing Body may by special resolution at any meeting suspend Standing Order 44 in whole or in part.

7.2. A decision to suspend Standing Order 44 together with the reasons for doing so shall be recorded in the minutes of the meeting.



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7.3. A separate record of matters discussed during the suspension shall be kept. These records shall be made available to the Governing Body’s audit committee for review of the reasonableness of the decision to suspend standing orders.

8. APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES

8.1. Appointment of committees and sub-committees

8.1.1. The Group may appoint committees and sub-committees of the Group, subject to any regulations made by the Secretary of State. The Governing Body may appoint, and make provision for the appointment of committees and sub-committees of its the Governing Body subject to any regulations made by the Secretary of State.

8.1.2. Other than where there are statutory requirements, such as in relation to the Governing Body’s audit committee or remuneration committee, the Group shall determine the membership and terms of reference of its committees and sub-committees and shall, if it requires, receive and consider reports of such committees at the next appropriate meeting of the Group. The Governing Body shall determine the membership and terms of reference of its committees and sub committees and shall if it requires receive and consider reports of such committees at the next appropriate meeting of the Governing Body.

8.1.3. The provisions of these standing orders shall apply where relevant to the operation of the Governing Body, the Governing Body’s committees and sub-committee and all committees and sub-committees unless stated otherwise in the committee or sub-committee’s terms of reference.

8.2. Delegation of Powers by Committees to Sub-committees

8.2.1. Where committees are authorised to establish sub-committees they may not delegate decision making powers to the sub-committee unless expressly authorised by the Group.

8.3. Approval of Appointments to Committees and Sub-Committees

8.3.1. The Group shall approve the appointments to each of the Group committees and sub-committees which it has formally constituted. The Governing Body shall approve the appointments to each of the Governing Body committees and sub-committees which it has formally constituted. including those of the Governing Body. The Group shall agree such travelling or other allowances as it considers appropriate.

9. DUTY TO REPORT NON-COMPLIANCE WITH STANDING ORDERS AND PRIME FINANCIAL POLICIES

9.1. If for any reason these standing orders are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances

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around the non-compliance, shall be reported to the next formal meeting of the Governing Body for action or ratification. All members of the Group and staff have a duty to disclose any non-compliance with these standing orders to the Accountable Officer as soon as possible.

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10. USE OF SEAL AND AUTHORISATION OF DOCUMENTS

10.1. The Group’s seal

10.1.1. The Group may have a seal for executing documents where necessary. The following individuals or officers are authorised to authenticate its use by their signature subject to the Scheme of Delegation:

a) the Accountable Officer;

b) the Chair or (if the Chair is unavailable) Deputy Chair;or

c) the Chief Finance Officer;

10.2. Execution of a document by signature

10.2.1. The following individuals are authorised to execute a document on behalf of the Group by their signature.

a) the Accountable Officer

b) the Chair (if the Chair is unavailable) Deputy Chair; or

c) the Chief Finance Officer

11. OVERLAP WITH OTHER CLINICAL COMMISSIONING GROUP POLICY STATEMENTS / PROCEDURES AND REGULATIONS

11.1. Policy statements: general principles

11.1.1. The Group Governing Body will from time to time agree and approve policy statements / procedures which will apply to all or specific Groups of staff employed by the Group. The decisions to approve such policies and procedures will be recorded in an appropriate minute of the Members’ CommitteeGoverning Body and will be deemed where appropriate to be an integral part of the Group’s standing orders.

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APPENDIX D – SCHEME OF RESERVATION & DELEGATION

1. The arrangements made by the Group as set out in this scheme of reservation

and delegation of decisions shall have effect as if incorporated in the Group’s Constitution.

2. The clinical commissioning Group remains accountable for all of its functions,

including those that it has delegated.

NHS Redbridge Clinical Commissioning Group’s Constitution - 66 -

SCHEDULE OF MATTERS RESERVED TO THE CLINICAL COMMISSIONING GROUP AND SCHEME OF DELEGATION

Decisions/ duties delegated by the Group and reserved to the Members’ Committee

1 The Members’ Committee

Determine those decisions that are reserved for the Members Committee.


The Committee will make decisions relating to:

a) Make recommendations to the NHS Commissioning Board for changes to the Constitution of the Group b) Amending these Standing Orders and/or the Scheme of Delegation (which for the avoidance of doubt are part of

the Constitution) c) Change the nature of the business of the Group or do anything inconsistent with the mission, values and aims of

the Group; d) Use any other name than that specified in Clause 1.1 of the Constitution in relation to the activities of the Group; e) Merge, amalgamate or federate the Group with any other clinical commissioning Group; f) Seek to remove any Member; g) Reorganise the boundaries of or change the organisational structure of the Group. Any such decision at a) to g) above will require the consent of the NHS Commissioning Board to the extent that they constitute a change to the Constitution.


Approve the arrangements for appointing and removing Clinical Directors to/from the Governing Body

Decisions/ duties delegated to the Governing Body

1 The Governing Body

General Enabling Provision The Governing Body may determine any matter, for which it has delegated or statutory authority, it wishes in full session within its statutory powers.



Overarching Scheme of Reservation and Delegation 1. Prepare the Group’s overarching scheme of reservation and delegation, which sets out those decisions of the

Group reserved to the membership and those delegated to the:

Group’s Governing Body

Committees and sub-committees of the Group, or

Its Members and employees and sets out those decisions of the Governing Body reserved to the Governing Body and those delegated to the

Governing Body’s committees and sub-committees,

Members of the Governing Body

An individual who is a member of the Group but not the Governing Body or

A specified person in the Group’s Constitution. 2. Approval of the Group’s operational scheme of delegation that underpins the Group’s ‘overarching scheme of

reservation and delegation’ as set out in its Constitution.


Regulations and Control a) Determine arrangements to manage conflicts of interest and potential conflicts of interest in accordance with

Clause 8 of the Constitution. b) Require and receive the declaration of Governing Body members’ interests c) Require and receive and the register of interest (s) as required by 8.3.5 of the Constitution and review the same

every quarter. d) Approve arrangements for dealing with complaints. e) Receive reports from committees including those that the Governing Body is required by the 2006 Act to establish

and to action appropriately. f) Confirm the recommendations of the Governing Body’s committees where the committees do not have executive

powers. g) Approve arrangements relating to the discharge of the CCG’s responsibilities as a corporate trustee for funds

held on trust. h) Establish terms of reference and reporting arrangements of all committees and sub-committees that are

established by the Governing Body.


i) Authorise use of the seal. j) Discipline members of the Governing Body and/ or employees who are in breach of statutory requirements or the

standing orders as set out in Appendix C. k) Approve any urgent decisions taken in accordance with Standing Order 6 for ratification by the Governing Body. l) Jointly with the Chief Finance Officer approve detailed financial policies that underpin the clinical commissioning

Group’s prime financial policies m) Approve any amendments to the prime financial policies.


Appointments/ Dismissal a) Approve the process for recruiting and removing non-elected members to the Governing Body (subject to any

regulatory requirements) and succession planning. b) Appoint the Deputy Chair of the Governing Body. c) Appoint and dismiss committees (and individual members) that are directly accountable to the Governing Body. d) Confirm appointment of members of any committee of the Group or Governing Body as representatives on

outside bodies.


Strategy, Local Delivery Plan and Budgets a) Identify the key strategic risks, evaluate them and ensure adequate responses are in place and are monitored. b) Approve plans in respect of the application of available financial resources to support the agreed Commissioning

Strategy Plan (Operating Plan/QIPP). c) Approve proposals for ensuring quality and developing clinical governance in services provided by the Group or

its constituent practices, having regard to any guidance issued by the NHS Commissioning Board and/ or the Secretary of State.

d) Approve (with any necessary appropriate modification) the Group’s commissioning strategy or plan. e) Approve annually (with any necessary appropriate modification) the Group’s CSP and Operating Plan/QIPP. f) Approve the Group’s policies and procedures for the management of risk. g) Approve budgets. h) Ratify proposals for acquisition, disposal or change of use of land and/or buildings. i) Approve the opening of bank accounts. j) Approve contracts in accordance with the Prime Financial Policies. k) Approve proposals in individual cases for the write off of losses or making of special payments above the limits of

delegation to the Accountable Officer and Chief Finance Officer (for losses and special payments) previously


approved by the Governing Body. l) Approve individual compensation payments above delegated limits. m) Approve proposals for action on litigation against or on behalf of the Group. n) Approve proposals for CCG or practice incentive schemes, having regard to guidance by the Secretary of State. o) Approve arrangements for managing exceptional funding requests. p) Define the vision, values , aims and overall strategic direction of the Group. q) Approval of variations to the approved budget where variation would have a significant impact on the overall

approved levels of income and expenditure or the Group’s ability to achieve its agreed strategic aims.


Terms of Employment/ Terms of Service a) Determine remuneration, fees and allowances payable to employees of the Group and to other persons providing

services to the Group, including the allowances payable under any pension scheme.Determine: b) the other terms and conditions of employment of the employees of the Group; and c)a) the other terms of service of persons providing services to the Group. d)b) Approve the arrangements for discharging the Group’s statutory duties as an employer. e)c) Approve human resources policies for employees and for other persons working on behalf of the Group.

7

The Governing Body

Audit a) Receive the annual management letter received from the External Auditor, taking account of the advice, where

appropriate, of the Audit Committee. b) Receive an annual report from the Internal Auditor and agree action on recommendations where appropriate of

the Audit Committee.


Annual Reports and Accounts a) Receipt and approval of the Group's Annual Report and Annual Accounts. b) Receipt and approval of the Annual Report and Accounts for any funds held on trust, which may be incorporated

within the Group’s annual report. c) Approval of the arrangements for discharging the Group’s statutory financial duties.


Tendering And Contracting a) Approval of the Group’s contracts for any commissioning support. b) Approval of the Group’s contracts for corporate support (for example finance provision)

10 The Commissioning And Contracting For Clinical Services


Governing Body

a) Approval of the arrangements for discharging the Group’s statutory duties associated with its commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation.

b) Approve arrangements for co-ordinating the commissioning of services with other clinical commissioning groups and or with the local authority(ies), where appropriate.


Operational And Risk Management a) Approval of the Group’s risk management and insurance arrangements. b) Approve arrangements for risk sharing and or risk pooling with other organisations (for example arrangements

for pooled funds with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006)

c) Approve proposals for action on litigation against or on behalf of the clinical commissioning Group. d) Approve the Group’s arrangements for business continuity and emergency planning.


Quality And Safety a) Approve arrangements, including supporting policies, to minimise clinical risk, maximise patient safety and to

secure continuous improvement in quality and patient outcomes. b) Approve arrangements for supporting the NHS Commissioning Board in discharging its responsibilities in

relation to securing continuous improvement in the quality of general medical services. c) Approve arrangements, including supporting policies, for safeguarding children and vulnerable adults.


Partnership Working a) Approve decisions that individual members or employees of the Group participating in joint arrangements on

behalf of the Group can make. Such delegated decisions must be disclosed in this scheme of reservation and delegation.

b) Approve decisions delegated to joint committees established under section 75 of the 2006 Act.


Information Governance a) Approve the Group’s arrangements for handling complaints. b) Approval of the arrangements for ensuring appropriate and safekeeping and confidentiality of records and for

the storage, management and transfer of information and data. c) Approval of the arrangements for information sharing protocols.

15 The Other functions


Governing Body

Exercise those functions of the Group which have not been reserved to the Members’ Committee, delegated to another committee or sub-committee of the Group or to one or more of its Members or employees.

Decisions/ duties delegated to the Chair of the Governing Body

1. Chair Appraise the Clinical Directors.

2. Chair Approve all communications to practices from the Governing Body.

Decisions/ duties delegated to the Accountable Officer

1. Accountable Officer

Operational Scheme of Delegation Prepare and recommend the Group’s operational scheme of delegation, which sets out those key operational decisions delegated to individual employees of the Group, not for inclusion in the Group’s Constitution.

2. Accountable Officer

Comprehensive System of Internal Control Approval of a comprehensive system of internal control, including budgetary control, that underpins the effective, efficient and economic operation of the Group. And otherwise exercise the functions set out in Clause 7.7 and Appendix E Prime Financial Policies insofar as they are not otherwise delegated.

Decisions/ duties delegated to the Chief Finance Officer

1. Chief Finance Officer

Prepare detailed financial policies that underpin the Group’s prime financial policies.

2 Chief Finance Officer

Exercise functions set out in Clause 7.8.2 of the core constitution and Appendix E Prime Financial Policies insofar as they are not otherwise delegated


Decisions/duties delegated by the Governing Body to committees

Decisions/duties delegated by the Governing Body to Committees or set out in the 2006 Act

Executive Committee

The Committee will

a) Develop and monitor delivery of the Group’s operating, business, QIPP and commissioning plans. b) Propose arrangements to minimise clinical risk, maximise patient safety and to secure continuous improvement in

quality and patient outcomes. c) Propose joint working with other clinical commissioning group, the local authority and other partner organisations

where collaborative approaches will yield tangible improvements and/or efficiencies. d) Exercise good budget management, including regular monitoring of financial performance and agree mitigating

actions where required. e) Exercise good asset management. f) Oversee service transformation and pathway redesign. g) Monitor and provide assurance to the governing body of provider quality through monitoring and acting on

performance information. h) Oversee process for developing and approving contracts for service delivery, commissioning support and

corporate support. i) Ensure regular engagement and two-way flow with member practices. j) Identify, review and mitigate operational risks.

The Committee will adopt Terms of Reference approved by the Governing Body.

Audit and governance committee

The Committee will: a) Advise the Governing Body on internal and external audit services; b) The committee shall review the establishment and maintenance of an effective system of integrated governance,

risk management and internal control, across the whole of the Group’s activities that supports the achievement of the Group’s objectives.

c) Review the findings of other significant assurance functions, both internal and external and consider the implications for the governance of the Group.

d) Monitor compliance with Standing Orders and Standing Financial Instructions; e) Review schedules of losses and compensations and making recommendations to the Governing Body;


f) Review the annual financial statements prior to submission to the Governing Body. g) Approve the appointment (and where necessary the dismissal) of Internal Auditors and advise the Audit

Commission on the appointment of External Auditors, including arrangements for the separate audit of funds held on trust.

h) Receive the annual management letter received from the External Auditor. i) Approve the Group’s counter fraud and security management arrangements. j) Reviewing the register (s) of interests (as provided for in 8.3.5 of the Constitution) every quarter. k) Approve the Group’s banking arrangements.

The Committee will adopt Terms of Reference approved by the Governing Body.

