board part i - wandsworth ccg · 14-12-2016 · sean morgan (sm) director of corporate affairs,...
TRANSCRIPT
Board Part I
MEETING14 December 2016 10:00
PUBLISHED13 December 2016
W A N D S W O R T H C C G P A G E 1 O F 2
Board Agenda14/12/2016 10:00 East Putney
Meeting of the Wandsworth CCG Board
Held at 73-75 Upper Richmond Road, East Putney SW15 2SR,
on Wednesday, 14th December 2016, at 10:00
P A R T A | M E E T I N G O P E N S T A R T D U R A T I O N
A01 Apologies, Declarations, Quorum 10:00 5 mins
A02 Clinical Chair’s Opening Remarks NJ 10:05 5 mins
A03Minutes – 12th October 2016 Approval &
Status of Actions (p.5)NJ 10:10 10 mins
A04 Items for AOB NJ 10:20 00 mins
P A R T B | D E C I S I O N S & D I S C U S S I O N S
B01 Operational Focus – St George’s Hospital S Mackenzie 10:20 30 mins
B02Clinical Focus – Continuing Health Care
(p.21/30)LW 10:50 30 mins
B03 London Health Devolution (p.60) SI 11:20 15 mins
B04 Board Assurance Framework (p.88) SI 11:35 10 mins
B05
Policies:
Prime Financial Policies (p.128)
Managing Conflicts of Interest (p.132)
NM
SI 11:45 10 mins
P A R T C | M A N A G E M E N T R E P O R T S
C01 Executive Report (p.137) GM/NJ 11:55 5 mins
C02 Performance Report (p.150) SI 12:00 5 mins
C03 Finance Report (p.158) NM 12:05 5 mins
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]
W A N D S W O R T H C C G P A G E 2 O F 2
P A R T D | B O A R D G O V E R N A N C E
D01
Summary Minutes:
Integrated Governance Committee
(p.197)
Finance Resource Committee (p.200)
Audit Committee (p.202)
Primary Care Committee (p.205)
12:10 5 mins
D02 AOB & Other Matters to Note 12:15 5 mins
D03
Open Space: Public’s Questions
Members of the public present are invited to
ask questions of the Board relating to the
business being conducted. Priority will be
given to written questions that have been
received in advance of the meeting
NJ 12:20 10 mins
P A R T E | M E E T I N G C L O S E
E01 Clinical Chair’s Closing Remarks NJ 12:30 5 mins
Next meeting of the Board: 01/02/2017 10:00-12:30 East Putney
Part A: Meeting Open
Page
1. Part A: Meeting Open 4
1.1. A01 Apologies, Declarations, Quorum
1.2. A02 Clinical Chair's Opening Remarks
1.3. A03 Minutes 12th October : Approval and Status of Actions 5
1.4. A04 Items for AOB
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Minutes of a meeting of the Board held on 12th October 2016
Present: Nicola Jones (NJ) CCG Clinical Lead (Chair)Graham Mackenzie (GM) Chief Officer Neil McDowell (NM) Acting Chief Finance OfficerStephen Hickey (SH) Lay Member GovernanceCarol Varlaam (CV) Lay Member Patient and Public InvolvementAndrew Neil (AN) Secondary Care DoctorDi Caulfeild-Stoker (DCS) Registered NurseZoe Rose (ZR) West Wandsworth Joint Locality LeadMike Lane (ML) Wandle Joint Locality Lead Nicola Williams (NW) Battersea Joint Locality LeadJonathan Chappell (JC) Battersea Joint Locality LeadSandra Iskander (SI) Director of Corporate Affairs, Performance
and QualitySean Morgan (SM) Director of Corporate Affairs, Performance and
QualityLucie Waters (LW) Chief of Commissioning OperationsAndrew McMylor (AM) Director of Primary Care DevelopmentHouda Al-Sharifi (HAS) Wandsworth Director of Public HealthCathy Kerr (CK) Wandsworth Director of Adult and Community
Services
In attendance:Jamie Gillespie (JG) Healthwatch WandsworthSandra Allingham (SA) (Minutes)
16/096 Apologies for AbsenceNone received. The meeting was quorate.
16/097 Declarations of InterestItem B05 Lay Member Board Roles – CV/SH declared an interest as current Lay Members. No action was required.
16/098 Minutes from the previous meeting held on 14th September 2016The Minutes were agreed as being an accurate record.
16/099 Matters ArisingNone.
16/100 Chair’s UpdateNJ welcomed Sandra Iskander back and noted that this would be Sean Morgan’s last Board meeting. NJ thanked SM for all of his work on behalf of the CCG during his time in post.
16/101 Clinical and Operational Focus – St George’s HospitalSt George’s Hospital (SGH) is the major acute, community, and tertiary (specialised) services provider for the CCG.
The paper outlines that through the significant due diligence undertaken as part of the FT process, SGH was identified as a high performing organisation. It was, therefore, a surprise that so quickly after becoming an FT, the Trust experienced financial deficit and service challenges against the core Constitutional standards for
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A&E, Referral to Treatment (RTT), and Cancer. A number of quality concerns were identified and addressed through the Clinical Quality Review Group (CQRG) and the Care Quality Commission (CQC).
The FT Board has the responsibility to deliver financial balance, high quality of care, and core Constitutional standards for all patients. The CCG has the responsibility to also achieve financial balance, and ensure delivery by providers, with a formal collaborative agreement across all SWL CCGs as the lead commissioner for services at SGH. The CCG also has the responsibility to align with NHS Specialised Commissioning, which makes up half of the total spend on services in SGH.
The CCG has a responsibility to support the Trust in taking action and, where actions were not having an effect, to take a formal contractual position. The Trust has been asked to product a Remedial Action Plan, which has been co-developed with the CCG, to deliver improvements.
Where multiple failures are identified, regulatory intervention is then put in place through NHS Improvement (NHSI) and NHS England (NHSE). Because of multiple issues, it is important to make sure that all improvements act in concert. A number of external agencies are available to provide advice and support. There will be an intensive programme of work to ensure the Trust can respond appropriately to the challenges. Currently there were a number of actions plans in place.
The Trust is required to improve in all three areas. Support mechanisms would be used through the CQRG and Clinical Reference Groups (CRGs), but formal notices to enact financial penalties would also be used.
The CCG Board’s input was invited to describe any further actions that can be taken by the CCG to support the Trust.
Comments and questions were invited from members of the Board:
SGH performance in the national context – Although it was acknowledged that there are a number of challenged Trusts, it was considered that the position at SGH was different from the national trend. A significant amount of due diligence had been undertaken through the FT process, but the rapid deterioration against many of the key domains was exceptional. NHSI has done a lot of work with the Trust to identify challenges relating to leadership with a number of changes made.
Single plan and governance going forward – Although there was a series of remedial action plans in place, there was no one single plan. Monthly Trust and Commissioner Assurance Board (TCAB) meetings review the key domains to look at performance in the round. It is the responsibility of the Trust to outline the plan in order to get back on track. The CCG has a role in supporting the Trust and has put in some additional resource. The CCG also has an assurance role, as lead commissioner, regarding the implementation of the plan. Work will be required to bring the multiple plans into one single plan. A six-month view has been provided but this would be dependent on leadership changes. Pressure should be put on the Trust for this to be done with a first draft by the end of the calendar year. It was noted that this paper would be taken to the TCAB meeting with the next step to develop a deliverable timeframe.
The plan would need to designate what the Trust was capable of delivering. The Trust’s prime role is to run a very high standard district hospital, therefore, the plan will need to be different and fundamental.
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Tertiary services duplication – There is some duplication of tertiary services with the DGH (District General Hospital) function, but there was also a very specific component of services, eg the Trauma Unit. There was not sufficient service line costing to identify benefit to the Trust from tertiary services.
Review of tertiary services across London – This review may provide an opportunity to make sure that there were really good pathways for patients, which might lead to some consolidation of services. This is a long term plan and will be looked at on a specialty by specialty basis.
The chronology in the paper sets out the journey to the current position, but was there an understanding of what led to this point, and was there a plan to mitigate that?
Roles and responsibilities of the various players - It was difficult to see tactically the way forward in the wider system and where all players aligned with the dimensions, with clarity regarding their roles in this critical set of relationships.
The CCG needs to consider whether sufficient action has been taken by them, or whether more should be done, with particular reference to the CCG leadership rating. – The CCG needs to continue the diagnostic review of decisions taken at different times. A number of themes have already been identified, including a much larger cultural theme around leadership and development. It was acknowledged that the CCG could have responded faster to re-align and prioritise, but it was not expected that the CCG would have to play a substantive leadership role for the Trust having been achieved FT status. This was now being taken forward by the CCG.
Board-to-Board – The CCG had previously held a Board-to-Board meeting regarding quality of care prior to achieving FT status. It was reasonable for the CCG to expect that Monitor and CQC would look deeper at any issues as part of the assurance role. A further Board-to-Board session would be taken forward once the substantive SGH Board was in place.
SGH leadership issue – This paper had been sent to SGH prior to the meeting. The CCG works closely with SGH on many levels, but it was very important for the CCG to also have an over-arching responsibility for the system – this was a difficult balance. The issue around making substantive appointments has been raised in a number of forums, particularly with the senior leadership team. There could be potential to escalate this to other regulators.
Estate issues – Significant issues had been identified which will require a significant amount of capital to address. These will impact on the services that can be provided. Plans will be developed on improving the quality of the physical state of the site but the full range of services cannot be provided. It was noted that the Trust had applied for a grant to enable remedial repairs to be done quickly.
It is important that the CCG continues to have a strong focus on Out of Hospital (OOH) plans.
Culture of the organisation and staffing – Plans need to address this to ensure that appropriately skilled staff are in place. This would need to be strongly emphasised.
Regulatory report and mechanism around improvement – No evidence of that had yet been received, although this could be requested.
Planning round and two-year contracts – It would be important to negotiate the most reasonable contract for the system – this could provide the opportunity to reset that in a transactional way for the next two-years.
It was important to keep and strengthen clinical connections between the Trust and CCG.
In summary of the discussion, it was noted that:
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a piece of work would be done to understand any learning;
the CG would continue to work closely with SGH;
issues regarding substantive leadership posts would be escalated to NHSI;
an invitation to be extended for the Interim CEO to attend the Integrated Governance Committee, with an invitation for the new substantive Chair/CEO to attend a CCG Board meeting once in post;
through TCAB, plan to put firmer milestones and timelines for plans and to encourage that process;
continued CCG focus on OOH plans.
Further consideration on how to take work forward would be discussed by the Management Team (MT).
16/102 Multi-specialty Community Provider (MCP) procurementAlthough much work has been put in place over the past few years to benefit patients, there was still further work that could be done, including one care/health plan for individual patients across agencies, better use of communities and the voluntary sector to make patients feel more empowered, and support for practices to take provide more complex services. This would be done through the MCP (Multi-specialty Community Provider), with a Lead Provider.
Work had been done over the past eighteen months to develop the MCP model in consultation with patients, stakeholders, and key providers. The Board had previously agreed that a procurement process should be put in place. The CCG had worked with Capsticks and NHS Shared Business Services (SBS) regarding the procurement process, which was signed off the by CCG’s Contract Procurement Management Group.
Members of the Evaluation Panel had been required to complete confidentiality and declaration of interests forms – no conflict of interests had been identified.
The procurement process included three stages, with three bidders initially identified at the Pre-Qualifying stage. Bidders were asked to submit further documentation for the next stage, including financial information. One response was received, with the two other bidders withdrawing from the process. The outcome from the Evaluation Panel was unanimous and scored the bidder above the threshold. The bidder was invited to the interview and presentation stage, which identified them as being well above the minimum criteria for award of contract.
The bidder was a non-profit making organisation across most of the Wandsworth practices. They were able to demonstrate their experience and understanding of the challenges, and their success in delivering a number of existing contracts which would be key enablers going forward. A number of areas had been highlighted for further assurance, which would be explored pending the Board decision, before any move to contract signature and rapid implementation.
The paper recommended award of the contract to Battersea Health Care Community Interest Company (CIC) subject to assurances as outlined in the paper.
NJ noted thanks to the members of the Evaluation Panel, and acknowledged the involvement of some members of the Board in the process.
Comments and questions were invited from members of the Board:
This had been a rigorous process, with a lot of preparation. The Evaluation
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Panel had been impressed at the presentation stage regarding the quality of thinking behind the proposals and enthusiasm of the bidder.
Healthwatch representation had been included in stage three of the process, and their enthusiasm for the recommendation was noted.
It was acknowledged that the proposed contract was for ten years, with a value of £200m.
Level of assurance regarding overall leadership of the MCP – It was acknowledged that the bidder was still a young organisation. During the Evaluation, a lot of scrutiny had been placed on the organisational structure of the organisation and timelines. Further work was required to provide assurances around general leadership and governance. Further discussions would be required regarding the structuring of the partnership with the CCG and further potential stretch. The outline assurance process would be discussed by MT prior to contracts being signed.
Services will be introduced in a phased approach with gateways for assurance to the CCG around delivery.
Organisation Development plan – It would be useful to have more assurance around delivery of the OD plan. – Development of the organisation would continue, and there was full awareness within the organisation of their current position, where they would need to be, and what is required to take on this contract.
Leadership – Leadership of the organisation continues to develop. There are a number of strong clinical leads in place. The organisation includes thirty-nine practices in Wandsworth - the three remaining practice contracts are managed on a different basis and not included in the CIC, but the CIC demonstrated that they were able to work with those three practices to deliver the contract. Previous small value contracts have been issue on a short term basis, which means that the CIC has not been able to put in place a critical core mass of staff. This had been raised by the Evaluation Panel, who was assured that, although this was still in development, there was a strong understanding of what was required.
Pace to develop the organisation – This organisation would be looking after the welfare of the CCG’s patients. The CCG has a role to help the organisation develop in a formative way and make sure there is assurance that is to the benefit of patients. – The CIC was keen to establish a collaborative partnership with the CCG and fully acknowledged the level of learning required. The Evaluation process included much time spent on the concept of the Lead Provider, and the Panel agreed that this was a reasonable ask at this stage and was a safe process.
SGH Community Services contract – The contract for Community Adult Health Services (CAHS) with a value of £16m, has been commissioned with SGH for this year. The Board had previously agreed to serve notice on the contract to SGH for 2017/18 – this could present a risk to SGH.
Engagement – The CIC had undertaken engagement with their members. A discussion had been held on how the organisation would respond as commissioners to any issues raised in practices and onward engagement with practices. They had described how the organisation would support their members, while acknowledging that sometimes more input may be required. The organisation’s long term vision was aligned with the CCG’s aspirations, with an aligned end point although the journey to achieve this would need to be worked through.
Local Authority – The LA had been included in the procurement process, which was seen as an exciting development to provide a real basis for people to receive well-coordinated care out of hospital. The LA was keen to continue to be part of that on-going journey. OD learning around partnership working should include the wider form and the LA was keen to be included in the on-
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going development of the CIC.
Patient and Public Involvement (PPI) – Currently, the CIC was an unknown organisation, if agreed as the Lead Provider for the MCP they would have to start to be more outward facing, with more PPI, and meetings in public. This should be included as part of the OD plan.
Recruitment of nurses – The CIC already has an education provider network in place and was confident that they can start to roll out more programmes to attract and retain nurses.
Interaction with SGH – SGH was keen to have the Federation take on more services and will take forward any opportunities for more services to be done in this way, where this was identified as the best way forward.
Following the discussion, the Board was asked whether they approved the recommended award of the contract to Battersea Health Care CIC, subject to the assurances required, OD plan, and due diligence. The Board agreed the recommendation.
16/103 Talking Therapies procurementIn July 2015, the Board had agreed a decision to re-procure the Improving Access to Psychological Therapies (IAPT) service. Work was done over the past year, with engagement from users and carers, to develop a new specification for Talking Therapies, which would be rolled out to provide benefit to more people in Wandsworth, aligning with prevention, and self-help, to address issues earlier in the pathway.
The specification was published on the procurement portal with an invitation to tender. Nineteen expressions of interest were received, of which three bidders went through to the evaluation phase. The scores of the Evaluation Panel identified a clear preferred provider. Two bids went forward to interview stage, from which there was a clear preferred provider. Three pre-conditions to contract signature have been identified around Crisis Planning systems, hard of hearing/sensory impairment, and suicide prevention.
On the basis of the process outlined, the view from the clinical lead, procurement support from NHS SBS, and support from users and carers, the Board was asked to approve award of the contract.
Comments and questions were invited from members of the Board:
This has been a good process, with the potential to use for other suitable procurements.
Assurance regarding performance issues – The issues around performance had been debated, with the Performance Manager included on the Evaluation Panel. All best practice for procurement had been followed, with a rigorous methodology used to evaluate the very high quality bids. This was a known provider and all of the mitigations and any performance issues would be picked up through the implementation process. Clear contract levers would also be in place.
Domiciliary service for housebound patients – This had been provided for within the specification. It was not known how patient transport would work, but this would only apply to a small number of patients.
Service users had been involved in the process and were happy to support the process and recommendation.
The Board was asked to approve award of the contract to bidder two, subject to delivery of the pre-conditions. The Board approved the recommendation.
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16/104 Battersea Locality Annual ReportEmma Gillgrass (EG), Locality Manager, and Sue Marshall (SM), Patient Representative, attended the meeting.
The following highlights from the report were noted:
The Locality includes twelve practices, with seventy-two GPs, covering a population of 96k patients. The population was diverse and vibrant, with areas of contrast regarding income, access, and cultural influence on health. The opportunities and challenges were similar across Wandsworth.
Significant input had been received from Public Health, providing data to inform work in the Locality.
In comparison with other Localities, Battersea had more complexity regarding providers with more choice of hospitals. However, this complexity provided some challenges regarding access to information. A solution to achieve better access to information at St Thomas’ Hospital was due to be put in place.
At the centre of the work in the Locality is the monthly GP Forum, with good engagement from practices and sharing of ideas for patient care. That level of engagement is continued in Locality meetings. The format of these meetings is split into two section – the first section includes constructive discussion around issues such as collaboration, feedback from patient groups on services, quality issues of commissioned services; the second section includes representation from specific commissioned services, and commissioning ideas generated from members, some of which are rolled-out to benefit all Wandsworth patients.
There was a strong level of patient participation and involvement, providing real meaning. There is a vocal patient group in Battersea, with the opportunity to feedback from other practices. The Members’ Forum includes two patient attendees from the Locality.
Initiatives:o Public Health works with the Locality to identify need and projects that
can be initiated.o Mindfulness courses – The course had initially started in Thurleigh Road
practice, and has since been rolled-out to all practices. Pre and post course surveys are completed by attendees, which indicate an increased level of confidence to deal with stress, improvements in sleep and general mood.
o Parenting Courses – This course was now being rolled-out to all Battersea practices. Seven courses have been held over the past year, with thirty new mothers attending. Pre and post course surveys provided positive feedback for the course.
o Birthday Card Scheme – The scheme has been implemented with Public Health support, to increase uptake of immunisations. Seven hundred cards had been sent out, with the effect that pre-school boosters mainly had increased, with a smaller increase in other immunisations.
o Obesity in Children – The aim of the project is to identify children earlier, with weight/height being measured when children receive their pre-school booster, and onward referral if required to weight management services. Results from the project were currently being analysed.
o Patient Welfare Advice Service – This service provides non-medical advice and support, working with Citizens Advice Bureau (CAS), Family Action, and DASCAS (Disability & Social Care Advice Service). Practices had referred one hundred and seventy patients to CAS. Feedback received indicates that the service has enhanced the quality of life and met users needs.
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As well as continuing the work around Childhood Obesity and Mindfulness, the following three priority areas would be taken forward in the coming year: COPD/Smoking; Cervical Screening; Learning Disability (LD) annual health checks.
Comments and questions were invited from members of the Board:
Good input received from Public Health. With the recent changes, PH would ensure continuity of input to the Locality.
Nine Elms Vauxhall (NEV) liaison – NW sits on the NEV Project Team on behalf of Battersea, which works with the Programme Board, and also provides clinical representation from the CCG.
Childhood Obesity – Learning from discussions with parents and onward referrals agreed, should be cascaded out to general practice and other services.
It was important to pull processes together across Localities to make sure that those most effective are applied in a common way.
NJ thanked the Battersea Locality team for the report and work done over the past year.
16/105 Lay Member Board RolesPart of the response to the revised statutory guidance for CCGs, was a requirement for each CCG to move from two to three Lay Members. The proposal has previously been reviewed, and supported, by the Integrated Governance Committee.
Consideration has been given around the roles and definitions for each of the Lay Member roles. It was proposed that the description for the Governance role should include the new Conflicts of Interest Champion. The PPI lead description would be retained. The third role would have a specific focus on finance, to help maintain financial control and financial forward look.
It was acknowledged that the current terms of office for both the Governance and PPI Lay Member roles were due to end at different times in 2017. Therefore, it was proposed to recruit to all three roles at the same time in the next few months, with staggered start dates for each role. The priority would be to recruit for the third post as soon as possible. The IGC discussion stated that the aim should be to have this post in place for January.
Comments and questions were invited from members of the Board:
Time requirement for three days per month was probably under-stated, and the salaries quite high. – It was noted that the salaries and time requirement has been benchmarked with other CCGs. It would be more important to reflect on appropriate use of time. Two Associate Lay Member posts would be retained, therefore, an overall sharing of responsibility would be appropriate to do.
The recommendation for a third Lay Member was agreed.
16/106 Executive ReportThe content of the report was noted.
16/107 Finance ReportThe Month 5 position builds on that previously reported at Month 4. The following
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key points were noted:
Targets still on track to be achieved.
QIPP target is unlikely to be achieved. Current under-performance of £1.6m-£2m, which was currently being offset from reserves, but there was a risk, as previously discussed, that the under-performance will continue.
Finance Recovery Group had now been set up to look in detail at contracts and QIPP.
Continuing Health Care – This remains an area of significant risk. It was expected that work would be done to review packages of care.
Acute – An increase had been reported at both SGH and Chelsea and Westminster.
Prescribing – Some benefit had been seen from some technical adjustments (one-off), and some changes in national prices have been factored in.
Balance position was currently being covered from reserves, but there was a risk if QIPP programmes are not achieved.
Planning Guidance had now been issued, which formalised information previously known. Two-year contracts would be put in place from 2017 – discussions with providers were starting to happen as part of the contract round.
Headlines:
Expectation that CCGs will achieve break even in-year.
No potential to draw down surplus from previous year – to be clarified.
1% non-recurrent reserve will have to be retained – 0.5% uncommitted, and 0.5% to be available for transformation.
CQIN – Previously set at 2.5%, only 1.5% to be available to providers to hit national targets next year.
Business rules generally in line with 16/17, to include 0.5% contingency, and 0.1% tariff uplift. The impact on CCGs this year from the tariff uplift had not taken into account the increase across all providers, which was probably nearer 0.8% rather than 0.1%.
Timetable:
1st November – initial Operating Plan submission
4th November – Contract offers to be issued to providers
24th November – first full draft of Operation Plan to be submitted
Final signed contracts by end of December
Comments and questions were invited from members of the Board:
Contracting round risk – The potential risk to the CCG will need to be considered.
Transformation funding for providers – STF funding includes two elements around financial targets and performance targets. Work was being done to work that through.
The content of the report was noted.
16/108 Performance ReportThe following key points were noted:
SGH – As noted in the earlier item.
Clinical Priority Area Assessment – This had now been published for Cancer to include four indicators. Wandsworth was rated as Needs Improvement, with
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the worst element around the sixty-two day target.
A&E – Performance at SGH had improved.
RTT data relates to other providers not SGH.
Mental Health – Most of the indicators were being met.
IAPT Recovery rates – Performance was improving.
Board Assurance Framework – A summary had been included in the report. The full report would be presented to the meeting in December.
The content of the report was noted.
16/109 Summary MinutesThe content was noted.
16/110 Any Other BusinessNone.
16/111 Open SpaceNo questions were received from members of the public.
16/112 Clinical Chair’s Closing RemarksThis had been a very full Agenda with a number of important issues discussed.
There being no further business, the meeting closed at 12:20
Date of next meeting: 14th December 2016
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Summary of discussion from Part II of the Board meeting held on 12th October 2016
Feedback was received from the members of the Board on the Part I meeting.
Procurements – Procurement and legal advice had been received, which stated in accordance with best practice guidance, that approval for procurement could be dealt with in Part I, unless there was a commercial in confidence issue, with names of bidders removed from the paper. Following discussion of the points raised, it was agreed that future procurements should be discussed and agreed in Part II, with decisions ratified at the next meeting in public.
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Role Status Name Details of Declaration Committee membership Comments
Wandsworth CCG - Governing Body (Chair); Integrated
Governance Committee (Chair); St George's Hospital Clinical
Commissioning Reference Group (Chair); Management Team
SWL - Chair System Resilience Group; Clinical Lead SWL &
Surrey Downs Health Care Partnership Clinical Board and
Programme Board; Clinical Lead for SWL & Surrey Downs
Health Care Partnership Clinical Board and Programme
Board, and Clinical Lead for SWL Transforming Primary Care
Programme;
Wandsworth - Health and Wellbeing Board
Wandsworth CCG - Governing Body; Management Team;
Integrated Governance Committee; Finance Resource
Committee; Audit Committee; Remuneration Committee;
Primary Care Committee; Workforce Committee
SWL - System Resilience Group
Wandsworth - Health and Wellbeing Board
Chief Finance Officer Voting Member Neil McDowell Spouse employed by Guildford and Waverley CCG Wandsworth CCG - Management Team; Audit Committee;
Finance Resouce Committee
Wandsworth CCG - Governing Body (Vice Chair); Finance
Resource Committee (Chair); Audit Committee (Chair);
Remuneration Committee (Chair); Workforce Committee;
Primary Care Committee
Removed interests - Chair, St George's Hospital Charity (term
ended September 2016); Member DLF Advisory Board;
Member Shaw Trust.
Wandsworth - Health and Wellbeing Board
Lay Member for Patient and
Public Involvement
Voting Member Carol Varlaam Trustee & Vice Chair, St George's Hospital Charity; Trustee, Wandsworth Care
Alliance; Member St George's University Hospital Foundation Trust
Wandsworth CCG - Governing Body; PPI reference Group
(Chair); Primary Care Commissioning Committee (Chair
elect); Audit Committee; Integrated Governance Committee;
Remuneration Committee; Communications and
Engagement Working Group.
Secondary Care Doctor Voting Member Andrew Neil None Wandsworth CCG - Governing Body; Integrated Governance
Committee; Information Governance Committee (Chair)
Registered Nurse Voting Member Diana Caulfield-Stoker Trustee Cavell Nurses Trust; Member Moorfields NHS Trust Wandsworth CCG - Governing Body; Integrated Governance
Committee (Vice Chair); Quality Group (Chair); Safeguarding
Sub-Committee (Chair)
West Wandsworth Joint
Locality Lead
Dr Zoe Rose GP Partner Putneymead Group Medical Practice (Holds PMS contract). Practice
is a member of the Wandsworth GP Federation(Battersea Healthcare CIC). No
roles or responsibilities held in GP Federation
Wandsworth CCG - Governing Body; Management Team;
West Wandsworth Locality Forum and Management Team;
Primary Care Committee; Primary Care CQRG (Chair)
Practice is a member of Battersea Healthcare CIC but Dr Rose
holds no director post and has no specific responsibilities
within that organisation other than those of other Member
GPs.
West Wandsworth Joint
Locality Lead
Dr Rumant Grewal GP Principal, Lead for Mental Health, Substance Misuse, Primary Care
Research, Referrals Management; on-going work as named author for a
Cochrane Review
Wandsworth CCG - Governing Body; Management Team Practice is a member of Battersea Healthcare CIC but Dr
Grewal holds no director post and has no specific
responsibilities within that organisation other than those of
other Member GPs.
Wandsworth CCG - Governing Body; Management Team;
Integrated Governance Committee; Finance Resource
Committee; Communications and Engagement Group;
Quality Group; St George's Clinical Quality Review Group;
Community Services Wandsworth Clinical Quality Review
Group (co-Chair); Clinical Scrutiny Group; Primary Care
Transformation Group; Wandle Locality Forum (co-Chair)
South West London - Clinical Advisory Group member;
Clinical Lead for Maternity Clinical Design Group
Voting Member Stephen Hickey Chair Community Transport Association;
Voting MemberWandle Joint Locality Lead
Declarations of Interest - Board Members 2016
Voting Member
Chair Voting Member Dr Nicola Jones Managing Partner Brocklebank Group Practice and St Paul's Cottage Surgery.
Both practices hold PMS contracts. Clinical Lead for Cardio Vascular Disease,
WCCG.
Practice is a member of Wandsworth Integrated Healthcare
Ltd but Dr Nicola Jones holds no director post and has no
specific responsibilities within that organisation other than
those of other member GPs.
Chief Officer Voting Member
GP Partner, Grafton Medical Partner; GP Partner, Lambton Road Medical
Partnership; Director, Raynes Park Health Ltd (building management company;
London Maternity Lead, Royal College of General Practitioners; Volunteer
Doctor, Crisis homeless charity; Member Agenda advisory panel, UK Health
Informatics Forum; Member London Clinical Senate Forum; Non-voting
Member of the Clinical Expert Panel for Maternity of the CCG Improvement and
Assessment Framework (IAF)
Dr Michael Lane Practice is a member of Battersea Healthcare CIC but Dr Lane
holds no director post and has no specific responsibilities
within that organisation other than those of other Member
GPs.
Graham Mackenzie Spouse is employed by Imperial College NHS Trust.
Lay Member for Governance,
Vice Chair
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Battersea Joint Locality Lead Dr Nicola Williams Partner Battersea Rise Practice Wandsworth CCG - Governing Body; Delivery Group;
Management Team; Primary Care Transformation Group;
Primary Care Quality Group
Practice is a member of Battersea Healthcare CIC but Dr
Williams holds no director post and has no specific
responsibilities within that organisation other than those of
other Member GPs.
Battersea Joint Locality Lead Dr Jonathan Chappell GP Partner Battersea Fields Practice Wandsworth CCG - Governing Body; Management Team;
Integrated Governance Committee; Finance Resource
Committee;
Practice is a member of Battersea Healthcare CIC but Dr
Chappell holds no director post and has no specific
responsibilities within that organisation other than those of
other Member GPs.