Remuneration and workforce committee

The Committee will: a) Make recommendations to the Governing Body about appropriate remuneration and terms of service for the

Accountable Officer and other senior employees of the Group including:

all aspects of salary (including any performance-related elements/bonuses);

any other fees and allowances, including the allowances payable under any pension scheme;

arrangements for termination of employment and other contractual terms; having proper regard to the Group’s circumstances and performance and to the provision of any national arrangements for such staff.

b) Reviewing the performance of the AO and other senior team members and determining annual salary awards, if appropriate

c) Consider other workforce issues and receive reports on HR related issues – such as sickness, turnover etc d) Make recommendations to the Governing Body about any remuneration and travelling or other allowances

payable to members of the Governing Body who are not employed by the Group. e) Make recommendations to the Governing Body about the, remuneration, fees and allowances payable to other

employees of the Group and to other persons providing services to the Group, including the allowances payable under any pension scheme.

f) Advise the Governing Body aboutDetermine the terms and conditions of employment of the employees of the Group and the terms of service of persons providing services to the Group other than any terms and conditions of employment or terms of service relating to the remuneration, fees and allowances payable by the Group (which shall be determined by the Governing Body).

f)g)Proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate advise on and oversee appropriate contractual arrangements for such staff;

g)h) Report in writing to the Governing Body the basis for its recommendations.


h)i) Consider and review succession planning arrangements for the CCG The Committee will adopt Terms of Reference approved by the Governing Body.

Quality and Safety Committee

If established Tthe committee will adoptexercise such powers as are delegated to it by the Governing Body and set out in Terms of Reference approved by the Governing Body.

Finance and Delivery Committee

If established Tthe committee will adopt exercise such powers as are delegated to it by the Governing Body and set out in Terms of Reference approved by the Governing Body.

Joint Executive Committee

If established Tthe committee will exercise such powers as are delegated to it by the Governing Body and set out in adopt Terms of Reference approved by the Governing BodyExecutive Committee.


APPENDIX E – PRIME FINANCIAL POLICIES

1. INTRODUCTION

1.1. General

1.1.1. These prime financial policies shall have effect as if incorporated into the

Group’s Constitution.

1.1.2. The prime financial policies are part of the Group’s control environment for managing the organisation’s financial affairs. They contribute to good corporate governance, internal control and managing risks. They enable sound administration; lessen the risk of irregularities and support commissioning and delivery of effective, efficient and economical services. They also help the Accountable Officer and Chief Finance Officer to effectively perform their responsibilities. They should be used in conjunction with the scheme of reservation and delegation found at Appendix D.

1.1.3. In support of these prime financial policies, the Group has prepared more

detailed policies, approved by the Chief Finance Officer known as detailed financial policies. The Group refers to these prime and detailed financial policies together as the clinical commissioning Group’s financial policies.

1.1.4. These prime financial policies identify the financial responsibilities which apply to

everyone working for the Group and its constituent organisations. They do not provide detailed procedural advice and should be read in conjunction with the detailed financial policies. The Accountable Officer and Chief Finance Officer is responsible for approving all detailed financial policies.

1.1.5. A list of the Group’s detailed financial policies will be published and maintained on the Group’s website.

1.1.6. Should any difficulties arise regarding the interpretation or application of any of

the prime financial policies then the advice of the Chief Finance Officer must be sought before acting. The user of these prime financial policies should also be familiar with and comply with the provisions of the Group’s Constitution, standing orders and scheme of reservation and delegation.

1.1.7. Failure to comply with prime financial policies and standing orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.

1.2. Overriding Prime Financial Policies

1.2.1. If for any reason these prime financial policies are not complied with, full details

of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Governing Body’s audit committee for referring action or ratification. All of the Group’s members and employees have a duty to disclose


any non-compliance with these prime financial policies to the chief finance officer as soon as possible.

1.3. Responsibilities and delegation

1.3.1. The roles and responsibilities of Group’s members, employees, members of the

Governing Body, members of the Governing Body’s committees and sub-committees, members of the Group’s committee and sub-committee (if any) and persons working on behalf of the Group are set out in chapters 6 and 7 of this Constitution.

1.3.2. The financial decisions delegated by members of the Group are set out in the

Group’s scheme of reservation and delegation (see Appendix D).

1.4. Contractors and their employees

1.4.1. Any contractor or employee of a contractor who is empowered by the Group to

commit the Group to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Accountable Officer to ensure that such persons are made aware of this.

1.5. Amendment of Prime Financial Policies

1.5.1. To ensure that these prime financial policies remain up-to-date and relevant, the

Chief Finance Officer will review them at least annually. Following consultation with the Accountable Officer and scrutiny by the Governing Body’s audit committee, the Chief Finance Officer will recommend amendments, as fitting, to the Governing Body for approval. As these prime financial policies are an integral part of the Group’s Constitution, any amendment will not come into force until the Group applies to the NHS Commissioning Board and that application is granted.

2. INTERNAL CONTROL

POLICY – the Group will put in place a suitable control environment and

effective internal controls that provide reasonable assurance of effective and efficient operations, financial stewardship, probity and compliance with laws and policies

2.1. The Governing Body is required to establish an audit committee with terms of

reference agreed by the Governing Body (see paragraph 6.8.4(a) of the Group’s Constitution for further information).

2.2. The Accountable Officer has overall responsibility for the Group’s systems of

internal control.

2.3. The Chief Finance Officer will ensure that:

a) financial policies are considered for review and update annually;


b) a system is in place for proper checking and reporting of all breaches of

financial policies; and

c) a proper procedure is in place for regular checking of the adequacy and effectiveness of the control environment.

3. AUDIT

POLICY – the Group will keep an effective and independent internal audit

function and fully comply with the requirements of external audit and other statutory reviews

3.1. In line with the terms of reference for the Governing Body’s audit committee, the

person appointed by the Group to be responsible for internal audit and the Audit Commission appointed external auditor will have direct and unrestricted access to audit committee members and the chair of the Governing Body, Accountable Officer and Chief Finance Officer for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity.

3.2. The person appointed by the Group to be responsible for internal audit and the external auditor will have access to the audit committee and the accountable officer to review audit issues as appropriate. All audit committee members, the chair of the Governing Body and the Accountable Officer will have direct and unrestricted access to the head of internal audit and external auditors.

3.3. The Chief Finance Officer will ensure that:

a) the Group has a professional and technically competent internal audit function; and

b) the Governing Body approves any changes to the provision or delivery of assurance services to the Group except where otherwise provided.

4. FRAUD AND CORRUPTION

POLICY – the Group requires all staff to always act honestly and with integrity to

safeguard the public resources they are responsible for. The Group will not tolerate any fraud perpetrated against it and will actively chase any loss suffered

4.1. The Governing Body’s audit committee will satisfy itself that the Group has

adequate arrangements in place for countering fraud and shall review the outcomes of counter fraud work. It shall also approve the counter fraud work programme.


4.2. The Governing Body’s audit committee will ensure that the Group has arrangements in place to work effectively with NHS Protect.

5. EXPENDITURE CONTROL

5.1. The Group is required by statutory provisions to ensure that its expenditure does

not exceed the aggregate of allotments from the NHS Commissioning Board and any other sums it has received and is legally allowed to spend.

5.2. The Accountable Officer has overall executive responsibility for ensuring that the Group complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money.

5.3. The Chief Finance Officer will:

a) provide reports in the form required by the NHS Commissioning Board;

b) ensure money drawn from the NHS Commissioning Board is required for

approved expenditure only is drawn down only at the time of need and follows best practice;

c) be responsible for ensuring that an adequate system of monitoring financial

performance is in place to enable the Group to fulfil its statutory responsibility not to exceed its expenditure limits, as set by direction of the NHS Commissioning Board.

6. ALLOTMENTS

6.1. The Group’s chief finance officer will:

a) periodically review the basis and assumptions used by the NHS

Commissioning Board for distributing allotments and ensure that these are reasonable and realistic and secure the Group’s entitlement to funds;

b) prior to the start of each financial year submit to the Governing Body for approval a report showing the total allocations received and their proposed distribution including any sums to be held in reserve; and

c) regularly update the Governing Body on significant changes to the initial

allocation and the uses of such funds.

7. COMMISSIONING STRATEGY, BUDGETS, BUDGETARY CONTROL AND MONITORING


POLICY – the Group will produce and publish an annual commissioning plan

that explains how it proposes to discharge its financial duties. The Group will support this with comprehensive medium term financial plans and annual budgets

7.1. The Accountable Officer will compile and submit to the Governing Body a

commissioning strategy which takes into account financial targets and forecast limits of available resources.

7.2. Prior to the start of the financial year the Chief Finance Officer will, on behalf of

the Accountable Officer, prepare and submit budgets for approval by the Governing Body.

7.3. The Chief Financial Officer shall monitor financial performance against budget and plan, periodically review them, and report to the Governing Body. This report should include explanations for variances. These variances must be based on any significant departures from agreed financial plans or budgets.

7.4. The Accountable Officer is responsible for ensuring that information relating to the Group’s accounts or to its income or expenditure, or its use of resources is provided to the NHS Commissioning Board as requested.

7.5. The Governing Body will approve consultation arrangements for the Group’s commissioning plan.

8. ANNUAL ACCOUNTS AND REPORTS

POLICY – the Group will produce and submit to the NHS Commissioning Board

accounts and reports in accordance with all statutory obligations,relevant accounting standards and accounting best practice in the form and content and at the time required by the NHS Commissioning Board

8.1. The Chief Finance Officer will ensure the Group:

a) prepares a timetable for producing the annual report and accounts and

agrees it with external auditors and the Governing Body

b) prepares the accounts according to the timetable approved by the Governing Body;

c) complies with statutory requirements and relevant directions for the

publication of annual report;

d) considers the external auditor’s management letter and fully address all issues within agreed timescales; and

e) publishes the external auditor’s management letter on the Group’s website.


9. INFORMATION TECHNOLOGY

POLICY – the Group will ensure the accuracy and security of the Group’s

computerised financial data

9.1. The Chief Finance Officer is responsible for the accuracy and security of the

Group’s computerised financial data and shall

a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Group's data, programs and computer hardware from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;

b) ensure that adequate (reasonable) controls exist over data entry,

processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;

c) ensure that adequate controls exist such that the computer operation is

separated from development, maintenance and amendment;

d) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the chief finance officer may consider necessary are being carried out.

9.2. In addition the Chief Finance Officer shall ensure that new financial systems and

amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.

10. ACCOUNTING SYSTEMS

POLICY – the Group will run an accounting system that creates management

and financial accounts

10.1. The Chief Finance Officer will ensure:

a) the Group has suitable financial and other software to enable it to comply with these policies and any consolidation requirements of the NHS Commissioning Board;

b) that contracts for computer services for financial applications with another

health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and


timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

10.2. Where another health organisation or any other agency provides a computer

service for financial applications, the Chief Finance Officer shall periodically seek assurances that adequate controls are in operation.

11. BANK ACCOUNTS

POLICY – the Group will keep enough liquidity to meet its current commitments


a) review the banking arrangements of the Group at regular intervals to ensure they are in accordance with Secretary of State directions, best practice and represent best value for money;

b) manage the Group's banking arrangements and advise the Group on the

provision of banking services and operation of accounts;

c) prepare detailed instructions on the operation of bank accounts.

11.2. The Governing Body’s Audit Committee shall approve the banking arrangements.

12. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS.

POLICY – the Group will

operate a sound system for prompt recording, invoicing and collection of all monies due

seek to maximise its potential to raise additional income only to the extent that it does not interfere with the performance of the Group or its functions

ensure its power to make grants and loans is used to discharge its functions effectively

12.1. The Chief Financial Officer is responsible for:

a) designing, maintaining and ensuring compliance with systems for the proper

recording, invoicing, and collection and coding of all monies due;

b) establishing and maintaining systems and procedures for the secure handling of cash and other negotiable instruments;

c) approving and regularly reviewing the level of all fees and charges other

than those determined by the NHS Commissioning Board or by statute.


Independent professional advice on matters of valuation shall be taken as necessary;

d) for developing effective arrangements for making grants or loans.

13. TENDERING AND CONTRACTING PROCEDURE

POLICY – the Group:

will ensure proper competition that is legally compliant within all purchasing to ensure we incur only budgeted, approved and necessary spending

will seek value for money for all goods and services

shall ensure that competitive tenders are invited for o the supply of goods, materials and manufactured articles; o the rendering of services including all forms of management

consultancy services (other than specialised services sought from or provided by the Department of Health); and

o for the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens) for disposals

13.1. The Governing Body may only negotiate contracts on behalf of the Group, and

the Group may only enter into contracts, within the statutory framework set up by the 2006 Act, as amended by the 2012 Act. Such contracts shall comply with: a) the Group’s standing orders;

b) the Public Contracts Regulation 2006, any successor legislation and any

other applicable law; and

c) take into account as appropriate any applicable NHS Commissioning Board or the Independent Regulator of NHS Foundation Trusts (Monitor) guidance that does not conflict with (b) above.

13.2. In all contracts entered into, the Group shall endeavour to obtain best value for

money. The Accountable Officer shall nominate an individual who shall oversee and manage each contract on behalf of the Group.

14. COMMISSIONING

POLICY – working in partnership with relevant national and local stakeholders,

the Group will commission certain health services to meet the reasonable requirements of the persons for whom it has responsibility

14.1. The Group will coordinate its work with the NHS Commissioning Board, other

clinical commissioning groups, local providers of services, local authority (ies), including through Health & Wellbeing Governing Boards, patients and their


carers and the voluntary sector and others as appropriate to develop robust commissioning plans.

14.2. The Accountable Officer will establish arrangements to ensure that regular reports are provided to the Governing Body detailing actual and forecast expenditure and activity for each contract.

14.3. The Chief Finance Officer will maintain a system of financial monitoring to ensure the effective accounting of expenditure under contracts. This should provide a suitable audit trail for all payments made under the contracts whilst maintaining patient confidentiality.

15. RISK MANAGEMENT AND INSURANCE

POLICY – the Group will put arrangements in place for evaluation and

management of its risks

15.1. The Group’s assurance framework will support the evaluation and management

of risk) by: a) The Governing Body receiving the assurance framework b) The process used to populate / score the assurance framework

16. PAYROLL

POLICY – the Group will put arrangements in place for an effective payroll

service

16.1. The Chief Finance Officer will ensure that the payroll service selected:

a) is supported by appropriate (i.e. contracted) terms and conditions; b) has adequate internal controls and audit review processes;

c) has suitable arrangements for the collection of payroll deductions and

payment of these to appropriate bodies. 16.2. In addition the Chief Finance Officer shall set out comprehensive procedures for

the effective processing of payroll 17. NON-PAY EXPENDITURE

POLICY – the Group will seek to obtain the best value for money goods and

services received


17.1. The Governing Body will approve the level of non-pay expenditure on an annual basis and the Accountable Officer will determine the level of delegation to budget managers

17.2. The Accountable Officer shall set out procedures on the seeking of professional advice regarding the supply of goods and services.


a) advise the Governing Body on the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in the scheme of reservation and delegation;

b) be responsible for the prompt payment of all properly authorised accounts and claims;

c) be responsible for designing and maintaining a system of verification,

recording and payment of all amounts payable.

18. CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

POLICY – the Group will put arrangements in place to manage capital

investment, maintain an asset register recording fixed assets and put in place polices to secure the safe storage of the Group’s fixed assets

18.1. The Accountable Officer will

a) ensure that there is an adequate appraisal and approval process in place for

determining capital expenditure priorities and the effect of each proposal upon plans;

b) be responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost;

c) shall ensure that the capital investment is not undertaken without

confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges;

d) be responsible for the maintenance of registers of assets, taking account of

the advice of the chief finance officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

18.2. The Chief Finance Officer will prepare detailed procedures for the disposals of

assets.


19. RETENTION OF RECORDS

POLICY – the Group will put arrangements in place to retain all records in

accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance

19.1. The Accountable Officer shall:

a) be responsible for maintaining all records required to be retained in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance;

b) ensure that arrangements are in place for effective responses to Freedom of

Information requests;

c) publish and maintain a Freedom of Information Publication Scheme. 20. TRUST FUNDS AND TRUSTEES

POLICY – the Group will put arrangements in place to provide for the

appointment of trustees if the Group holds property on trust

20.1. The Chief Finance Officer shall ensure that each trust fund which the Group is

responsible for managing is managed appropriately with regard to its purpose and to its requirements.


APPENDIX F - NOLAN PRINCIPLES

1. The ‘Nolan Principles’ set out the ways in which holders of public office should

behave in discharging their duties. The seven principles are:

a) Selflessness – Holders of public office should act solely in terms of the

public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends.

b) Integrity – Holders of public office should not place themselves under any

financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

c) Objectivity – In carrying out public business, including making public

appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

d) Accountability – Holders of public office are accountable for their decisions

and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

e) Openness – Holders of public office should be as open as possible about all

the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

f) Honesty – Holders of public office have a duty to declare any private

interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

g) Leadership – Holders of public office should promote and support these

principles by leadership and example. Source: The First Report of the Committee on Standards in Public Life (1995)


APPENDIX G – NHS CONSTITUTION

The NHS Constitution sets out seven key principles that guide the NHS in all it does: 1. the NHS provides a comprehensive service, available to all - irrespective of

gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to Groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population

2. access to NHS services is based on clinical need, not an individual’s ability

to pay - NHS services are free of charge, except in limited circumstances

sanctioned by Parliament. 3. the NHS aspires to the highest standards of excellence and

professionalism - in the provision of high-quality care that is safe, effective and

focused on patient experience; in the planning and delivery of the clinical and other services it provides; in the people it employs and the education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion and conduct of research to improve the current and future health and care of the population.

4. NHS services must reflect the needs and preferences of patients, their

families and their carers - patients, with their families and carers, where

appropriate, will be involved in and consulted on all decisions about their care and treatment.

5. the NHS works across organisational boundaries and in partnership with

other organisations in the interest of patients, local communities and the wider population - the NHS is an integrated system of organisations and

services bound together by the principles and values now reflected in the Constitution. The NHS is committed to working jointly with local authorities and a wide range of other private, public and third sector organisations at national and local level to provide and deliver improvements in health and well-being

6. the NHS is committed to providing best value for taxpayers’ money and the

most cost-effective, fair and sustainable use of finite resources - public

funds for healthcare will be devoted solely to the benefit of the people that the NHS serves

7. the NHS is accountable to the public, communities and patients that it

serves - the NHS is a national service funded through national taxation, and it is

the Government which sets the framework for the NHS and which is accountable to Parliament for its operation. However, most decisions in the NHS, especially those about the treatment of individuals and the detailed organisation of services, are rightly taken by the local NHS and by patients with their clinicians. The system of responsibility and accountability for taking decisions in the NHS


should be transparent and clear to the public, patients and staff. The Government will ensure that there is always a clear and up-to-date statement of NHS accountability for this purpose

Source: The NHS Constitution: The NHS belongs to us all (March 2012)

To: Meeting of the Redbridge Governing Body From: Kash Pandya, Lay member – governance and Chair of Remuneration and Workforce

committee Date: 25 March 2014 Subject: Remuneration and workforce committee annual report Executive summary This report provides details of the role of the joint Barking & Dagenham, Havering and Redbridge Remuneration and Workforce Committee and the work it has undertaken during the year 1 April 2013 to 31st March 2014. The report incorporates a summary of the work of the Committee and identifies any issues which the Committee considers pertinent for the attention of the Governing body.

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


This report provides details of the role of the Joint Barking & Dagenham, Havering and Redbridge Remuneration and Workforce Committee and the work it has undertaken during the year 1 April 2013 to 31st March 2014. The report incorporates a summary of the work of the Committee and identifies any issues that the Committee considers pertinent for the attention of the Governing body.


The Joint Remuneration and Workforce Committee is a Committee of the Barking & Dagenham, Havering and Redbridge CCG Governing Bodies. The Committee’s main responsibilities are laid out in its Terms of Reference, in summary these are to:

• Determine the remuneration and conditions of service of the Governing Body Members and the senior team.

• Review the performance of the accountable officer and other senior team members and determining annual salary awards, if appropriate.

• Considering the severance payments of the accountable officer and other senior staff, seeking HM Treasury approval as appropriate in accordance with the guidance ‘managing public money’.

• Consider other workforce issues and receive reports on HR related issues – such as sickness and turnover.

• Consider and review succession planning arrangements for the CCG.

The Remuneration and Workforce Committee consisted of the following:

Members

Name Role

Kash Pandya Chair and lay member for governance, BHR CCGs Sahdia Warraich Lay member, patient and public involvement, Barking & Dagenham CCG Richard Coleman Lay member, patient and public involvement, Havering CCG Khalil Ali Lay member, patient and public involvement, Redbridge CCG Dr Waseem Mohi Chair, Barking & Dagenham CCG Dr Atul Aggarwal Chair, Havering CCG Dr Anil Mehta Chair, Redbridge CCG Tan Vandal Secondary care consultant, Barking & Dagenham and Havering CCGs Ah-Fee Chan Secondary care consultant, Redbridge CCG

In attendance

Name Role

Conor Burke (11 February 2014 only)

Chief Officer, BHR CCGs

Marie Price (April to August 2013)

Director of Corporate Services, BHR CCGs

Sue Assar (September 2013 - March 2014)

Interim Director of Corporate Services, BHR CCGs

Martin Hayes Deputy Head of HR, North and East London Commissioning Support Unit Anne-Marie Keliris Company Secretary, BHR CCGs

Meeting schedule

The Committee met on the dates below:

• 8 May 2013

• 15 July 2013

• 14 November 2013

• 11 February 2014

The Committee was quorate at each meeting for the individual CCGs.

The following list of key topics were discussed by the Committee in 2013/14.

• Terms of reference

• Agreement on Human Resource policies for staff transferring from PCTs and new staff.

• Contractual arrangements

• Remuneration - The committee considered and agreed the remuneration of the CCG Chairs, accountable officer, chief finance officer, lay members, secondary care consultants, clinical directors and directors.

• Performance management and appraisal arrangements

• Chief Finance Officer appointment

• Staff Survey

• Whistleblowing policy

• Workforce report that included reviewing turnover, sickness absence and were assured there were no issues of concern.

• Values and behaviours

The committee is planning to consider and discuss the following topics in 2014:

• Staff wellbeing and personal development plans, including talent management

• Organisational development plan

• Equality & diversity policy update

• Management structure of the 3 CCGs

• Appointment of additional clinical leads and other nominations to the CCGs

• Staff survey results

• Performance appraisal system update

• Policy on attendance of conferences

• Review the committee’s effectiveness and terms of reference.

3.0 Resources/investment 3.1 There are no additional resource implications/revenue or capitals costs arising from this report.


5.0 Risk 5.1 There are no risks arising from this report.

Kash Pandya Committee Chair

Author: Anne Marie Keliris Date: 6 March 2014

To: Meeting of the Redbridge Governing Body From: Sue Assar, Interim Director of Corporate Services Date: 25 March 2014 Subject: Values and Behaviours

1.0 Purpose of the Report 1.1 The report presents the final draft of a set of values and behaviours which articulate how the

CCG will operate and how individuals will reflect these values in their behaviour. Formal approval by the Governing Body is required so that there is explicit support for the values and behaviours as set out and commitment to abiding by them.

2.0 Background/Introduction 2.1 Many organisations, both in the public and private sector have clearly stated values and

behaviours, codes of conduct, sets of principles that describe how the organisation intends to conduct its business and how its staff will conduct themselves. At the away day for the three BHR governing bodies in December discussion took place about the production of a set of

Executive summary The purpose of this report is to seek the Governing Body’s approval of a set of values and behaviours for the CCG. Following discussions at the joint BHR Governing Bodies’ away day in December 2013 where a number of examples from other organisations’ were reviewed a draft document was prepared and widely disseminated to teams of staff across the three CCGs. Comments were sought and the feedback received has been positive and generally supportive of having a clearly stated set of values and behaviours in place which set the tone for how the CCG operates both as an organisation and as individuals working in that organisation. Once approved the values and behaviours will be used in a number of ways. They will form part of the induction of all newly appointed staff, they will feature in appraisal discussions, they will be used in documents such as the Annual Report and in the criteria used to assess papers for the Governing Body. They will also be publicised to members through a members committee meeting and brought to the attention of stakeholders, and as the foundation of our organisational development programme. The values and behaviours will be reviewed on an annual basis.

Recommendations The governing body is asked to approve the values and behaviours as set out in the attached document.

values and behaviours for each of the CCGs and there was a good level of support for this. Some group work was undertaken, looking at examples from other organisations and a number of themes emerged. Following the away day further work was undertaken to develop these themes using some of the examples reviewed at the meeting and a draft document was produced. The draft was widely circulated to staff teams and governing body members at the end of January and comments sought. Feedback has been positive and a number of constructive amendments received. The main issue raised has been in relation to how the document will be used/implemented.

3.0 Report Content 3.1 The finale draft of the CCGs values and behaviours is attached.

4.0 Resources/investment 4.1 There are no resource implications.

5.0 Equalities 5.1 The set of values and behaviours will positively support equalities.

6.0 Risk 6.1 There is reputational risk if the CCG does not have a clearly stated set of values and behaviours

that it reflects in its work corporately and the work of its staff.

Attachments: 1. Values and behaviours

Author: Sue Assar, Interim Director of Corporate Services Date: 14 March 2014

FINAL DRAFT

B H R VALUES AND BEHAVIOURS

Barking & Dagenham, Havering and Redbridge CCGs share common values as organisations which inform the behaviours of its Governing Bodies and its staff. These values are the building blocks of each of the organisations. They are

Honesty Responsibility Caring Respect Professionalism

Responsive Courageous Collaborative Integrity

These values are embedded in the NHS Constitution and in the organisations’ commitment to promote equality and human rights

These values are reflected in the behaviours and actions of our Governing Bodies and our staff as follows:

Honesty We will demonstrate our honesty as an organisation by

- Working honestly and openly with the public, our patients and all other stakeholders about the reasons and processes underpinning decisions and actions to build a mutual level of trust and understanding

As an individual by -acting with honesty in all my actions, transactions, communications and decision making and will resolve any conflicts of interest that could influence my decision making

Responsibility We will demonstrate our responsibility as an organisation by

- By being fully accountable for the decisions we make and responsible for implementing them ,taking account of the resources available to us as commissioners

As an individual by - taking personal responsibility for all my work and

supporting the decisions of the CCG,leading by example

Caring We will demonstrate our care and empathy as an organisation by

- Listening to the people and communities we serve to take account of their views in the decisions we make

-

As an individual by - Putting myself in our patients, public, stakeholders and

colleagues shoes in order to understand their point of view

Professional We will demonstrate our professionalism as an organisation by - Ensuring that we work within the legal, regulatory and

accountability frameworks, follow best governance practice and that our staff adhere to the professional or other codes by which they are bound and are supported in their professional development

-

As an individual by - Taking responsibility for ensuring I have the relevant skills

and knowledge, identifying gaps and participating in appraisal and training and development

Responsive We will demonstrate our responsiveness as an organisation by -proactively adapting and responding to challenges, both large and small, national and local external and internal to find a resolution, take action and learn

-

As an individual by - Responding positively to new and different ideas when

they are presented demonstrating a “can do” attitude and a commitment to improve and learn

Courageous We will demonstrate our courage as an organisation by

- Challenging decisions and activities when they are not aligned to our aims and priorities as commissioners of healthcare

-

As an individual by - Challenging the organisation to be the best it can be

Collaborative We will demonstrate our collaborative approach as an organisation by

- Working collaboratively with our public, patients and stakeholders, involving them in the decision making process, particularly when the decision impacts on them

-

As individual by - By working constructively with colleagues from all sectors

to make a real difference to services for local people

Respect We will demonstrate our respect as an organisation by -Respecting patients, equality and diversity, rights to consent, privacy and confidentiality, and access to information as enshrined in data protection and freedom of information law and guidance

As an individual by Treating patients, carers, members of the public, colleagues and staff with dignity and respect at all times

Integrity We will demonstrate our integrity as an organisation by

- Acting consistently and fairly, applying the CCG’s values in all its actions and decisions

As an individual by - Working as part of a team, treating others fairly and with

respect, raising concerns if I see harmful behaviour or misconduct by others

These values and behaviours will be reviewed and updated annually with full involvement from all.

March 2014

To: Meeting of Redbridge Clinical Commissioning Group Governing Body

From: Martin Sheldon, Chief Financial Officer

Date: 27 March 2014

Subject: 2014/15 Contract with North and East London Commissioning Support Unit

Executive Summary

Discussions and negotiations between the CCGs and CSU leads has continued across February and March and we now have a position which offers improved cost along with greater clarity regarding the services and standards we can expect from North and East London Commissioning Support Unit (NELCSU).

Key points to highlight are:

• We have reviewed costs and service specifications (attached) to ensure that on a like for like basis the CSU proposal offers at least the same support to CCGs while improving cost effectiveness. By negotiating collectively, the BHR CCGs have achieved a better outcome.