Wandsworth CCG - Governing Body; Management Team;
Integrated Governance Committee; Finance Resource
Committee; Audit Committee; Remuneration Committee;
Primary Care Committee; Workforce Committee
South West London - System Resilience Group
Director of Corporate Affairs,
Performance and Quality
(Maternity Leave)
Non Voting Member Sandra Iskander None Wandsworth CCG - Governing Body; Management Team;
Integrated Governance Committee; Workforce Committee;
Information Governance Group
Wandsworth CCG: Board; Management Team; Integrated
Governance Committee; Delivery Group; GP Resources
Committee; Primary Care Implementation Group; Primary
Care Transformation Group (co-Chair); Estates Steering
Group; Business Intelligence Group
SWL: SRO SWL Out of Hospital Clinical Delivery Group
Director, Commissioning and
Planning
Non Voting Member Rebecca Wellburn None Wandsworth CCG - Management Team; Integrated
Governance Committee
Local Authority Director of
Public Health
Non Voting Member Houda Al Sharifi None Wandsworth CCG - Governing Body
Local Authority Director of
Children's Services
Non Voting Member Dawn Warwick None Wandsworth CCG - Governing Body
Healthwatch Wandsworth Non Voting Member Jamie Gillespie Executive member Healthwatch Wandsworth; Family member employed by
SLAM; Affiliations - 38 Degrees member, SNP member
Wandsworth CCG - Governing Body
Associate Lay Member Chris Savory Advisor Interserve PLC Ltd; Advisor to Liberata and Capacity Grid; Member of
the Dorset NHS Trust
Wandsworth CCG - Integrated Governance Committee;
Finance Resource Committee; Audit Committee;
Remuneration Committee
Associate Lay Member Kimball Bailey Director of Alastor - an independent management consultancy practice that
has, over the past five years, carried out work directly or indirectly for the
Department of Health and various NHS Trusts and other organisations
(including Springfield Hospital). None of this has had a direct impact on
commissioning nor is material to my role as Associate Lay Member for
Governance; member of Essentia advisory board
Wandsworth CCG - Integrated Governance Committee; Audit
Committee; Remuneration Committee; Estates Committee
SGH CQRG Clinical Lead Tom Coffey Partner, Brocklebank Group Practice; MICAS Advisor/OD Lead Battersea
Healthcare CIC; Clinical Assistant A&E Charing Cross Hospital; Advisor EY
(Ireland); Informal advice to London Mayoral candidate Sadiq Khan
Wandsworth CCG - Management Team; SGH CQRG (Chair)
Wandle Joint Locality Lead Voting Member Dr Seth Rankin Partner - Wandsworth Medical Centre; Director - London Travel Clinic Ltd
providing private travel vaccinations; Director - London Doctors Clinic Ltd
providing private GP services; Director - Medilaser Ltd (trading as Wandsworth
Village Skincare) providing cosmetic and medical laser therapy not available on
the NHS; Director - Rankin Press Ltd (dormant) intending to publish books;
Director - Healthy Lifestyle Enterprises (dormant) intended to provide and
deliver weight management programmes; Director - Ezimed Ltd intended to sell
networked panic alarm buttons to GP surgeries; Trustee - Sustainable Medical
Charities International (CIO) providing the resources to deliver healthcare to
the people of Darsilameh Village in the Upper River Region of The Gambia;
Consulted by Circle Partnership in Community Services Redesign;
Advisor/consultant to the Nuffield Trust about Virtual Wards in Community
Services; Consulted by The Sollis Partnership about risk prediction modelling of
patients in primary care
Wandsworth CCG - Governing Body; Management Team;
CAHS Project
Practice is a member of Battersea Healthcare CIC but Dr
Rankin holds no director post and has no specific
responsibilities within that organisation other than those of
other Member GPs. Resigned wef 01/10/2016
Director of Corporate Affairs,
Performance and Quality
Non Voting Member Sean Morgan Substantive employer is South East CSU Wandsworth CCG - Governing Body; Management Team;
Integrated Governance Committee; Workforce Committee;
Information Governance Group; Primary Care Committee
Stepped down from Board role wef 11/10/2016
Director of Primary Care
Development
Non Voting Member Andrew McMylor None
Chief of Commissioning
Operations
Non Voting Member Lucie Waters None
Voting Member
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Last updated 17/08/2016
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Meeting
date
Minute
No.Item Lead Decision Action Target Date Progress
Date
CompletedConflicts of Interest
Action to manage
Conflicts
Request for Chair's
ActionApologies Quorate
16/101 Clinical and Operational Focus - St
George's Hospital
LW Further consideration on how to take work
forward would be discussed by MT
ASAP
16/102 Multi-specialty Community
Provider (MCP) procurement
AM Board agreed the recommendation to award
the contract to Battersea Health Care CIC
16/103 Talking Therapies Procurement LW Board approved award of the contract to
bidder two, subject to delivery of the pre-
conditions.16/104 Battersea Locality Annual Report NW/JC
16/105 Lay Member Board Roles GM Recommendation to proceed with
recruitment of a Lay Member was agreed
S Hickey and C Varlaam -
current Lay Members
No action required
16/106 Executive Report GM
16/107 Finance Report NM
16/108 Performance Report SM
None None Yes
LOG OF DECISIONS AND ACTIONS - Board
12/10/2016
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Part B: Decisions and Discussions
Page
2. Part B: Decisions and Discussions 20
2.1. B01 Operational Focus - St George's Hospital
2.2. B02 Clinical Focus - Continuing Health Care 21
2.2.1. Equity and Choice Policy 30
2.3. B03 London Health Devolution 60
2.4. B04 Board Assurance Framework 88
2.5. B05 Policies 128
2.5.1. Prime Financial Policies 128
2.5.2. Managing Conflicts of Interest 132
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W A N D S W O R T H C C G P A G E 1 O F 8
Continuing Healthcare Clinical FocusAuthor: Debbie Baronti Sponsor: Rebecca Wellburn Clinical Sponsor: Andy Neal Date: December 2016
Executive Summary
Context
NHS Continuing Healthcare is a needs led service; the CCG has responsibility for commissioning care that meets the needs of eligible patients. Eligibility to CHC is based on assessed need and not on the patient’s ability to pay, therefore if an individual's health needs change, responsibility for funding their care and support may also change. This is a complex and highly sensitive area which can affect individuals at a difficult stage of their lives and can be a very challenging time for them and their families who are often called on to make difficult decisions. It is therefore important that the process and decision making is robust and transparent for all parties.
This paper provides an overview of the WCCG Continuing Healthcare Service and outlines
the process of assessment to establish eligibility for NHS Continuing Healthcare. The paper
also summaries the legacy issues arising from the service delivered by the previous provider
and summaries the actions taken to address these by the CCG and CHS Healthcare since
the service transitioned to the new provider in April 2016.
Question(s) this paper addresses
1. What is CHC and how is eligibility decided?
2. CHC in Wandsworth; what are the current issues?
3. What is the role of the CCG (market management, quality assurance, funding)
Conclusion
1. NHS CHC is a package of care arranged and funded solely by the NHS for patients
aged 18 or over; eligibility is assessed through a legally prescribed decision-making
process based on assessed need.
2. The previous service provider was decommissioned due to poor performance and the
service transitioned to the new provider from 1 April 2016; a range of legacy issues
were identified following transition.
3. The CCG has a duty to provide care to a person assessed as eligible for continuing
healthcare in order to meet their assessed needs.
Input Sought
We would welcome the board’s input regarding the issues raised in this report and for the
Board to note its contents
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [
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W A N D S W O R T H C C G P A G E 2 O F 8
1. What is CHC and how is eligibility decided?
What is CHC?NHS continuing healthcare (NHS CHC) is a package of care arranged and funded solely by the NHS for patients aged 18 or over to meet physical or mental health needs arising because of a disability, accident or illness. NHS Continuing Healthcare provision can take the form of a care home placement or a package of care in the individual's own home or elsewhere.
How is NHS CHC eligibility decided?
In order for someone to receive NHS Continuing Healthcare funding they have to be assessed according to a legally prescribed decision-making process to determine whether they have a 'primary health need'. NHS CHC eligibility decisions are based on whether the patient’s needs for long term care are primarily health related because of complicated, intense or unpredictable healthcare needs. Therefore eligibility is not based on a specific condition or diagnosis and people with the same health condition can have very different needs. The CCGs responsibility to commission, procure or provide care, including NHS Continuing Healthcare, is not indefinite, as needs can change. If the CCG is commissioning, funding or providing any part of the care, a case review should be undertaken three months after the initial eligibility decision (or sooner if needs are thought to have changed), in order to reassess care needs and eligibility for NHS CHC and to ensure that those needs are being met. Following this reviews should then be undertaken annually, as a minimum.
The process to assess eligibility is described in the National Framework for NHS continuing healthcare and NHS-funded nursing care and once consent has been obtained and capacity established one or more of the following tools will be used in the process:
Fast Track Tool.
The Checklist
Decision Support Tool
Fast Track Tool - if a patient has a rapidly deteriorating condition and appears to be reaching the end of their life, the Fast Track Tool can be used to recommend they move quickly onto NHS CHC.Fast tracking is not the usual way and in most cases the type and level of needs should prompt staff to apply the Checklist.
Checklist – The first step in the process for most patients will be a screening process using the NHS Continuing Healthcare checklist; a positive Checklist triggers a full assessment of need. If a patient is about to be discharged from an acute hospital and has significant health and care needs, consideration should be given as to whether they have the potential to improve if offered services such as rehabilitation or intermediate care in a community hospital or other setting before applying the Checklist. If additional services are provided the Checklist should be applied at the end of this period, when the patients’ needs are clearer.
Decision Support Tool (DST) -. Where completion of the checklist triggers a full assessment the
DST is applied; the DST features 12 ‘domains’ or areas of need which are considered to decide if the quantity and/or quality of care needed fulfils criteria for a ‘primary health need’. The 12 domains are:
Behaviour
Cognition
Psychological & emotional needs
Communication
Mobility
Nutrition, food and drink
Continence
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W A N D S W O R T H C C G P A G E 3 O F 8
Skin & tissue viability
Breathing
Drug therapies and medication
Altered states of consciousness
Other significant care needs to be taken into consideration
Each domain has descriptions of between four and six levels of need ranging from no need through
to severe and priority. Consideration is given to the nature, intensity, complexity and unpredictability of the needs. The DST is completed by a multi-disciplinary team (MDT), which in turn informs the eligibility recommendation to the CCG. The multidisciplinary team (MDT) is defined in the framework as:
two professionals from different health professions or
one professional from a healthcare profession and one who is responsible for assessing individuals for community care services.
Whilst as a minimum an MDT can comprise two professionals from different healthcare professions, the CCG endeavour to follow best practice by including both health and social care professionals who are knowledgeable about the individual’s health and social care needs in the MDT.
Involving the patient and their family is a core component of the MDT process.
The MDT recommendation is required to be ratified by the CCG within 28 days of the receipt of a positive checklist; this is a quality target for the CCG. The allocation of Social Workers to attend the MDT is a potential risk factor to achieving the 28 day deadline for decision. Therefore whilst every effort is made to include a Social Worker in the MDT, in line with the guidance, the MDT can progress without a social worker if necessary.
A flow diagram of the decision making process is attached at appendix 1. A copy of the Decision
Support Tool can be found at www.gov.uk/government/uploads/Decision_Support_Tool
Case study
Mrs W lived in the community and was known to Social Services Her social worker noticed a decline in her general health – a checklist was completed by
the Social worker which triggered a full CHC assessment. The checklist was received by the CHC team and the case was assigned to a nurse
assessor. The nurse assessor completed the LHNA and gathered all relevant data from other
professionals. The nurse assessor arranged to complete DST for Mrs W The Primary Health Needs test was applied by the MDT – Mrs W was CHC eligible The DST was sent to the CHC team leader who ratified the MDT recommendation for CHC The CHC brokerage team worked with the nurse assessor to source the appropriate care
provider or care home.
2.CHC in Wandsworth; what are the current issues?
Following concerns about the service delivered by the previous provider the CHC service was recommissioned and transitioned to the new provider CHS Healthcare (CHS) on a phased basis, with CHS taking responsibility for the full caseload from 1 April 2016.
Although concerns had been identified previously the full range and extent of these became evident following transition; these are described below together with the steps taken to date.
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W A N D S W O R T H C C G P A G E 4 O F 8
Growth and forecast spend - A full reconciliation of the database has been undertaken since
transition to cross reference the current caseload in terms of the number of eligible clients, care
commissioned and costs to ensure that all elements are being fully captured and reported. The table
below tracks the month by month impact of this work as the true caseload numbers and the
associated costs have fully emerged. The forecast outturn at month 7 includes these additional
costs which, although already committed at month 1, were not visible. As a result there is a
significant cost pressure against the budget position for the service because the month 1 position
was understated.
YTD
num
ber
Variances 16/17 Budgets
Full Year Outturn
including one
time cost for
CHC FNC Total CHC FNC CHC FNC CHC FNC
M1 313 226 539 - - £23,494,694 £2,061,020 £21,237,887 £684,250
M2 311 231 542 -2 5 £23,494,694 £2,061,020 £22,881,160 £1,378,202
M3 340 215 555 29 -16 £23,494,694 £2,061,020 £26,412,362 £1,268,584
M4 352 213 565 12 -2 £24,041,471 £1,514,243 £26,868,687 £1,589,920
M5 352 221 573 0 8 £24,041,471 £1,514,243 £27,442,411 £1,657,078
M6 363 229 592 11 8 £24,041,471 £1,514,243 £27,630,976 £1,963,379
M7 361 242 603 -2 13 £24,041,471 £1,514,243 £28,114,269 £2,064,698
Strengthening Commissioning & contracting processes – On transfer of the service in April our new provider, CHS Healthcare, implemented a range of measures to strengthen the commissioning and contracting arrangements with providers. One of these is a regular audit of care delivered against care commissioned from domiciliary providers. Since April this process has evidenced efficiencies that are expected to equate to 250k fye without any change to the care delivered to the patient.
Application of the checklist and use of the Fast Track tool A high proportion of new CHC referrals currently come via the Fast Track process and some disparity has been noted in the application of the Fast Track Tool. We have worked with St Georges, our main provider, to agree that the route for all Fast Track referrals will be via the Integrated Discharge Team, thereby ensuring consistent and appropriate application of the Fast Track Tool. In addition an audit of the use of the Fast Track tool has been completed to identify areas where additional training in compliance with the tool may be necessary. This will improve access and ensure eligible patients in this cohort are able to access care quickly.
Backlog of assessments – A case review should be undertaken three months after the initial eligibility decision and then, as a minimum, on an annual basis. Regular reviews are built into the process to ensure that where eligibility is maintained the care package continues to meet the person's needs. On transition of the service it was noted that routine reviews had not taken place since August 2015. These routine reviews of care needs can result in changes in eligibility/care packages where the patients’ needs have changed. Given that these reviews have not taken place the CCG has no assurance that the care commissioned continues to be appropriate to meet the level of assessed need. The CCG has therefore commissioned a fixed term project to undertake this work, which commenced with a clinical triage/desk top review of individual patients and relevant assessments to identify high risk cases. This project is due for completion by March 2017.
24hr domiciliary care - There has been a tendency to allocate 24 hour packages of care for domiciliary patients referred via the Fast Track process. Care packages at home will, on the whole, be more expensive than a Nursing Home placement in cases where the patient requires 24 hour
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W A N D S W O R T H C C G P A G E 5 O F 8
care with two 12 hour shifts. Analysis of September data identified 28 patients with 24 hour care packages commissioned by the previous provider at a full year cost of £4.8m.
The CCG aims to commission the provision of NHS funded Continuing Healthcare in a manner which reflects the choice and preferences of individual patients and their families whilst ensuring we meet our statutory responsibilities for patient safety, quality of care and making best use of resources. Whilst the CCG will take into account the views of the individual so far as is possible, the CCG must consider a range of factors and must comply with its statutory financial obligations. The final decision as to the care package is one for the CCG; however it will act on all reasonable requests to the best of its ability.
As a result of the lack of routine review by the previous provider the CCG needs to seek assurance, through the backlog review project, that the packages of care commissioned are safe, appropriate to meet the assessed needs and represent value for money. The review process offers an opportunity to consider efficiencies within the care commissioned. As an example the current average weekly cost of 12 hour shifts is £3100 compared to the AQP rate for live in care at tier 3 of £1300 per week.
High Cost Packages - Continuing Healthcare is based on delivering care to meet the patients assessed need. There are currently 115 clients within Wandsworth who are classified as high cost, in that the care they are receiving exceeds the threshold of £1500 per week. It is recognised that there are some clients whose clinical condition means that they will require an on-going and sometimes increasingly high cost package of care. However as follow up reviews have not been undertaken the CCG needs assurance that the packages of care commissioned are safe, appropriate to meet the assessed needs and represent value for money
Social care
Health and social care systems are underpinned by a number of different legal frameworks and funding systems. Social care, unlike NHS services, is subject to means tested charges.
The increasing pressures on social care arising from an ageing population and the impact of budget restraints are placing a greater emphasis on the accessibility of continuing healthcare and it is important that we ensure that eligibility criteria are consistently and robustly applied in line with the CHC Framework so that patients are treated in a fair and equitable way. The funding arrangements for ongoing care are complex and it is recognised that this is a highly sensitive area which can affect individuals at a difficult stage of their lives and can be a very challenging time for families who are often called on to make difficult decisions.
Eligibility to CHC is based on assessed need and not on the patient’s ability to pay. If an individual's health needs change, responsibility for funding their care and support may also change and it is important that the process and decision making is transparent for all parties.
Our CHC Commissioning and Choice and Equity Policies will set out the process to determine eligibility and our approach to the commissioning of care packages for eligible patients.
Delay in hospital discharge
The constraints within the system described above can impact on the ability to source appropriate care packages for eligible patients in a timely manner which can result in delay in hospital discharge, placing additional pressure on hospital beds.
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W A N D S W O R T H C C G P A G E 6 O F 8
3.What is the role of the CCG?
Care home market
The CCG has a duty to provide care to a person assessed as eligible for continuing healthcare in order to meet their assessed needs. An individual or their family/representative cannot make a financial contribution to the cost of the care identified by the CHC team as required to meet the individual’s needs. An individual however, has the right to decline NHS services and make their own private arrangements
Many patients who require Continuing Healthcare will receive it in a specialised environment. The treatments, care and equipment required to meet complex, intense and unpredictable health needs often depend on such environments for safe delivery, management and clinical supervision. Specialised care, particularly for people with complex disabilities may only be provided in a specialist Care Home, which may sometimes be distant from the patient’s ordinary place of residence. These factors mean that there is often a limited choice of safe and affordable packages of care.
Market Management
The CCG has a responsibility to work with providers to ensure suitable, high quality and affordable care for our patients. The CCG has participated in the pan London AQP Domiciliary Care procurement through which a number of new providers were identified. These providers are now
being rolled out for newly commissioned packages of care.
The CCG also previously participated in the pan London AQP Care Homes procurement. This framework ensures consistent standards of care are applied across a range of providers. However as there is a large contingency of self-funding clients within Wandsworth this results in lower interest from Care Homes in participating in the AQP Framework and therefore placements sometimes have to be made outside of the AQP Framework.
FundingThe CCG holds the responsibility to promote a comprehensive health service on behalf of the Secretary of State and we must not exceed our financial allocation. |The CCG is expected to take
account of patient choice but must do so in the context of these two responsibilities. The CCG is therefore required to balance the patient’s preference alongside safety, quality and value for money.
Quality assurance
Quality Assurance within the NHS is made up of the three components - Patient Safety, Patient Experience and Clinical Effectiveness. We have a system of quality assurance which provides
information relating to safety, effectiveness and patient experience to support us to secure positive health outcomes from the care commissioned and improve the quality of the services delivered to our patients.
The CCG also needs to provide NHS England with assurance that arrangements are in place to
meet the overall strategic challenges for NHS Continuing Healthcare in terms of:
the delivery of the National Framework
assessment processes that achieve a consistent approach to eligibility
decision making that is sound and legally complaint
high quality care being delivered to those found eligible for NHS Continuing Healthcare
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W A N D S W O R T H C C G P A G E 7 O F 8
C O N C L U S I O N
This report has set out the process for establishing eligibility for NHS Continuing Healthcare and the actions undertaken to improve the management and delivery of the service since April 2016.
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W A N D S W O R T H C C G P A G E 8 O F 8
For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications [Yes]
The risks [Yes]
Impact on our reputation [Yes]
Impact on our patients [Yes]
Impact on our providers [Yes]
Impact on our finances [Yes]
Equality impact assessment [Yes]
Patient and public involvement [Yes]
1. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities [Yes]
Make the best use of resources, continually improve performance and deliver
statutory responsibilities [Yes]
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities [Yes]
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting [Yes]
Develop the CCG as a continuously improving and effective commissioning
organisation [Yes]
2. Executive Summaries should not exceed 1 page. [My paper does comply]
3. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does comply]
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Appendix 1 -Stages in the process to determine eligibility for NHS CHC
Ye
s
Individual possibly eligible for NHS CHC
Has rapidly
deteriorating
condition
FAST TRACK
Recommendation
by appropriate
clinician
CCG actions
request and care
arranged, ideally
within 48 hours
Could individual benefit
from further NHS
services?
Explain process and sources of
support; provide written
information and seek consent to
start process
Arrange services then review
progress.
Complete CHECKLIST involving
individual/their representative
Write to individual explaining
checklist outcome.
Eligible for next stage: Full needs
assessment + DECISION SUPPORT
TOOL (DST)
NHS appoint Nurse Assesor Identify
assessment information required for
consideration at multidisciplinary team
(MDT) meeting. Invite individual/their
representative to participate
MDT discusses needs, completes DST
and makes recommendation.
CCG verifies MDT
recommendation
Individual/representative sent
written explanation of decision and
completed DST. Where necessary
information
Eligible: care planning
discussions to agree care
package to be fully funded by
CCG.
Not eligible: care planning
discussions to agree how to
meet needs. Means test.
Review needs after 3
months then at least
every 12 months. May
need to reconsider
eligibility.
Not eligible for next stage.
Full health and social
care assessment to
identify eligible needs
then care
planning/means test
Appeal:
Local process then
Independent Review
Panel then
Ombudsman
If still unhappy
can use NHS
complaints
process
Ask CCG to
reconsider
CHECKLIST
outcome.
No
Yes No
Yes No
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W A N D S W O R T H C C G P A G E 1 O F 5
Equality and Choices PolicyAuthor: Debbie Baronti Sponsor: Rebecca Wellburn Clinical lead: Andy Neal Date: December 2016
Executive Summary
Context
Continuing Healthcare is a significant area of care for a vulnerable group of individuals. The CCG
needs to ensure that our processes for delivering CHC meet the requirements set out in the National
Framework; that they are clear and transparent and that our allocation of resources is applied
equitably with robust decision making that is legally compliant.
This paper provides an overview of the Continuing Healthcare Commissioning and Equity and
Choice Policies. These policies have been developed to strengthen our governance arrangements
for the service and provide assurance that the CCG is fully meeting its commissioning
responsibilities.
Questions addressed in this paper
1. Why do we need the CHC Commissioning and Equity and Choice Policies?
2. What are the risks and opportunities associated with implementation?
3. What are the risks of delaying approval?
Conclusion1. The CCG needs to ensure that our processes for delivering CHC meet the requirements
set out in the National Framework and are clear and transparent, applied equitably and that
our decision making processes are robust and legally compliant.
2. Care may not be aligned to meet assessed needs and our commissioning decisions may
be viewed as inequitable and open to challenge. The policies will support transparent, fair
and equitable decision making.
3. There will be no clear and transparent framework for decision making and allocation of
resource.
Input Sought
To note the contents of the report and approve
the CHC Commissioning and Equity and Choice
Policies
Input Received
The draft policies have previously been shared
with Management Team and Capsticks
Context
W A N D S W O R T H C C G P A G E 1 O F [ X ]
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W A N D S W O R T H C C G P A G E 2 O F 5
NHS continuing healthcare is a package of care arranged and funded solely by the NHS for patients
aged 18 or over to meet physical or mental health needs arising because of a disability, accident or
illness. In order for someone to receive NHS Continuing Healthcare funding they have to be
assessed according to a legally prescribed decision-making process to determine whether they have
a primary health need. WCCG is responsible for commissioning and procuring services for
Wandsworth patients who qualify for NHS Continuing Healthcare and in meeting our commissioning
responsibilities the CCG must balance a number of issues. The fundamental challenge is how we
allocate our limited resources to best serve the local population as a whole, whilst also having due
regard to individual rights and choices.
We need to ensure that our processes for delivering CHC meet the requirements set out in the
National Framework and that we can demonstrate clear transparent processes that are applied in
an equitable way, underpinned by robust, legally compliant decisions. We have developed the
Wandsworth CCG CHC Commissioning Policy (appendix 1) and Wandsworth CCG Choice and
Equity Policy (appendix 2) to support this.
1.Why do we need the CHC Commissioning and Equity & Choice Policies?
These two policies set out our approach and how we will make provision of care once eligibility to
CHC has been established. Neither policy relates to eligibility to NHS Continuing Healthcare funding;
this is a legally defined process as described in the NHS Continuing Healthcare and Funded Nursing
Care Framework (revised 2012).
CHC Commissioning Policy
This policy relates to patients eligible for NHS Continuing Healthcare, NHS funded nursing care, or
a joint package of health and social care who are registered with a GP in Wandsworth or where the
CCG is responsible under the responsible commissioner guidance, Who Pays - NHS England 2013.
The purpose of this policy is to support the CCG to meet our statutory and other legal obligations
and ensure that the reasonable requirements of eligible individuals are met. Elements covered by
the policy include:
The range of factors the CCG will consider when commissioning a package of care
The approach to sourcing care providers
The elements the CCG will cover through NHS Continuing Healthcare funding
The process of review
CHC Equity and Choice Policy
This policy describes the way in which Wandsworth CCG will ensure equity and choice in the
provision for the care of people who have been assessed as eligible for fully funded NHS Continuing
Healthcare. It describes the process of decision making for provision subsequent to an assessment
of eligibility under the National Framework.
Elements of the policy include:
How the CCG will make provision of NHS funded Continuing Healthcare in a manner which
reflects the choice and preferences of individuals as far as is reasonably possible.
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W A N D S W O R T H C C G P A G E 3 O F 5
How we will source care home placements using the preferred provider framework and our
approach where an assessed individual wishes to move into a home outside of the preferred
provider list.
The elements that need to be considered prior to commissioning a care package at home.
Out of Area Care at Home and the Responsible Commissioner
Choice and the Mental Capacity Act 2005
Approach to development
The issues addressed in these policies are not unique to Wandsworth and in developing our
approach we have been guided by national and local policy and relevant case law. Similar
arrangements are already in place in a number of CCGs nationally and are in development with
other CCGs in South West London. Local stakeholders have contributed to the development of these
policies the approach described takes into account relevant case law.
What are the implications for the board and the business?
The policies will guide decision making on the provision of Continuing Healthcare and that our
approach will:
Ensure the process is robust, fair, consistent and transparent
Ensure that there is consistency in the services that individuals are offered
Inform robust, consistent and transparent commissioning decisions for the CCG
Promote individual choice as far as reasonably possible
Facilitate effective partnership working between health care providers, NHS bodies and the
Local Authority
Ensure the CCG achieve best value in their purchasing of services for individuals eligible
for NHS Continuing Healthcare and joint packages of care
Ensure compliance with and adherence to the CCG’s Standing Financial Instructions and take into account the need for the CCG to allocate its financial resources in the most cost effective way.
Offer choice where available in the light of the above factors
The National Framework sets out the key considerations to take into account when a service user has requested a package of care that is outside of the agreed thresholds. The CCG must be able to demonstrate that it has taken all relevant factors into consideration in our decision making whilst at the same time ensuring that we equitably distribute public resources. There must therefore be a process to ensure that an individual could be enabled to have a package of care outside of the agreed process, on the grounds of exceptionality. The policies include the provision for a review for care packages commissioned outside of policy on grounds of exceptionality; this would be by panel, the draft terms of reference are attached at appendix 3.
2. Risks and opportunities
Risks
Whilst the policies provide a framework for decision making and a transparent process it is
recognised that provision of NHS Continuing Healthcare funding is a complex and emotive
issue for individuals and their families. Therefore implementation of the policies in
consideration of patients currently in receipt of NHS CHC will need to dealt with sensitively
on a case by case basis.
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W A N D S W O R T H C C G P A G E 4 O F 5
Opportunities
Implementation of these policies will have a beneficial impact in ensuring equitable
distribution of resources and offer of choice to eligible patients.
Sourcing and commissioning packages of care through agreed frameworks is likely to lead to
financial efficiencies.
Equality Impact AssessmentAn understanding of cultural differences and attitudes is needed for effective healthcare to be
delivered appropriately. E.g. different attitudes to clinical examination and what is acceptable to the
patient and patient’s preferences for doctors or nurses of particular gender. Providers will be
required to provide detailed training on equality and diversity, to all staff both clinical and non-clinical,
nurturing their workforce and leadership and commitment to E&D.
Ethnicity may impact on healthcare and access to it at many levels, acting through factors such as:
• differences in service uptake
• communication issues
• culture and attitudes
• socio-economic factors
• differences in disease prevalence
These differences affect access to services and act as barriers to good healthcare.
Effective advertising by providers will help to address issues such as hard to reach groups,
encouraging inclusion with those who may feel that they are unable to access services.
Following the qualities Act of 2010, providers of health and social care services will also be required
to ensure that information is available in a variety of formats, with the provision of language
interpreters where necessary.
All providers that provide NHS care or adult social care are legally required to follow the Accessible
Information Standard. The standard aims to make sure that people who have a disability, impairment
or sensory loss are provided with information that they can easily read or understand with support
so they can communicate effectively with health and social care services. Successful
implementation will lead to improved outcomes and experiences, and the provision of safer and more
personalised care and services to those individuals who come within the Standard’s scope.
3. What would the impact be of delaying approval?
Care may not be aligned to meet assessed needs and our commissioning decisions may be
viewed as inequitable and open to challenge.
Without a clearly defined process care packages may be procured outside the framework and this is likely to lead to increased costs.
The CCG Board are asked to note the contents of this report and approve the CHC Commissioning and Equity and Choice Policies
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W A N D S W O R T H C C G P A G E 5 O F 5
For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications [Yes ]
The risks [Yes]
Impact on our reputation [Yes]
Impact on our patients [Yes]
Impact on our providers [Yes]
Impact on our finances [Yes]
Equality impact assessment [Yes]
Patient and public involvement [Yes]
2. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities [Yes]
Make the best use of resources, continually improve performance and deliver
statutory responsibilities [Yes]
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities [Yes]
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting [Yes]
Develop the CCG as a continuously improving and effective commissioning
organisation [Yes]
3. Executive Summaries should not exceed 1 page. [My paper does comply]
4. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does comply]
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Wandsworth CCG
Continuing Healthcare Commissioning Policy
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Document Control
Title Wandsworth CCG Continuing Healthcare
Commissioning Policy
Originator/author: Alison Kirby / Munya Nhamo
Approval Body Wandsworth CCG Governing Body
Approval Date
Document Status Final
Approved by: Wandsworth Clinical Commissioning Group Board
Review Date December 2018
Stakeholders engaged in development or review London Borough of WandsworthWandsworth EOLC Centre
Target audience: WCCG employees and members
London Borough of Wandsworth (Social Services)
All Commissioned Services
Patients and, where indicated, their
representative(s) who are subject to NHS
Continuing Healthcare Funding.
Implementation of the Public Sector Equality Duty 2011 (PSED) forms the foundation of equality and
diversity activities in Wandsworth CCG. The PSED applies to the CCG as a public authority and
therefore requires that the CCG, in the exercise of its functions, have due regard to the need to:
(a) eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by
or under this Act;
(b) advance equality of opportunity between persons who share a relevant protected
characteristic and persons who do not share it;
(c) foster good relations between persons who share a relevant protected characteristic and
persons who do not share it
These are known as the three sections of the “general duty”
The CCG intends to utilise the NHS equality delivery system (EDS) as the principle means of fulfilling
our commitments under the PSED.
Public Sector Equality Duty - Equality Statement:“This document demonstrates the organisation’s
commitment to create a positive culture of respect for all individuals, including staff, patients, their families
and carers as well as community partners. The intention is, as required by the Equality Act 2010, to
identify, remove or minimise discriminatory practice in the nine named protected characteristics of age,
disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief,
and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote
positive practice and value the diversity of all individuals and communities”.
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1.0 Introduction
1.1 ‘NHS Continuing Healthcare’ (NHS CHC) means a package of continuing care that is arranged and
funded solely by the NHS. ‘Continuing care’ means care provided over an extended period of time, to
a person aged 18 or over, to meet physical or mental health needs that have arisen as a result of
disability, accident or illness.
1.2 This is the Wandsworth Clinical Commissioning Group (WCCG) policy on the commissioning of
care packages for patients who are eligible (see section 4.1) for an episode of Continuing Healthcare
(CHC). WCCG is responsible for commissioning and procuring services for all individuals who qualify
for NHS Continuing Healthcare.
2.0 Purpose
2.1 The purpose of this policy is to assist WCCG to ensure that the reasonable requirements of eligible
individuals are met, while meeting the CCG’s statutory and other legal obligations.
2.2 This policy applies once an individual has received a comprehensive, multidisciplinary assessment
of their health and social care needs and the outcome shows that they have a Primary Health Need
and are therefore eligible for an episode of NHS Continuing Healthcare funding
2.3 This policy has been developed to help provide a common and shared understanding of CCG
commitments in relation to individual choice and resource allocation (please refer to WCCG Choice and
Equity Policy)
2.4 The benefits of this policy are to:
Improve the quality and consistency of care
Ensure that there is consistency in the local area over the services that individuals are offered
Inform robust, consistent and transparent commissioning decisions for the CCG
Ensure objective assessment of the patient’s clinical need, safety and best interests
Promote individual choice as far as reasonably possible
Facilitate effective partnership working between health care providers, NHS bodies and the
Local Authority in the area
Ensure the CCG achieve best value in their purchasing of services for individuals eligible for
NHS Continuing Healthcare and joint packages of care
Ensure compliance with and adherence to the CCG’s Standing Financial Instructions
3.0 Aligned Policy
3.1 WCCG CHC Operational Policy
3.2 WCCG Choice and Equity Policy
3.3 WCCG Personal Health Budgets Policy
3.4 Mental Capacity Act
3.5 WCCG Safeguarding Policy
4.0 Scope of the Policy
4.1 This policy relates to patients eligible for NHS Continuing Healthcare, NHS funded nursing care, or
a joint package of health and social care who are registered with a GP in Wandsworth or where the
CCG is responsible under the responsible commissioner guidance, Who Pays - NHS England 2013.
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4.2 The NHS Continuing Healthcare and Funded Nursing Care Framework (revised 2012) is a legal
framework that is used to identify whether patients are eligible for NHS Continuing Healthcare or funded
nursing care. See link below:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213137/National-
Framework-for-NHS-CHC-NHS-FNC-Nov-2012.pdf
5.0 Duties / Accountabilities and Responsibilities
5.1 This policy is issued to support WCCG to meet its commitments under The National Health Service
and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 (“the
Standing Rules”) for Continuing Healthcare, in accordance with the National Framework. See link
above.
5.2 This policy will ensure that the CCG adheres to national and local requirements to safeguard adults
and adhere to the principles identified within the Mental Capacity Act and its associated Code of
Practice, including the Deprivation of Liberty Safeguards (2009).
6.0 Policy Document Requirements Details
6.1(a) where an individual qualifies for NHS Continuing Healthcare, the package to be provided is that
which the CCG assesses is appropriate to meet all of the individual’s assessed health and associated
social care needs
6.1(b) The CCG will seek to promote the individual’s independence subject to the factors set out in
paragraph 6.1(d).
6.1(c) The CCG’s responsibility to commission, procure or provide NHS Continuing Healthcare is not
indefinite, as needs could change. As defined in the national framework, regular reviews are built into
the process to ensure that the care provision continues to meet the individual’s needs and is funded
appropriately.
6.1(d) When commissioning services for individuals based on their assessed needs, the CCG will
consider a range of factors including:
Safety, Governance & Assurance
Clinical need;
Individual safety;
Public safety;
Individual choice and preference;
Individual’s rights to family life;
Value for money; and
The best use of resources for the population of Wandsworth.
Personalisation, choice & Diversity
Ensuring services meet the required quality standards;
Ensuring services are culturally sensitive; and
Ensuring services are personalised to meet individual need.
These lists are not exhaustive.
6.2 Identification of care provision
6.2(a) Where an individual is eligible for an episode of NHS Continuing Healthcare funding, WCCG will
commission care which meets the individual’s assessed needs. The CCG will only fund services to
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meet the needs that are identified in the care plan, for which it has a statutory responsibility and that
are needed to meet the individual’s reasonable requirements based on all relevant factors, including
those in 6.1(d).
6.2(b) The CHC Nurse Assessor/ individual’s care coordinator will discuss the proposed care provision
with the individual and their representative(s) where the individual gives consent for such a discussion
or where the individual lacks capacity. The care coordinator should identify different options for
providing the care, indicating which of these the individual prefers. The Care Plan will identify the
outcomes the individual wishes to achieve
6.2(c) The care coordinator will use the CCG’s ‘Funding Request Brokerage Form’ to set out the
requested care package and associated information. The brokerage form must be completed in full for
every proposed care package.
6.2(d) The CCG will seek to take into account any reasonable request from the individual and their
representative(s) in making the decision about the care provision, subject to the all relevant factors,
including those set out in paragraph 6.1(d).
6.2(e) The CCG will endeavour to offer a reasonable choice of available, preferred providers to the
individual. Where the individual wishes to receive their care from an alternative provider the CCG will
consider this subject to the following criteria:
Provider’s acceptance to sign up to the NHS Standard Contract;
The individual’s preferred care setting is considered by the CCG to be suitable in relation to the
individual’s needs as assessed by the CCG;
The cost of making arrangements for the individual at their preferred care setting would not
require the CCG to pay more than they would usually expect to pay having regard to the
individual’s assessed needs;
The individual’s preferred care setting is available;
The people in charge of the preferred care setting are able to provide the required care to the
individual subject to the CCG usual terms and conditions.
6.3 Registered care settings
6.3(a) Where care is to be provided in a registered care home setting the CCG will only place individuals
with providers which are:
I. Registered with the Care Quality Commission (CQC), or any successor as providing the
appropriate form of care to meet the individual’s needs; and
II. Not subject to an embargo by the CCG or Local Authority, including the lead CCG or Local
Authority if the provider is not located in WCCG boundaries; and (subject to paragraph 6.3(b)
below), and
III. Contracted as an approved provider under the Pan London AQP (Continuing Healthcare)
agreement OR
IV. Can demonstrate compliance with the non AQP Care Home (CHC) Service specification.
6.4 Care At Home
6.4(a) Where home care is to be provided, the CCG will use domiciliary care agencies it has
commissioned through AQP to provide such care, including agencies commissioned by the Local
Authority on its behalf. Home care will be provided by agencies suitably qualified to deliver the care that
meets an individual’s assessed needs, see paragraph 6.3(a), (i) and (ii).
6.4(b) The cost of home care provision should not exceed the equivalent cost of care in a registered
care setting capable of meeting the needs of the individual.
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6.4(c) If an individual with a domiciliary care package is admitted into an acute setting, the CCG will
only pay for the carer to accompany the service user for the journey and to ensure the service user is
settled on arrival. The CCG will pay to the end of that particular shift or a maximum of 3 hours after the
shift has ended.
6.4(d) In exceptional circumstances, the CCG will fund a care retainer for services where the continuity
of service delivery (most specifically with particular carers skills) is of paramount importance. In such
instances, we would expect the carer to maintain service delivery throughout an acute in-patient
experience, and that the provider liaises directly with the Acute Trust to ensure compliance with local
policy.
6.5 CCG Preferred Providers
6.5(a) To assist the CCG in achieving consistent, equitable care, the CCG will endeavour to offer and
place individuals with preferred providers that are on the CCG’s Approved List of Preferred Providers
and / or part of the Pan London AQP Protocol.
6.5(b) Where a Preferred Provider is not available to meet the individual’s reasonable requirements,
the CCG may make a specific purchase and place the individual with another care provider who meets
the individual’s needs. Where such an arrangement has been agreed the CCG reserves the right to
move the individual to a suitable Preferred Provider when available, where this will provide a clinical
benefit to the patient or better value for money to the CCG.
6.5(c) Though all reasonable requests from individuals and their families will be considered, the CCG
is not obliged to accept requests from individuals for specific care providers which have not been
classified as Preferred Providers.
6.6 Location – Care at Home
6.6(a) The CCG will take account of the wishes expressed by individuals and their families when making
decisions as to the location or locations of care to be offered to individuals to satisfy the obligations of
the CCG to provide NHS Continuing Healthcare.
6.6(b) The CCG acknowledges that many individuals with complex healthcare needs wish to remain in
their own homes, with support provided to the individual in their own homes. Where an individual or
their representative(s) express such a desire, the CCG will investigate to determine whether it is
clinically feasible and within the duties of the CCG to provide a sustainable package of NHS Continuing
Healthcare for an individual in their own home.
6.6(c) Any Care At Home requests will be accompanied by an offer of a Personal Health Budget
(please refer to PHB Policy)
6.6(d) where an individual expresses the preference to receive care at home, the CCG will benchmark
the cost of such a package against the cost of a suitable package of care in a registered care setting
(per Choice and Equity Policy)
6.7 Location – Registered Care Settings
6.7(a) Through discussions with the individual, and/or their representative(s), location requests will be
accommodated as much as reasonably possible, and in accordance with this policy, taking into account
all the relevant factors, including, for example, proximity to relatives. Location requests will be subject
to the criteria described in paragraph 6.3 of this policy.
6.7(b) If the individual requests a care home that was not originally offered, the CCG will accept the
individual’s selection providing it complies with the criteria set out in paragraph 6.3 of this policy.
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6.7(c) The CCG understands that individuals may want to be located near specific places to stay in the
local community and enable family and friends to visit easily. To accommodate this, where the CCG’s
preferred available care homes are not within a reasonable travelling distance, the CCG may choose
to make a specific purchase for that individual to enable them to be accommodated in their preferred
area where the anticipated cost to the CCG may be more than the available CCG preferred
accommodation (based on CCG agreed standard rates for equivalent levels of need).
6.7(d) The CCG will consider such requests on a case by case basis, guided by all the relevant factors
including those set out in paragraph 6.1(d) and using the two stage process for determining exceptional
circumstances set out below in paragraph 6.16(b).
6.7(e) Reasonable travelling distance will be based on a case by case assessment of an individual’s
circumstances, and will take into account factors such as ability of family and friends to visit, which may
include public transport links and mobility of the family and friends.
6.8 Additional services
6.8(a) The individual or their representative(s) has the right to enter into discussions with any provider
to supplement the care provision, over and above that required to meet assessed needs. Any such
costs arising out of any such agreement must be funded by the individual or through third party funding
6.8(b) The decision to purchase additional services to supplement a CHC package must be entirely
voluntary for the individual. The provision of the CHC package must not be contingent on or
dependent on the individual or their representative(s) agreeing to fund any additional services. This
means that the care home must be willing and able to deliver the assessed CHC needs to the
individual, without the package being supplemented by other services as described in this policy.
6.9(a) Any funding provided by the individual for additional services should not contribute towards costs
of the assessed need that the CCG has agreed to fund. Similarly, CHC funding should not in any way
subsidise any additional service that an individual chooses outside of the identified care plan.
6.9(b) Where an individual is funding additional services, the associated costs to the individual must be
explicitly stated and set out in a separate agreement with the provider. If the individual chooses to hold
a contract for the provision of these services, it should be clear that the additional payments are not to
cover any assessed needs funded by the CCG.
6.9(c) If the individual or their representative(s), for any reason, decides that they no longer wish to fund
any such additional services, the CCG will not assume responsibility for funding those additional
services.
6.9(f) Where the CCG is aware of additional services being provided to the individual privately, the CCG
will satisfy itself that they do not constitute any part of the provision to meet assessed needs.
6.10 Availability
6.10(a) To enable individuals to receive the correct care promptly, individuals will be offered available
care as soon as possible. If an individual’s first choice from the CCG’s Preferred Providers is not
available, they will be offered another CCG Preferred Provider to ensure provision as soon as possible.
The CCG will offer care from Preferred Providers before any other unless exceptional circumstances
apply.
6.10(b) If the individual requests care which is currently unavailable, and is unwilling to accept the
CCG’s offer of care, there are several options available to the CCG:
I. Temporary placement of the individual with alternative care provision until the care from the
CCG’s preferred care is available.
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II. The individual may choose to go to their own or a relative’s home without the assessed care
provision until the preferred care is available. The terms set out in paragraph 6.11 of this policy
will apply. The individual will, however, retain the right subsequently to change their mind and
elect to accept the care provision offered by the CCG. If the individual does not have mental
capacity to make this decision, a best interest’s decision will be made in accordance with the
Mental Capacity Act 2005;
III. If it has been agreed with the individual that the assessed needs can best be met through a
care home placement, the CCG may choose to provide home care until the preferred care
home is available, but cost implications to the CCG must be considered. This will be in
accordance with paragraph 6.2 of this policy.
IV. If the individual’s representative(s) are delaying placement in a care home due to non-
availability of a preferred home, and the individual does not have the mental capacity to make
this decision themselves, the CCG will have recourse to the Wandsworth (and Pan London)
Multi Agency Safeguarding Adults Policy, local safeguarding procedures and the Mental
Capacity Act 2005, as appropriate.
V. If the individual is in an acute healthcare setting, they must move to the most appropriate care
setting as soon as they are medically fit for discharge, even if their first choice of care provision
is not available.
6.11 Acceptance
An individual is not obliged to accept a Continuing Healthcare package. Once an individual is eligible
and offered NHS Continuing Healthcare, and they choose not to accept the Continuing Healthcare
package, the CCG may, in appropriate cases, take reasonable steps to make the individual aware that
the Local Authority does not assume responsibility to provide care to the individual. The CCG will work
with the individual to help them understand their available options and facilitate access to appropriate
advocacy support. As appropriate, the CCG will have recourse to Wandsworth (and Pan London) Multi
Agency Safeguarding Adults Policy, local safeguarding procedures and the Mental Capacity Act 2005.
6.12 Withdrawal
The NHS discharges its duty to individuals by making an offer of a suitable care package to individuals,
whether or not they choose to accept the offer.
6.12(a) Where an individual exercises their right to refuse, the CCG will ask the individual or their
representative(s) to sign a written statement confirming that they are choosing not to accept the offer
of care provision.
6.12(b) It may be appropriate for the CCG to remove Continuing Healthcare services where the situation
presents a risk of danger, violence to or harassment of care staff that are delivering the package.
6.12(c) The CCG may also withdraw Continuing Healthcare funded support where the clinical risks
become too high. This can be identified through, or independently of, the review process. Where the
clinical risk has become too high in a home care setting, the CCG may choose to offer Continuing
Healthcare in a care home setting.
6.12 (d) In all such instances, the decision of the CCG will be made by a senior panel of members. No
decision will be made or undertaken unilaterally or without consultation with our Local Authority
This list is not exhaustive.
6.13 Appeals
An individual may appeal against a decision by the CCG as to the nature, extent or location of a care
package being offered. Appeals will be dealt with through the CCG’s Appeals procedure. If the appeal
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cannot be resolved locally the individual or their representative can be referred directly to the Health
Service Ombudsman.
6.14 Continuing Healthcare review
6.14(a) A case review should be undertaken by a Continuing Healthcare nurse no later than three
months after the initial eligibility decision, in order to reassess the individual’s care needs and eligibility
for NHS Continuing Healthcare and to ensure that the individual’s assessed needs are being met.
Clinical reviews undertaken by a Continuing Healthcare nurse should thereafter take place annually as
a minimum.
6.14(b) If the review demonstrates that the individual’s condition has improved to an extent that they no
longer meet the eligibility criteria for Continuing Healthcare provision, the individual, family carers where
appropriate and the CCG will work collaboratively with the Local Authority to ensure the individuals
needs will be met.
6.14(c) At this point the Local Authority has 28 days to review the individual’s requirements and the
individual will be notified they may no longer be eligible for Continuing Healthcare. CCG funding for an
individual’s care may be continued for 28 days where a Local Authority is undertaking such a review or
such longer period as seems reasonable in the circumstances.
6.14(d) The Continuing Healthcare review may identify an adjusted, decreased or increased care need.
6.14(e) where an individual is receiving home care, the CCG will consider the ability of the package to
be delivered in the home environment and also the cost effectiveness of this package.
6.15 Fast Track
The eligibility criteria for a Fast Track application are defined within the National Framework for NHS
Continuing Healthcare and NHS-funded Nursing Care (DH, revised 2012),
Care provision for individuals assessed on the Fast Track will be subject to the same principles as set
out in this policy.
WCCG commissions the EOLC Coordination Service (EOLCCS) Provider as the single point of access
for all fast tracks (except for care required within Care Homes with Nursing) and to take the lead in
sourcing the required care packages at home which will be approved after referral ratified by the CCG.
The EOLCCS Provider will brokerage care packages in accordance with the WCCG Commissioning
and Choice and Equity Policies.
7. Public Sector Equality Duty
7.1 Public Sector Equality Duty - Wandsworth CCG aims to design and implement services, policies
and measures that meet the diverse needs of our service, population and workforce, ensuring that none
are placed at a disadvantage.
7.2 The general equality duty requires public sector bodies, in the exercise of their functions, to have
due regard to the need to the need to:
Eliminate discrimination, harassment and victimisation and any other conduct that is prohibited
under the equality Act 2010
Advance equality of opportunity between people who share a relevant protected characteristic
and people who do not share it
Foster good relations between people who share a relevant protected characteristic and those
who do not share it
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7.3 Staff should be alerted to the increased likelihood of harm being suffered by disabled children,
young people and Adults at Risk, along with those living in special circumstances, whose needs may
not be recognised by staff employed in providing services.
Any individual’s communication needs will be considered at all times.
Equality Act 2010 - The Equality Act provides protection from direct or indirect discrimination;
harassment and victimisation for people with a ‘protected characteristic’ that relate to: disability, gender
reassignment, pregnancy and maternity, race, religion belief or non-belief, sex, sexual orientation and
age.
8.0 Documents Relied Upon
Department of Health Policy guidance relating to this document includes the following:
The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care,
Department of Health 2012 (revised)
Continuing Healthcare - Single Operating Model (2015)
DH published guidance - additional Private Care guidance March 2009
Standards for Better Health, Department of Health,
High Quality Care for All, Department of Health, 2008
The Human Rights Act 1998
The Equality Act 2010
Personal Health Budgets, Department of Health 2009
Mental Capacity Act 2005
Deprivation of Liberty Safeguards 2009
Who Pays, NHS England 2013
Care Act 2014
Appendices
Appendix A EQUALITY IMPACT ASSESSMENT (EQIA)
This EQIA aims to embed within the Commissioning intentions and the potential impact and
implications of Continuing Health Care for groups of people who are protected under the Equality Act
(2010) in relation to: • Age • Disability – vision, hearing, LD, autism, carers by association & Physical
impairment and Mental Health • Gender reassignment • Marriage & Civil partnership • Pregnancy &
Maternity • Race, Nationality, Ethnicity • Religious Belief • Gender/Sex - Men & Women • Sexual
Orientation
UNDERSTANDING IMPACT: This policy is likely to have a positive impact on patients and carers.
Any future procurement of provision may result in a service from a non-NHS provider and the
potential impact of this will need to be factored in terms of impact on all equality groups, and fully
considered; as articulated within the recommendations in this EQIA.
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Name of Policy / Strategy / Service redesign etc.
1 Continuing Healthcare Commissioning Policy
2 Briefly describe the aim of the policy, strategy or project. What needs or duty is it
designed to meet? Clinical Commissioning Groups (CCGs) are under a duty to make
arrangements to ensure that, in discharging their functions, they have regard to the need to
procure sound and safe packages of care for those adults in receipt of NHS Continuing
Healthcare
The purpose of the policy is to ensure all CCG staff and patients are aware of their roles and
statutory responsibilities.
This Policy provides support to Wandsworth CCG and their Commissioning Support Services
and strengthens local assurance arrangements for services commissioned for our patients.
3 Is there any evidence or reason to believe that the policy, strategy
or project could have an adverse or negative impact on any
group/s?
Yes No
X
4 Is there any evidence or other reason to believe that different
groups have different needs and experiences that this policy is
likely to assist i.e. there might be a relative adverse effect on
other groups?
Yes No
X
5 Has prior consultation taken place with organisations or groups
which has indicated a pre-existing problem which this policy,
strategy, service redesign or project is likely to address?
Yes No
X
Signed by the manager undertaking the assessment:
Date Completed:
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WANDSWORTH CLINICAL COMMISSIONING GROUP
Continuing Health Care (CHC) and Funded Nursing Care (FNC) Choice and Equity Policy
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Document Control
Title:WCCG Continuing Health Care (CHC) and Funded
Nursing Care (FNC) Choice and Equity Policy
Original Author(s): Alison Kirby/Munya Nhamo
Approval Body: Wandsworth CCG Governing Body
Approval Date:
Title /Version Number/(Date) WANDSWORTH CLINICAL COMMISSIONING GROUP Continuing Health Care (CHC) and Funded Nursing Care (FNC) Choice and Equity Policy
Document Status Final
Approved By WCCG Governing Body
Review Date December 2018
Stakeholders engaged in development or review
London Borough of WandsworthWandsworth EOLC Centre
Equality Analysis Equality AnalysisThis Policy is applicable to all staff employed by the CCG and those staff who work on behalf of the CCG. This document has been assessed for equality impact on the protected groups, as set out in the Equality Act 2010. This document demonstrates Wandsworth’s CCG’s commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners.
The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote positive practice and value the diversity of all individuals and communities.
Document Review Control Information
Version Date Reviewer Name(s) Comments
V 1 April 2016 AK
V1.1 April 2016 MN
V1.2 July 2016 AK Updated following comments from WBC
V1.3 Nov 2016 MN Updated following comments from WELCC
V1.4 Dec 2016 DB Update by Capsticks
This policy progresses the following Authorisation Domains and Equality Delivery System (tick all relevant boxes).
Clear and Credible Plan Commissioning processes
Collaborative Arrangements Leadership Capacity and Capability
Clinical Focus and Added Value Equality Delivery System
Engagement with Patients/Communities
NHS Constitution Ref: 4A
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1. Introduction
1.1 This policy describes the way in which Wandsworth CCG will make provision for the care of
people who have been assessed as eligible for fully funded NHS Continuing Healthcare. It describes
the process of decision making for provision subsequent to an assessment of eligibility under the
National Framework.
1.2 It should be read in conjunction with:
The National Framework for NHS Continuing Healthcare revised (2012)
Wandsworth Clinical Commissioning Group’s Continuing Healthcare Pathways and Protocols
WCCG Continuing Healthcare Commissioning policy
Wandsworth CCG Personal Health Budgets Policy. Further information can be found at
Guidance on Direct Payments for Healthcare; Understanding the Regulations. (DH 2014)
The National Health Service Commissioning Board and Clinical Commissioning Groups
(Responsibilities and Standing Rules) Regulations 2012 (“the Regulations”)
2. Context
2.1 Continuing Care is a general term defined as:
Care provided over an extended period of time to a person aged 18 or over, to meet physical or
mental health needs which have arisen as a result of disability, accident or illness. It may require
services from the NHS and/or social care and can be provided in a range of settings. Access to these
services is based on assessed need.
2.2 Fully funded NHS Continuing Healthcare describes a package of on-going care arranged and
funded solely by the NHS.
2.3 The term ‘Continuing Healthcare’ is used in this policy as an abbreviation of ‘fully funded NHS
Continuing Healthcare’.
3.0 Choice and Person Centred Care
3.1 The National Framework for NHS Continuing Healthcare & NHS funded-nursing care (2012,
Department of Health) states:-
“Where a person qualifies for NHS continuing healthcare, the package to be provided is that which the
CCG assesses is appropriate to meet all of the individual’s assessed health and associated social
care needs.”
Whilst the CCG will take into account the views of the individual so far as is possible, the CCG must
consider a range of factors and must comply with its statutory financial obligations. The final decision
as to the care package is one for the CCG; however it will act on all reasonable requests to the best
of its ability.
3.2 Wandsworth Clinical Commissioning Group will commission the provision of NHS funded
Continuing Healthcare in a manner which reflects the choice and preferences of individuals as far as
is reasonably possible, ensuring patient safety, quality of care and making best use of resources.
Cost has to be balanced against other factors in each case, such as a patient’s desire to live at home.
3.3 Patient safety will always be paramount in planning a care package and will not be compromised.
3.4 Wandsworth Clinical Commissioning Group is required to balance the patient’s preference
alongside safety and value for money. Patients will have a choice, whenever possible, from providers
who have a contract with Wandsworth Clinical Commissioning Group (or vicariously through our
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agreed Pan London Procurement Frameworks) and has agreed to Wandsworth Clinical
Commissioning Group quality and pricing structure. This applies equally to Home Care packages as
well as placements.
3.5 The CCG has a duty to provide care to a person with continuing healthcare needs in order to meet
those assessed needs1. An individual or their family/representative cannot make a financial
contribution to the cost of the care identified by the CHC team as required to meet the individual’s
core needs (see paragraphs 3.6 and 3.7). An individual however, has the right to decline NHS
services and make their own private arrangements.
3.6 Wandsworth CCG is not able to allow personal top up payments into the package of healthcare
services under NHS CHC, where the additional payment relates to core services assessed as
meeting the needs of the individual and covered by the fee negotiated with the service provider (e.g.
the care home) as part of the contract.
3.7 However, where service providers offer additional services which are unrelated to the person’s
needs as assessed under the NHS CHC framework, the person may choose to use personal funds to
take advantage of these services (e.g. hairdressing, a bigger room or a nicer view), but only so far as
these costs can be clearly separated and invoiced. Any additional services which are unrelated to the
person's primary healthcare needs will not be funded by the CCG as these are services over and
above those which the service user has been assessed as requiring, and the NHS could not therefore
reasonably be expected to fund those elements.
4. The provision of Continuing Healthcare
4.1 Many patients who require Continuing Healthcare will receive it in a specialised environment. The
treatments, care and equipment required to meet complex, intense and unpredictable health needs
often depend on such environments for safe delivery, management and clinical supervision.
Specialised care, particularly for people with complex disabilities may only be provided in specialist
Care Home (with or without nursing), which may sometimes be distant from the patient’s ordinary
place of residence.
4.2 These factors mean that there is often a limited choice of a safe and affordable packages of care.
4.3 In accordance with the NHS Constitution and the duties at s. 14U (duty to promote patient
involvement) and 14V (duty to promote patient choice) of the National Health Service Act 2006 (“the
NHS Act”). The CCG fully recognises these obligations, but must balance them against its other
duties.
4.4 In commissioning CHC care, the CCG must have constant regard to its financial duties. In brief,
section 223G of the NHS Act provides for payment to the CCG from the NHS Commissioning Board
(“NHS England”) in respect of each financial year, to allow the CCG to perform its functions. Section
223I provides that, in summary, that each CCG must break even financially each financial year. In the
case of Condliff v North Staffordshire Primary Care Trust [2011] EWHC 872 (Admin), the Court
stressed the fundamental challenge for commissioners in allocating scarce resources so as to best
serve the local population as a whole, whilst also having due regard to individual rights and choices.
4.5 The CCG acknowledges that it must also have due regard to the rights of individuals under Article
8 of the European Convention on Human Rights to private and family life, and any interference with
this right must be clearly justified as proportionate, in accordance with Gunter v South Western
Staffordshire Primary Care Trust [2005].
1 See the Regulations, paragraph 21.
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4.6 The CCG must also have due regard to its equalities duties, both under s.14T of the NHS Act
(duty to reduce inequalities) and the Public Sector Equality Duty under s.149 of the Equality Act 2010
(duty to eliminate discrimination and advance equality of opportunity between persons with and
without protected characteristics). The CCG is again guided in balancing its obligations by the case of
Condliff, in which the Court held that a policy of allocating scarce resources on the strict basis of a
comparative assessment of clinical need was intentionally non-discriminatory, and did no more than
apply the resources for the purpose for which they are provided without giving preferential treatment
to one patient over another on non-medical grounds (para. 36).
4.4 In the light of these constraints, Wandsworth CCG has agreed this policy to guide decision making
on the provision of Continuing Healthcare. The policy sets out to ensure that decisions will:
be robust, fair, consistent and transparent,
be based on the objective MDT assessment of the patient’s clinical need
be “person-centred”, which means that the decision will involve the individual and their family
or advocate to the fullest extent possible and appropriate,
take into account the need for the CCG to allocate its financial resources in the most cost
effective way,
offer choice where available in the light of the above factors.
4.5 Once a decision on eligibility is agreed, an offer of a Personal Health Budget will be made to the
patient (or their representative). Where such an offer is accepted, please refer to the Wandsworth
CCG Personal Health Budgets Policy) A personal Health Budget will enable more a flexible approach
to meeting the individual assessed needs outlined on the Support Plan.
4.6 Collaborative commissioning arrangements
4.7 Wandsworth CCG is part of a collaborative commissioning arrangement - the Pan London
Continuing Healthcare ‘Any Qualified Provider’, managed by the London Purchased Healthcare
Team.
5.0 Continuing Healthcare funded care within a placement
5.1 Where a care Home (with or without Nursing) is the most appropriate option, the allocated CHC
Nurse Assessor will work together with the patient and their representatives (where indicated) to
identify establishments which are capable of meeting the assessed needs and which are in a position
to provide a place within a reasonable space of time in line with the Brokerage criteria set out in bullet
point below
the CHC team operates a preferred provider list and the expectation is that individuals
requiring placement will have their needs met in one of the Care homes on the AQP
framework subject to bed availability and capacity to meet the needs of the assessed
individual.