• As agreed at the January Governing Body meetings, the CCGs will be taking patient facing CHC services in-house, bringing together the components currently provided by NELFT, the CSU and the CCGs in order to improve controls, quality and cost effectiveness. The cost of this service will be removed from the contract with a residual amount to reflect the invoicing and contract management functions that will remain with the CSU.

• We have developed an addendum to the SLA (attached) which articulates the local operating model and in particular the teams and functions that sit locally at Beckett’s House

The cost of the CSU service offer for 2014/15 is £3489k. This compares with the 2013/14 cost of £3882k representing a reduction of £393k on a like for like basis. The proposed contract is for 2014/15 only. Commissioning intentions for future years will be will be influenced by CSU service delivery as well as the emerging national policy for commissioning support services.

Recommendations

The Governing Body are asked to:

• Agree the continuation of the CSU core and additional services in 2014/15, amended to remove the patient facing CHC services and costs.

• Agree that the CFO should continue to work with CCG and CSU colleagues to finalise service specifications and to develop a set of local KPIs across key aspects of the CSU services.

• Delegate to the CFO the authority to finalise negotiations and agree the 2014/15 contract with NELCSU.

1.0 Purpose of the Report 1.1 The purpose of the report is to provide an update on the position regarding the negotiations with NELCSU

and to recommend a 2014/15 contract for commissioning support services.

2.0 CSU Proposal / Service Offer

2.1 The 2014/15 service offering from the CSU represents a step forward from last year, where the vast majority of services were in an ‘end to end’ core service bundle. The service model now has a much smaller core service bundle comprising the key commission support elements of (contracting, finance, analytics etc.) along with a range of optional additional services. These service lines are separately priced. This is more in line with our local requirements as it facilitates consideration of alternative models for aspects of the service. Specifically, CHC Commissioning Support is now a separate additional service that can be easily removed from the contract as agreed at the January Governing Body meeting.

2.2 The final element of the CSU service offer comprises bespoke or consultancy services, encompassing the Transformational Change, Delivery Improvement and Finance Project Teams. Last year’s core offer included some contribution from these teams – the 2014/15 proposal gives greater flexibility regarding the capacity that CCGs wish to have access to and offers a price reduction for agreeing this in advance rather than in-year. This aspect of the contract is being negotiated and will be finalised shortly.

2.3 Our approach is to agree a contract for 2014/15 – intentions for future years will be developed throughout the year and will be influenced by CSU service delivery as well as the emerging national policy for commissioning support services.

3.0 Service Line Detail

3.1 The 2014/15 service specifications are attached. These specifications were rewritten following feedback from CCGs and are now more detailed and give greater clarity on the scope of the services, the CCG and CSU roles and responsibilities and the service standards.

3.2 The discussions between CCG and CSU service leads to review the detail of the service specifications, agree local amendments and KPIs has progressed but has not yet concluded. However it is sufficiently far advanced for us to agree the main terms of the 2014/15 contract with the CSU. A number of changes to specifications have been proposed (including performance, quality and HR) and others may follow as the discussions conclude. The development of local KPIs is less well advanced and will need to continue over the next few weeks.

4.0 Costing

4.1 The CSU offer provides service line prices rather than the single core bundle price provided last year. This is a positive step as it allows us to assess the value of each service line and supports changes to aspects of the existing contract such as CHC where we can see the impact on the CSU contract of bringing the service largely in-house.

4.2 The methodology has moved away from a capitation based model to one based on usage. This has benefitted CCGs with larger populations as usage of CSU services has not proven to be significantly influenced by CCG population size. Consequently, CCGs with a larger population have seen more substantial price reductions. The CSU has adopted a principle of protecting foundation CCG customers from any cost increases resulting from these changes.

4.3 The negotiated price for 2014/15 and the comparison with the current year’s contract is as follows (items marked with a * reflect the current proposal – these aspects of the contract need further discussion and agreement):

2013/14 Contract Value Redbridge CCG £000

Total Core services Additional services – 111 Additional Services – surge management

3,851 11 20

Total - 2013/14 3,882 2014/15 Proposal Core Services: Reporting and BI Contracts & Quality Management Corporate Finance Support for Commissioning, Planning & Redesign

779 1,368 27 442 221

Total Core Services 2,838 Additional Services Communications CHC Commissioning Support* HR IFR Process Management Surge Management & Seasonal Planning

135 291 42 101 22

Total Additional Services 591 Bespoke Services Finance Project Team * Delivery Improvement & Transformational Change Team *

18 65

Total Bespoke Services * 83 2014/15 discount -22 Total - 2014/15 3,489

5.0 CHC Transfer

5.1 CCGs agreed at their January Governing Body meetings to bring together the patient-facing CHC services currently provided by NELFT, the CSU and the CCGs into a unified in-house service. This will improve controls, quality and cost effectiveness and will go a long way to mitigating the risks associated with this service.

5.2 The 2014/15 CSU price for the CHC service is £291k – in time this will be removed from the CSU contract, with a proposed residual amount of £75k retained to reflect the transactional functions (invoicing, contract management etc.) that will remain with the CSU. The details of the contract changes related to the CHC transfer need to be finalised

6.0 Timeline / Next Steps

6.1 Work will continue to review any outstanding service specifications and identify and amendments required to fit with the local operating model and priorities. This will be concluded by the end of April, but as the service specifications are significantly improved over last year, this is expected to represent relatively minor changes to the specifications that went to the January Governing Body meeting.

6.2 As noted above, further work is needed on three areas - final agreement on the details of the CHC transfer, further discussions around bespoke services and the development and agreement of specific local KPIs. While this work is ongoing, it is sufficiently advanced for us to agree the main terms of the CSU contract. The conclusions will be included in a future quarterly update to the Governing Body.

7.0 Resources / Investment

7.1 There will be a cost of £3489k in 2014/15 for the agreed level of CSU support (prior to the reduction relating to CHC).

8.0 Equalities

8.1 There are no equalities implications arising from this report.

9.0 Risk

9.1 The main risks relate to delivery of the required services and the achievement of the identified standards. While there have been a number of issues with CSU delivery in the current year, these have largely been resolved and the CSU performance and working relationships have improved over the course of the year. The exception is CHC which has led to the changes already agreed and outlined above.

9.2 Bringing CHC in-house presents a transitional risk to CCGs. This risk will be managed through an already established project management approach with appropriate controls and assurances. Reporting will be through the Joint Management Team, with separate reports to the Joint Executive Team and Governing Bodies as appropriate.

2015/15 SLA Between NELCSU and the BHR CCGs

Operating Model

1. Overview

NELCSU will provide commissioning support services to Barking & Dagenham, Havering and Redbridge CCGs through a combination of dedicated local staff - the Point of Delivery (POD) team - based in Beckett’s House and co-located with the BHR CCGs’ joint management team and central CSU teams based at Clifton House. This will provide a structure that prioritises local responsiveness and relationships while delivering the benefits of scale and expertise that the CSU is set up to deliver.

2. BHR POD Team

The localised service will focus on the BHR POD team which comprises a multidisciplinary team of CSU staff dedicated to and aligned with the BHR CCGs and single points of contact for certain key critical services. Some commissioning support services will be provided by staff in the other two POD teams (WELC and NCL) where this reflects the established lead commissioning arrangements. All remaining staff will be located primarily at the CSU headquarters, working closely with POD teams and CCGs.

The BHR POD team will comprise the following staff groups:

A) Commissioning Support Team

The Commissioning Support Director (CSD) and team provide the main point of contact for Barking and Dagenham, Havering and Redbridge CCGs and the BHR Joint Management Team. The CSD will play a pivotal role in the contractual relationship between both Parties, and will be a first point of escalation for any performance issues and other concerns. The CSD team will provide the BHR CCGs with a range of advice, expertise and support including co-ordinating planning processes and reporting on QIPP delivery. In addition, the Senior Commissioning Support Managers who are aligned with individual CCGs, will provide an element of flexible capacity to support CCG priorities. A bespoke work plan will be negotiated with Chief Operating Officers at the start of the year.

B) Contracting, Quality and Performance Team

The Contracting Director and team are responsible for providing procurement, market management, quality and provider management services, supporting the three BHR CCG Chief Operating Officers in their role as lead commissioners. Contracting, quality and

performance teams work as multidisciplinary teams deployed to key contracts, working closely with POD based finance and analytics colleagues and drawing on central CSU expertise as necessary to support the CCGs’ collaborative commissioning arrangements.

C) Analytics Team

The Associate Director of Business Intelligence leads a team of CCG analysts who support CCGs in interpreting data, undertaking specific analyses and developing commissioning strategies and plans. A major focus is the provision of specialist Business Intelligence support to the annual commissioning cycle. In addition, the team provide informatics input into procurement and claims processes, on-going provider management and activity and financial reporting tailored to local contracts and CCG needs. The POD based team also draw on central informatics expertise as necessary.

D) Finance Team

The Finance Director and team are dedicated to supporting CCG planning & control functions. Their remit encompasses all aspects of management accounting and financial accounting, including accounts payable/receivable, cash management, financial governance and budget setting. In addition, the team provide financial support to contracting and performance teams in contract negotiation and provider performance management.

3. Single Point of Contact for Specific Services

For the following services there will be a single point of contact for Barking and Dagenham CCG, to ensure that at all times they can easily contact someone that understands their local content, while maintaining the economies of skill and scale of having a central team:

A) Human Resources

The HR Business Partner is responsible for co-ordinating the HR support received by the BHR CCGs and supports / advises on complex issues. This includes providing specialist advice to CCG remuneration committees, advising on employee relations, providing learning and development advice and co-ordinating CSU support to routine processes such as recruitment, payroll and workforce information.

B) Communications

The Communications lead works with the BHR CCGs to develop CCG-specific communications strategies, and supports / advises on complex issues. In addition, the POD lead co-ordinates overall communications support to the CCGs, including briefings and public affairs management, media / reputation management and PR, marketing and digital communications.

NHS Redbridge CCG Executive Committee 4 December 2013 Page 1 o

Redbridge Executive Committee 24 February 2014

1:00 – 3:00 Board Room A Becketts House

Present: Dr Anil Mehta (AM) Chair NHS Redbridge CCG Louise Mitchell (LM) Martin Sheldon (MS) Dr Muhammad Tahir (MT) Dr Sarah Heyes (SH) Dr Chidi Okorie (CO) Dr Jyoti Sood (JS) Dr Shabana Ali (SA)

Chief Operating Officer Chief Financial Officer BHR CCGs Clinical Director Cranbrook & Loxford Locality Clinical Director Wanstead & Woodford Locality Clinical Director Cranbrook & Loxford Locality Clinical Director Seven Kings Locality Clinical Director Wanstead & Woodford Locality

In Attendance: Dave Game (DG) Head of Primary Care IT Services Tracey Murphy (TM)

Executive Assistant (Minutes)

Apologies: Conor Burke, Dr Springer, Jacqui Himbury, Dr Azeem

Item Action 1.0

Welcome and introductions The chair welcomed the members to the committee.

1.1 Declaration of conflicts of interest There were no conflicts of interest declared.

1.2 Notes of meeting 15 October 2013 Amendments to Items 2.1 and 2.2 (comments by SH amended). Otherwise Notes were agreed as an accurate account.

TM

1.3 Matters/actions arising No matters arising

2.0 Risk Assurance 2.1

Update on the risk register - Redbridge LM reported there are seven RED rated risks across BHR, four of which relate to Redbridge only. Since December 4 new risks have been added, two RED and two AMBER:

• Unpaid invoices. MS updated that the delay in payment of invoices has improved although there are still delays and has resulted in £1/4m of fines.

• BH Contract has not been signed. MS reported that this is because Q1 has not been agreed as BH has not yet been able to answer queries on the discrepancies. A clause has been written into next year’s contract to avoid the risk of the contract not being signed off.

Other Redbridge Risks include:

• NHS E Balance Scorecard


• Overarching QIPP Risks – but overall delivering well • Lack of ownership of risks • Anti-coagulation

AM asked to be updated on possible risk relating to PELC. LM reported that there are organisational risks that have been brought to the attention of commissioners who are in turn seeking additional assurance on service delivery and closely monitoring ongoing delivery and quality of provision. No heightened clinical risk has been raised and the work of the investigation group continues at this point in time.

LM/AM

3.0 Strategy and Planning 3.1

3.2

3.3

CSP Update LM updated that the first Draft 2 year operating plan had been submitted on 14th February 2014 with a final submission due on 4 April. BCF was submitted on 14 February 2014 following partnership development via the Better Care Fund working group with LBR and CCG officer and finance colleagues. MS reported that the 5 year finance plan shows that in year 3 QIPP will be £5/6m. JS highlighted that information should be available to the public and be user friendly using plain English. LM agreed that there is a need to get better at what we do and to use clear language and further work is being undertaken to determine what good engagement looks like via the CCG wide Engagement forum. AM stated that he would like to see further progress reports at Executive Committee. CSP Operating Framework/QIPP Report – Overview 14/15 plans LM provided a Candlestick report that shows a £5m gap and reported that plans need to be formally agreed and signed off once they are worked up for the 14/15 QIPP. AM & LM agreed that individual areas of QIPP need dedicated time at the QIPP/Innovation meetings and then taken to Members Committee for information. TM raised that it would be helpful to know who is responsible for each of the areas. Better Care Fund LM reported that the first DRAFT submission has now been signed off at the Health & Wellbeing Board MS confirmed that this is an additional cost to CCG as the contribution by CCGs will be greater in 15/16. LM informed that relations with LA are constructive and confirmed that performance and activity metrics will be determined at i future meetings as the BCF work progresses prior to final submission .


MS confirmed that the fund will be managed jointly with the LA. SA requested a list of services that are available under the BCF. AM agreed that a directory would be useful for GPs to be made aware of where patients can be referred to.