The CHC Team will source a Care Home (with or without nursing) which is an accredited
member of the Pan London AQP (Continuing Healthcare) Framework
The CHC Brokerage Team will source a Care Home (with or without nursing) which accepts
the standard terms of the AQP Framework. In the exceptional circumstances were the costs
of care are above the threshold for AQP tier 2 rate (by more than 6% ) funding approval will
be sought from Wandsworth CCG CHC Lead Commissioner .( High cost and cases outside
AQP threshold will be referred to the Exceptions Panel)
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The CCG approval process will utilise the existing Needs Assessment Resource Allocation
model to determine patient needs and the resources deemed adequate to meet the individual
assessed as eligible for CHC
In the event that the assessed individual wishes to move into a home outside of the preferred
provider list, the CHC team will be required to liaise with the receiving CCG and confirm local
contracting arrangements (to include any potential contract suspensions). As long as the fee
for the bed is comparable to the fee agreed with the preferred AQP provider and the home
can meet the patients care needs the CHC team will consider this option, accepting our
partner agencies local contractual arrangements in relation to good governance. Where there
is a conflict between cost of care and personal choice, Wandsworth CCG will ask its own
internal Expert Case Panel to take a determination.
In the event that the assessed individual is already in a Care Home which is not under the
AQP contract, the CHC Brokerage Team will undertake the due diligence process described
above. A standard NHS contract will be put in place and efforts made to align the CHC
contract weekly costs with the AQP Framework rates.
6.0 Continuing Healthcare Funded Packages of Care At Home
6.1 Many people wish to be cared for in their own homes rather than in residential care, especially
people who are in the terminal stages of illness. A person’s choice of care setting should be taken into
account but there is no automatic right to a package of care at home. The option of a package of care
at home should be considered, even if it is later discounted, with documented reasons.
6.2 In situations where the model of support preferred by the individual will be more expensive than
other options offered by the CHC Team, Wandsworth CCG will take comparative costs and value for
money into account when determining the model of support that will be provided. It may be necessary
to pay more to meet an individuals assessed needs in a way that does not discriminate against them
but the NHS does not have to provide a home care package if it is disproportionately more expensive
than providing care in a Care Home setting.
The CHC team operates a preferred provider list and the expectation is that individuals requiring care
at home will have their needs met by a provider on the AQP framework subject to availability and
capacity to meet the needs of the assessed individual. It is important to note that there may be
exceptions were it would be appropriate to commission outside of the AQP framework. For instance, if
a patient already had a care package with a Provider that is off the AQP framework before becoming
CHC eligible which effectively meeting all their needs.
6.3 The CHC team and WEOLCC will take account of the following issues before agreeing to
commission a care package at home:
Care can be delivered safely and without undue risk to the person, the staff or other
members of the household (including children).
Safety will be determined by a written assessment of risk undertaken by an appropriate
referring clinician, and ratified by the CHC Lead, in consultation with the person or their
family for patients having a full CHC assessment. The proposed plan of can will then be
checked by the relevant CHC clinical lead to ensure it is appropriate to meet the identified
needs. For fast track assessment, the initial risk assessment is completed by the Clinician
making the referral which will then be checked by WEoLCCC before ratification and
proposed care plan by selected Domiciliary Care Provider checked to ensure it safely
meets the needs identified.
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The commissioned Care Home or Domiciliary Care Provider will be expected to conduct
their own risk assessment which will include the availability of equipment, the
appropriateness of the physical environment and the availability of appropriately trained
care staff and/or other staff to deliver the care at the intensity and frequency required.
The acceptance by the CHC team and/or WEOLCC and each person involved in the
person’s care of any identified risks in providing care and the person’s acceptance of the
risks and potential consequences of receiving care at home.
Where an identified risk to the care providers or the person can be minimised through
actions by the person or their family and carers, those individuals agree to comply and
confirmed in writing with the steps required to minimise such identified risk.
The person’s GP agrees to provide primary care medical support;
Care packages or Care Home placements that exceed the set out funding threshold will
be considered on assessed needs through the Resource Allocation function on a case by
case basis to ensure adequate care commissioned for the individual deemed eligible for
CHC.
The cost of the care package will be considered in line with paragraph 6.4 below.
6.4 The CCG will take into account the following factors when considering the cost of a home
placement:
The cost comparison will consider the genuine, rather than assumed costs of alternative
models, so far as this is possible.
Where a person prefers to be supported in a certain location which is not the most cost
effective model, the CCG will work with that person to identify if care can be delivered in
their preferred location in a more effective way.
The cost will be balanced against other factors in the individual case, such as the
individual’s preference as to location.
Where the total cost of providing care is within 10% of the equivalent cost of an AQP
Care Home (with or without nursing) placement (i.e. The cost of the Care Home (with or
without nursing) placement + 10%) the CCG will not fund the placement, save as where
the circumstances have been assessed by the Expert Case Panel as being so
exceptional that the costs are justified in the public interest.
6.5 Wandsworth CCG must consider risks that could potentially cause harm to the individual, any
family and the staff. Where an identified risk to the care providers or the individual can be minimised
through actions by the individual or his/her family and/or carers, those individuals must agree to
comply with the steps required to minimise such identified risk. Where the individual requires any
particular equipment then this must be able to be suitably accommodated within the home.
6.6 Wandsworth CCG is not responsible for any alterations required to a property to enable a home
care package to be provided, save for where these are agreed in accordance with the criteria above.
For the avoidance of doubt, where an individual or representative has made alterations to the home
but Wandsworth CCG has declined to fund the package, Wandsworth CCG will not provide any
compensation for those alterations.
6.7 The suitability and availability of alternative care options:
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The CCG can only provide services in accordance with assessed need following a decision on the
appropriate allocation of the finite resources available to the CCG for all patients it has responsibility
for.
Where there is a conflict between cost of care and personal choice, Wandsworth CCG will ask its own
internal Exceptions Panel to consider the factors set out above, in addition to -
• The cost of providing the care at home in the context of cost effectiveness;
• The relative costs of providing the package of choice considered against the relative benefit to the
person. Examples of particular situations requiring careful consideration are as follows:
Home care packages in excess of eight hours per day would indicate a high level of need
which may be more appropriately met within a Care Home placement. These cases would be
carefully considered and a full risk assessment undertaken.
Persons who need waking night care would generally be more appropriately cared for in a
Care Home placement. The need for waking night care indicates a high level of supervision
day and night and usually Care Home placements are deemed more appropriate for persons
who have complex and high levels of need. Residential placements benefit from direct
oversight by registered professionals and the 24 hour monitoring of persons.
If the clinical need is for registered nurse direct supervision or intervention throughout the 24
hours the care would normally be expected to be provided within a nursing home placement.
6.7 Out Of Area Care At Home and the Responsible Commissioner
If a person is deemed eligible and the choice is to move to a family home in another area, the
responsible commissioner will be the receiving CCG (GP registration applies) but the two CCGs need
to positively discuss the transfer to allow the receiving CCG to assess the care package.
7.0 Choice and the Mental Capacity Act 2005
7.1 Wandsworth CCG will always consult directly with the patient over Choice of Care. In accordance
with the Mental Capacity Act, we will assume that the individual retains the Capacity to make
decisions over every aspect of their life, unless demonstrated otherwise through formal processes.
7.2 The Patient may consciously delegate their decision making function to another nominated
deputy. Wandsworth CCG will be under duty to consult with this person direct.
7.3 Where an individual lacks the capacity to make such a decision then the registered Deputy with
the Lasting Power of Attorney for Health and Welfare will be nominated as The Decision Maker.
N.B While the Decision Maker will speak with the authority of the Patient, the NHS via the CCG
retains responsibility for the final offer of care delivery.
7.4 Where no Deputy has been appointed then all decisions will be made in the Best Interest of the
Patient in accordance with the Mental Capacity Act.
7.5 All decisions will be recorded on the appropriate documentation
8.0 Review of NHS Continuing Healthcare support
8.1 All service users will have their care reviewed at 3 months and thereafter on an annual basis or
sooner if their care needs indicate that this is necessary.
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8.2 The review may result in either an increase or a decrease in support offered and will be based on
the assessed need of the individual at that time. Reviews will involve the individual, their family or
advocate as possible and appropriate.
8.3 Where the individual is in receipt of a home support package and the assessment determines the
need for a higher level of support ,this may result in care being offered from a Care Home (with or
without nursing), whichever best meets the patients overall needs and in line with the Choice and
Equity thresholds of Wandsworth CCG.
8.4 The individual’s condition may have improved or stabilised to such an extent that they no longer
meet the criteria for NHS fully funded Continuing Healthcare. Consequently, the individual will
become either self-funding or the responsibility of the Local Authority who will assess their needs
against the Fair Access to Care criteria. This may mean that the individual will be charged for all or
part of their on-going care.
8.5 Where the review of need results in the Patient no longer meeting the CHC eligibility criteria,
Wandsworth CCG will issue a 28 day notice of transfer of care to both the Patient (or their nominated
representative) and our partners in Wandsworth Local Authority.
8.6 In line with the National Framework for CHC, Wandsworth CCG will ensure that no gap in service
exists and that any transfer of responsibilities maintains the Patients safety as paramount. Neither
Wandsworth CCG nor Local Authority should unilaterally withdraw from an existing funding
arrangements without a joint re assessment of the individuals needs or without first consulting one
another and the individual about the proposed change of arrangement.
8.7 All decisions will be transparent and shared with the Patient and their nominated representatives
where indicated.
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References
a) Department of Health, November 2012 (revised), The National Framework for NHS
Continuing Healthcare and NHS-funded Nursing Care
b) Wandsworth Clinical Commissioning Group , Safeguarding Adults Policy
c) Who Pays? Determining responsibility for payments to providers August 2013 DH
d) Guidance on Direct payments for Healthcare; Understanding the regulations (DH March
2014)
e) DH Practice Guidance for NHS Continuing Healthcare and NHS Funded Nursing Care 2013
f) NHS England Operating Model for Continuing Healthcare 2015
g) NHS England Compassion in Care Assurance Framework 2014
Public Information and Choice.
My NHS care: what choices do I have?
The NHS now gives you more choices about your health care.
This is a guide to your choices about your NHS care and treatment. It explains:
• when you have choices about your health care
• where to get more information to help you choose
• how to complain if you are not offered a choice
For some health care services, you have the legal right to choose and must be provided with choices
by law.
For other health care services, you do not have a legal right to choose, but you should be offered
choices, depending on what is available locally.
This guide covers:
• Choosing:
- your GP and GP practice
- which organisation you can go to for your first appointment as an outpatient for
physical or mental health conditions
- to change hospital if you have to wait longer than the maximum waiting times (18
weeks, or two weeks to see a cancer specialist)
- who carries out a specialist test if you need one
- maternity services
- services provided in the community
- to take part in health research
- to have a personal health budget
- to travel to another European country for treatment
• Where you can obtain more information to help you choose
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• What you can do if you are not offered choice
Where can I get more information to help me choose?
You can find advice on how to get information for particular health services in each section of this
guide.
There are also lots of ways to get general information to help you make the right choice.
• NHS Choices: www.nhs.uk. This website can help you make important health decisions, including
which GP surgery you register with and which hospital you attend for treatment. It provides tools and
resources that help you look at your options and make the right decision.
• Care Quality Commission checks many care organisations in England to ensure they are meeting
national standards. They share their findings with the public, which can be found at: www.cqc.org.uk
or call their National Customer Service Centre: Tel: 03000 616161 (Mon to Fri, 8.30am - 5:30pm).
• The NHS Constitution tells you what you can and should expect when using the NHS. Visit
www.nhs.uk and search for ‘NHS Constitution’. The Handbook to the NHS Constitution provides
additional explanation about the rights and pledges set out in the NHS Constitution. s
• Healthwatch is an independent consumer champion for health and social care in England. It
operates as Healthwatch England at national level and local Healthwatch at local level. Visit
www.healthwatch.co.uk for more information.
What can I do if I am not offered these choices?
First, you can speak to your GP or the health care professional who is referring you, as set out in
the boxes above. In the case of maternity services, speak to your GP, midwife or Head of Midwifery.
If you are still unhappy that you have not been offered these choices, you can make a complaint. You
can complain to the organisation that you have been dealing with or you can make a complaint to
your local clinical commissioning group. Clinical commissioning groups must publish their
complaints procedure. If they agree with your complaint, the clinical commissioning group must make
sure that you are offered a choice for that health service.
To contact your local clinical commissioning group:
• Ask your GP practice, they can tell you how to contact your local clinical commissioning
group; or
• Visit NHS Choices, www.nhs.uk click on the ‘Health services near you’ section on the
homepage. You cIf you are unhappy with the decision from the clinical commissioning group,
NHS England or Monitor you have the right to complain to the independent Parliamentary
and Health Service Ombudsman. The Ombudsman is the final stage in the complaints
system. To contact the Ombudsman:
• visit www.ombudsman.org.uk;
• call the Helpline: 0345 015 4033;
• use the Textphone (Minicom): 0300 061 4298;
• text ‘call back’ with your name and your mobile number to 07624 813 005; you will be called
back within one working day during office hours (Monday to Friday, 8.30am - 5:30pm).
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You can also contact an NHS complaints advocacy service if you have concerns regarding your right
to choose. Contact your local Healthwatch to find out your local advocacy service.
• visit http://www.healthwatch.co.uk/find-local-healthwatch. an search for your clinical commissioning
group by your postcode or location.
Choosing to have a personal health budget
Is this a legal right? You have a legal ‘right to have’ a personal health budget (with some
exceptions) from October 2014, for people receiving NHS Continuing
Healthcare (including children).
NHS Continuing Healthcare is a package of care arranged and funded solely
by the NHS and provided free to the patient. This care can be provided in
any setting – including an individual’s own home. An assessment is carried
out by the clinical commissioning group using a multi-disciplinary team of
health and social care professionals.
You can find more about NHS Continuing Healthcare at NHS Choices:
www.nhs.uk.
Clinical commissioning groups will also be able to provide personal health
budgets to other groups of patients on a voluntary basis, if they recognise
that there is a benefit to the patient and the NHS from offering packages of
care in this way.
What choices do I have? For some NHS services (including Continuing Healthcare provided at
Home), you can choose to have a personal health budget if you want one.
A personal health budget is an amount of money and a plan to use it. The
plan is agreed between a patient and their health care professional or clinical
commissioning group. It sets out the patient’s health needs, the amount of
money available to meet those needs and how this money will be spent.
With a personal health budget, you (or your representative) can:
• agree with a health care professional what health and wellbeing outcomes
you want to achieve;
• know how much money you have for this health care and support;
• create your own care plan if you wish, with the help of your health care
professional or others;
• choose how to manage your personal health budget;
• spend the money in ways and at times that makes sense to you, in line with
your care plan.
Once you have a care plan agreed, you can manage your personal health
budget in three ways, or a combination of these:
• a ‘notional budget’: the money is held by your clinical commissioning
group or other NHS organisation who arrange the care and support that you
have agreed, on your behalf;
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• a ‘third party budget’: the money is paid to an organisation which holds
the money on your behalf (such as an Independent User Trust) and
organises the care and support you have agreed;
• direct payment for health care: the money is paid to you or your
representative. You, or your representative, buy and manage the care and
services as agreed in your care plan.
In each case there will be regular reviews to ensure that the personal health
budget is meeting your needs.
You do not have to have a personal health budget if you do not want one.
When am I not able to
make a choice?
You will not be able to have a personal health budget for all NHS services
(for example, acute or emergency care or visiting your GP).
A few individuals or groups of people may not be eligible for a personal
health budget or a direct payment.
Who is responsible for
giving me choice?
Your local clinical commissioning group is responsible for giving you choice.
Where can I get
information and support to
help me choose?
If you would like to manage your own personal health budget:
• contact your local clinical commissioning group.
You can find out more about personal health budgets from:
• NHS England ‘Personal health budget learning network’, at:
http://www.personalhealthbudgets.england.nhs.uk/index.cfm
• NHS Choices: www.nhs.uk
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Appendix 3
Wandsworth CCG Exceptions Funding Request Panel
Terms of Reference
1. Constitution
The Exceptions Funding Request Panel will be a subcommittee reporting to the
Integrated Governance Committee
2. Membership
Clinical Lead (Chair)CommissionerFinance ManagerAdditional members as required by the Chair
3. Quoracy
At least one clinical representative and one commissioner/finance lead
4. Frequency
The panel will meet as and when required in order to respond to urgent requests
5. Duties
To consider individual funding requests that are an exception to the CCGs internal CHC policy.
These may include but are not restricted to:
Cases requiring a complex or atypical package of care
Exceptional cases which breach the WCCG CHC Commissioning and Equity and Choice Policy thresholds in terms of costs of care
6. Underpinning principles of decision making process
Commissioning decisions will be considered in light of the WCCG Commissioning and Equity and Choice Policies
All decisions will be recorded, evidenced and communicated to all stakeholders
The process will seek to ensure consistency and fairness
7. Review
Terms of reference will be reviewed annually.
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W A N D S W O R T H C C G P A G E 1 O F 5
London Health DevolutionAuthor: Sponsor: Sandra Iskander Date: 14 December 2016
Executive Summary
Context
In December 2015, a London devolution agreement was signed which let to five pilot
areas working on how aspects of devolution would work in practice. This work has led to a
number of proposed devolution ‘asks’ related to integration, estates and prevention.
These proposals are being consulted on with business cases for specific proposals in
development.
Question(s) this paper addresses
1. What progress has been made on devolution to date?
2. What is the thinking on the most appropriate approach for individual proposals?
3. What is the timeline and process for the next steps?
Conclusion
Wandsworth currently does not have any devolution plans, and so is not directly affected
by the proposals. However, we will follow developments to determine whether any of the
devolution models offer opportunities in the future to support delivery of our priorities.
Input Sought
The Board is asked to:
1. Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015.
2. Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs.
3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to agree and sign off the agreement on behalf of the CCG.
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]
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The Report
London is on a journey to become the healthiest city in the world. Over the past few years,
our health and care system has made significant strides to organise services around the
changing needs of our city’s growing and diverse population. In support of this progress,
the Government recently invited London to explore whether devolution could make these
improvements go further and faster.
In December 2015, all 32 Clinical Commissioning Groups (CCGs), London Councils on
behalf of the 32 London boroughs and the City of London, the Mayor of London, NHS
England and Public Health England came together as ‘London Partners’, and signed the
London Health and Care Collaboration Agreement. Through this, the Partners committed
to work more closely together to support those who live and work in London to lead
healthier independent lives, prevent ill-health, and to make the best use of health and care
assets.
Central government and national bodies backed this vision through the London Health
Devolution Agreement, and invited London to explore devolution – the transfer of powers,
decision-making and resources closer to local populations – as an important tool to
accelerate transformation plans and respond to the needs of Londoners more quickly.
Many decisions about health service planning and budgets are taken at national level. This
can sometimes create unintended barriers to delivering the connected and tailored local
services that Londoners want. London has already made significant progress in integration
and collaboration within the current system through: co-commissioning in almost all CCGs; cross-borough STPs; pooling budgets through the Better Care Fund; joint decision-making
by health and wellbeing boards; and innovative transformation through NHS vanguards
and integration pioneers.
Devolution aims to allow us to go even further by enabling health and care decisions to be
made for London, in London.
Through the devolution agreements, London Partners aim to minimise unnecessary
bureaucracy, and provide new opportunities for CCGs and boroughs to support Londoners
to be as healthy as possible and to ensure that the health and care system is on a
sustainable footing.
London’s health and care landscape contributes significantly to the rest of the UK: a
quarter of NHS doctors and more than half of England’s nurses are trained in the capital,
and London is a centre of excellence for health training, education and specialist care.
London’s health and care system is also very large, with hundreds of organisations and a
considerable proportion of the NHS budget. Given this size and complexity, we are
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exploring how devolution could work in practice through five pilots. These pilots have
focused on our three priorities - prevention, health and care integration and making best
use of health and care buildings and land - and are exploring decision-making at the most
appropriate and local level.
When developing their proposals, pilots have been exploring what is possible within the
current system and what explicit devolved powers are sought. It is clear that much can be
done within existing powers, but that by overcoming some specific challenges, efforts to
transform health and care could go further and faster. Pilots are setting out their
transformation vision, ‘offers’ by the local system to accelerate action and devolution ‘asks’
to overcome identified barriers to progress.
This paper aims to update CCG governing bodies on the progress of the London Health
and Care Devolution Programme as we move towards a second devolution agreement
and to confirm ongoing support.
We are keen to ensure the asks are coproduced and are reflective of the London-wide
system’s thinking. As we draft the final agreement and shape our final asks, CCG
governing bodies are asked to:
1. Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015.
2. Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs.
3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to agree and sign off the agreement on behalf of the CCG.
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For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications [Yes]
The risks [Yes]
Impact on our reputation [No]
Impact on our patients [No]
Impact on our providers [No]
Impact on our finances [No]
Equality impact assessment [No]
Patient and public involvement [No]
The CCG has considered whether entering into devolution arrangements is a priority. However as we
have no direct plan, we have not considered the detailed impact on specific areas.
2. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities [Yes ]
Make the best use of resources, continually improve performance and deliver
statutory responsibilities [No]
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities [No]
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting [Yes]
Develop the CCG as a continuously improving and effective commissioning
organisation [Yes /]
Please explain your answers:
3. Executive Summaries should not exceed 1 page. [My paper does comply]
4. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does not comply]
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London Health and Care
Devolution
Enabling health and care
transformation through devolution:
Update and next steps
19 October 2016
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Background
• This paper aims to update CCG governing bodies on the progress of the London Health and Care Devolution Programme as we move towards a second devolution agreement.
• Following the devolution agreements in December 2015, London partners have been working with five local and sub-
regional pilots to support the development of business cases for devolution.
• When developing their proposals, pilots have been exploring what is possible within the current system and what explicit
devolved powers are sought. It is clear that much can be done within existing powers, but that by overcoming some specific challenges, efforts to transform health and care could go further and faster. Pilots are setting out their transformation vision, ‘offers’ by the local system to accelerate action and devolution ‘asks’ to overcome identified barriers to progress.
• The emerging work of the pilots has reiterated the need for multi-level action, based on the foundational principle of subsidiarity. The devolution agreement last year described three levels for devolved powers: borough-level, STP-level and London, with aggregation only where necessary.
• This paper contains:
‒ A summary of current devolution proposals.
‒ This includes a description of the current thinking on the most appropriate approach for individual proposals (e.g. London level or voluntary draw-down by individual boroughs).
‒ These proposals continue to evolve as pilots finalise their business cases and with ongoing input from national
bodies and central government and wider engagement. As such, the detail of proposals and spatial levels is still evolving. The proposals are therefore draft and work in progress.
‒ Timeline and process for the next steps
2
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London already has a shared vision for better health and care
2012
London Health
Devolution
Agreement
2013 2014 2015
London Health Board
formed
London Health and
Care
Collaboration Agreement
London Health and
Care
Devolution Programme
established
Health and Social Care Act passed
Better Care Fund
Transformation in
integrated health
and social care
Better Health for London
64
recommendations
for London
Five Year Forward View the NHS’ strategy
Greater Manchester’s
health and
social care devolution
deal
Better Health for London: Next Steps
First collaborative
vision for London
2016
44 STPs under
development
Sustainability
and
transformation
plans (STPs)
announced
Healthy London
Partnership
established
Na
tio
na
l m
ile
sto
ne
s
Lo
nd
on
m
ile
sto
ne
s
Devolution pilots
underway
New Models of Care
Programme
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Transformation plans
Devolution aims to unlock barriers and enable transformation plans to go further and faster
Improving the
health and
wellbeing
of Londoners
Devolution
Learn more at: https://youtu.be/ir7oKEND9zs
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The devolution journey
Test how devolution
could work in five areas
of London
Secure devolution
based on robust
business cases
Devolution available
across London
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Key: type of pilot
Local prevention – note that this borough is also part
of the sub-regional estates pilot
Sub-regional care integration
Sub-regional estates
Local care integration
Integration in Lewisham: creating “One Lewisham Health and Social Care system” by combining mental and physical health
services and social care
Integration across Barking & Dagenham,
Havering and Redbridge:
delivering a personalised health and care
service focusing on self-care,
prevention and local services that enable the
sustainability of the health and care system
Prevention in Haringey: exploring licensing and
planning powers needed to ensure
that local environments support health, and
looking at early intervention to
support those who have fallen out of work due to mental
health issues
Integration in Hackney: Bringing together mental and physical health services, and health and social care budgets
Estates in Barnet, Camden,
Enfield, Haringey and
Islington (‘North Central London’):
making better use of health
and care buildings and land
London’s five pilots are exploring how devolution could work at different spatial levels
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01 Current status of proposals
If you have any questions on the following please contact the programme
team [email protected]
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Some asks are for the whole London system, others would be permissive, subject to local appetite and business cases
8
The terms of application of each proposed ask are specified in the pages below. These broadly fall into two categories:
- ‘London level’ asks, which consist of the freedoms, powers and variations which, if granted, will apply to the London system as a whole; and
- ‘Local/multi-borough draw-down’ asks are the freedoms, powers and flexibilities which, if granted, will be made available to sub-regional and local health economies to adopt should they so wish, subject to robust business cases.
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9
Integration: Summary of potential devolution asks
2c
Greater alignment between NHS England, NHS
Improvement and CQC for
regulatory functions in
London
The ability for an integrated / single delivery
system to be regulated as a
whole, despite underlying
distinct organisational operating units*
Supporting greater integration of the health and care
workforce and addressing
recruitment/retention
challenges (London, sub-regional/local)
Funding and governance to support workforce
transformation
(London/sub-regional)
Delegation / devolution of NHS England functions
including primary care
commissioning, capital and
transformation budgets
The ability for a joint local authority/CCG structure to
take on commissioning
functions, with pooling of
budgets*
Commissioning levers
and financial flows Regulation Workforce
DRAFT
Draft scope of ask
Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London)
London level
Other
*Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework
Freedoms and flexibilities during the development and
initial implementation stage of
the pilot
Supporting pilots to co-develop and adopt innovative payment
models
• Enabling the delivery of integrated care and more consistent mental health and acute care; strengthening primary and community care, reducing hospitalisation and improving outcomes.
• Thus, enabling people to live more independently and contributing to the financial sustainability of the system
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10
Estates: Summary of potential devolution asks
2c
Delegation of capital business case review and
approval functions
(sub-regional or London,
depending on the delegation limit)
Retaining the capital receipts generated by the London
system to enable investment in
health and care in London
Adoption of a commissioner capital control total
(London with sub-regional
draw-down)
A London estates board comprising local health
economies, London and
national partners to ensure
clarity on London’s assets, projects and capital needs,
building up from STP
estates strategies.
An estates delivery unit to consolidate existing
London-level and national
expertise to support local
areas to develop and deliver high-quality capital cases
London governance
and delivery Business case approval Capital
DRAFT
Draft scope of ask
Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London)
London level
Utilisation
*Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework
Accountability within London for utilisation of existing health and
care estates
• Releasing capital from surplus estate to invest in primary, community and hospital estate • Releasing surplus land for housing and wider public sector use
• Accelerating estate transformation by streamlining decision-making
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London partners recognise significant opportunities to enable greater value for Londoners from the NHS estate. These form the basis of London’s devolution proposals. An estates board aims to directly solve some of the challenges of NHS estates approvals and disposals, by providing a single forum for NHS estate discussions in London and through early involvement
of London government partners and national bodies. As it matures, the Board would also provide a mechanism to administer devolved responsibilities, including delegated business case approvals.
The Board aims to enable strategic and decision-making functions to enhance efficiency, quality and transparency of discussions and decisions that are currently taken nationally. These functions would be phased over time, with the Board commencing with strategic and advisory role.
11
An estates board for London
The Board would aim to operate according to key principles: • Subsidiarity, with decisions taken at the lowest appropriate level, and only taken at the London level when needed. • Transparency – with all relevant discussions taking place at the London estates board
• All partners bringing the collective expertise of their constituent organisations to achieve the greatest value for Londoners. • Decision-making will seek to achieve consensus so far as is possible, while respecting the views and statutory
accountabilities of constituent organisations.
The role and function of the board has significant interdependencies with wider devolution proposals. Detailed discussions
continue to clarify the proposed nature and scope of such devolved powers, and the board in its initial phase will be a valuable vehicle to collate expertise and streamline decision-making in this respect, allowing proposals to be developed at pace. The
board’s ability to fulfil the desired objectives would therefore be contingent on these devolved or delegated powers and resources being granted.
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Prevention: Summary of potential devolution asks
Devolution asks focusing on prevention have been progressed across three themes:
Powers to address problem gambling
Health as a fifth licensing objective for alcohol
(for local trial)
Powers to reduce tobacco consumption,
distribution and illicit
circulation
(some pan-London elements for illicit tobacco)
Devolve part of health and work budget to trial
initiatives tailored to
local needs (London ask with
funding devolved to local/multi-borough level)
Contractual variations to Fit for Work
service
Planning, licensing and fiscal powers to
encourage healthier
high streets
(London and local)
Use sumptuary tax revenue to invest in
London health
priorities
Tackling Obesity Healthier environments Health and Employment
DRAFT
Draft scope of ask
Local/multi-borough voluntary draw-down (commencing with Haringey prevention pilot)
London level
Complement individual Londoners’ efforts on staying healthy in their daily lives. Using devolution as a means to create better environments in which people can flourish
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Ongoing activity
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Iterating proposals
Exploring governance and accountability
Engagement on devolution asks and
offers
Discussions re: legislative change
Sharing learning
• Workshops with central government, national bodies, London partners and pilots to align objectives and test the appropriate devolution levers to bring about intended health outcomes
• Maximising opportunities for alignment with STPs • Supporting pilots to develop business cases by late October
• To be developed based on emerging pilot governance proposals and engagement with constituent organisations and London partners.
• Phased approach based on devolution requirements e.g. need for financial accountability
• In partnership with DH, DCLG, NHSE and NHSI. London is examining amendments to existing legislation and considering additional legislative requirements
• Engagement on and iteration of devolution offers and asks with the wider London system
• Including shared learning from the pilots and development of a support package for non-pilot areas
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01 Shaping final asks and the
December agreement
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CCG involvement in shaping devolved health powers in London
• Engagement has been key to developing the current set of asks and proposals. The high level proposals are subject to ongoing discussions with borough leaders, CCG Chairs and Chief Officers, LHCOG, BCF leads, London Prevention Board, LRET, HWBB chairs and the ADPH network.
• These opportunities for engagement with the developing devolution propositions will be critical, but they will not by themselves offer the mechanism for propositions to be explored comprehensively in detail, nor will these opportunities allow
for the detailed and ongoing engagement likely to be required in the run up to December. For example, as pilot areas develop asks and discussions with London partners refine the detail, London’s health and care system leaders may wish to be able to offer engagement which can respond flexibly and in an iterative way.
• The strategy for reaching agreement on London’s December asks will require an approach which recognises that decision making will be necessary for different asks at different spatial levels. For example, where asks are emerging which would not of themselves affect all of London if granted (i.e. they are permissive and discrete to local or sub-regional footprints)
then the appetite and support from a pan-London level would be beneficial but may not be essential to the case being made by the pilot area. However, where asks are emerging which would affect the whole of London if granted (i.e. where a pilot is
making the case for devolution which would impact on all boroughs), then broad agreement of the London system would be needed.
• We are keen to ensure the asks are coproduced and are reflective of the London-wide system’s thinking. As we draft the
final agreement and shape our final asks, CCG governing bodies are asked to:
15
1. Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015.
2. Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable
the potential to devolve certain powers across London partners, including CCGs.
3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG
Chair) to agree and sign off the agreement on behalf of the CCG.
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Engagement with local government
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Month Meeting or event
June Healthwatch Hackney
July London Councils and HSCIC Meeting
September Chief Executives (of local councils) of London Committee (CELC)
September Health and Wellbeing Board Chairs
October CELC
November CELC (TBC)
December Health and Wellbeing Board Chairs (TBC)
Local councils are engaged in discussions about health and care devolution. Illustrative engagement undertaken to date is described below:
In addition, significant engagement is underway at local level within pilots, among all stakeholders and political leadership.
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Key dates
CCG
engagement
Develop business cases and clarify asks and offers
Oct Nov Dec Jan Feb Mar April April June Aug Sept July
STPs submitted
LHB
Pilots Iterate business cases and negotiate
devolution
Menus of devolution developed for London
Implement shadow
arrangements
Develop business cases for devolution if locally desirable
London-wide
activity
Spreading learning
Sharing learning from pilots
Develop new working arrangements with phased implementation of activities within current powers
(TBC) Further devolution
announcement
2016 2017 2018
STP operational plans submitted
Non-pilot areas Engagement on devolution asks and offers
Implement shadow
arrangements
Implement devolved
arrangements
Develop London-level proposals Develop new working
arrangements with phased
implementation of activities within
current powers
Implement shadow
arrangements
Implement devolved
arrangements
Chief officers meeting London
Prevention Board
CCG chairs
12 14 14 15
29 27
19 Chief officers
LTG
LTG LTG 20
LTG
CCG CFO 17 Chief
officers & Chairs
CCG CFO
14 Chief officers
Themes, processes, timelines
Excerpts of
draft
agreement
and emerging
proposals
Updated agreement
and proposals
Final
agreement
Pilot OBCs developed
Current programme and engagement timeline
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01 Initial agreements published in 2015
Annex
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• The London Health and Care Collaboration Agreement • The London Health Devolution Agreement
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Two London agreements were signed in December 2015
Agreement to transform health and wellbeing outcomes and services, recognising:
• the need to shift from reactive care to prevention,
early intervention, self-care and care closer to home
• the scale and complexity of the health and care system
in London - transformation will be driven at three geographical levels
• the need to tailor solutions to the different needs of
people and places and that locally shaped solutions will progress at different paces
• The importance of enablers, including estates
Full report available here:
https://www.london.gov.uk/sites/default/files/london_health_and_care_collaboration_agreement_dec_2015_signed.pdf
The London Health and Care Collaboration Agreement
Commitment by government and national bodies to work with London to explore:
• aligning capital programmes and removing barriers to make
best use of the NHS estate
• flexibility of payment mechanisms
• developing place-based provider regulation
• workforce planning and delivery of education and training
• devolving transformation funding
• using planning & licensing to support prevention
• joint working on employment and health.
Full report available here: https://www.gov.uk/government/publications/london-health-
devolution-agreement/london-health-devolution-agreement#parties
The London Health Devolution Agreement
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Summary of agreements
The key elements of the agreement are: i) Multi-level action: Given the size of the London system three levels of action will be needed: borough (local); multi-borough
(sub-regional); London-wide (regional).
ii) Underpinned by the principle of subsidiarity: This means that decisions should always be taken at the most local appropriate level and aggregated up to multi-borough or London-wide only as needed.
iii) London’s health and care system is highly complex. We have a large number of health and care organisations and population and patient flows occur with frequency across local boundaries. For these reasons London will be running pilots to test
different elements of health and care devolution at different spatial levels. iv) Focus on integration, prevention and estates
What does it mean for London?
Through Better Health for London, our city already has a plan making it fairly unique in England. All organisations have committed to delivering on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and in doing so, deliver on the NHS Five Year Forward View.
If decisions about London are made within the London system, they will respond more closely to the challenges and
opportunities of our city and population. We plan to test how this works in practice through devolution pilots with the ambition to scale up across the city. For Londoners we expect this to mean a more effective, streamlined health and care service, greater support to stay as healthy as possible for as long as possible and ensuring health and care resources are used most efficiently.
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Aspirations and objectives of London devolution (from 2015 agreements)
The parties have a shared commitment to deliver on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and, in doing so, deliver on the NHS Five Year Forward View and secure the sustainability of health services and social care.
21
To meet these aspirations, the parties share the following objectives:
• To achieve improvement in the health and wellbeing of all Londoners through a stronger, collaborative focus on health promotion, the prevention of ill health and supporting self-care
• To make rapid progress on closing the health inequalities gaps in London
• To engage and involve Londoners in their health and care and in the health of their borough, sub-region and city including
providing information so that people can understand how to help themselves and take responsibility for their own health
• To improve collaboration between health and other services to promote economic growth in the capital by addressing factors that affect both people’s wellbeing and their wider economic and life opportunities, through stronger partnerships
around housing, early years, employment and education
• To deliver integrated health and care that focuses on maximising people’s health, wellbeing and independence and when
they come to the end of their lives supports them with dignity and respect
• To deliver high quality, accessible, efficient and sustainable health and care services to meet current and future population needs, throughout London and on every day.
• To reduce hospitalisation through proactive, coordinated and personalised care that is effectively linked up with wider services to help people maintain their independence, dignity and wellbeing.
• To invest in fit for purpose facilities for the provision of health and care services and to unlock the potential in the health
and care estate to support the overall sustainability and transformation of health and care in the capital
• To secure and support a world-class workforce across health and care
• To ensure that London’s world-leading healthcare delivery, academic and entrepreneurial assets provide maximum benefit for London and the wider country and that health and care innovation is facilitated and adopted in London.
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All parties agreed to the following principles
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• Improving the health and wellbeing of Londoners will be the overriding driver for reform and devolution.
• We will work to secure a significant shift from reactive care to prevention, early intervention, self-care and care close to home that supports and
enables people to maximise their independence and wellbeing.
• London will remain part of the NHS and social care system, upholding national standards and continuing to meet and be accountable for statutory
requirements and duties, including the NHS Constitution.
• Joint working will improve local accountability for services and public expenditure. Where there is local agreement to change accountability
arrangements, accountability to NHS England will be maintained – in relation to issues including delivery of financial requirements, national
standards and the NHS Constitution. Changes to current accountabilities and responsibilities will be agreed with government and national bodies as
necessary and may be phased to balance the pace of progress with ensuring a safe transition and strong governance. We commit to fulfil the legal
requirements for making significant changes to commissioning arrangements.
• Decision-making will be underpinned by transparency and the open sharing of information between partners and with the public.
• Transformation will be locally owned and led and will aim to get the widest possible local support. We will ensure that commissioners, providers,
AHSNs, patients, carers, the health and care workforce, the voluntary sector and wider partners are able to work together from development to
implementation to shape the future of London’s health and care.
• All decisions about London will be taken in or at least with London. Our goal is to work towards resources and control being devolved to and within
London as far as possible, certainly in relation to outcomes and services for Londoners.
• Collaboration and new ways of working will be needed between commissioners, providers, patients, carers, staff and wider partners at multiple
levels. Recognising that the London system is large and complex, commissioning and delivery will take place at three levels: local, sub-regional or
pan-London. A principle of subsidiarity will underpin our approach, with decisions being made at the lowest appropriate level.
• Given London’s complexity we recognise that progress will happen at different paces and in different orders across the different spatial levels. We
will ensure that learning, best practice and new models for delivery and governance are shared to support and accelerate progress in all areas.
Subsidiarity as a principle will extend to the adoption of ideas piloted in other areas to allow flexibility and adaptation to local conditions.
• The people that work in health, health care and social care are critical to achieving London’s transformation goals. We will build on London’s position
as the home of popular and world-class health education, to develop new roles, secure the workforce we need and support current and future staff to
forge successful and satisfying careers in a world-class London health and care system.
• We recognise that considerable progress can be made, building on existing foundations, with existing powers and funding – and we are committed to
doing so. But devolution is sought to support and accelerate improvements. A series of devolution pilots will be established through which detailed
business cases for devolution of powers, resources and decision-making can be developed in partnership with government and national bodies.
Through these, devolution may be secured both for the pilots themselves and also for other parts of London, contingent on these areas also
developing suitable plans, delivery and governance arrangements.
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Continued…
• While embedding subsidiarity, we will ensure the strategic coherence and maximise the financial sustainability of the future health and care system
across London. Political support for jointly agreed change will be an important feature of the arrangements.
• New London-level arrangements, including governance and political oversight, will be established to secure this. We commit to minimising bureaucracy
as much as possible to enable delivery of local innovation.
• In 2016/17 - and drawing from the experiences of the pilots - sustainability and transformation plans for health and care will be developed as part of
NHS and local authorities’ planning arrangements. These will draw on learning from the devolution pilots, other transformation initiatives including the
Vanguard programme and any London-wide initiatives.
• A London-level picture, drawn from sub-regional health economy plans, will enable oversight of the impact on health outcomes and financial
sustainability of the system across the capital.
• We recognise that London provides expertise and services for people who live outside the capital and that benefit the country more widely. London will
work collaboratively with other regions and national bodies to consider and mitigate the impact of London decisions on surrounding populations reliant
on London-based services.
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W A N D S W O R T H C C G P A G E 1 O F 2
Board Assurance FrameworkAuthor: Sandra Allingham Sponsor: Sandra Iskander Date: 14th December 2016
Executive Summary
Context
The Board Assurance Framework (BAF) has been developed to report on the principal
risks to the organisation’s corporate objectives, and is the main process through which the
Board receives assurance on the management of risks.
Question(s) this paper addresses
1. Does the BAF include sufficient information on the controls and actions required to
mitigate the risks?
2. Does the BAF provide sufficient assurance against the achievement of each objective?
Conclusion
1. The report includes information on controls that have been put in place, and actions
identified, in order to manage and mitigate the risks. The detailed review and scrutiny
of the BAF ensure that appropriate controls and assurances are in place to manage the
mitigation of these risks.
2. All risks and their actions are regularly reviewed and scrutinised. The scrutiny process
involves the Risk Review Group, the Integrated Governance Committee, and the CCG
Board. Risk scores are tracked during the year to enable monitoring of the
effectiveness of the actions, controls and assurances.
Input Sought
We would welcome the board’s input to:
Review the Board Assurance Framework as a whole and assess on whether the
principal risks are accurately reflected.
Consider whether any further actions or controls are required.
Note the level of risk detailed in the report.
Approve the report.
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]
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W A N D S W O R T H C C G P A G E 2 O F 2
For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications [Yes]
The risks [Yes]
Impact on our reputation [Yes]
Impact on our patients [Yes]
Impact on our providers [Yes]
Impact on our finances [Yes]
Equality impact assessment [Not applicable]
Patient and public involvement [Yes]
Please explain your answers:
2. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities [Yes]
Make the best use of resources, continually improve performance and deliver
statutory responsibilities [Yes]
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities [Yes]
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting [Yes]
Develop the CCG as a continuously improving and effective commissioning
organisation [Yes]
Please explain your answers:
3. Executive Summaries should not exceed 1 page. [My paper does comply]
4. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does not comply]
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Page 1 of 38
BOARD ASSURANCE FRAMEWORK
INTRODUCTION
The Integrated Risk Management Framework was approved in June 2012 by the CCG Board and reviewed by the Integrated Governance Committee in July 2014. The Board Assurance Framework and Risk Management process were reviewed by Internal Audit in October 2014, with identified recommendations, which have been actioned.
The risk process and framework is fully established across the CCG. Risks at all levels are identified, assessed, scored, reported, owned and recorded. Some risks will be identified by the Board; others will be raised by managers and staff as part of their day-to-day work. Each risk is assessed in terms of both its potential likelihood and impact. Those two dimensions are each given a score between 1 and 5 (in line with the National Patient Safety Agency’s Model 2 Risk Matrix) - the risk score is then calculated by multiplying those two numbers. Controls are put in place to reduce the likelihood or the impact of each risk.
The Board Assurance Framework has been developed from the organisation’s key objectives and principal risks to those objectives (identified by the Board). The Board Assurance Framework is the main process through which the Board receives assurance on the management of risks to the achievement of the strategic objectives.
Higher scoring operational risks are also reported and escalated within the wider system of risk across the organisation. This provides the Board with an overview of the totality of the high level risks which face the organisation together with the action plans to address them. The detailed review and scrutiny of the Board Assurance Framework ensures that appropriate controls and assurances are in place to manage the mitigation of these risks. Analysis identifies any objectives that are at a greater risk and provides opportunities for remedial action which will increase the level of assurance.
The Board Assurance Framework outlines details of the principal risks as at October 2016 that may prevent the CCG from achieving its strategic objectives. Information included in the report identifies:
Controls that have been put in place to manage the risks;
Assurances that have been received to demonstrate if the controls are having the desired impact;
Performance against Key Performance Indicators;
Details of any gaps in the assurance; and
Comments and further actions required.
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There are currently fourteen BAF risks, six rated very high (15-25), six rated as high (8-12), and two moderate (4-6). The highest level individual risk is: (R99) ‘Challenges facing main provider’ with a risk score of 20.
All risks and their actions are regularly reviewed and scrutinised. The scrutiny process involves the Risk Review Group, the Integrated Governance Committee, and the CCG Board. Risk scores are tracked during the financial year, to enable monitoring of the effectiveness of the actions, controls and assurances.
The following operational risks scoring twelve and above are being reported by exception:
(R72) Failure to provide assurance that those most vulnerable in care homes and in the community are free from harm – risk score 12
(R77) Failure to reduce inequalities because of absence of specific focus – risk score 12
(R89) Financial distress of main provider – risk score 16
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The dashboard below summarises the Corporate Objectives and lists the relevant principal risks.
Corporate Objective Potential Principal Risk Initial Score
Current Score
Tolerance Score
Movement from previous
review
Date of last
Review
Risk 16 – Failure to receive the appropriate level of funding allocation. 20
(5x4)16
(4x4)9
(3x3)↔ 04/10/16
Risk 33 – Failure to have sufficient plans to cater for surges in activity and growth in population caused by local community developments.
9(3x3)
9(3x3)
6(3x2)
↔ 04/10/16
Risk 47 – Failure to have a shared understanding with providers of what safe high quality care looks like and how to recognise failure of care in light of the Francis, Keogh and Berwick reviews.
16(4x4)
8(4x2)
8(4x2)
↔ 04/10/16
Risk 50 – Failure to commission services in a way that delivers integrated and sustainable models of care.
16(4x4)
2(2x1)
8(4x2)
↓(3x2)
04/10/16
Objective 1:Commission high quality services which improve outcomes and reduce inequalities
Risk 99 – Challenges facing main provider20
(5x4)20
(5x4)New 04/10/16
Risk 7 – Financial pressures across the health and social care economy. 16
(4x4)16
(4x4)9
(3x3)↔ 04/10/16
Risk 9 – Failure to plan expenditure to reflect budget and maximise use of resources. 16
(4x4)16
(4x4)6
(3x2)↔ 04/10/16
Risk 68 – Failure to achieve performance ambitions set out in the 2015/16 Assurance Framework and the 2015/16 Operating Plan.
16(4x4)
16(4x4)
8(4x2)
↔ 04/10/16
Objective 2:Make the best use of resources, continually improve performance and deliver statutory responsibilities
Risk 75 – Sustainable health economy16
(4x4)12
(4x3)9
(3x3)↔ 04/10/16
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Risk 95 – 1% non-recurrent uncommitted reserve16
(4x4)
12(3x4)
↔
Risk 97 – Primary Care Commissioning20
(5x4)
12(4x3)
6(3x2)
↔ 04/10/16
Objective 3:Continually improve delivery by listening to and collaborating with our patients, members, stakeholders and communities
No corporate risks currently highlighted
Objective 4:Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting
Risk 29 – Failure to reshape the local out of hospital and urgent care services to respond to local system.
20(5x4)
16(4x4)
6(2x3)
↔ 04/10/16
Risk 65 – Failure to develop and improve the CCG as an organisation. 9
(3x3)4
(2x2)1
(1x1)↔ 04/10/16
Objective 5:Develop the CCG as a continuously improving and effective commissioning organisation Risk 102 – New operational model 20
(4x4)12
(4x3)8
(4x2)New 01/12/16
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BAF Risk Profile Summary October 2016
5Moderate High Very
High1 Very
High
4 Moderate 1 2 6 Very High
3 Low Moderate 1 1 Very High
21 1 Moderate High High
IMP
AC
T
1 Low Low Low Moderate Moderate
1 2 3 4 5LIKELIHOOD
Objective Low Moderate
High Very High
1: Commission high quality services which improve outcomes and reduce inequalities 1 0 2 2
2: Make the best use of resources, continually improve performance and deliver statutory responsibilities 0 0 3 3
3: Continually improve delivery by listening to and collaborating with our patients, members, stakeholders and communities
0 0 0 0
4: Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting 0 0 0 1
5: Develop the CCG as a continuously improving and effective commissioning organisation 0 1 1 0
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The table bellows identifies whether risks are influenced by Internal or External factors and whether risks are stable or changing:
External factors
Internal
Stable/known Unstable/new
St George’s Hospital
challenges (No.99, 5x4)
Funding
allocation(No.16, 4x4)Surges in activity &
growth in population(No.33, 3x3)
Financial pressures
across SWL(No.7, 4x4)
NHS Constitutions
domains(No.68, 4x4)
Quality of care within
commissioned services(No.47, 4x2) Sustainability and
Transformation Plan(No.75, 4x3)
SWL Operating Model(No.102, 4x3)
Transition of Primary
Care Commissioning(No.97, 4x3) OOH and Urgent Care
Services(No.29, 4x4)
1% non-recurrent
reserve(No.95, 3x4)
QIPP(No.9, 4x4)
Commissioning of
integrated & sustainable
models of care(No.50, 2x1)
Organisation
Development(No.65, 2x2)
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Objective 1: Commission high quality services which improve outcomes and reduce inequalities
Director Lead: N McDowellRisk 16 (Finance) – If the Department of Health reduced the CCG’s allocation, this would impact on the CCG’s recurrent investments and ability to achieve business rules, eg deliver target surplus.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 5 x 4Current: 4 x 4Tolerance rating: 3 x 3
Risk History Rationale for current score: NHS England set Business Rules for CCGs to operate within. The implication of the rules will impact the budgets after CCG allocations have been confirmed.
There are a number of variables which need to be confirmed in order to plan appropriately, such as the way primary care services are commissioned/ contracted for.
National tariff for 2017/18 has now been issued but is draft and subject to change. Full impact overall will not be known until contracts are signed at the end of December.
Internal Assurances
Management Team
Finance Resource Committee
Audit Committee
Finance Recovery Group
Board
Main controls in place: (What are we currently doing about the risk?)
Review of position and plans by monthly Finance Resource Committee.
Management Team receive regular reports on the financial plan.
NHS England Assurance meetings to review performance.
Reserves in place if adverse impact on financial position.
New Finance Recovery Group established to review the overall position including QIPP delivery and budget position.
External Assurances:
Internal Audit
External Audit
NHS England
Gaps in Assurances and Controls: (What additional assurances should we seek?) 1. Level of resources secured and plan for the year to be confirmed.2. QIPP plan assurance.3. Reserves analysis.
Further actions required: (What more should we do?) 1. Regular analysis of financial position at Finance Resource Committee
(31/03/2017).2. Monthly oversight at FRC of underlying recurrent financial position
(31/03/2017).
Additional comments: (With these actions taken, how serious is the problem?) If CCG allocations change without sufficient risk management then plans and targets will not be met. In addition, assumptions made in the Sustainability and Transformation Plan (STP) will be out of date and in need of refreshing which could increase the financial gap across SWL.
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Objective 1: Commission high quality services which improve outcomes and reduce inequalities
Director Lead: A McMylorRisk 33 (Planning) – Rising population growth coupled with the projected increase in patients with long-term conditions places significant pressure on estates with primary and community services. If there is no coherent estates strategy factoring in the different health needs across Wandsworth, the population could suffer through unmet need or areas of the borough not having sufficient access to services.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 3 x 3Current: 3 x 3Tolerance rating: 3 x 2
Risk History Rationale for current score: The CCG’s current plans are based on a fundamental shift in setting of care (ie away from hospital) and there is a risk that these plans could be derailed if the increase in population, such as Nine Elms Vauxhall (NEV), or more patients being managed with a long-term condition are not able to access care in the appropriate out of hospital setting. This would drive up acute activity and spend.
This score remains the same as the CCG are planning a strategic response to the issues faced.
Internal Assurances:
Management Team
Estates Steering Group
Main controls in place: (What are we currently doing about the risk?)
An Estates Steering Group has been established, led by the CCG, bringing together partners from NHS England and NHS Property Services to maintain an overview of primary care estate within Wandsworth including opportunities for development.
Scoping work to identify MCP (Multi-specialty Community Provider) hub locations in light of expected population changes is on-going via the Estates Strategy Steering Group.
An Estates Strategic Framework has been developed and approved by Board in December, which detailed our broad approach to Estates Development in Wandsworth.
Joint Strategic Needs Analysis in place and referenced as part of the Estates and service development work.
All practice baseline surveys have been completed. These have been used to support practices in identifying potential opportunities to request IG funding as part of the next round of bids.
External Assurances
NEV Programme Board
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Gaps in Assurances and Controls: (What additional assurances should we seek?)
Review the outcomes of the Estates and Transformation Fund (ETTF) bid once known (11/16). Review options where we may not have been successful in funding specific schemes.
Further actions required: (What more should we do?)1. Continue to develop collaborative working to establish joint appointment
to develop Section 106 submissions. Additional resource identified to support development of joint process and delivery of Section 106 (01/01/2017).
2. Further meetings with SGH, NHSPS and Damson Health re potential to establish a Multi-specialty Community Provider (MCP) hub at Doddington (01/01/2017).
3. Review outcomes of ETTF bid once these become available (01/12/2016).
4. Review practice surveys and identify any priority areas that will affect practice capacity and report back to the Estates Working Group (31/12/2016).
Additional comments: (With these actions taken, how serious is the problem?) Monitoring arrangements are currently being put in place to work with Lambeth and Wandsworth Public Health departments to create a clear review process of the impact of the incoming population. The changes to the development will be reviewed either six monthly or annually as the development progresses. The on-going monitoring plans will directly involve LCCG and WCCG members of the Health Project Board.
Follow-up Health Input Assessment for Nine Elms Vauxhall being developed to be reviewed at the Project Board.
Estates and Technology Transformation Fund submission completed on 30th June; this includes bids that support the growth in West Wandsworth and other wards, as well as better use of Queen Mary’s Hospital (QMH).
All practices have the opportunity to bid in the new round of Improvement Grant (IG) funding. Applications from practices require support from the CCG in order to ensure that there are no revenue implications associated with any bids and that these align with our Estates Strategic Framework. Deadline for applications is 30/09/16.
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Objective 1: Commission high quality services which improve outcomes and reduce inequalities
Director Lead: S IskanderRisk 47 (Quality) – Failure to develop effective early warning systems to monitor soft intelligence will hinder the early detection of poor, or potentially poor, quality of care within commissioned services.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4 Current: 4 x 2 Tolerance rating: 4 x 2
Risk History Rationale for current score: The impact of failing to detect quality failures can be very severe both to patient safety and the reputation of the CCG/NHS. Learning from the Francis report shows that quality deterioration is more likely during periods of financial challenge. Although the CCG has monitoring systems and processes in place to triangulate hard and soft data, further developments can be made.
Enhanced surveillance process established with St George’s Hospital as part of the lead commissioner role to monitor current financial and quality concerns.
Internal Assurances:
Integrated report to the Integrated Governance Committee.
Board receives summary minutes from Integrated Governance Committee.
Key indicators tracked through Quality Monitoring System.
Quality Group monitors Serious Incidents.
Safeguarding Committee monitors Safeguarding Key Performance Indicators.
Pressure sore incidents monitored through Quality Group.
Review of themes from complaints and patient feedback.
Main controls in place: (What are we currently doing about the risk?)
CCG leading at monthly Clinical Quality Review Groups (CQRGs) with the main providers, Quality Surveillance Group (QSG), and Professional Standards Board (Local Authority – Quality Surveillance).
Board and Integrated Governance Committee receive copies of reports and high level summaries from all Quality meetings (including CQRGs, Quality Group, Safeguarding Committee and other Task and Finish groups).
Programme of commissioner-led quality visits (quality walkabouts) at St George’s Hospital have been established to provide an opportunity to listen to patients, families, service users and staff during the visits.
Quality alert systems in place (‘Make A Difference’ at practices for healthcare professionals to raise quality concerns; Care Connect at St George’s Hospital; Google alerts; Twitter).
Monthly CCG Integrated Governance report details clinical quality concerns and actions to address highlighted issues.
Quarterly Quality and Patient Safety Report provided to Integrated Governance Committee providing details of clinical quality concerns and mitigations with a monthly highlight exception summary report.
Enhanced quality surveillance measures implemented for SGH during period of financial recovery.
Quality Group established to undertake more in-depth analysis of systems including for small contracts.
External Assurances
CQC Inspections and Reports
Quality Risk Summits
Healthwatch Reports
Provider Quality Accounts and quality / performance dashboards
Clinical Quality Review meetings with providers
Clinical Senates / Networks
Monthly meeting of NHS England London Quality Surveillance Group.
Friends and Family Test scores
Quarterly Assurance meetings with NHS England
Overview and Scrutiny Committee
Local Adults Safeguarding Board and the Local Safeguarding Children’s
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Clinical Reference Groups report quality issues to the Integrated Governance Committee.
Clinical commissioning representation on SGH quality inspection visits.
Clinical Harm Group set up to oversee clinical impact on patient care from delays in treatment – represented by CCG Clinical Quality Leads.
Board
Patient Experience reports (complaints, surveys, compliments) Care Quality Commission Reports
Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Data on quality comprises some hard data (e.g. on HCAIs) and also soft intelligence
and is in disparate places and multiple formats, and collating a holistic view of quality across a provider is challenging, and assuring quality across a pathway across multiple providers is highly challenging.
2. The CCG commissions from a number of small providers including non-NHS providers, which do not have formal CQRG meetings.
Further actions required: (What more should we do?)1. Use Quality Group to triangulate data and review processes
(31/03/2017).2. Consider escalation of quality concerns through Management Team and
Integrated Governance Committee (31/03/2017).3. Develop action plan to address concerns raised in CQC reports
(31/03/2017).4. Roll-out quality dashboard to monitor smaller contracts (31/03/2017).5. Quality Oversight Group to be set up (31/01/2017).
Additional comments: (With these actions taken, how serious is the problem?) There continues to be a balance between developing trusting relationships with our main providers and establishing systems of control. Whilst the controls in place provide good assurance, risks of quality failures are exacerbated by financial pressures and also challenges in recruiting permanent staff to some roles.
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Objective 1: Commission high quality services which improve outcomes and reduce inequalities
Director Lead: R WellburnRisk 50 (Commissioning) – If collaborative and partnership working with the Local Authority, NHS England and other CCGs does not secure the intended joined up approaches, this will impact on the CCG’s ability to achieve the transformational change necessary to improve the quality, value and viability of commissioned services. Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4Current: 2 x 1Tolerance rating: 4 x 2
Risk History Rationale for current score: Responsibility for health has been split between CCGs, Local Authorities (Public Health) and NHS England. The complexity of this arrangement has the potential to lead to fragmented pathways across the wider health and social care landscape if there is no effective engagement, or alignment of health priorities.
A Health and Social Care Integration Group has been established by the CCG and Wandsworth Borough Council to oversee delivery of integrated commissioning programmes for Older People, Mental Health, Learning Disabilities, Children and Public Health.
WCCG is an integral partner of the South West London Five-Year Strategic Plan ensuring aligned CCG work plans and working within the SW London Sustainability and Transformation Planning Group.
Internal Assurances:
Management Team
CCG Board
Delivery Group
Main controls in place: (What are we currently doing about the risk?)
Proposed single leadership model across the five CGs (Kingston, Merton, Richmond, Sutton and Wandsworth) to work collectively under one Accountable Officer to deliver the ambitions set out in the Sustainability and Transformation Plan (STP).
The move towards deeper collaborative working will include optimising governance arrangements to ensure streamlined and efficient decision making.
SRG (System Resilience Group) established with Merton CCG, Local Authorities and SGH to deliver the transformation and integration of services at local level.
The commissioning programmes are aligned to commission services that will deliver integrated and sustainable models of care. Joint programmes established with Merton CCG for urgent and planned care.
Cross CCG meetings established (Chief Officers, Finance, Commissioning) to take forward areas of shared interest. Monthly Joint Executive Committee established.
Two-year plan for integrated services within Better Care Fund owned by Health and Wellbeing Board.
WCCG is an integral partner of the South West London Five-Year Strategic Plan ensuring aligned CCG work plans and working within the SWL Sustainability and
External Assurances
Health and Wellbeing Board.
Overview by Joint Commissioning Executive, and Health and Wellbeing Board.
Better Care Fund Working Group
System Resilience Group
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Transformation Planning (STP) Group.
Health and Social Care Integration Steering Group established. Joint Commissioning Programmes agreed, with joint governance framework.
Lead provider commissioning arrangements in place.
Gaps in Assurances and Controls: (What additional assurances should we seek?)None currently identified.
Further actions required: (What more should we do?) 1. Continue to monitor. (31/03/2017)
Additional comments: (With these actions taken, how serious is the problem?) Effective joint working is likely to remain an area of significant risk, but shared governance arrangements and mutually agreed commissioning programmes will contribute to risk reduction during 2015/16.
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Objective 1: Commission high quality services which improve outcomes and reduce inequalities
Director Lead: S IskanderRisk 99 (Delivery) – As lead commissioner the CCG has to give assurance to associate commissioners of services at St George’s Hospital about the management of risks relating to the significant challenges currently faced by the Trust. Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 5 x 4Current: 5 x 4Tolerance rating: 3 x 2
Risk History Rationale for current score: The main provider for health services for Wandsworth residents is St George’s University Hospital NHS Foundation Trust which is facing a number of significant challenges currently, including a large number of changes to the Board and senior leadership team, a sizeable savings programme in 2016/17 to deliver its financial control total, ongoing performance and quality issues including estates issues, workforce recruitment and retention issues, particularly in community services, and data quality and reporting issues linked to IT implementation and staff training, which has resulted in the Trust temporarily suspending national reporting of RTT (Referral To Treatment) waiting times. The contract with the Trust is the largest the CCG holds, the Trust is by far the largest provider of acute care, and is the CCG’s main provider of community services.