4.0 Service Transformation and Development 4.1

4.2

4.3

4.4

Update on Procurement Anticoagulation SA updated that Redbridge has commenced an engagement process, explaining the Model of Service, with GPs and service users which is expected to be completed by 10 March. Evaluation from the engagement will influence the final specification. Discussions are taking place at senior level with BHR CCGs to review if the service can be procured jointly as Havering CCG no longer wish to be part of the procurement and the resource of the project manager is no longer available. Despite the setback in the timeline, Redbridge plan to commence with the procurement process with a view to go live in September. The risk of delay to procurement has an impact on patient care and governance risks that will become greater to Redbridge in particular. Members agreed that the procurement process should continue using the model of: Initiation in Secondary Care, once stable patients can be seen in the community receiving services from both Trusts and with a provision for housebound patients. Richmond Fellowship 14/15 – Approval LM reported that the contract expires at the end of March. The contract is jointly funded but managed on our behalf by LBR and is due to expire 31 March 2014. The contract value is £103,000 (Redbridge CCG pay £71,600 and LBR pay £31,400)

LM requested the Committees permission to extend for six months to give time conduct a full service review and determine future commissioning requirement options. This was agreed by the committee. Community Development Worker – Mental Health Services – Approval LM reported this is a service that is jointly funded between Redbridge CCG and LBR. There is an implied contract as the previous contract has ended and this paper proposes the agreement of a further 12 months whilst outcomes are agreed and decision made with regard to future service requirements. The annual contract value is £60k. This was agreed by the Committee. Community Glaucoma & Osteopathy Contracts- Approval


LM reported that Redbridge CCG is currently developing new pathways for Musculoskeletal (MSK) and Ophthalmology services for procurement and implementation during 2014/15 as part of our current future QIPP planning. This paper requests approval for a six month contract extension for osteopathy providers and the Community Glaucoma service to cover the period until the new services are in place and prevent additional activity flowing to the hospitals at a rate that is in excess of our current community services and therefore having a detrimental effect on our QIPP. The budget for the service is £78k per annum. The contract spend and activity will be within budget for 2013/14 as the spend at month 10 is £62k. Without the contract extension there is a risk of an additional cost of up to £13.6k in six months as a result of patients going to secondary care. AM raised a concern that there is a conflict of interest as Stephen Bryan works in both services. MS agreed and stated that if the contract is to be extended that the conflict of interest should be made clear and no further extensions should be made as the contract has previously been extended. The Committee agreed.

5.0 Quality & Performance 5.1

Finance and Contracting Report Month MS reported As at the end of January (Month 10) the CCG did not achieve the planned year to date surplus but delivered a £12k surplus, The forecast for the year end is that the CCG will not achieve its overall surplus of £2.9m, but will deliver a break-even position as agreed at month 6. The main drivers to the position are overspends within Acute contracts and continuing care. There is significant year to date pressure within acute contracts with year to date over performance of £4.4m. Most of the variance relates to the three highest value contracts. These are Barts Health contract (£2.6m), BHRUT (£1.1m) and Homerton (£0.7m). A number of claims and challenges have been raised against acute contracts. The Lead Commissioner has reached agreement with Barts Health Trust on the 2013/14 contract however BHR CCGs have not agreed the contract until the Q1 position has been finalised and agreed. Special measures have been imposed on BHRUT. This means the trust is in financial turn around and are being scrutinised by the National Trust Development Authority (NTDA). This may impact on contractual arrangements for this year and next year. The CCG is working with the Trust to agree a year end position. The CCG has written formally to the Trust to outline the CCG position with the offer of £301m including £3.1m winter pressures and are waiting for a formal response from the Trust The CCG has requested that the Commissioning for Quality and Innovation (CQUIN) payment is withheld for contracts that have not been signed. The QIPP projects at month 10 are £1.11m below plan.


5.2

Some of the CCG reserves (For example the 0.5% contingency) have been utilised within the year to date position to partially offset some of the acute overspends. However a number of risks remain; Key financial risks;

• BHRUT Health Contract – The month 9 (December) SLAM wasn’t received in time for reporting. The last available information was the month 8 dataset which included an accrual for just over £2m. Therefore, the last complete dataset relates to activity in October. This means an in depth analysis of data and spend cannot be carried out.

• Barts Health Contract – Significant levels of over performance has been built into the reported position.

• Adjustments to the Financial Position – There are a range of financial adjustment made to the reported financial position for the two largest contracts.

• Associate Contracts – A number of smaller associate contracts have been signed off this month however there still remains a few unsigned.

• NCA’s Invoices – There are a large number of NCA invoices that remain un-validated and unpaid. Until the invoice backlog is cleared there is a risk that the reported position contains an element of specialist costs.

• The potential for other volume related costs, acute activity Continuing Health Care/individual placements packages. Mitigations include robust contract management, winter planning project implementation and CHC review process underway and action higher than anticipated plans in place.

MS summarised that strong processes need to be in place for next year re Never Events. Quality & Safety Report LM in JH absence provided a report detailing a summary of the performance of Barts Health NHS Trust with a focus on Whipps Cross Hospital (WXH) across the quality indicators. All quality performance indicators are regularly reviewed at the Clinical Quality Review Meeting (CQRM) which is held monthly. LM reported that JH would like to provide assurance to members that the monthly reporting from the CSU is robust and covers all the expected quality indicators. Main point: The number of Never Events – Concerns that these are being addressed through the contract.


6.0 Development and Governance 6.1

6.2

Formal Call for General Meeting of Members LM reported that at the Members General Meeting which took place on the 12 February 2014 those present were informed that a further General Meeting would take place on the 19 March 2014. However, there has been no formal resolution either by the Governing Body or the requisite number of practice representatives to call the meeting. In the circumstances the General Meeting of the Members Committee needs to be formally called for the 19 March. Various amendments are proposed to the Constitution. All amendments require the agreement of the Members Committee of the CCG and thereafter the agreement of NHS England to consider and if appropriate give their agreement to the proposed amendments. The Committee agreed to the holding of a committee on 19th March CMC Pilot LM updated on the CMC Pilot in Redbridge and provided a report outlining the current position. Current BHR position London borough of Redbridge has agreed to take part in a CMC pilot. CMC Awareness Training for Social workers has taken place and feedback on the design of the Social Services tab in CMC has begun. As part of the 111 implementation process in 2012, CMC training was provided to front-line staff in BHR however use of CMC has not progressed in the area. Health Analytics is used by the Integrated Case Management (ICM) services within Barking and Dagenham, Havering and Redbridge as a care planning tool to support patients with multi co morbidities and complex needs. In the event an ICM patient attends BHRUT A&E, the ICM care plan can be viewed in order that clinical decision making is supported by a comprehensive view of the patient’s holistic ICM care plan. Health Analytics (HA) is also used for management of the continuing health care (CHC) fast track process and Children’s CHC, with Adult CHC due to start using HA early in 2014. CMC pilot in Redbridge It is planned to undertake a pilot with a group of GPs in Redbridge and the key end of life services which support these practices. This pilot will attempt to include as a feature plans by the London Borough of Redbridge to pilot the social care tab of CMC and the interest expressed in CMC by Springfield care home. The Redbridge CMC pilot will operate alongside the current use of Health Analytics by the ICM service, and process mapping will be undertaken to ensure the process to transition from LTC to EOL services is clear and tested. Going forward and to evaluate the pilot, more practices need to be identified to join the pilot.


The following practices agreed to take part in the pilot: Fullwell Cross Medical Centre – Dr Mehta Ilford Lane Surgery - Dr Okorie Southdene Surgery – Dr Ali The Shrubberies – Dr Heyes

7

7.2

Items for information Deferred.

8 AoB Video Conference Borough Pilot

Dave Game requested the Committee permission to pilot software to support video conference functionality into Redbridge practices. This is already being tested in two Redbridge practices. I.T. is working with Brother UK to see if a deal can be agreed for them to support the work. There is no cost for the equipment and currently negotiating for the first year subscription to be free, with a likely cost thereafter. Training and technical support will be provided to practices that participate in the pilot. The Committee agreed.

9. Date of next meeting 29 April 2014 – 1pm -3:00pm

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

Key Messages from the 11 February 2014 BHR Audit & Governance Committee meeting

Data quality: Arrangements for validating financial and non-financial data quality are strong and the Audit Committee were assured that the information used to make our decisions is reliable. However, as data from some of our providers, in particular the Barts Health London is poor, significant staffing resources are needing to be deployed to validate data. This is unlikely to be sustainable in the longer term and efforts to raise the standard of data provided need to be continued and monitored by the GBs

Risk management: Board Assurance Framework (BAF) and risk management arrangements, though effective, can be strengthened by adding longer time horizons for mitigating risks (at present, BAFs consider risk management action only to the financial year end, while in reality some risks will take several years to mitigate) and adding in accountabilities for specific risks to a CD and the responsible committee. The NHSE's requirement to move to 2 year operational and 5 year strategic planning give us the opportunity to do so. The Audit Committee recommends this development, together with more clarity about risk appetite.

Information governance: The Audit Committee commended officers for the efforts put in to achieve the safe haven status. The Committee asked officers to continue to seek satisfactory information governance assurances from our providers, in particular NELFT and PELC. The Committee also wanted officers to monitor and report back on the completion of the information governance e-learning package by GB members, more regular reporting of information governance incidents against the BHR CCGs (e.g data losses, hacking, etc) to the Committee and an assessment of the arrangements in place for minimising our vulnerability to cyber-fraud.

External audit and the accounts and annual reports for 2013/14: The date for submission of the audited accounts and the annual reports to the NHSE has been brought forwards. A timetable for achieving this new requirement was agreed, including special GB meetings to adopt the accounts. The Committee is satisfied that the new timetable is achievable though it will place additional pressures on staff, auditors and GB members.

Internal audit: Audit work is currently on target and is expected to be complete by 31st March 2014. Internal audit have rated the arrangements for continuing healthcare as RED. This will be recorded as a reservation on the Head of Internal Audit Opinion for 2013/14. GB members will recall that this has been an area of concern and the remedial action already taken to address it. The Committee is also seeking more details from the NHSE about the proposed new arrangements for assessing the effectiveness of the CSUs financial control systems. It is understood that in future, these assurances will be provided by the CSU's internal auditors at the year end, rather than through the year as was the case in 2013/14 through our own internal auditors

Item

Audit Committee effectiveness: The Committee agreed how it might assess its effectiveness and to consider areas for improvement at the next meeting in April. The Committee recommends that a similar exercise is undertaken for the GBs and all committees.

April meeting agenda: The Committee intends to review the year end draft accounts, annual reports and other supporting documents at its next meeting and the arrangements for handling complaints by the BHR CCGs.

Kash Pandya

Audit Chair

1 Draft BHR Audit Minutes 11 Feb 2014 v2

Draft Minutes of the joint Barking & Dagenham, Havering and Redbridge CCG’s

Audit & Governance Committee held on 11 February 2014 at Becketts House

Present -Members Kash Pandya (KP) BHR Audit Chair, Lay Member for Audit & Governance Khalil Ali (KA) Lay Member PPI Redbridge CCG Charles Beaumont (CB) BHR Co-opted Member for Audit & Governance Ah Fee Chan (AFC) Secondary Care Consultant Tan Vandal (TV) Secondary Care Consultant Sahdia Warraich (SW) Lay Member PPI Barking & Dagenham In attendance-Officers Rob Meaker (RM) part BHR Director of Innovation Martin Sheldon (MS) BHR Chief Financial Officer Angela Ward (AW) BHR Company Secretary Oge Chesa (OC) part BHR Deputy Chief Pharmacist In attendance-auditors John Always (JA) LCFS Bakertilly Nick Atkinson (NA) Internal Auditor, BakerTilly Colin Edwards (CE) LCFS BakerTilly Kevin Lowe (KL) External Auditor, PWC

Action

9.00-9.15am

Committee Members held a private pre-meeting.

9.15-10.00

A workshop, with all attenders, was held to discuss data quality checks and processes in place to validate financial and non-financial data. Notes are attached separately.

01/14 Apologies for absence 10.00 The Chair welcomed Members and other attendees and noted apologies for

absence from Richard Coleman.

02/14 Declaration of Interests Changes to the Declaration of Interest Register were reported by Sahdia

Warraich and Kash Pandya and the Register would be updated for the next meeting. No further interests in relation to the meeting were noted.

AW

03/13 Minutes of meeting held on 12 November 2013 The minutes of the previous meeting were agreed as a correct record to be

signed by the Chair.

04/14 Matters Arising The actions that were being addressed on today’s agenda were noted

9/13 External Audit Plans- MS had raised the late timing of McKesson and SBS assurance documentation with the NHSE CFO and this was being considered. It was noted assurance would be sought via external audit.

05/14 Risks Update MS presented Sue Assar’s report and gave assurance of the diligent approach

taken and good progress made with improvements in year. PD held regular


meetings with Directors and the GBs were kept informed. There was a solid base position but greater data capture was required such as from CQRMs. NA added that he had liaised with SA and PD and work was moving on well. TV, in noting officer leads, questioned clinical ownership of risk and greater engagement. He acknowledged CD portfolios that could be affiliated and MS responded that the officers were full time with an active management role and there were challenging demands on the CDs but we would try to achieve the best balance going forward. It was agreed opportunities for further clinical engagement would be explored in 2014/15. KA raised the patient experience when considering CHC work and questioned if this was a risk in itself and proposed any risk mitigation would need to be budgeted for. He also proposed that account should be taken of public health work on demographic change. NA added that it was vital the CCG had good baseline data first and MS added that there was a need to study trends and plan for preventative measures. Members were informed of arrangements afoot to bring CHC totally in-house from the CSU and NELFT. KP added that BAF was re-assuring and good progress with internal audit review had been made. It was important to see the BAF as a rolling risk record with realistic timeframes of what could be achieved. KP added that BAF/Risk Registers were seen by several committees and that accountability should be recorded. A 2-5 year view to match strategic plans and financial plans was recommended for longer term ambitions and supported. The contents of the progress report were noted.

PD

06/14 Information Governance reports The Committee received an anonymised breakdown of the completion of basic

IG training by staff and noted 100% compliance by employed staff. More difficult was the capture of the CD’s reporting and RM was addressing this and paper copies of the CD’s certificates may be requested. The Lay Members had experienced similar problems with linking into the system and similarly RM would assist. A detailed internal audit review of toolkit compliance had taken place and NA presented the final report. It was noted that RM’s team were taking a diligent approach and responding to substantiate their assessment with further documentation before year end. RM tabled the Information Governance Management Framework that was the overarching framework for the CCGs to effectively manage IG. The document outlined key management roles and nominated personnel. Members were invited to forward any further comments to the Audit Chair by the end of February who would forward them to RM. Following this, it was agreed that Chairs Action would be taken to sign the document on behalf of the Audit and Governance Committee. The Chair raised risks around cyber-fraud e.g. hacking, tele-working, mobile computing, loss of memory sticks or laptops, NHS staff use of social media sites and questioned general risk mitigation. RM tabled a report on 10 incidents and advised that staff we asked to report any risk even if uncertain as it was important to collate near misses. The risks were mainly low level bar one around missing information and this was being investigated further with the CSU. MS added that there was also risk if equipment held a memory e.g. a scanner. TV also questioned risk when transferring data to home computers,

All to KP CE/RM


noting Boardpad was secure. CE would discuss some tips available with RM. The IG reports were noted and an update on arrangements to mitigate cyber-fraud requested.

RM/MS

07/14 LCFS progress against plan CE had been appointed as assistant LCFS manager to Mark Trevallion and

was committed to improving visibility with John Always. He was pleased to share Committee discussion on CHC issues and Cyber-fraud risk. The arrangements for CSU counter fraud were noted and the role of NHSE and NHS Protect and a meeting was imminent to discuss work that NHS Protect were undertaking. MS added that a view would need to be taken on whether CSU fraud could impact on CCGs and whether assurances on CSU were adequate or a more localised approach to gain assurance sought. The Committee supported the CFO in securing transparent and co-operative arrangements. JA added that until it was clear of what was being reported and when, LCFS were capturing some referrals and co-ordinating as a safeguarding measure. The local reactive work was noted with nothing to report back and the proactive work, by comparison, may benefit from more awareness sessions. TV raised primary care risk, noting they were also major providers. MS confirmed that it was part of the standard contract for the hospital trusts to have LCFS and where we had contracts with primary care providers this was a requirement too. The Chair would meet separately with CE and JA. The LCFs progress report was noted.

KP/CE/JA

08/14 Business Continuity Planning (BCP) update Members received an updated BCP and noted that a test exercise was being

planned for April. MS advised that NELFT had provided some assurance on their plans. Whilst PELC had offered some assurance the risk of staff sickness on key areas of provision felt a little fragile. It was confirmed that this was being addressed within Urgent Care Review procurement.

The updated Plan was noted and an update on NELFT and PELC business continuity plans sought.

SA/MS

09/14 External Audit progress report

KL’s report addressed three elements, firstly the planning phase of the audit programme that was progressing well with the CCG and CSU. Secondly, the report referred to deadline for final submission of Annual Accounts (updated to 6 June) and the arrangement of Audit Committee meetings and sign-off. The third element was external audit fees that had reduced from the previous PCT fees and were likely to reduce further.

It was agreed the Committee would receive draft Annual Accounts and Annual Reports around 22 April and the final drafts around 27 May. MS stressed that the Governing Bodies would need to meet to receive the Committee’s recommendation for sign off after that date and to allow some time for final


amendment before the 6 June submission date. The Boroughs would be asked to agree to three short GB meetings late May/early June.

The treatment of provisions was discussed and alternatives such as holding elsewhere until payment hit our accounts. KL explained the statutory accounts and a memo account of provision e.g. £9m. held for CHC claims. It was agreed that this was a difficult environment to work with and the legality and principals needed to be addressed nationally. In last year’s accounts a lot of text was used to explain the treatment of CHC funds. CB noted the national/corporate body approach to handling noting a wide difference from provision to actuals. KA supported a public demonstration of how funds were utilised and VFM achieved. KL added that he Accounts were subject to Audit Commission guidance but the Annual Report could be more descriptive. MS added that the CCGs may be asked to take IT assets onto asset register and a validation of fixed assets was required.

The External audit progress report was noted.

AW

10/14 Internal Audit progress reports

NA presented the final report following the CSU audit on Continuing Health Care. The report concluded with a red rated risk and outlined reasons for lack of assurance to the CCGs and this would feature in the internal auditor’s end of year HOIAO report. (Head of Internal Audit Opinion). The position would however be reviewed again before year end.

Further final reports had been issued on IG Toolkit and BAF. For Clinical Governance and Quality there were no significant issues identified. A further report on QIPP was in draft form and awaited management response. Further reports would be provided in the coming weeks. The CSU’s follow up on previous recommendations had gone well.

Arrangements for audit 2013/14 and next year were discussed and the NHSE preferred direction was similar to auditing of SBS. However the local view was of a second audit focused on agreed key areas due to the lack of universal systems and controls. It was noted that the CSU were committed to responding to customer wishes and supported additional scrutiny. Committee members and the external auditor supported this management approach in preference to the more centralised NHSE approach. The Chair added that this had been raised at the Audit Chairs meeting and would be taken up with the NHSE CFO. NA was asked to assist with summarising pros and cons of audits for meeting with the NHSE CFO.

The final report on Financial and Payroll Feeder Systems was provided and this had led to an amber/green rating that offered reasonable assurance. A number of medium to low recommendations had been made.

The Chair noted the in-progress and final reports and the management action required. He raised new clinical standards that the acute trusts would have to provide action plans to respond to and questioned any financial implications of

NA/KP


new seven day working. MS added that the 7 day working was embedded in the national tariff and not an extra although there was likely more impact on mental health trusts. Impact on primary care was raised and the current piloting of weekend working to respond to pressures. In support of the extended GP service, access to other community services 7 days per week was under consideration.

NA was pleased to report a green rating on clinical governance following one medium recommendation since resolved.

The impact on the CSU of the historical quality of data transferred from PCTs was acknowledged. However concerns raised in-year had led to limited CCG assurance. The CSU had not found an effective way to utilise the Broadcare system to provide useful data although the CSU had committed to catch up before year end and would test early March. The Quality & Safety Committee had also tracked progress and improvement. MS noted that the outputs from the Broadcare system did not provide reliable financial data and commended the input from the BHR CCG’s small Nursing Directorate but this was not sustainable longer term. After much discussion and deliberation the CCGs were minded to shift the service provision in-house in 2014/15. As Chair of the Quality & Safety Committee, TV reported on concern raised of quality of care patients received and JH had worked very hard to address this and improvement had followed.

In discussing Broadcare, NA advised that there was not a market of systems and any system relied on the input of good data. It was noted that data had been cleansed but reduction in cost had not followed. MS added that the CCGs were awaiting a list of Care Homes and funded patients and AFC added that the Quality & Safety Committee had noted the limited response from nursing homes to the CCGs communication on quality metrics. MS stressed good data/information was vital and robust systems were vital in the new arrangements for 2014/15.

The final reports were noted and the reports still in-progress.

11/14 Financial updates

Legacy Balance transfers/Invoice Management and Accounts close-down arrangements.

Month 9 had gone well but NHSE had not been able to provide the reporting tools to fully trial the accounts preparation process. However the CCGs were in a good position despite lack of detailed guidance. However it was important the tools were available late February to test prior to year-end.

The CSU were working closely with the CCGs to resolve all outstanding legacy issues and invoices were coming through for payment. The report provided a February position where re-imbursement of monies paid through 2013/14 ledgers was under review and a refund of almost £400k requested for amounts


residing on CCG balance sheets.

Invoice management by the CSU was improving but penalties for performance had now been initiated and the CSU were committed to achieving a year-end deadline to get back on track. In response to SW’s concerns on impact of late payments, MS added that he would review processes in the new year when the targets had been met but was unable to pay in advance particularly where a provider had not yet signed a contract.

A draft year-end timetable was provided setting out the key tasks in place for statutory accounts.

The financial updates were noted.

12/14 Audit Committee Effectiveness-Member review template

Members and auditors were asked to complete an assessment of the Committee’s effectiveness on the template provided and return to AW by 28 February. This practice was in line with Audit Member’s Handbook recommendations.

As part of the effectiveness survey the Chair would give further thought to rationalising agenda items and reducing long reports to summaries to reduce the volume of Committee work. It was also important to take account of the use of plain English for these public papers.

All to AW KP

13/14 Annual Committee Work-plan

The arrangements for receiving Draft Accounts and Draft Annual Reports and finalised copies, would be built in to the work-plan and also further review of Cyber-fraud Risk. AW would liaise with auditors around timing of reports for the new year and provide a new Committee work-plan for the next meeting.

The Committee wished to receive a report giving assurance on the processes for managing complaints received by all parties e.g. CCG, CSU, GP practices.

AW SA/PD

14/14 Tender Waiver

Noting very few tender waivers this year, MS advised that he would sign waivers only on a very exceptional basis. The pragmatic approach taken by the CFO to this waiver would not be repeated and the relevant team involved needed to make early arrangements this year for quotes. The Committee noted the tender waiver.

15/14 Any Other Business

Policy on Sponsorship and Joint Working with the Pharmaceutical Industry The policy for consideration had been previously seen by the BHR Solicitor and In House Counsel together with the local LMC. It had more recently been approved by the BHR CCG Area Prescribing Committee. It was planned the policy would be added to the intranet and attention of staff would be drawn to


the policy and process of application (together with the non-pharmaceutical sponsorship policy).It was noted the policy applied to all staff but not to individual GP practices. Members were asked to provide feedback to AW by month end and SM requested that the policy now be ratified by the March Governing Body meetings. The author agreed to check the TOR to clarify powers of the Area Prescribing Committee in approving policy.

All to AW

16/14 Messages for Governing Bodies

Following the meeting, the Chair would list the key messages to the March Governing Bodies. The following messages were subsequently provided: Data quality: Arrangements for validating financial and non-financial data quality are strong and the Audit Committee were assured that the information used to make our decisions is reliable. However, as data from some of our providers, in particular the Barts Health London is poor, significant staffing resources are needing to be deployed to validate data. This is unlikely to be sustainable in the longer term and efforts to raise the standard of data provided need to be continued and monitored by the GBs. Risk management: Board Assurance Framework (BAF) and risk management arrangements, though effective, can be strengthened by adding longer time horizons for mitigating risks (at present, BAFs consider risk management action only to the financial year end, while in reality some risks will take several years to mitigate) and adding in accountabilities for specific risks to a CD and the responsible committee. The NHSE's requirement to move to 2 year operational and 5 year strategic planning give us the opportunity to do so. The Audit Committee recommends this development, together with more clarity about risk appetite. Information governance: The Audit Committee commended officers for the efforts put in to achieve the safe haven status. The Committee asked officers to continue to seek satisfactory information governance assurances from our providers, in particular NELFT and PELC. The Committee also wanted officers to monitor and report back on the completion of the information governance e-learning package by GB members, more regular reporting of information governance incidents against the BHR CCGs (e.g data losses, hacking, etc.) to the Committee and an assessment of the arrangements in place for minimising our vulnerability to cyber-fraud. External audit and the accounts and annual reports for 2013/14: The date for submission of the audited accounts and the annual reports to the NHSE has been brought forwards. A timetable for achieving this new requirement was agreed, including special GB meetings to adopt the accounts. The Committee is satisfied that the new timetable is achievable though it will place additional pressures on staff, auditors and GB members. Internal audit: Audit work is currently on target and is expected to be complete by 31st March 2014. Internal audit have rated the arrangements for continuing healthcare as RED. This will be recorded as a reservation on the Head of Internal Audit Opinion for 2013/14. GB members will recall that this has been an area of concern and the remedial action already taken to address it. The Committee is also seeking more details from the NHSE about the proposed

KP


Signed…………………………………………….………

Dated………………………………………

new arrangements for assessing the effectiveness of the CSUs financial control systems. It is understood that in future, these assurances will be provided by the CSU's internal auditors at the year end, rather than through the year as was the case in 2013/14 through our own internal auditors. Audit Committee effectiveness: The Committee agreed how it might assess its effectiveness and to consider areas for improvement at the next meeting in April. The Committee recommends that a similar exercise is undertaken for the GBs and all committees. April meeting agenda: The Committee intends to review the year end draft accounts, annual reports and other supporting documents at its next meeting and the arrangements for handling complaints by the BHR CCGs.

17/14 Quality & Safety Committee Minutes

The minutes of the meeting held on 9 January were noted.

18/14 Information Governance Minutes The minutes of the meetings held on 18 November 2013 and 27 January 2014

were noted.

19/14 Assurance Committee Minutes (CSU) The minutes of the meeting held on 9 December 2013 were noted.

20/14 CCG Finance & Delivery Committee Minutes Minutes of the Barking & Dagenham meeting held on 14 November 2013 were

noted. Minutes of the Havering meeting of 20 November 2013 were noted. Minutes of the Redbridge meeting on 12 November 2013 were noted.

21/14 B& D CCG Urgent Action Group The minutes of the 7 January 2014 meeting were noted.

22/14 Next Meeting Following the meeting the Committee dates were re-arranged to meet national

submission deadlines. Two revised Spring meeting dates were subsequently confirmed as: Tuesday 22 April 2014 9.00-12.30 Tuesday 27 May 2014 9.00-1.00. The following dates remained unchanged; 15 July 2014 9.00-12.30 9 September 2014 9.00-12.30 11 November 2014 9.00-12.30 13 January 2015 9.00-12.30 10 March 2015 9.00-12.30.

Draft Quality & Safety Committee 4 February 2014 Page 1 of 4

Draft Joint BHR CCGs Quality & Safety Committee Date: 4 February 2014

Venue: Boardroom A, Becketts House Time: 1.00 – 3.00pm

Present: Dr Ah-Fee Chan (AFC) Secondary Care Consultant Redbridge Sharon Morrow (SM) Chief Operating Officer Barking and Dagenham CCG Alan Steward (AS) Chief Operating Officer Havering CCG Louise Mitchell (LM) Chief Operating Officer Dr Sarah Heyes (SH) Clinical Director Redbridge CCG Dr Samia Azeem (SA) Clinical Director Redbridge In Attendance: Diane Jones (DJ) BHR Deputy Nurse Director Rachel Brady (RB) NELCSU Quality Assurance & Clinical Governance Manager Angela Ward (AW) BHR Company Secretary Shelley Eadie (SE) BHR Business Manager

Apologies: Mr Tan Vandal (TV) Secondary Care Consultant BD & Havering CCGs Jacqui Himbury (JH) BHR Nurse Director Dr Raj Kumar (RK) Clinical Director Barking & Dagenham CCG Dr Ashok Deshpande (AD) Clinical Director Havering CCG Item Action 10/14 Apologies for absence

The Chair welcomed those present and the apologies were noted. The Chair confirmed the meeting was not quorate and that the committee would not be able to make any formal decisions.

11/14 Declarations of conflicts of interest There were no additional interests declared other than those already on

the CCGs Register of Interest.

12/14 Minutes of meeting held on 9 January 2014 and matters arising The minutes of the last meeting were agreed as a correct record.

13/14 Matters/Actions arising The following updates on Matters arising were discussed:

3/14 CQRMs DJ reported that all issues had been formally addressed at CQRM with an action plan in place to address the deficiencies in access. The committee would have sight of the NELFT action plan at the April meeting. SH confirmed that the specific patient incident she had raised had not been resolved and the patient was still without an appointment. It was noted that as this was a NELFT improvement plan that should provide assurance to the Committee that it works for all patients, it should contain clear guidelines for GPs to raise issues regarding discharged patients. The Redbridge clinical representative CO would be asked to raise this at

DJ/JH RB/DJ


the next CQRM. Action open. 3/14 Any other business The listing of smaller contracts was not available to the Committee but would be provided at the April meeting. Action open. 07/14 Serious incidents Qtr. 2 These actions would be taken forward at CQRM and an update brought to the April Q&S meeting. Action open.