Any provider facing all of these challenges at the same time will be at greater risk of performance failures, and potentially of experiencing a delay in identifying significant performance or quality.
Internal Assurances:
Management Team
Quality Group
Integrated Report to Integrated Governance Committee
Main controls in place: (What are we currently doing about the risk?)
CEO/CO regular meetings (as well as at executive level).
Continued quality oversight through Clinical Quality Review Group and Integrated Governance Committee.
Revised governance arrangements in place with the Trust and major associate commissioners, including with NHS Improvement and NHS England. External Assurances
System Resilience Group
Clinical Quality Review Group oversight of quality and review of Trust Cost Improvement Programmes
CQC Inspection undertaken 15th June 2016
Joint governance structure with NHS Improvement and NHS England
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Gaps in Assurances and Controls: (What additional assurances should we seek?)
Significant leadership changes at the Trust, with high number of roles filled by Interims. This impacts on the extent of assurance that can be given by the Trust
The normal contractual levers in the standard NHS Contract are not available in 2016/17 where providers are in receipt of Sustainability and Transformation Funding, which includes St George’s.
Further actions required: (What more should we do?)
Potential Board to Board, once new permanent Trust senior leadership team is in place. (31/03/2017)
Additional comments: (With these actions taken, how serious is the problem?) Given the range of factors applying at the same time and the gaps in assurance the risk level remains well above the tolerance rating, and some of the challenges facing the Trust do not have short term fixes.
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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities
Director Lead: N McDowellRisk 7 (Finance) – If one or more SWL CCGs experience financial and performance difficulties, this would impact on Wandsworth’s ability to deliver statutory functions and responsibilities.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4Current: 4 x 4Tolerance rating: 3 x 3
Risk History Rationale for current score: Most of the acute providers in SWL are experiencing financial distress. For 2016/17 a number of CCGs in SWL are also reporting a deficit position.
WCCG’s main provider is experiencing significant financial pressure for 2016/17.
Internal Assurances:
Management Team
Finance Resource Committee
Board
Main controls in place: (What are we currently doing about the risk?)
Assurance meetings established with NHS England – triangulation of plans between providers and commissioners.
Monthly South West London Chief Finance Officers’ meetings in place.
Monthly South West London Finance Review Group meetings set up across SWL to monitor the on-going position – reports provided to Finance Resource Committee.
Regular finance reports to Management Team, Finance Resource Committee, and Board – reports detail risks and mitigating action, including utilisation of reserves.
Trust and Commissioner Assurance Board (TCAB) in place with main provider to review financial position.
External Assurances
Internal Audit review that budgets have been set appropriately
NHS England Assurance meetings.
Finance Review Group
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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Impact of in-year over performance on the STP.2. Review main provider financial turnaround plan.3. CCG plans to be shared and discussed through Finance Review Group.
Further actions required: (What more should we do?)1. To review South West London financial and performance issues in year
(31/03/2017).
Additional comments: (With these actions taken, how serious is the problem?) Provider and CCG’s financial challenge could impact ability to meet clinical performance targets and general stability in the health economy.
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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities
Director Lead: N McDowellRisk 9 (Finance) – If the CCG does not deliver QIPP (Quality, Innovation, Productivity and Prevention) savings, this will jeopardise delivery of the financial control total, which would impact on the opportunity to improve quality and innovation Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4Current: 4 x 4Tolerance rating: 3 x 2
Risk History Rationale for current score: CCG QIPP has areas which are high risk such as reduction in non-elective activity.
Historic performance has shown some schemes failed to deliver due to over optimistic savings and delays in delivery.
No significant new transformation programme implemented.
New schemes developed and implemented during the year.
Internal Assurances:
Delivery Group
Finance Recovery Group
Management Team
Finance Resource Committee
Board
Main controls in place: (What are we currently doing about the risk?)
Business Intelligence Group (BIG) established, which will review any opportunities for establishing new QIPP schemes either in-year or subsequent years.
Finance Recovery Group established, chaired by Chief Officer, to oversee and ensure that QIPP schemes are managed in line with the project initiation documents and that performance is as expected. Where performance is not being delivered actions are agreed with Director responsible for that area.
Monthly Delivery Group meetings to review progress of delivery against Quality, Innovation, Prevention and Performance (QIPP) schemes reporting to Management Team.
All QIPP schemes have detailed plans, which where appropriate have been agreed with providers
2016/17 QIPP plan approved by the Board following Finance Resource Committee scrutiny.
Performance reported in finance report to Management Team, Finance Resource Committee, and Board.
NHS England assurance process monitors financial performance.
Internal Audit planned on the overall QIPP process from planning to monitoring.
External Assurances
Internal Audit
NHS England
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Gaps in Assurances and Controls: (What additional assurances should we seek?)None currently identified.
Further actions required: (What more should we do?)1. QIPP plan for 16/17 to be monitored monthly with a new Director level
Financial Control Group, reporting to CCG Finance Resource Committee (31/03/2017).
2. Continual development of schemes throughout the year – no investment released until risks are fully mitigated (31/03/2017).
Additional comments: (With these actions taken, how serious is the problem?) CCG holds a small contingency reserve but this might be utilised by other cost pressures emerging.
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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities
Director Lead: S IskanderRisk 68 (Performance) – Failure to deliver performance improvements in commissioned services, resulting in non-delivery of the NHS Constitution Domains, core standards, targets, Quality Premium, or planned health outcomes. Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4 Current: 4 x 4 Tolerance rating: 4 x 2
Risk History Rationale for current score: The CCG has faced a number of performance pressures over recent years. It has proved challenging to deliver some of the NHS Constitution standards, such as A&E four-hour maximum wait, RTT (Referral to Treatment) waits, cancer waits, and IAPT (Improving Access to Psychological Therapies). The standard on A&E four-hour maximum wait is unlikely to be achieved in 2016/17. Performance on the two-week urgent outpatient cancer wait, and sixty-two day maximum wait for treatment has been below the standard in 2015/16, but a recovery plan has been agreed with St George’s. There are significant issues with data quality of RTT waiting times information and St George’s has temporarily suspended national performance reporting.
Internal Assurances:
Integrated report to the Integrated Governance Committee (IGC). The Board receives copies of the minutes from IGC.
Performance alerts and risks are reported to Management Team by exception.
Delivery Group gives detailed scrutiny of performance plans and 15/16 performance.
Commissioning Reference Group and CQRG monitor and report Acute Provider performance to the CCG.
Main controls in place: (What are we currently doing about the risk?)
Performance reporting mechanisms are in place for all the main providers and cover achievement against key performance measures as well as highlighting risks. Issues highlighted through Contract monitoring and CQRG meetings.
Minutes of Clinical Quality Review Groups are reported to the Integrated Governance Committee.
Dashboards for Clinical Reference Groups developed to enable progress to be tracked.
Performance reporting is a standing item on the Board and Integrated Governance Committee agenda. Board receives regular updates on areas of under-performance.
Assurance reviews with NHS England are scheduled to review current performance.
New governance structure now in place on performance at St George’s with NHS Improvement and NHS England.
Clinical harm review meeting in place.
Internal escalation process agreed and intensive support in place for high risk targets.
Following the One Version of the Truth diagnostic review a Flow Programme is in place for the emergency and urgent care system.
A remedial action plan is in place for Cancer access.
External Assurances
NHS England Assurance monitoring (face-to-face meetings/telephone calls).
NHS England Performance Improvement Forum.
A&E Delivery Board focus on urgent and emergency care across the system.
Joint governance arrangements in place with NHS Improvement (NHSI) and NHS England (NHSE).
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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Performance position on RTT waiting times and size of backlog is uncertain due to
data quality issues identified.2. Recovery plan for RTT from St George’s will be dependent on issues with the quality
of performance reporting being resolved, which is likely to take some time.3. The normal contractual levers in the standard NHS Contract are not available in
2016/17, where providers are in receipt of Sustainability and Transformation Funding, which includes St George’s.
Further actions required: (What more should we do?)1. Continued scrutiny from Delivery Group (31/03/2017).2. Implementation of new governance framework with NHS England, NHS
Improvement and St George’s (31/01/2017).3. Given the extent of the RTT waiting time issues additional capacity is
being sourced in other local providers, both NHS and independent sector. (31/03/2017)
Additional comments: (With these actions taken, how serious is the problem?) The CCG is commissioning providers to deliver the NHS Constitution standards, and is commissioning sufficient activity to do so. The CCG is performing a leadership role in improving patient pathways on a system-wide basis. However, performance is clearly not entirely within the influence of commissioner actions.
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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities
Director Lead: G MackenzieRisk 75 (Delivery) – The SWL Sustainability and Transformation Plan (STP) sets out the financial case for change as well as the non-financial. If the programme does not deliver or proceed, there is a risk that the financial pressures set out would appear across the health economy. This would result in some providers not being financially viable as well as CCGs having a shortfall in delivery of shifts of care (impacts delivery of QIPP).
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4Current: 4 x 3Tolerance rating: 3 x 3
Risk History Rationale for current score: The System Transformation Plan (STP) has been developed by the CCGs and provider organisations and highlights the risks facing SWL if transformational change is not undertaken.
The 5 year plan is driven by reductions in acute activity and more activity taking place in the community along with general efficiencies brought about by collaborative working. Therefore if the SWL plans do not deliver this will put the strategy at risk. Plans so far such as QIPP across SWL have not been fully delivered and as a result acute activity continues to grow.
Financial position for providers is deteriorating faster than expected and the need for change is greater. CCG positions are also under significant pressure.
Internal Assurances:
Delivery Group
Finance Resource Committee
Management Team
Board
Main controls in place: (What are we currently doing about the risk?)
The STP has been developed to resolve the financial gap across the SWL economy. WCCG play a significant role in supporting the delivery of the programme and lead in a number of areas.
WCCG has significant clinical and non-clinical input to ensure the priorities of the CCG are represented.
Investment fund created to implement changes required to transform services.
Financial performance is monitored through Finance Resource Committee, Management Team, and Board.
External Assurances
NHS England
SWL Programme Board
SWL Finance and Activity Committee
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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Contingency plan2. Understanding provider position on a regular basis.
Further actions required: (What more should we do?)1. CCGs reviewing the operational model for 2017/18 onwards to ensure
delivery of the STP (31/03/2017).2. Securing contracts with providers for 2017-19 that reflect STP planning
and financial requirements (31/12/2016).
Additional comments: (With these actions taken, how serious is the problem?) Risk is still high as programme develops.
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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities
Director Lead: N McDowellRisk 95 (Finance) – The impact of central policy restricts CCG decisions regarding application of the 1% NR reserve, which reduces the potential for investment in services.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4Current: 3 x 4Tolerance rating: TBC
Risk History Rationale for current score: Currently, the CCG has to report the reserve as uncommitted but has to assume for reporting purposes it is available to the wider NHS system.
Internal Assurances:
Finance Resource Committee
Management Team
Board
Main controls in place: (What are we currently doing about the risk?)
Delivery of 0.5% surplus instead of 1% surplus was agreed by the Board.
Reduced level of planned investments.
No contribution to SWL risk pool agreed by the Board.
External Assurances:
NHS England
Gaps in Assurances and Controls: (What additional assurances should we seek?)Can we make a case for this funding to be retained by commissioners either locally or across SWL?
Further actions required: (What more should we do?)
On-going review to identify any in-year slippage (31/12/2016)
Review of all recurrent budgets (31/12/2016).
Additional comments: (With these actions taken, how serious is the problem?) No additional comments at this time.
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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities
Director Lead: A McMylorRisk 97 (Primary Care Development) – Risks associated with the transition of functions associated with taking on Delegated Commissioning responsibilities
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 5 x 4Current: 4 x 3Tolerance rating: 3 x 2
Risk History Rationale for current score: The CCG took on fully delegated Primary Care Commissioning functions from 1st April 2016. Since taking on these responsibilities, we are working closely with NHS England colleagues to understand the functions in more detail and work through the transition process.
A number of risks were identified as part of the due diligence exercise conducted prior to taking on delegated responsibilities, therefore, the CCG has already begun to implement a number of strategies to mitigate against those risks.
Internal Assurances:
Primary Care Committee
CCG Board
Primary Care Operational Group
Finance Resources Committee
Primary Care Quality Review Group
Primary Care Quality Tracker
Main controls in place: (What are we currently doing about the risk?)
A Primary Care Commissioning Committee has been established to oversee the management of the delegated functions.
A Primary Care Operational Group has been established to support the day to day management and decision making process.
A Primary Care Quality Review Group has been established.
A Quality Contract is in place, which identifies gaps in quality across the borough and within individual practices, as well as providing a mechanism to support practices with any issues.
Practices have submitted their questionnaires as part of the baseline audit (deep dive) programme. These will be used to highlight any immediate areas of concern, and focus practice visits where additional information is required or area of support highlighted.
External Assurances
NHS England
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Gaps in Assurances and Controls: (What additional assurances should we seek?)
A more detailed risk register to be developed for Primary Care Commissioning to include quality, finance and commissioning.
An integrated Primary Care Commissioning report will be developed, that will provide the Primary Care Committee with oversight of the management of primary care contracts and quality. This will be taken to the Primary Care Committee in December.
Further actions required: (What more should we do?)
Finalise operating model which will detail the on-going processes and arrangements for the day to day management of the delegated functions (31/03/2017).
On-going transition process in place with NHS England (31/03/2017).
Weekly meetings taking place with NHS England colleagues to support the transfer and management of the delegated functions (31/03/2017).
Primary Care Commissioning risk register to be developed which combines both performance, contracting and quality areas (311/8/2016).
Individual practice ‘deep dive’ visits to take place to identify any legacy issues and to identify any possible issues, concerns or achievements. Key themes to be identified from the practice deep dive questionnaire; follow-up visits to take place where specific areas of concern are raised (01/12/2016).
Additional comments: (With these actions taken, how serious is the problem?) We continue to work with NHS England colleagues to manage the day-to-day activities associated with Primary Care Commissioning, and as such are in a position to better understand the current risks associated with these new functions. These additional assurances now in place, including a robust governance structure, ensure that risks can be identified earlier and any mitigating controls/actions can be put in place. We continue to monitor the various aspects of Primary Care Quality through our PCQRG; this includes any issues raised as a result of practice CQC visits, or infection control audits.
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Objective 4: Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting
Director Lead: R WellburnRisk 29 (Planning) – If the CCG does not engage with the Collaborative Commissioning programme and the drive for integrated commissioning, or react to the call to action for transforming primary care and make robust plans in relation to the change in financial allocation, this will put the CCG at financial risk and impact on the ability to commission high quality services for patients in Wandsworth in the future.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 5 x 4 Current: 4 x 4Tolerance rating: 2 x 3
Risk History Rationale for current score: If the CCG does not engage with the South West London Collaborative case for change and the drive for integrated commissioning, or react to the call to action for transforming primary care and implement robust plans to address the change in financial allocations, this will put the CCG at financial risk, and impact on our ability to commission high quality services for patients in Wandsworth in the future.
Although we have robust plans in place for delivering the required shift to out of hospital care and are monitoring them closely, we are in the early stages of implementation and therefore are yet to see whether we will continue to deliver the reductions in activity expected in the longer term and therefore the risk score remains.
The Planned Care Programme has been established and the Programme Lead appointed. The objective will be to focus on areas where the CCG can reduce outpatient attendances using the Right Care approach through better care pathways and alternatives to hospital attendance.
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Internal Assurances:
Out of Hospital Programme monitoring and evaluation overseen by the Delivery Group.
Regular reports from the Delivery Group to Management Team
Progress on out of hospital initiatives being monitored and evaluated by the Business Intelligence Team.
Main controls in place: (What are we currently doing about the risk?)
Focus on Right Care programme embedded within commissioning programmes and regular scrutiny on progress through Delivery Group.
Monthly reports to the Delivery Group on progress against overarching key performance indicators and secondary care activity trajectories.
Significant two year non-recurrent funding invested in Out of Hospital initiatives, which are monitored and evaluated by the Business Intelligence Team to ensure they are delivering on the Key Performance Indicators set out in the original plan and in QIPP.
A Primary Care Transformation Group has been established to oversee development of the Multi-specialty Community Provider (MCP) model and the wider primary care work programme.
Funding has now been agreed to continue successful programmes into 2016/17.
Sub-regional STP in place.
External Assurances
South West London Collaborative Out of Hospital Clinical Design Group.
Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Further work required on the evaluation of the programme via the work commissioned from GE
Finnamore.2. Whilst activity for NELs has reduced, we have seen an increase in cost and the reasons for this
need to be understood.
Further actions required: (What more should we do?)1. Multi-speciality Community Provider (MCP) procurement –
new provider in place October 2017 (31/10/2017)
Additional comments: (With these actions taken, how serious is the problem?) Although a large number of out of hospital initiatives have already been developed and implemented, significant challenge remains, most notably around ensuring delivery of the ambitious targets identified for the remainder of year one and year two of implementation.
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Objective 5: Develop the CCG as a continuously improving and effective commissioning organisation
Director Lead: S IskanderRisk 65 (Organisation Development) – If there was not an effective workforce and strong leadership in place, it would be difficult for the CCG to be a high performing organisation, and undertake strategic plans to deliver on corporate objectives. Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 3 x 3 Current: 2 x 2 Tolerance rating: 1 x 1
Risk History Rationale for current score: The CCG continues to have a stable executive team with good clinical succession planning. The CCG continues to provide significant leadership to the SWL Collaborative Commissioning and across other London-wide programmes.
Although the risk is low, there are some challenges in management and clinical capacity.
Internal Assurances:
Annual Staff Survey results.
Appraisal process and regular reviews of individual performance in place.
Main controls in place: (What are we currently doing about the risk?)
Structure and functions regularly reviewed by Executive Directors.
Workforce Committee maintains an overview of workforce related issues.
Aligned organisational objectives with team and individual objectives.
Regular staff Away Day sessions (three per year) and bi-monthly Team Briefing sessions.
Training sessions delivered as part of Board Seminar sessions.
Flexible working arrangements available for staff.
All staff have set work objectives and PDPs (personal development plans) which are reviewed regularly with their line manager to ascertain progress against the actions they have set themselves.
Coaching sessions for all Board members are on-going.
Workforce Committee agreed the action plan to implement the staff survey results including further training on objective setting.
External Assurances
Annual 360o survey of key CCG stakeholders.
CCG Assurance Framework.
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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Management and clinical capacity reviews needed.
Further actions required: (What more should we do?) 1. Contribute to the design and implementation of a new operating model for
five CCGs in SWL; refresh the CCG organisational development plan in accordance with the new operating model (31/12/2016).
Additional comments: (With these actions taken, how serious is the problem?) Reduction in management running costs may place additional pressures on workforce.
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Objective 5: Develop the CCG as a continuously improving and effective commissioning organisation
Director Lead: G MackenzieRisk 102 (Delivery) – A new operating model for CCGs is currently in development across SWL. This risks staff losing focus on operational priorities and key staff may leave the organisation.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 4 Current: 4 x 3 Tolerance rating: 4 x 2
Risk History Rationale for current score: Whilst the broad framework of the proposed operating model across SWL is described, some areas of the proposals remain subject to further development. Staff engagement and discussion is strongly encouraged about the detailed design of the proposals during the consultation period. During the period of consultation, staff will be given the opportunity to discuss the plans in team meetings and, where requested in 1:1 meetings.
Internal Assurances:
Management Team
CCG Board
Main controls in place: (What are we currently doing about the risk?)
Formal HR process beginning shortly
Regular briefings from Chief Officers
Affected staff have had the opportunity to comment on proposalsExternal Assurances
SWL Chief Officers Group
Gaps in Assurances and Controls: (What additional assurances should we seek?)None currently identified.
Further actions required: (What more should we do?) 1. Further opportunities to comment provided through consultation period
(31/12/2016).2. Regular 1:1s to be held with affected staff through the process
(31/03/2017).3. Posts to be appointed to as quickly as possible to provide staff with
certainty (31/01/2017).4. Informal support to be offered from staff side / HR (31/03/2017).
Additional comments: (With these actions taken, how serious is the problem?) This would remain a serious issue as a degree of staff disruption is unavoidable until the formal HR process is completed.
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The following detailed Operational Risks are currently rated 12 or above and have been included for information:
Objective 1: Commission high quality services which improve outcomes and reduce inequalities
Director Lead: S IskanderRisk 72 (Quality) – If the CCG is unable to provide appropriate oversight, scrutiny and assurance within the care home setting, this increases the risk of potential harm to vulnerable clients/service users.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 3Current: 4 x 3Tolerance rating: 4 x 2
Risk History Rationale for current score: Care homes care for some of our most vulnerable groups of patients. There is limited capacity available with several homes having closed in Wandsworth over the last two years and some patients are placed out of area. Systems for monitoring the quality of care homes are not as well developed as for other sections. Further work with the Local Authority and with Healthwatch is on-going.
Internal Assurances:
Review of progress at Safeguarding Sub-committee (action plans, work plans in place and monitored).
Oversight at Integrated Governance Committee through Integrated Report.
Service Standards Board created to provide strategic direction to improving care home quality.
Feedback from health professionals working in care homes (BACS and GPs).
Quality Review Committee led by Local Authority in place with health involvement.
Main controls in place: (What are we currently doing about the risk?)
Adult Safeguarding Nurse in place enabling close working relationship with the Continuing Health Care team. Also attends contract monitoring meetings.
Executive Board Safeguarding lead in post.
Partnership working with Local Authority Safeguarding team and Local Adult Safeguarding Board membership.
Liaison Nurse post in place to support quality in care homes.
Quality Board with Wandsworth Healthwatch to focus on quality in care homes.
Joint Quality Dashboard to monitor key quality indicators.
External Assurances
Local Adult Safeguarding Board (SAPB).
Serious Incidents reported and reviewed.
CQC and Healthwatch reports.
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Gaps in Assurances and Controls: (What additional assurances should we seek?)A number of issues with the database of the previous support supplier were identified, which are in the process of being rectified in the move to the new supplier. This has highlighted that we are not able to be assured at this time that all funded patients have received their six-monthly reviews and therefore their circumstances or needs may have changed and not been actioned.
Further actions required: (What more should we do?) 1. Continue to share information with key partners (31/03/2017).2. Develop frailty work stream to support better commissioning for
vulnerable patients (31/03/2017).3. Implement quality dashboard for smaller contracts for Care Home Select
(CHS) (31/03/2017).
Additional comments: (With these actions taken, how serious is the problem?) Requires constant review and scrutiny to ensure service continues to meet requirements.
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Objective 1: Commission high quality services which improve outcomes and reduce inequalities
Director Lead: G MackenzieRisk 77 (Quality) – If the CCG does not have robust data to guide understanding of health inequalities, or a strategy in place to address them, there is a risk that inequalities will continue or worsen.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 4 x 5 Current: 4 x 3 Tolerance rating: 3 x 2
Risk History Rationale for current score: Health inequalities are increasing across most London Boroughs.
Analysis based on the Joint Strategic Needs Assessment (JSNA) defines the Wandsworth population and sets out the challenge.
Differential health benefits across Wandsworth have been identified.
Health and Wellbeing Board strategy in place.
Internal Assurances:
Management Team
Main controls in place: (What are we currently doing about the risk?)
Equality Impact Assessments when completed identify equalities impact used to measure outcomes.
Joint Strategic Needs Assessment has identified some areas of inequalities.
Corporate Objectives are monitored through the Board Assurance Framework (BAF).
Annual Equalities training delivered to staff.
Regular updates to Management Team.
Actual measure of life expectancy across Wandsworth used as a control to monitor achievement.
External Assurances
Health and Wellbeing Board
Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Differential commissioning.2. Joint approach with Local Authority (H&WB)3. Regular updates to Board.
Further actions required: (What more should we do?) 1. Equality Impact Assessment process to be strengthened, with additional
scrutiny by the Patient and Public Involvement (PPI) team to ensure that strategies and policies take into account CCG priorities for reducing inequalities. Part of Board reporting review (31/12/2016).
2. Health inequalities project worked through Thinking Partners Group (31/12/2016).
Additional comments: (With these actions taken, how serious is the problem?) Making a difference in health inequalities is a long term issue.
Addressing health inequalities will require all partners to work together.
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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities
Director Lead: N McDowellRisk 89 (Quality) – The main provider for health services for Wandsworth residents is St George’s Hospital Foundation Trust who are reporting a significant financial deficit for the year 2015/16. There are a number of risks which impact the CCG as a result of the financial position, such as quality, workforce levels, capacity, focus on delivery, waiting times etc.
Date last reviewed: 01/12/2016
Risk Rating:(consequence x likelihood)
Initial: 5 x 4Current: 4 x 4Tolerance rating: TBC
Risk History Rationale for current score:
Trust under review with turnaround plan in place.
Large deficit forecast for 16/17.
Performance targets proving to be challenging.
Staffing gaps appearing.
Internal Assurances:
Finance Resource Committee
Quality Group
Integrated Governance Committee
Main controls in place: (What are we currently doing about the risk?)
Enhanced quality surveillance in place to include increased walk rounds, close monitoring of Cost Improvement Programmes, encouragement of further GP alerts, and dedicated Director role.
Chief Executive Officer/Chief Officer regular meetings (as well as at executive level).
Monitoring performance against existing quality indicators and dashboards.
Continued quality oversight through Clinical Quality Review Groups and Integrated Governance Committee.
Tripartite analysis and meetings – regulatory bodies exchanging views.
External Assurances:
Tripartite meetings – Monitor, NHS England, Wandsworth CCG
Gaps in Assurances and Controls: (What additional assurances should we seek?)
Turnaround plan.
Meetings with Regulator.
Further actions required: (What more should we do?) 1. Review by external assessors – Finance Resource Committee to assess
impact (31/03/2017).
Additional comments: (With these actions taken, how serious is the problem?) Financial challenges faced by SGUFT will see the Trust providing a different range of services which will impact CCG’s commissioning priorities.
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W A N D S W O R T H C C G P A G E 1 O F 4
Financial PoliciesAuthor: Sandra Allingham Sponsor: Neil McDowell Date: 14/12/16
Executive Summary
Context
Following an initial review earlier in the year prompted by the introduction of Primary Care
co-commissioning it was identified that a full review of all financial polices was required to
ensure the CCG has a set of policies which together could be viewed as a complete
package.
Question(s) this paper addresses
1. Is the delegation of primary care commissioning reflected in the Standing Orders?
2. Do the documents accurately reflect the CCG Constitution?
3. Do the Prime Financial Policies provide sufficient information on financial governance
processes?
Conclusion
1. The amended Scheme of Reservation and Delegation reflects Primary Care co-
commissioning and amended job titles in partner organisations.
2. Standing orders have been reviewed and minor changes incorporated to reflect links
to the CCG constitution. A review of the policies has been undertaken to ensure
they align with the constitution where appropriate and integrated in a coherent way
with appropriate cross referencing.
3. The Prime Financial Policies have been significantly expanded to assist in clarity and
coverage.
4. A summary of the changes are set out in the report.
Input Sought
The Board is asked to approve the amendments to the Prime Financial Policies, Standing
Orders, and Scheme of Reservation and Delegation. Comments raised during the
discussion at the Finance Resource Committee meeting have been taken into account
during the review.
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]
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W A N D S W O R T H C C G P A G E 2 O F 4
The ReportA summary of the changes to the policy are listed below:
Standing Orders:
Section Title Amendments
1. Introduction 1.1.2 Reference to appointment of the Governing Body included.
2. CCG Composition of Membership, key roles and appointment process
Information updated for Board roles and inclusion of Primary Care Committee.
3. Committees and Sub-Committees
Information updated to accurately reflect the Constitution and CCG Conflicts of Interest policy.
Inclusion of new section (3.7) relating to Primary Care Committee meetings.
4. Conflicts of Interest No changes made.
5. Emergency Powers and Urgent Decisions
No changes made.
6. Suspension of Standing Orders Additional information included.
7. Duty to report non-compliance with Standing Orders and Prime Financial Policies
No changes made.
8. Use of Seal and Authorisation of Documents
Additional information included.
9. Overlap with other CCG policy statements/procedures and regulations
No changes made.
Prime Financial Policies:
Section Title Amendments
1. Introduction 1.1.3 New paragraph re Shared Service provider.
2. Internal Control Expanded section clearly setting out relevant responsibilities.
3. Audit Expanded section setting out responsibilities for individual roles.
4. Fraud and Corruption Section expanded to include more detailed information including Security Management.
5. Expenditure Control No changes made.
6. Allocations No changes made.
7. Commissioning Strategy, Budgets, Budgetary Control and Monitoring
Expanded section to provide more detailed information on processes including Budgetary Delegation, Budgetary Control and Reporting, and Capital Expenditure.
8. Annual Accounts and Reports No changes made.
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W A N D S W O R T H C C G P A G E 3 O F 4
9. Information Technology Section expanded to include Freedom of Information Publication Scheme, and assurance around corporate financial systems.
10. Accounting Systems No changes made.
11. Bank Accounts Section expanded to provide more detailed information on processes.
12. Income, Fees and charges and security of cash, cheques and other negotiable instruments
Expanded section to include more information on fees and charges, debt recovery, and security of cash, cheques and other negotiable instruments.
13. Tendering and Contracting Section expanded substantially to include comprehensive information relating to formal competitive tendering.
14. Commissioning Section expanded to include responsibilities for individual roles.
15. Risk Management and Insurance
Expanded section to provide further detailed information.
16. Payroll Section expanded to include line management responsibilities.
17. Non-Pay Expenditure Section expanded to include responsibilities of individual roles, duties of managers and officers, and joint finance arrangements.
18. Capital Investment, fixed asset registers and security of assets
Section expanded to include private finance, asset registers, security of assets, and NHS Local Investment Finance Trusts (LIFT).
19. Disposals and Condemnations, Losses and Special Payments
New section included.
20. Retention of Records Section of expanded.
21. Trust Funds and Trustees Section expanded.
Scheme of Reservation and Delegation:
The Scheme of Reservation and Delegation has been revised to reflect the delegation of
Primary Care Commissioning in April 2016. Information relating to GMS and PMS
Expenditure has been included in section 9 (h) of the Detailed Scheme of Delegation.