DJ/JH DJ/JH

14/14 ED review of emergency care After concerns were raised by the Chief Executive of BHRUT regarding

current and future medical staffing issues in A&E, a review of the services provided by King George (KGH) and Queens Hospital (QH) A&E was undertaken in August 2013. The outcome of the review acknowledged medical staffing issues but found no evidence of any immediate risk to patients and therefore to close KGH A&E services overnight in an unplanned way might introduce more risk overall. The review made 26 recommendations and these will be included in the recovery plan to be agreed now that the Trust has been placed in ‘Special Measures’ by the Care Quality Commission (CQC). An international recruitment drive of middle grade and consultant grade staff is ongoing with the first tranche of recruits due to start in February and the second tranche in September. It was noted that some consultants are being paid more than current rate to take up or stay in positions. The committee requested assurances that all new recruits had gone through the appropriate testing and screening relevant to their appointments. DJ provided assurance that there was evidence of good screening in nurse recruitment. Winter money has been used to recruit ENPs and HCAs in the urgent care centre. There were significant issues with regards to patient flow although there had been some improvements as a result of LAS diverting patients to other settings. A partnership approach was being taken on discharge measures and a workshop had been arranged to address flows. An immediate review of the UCCs services on both sites was recommended following concerns regarding the UCC model. A draft specification incorporating best practice and quality standards had been agreed with CCG clinical leads. BHRUT will be penalised for failure to achieve set targets; both sites are expected to achieve the 50% target set. Targets will be included in the 2014/15 contracts. The likely impact on staff morale of the special members was discussed and it was noted a ‘pride programme’ had been established. The urgent care board will monitor all recommendations and ensure they are included into the CQC special measures care plan. The Committee noted the report and that it would receive a further report relating to implementation of recommendations within BHRUT special measures.

AS


15/14 Francis recommendations – progress report The committee were asked to note the progress made to date by the task

and finish group members. There had been positive engagement and work was progressing well. There was a discussion about how these actions are taken forward in the ‘real world’ and the impact being made. It was agreed that some examples of change should be brought to the committee; this could take the form of examples of good practice or patient stories told by the patients themselves. The MH issue raised by SH was an example of testing change. SA would email a locality template capturing positive and negative feedback to JH. DJ would discuss the idea with JH and agree an appropriate way to take this forward. The Committee noted the report.

SA DJ/JH

16/14 Quality monitoring of care homes (with nursing) The Committee noted the annual monitoring plan and progress to date

detailed in the report. Quality and contract monitoring is undertaken for patients who are funded or part funded in placements by the CCGs. The quality monitoring template is based on CQC and National Quality Framework requirements and is completed for each care home visited. Each service user has an independent review on their own as well as one with members of their family as an opportunity to highlight any concerns. Formal incident reporting is undertaken by the care home to the CQC and CCG as appropriate. Failure to undertake reporting will impact on contract reviews. The CCGs have a responsibility to improve quality through end of life care and pressure ulcers etc.; all common themes will be collated and taken forward as appropriate. Visits are undertaken jointly by the local authority and the CCGs. Although the timetable of care home visits is scheduled according to known intelligence, visits take place according to the availability of team. A more significant risk was that domiciliary care is not monitored due to lack of resources. Changes have been seen in certain care homes where locums are in place instead of permanent staff and this affected continuity of care. It was noted that care homes are often difficult to recruit to due to poor wages and no sick pay. Payments can be held back where issues are identified with the care home; issues with patient choice are more difficult to manage if there is nowhere else to send the service user. The Committee asked to receive a further report in 6 months. The Committee noted the report and monitoring arrangements.

DJ/JH

17/14 CCG complaints at Quarter Three All complaints received by the CCG are logged managed by the CSU.

BHR CCGs have agreed that all complaints will be acknowledged in writing within three working days and a response sent out within twenty five days. Currently this is not happening and further work is needed to streamline the process.


To date there have been very few complaints received possibly as a result of complainants not aware of where they should direct their complaints and queries too. Similarly few MP enquiries had been received this year. It was suggested that a notice is put on the CCG websites of who to contact in the event of a complaint. SH highlighted a never event that had occurred in Newham of which she had heard via a meeting at Bart’s Health and not personally. The Clinical Directors (CDs) felt these incidents should be communicated directly to them in order for example to allay patients’ fears and worries but ultimately to be assured that these events are being investigated. The CSU currently sends all SI’s to the BHR Nurse Director and BHR Deputy Nurse Director on a weekly basis. DJ would look at how best to communicate these incidents in a timely way to the CDs outside of the meeting. It was agreed the next report to the committee would include response time data. The Committee noted the progress report.

DJ/JH

18/14 Winterbourne review The report provided an update on patients with learning difficulties

receiving care in an assessment and treatment unit (ATU). The purpose of the review is to ensure that all patients are receiving the appropriate care, support and treatment. DJ noted that the work was on track with the CLDT in place to review settings and placements. The next deadline (1 June 2014) is to ensure that all patients are receiving personalised care and appropriate support. The last report to NHS England did not accurately reflect the position in each of the CCGs; to do this a separate response from each CCG would need to be sent. SM emphasised that more localised community placements needed to be made available to achieve the standards and joint work was continuing with the local authority to manage this. The progress report was noted.

19/14 AOB POLCV policy review

It was noted that the POLCV policy review document had already been sent to Clinical Directors and other appropriate individuals. The Committee were asked to provide any additional comments on the changes made, particularly those that affected quality and safety, to SE by 14 February to forward to Jessica Arnold. The new policy would come back to the committee for review after 1 April 2014.

SE JH

20/14 Next meeting 1 April 2014, 1-3pm

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

1 Draft Red F & D Minutes 4 March 2014 v1

Draft Minutes of Redbridge CCG Finance and Delivery Committee held on

4 March 2014 at Becketts House

Present -Members Dr Mehul Mathukia (MM) Chair, Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Muhammad Tahir (MT) Clinical Director Dr Joyoti Sood (JS) Clinical Director Kash Pandya (KP) Lay Member Governance Martin Sheldon (MS) Chief Finance Officer Louise Mitchell (LM) Chief Operating officer In attendance Angela Ward (AW) Company Secretary

Action

01/14 Apologies for absence The Chair welcomed attendees to the meeting and noted there were no

apologies for absence.

02/14 Declaration of Interests There were no interests declared other than those in the register available at the

meeting. The details relating to Dr Sood were to be updated. AW

03/14 Minutes of previous meeting held on 12 November 2013 The minutes of the previous meeting were agreed subject to a typographical

error on P1 –‘EEG changed to ECG’.

AW

04/14 Matters Arising

3.13 Minute -MS was pursuing the issue of maternity tariffs and shared care payments with Barts. Action open. 16.4 Minute -LM was checking IVF cases at the Homerton, NICE criteria and variation. Action open 4.13 Risk Register-Members had received the BAF at the January Governing Body and the red rated risk report was provided at this meeting. Action closed 5.13 Finance & activity-Rob Meaker was able to share referral data by practice using Health Analytics in 2014/15.Action closed. 13.7 Estate voids- The risk register had been updated to reflect risk. A report was also provided to this meeting. Action closed. 13.9 Procurement update- The report was provided to this meeting. Action closed.

MS LM


6/13 QIPP update –Report provided to this meeting. Action closed.

05/14 QIPP progress report, M9 flex data and a planning update for 2014/15

LM reported on an achievement of 89% planned savings at M9 and actions to mitigate risk of non-delivery of any schemes by year end. Highlighting the risk areas, LM added that Medicines Management had helpfully over-delivered on their target. KP congratulated the CCG team on an outstanding achievement in the face of this biggest ever QIPP target and it was felt good experience and confidence had been gained of what worked and that would be built on next year. MS referred to the next two year planning phase and assistance from KPMG in modelling. Members discussed risk areas and further scope in A & E, elective work and RTT, urgent care and non-elective work, care homes. IT was noted Medicines Management would be tackling waste medicines next year. MT referred to the input of individual practices when they had their own data and called for further liaison with consultants to gain some soft information feedback on appropriateness of referrals. SH referred to quality of referrals and had noted a wide variance in late maternity bookings across the CCGs. Attention was drawn to the Candlestick report that showed an additional row of pipeline projects to supplement savings worth around £500k. MS and LM would meet to discuss how best to build a better two-way relationship between GP and Consultant to gain further improvement. Noting the successes this year, KP referred to the good practice awards made by some journals and proposed entry. From the current position, risk had been minimised but Barts position added some fragility. The Chair called for an increase in innovative approaches this year and MS referred to the bid to the PM Challenge Fund the outcome of which was awaited. Also there was the frailty project to better manage those people with multi-conditions at a dedicated site. JS noted 90% achievement but a red rating for ICM and MS explained the measure was output reduction in acute delivery and LM would explain further outside of the meeting. MS and LM would discuss why acute delivery did not appear to be impacted by lower A & E levels. The QIPP progress reports were noted.

LM/MS JS/ MM/ LM LM/MS

06/14 Red Rated Risk Action Plan

LM’s report described how the red risks discussed at the November finance meeting had now been halved from 12 to 6 but two new risks added. The new risks were a red rated reputational risk and impact on management of winter pressures and a high amber risk of failure to meet the revised 111 call response rate. For the latter monitoring had moved from weekly to daily. Members read through the red rated risk report and KP welcomed the risk mitigation to date but questioned outstanding risk within the CCG’s direct control such as the domiciliary coagulation service. The collaborative approach to procurement was described but due to differing CCG requirements of the specification it had been essential to move to three separate procurements that had caused delay. JS added that there was new NICE guidance involving a new drug and this would be a new financial risk. The Chair added that higher drug costs may lead to savings elsewhere longer term and LM would consider this

LM


new element further. The responsibility for 111 risk was questioned and LM explained that the CCG commissioned the service and would therefore support. MS explained that the finance risks remained until the final condition was lifted and the CCG were fully authorised and the KPMG review would assist making that credible. Noting the contract risks, JS reported that Whipps Cross discharge letters were very efficient and this only related to BHRUT. MS described the difficulties with the new BHRUT PAS system that was affecting bookings, discharges, letters from clinics and monitoring data and it was expected recovery could take several months. The impact was being discussed with the Trust. Noting risk around the 2013/14 Barts contract, MS was awaiting Q3 data but there appeared to be a drop down to planned level. Noting IT services provided by NELFT, options for re-provision were under consideration and there was a critical issue of IT assets which linked to the PM Challenge Fund. It was vital that the CCG had good control of information flows. It was confirmed that the current service controlled and managed the network and entry points but Rob Meaker, in-house, managed the GP’s infrastructure. The Committee agreed the current risk position and agreed that mitigating actions were sufficient to lessen the impact of risks to the CCG.

07/14 Finance and Delivery reports

7.1 Finance & contracting The headlines of the current financial position were that there was a forecast out-turn of £2.9m overspend but the CFO was working towards break-even. The main risk remained acute provision, predominantly Barts but Homerton was overspent on maternity with IVF being further examined and there was some concern on over-performance of small contracts. This was the first year of CCG contracting and this year’s overspends had been factored in to the second year plans as worst case scenario positions. Members raised cancer targets and waits and noted Barts had not met the 2 week and 62 day referral standard, with a response from the Trust awaited. SH noted distress caused and believed the conversion rate of referrals was around the average of 18%. JS added that this had been raised at the cancer collaborative but clinicians were not yet clear of what the issues were and MS agreed to pursue this via the regular contracting meetings. Noting a revised pathway for prostates, that was agreed with assurances, Members required further clarification of what can be expected from the pathway and details of their own patient breaches. Also discussed was the high rate of day cases and preference for a shift to OP clinic treatment such as for ENT, joint injections, skin tag removal and pathway design was required to address this. The Committee noted the M8 report.

MS LM

7.2 Continuing Health Care-retrospective cases The report provided an update on Redbridge’s 134 retrospective (2004-2012) claims, noting validation of the total numbers was not yet possible. Monies had been set aside, but not yet transferred to the CCG, but it was too early to tell if funds were adequate. The CCG was ahead of others in progressing the claims with Capita Medical Resourcing now appointed until July to process claims.


Capita were currently engaged in gaining consent to deal with each individual claim. Following assessment Capita will recommend approval to the CCG, on a case by case basis. The establishment of Panels are proposed to assist the approval process and there would be an appeals mechanism. LM referred to use of the Better Care Fund through the new S75 agreement in future and the Committee would hear next time of progress made in establishing robust governance arrangements. The Broadcare work was discussed and proposals to bring this workload in-house were being developed with some revalidation required at that time. The Committee noted the report and they would receive a further update in June.

LM/ MS MS

7.3 Legacy Balance Transfers The report described the latest position in the treatment of legacy balances and that NHSE now planned to account for the majority but proposing the CCG addressed fixed assets, inventories and finance lease liabilities. However the CCG was taking a risk adverse approach and has not yet accepted the position on transfer of assets until it knew what they were and they could be validated. This matter was to be discussed further with the NHSE CFO. MS added that a London solution was being sought on new guidance requiring provider hosts of urgent care centres to charge and CCG providers of such Centres to pay. A cost neutral outcome would be sought. The contents of the update report were noted.

7.4 Invoice Backlog Further to previous reports, the backlog position had improved and was reaching near normal acceptable levels. There were still some outstanding queries and CSU had missed their planned target for January, and been penalised, but were fully committed to meeting their revised end of March backlog clearance target. Members noted the update report.

7.5 Specialist Commissioning update MS re-iterated the cost neutral funding approach proposed when NHSE accepted responsibility for specialised commissioning. The outcome had been a proposed top-slice to Redbridge of £10m. A London CFO technical group had been formed to challenge proposals that had resulted in £3.1m funding being given back to the CCG. However there was further work being done on mis-attributed cases across London and beyond and a further report would be provided at the next meeting. The Committee noted the receipt of £3.1m funding and the risk would be removed from the BAF.

MS

7.6 NHS Propco and Estates risk. The report confirmed that a national change to Property Services charges in the latter part of the year had occurred and the CCG would now be charged in line with its baseline position of £1.656m. The position for 2014/15 was awaited. Members noted the update report.


Signed…………………………………………….………

Dated………………………………………

7.7 Allocations 2014/15 The notified allocations for the next two years provided an uplift of 4.8% in 2014/15 and 4.4% the following year. The report added the expectation of the continued specialist commissioning funds, highlighted the increase running cost allocation to £7m this year but with a 9%reduction the following year and also referred to the Better Care Fund held by the Local Authority. The CCG was using these assumptions in their operating plan and there was some potential for risk. MS tabled an early draft of a 5 year financial plan requiring £15m from QIPP in the first year, £11m the second and £6m the third year. Attention was drawn to both positive and negative impacts, the revenue resource limit, I&E, key planning assumptions, and Non-Recurrent requirements. The plan, if fully achieved, would lead to opportunity for investment. The Chair questioned the distance from target position and it was noted the CCG was below target and would therefore benefit from their current position. The utilisation of the Better Care Fund would be critical over the next two years and LM was working closely with the Borough on arrangements. KP noted the challenge over three years of a large QIPP savings programme whilst accommodating a reduction in running costs, noting current expenditure with the CSU. The Committee noted the allocations information and potential risk of assumptions and further drafting of the 5 year financial plan would follow.

7.8 Procurements-list of contracts awarded 2013/14 and procurement update. The report described the new CCG Coflow system that provided details of Out of Hospital clinical contracts and further refinement was expected to follow. KP hoped the system could be expanded over time to capture performance and patient experience. The clinicians reported delays in payment for services e.g. Winter payments, Healthchecks and these would be followed up by MS. Members asked for a comparison of spend per head cross BHR next time. The new system was welcomed and noted.

MS MS

08/14 Any Other Business

There was no other business.

09/14 Date of next meeting

The next meeting was being held on 25 April 2014 from 1.00-3.00pm at Becketts House.

1

Redbridge Clinical Commissioning Group Patient Engagement Forum (PEF)

Tuesday, 18 February 2014

5pm-7pm

Becketts House, Ilford

Present: Khalil Ali Louise Mitchell Dr Jyoti Sood

PEF Acting Chair (Lay member for Redbridge CCG) Chief Operating Officer, Redbridge CCG Clinical Director (Engagement Lead)

Boba Rangelov Dee Datta Jay Solanki Lorraine Silver Barbara Stuchfield Howard Clarke-Melville Alan Banner Anne Bertrand Angela Banner Swati Vyas Raina Gee Joseph Perry Navnit Dhaliwal

Apologies: Shush Patel Cllr Filly Maravala Michelle Green Raymond Eglon Absent: SR Khosla David Lyons Atia Kazmi Martine Carter Catherine Hunt

PPE Advisor BHR CCGs PEF member, Cranbrook and Loxford PEF member, Cranbrook and Loxford PEF member, Fairlop PEF member, Fairlop PEF member, Seven Kings PEF member, Seven Kings PEF member, Wanstead and Woodford Vice- Chair of The Palms PPG, Seven Kings Health Partnerships Manager, CVS Redbridge Youth Involvement and Volunteering Development Worker, Redbridge Council Redbridge Youth Council member Redbridge Youth Council member PEF member, Cranbrook and Loxford PEF member, Cranbrook and Loxford PEF member, Wanstead and Woodford PEF member, Wanstead and Woodford PEF member, Cranbrook and Loxford PEF member, Fairlop PEF member, Fairlop PEF member, Seven Kings PEF member, Seven Kings

2

1.0 Introduction and apologies Chair welcomed everyone and introductions were made and apologies were accepted. 2.0 Minutes and matters arising-meeting held on 10 December 2013 KA asked everyone to note gratitude and appreciation for Melvyn Weinberg (previous PEF Chair) and Vivien Nathan (previous PEF Vice-Chair) for their excellent work. “Thank you” letter had been sent to both of them on behalf of the CCG. The minutes were noted as a correct record of the meeting. Matters arising

• Phlebotomy (blood tests) clinics: More clarification to obtain about locations of the clinics. This can be followed up with Simon James, Senior Locality Lead. ACTION:BR

• A list of all GP practices who have PPGs to be sent to all PEF members. ACTION:BR

• Redbridge Healthwatch report about PPGs to be included in Agenda for the next meeting. ACTION:BR

• Community Treatment Team (CTT) and Intensive Rehabilitation Service (IRS) to be promoted via Redbridge CVS Newsletter ACTION:SV

3.0 PEF workshop in March 2014 (LM)

• LM to advice of two possible dates/times for the workshop (LM) • Working title: “What does good engagement look like?” • ACTION: BR to send an email to the members and ask for preferred date

4.0 Introduction of a new PEF (Chair) (Membership, TOR, an election of a new Chair and Vice Chair)

• Mental health and learning disability representatives to be invited to the next PEF meeting (ACTION:KA and LM)

• An election of a new PEF Chair and Vice-Chair: ACTION: BR to send an email ASAP to invite PEF members to put their name forward for those two positions. They should submit a short summary including relevant experience and background. The time scale for submission is two weeks (by 28th February 2014). Voting will be done at the beginning of the March workshop (BR)

5.0 Updates from four localities This will be standard agenda item for all future PEF meetings. Locality (PPG) representatives will be required to present at the PEF meeting an update from their locality, verbally or in writing (one A4 paper) and/or any issues they may wish to discuss.

3

1. Seven Kings locality update (Goodmayers Medical Practice)

• A lot of outreach work had been done to those surgeries that don’t have PPG. They were asked what support to help them to establish a PPG

• Two PPG members gave a presentation at the GP Network meeting, which they found to be useful

• There were some issues raised about standard of care in care homes and also information about residents’ GPs passed onto the family

2. Wanstead and Woodford locality update (The Evergreen Practice)

• They discussed at their meeting how to get more participation. • PPG members thought that Pharmacy Medication Passport was a good idea • The Evergreen Practice has an issue with the current membership. This could

be picked up by Kirsty Boettcher, Senior Locality Lead. Also, it was suggested to seek some clinical input at the Protective Learning GP Events

• More visible information (posters, leaflets) to be visible and displayed in GP surgeries

3. Fairlop locality update (Eastern Avenue practice)

• They have a guest speaker at their meetings. • At the last meeting they had some new members. They were provided with an

introduction about PPGs and what benefits they have if they become a member.

• They also have their newsletter • They have problems with getting younger members on a board • Out of 9 practices, two don’t have a PPG

4. Cranbrook and Loxford locality update

Granville GP Surgery

• They have different patient groups • They have requested that GPs do something about patients who have

diabetes and are drivers, as they have to inform DVLA on a regular basis about their condition

Balfour Road GP Surgery

• They have a new system in place of recruiting new PPG members and they

are hoping to increase their membership. Five to six people attend the meetings regularly. They are looking into having more diverse group.

4

St Clements GP Surgery

• They established their TOR and dates of regular meeting in 2014 • They organised dates for regular drop in sessions in the practice by PPG

members to inform and work with other patients; issues include registering on line prescription, assistance with EMIs applications on mobile and downloads, Did Not Attend (DNA) etc

• To assist practice to recruit Patient Reference Group members • PPG designed a Patient Satisfaction Survey which will start from 17 July 2014

6.0 AOB

• JP informed everyone about Local Democracy Week. 35% of young people voted for mental health being one of the health priorities. To promote this via CCG staff newsletter ACTION:BR, RG and JP

• LS raised a concern relating to the Care Data. LM advised that the project had been put on hold by NHS England.

7.0 Close and dates of the future meetings KA thanked everyone for coming and the meeting was closed. Future meeting dates will be confirmed and sent to all members in due course (after March Workshop). Please note that a date for the PEF workshop “What does good engagement look like?” has been agreed and it is Thursday, 13 March 2014 5pm-7pm in Becketts House, Redbidge CCG, Ilford, Boardroom. Light refreshments and snacks provided. 24 February 2014

1

Joint Executive Team Meeting

6 February 2014

MINUTES Attendees: Dr Waseem Mohi Chair – Barking and Dagenham CCG Sharon Morrow Chief Operating Officer – Barking and Dagenham CCG

Dr Atul Aggarwal (meeting Chair) Chair – Havering CCG Dr Alex Tran Clinical Director – Havering CCG Clare Burns Deputy Chief Operating Officer – Havering CCG

Dr Anil Mehta Chair – Redbridge CCG Dr Shabana Ali Clinical Director – Redbridge CCG Dr Sarah Heyes Clinical Director – Redbridge CCG Dr Mehul Mathukia Clinical Director – Redbridge CCG Dr Muhammad Tahir Clinical Director – Redbridge CCG Dr Jyoti Sood Clinical Director – Redbridge CCG Dr Heath Springer Clinical Director – Redbridge CCG Louise Mitchell Chief Operating Officer – Redbridge CCG

Conor Burke Chief Officer – BHR CCGs Martin Sheldon Chief Finance Officer – BHR CCGs Jane Gateley Director of Strategic Delivery – BHR CCGs

Roy Weston North East London CSU

1.0 Welcome, Introduction and apologies

Apologies were noted from: B&D: Dr Richard Burack and Dr Arun Sharma Havering: Dr Maurice Sanomi and Alan Steward Redbridge: Dr Samia Azeem, Dr Syed Raza and Dr Chidi Okoirie BHR CCGs: Sue Assar and Jacqui Himbury NEL CSU: Graham Simpson

2.0 Declaration of interest There were no new declarations of interest raised.

3.0 3.1

Minutes from previous meeting/Matters arising The minutes from the meeting held on 9 January were agreed but Dr Tran advised there was an action missing which was that Havering CCG had requested detail on what practices had attained for invoice checking on Health Analytics. Martin Sheldon to action this as soon as possible. With regards to the Prime Minsters Challenge Fund bid Conor Burke agreed to circulate the draft expression of interest, acknowledging this was a work in progress and advised that a meeting for all GPs has been arranged for after the Governing Body awayday next Thursday at the Holiday Inn Newbury Park. Reprocurement of Community Health Services Sharon Morrow advised the paper circulated was a position statement of where the

MS CB

2

CCGs are in the process. Sharon highlighted that the current contract with NELFT (North East London Foundation Trust) does not provide a service line breakdown so it is not possible to see for this year what is not performing but that this due to be included as part of the contract negotiations for 14/15. Sharon outlined the next steps for the work to progress which includes the Planned Care Steering Group to lead on the redesign of the MSK pathway, led by Havering CCG. Dr Tahir advised that as there are differences in the way the service is delivered across the three CCGs there may not be one single solution. Dr Tran asked about the Walk in Centre in Havering run by the Hurley Group. Clare advised that a meeting was held today to review this as the contract for the whole service is held by NHS England and that work needs to be undertaken to separate this. Clare agreed to arrange a briefing for the Havering Clinical Directors on this.

CBu

4.0 4.1

Risk Assurance Collaborative Risk Log Conor gave a brief overview of the risk slides noting the following; - Continuing Healthcare - the risk had considerably reduced. Conor advised that

once the new system is set up all GPs will be able to see which of their patients are receiving continuing healthcare.

- Obesity surgery – following concerns raised at the recent Governing Body meetings a letter had been sent to the Head of Specialised Commissioning for London outlining the concerns and asking for assurance on the backlog of any BHR CCGs patients and the plan and timescales for dealing with this.

- PELC – performing as they should and no more issues identified. A Care Quality Commission visit of the King George Hospital Urgent Care Centre took place this week. No feedback on the visit has yet been received.

- Specialised Commissioning - the risk has reduced.

5.0 5.1 5.2

Contract Quality and Performance Barking, Havering and Redbridge University Hospital Trust (BHRUT) Dr Aggarwal advised that for Havering there has been an increase on maternity spend at BHRUT but that this is being reviewed as it looks like this could be due to double charging. Martin advised that we are close to agreeing a year end position with the Trust and that we are awaiting a response to our offer. Following concerns raised about issues with discharge summaries Dr Aggarwal advised that this is being looked at as part of the contract review and that this will include looking at IT options for GPs to receive electronic discharge summaries. Concerns were also raised about the communication from BHRUT to GPs. Dr Aggarwal advised that clinical forums are due to be set up with secondary care consultants and GPs to discuss pathway issues etc so that should help. North East London Foundation Trust (NELFT) Sharon asked for members to note the following; - the ICM caseload target was met for Quarter 3 - Heads of Terms were issued to NELFT last week. A discussion followed around the CQUIN for customer satisfaction scores and how this is and should be managed. It was suggested we look at the questions NELFT are asking or that we provide our own questionnaire. Martin advised that this could be included in the contract negotiation discussions. Sharon stressed the need to be clear on what it is we would want to gain from the questionnaire. As Clinical Directors advised that they had never seen the full list of services that NELFT provide it was agreed at the next JET meeting a directory of services by CCG be available for review. Conor suggested that this be accompanied by a

MS SM

3

5.3 5.4 5.5

briefing on our strategy for managing and improving NELFT. Barts Health (BH) Martin advised that for the RTT backlog all practices will be advised if any of their patients are on the list. There was a query raised on whether this also included taking responsibility for informing the patients. Martin agreed to check this. There was a discussion on whether we could be confident that Barts are aware of all the patients that should be on the list and if GPs should provide the information to them to check or if they should be removed from Choose & Book so that no more referrals are sent to them until we are sure they have dealt with the backlog. A question was raised on the issue of being charged twice if a patient waiting too long and was then referred somewhere else. Clare advised that there is an established process for this to ensure we are not charged for the first referral. Partnership of East London Co-operatives(PELC) It was noted on the slide that the UCC value was shown all under Redbridge and that this should also shows the values for B&D and Havering if applicable. This is to be updated for the next meeting. It was also noted that the clinical risk that was raised at the last JET meeting has been discussed with PELC. Update on Contract Negotiations 2014/15 Roy Weston confirmed that Heads of Terms had been issued to BHRUT and NELFT and that PELC will be sent tomorrow. There is a week by week plan for all contract negotiations which is on target and progressing. The aim is to have all Heads of Terms agreed by 21 February which leaves a week to formalise these by the national deadline of 28 February. A discussion followed on the status of BHRUT and how much influence and intervention the CCGs should have around the management of the Trust. Conor advised that our main priority and focus should be on ensuring we commission quality and safe services for patients of the CCGs.

MS LM

6.0 14/15 Commissioning Plans / Better Care Fund (BCF) Jane Gateley provided a brief overview of the progress of the plans and the key activities to strengthen the plans before the final draft submission. The first drafts of the BCF templates and the 2 year operating models will be submitted on 14 February. The first detailed draft of the 5 year strategic plan is to be submitted on 4 April. Jane advised there is a workshop on 10 February which will review priorities and agree next steps. Sharon, Louise and Clare provided an overview on the progress of the development of the operating plans and BCFs for each of their CCGs. It was agreed that all three CCGs had some positive success stories and it was suggested that at a future JET these could be shared.

7.0 Q&A with management team Dr Heyes asked if there had been any progress on discussions with NHS England on the minor surgery DES. Conor advised this had not yet happened as yet but will ensure this happens and the outcome fed back at the next JET meeting.

CB

8.0

Any other business No items were raised.

9.0 Date of next meeting Thursday 6 March 2014 1.30-3.30pm.

Note