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W A N D S W O R T H C C G P A G E 4 O F 4
For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications [Yes]
The risks [Yes]
Impact on our reputation [Yes]
Impact on our patients [Not applicable]
Impact on our providers [Not applicable]
Impact on our finances [Not applicable]
Equality impact assessment [Not applicable]
Patient and public involvement [Not applicable]
Please explain your answers:
2. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities [Not applicable]
Make the best use of resources, continually improve performance and deliver
statutory responsibilities [Yes]
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities [Not applicable]
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting [Not applicable]
Develop the CCG as a continuously improving and effective commissioning
organisation [Yes]
Please explain your answers:
3. Executive Summaries should not exceed 1 page. [My paper does comply]
4. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does comply]
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Conflicts of Interest PolicyAuthor: Sandra Allingham Sponsor: Sandra Iskander Date: 14/12/16
Executive Summary
Context
Following on from the publication of the revised Conflicts of Interest guidance in June,
work has been done to review the CCG’s Conflicts of Interest policy to ensure that the
guidance is appropriately reflected. The revised policy has been reviewed at the
Integrated Governance Committee and by Internal Audit.
Question(s) this paper addresses
1. What changes have been required?
2. Does the revised policy adequately reflect the new guidance?
Conclusion
1. A summary of the changes are set out in the report.
2. The revised policy encompasses all of the recommendations from the guidance.
Input Sought
The Board is asked to approve the revised version of the policy. Comments raised during
the discussion at the Integrated Governance Committee meeting have been addressed.
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]
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The ReportA summary of the changes to the existing policy are listed below:
Section Title Amendments
1. Introduction Revised wording (paragraphs 2, 3, and 4)
2. Definitions Conflicts of Guardian role included
3.3 Interests redefined3. What are Conflicts of Interest?
Paragraph relating to the Bribery Act 2010
removed – link to the Act included in Section 18
4. Principles Content reformatted
5. Identification and Management
of Conflicts of Interest
5.2 Appointment to Conflicts of Interest Guardian
role
6. Declaration of Gifts and
Hospitality
New section
7. Appointments, Roles and
Responsibilities in the CCG
New section
8. Managing Conflicts of Interest
at meetings
8.1 List of Committees included
8.4 Waiver – section removed as covered in
previous paragraphs
9. Preserving Integrity of Decision
Making Process when all or
most GPs have an interest in a
decision
No changes made
10. Procurement and Competition Section updated
11. Managing Conflicts of Interest
throughout the Commissioning
Cycle
New section
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12. Contract Monitoring New section
13. Raising Concerns and
Breaches
New paragraphs 13.1 and 13.2 included
14. Impact of Non-Compliance New section
15. Record Keeping No changes made
16. Reporting and Assurance New section
17. Conflicts of Interest Training New section
18. Linked Policies/Guidance Additional links included
Appendices 1-5 Revised
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W A N D S W O R T H C C G P A G E 4 O F 4
For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications [Yes]
The risks [Yes]
Impact on our reputation [Yes]
Impact on our patients [Not applicable]
Impact on our providers [Not applicable]
Impact on our finances [Not applicable]
Equality impact assessment [Not applicable]
Patient and public involvement [Not applicable]
Please explain your answers:
2. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities [Not applicable]
Make the best use of resources, continually improve performance and deliver
statutory responsibilities [Yes]
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities [Not applicable]
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting [Not applicable]
Develop the CCG as a continuously improving and effective commissioning
organisation [Yes]
Please explain your answers:
3. Executive Summaries should not exceed 1 page. [My paper does comply]
4. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does comply]
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Part C: Management Reports
Page
3. Part C: Management Reports 136
3.1. C01 Executive Report 137
3.2. C02 Performance Report 150
3.3. C03 Finance Report 158
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W A N D S W O R T H C C G P A G E 1 O F 1 3
Executive ReportAuthor: Sandra Allingham Sponsor: Nicola Jones / Graham Mackenzie 14/12/2016
Executive Summary
Context
The report provides information on the following items for information:
Management Team Summary
Sustainability and Transformation Plan
Lay Member Recruitment
SWL Operating Model
Off-Payroll Policy
Merton CCG Quality Function
Talking Therapies Contract
Children and Adolescent Mental Health Services
Input Sought
The Board is asked to note the content of the report.
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]
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The Report
Management Team SummaryA summary of the main issues discussed by the Management Team in the period following the previous Board meeting is outlined below:
Performance
Serious Incidents and ‘Make A Difference’ Alerts
St George’s University Hospital Foundation Trust
Procurement
Quality and safety issues
Financial recovery
Personal Health Budgets
Safeguarding
Planning Round
Multi-specialty Community Provider
Continuing Health Care
IT
Effective Commissioning Initiatives
Sustainability and Transformation Plan (STP)
SWL CCGs submitted a revised Sustainability and Transformation Plan (STP) at the end of October in line with the national timetable. WCCG Governing Body reviewed the revisions before submission. Content has not changed significantly from the earlier version, however additional detail has been added to describe delivery, particularly in relation to Right Care Best Setting which describes new models of integrated out of hospital care.
The SWL STP has been published on the CCG and council websites and is now subject to wider engagement including presentations to the Health and Wellbeing Board, Wandsworth Healthwatch Alliance and at the CCGS annual equalities (EDAY) event.
The STP can be accessed via the following link: http://www.swlccgs.nhs.uk/documents/our-plan-for-south-west-london/
CCGs Operating Model
The six CCGs in SWL, together with partner organisations, have recently submitted the
SWL Sustainability & Transformation Plan (STP). The scale of the challenge ahead, as
described in the STP, has led the leaders of the CCGs in SWL to consider whether current
commissioning arrangements are sufficient to enable the delivery of the change
programme ahead.
A proposal for the consolidation of senior leadership roles and accountability amongst
local CCGs has been developed and is currently the subject of a formal consultation with
CCG staff that concludes on 21st December.
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Two organisational diagrams that illustrate the proposed future structures across CCGs in
SWL are attached for reference.
A key element of the proposals is for the creation of a single Accountable Officer post to
operate across 5 CCGs in SWL (in full by 2018). This post is currently subject to open
recruitment and it is hoped that an appointment will be made in the near future.
Final decisions on the overall structure and implementation arrangements will be taken in
the early New Year.
Operational Plan 2017-19The planning and contracting timetable has been brought forward this year, to ensure that contracts are agreed and in place prior to the new financial year. The planning round covers a two year period, 2017-19, and Operational Plans are expected to be based on delivering progress on the Sustainability and Transformation Plan for South West London. The national timetable for submission of final Operational Plans and contract signatures is 23 December, which is extremely challenging. In practice commissioners and providers are aiming to have the baselines and the principles agreed for the 2017-19 contract by that date, with further work on QIPP and closing any financial gaps to be concluded in the New Year. Contract offers were made to providers on 2 November, in line with the national timetable. These incorporated the QIPP savings identified at that time, with corresponding reduced activity levels, and also a level of yet to be identified transformational QIPP which is required to achieve the SWL CCG control total. The current requirement for QIPP savings for 2017/18 is £20.1m, which is significantly greater than the level of QIPP savings the CCG has needed to realise in previous years. At the time of writing c. £5m of transformational QIPP initiatives were still unidentified. Options for the further QIPP savings required are being explored, including further analysis of RightCare opportunities and through a comprehensive review of all budget lines with Directors and budget holders. Options for innovative contract models are being explored with acute providers in South West London, including St. George’s, with the objective of sharing the responsibility for managing risks around activity and finance variances between commissioners and providers, and enabling a greater focus on implementation of the strategic transformation as described in the South West London Sustainability and Transformation Plan.
Negotiations are progressing with South West London and St. George’s Mental Health Trust, with the main outstanding issue relating to the cost of living supplement. The Operational Plan comprises a finance plan, a QIPP programme, activity trajectories, Improvement and Assessment Framework trajectories and a Quality Premium submission. A draft plan was submitted to NHS England on 24 November, and the CCG is awaiting any feedback. Activity trajectories have been submitted incorporating growth in line with the Sustainability and Transformation Plan assumptions for 2017-19. The trajectories will need to be refreshed for the 23 December submission to incorporate the agreed position with providers on QIPP programmes.
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Improvement and Assessment Framework trajectories were also submitted which demonstrated that the performance standards will be achieved in 2017-19, with two significant exceptions. A trajectory for performance on the A&E 4-hour waiting time standard has been jointly submitted by both St. George’s and the CCG, which shows achievement of the 95% standard in three months in 2017/18 but an overall aggregate performance of 93.1% based on the expected improvements from the existing work programme mapped onto the historical seasonal activity and performance trend. The national expectation is that 80% of GP outpatient referrals will be made through the E-referral system by the end of Q2 in 2017/18 which is not expected to be achieved pending St. George’s making substantial progress with its outpatient transformation programme to make capacity available for appointment slots within reasonable timeframes. The biggest risks remain the unidentified QIPP savings gap and the financial gap between St. George’s starting position and SWL commissioners. The main performance risk, which also impacts on activity, relates to RTT at St. George’s, given that the Trust ceased national reporting from May 2016 due to the extent of the data quality issues the extent of the actual RTT backlog and any mis-match between available capacity and demand is impossible to quantify with any degree of confidence. Full reports on both the Finance Plan and Budgets and also the Operational Plan will come to the March 2017 Board meeting.
Lay Member Recruitment
As agreed at the Board meeting in October, the recruitment process for the three Lay
Members with specific responsibility for Governance, Patient and Public Involvement, and
Finance respectively, has been put in place, with the closing date for applications being
15th December. The periods of appointment for the current Lay Members are due to end
on 31st March 2017 (Governance) and 31st August 2017 (PPI) respectively. Appointment
of the third Lay Member (Finance) will be taken forward as priority, with the additional
appointments further into the year.
Merton CCG Quality Function The Director of Quality at Merton CCG will be leaving for a new role. Given the current
proposals to work collaboratively across SWL, the post will not be recruited to. We have
therefore agreed that Sandra Iskander will provide Director level support to the quality
team at Merton one day a week. Chris Clarke, the Merton Director of Performance will
provide some backfill support in return. This arrangement will begin in the New Year and
is expected to continue until the end of the financial year.
Concurrently, Wandsworth and Merton CCGs are consulting with staff about a proposal to
share safeguarding nursing teams. The proposal is to create three new posts (Head of
Safeguarding, Designate Nurse for Safeguarding Adults, and Designate Nurse for Looked
After Children) who would work across both CCGs providing a more resilient service.
Designate Doctor roles would remain unchanged. The staff consultation will end on 28th
December and the Board will be updated on the final proposal.
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Talking Therapies Contract Contract negotiation and mobilisation of the new Integrated Wandsworth Talking
Therapies have commenced. The Wandsworth CCG IAPT Transition and Mobilisation
Project Board has been established to manage existing IAPT performance in Quarter 3
and Quarter 4 of this financial year and oversee delivery of the mobilisation plan for the
new service. It is anticipated that contract will be signed before the 31 December 2016.
Children and Adolescent Mental Health Services (CAMHS)Local Implementation - Wandsworth CAMHS transformation plan was submitted in
October 2015 to deliver the Future in Mind recommendations to deliver the following
themes;
Promoting Resilience
Prevention and early intervention
Improving access to effective support
Care for the vulnerable children sexually abused / Edge of Care
Developing the workforce Eating Disorders
We were allocated transformation funding of £422,000 for general CAMHS service and
£168,000 for Eating Disorder Services from 2015/16 onwards.
Some of the achievements for Wandsworth over the last year have included:
CAMHS Access Service continues to perform well working to 2 -4 week target for waiting times for first appointments and has reduced referrals to Specialist T3 CAMHS by 33%.
We have increased P2B counselling services in Primary schools to 5 more primary schools in Sept 16.
An evidenced based parenting programmes has been developed to build self-esteem , attachment and emotional resilience.
We have developed a transition service model for children with neuro developmental disorders 18-25 the service is being implemented.
2016 Update - In February The Five Year Forward View for Mental Health set out a
roadmap for delivering the commitments made in the Mental Health Taskforce report.
The NHSE sets out a range of objectives to achieve by 2020/21 including:
A significant expansion in access to high-quality mental health care for children and young people
At least 70,000 additional children and young people each year to receive evidence-based treatment
To support this CCGs were given additional funding of £281,000 from 2016/17 in addition
to the £592,000 from last year.
CCGs were written to in Summer 2016, advising that we would need to submit a refresh update of our original CAMHS Transformation Plan by 31st October 2016. The plan articulated our progress in delivering the plan since last year, as well as how we work in
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the coming year on delivering broader transformational programme linked to the STP programme.
The local Wandsworth strategy is:
Our ambition is to give every child the best start in life and help them develop into healthy and resilient adults. Families will receive a rapid response to their needs, have access to information and advice that is high quality and evidenced based. The support they receive will be flexible, person centred, convenient and promotes their wellbeing and improved mental health.
Wandsworth CCG have identified the following priorities and are working together at an STP level to determine how we will implement these including:
Access to appropriate beds locally thus not having to travel long distances, face long waiting times, or disconnect from family and their local community
Availability of services out of hours
Support for young people when they return home after Specialised CAMHS admission
Consistent commissioning arrangements between community and Specialised CAMHS
Consistency in care and discharge plans
More multi-agency support to help children and young people with mental health problems to stay in community and prevent hospital admission
The plan was submitted to agreed deadline set and was endorsed by Wandsworth Health
and Wellbeing Board.
Future implementation - We are now working on a detailed implementation plan of how we
will deliver these programmes locally in Wandsworth. The detailed plans for the use of the
additional funding and increased KPIs will be brought to the CCG Board in January 2017.
Use of the Seal
The corporate seal has not been applied since the previous report.
Conclusion
The Board is asked to note the information on the items above.
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For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications [Not applicable]
The risks [Not applicable]
Impact on our reputation [Not applicable]
Impact on our patients [Not applicable]
Impact on our providers [Not applicable]
Impact on our finances [Not applicable]
Equality impact assessment [Not applicable]
Patient and public involvement [Not applicable]
Please explain your answers:
The content included in the report relates to items for information only.
1. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities [Not applicable]
Make the best use of resources, continually improve performance and deliver
statutory responsibilities [Not applicable]
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities [Not applicable]
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting [Not applicable]
Develop the CCG as a continuously improving and effective commissioning
organisation [Not applicable]
Please explain your answers:
The content included in the report relates to items for information only.
2. Executive Summaries should not exceed 1 page. [My paper does comply]
3. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does comply]
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Operating Model at April 2018
7
Croydon CCG Chair
Accountable Officer
CroydonLocal Delivery
Unit(incl CFO)
(Functions by MoU)
Sutton MDLocal Delivery
Unit
Chief Finance Officer
Director of Quality &
Governance
Director of Contracting
Accountable Officer
Merton CCG Chair
Merton & Wandsworth MD
Local Delivery Unit
Wandsworth CCG Chair
Kingston CCG Chair
Richmond CCG Chair
Kingston & Richmond MD
Local Delivery Unit
Sutton CCG Chair
Director of Performance
AcutePrimary
Care
Mental Health
Wandsworth Clinical Commissioning Group
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W A N D S W O R T H C C G P A G E 9 O F 1 3
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W A N D S W O R T H C C G P A G E 1 0 O F 1 3
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Operating Model at April 2018
7
Croydon CCG Chair
Accountable Officer
CroydonLocal Delivery
Unit(incl CFO)
(Functions by MoU)
Sutton MDLocal Delivery
Unit
Chief Finance Officer
Director of Quality &
Governance
Director of Contracting
Accountable Officer
Merton CCG Chair
Merton & Wandsworth MD
Local Delivery Unit
Wandsworth CCG Chair
Kingston CCG Chair
Richmond CCG Chair
Kingston & Richmond MD
Local Delivery Unit
Sutton CCG Chair
Director of Performance
AcutePrimary
Care
Mental Health
Wandsworth Clinical Commissioning Group
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W A N D S W O R T H C C G P A G E 1 2 O F 1 3
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W A N D S W O R T H C C G P A G E 1 3 O F 1 3
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Performance Report Author: Iain Rickard Sponsor: Sandra Iskander Date: 14 December 2016
Executive Summary
Context
This paper details the current and year-to-date performance against all NHS Constitution and Improvement and Assessment Framework (IAF) indicators (subject to available data). NHS England have not yet published a methodology for determining overall CCG performance for the ED 4-hour target, therefore this report focuses slightly more on the performance of our local providers and, in particular, St. George’s progress against its Sustainability and Transformation Plan trajectories. As of 8th July 2016, St. George’s have suspended formal national reporting against the 18 week RTT target until further notice, although St. George’s will continue to informally report some data locally. The CCG is working with the Trust, other commissioners and the regulators to ensure that the improvement plans will result in recovery of both data quality and performance delivery as soon as practically possible, although this is expected to take many months.
Clinical Priority Area: Mental Health
NHS England has published assessments of the mental health clinical priority area under the Improvement and Assessment Framework for all CCGs. The CCG has been rated as “Needs Improvement”. IAPT recovery rate is improving. We achieved 50.9% in July 2016, but this needs to be sustained. We are supporting practice based counsellors to improve collection of recovery data. The Children and Young People’s Mental Health indicator has been marked down in Q1 due to a reporting error on the finance return, which indicated that we were not planning to sufficiently increase spending on CYPMH. This has been corrected and subsequent quarterly ratings will show CYPMH as being fully compliant.
W A N D S W O R T H C C G P A G E 1 O F 8
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Clinical Priority Area: Maternity
The CCG has been assessed as performing well against the maternity indicators.
Although a high score out of 100, our score for women’s experience of maternity services is in the lowest 25% of CCGs nationally.
Our score for choices in maternity services is similar most other CCGs in England.
The rate of stillbirths and deaths within 28 days of birth for Wandsworth CCG is among the lowest in
the country.
Looking Back
W H A T H A S G O N E W E L L ?
C. Difficile & MRSA Infection Rates
No cases of MRSA reported in September. 6 C. Difficile cases reported in September,
equalling 19 in the year to date, although this is well within the expected upper limit of 25
cases.
6-Week Diagnostics Waiting Time
Diagnostic 6-week wait performance remains at 99.3% in October and we are now
meeting the year-to-date target.
IAPT Waiting Times
6 and 18 week waiting time targets for IAPT continue to be met and were consistently
achieved during 2015/16.
Early Intervention in Psychosis 2-week Wait Target
This target is being met, although performance is sensitive to small numbers of patients.
Ambulance Response Times
London Ambulance Service has met response time targets for Wandsworth patients.
Maternity Clinical Priority Area
Rated as “Performing Well” although there is room for improvement around choice and
experience.
Improvement and Assessment Framework Indicators
We have improved against a number of Improvement & Assessment Framework
indicators and we have reduced the number of indicators in the lowest 25% of CCGs from
9 to 3.
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W H A T H A S N O T G O N E W E L L ?
ED 4 Hour Waiting Time
Performance is below 95% at all 5 of our main providers. However, St. George’s have achieved their STF trajectory target in October.
18-Week Referral to Treatment Waiting Time (Incomplete Pathways)
With St. George’s temporarily not reporting national data Chelsea and Westminster is now the biggest driver of the CCG’s 18-week performance. It has been achieving the 92% target
as a Trust, but has specific capacity issues at the Chelsea site, which are affecting waiting
times for Wandsworth patients.
52-Week Waiters
Provisional data shows 5 52-week waiters for October. 4 at Imperial (ENT x 2, Plastic
Surgery and T&O) and 1 at King’s in General Surgery. These are currently being investigated.
Cancer Waiting Times
We have not met the 2-week, 31-day (surgery) and 62-day cancer targets according to
the provisional data for October. St. George’s have met all the targets and are achieving their STF trajectory.
Mental Health Clinical Priority Area
Rated as “Needs Improvement”. However, Children and Young People’s services is now assessed as fully compliant, therefore the overall assessment of mental health is
expected to improve.
Looking Ahead
O P P O R T U N I T I E S ?
We continue to see the following positive trends:
Zero MRSA infections
Diagnostic waiting times consistently being met and YTD performance improving.
Maintenance of IAPT waiting times
Continued high levels of dementia diagnosis rates.
Improvements in ambulance response times.
R I S K S O R C O N C E R N S ?
18-Week Waits at St. George’s
Due to the data quality issues, we cannot know with certainty the length of time patients
are waiting for outpatient appointments and for operations at St. George’s. The Trust is supplying regular updates on waiting list size and activity, but due to the data quality
issues identified that information is not necessarily a reliable indicator of actual
performance.
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ED Performance at St. George’s
Much of the recent improvement in performance has been supported by bed availability.
Looking ahead to the winter period and based on historical experience, there is unlikely to
be excess bed capacity to support initiatives that have improved ED performance.
IAPT Access and Recovery
There is a risk that performance against these targets will reduce while the current
service is redesigned. Additionally, there is an indication that the prevalence of anxiety
and depression has increased by up to 25% nationally, which will mean that the access
target is more challenging as well as being increased in 2017/18 and 2018/19.
Dementia Diagnosis Rates
From 2017/18, Dementia prevalence will be calculated using registered patient population
instead of resident population. This will increase the potential number of patients with
Dementia by approximately 9% and cause a drop in our current performance. However,
we expect to continue to meet the 66.7% target in 2017/18.
In Conclusion C O NF I DE NC E ? I M P L I CAT I O NS ?
We have seen improvements in a number of
the NHS Constitution indicators in recent
months, although we need to work to ensure
these are sustained as winter approaches. The
greatest risk is around the uncertainty around
18-week RTT performance at St. George’s.
There are a small number of indicators which
are not supported by work programmes or
which have determinants that are difficult for a
CCG to influence, certainly in the short term.
It will be difficult for us to assure ourselves on
performance and progress towards resolving
18-week RTT data quality issues without robust
data.
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W A N D S W O R T H C C G P A G E 5 O F 8
NHS Constitution Scorecard
Jul-16 Aug-16 Sep-16
Summary EAS04 MRSA - Incidence of HCAI YTD 0 0 0 0 (YTD) Sep-16 0 0 0 ▼Summary EAS05 C. difficile - Incidence of HCAI YTD 25 19 6 0 (YTD) Sep-16 5 3 6 ►
NHS Constitution
Summary EE001 RTT incomplete (Provisional) 92% 91.4% 90.6% 950 Oct-16 91.5% 91.0% 91.0% ▼Summary EBS04(3) RTT 52+ week waiters (Provisional) 0 22 5 5 Oct-16 3 1 3 ►Summary EE004 Diagnostics (Provisional) Diagnostics - 6 weeks + (Provisional) 99% 99.0% 99.3% 35 Oct-16 99.9% 99.3% 99.3% ▲Summary EB006 2 week wait 93% 91.1% 92.8% Oct-16 93.7% 94.5% 94.0% ▲Scorecard EB007 Breast symptoms 2 week wait 93% 92.7% 98.6% Oct-16 93.8% 93.3% 94.4% ►Summary EB008 31 day first definitive treatment 96% 97.9% 98.2% Oct-16 97.6% 98.2% 98.6% ►Scorecard EB009 31 day subsequent treatment surgery 94% 98.6% 90.0% Oct-16 100.0% 100.0% 100.0% ▲Scorecard EB010 31 day subsequent treatment drug 98% 99.4% 100.0% Oct-16 100.0% 100.0% 100.0% ▲Scorecard EB011 31 day subsequent treatment radiotherapy 94% 97.0% 96.8% Oct-16 93.8% 97.9% 100.0% ►Summary EB012 62 day standard 85% 84.5% 83.9% Oct-16 93.0% 79.3% 84.1% ►Scorecard EB013 62 day screening 90% 89.7% Oct-16 100.0% 50.0% ►Scorecard EB014 62 day upgrade 92.3% 100.0% 0 Oct-16 100.0% 80.0% ►Scorecard EBS01 Mixed-sex accommodation breaches 0 3 1 1 Oct-16 0 2 0 ►Scorecard Local9 Total number of Delayed Transfers of Care 0 592 97 97 Sep-16 87 102 97 ►CCG EBS03 CPA follow up within 7 days 95% 95.4% 95.1% 7 Sep-16 95.1% ►CCG EH01 IAPT 6 week target 75% 93.6% 94.2% 30 Aug-16 89.1% 94.2% ►CCG EH02 IAPT 18 week target 95% 98.5% 98.1% 10 Aug-16 96.6% 98.1% ►CCG EH03 IAPT in recovery 50% 46.3% 44.9% 190 Aug-16 50.9% 44.9% ▲CCG EH04 Early Intervention Psychosis 2 week target 50% 72.7% 80.0% 1 Sep-16 66.7% 81.8% 80.0% ►CCG EAS01 Dementia 67% 73.6% 75.7% 456 Oct-16 73.7% 73.7% 73.4% ▲
A&E 4 Hour Waits
Summary EB005 % within 4 hours ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 95% 92.8% 92.2% 1107 Sep-16 94.4% 92.7% 92.2% ▼Summary EB005 % within 4 hours CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 95% 94.9% 93.8% 1437 Sep-16 95.0% 94.8% 93.8% ▼Summary EB005 % within 4 hours KINGSTON HOSPITAL NHS FOUNDATION TRUST 95% 92.7% 92.3% 760 Sep-16 93.8% 91.3% 92.3% ►Summary EB005 % within 4 hours KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 95% 84.3% 82.0% 4292 Sep-16 83.5% 88.2% 82.0% ►Summary EB005 % within 4 hours GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 95% 90.0% 89.2% 1746 Sep-16 90.8% 89.0% 89.2% ▼Summary EBS05 Trolley Waits >12Hrs ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 0 1 0 0 Sep-16 0 0 0 ▼Summary EBS05 Trolley Waits >12Hrs CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 0 0 0 0 Sep-16 0 0 0 ▼Summary EBS05 Trolley Waits >12Hrs KINGSTON HOSPITAL NHS FOUNDATION TRUST 0 0 0 0 Sep-16 0 0 0 ►Summary EBS05 Trolley Waits >12Hrs KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 0 24 2 2 Sep-16 6 5 2 ►Summary EBS05 Trolley Waits >12Hrs GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 0 0 0 0 Sep-16 0 0 0 ►Scorecard EB015(1) Red 1 75% 78.5% 82.8% 5 Oct-16 84.6% 78.4% 82.4% ▲Scorecard EB015(2) Red 2 75% 73.5% 75.5% 325 Oct-16 72.2% 76.0% 73.2% ▲Scorecard EB016 Cat A19 95% 97.5% 98.1% 26 Oct-16 97.7% 97.3% 97.2% ▲
Latest Month data shows an increase over previous 12 months (using 6 sigma methodology), which is an Improvement in performance ▲Latest Month data shows an increase over previous 12 months (using 6 sigma methodology), which is a Deterioration in performance ▲
Latest Month data shows an Decrease over previous 12 months (using 6 sigma methodology), which is an Improvement in performance ▼Latest Month data shows an decrease over previous 12 months (using 6 sigma methodology), which is a Deterioration in performance ▼
Latest Month data is within normal variation of previous months data and is neither showing a statistical increase or decrease ►Achieving Target
Failing Target
LAS
Trust Measures
Previous MonthsPerformance
YTD
Performance
Month
Latest
Data
SEL/SWL/
KentCode Health Outcomes Framework / Every one Counts
Safe environment and protecting
from avoidable harm
A&E
Mental Health
RTT (Provisional)
Cancer - 2 weeks
Cancer - 31 days
Cancer - 62 days
Target Breaches 12M Trend
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W A N D S W O R T H C C G P A G E 6 O F 8
Improvement & Assessment Framework Scorecard: October 2016 Update
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W A N D S W O R T H C C G P A G E 7 O F 8
Sustainability & Transformation Programme Trajectories
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W A N D S W O R T H C C G P A G E 8 O F 8
For Reference Edit as appropriate:
1. The following were considered when preparing this report:
The long-term implications
The risks
Impact on our reputation
Impact on our patients
Impact on our providers
The performance report provides a view of current performance and, based on this and
wider intelligence, likely future trends. If future performance is expected to be below targets
or expected levels, then this is highlighted as a risk. Our performance relates to the work
of our providers in many areas and is a reflection of our reputation and the quality of care
our patients are receiving.
2. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities
Make the best use of resources, continually improve performance and deliver
statutory responsibilities
Develop the CCG as a continuously improving and effective commissioning
organisation
Our overall performance and performance in specific areas reflects how successfully we
are meeting these objectives.
3. Executive Summaries should not exceed 1 page. [My paper does not comply]
4. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does comply]
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W A N D S W O R T H C C G P A G E 1 O F 7
Month 7 Finance Report Author: Peter Ifold, Deputy CFO Sponsor: Neil McDowell, Acting CFO Date: 12/2016
Executive Summary
Context
The Finance Team is responsible for reporting the financial position for the CCG each
month. This paper provides information on the month 7 financial position, highlighting key
issues and the forecast outturn. In addition, this paper updates the Board on the 2017-19
planning round and highlights key information from the recently published operating plan
guidance together with key points relating to the full draft submission at the end of
November
Questions addressed in this report
1. What is the CCG’s year to date financial performance against the approved budget?
2. Is the CCG on target to meet the planned 0.5% financial surplus at year end?
3. Implications around financial governance, strategy, performance and risk.
4. Can we keep running costs within the target set?
5. Are we meeting business rules in 2017/18 and is SWL achieving its control total set?
Conclusion
1. The CCG is on course to meet its target surplus of £2.08m.
2. We expect to meet the running cost target.
3. The CCG is only able to achieve an in year break even position as opposed to the
0.5% surplus required to meet business rules
4. In addition South West London as a whole based on the financial plan submission
made at the 24 November, 2016 is not achieving the control total set (£4.6m surplus)
W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [
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W A N D S W O R T H C C G P A G E 2 O F 7
Input Sought
The decision we would like from the Board
is:
To note the contents of the report and the
current planning position for 2017/18
Input Received
This paper has been reviewed by the
Finance & Resources Committee in
November 2016 (apart from the key points
arising from the November 24 Plan
submission).
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W A N D S W O R T H C C G P A G E 3 O F 7
The Report[Consider each question with reference to: (1) Strategy: progress towards our long-term goals
(2) Performance: delivery of this year’s results
(3) Governance: whether we are working in the ‘right way’]
Looking Back
W H A T H A S G O N E W E L L ?
The CCG is on course to achieve a balanced Financial Position and achieve the
planned 0.5% financial surplus at year end.
We are on course to meet the running cost target.
W H A T H A S N O T G O N E W E L L ?
At this point of the financial year The CCG are facing significant financial pressures
and we are forecasting a net overspend of £5.4m on operational budgets. Whilst this
may imply an improvement on the previously reported position this reflects the
treatment of reserves and excludes some potentially high level risks.
Potential unmitigated risks total £4m and a recovery plan is being developed to
ensure the achievement of financial targets.
As the financial year progresses achievement of this level of recovery plan
becomes more challenging and a greater cause for concern
Whilst the new provider for the management of Continuing Healthcare has made
good progress in identifying the financial pressures in this area, further financial
pressures have recently been identified which has put greater financial pressure on
the budgets than we had envisaged. For reporting purposes it is assumed that some
savings will still be implemented before year end.
The CCG continues to receive limited detailed information on Primary Care co-
commissioning budget from NHSE, in particular the lack of a forecast outturn, and we
are assuming an overall breakeven which is dependent on achievement of a £233k
QIPP which to date reflects no savings.
Looking Ahead
O P P O R T U N I T I E S ?
Investment in non-acute services that started in 2015/16
By investing in out of hospital services this should help manage demand and costs
around acute and other high cost services. Additional QIPP schemes are being
investigated to support the shortfall and whilst this will reduce the gap on the original
QIPP plan, the scale of impact will reduce as the year progresses.
CCG Directors have been asked to identify savings which would release 0.75% of
their budget responsibility
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W A N D S W O R T H C C G P A G E 4 O F 7
To support this internal budget reviews are being held and underspend areas
“frozen” to support the position.
R I S K S O R C O N C E R N S ?
Further escalation of financial pressures will put increasing pressure within a
decreasing timescale and limit our ability to manage within the resource limit in 16/17
and meet the business rules set, Specific areas of concern are:
Managing acute performance, including acute QIPP phased in the 2nd half of the
year and managing the financial impact if Continuing Healthcare growth
continues.
Non delivery QIPP
QIPP delivery is essential for the future financial health of the CCG.
In ConclusionC O N F I D E N C E ? I M P L I C A T I O N S ?
I am confident that the financial position
outlined in this paper is accurate based on
available information and reflects the risks
moving forward.
Whilst the CCG is still on course to
achieve a balanced Financial Position
and achieve the planned 0.5% financial
surplus at year end, significant pressures
exist and unless further mitigations are
introduced immediately the CCG will have
difficulty maintaining this position.
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W A N D S W O R T H C C G P A G E 5 O F 7
Data DashboardSee following PowerPoint slide pack.
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W A N D S W O R T H C C G P A G E 6 O F 7
For ReferenceEdit as appropriate:
1. The following were considered when preparing this report:
The long-term implications Yes
Ensuring that we understand cost drivers that will impact on future years
The risks Yes
Mitigations against a number of risks have been considered and implemented
where appropriate
Impact on our reputation Yes
By not achieving the targets set would have an adverse impact on our
Organisational reputation.
Impact on our patients Yes
Insufficient funding or poor planning would impact on our ability to commission
services in an efficient way.
Impact on our providers Yes
Prompt payment, accurate reflection of activity and finance
Impact on our finances Yes
Throughout the report
Equality impact assessment Not applicable
Patient and public involvement Not applicable
Please explain your answers:
2. This paper relates to the following corporate objectives:
Commission high quality services which improve outcomes and reduce
inequalities Yes
Make the best use of resources, continually improve performance and deliver
statutory responsibilities Yes
Continually improve delivery by listening to and collaborating with our patients,
members, stakeholders and communities Not applicable
Transform models of care to improve access, ensuring that the right model of care
is delivered in the right setting Yes
Develop the CCG as a continuously improving and effective commissioning
organisation Yes
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W A N D S W O R T H C C G P A G E 7 O F 7
Please explain your answers:
3. Executive Summaries should not exceed 1 page. [My paper does comply]
4. Papers should not ordinarily exceed 10 pages including appendices.
[My paper does not comply]
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Wandsworth Clinical Commissioning Group
Finance Report up to the end of October 2016
Presented by Finance –
December 2016
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Wandsworth Clinical Commissioning Group
Contents1. Month 7 Financial Position
2. Balance Sheet
3. 2017-19 Planning
4. Recommendations
Board December 20162 15 December 2016
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Finance Scorecard up to October 2016
Board December 2016
Financial Strategy Financial Performance• SWL Collaborative Commissioning programme
work is ongoing to deliver system transformation plan.
• Allocations have been published for the next 4 years from 17/18 with the next 2 years confirmed (hard) and the following 2 years indicative (soft)
• 1% non recurrent reserve cannot be committed in 2016/17
• Planning guidance for 2017-19 now issued• Contracts to be agreed by end of December for 2
years• CCG control totals have now been issued.
• Plan to achieve the target surplus of £2.08m (0.5%)• QIPP target is not forecast to be met but we are
forecasting to meet the running cost target• Action is being taken to manage Continuing Health
Care costs following concerns raised• Acute contracts are also over performing.• Overall there is no variance from plan at month 7 but
note the significant risks to this position.
Financial Governance Financial Risk• Annual internal audit plan is in place.• Board Assurance Framework has been updated in
October 2016.• Financial control environment assessment has
been submitted with action plan in place• Finance Recovery Group set up in September
2016 to oversee the QIPP programme and report into the Finance & Resources Committee.
• Financial ledger system has limited capability to do detailed analysis.
• Emerging issues around acute contracting and continuing care may impact on our ability to achieve the target surplus. Further mitigations are being developed to ensure that flexibility is built into the position.
• 2016/17 QIPP delivery represents a significant risk due to size of the programme and the level of reserves held to mitigate against performance.
15 December 20163
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Month 7 – WCCG Key Messages
Board December 2016
• We still plan to achieve the target surplus set (£2.08m)
• The overspend on Continuing Healthcare has increased to £2.7m (year to date) and £3.3m (full year). As the database becomes more robust the true level of spend is being identified. Though there is still more work to be done on this, it is envisaged that the majority of the movements in the worsening outturn prior to the positive impact of savings plans have been identified.
• The overall full year forecast for the Acute SLAs has improved slightly this month, mainly in relation to Chelsea and Westminster. However, concerns remain as this position is dependent on the achievement of £1.6m QIPP at St George’s which is phased in the second half of the year.
• We are now forecasting a full year underspend of £1,365k on Prescribing due in part to a reduction in national pricing.
• Reserves are being used to support the £5.4m forecast overspend on operational expenditure.
• We expect to meet running costs.
• To ensure the target surplus is achieved the CCG is identifying and progressing mitigating actions with a view to implementing savings that will generate £4m in 16/17 to ensure financial targets are met.
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Month 7 – Revenue Resource Limit
Board December 2016
• The Resource Limit reflects the amount of money the CCG has available to commission services (programme) and to run the CCG (admin). At Month 6, the CCG received £150k for consultant support to the SWL Collaborative, and £74k for Children and Young People Mental Health.
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Month 7 Financial Position
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Month 7 Acute Analysis
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Month 7 – Acute Commentary• Overall we are reporting an adverse forecast outturn variance of £3.5m, compared to a £3.8m overspend
at month 6. The major improvement area is Chelsea and Westminster.
• The main areas of forecast overspend are focussed on St George’s (£2,153k), Guy’s & St Thomas (£695k), Chelsea & Westminster (£555k) and UCLH (£390k) offset by Kingston Hospital (£710k) and Elective Orthopaedic Centre (£639k).
• St George’s over performance is against Emergency, Out patient attendances and Direct Access partially offset by underspends on elective and maternity. Within the SLA there is a significant QIPP (£1.6m), which has not impacted on the year to date position and is phased to impact in the second half of the year.
• Chelsea & Westminster over performance has reduced and the major areas of overspend are focussed on emergency and 1st out patients, offset by an underspend on maternity.
• The Guy’s & St Thomas overspend is focussed on elective and drugs & devices whilst the UCLH overspend is widely distributed with the main focus on elective and emergency.
• Elective Orthopaedic Centre are the most significant under performer on elective and Kingston Hospital the most significant underperformer on emergency. Imperial Hospitals are showing an over performance on critical care.
• There is still pressure on the non contracted activity with acute providers
• Charge exempt overseas visitors expenditure is assumed to be within the allocation. However the allocation has not been confirmed yet (expected for month 8).
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Primary Care Month 7
Board December 2016
• The most recent report from NHSE for Primary Medical Care covers the M06 period so the figures have been extrapolated to M07 which may result in minor year to date variations when the M07 report is received. There is an overspend in the year to date position largely reflecting the under-achievement of QIPP. NHSE have not provided a forecast outturn and we are continuing to pursue this issue. Based upon our understanding of information received we have assumed for now that the delegated budget will break even at year end, e.g. because refunds relating to prior year business rates are expected to contribute towards the QIPP target. However, there remains a risk of an overall overspend on the delegated budget.
• Reflecting the recent Prescribing information, the Primary Care budgets are now forecasting an overall underspend of £1.179m being the Prescribing underspend (£1.365m mentioned above) offset by other small overspends elsewhere – APMS: Walk In Element and cost pressures on OOH, GP In hours, and SPA111.
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Month 7 – Other Commentary• Non-Acute Services are reflecting an overspend of £2.124m year to date and £3.426m full year, so there
has been an adverse movement from Month 6 of £0.677m YTD with a slight improvement of £0.062m in the full year.
• Continuing Healthcare and Free Nursing Care (combined overspend £3.823m) are offset by one or two areas of underspend (circa £0.4m) where it has been identified that spend is unlikely to be incurred. Whilst the new provider for the management of Continuing Healthcare has made good progress in identifying the financial pressures in this area, further financial pressures have recently been identified which has put greater financial pressure on the budgets than we had envisaged. For reporting purposes it is assumed that some savings will still be implemented before year end.
• Spend on the South London & Maudsley SLA and the s117 agreement with the Council continue to show an overspend though these have not changed since last month. These overspends are offset by an underspend on the Mental Health Placements line. Overall mental health expenditure is meeting the value to achieve parity of esteem.
• Running Costs are reflecting a year to date underspend of £133k, with a forecast outturn underspend of £115k. On Corporate Programme Costs, there is YTD overspend of £211k with a forecast underspend of £85k. This improvement in the forecast position reflects anticipated recharges on the Continuing Healthcare management budget.
Board December 201615 December 201610
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Running Costs at Month 7
Board December 2016
The forecast spend is within the CCG’s Running Cost resource allocation of £7,481k
15 December 201611
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CCG Risks and Mitigations
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CCG Underlying Recurrent Position• The CCG has always had a healthy
underlying recurrent surplus.
• This means that it always had funding it could commit non recurrently for pump priming, investments etc.
• However our financial position has meant that we have had to use more of this resource to prop up the recurrent pressures coming through
• This is not sustainable and needs to be addressed through a savings programme that slows current run rate below the level of growth in our allocation.
15 December 2016 Board December 201613
• The chart above shows the underlying recurrent surplus at a high of £11m in April 2015 with a projected £0.5m at March 2017.
• The increase to £6.8m at April 2017 is due to the growth allocation to the CCG in 2017/18• Reality is that most of this will be needed to fund contracts so the savings plan for 17/18 will
be key in addressing this issue.
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Contents1. Month 7 Financial Position
2. Balance Sheet
3. 2017-19 Planning
4. Recommendations
Board December 201614 15 December 2016
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Statement of Financial Position at Month 7
Board December 2016
• This balance sheet snapshot reflects payments to be made on 1st November (in month 8). Therefore cash position above is not correct. Real cash position is a surplus of £85k as per Cash Drawdown slide
15 December 201615
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Cash flow Statement at Month 7
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Cash Drawdown to Month 7
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Better Payment Practice Code
Board December 2016
• We are achieving the target, which is 95%
15 December 201618
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Contents1. Month 7 Financial Position
2. Balance Sheet
3. 2017-19 Planning
4. Recommendations
Board December 201619 15 December 2016
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Approach to 17/18 PlanningOverview
• The publication of the “Strengthening Financial performance and Accountability 2016-17” document recently has given added impetus to setting clear commissioning intentions early and moving the business cycle forward, to get contracts signed by the end of December 2016 that cover a two year period.
• All CCG’s are expected to have signed all NHS contracts by the end of December, and the tariff and business rules guidance will be brought forward to facilitate this. Formal guidance is yet to be issued but it is expected that contracts will be based on activity assumption with financial values based on the draft 17/18 tariff.
• NHSE have signalled a much more structural approach to linking STPs with and contracts. Tariffs will be set for two years and local systems will be incentivised to work together more collaboratively. It is clear there will need to be a radical change in the behavioural dynamic of planning/contracting towards a more collaborative process
Approach
• A contracting and financial framework is in the process of being agreed, which will outline the agreed core principles at an STP level with clear lines of accountability and delegation between CCGs at a sub-regional level and the parameters each sub region can negotiate within. Each sub regional lead CCG DoC will establish negotiation teams and negotiating mandates such that all contracts are set within the parameters defined by the CCGs. The CCG lead will negotiate and deliver specified contracts for 2017/18 18/19, on behalf of their own CCG, SWL CCGs and London CCGs.
• Formation of a SWL Contract Delivery Group formed of directors from each of the 6 SWL CCGs as well as senior representatives of the CSU.
• The role of this group is to provide assurance, direction and support to unblock challenges as required of the overall contracting round
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Planning Guidance – Headlines Updated2 year contracts signed by 23 December 2016
London CCGs are being held to a regional control total
For SWL this is across the 6 CCGs and is a £4.6m surplus.
This means for Wandsworth the expectation is that we deliver a 1% surplus (a 0.5% in year surplus) at the very least to contribute to SWL control total.
1% non recurrent reserve comprises:
0.5% uncommitted
0.5% invested in STP transformation
CQUIN – 1.5% for national initiatives, remaining 0.5% to providers for achieving 16/17 financial target and 0.5% linked to the STP objectives.
Control totals to be issued to all providers which will feed into CCG control totals noted above.
Sustainability and transformation funding available for 2 years to providers (subject to hitting agreed performance targets)
Commissioner allocations have been refreshed for identification rule changes with NHS England specialised and the impact of moving to HRG 4+.
15 December 2016 Board December 201621
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Business Rules - UpdatedTaken from the 2017-19 Planning Guidance:
• In year break even where organisations are already achieving 1% surplus.
• 0.5% contingency reserve.
• 1% non recurrent reserve but note the use as per previous slide
• 2.09% growth in our allocation.
• 0.1% net national tariff uplift but actual considerably higher.
• Separate growth assumptions to be planned for Prescribing and continuing health care.
• Mental health parity of esteem continues (links to allocation growth) but is now called mental health investment standard.
• No investments planned.
• Expectation that individual CCG and provider organisations as well as local systems overall need to deliver within a financial control total
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Looking Forward – Issues - Updated• Issues from 16/17 moving forward:
• Growth in continuing care has continued through 16/17 so will be a pressure moving forward together with the new rates for Free Nursing Care.
• Prescribing cost pressures appear to be less of an issue in 16/17 but we have to be mindful of price changes both up and down
• Acute contracts continue to over perform & given 2 year planning cycle will be critical that these exit at as close to plan as possible. Current offers are showing significant gaps which have been covered by unidentified QIPP.
• Making good the non achievement of 16/17 QIPP
• Ensuring that the deterioration in the underlying recurrent position is addressed.
• Into 17/18
• Another challenging year with a complex contracting round for the acute sector caused by control totals and the STP expectations.
• Minimal growth has been given to the CCG so will be key to understand those areas where we will be mandated to fund.
• QIPP ask is significant again for this year (current estimate is around £20m). This also includes where recurrent pressures in 16/17 were covered from non recurrent resources.
15 December 2016 Board December 201623
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Risk Analysis - UpdatedRisk BAF Ref
(likely x impact)
Detail / Mitigating Actions
Allocation is less than expected
Risk:16(5x4)
Current draft plans assume low growth. However any non discretionary allocations will further eat into the growth available. Specialist commissioning transfers are not fully funded.
Financial pressure in SWL economy
Risk:75(4x4)Risk: 7(4x4)
Providers and commissioners are working on delivering a sustainable health economy with improved quality health outcomes. Key will be to linking CCG QIPP initiatives with Provider cost improvement programmes.
Financial distress of main provider
Risk: 89(4x4)
CCG continues to work closely with St George’s and regulators on a recovery plan. This may impact the way some of the services are currently commissioned and the way we contract for services in 17/18
Deliver a balanced financial plan
Risk: 9(4x4)
Large QIPP challenge planned for 17/18 will put pressure on the plan to deliver a 1% surplus. Plans are currently being drawn with mitigating actions to manage the riskOther factors to note include the late issuing of the final tariff after contracts have been agreed.
15 December 2016 Board December 201624
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Financial Plan – Headlines (1 of 2)
15 December 2016 Board December 201625
For 2017/18 the CCG is planning for a 0.5% surplus which does is an in year break even position and is not meeting business rules.
The main risks to the CCG position in 16/17 relate to:
• Uncertainty around provider contracts given the very early stage of the year and the chance to get QIPP agreed and into contracts.
• Ensure that in setting contracts that we purchase enough activity to deliver all the core national standards of performance around A&E and RTT.
• Continuing healthcare continues to increase above the level of growth allocated to the CCG. However for 17/18 it is expected the investment in the new provider will start to have an impact and limit this growth.
• Whilst prescribing has been kept well within budget to note that some opportunities may have been brought forward early therefore limiting opportunity in 17/18.
• We are also mindful that as patients become aware of their right to a personal health budget there will be an increase in requests.
• There are very low levels of reserves to support in year over performance of contracts or to cover contracts that come in above the plan value.
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Financial Plan – Headlines (2 of 2)• We currently have a QIPP of £20.2m which is 4.3% of our allocation and this is above the
level that we have had in previous years. We are assuming an investment of £4m to delivery this programme.
• This year we are negotiating an acute contract with SWL providers which aligns Trust CIP and CCG QIPP schemes.
• Acute growth is in line with the STP (circa 2.3%)
• We have included an investment in primary care that is linked to the £3 per head of population. This has been assumed to be spent evenly across the 2 years i.e. £1.50 in each year.
• For mental health we have assumed a parity of esteem uplift in line with our growth. We will be working with mental health providers to determine how we use this additional funding, ensuring we are getting value for money/achieving outcomes and agreeing uplifts at least in line with demographic growth.
• The 1% non recurrent risk reserve has been reinstated with 0.5% released back to CCGs and 0.5% to remain uncommitted. The CCG will use this to fund the SWL collaborative and Health London Partnership contributions.
• We have assumed that the allocation received in 16/17 for the move to market rates for our properties is non recurrent which has created a cost pressure of £1.9m.
15 December 2016 Board December 201626
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Financial Summary 16/17 to 17/19
15 December 2016 Board December 201627
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Assumptions Underpinning The Submission
15 December 2016 Board December 201628
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Timetable
Board December 2016
Item Date
Provider Control Totals & STF Allocations published 30/09/16
Commissioner allocations published 21/10/16
Submission of STPs 21/10/16
National tariff section 118 consultation published 31/10/16
Final CCG & specialised service CQUIN scheme guidance published 31/10/16
Submission of summary level 17/18 and 18/19 operational financial plans 01/11/16
Issue initial contract offers to providers 04/11/16
Providers to respond to initial contract offers 11/11/16
Submission of full draft 17/18 to 18/19 operational plans 24/11/16
Submission of progress on contract negotiations (weekly from…) 21/11/16
Contract mediation advised and entered into. 05/12/16
Publish national tariff 20/12/16
National Deadline for Signing contracts 23/12/16
Submission of final 17/18 and 18/19 operational plans aligned to contracts 23/12/16
15 December 201629
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Contents1. Month 7 Financial Position
2. Balance Sheet
3. 2017-19 Planning
4. Recommendations
Board December 201630 15 December 2016
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Recommendations
• The Board are asked to note the month 7 position and the risks contained within it
• The Board are also asked to note that the 2017-19 planning section has been updated to reflect the recently published operating plan guidance
Board December 201615 December 201631
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Part D: Board Governance
Page
4. Part D: Board Governance 196
4.1. D01 Summary Minutes: 197
4.1.1. Integrated Governance Committee 197
4.1.2. Finance Resource Committee 200
4.1.3. Audit Committee 202
4.1.4. Primary Care Committee 205
4.2. D02 AOB and Other Matters to Note
4.3. D03 Open Space
4.3.1. Members of the public present are invited to ask questions of the Boardrelating to the business being conducted. Priority will be given to writtenquestions that have been received in advance of the meeting.
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COMMITTEE FEEDBACK FORM
Committee: Integrated Governance Committee
Meeting date: 20th September 2016
Main items discussed: CSU Update
Continuing Health Care External Governance Report
Lay Member Board Roles
Conflicts of Interest Guidance
Record Sharing and Planning
Integrated Governance Report
Decisions: Lay Member Board Roles – In compliance with the new guidance published in June 2016, the Committee was asked to discuss and agree the proposal to recruit a third Lay Member to the CCG Board. The Committee approved the recommendation to the Board to increase Lay Member appointments to a total of three.
Particular points to note:
CSU (Commissioning Support Unit) Update – Two workshops had been held to identify any opportunities for synergies of services commissioned from the CSU and delivered in-house across the six CCG and through the SWL Collaborative; to identify any areas for improvement; consider and agree the process and options appraisal criteria; develop options. A further workshop was scheduled in September to finalise proposals. Following discussion, the Committee requested a further report to be brought back in a couple of months.
Continuing Health Care (CHC) External Governance Report – The Committee received the report from the assessment, undertaken by the Good Governance Institute, of Continuing Health Care arrangements in Wandsworth. A number of actions were identified, which would be taken forward. The recommendations from the report would be shared with the CHC provider. A redacted version of the document would be made available on the website.
Conflicts of Interest Guidance – An update was provided on the work required following publication of the latest guidance. The Conflicts of Interest policy will be taken to the October meeting for review and comment. Further work also remained to review Terms of Reference for all Committees and Sub-committees, and the Constitution.
Record Sharing and Planning – A number of issues were highlighted around IT, governance, and Information Governance, which, it was considered, were not being addressed within the existing CCG structures. A paper would be taken to the Management Team for further discussion.
Integrated Report - The report provided an update on performance with
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particular focus on the following areas: risks, Information Governance, finance, QIPP, A&E, Referral to Treatment, Cancer, Diagnostic Waits, CCG Assurance, and quality.
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COMMITTEE FEEDBACK FORM
Committee: Integrated Governance Committee
Meeting date: 18th October 2016
Main items discussed: Review of Conflicts of Interest Policy
Conflicts of Interest Self-Certification
Integrated Governance Report
Decisions: No decisions were required.
Particular points to note:
Review of Conflicts of Interest Policy – The Conflicts of Interest policy had been reviewed in light of the new national statutory guidance for CCGs issued in June. The main areas of change related to the third Lay Member, changes around governance, contract and procurement, and management of the process. A number of further amendments were highlighted during the discussion. The final version of the policy would be presented for sign off at the Board meeting in December.
Conflicts of Interest Self-Certification – The CCG was required, as outlined in the guidance, to submit quarterly self-certification returns starting with Q2 2016 onwards. A copy of the proposed submission was provided for comment. Currently the CCG was compliant with requirements.
Integrated Governance Report - The report provided an update on performance with particular focus on the following areas: risks, Information Governance, finance, QIPP, A&E, Referral to Treatment, Cancer, Diagnostic Waits, Infection Control, Improving Access to Psychological Therapies (IAPT), and quality.
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COMMITTEE FEEDBACK FORM
Committee: Finance Resource Committee
Meeting date: 18th October 2016
Main items discussed: Review of Financial Policies
2017/19 Operational Plan Guidance
Balancing the Finances
Financial Position
Month 4 QIPP
St George’s Position
Decisions: No decisions required.
Particular points to note:
Review of Financial Policies – A detailed review of the Prime Financial Policies (PFP) and Standing Orders (SO) had been undertaken. A number of the existing PFP sections were expanded to provide more comprehensive information and detail regarding process. This review has resulted in a more comprehensive and coherent document, with the proposal that this should be taken forward to the Board for approval. It was agreed that as a full review of the PFP had not been done for a while, an in-depth review would be included on the next meeting Agenda.
2017/19 Operational Plan Guidance – The main headlines from the planning guidance. It was expected that the position around the control total and allocation would be clearer. The content of the report outlining the current position was noted.
Balancing the Finances – The paper highlighted work being done to address the financial position and processes that have been put in place. Discussions have been held to consider potential options, which included clinical oversight. Some additional schemes were identified alongside those that could be delivered immediately. A series of clinical audits will be undertaken on ECI procedures but it was not expected that this would achieve significant gain. The content of the report was noted.
Financial Position - The current position was noted. Continued over-performance was noted around Continuing Health Care, which was currently covered in the overall position. The position at Month 6 was generally on track, due to a positive technical adjustment in prescribing, and some additional QIPP delivery. NHSE was now proposing that the 1% non-recurrent uncommitted reserve would remain in CCG positions if a break-even position was achieved. This was contrary to previous guidance which stated that this funding would be used to balance the national provider position. If available to the CCG, this funding would be used to cover recurrent pressures.
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Month 4 QIPP – Performance was in line with the previous forecast. There were some risks around schemes due to deliver in the second half of the year. It was assumed that the acute QIPP of £1.6m would be achieved, but there remained a high level of risk. The Committee continued to express concern regarding the forecast shortfall against target, with other proposals to bridge the gap to be considered.
St George’s Position – The latest report to the Trust Board reported an upper end forecast deficit position of £80m approximately. The Trust was currently reporting a £55m forecast over-performance. The Trust was expecting to address the current run rate and bring this back to £1m deficit per month.
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COMMITTEE FEEDBACK FORM
Committee: Audit Committee
Meeting date: 15th July 2016
Main items discussed: SBS Service Auditor Report
Internal Audit Update
External Audit – Annual Audit Letter
Counter Fraud Update
External Audit Procurement
Decisions: External Audit Procurement – The Committee was asked to review proposals submitted for the proposed procurement process. A recommendation was presented to all SWL CCG Audit Committees that this should be done as a collective process, but not as a collective appointment. The proposal was discussed and a number of comments were noted. Following on from the discussion, a revised proposal was recommended to be fed back to Merton CCG, as the lead organisation for the process.
Particular points to note:
SBS Service Auditor Report – The report covered the period to 31st March 2016. During the discussion a number of comments were noted.
Internal Audit Update – An update on work to date was received. No significant issues were highlighted from the reviews undertaken. The content of the report was noted.
External Audit – Annual Audit Letter – The letter provided a summary of all the work undertaken over the past twelve months. The content was noted.
Counter Fraud Update – An update was provided to the Committee including the Counter Fraud Annual Report. Some comments were noted regarding the self-review return to NHS Protect, which would be followed up. No reactive investigations had been undertaken over the past year. The content of the report was noted.
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COMMITTEE FEEDBACK FORM
Committee: Audit Committee
Meeting date: 21st October 2016
Main items discussed: Conflicts of Interest Stock-Take
Review of Prime Financial Policies
Internal Audit Update
External Audit Update
Counter Fraud Update
Future Operating Model for CCGs
External Audit Procurement
Decisions: No decisions were required.
Particular points to note:
Conflicts of Interest Stock-Take – An update was presented on the work to review the Conflicts of Interest policy to reflect the guidance published in June. The main updates to the policy were around procurement, gifts, and role of Conflicts of Interest Guardian. The updated policy has been reviewed at Integrated Governance Committee – the final version will be presented to the Board for sign off in December. An internal audit of Conflicts of Interests was required to be undertaken in Q4. It was noted that NHSE was undertaking a further review of the wider NHS conflicts of interest issue, which could result in further amendments to the policy being required.
Review of Prime Financial Policies – An update was provided for information. Details of the work had previously been discussed by the Finance Resource Committee. The detail in a number of sections have been expanded to provide further information and processes. The FRC will review the final documents, with recommendation to the Board for final approval.
Internal Audit Update – An update on work to date was received. No significant issues were highlighted from the reviews undertaken. The content of the report was noted.
External Audit – An update was provided to the Committee, including a comparison review of the risk register with a number of CCGs across London and the South East. It was agreed that the report would be taken to IGC for discussion and work would be considered to localise some of the recommendations from the review.
Counter Fraud Update – An update was provided to the Committee. The Committee was informed of a referral reported through the National Fraud Reporting Line. The content of the report was noted.
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Future Operating Model for CCGs – SWL CCGs have been engaged in a review process to fundamentally change lines of accountability and senior leadership. A new shared Executive Team would be put in place, and a change to local CCG team arrangements. The proposal in development is subject to consultation. Audit Committees governance was being reviewed, but these would remain local at the moment.
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COMMITTEE FEEDBACK FORM
Committee: Primary Care Committee
Meeting date: 6th September 2016
Main items discussed: Primary Care Commissioning – Update on decisions / Practice Baseline Reviews
Review of APMS Contracts
Primary Care Commissioning Intentions
Tuberculosis Local Incentive Scheme
Anticoagulation Local Incentive Scheme for Direct Oral Anticoagulant
Primary Care Quality Review Group Update
Estates Update
Finance Report
Decisions: Review of APMS Contracts – Information was received relating to two contracts that were coming to an end.
The Practice Furzedown – The CCG has been working with NHSE to review the options, which had also been reviewed by the Primary Care Operational Group. It was noted that the anticipated growth in list size had not materialised, with one-third of patients on the current list size being out of borough. The practice was only achieving 63% QOF compared on average to 92% for Wandsworth practices within a two mile radius. Engagement with stakeholders regarding potential dispersal of the list recommended this as the preferred option. Work has been done with other practices in the area regarding the potential list dispersal.
Following detailed discussion, the Committee agreed the preferred option, to close the practice and for dispersal of the patient list, subject to engagement, with the final decision to be made in December.
The Junction – The Committee was asked to review the recommendation for the practice to be extended. The practice has a current list size of 7300, with 96% QF performance. This was a high performing practice which meets the needs of the local population. Two contracts were in place at the practice – APMS and Walk-In – delivered by the same provider.
The Committee agreed the preferred option to extend the contract for a minimum of one year from 1st April 2017, with further discussion with the current provider. A paper for final decisions would be held in Part II at the December meeting of the Committee.
Primary Care Commissioning Intentions – Three main areas were identified which link with those set out in the STP around primary care transformation – London Strategic Commissioning Framework Specifications, Commissioning of MCP Model, Quality. An extensive
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programme of engagement with patients would be put in place.
Following on from the discussion, the Committee agreed the proposed Commissioning Intentions.
Anticoagulation Local Incentive Scheme for Direct Oral Anticoagulant (DOAC) – The paper outlined the proposal to address this urgent medical need for a streamlined pathway, through a procurement process, which would take up to nine months. The proposed scheme would relieve the pressure whilst long term options were considered. GPs were already managing patients and issues around capacity in secondary care.
The Committee agreed the proposal.
Particular points to note:
Primary Care Commissioning – Update on decisions – The paper provided an update on decisions taken by the Primary Care Operational Group, including NHS England, most of which related to contract variations.
Practice Baseline Reviews – An update was provided on the programme, which had been agreed as part of the due diligence exercise. Once completed the reviews will be used to inform discussions to be held with practices. Key findings would be brought back to the Committee for review.
Tuberculosis Local Incentive Scheme – This was a national scheme, with funding allocated. The paper was provided for information. Discussions had been held with GPs and the LMC – currently there was a high rate of cases in Wandsworth. The content of the report was noted.
Primary Care Quality Review Group Update – The report provided an update on work undertaken since the previous meeting, including Patent Engagement, GP patient survey, General Practice Resilience Framework and General Practice Development Programme, CQC reports. The content of the report was noted.
Estates Update – An update on the current position was noted.
Finance Report – The content of the report was noted.
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Part E: Meeting Close
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5. Part E: Meeting Close 207
5.1. E01 Clinical Chair's Closing Remarks
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5.P
art E: M
eeting C
lose
207