nel joint commissioning committee meeting part 1 us... · nel joint commissioning committee meeting...

An alliance of North East London Clinical Commissioning Groups

City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs

Chair: Dr Anwar Khan I Accountable officer: Jane Milligan

NEL Joint Commissioning Committee Meeting Part 1

12.30-2.15pm Wednesday 11 September 2019

Committee rooms, Unex Tower

5 Station Street, Stratford, E15 1DA

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NELCA Joint Commissioning Committee - Part 1 Date and time: 12.30-2.15pm Wednesday 11 September 2019

Venue: Committee Rooms, Unex Tower, 5 Station Street, Stratford, E15 1DA

Agenda

No. Time Item Page Action required Owner

1. Welcome

1.1

12.30pm

Welcome, introductions, apologies

Declarations of interestVerbal Chair

1.2 Minutes of the last meeting and matters arising

Action log

18

22

Approve

Monitor Chair

2. Patient and public engagement

2.1 12.35pm Questions from the public Verbal Discussion Chair

3. Strategy

3.1 12.55pm NEL mental health strategy 23 Note David Maher

3.2 1.05pm Long Term Plan draft submission Tabled Discussion Simon Hall

3.3 1.20pm WEL surgical strategy and initial engagement

43 Note Chris Neill

4. Commissioning

4.1 1.30pm Child sexual assault and abuse hub in north east London - update

59 Approve Chris Neill

4.2 1.40pm Evidence Based Interventions policy – engagement outcome

67 Note Les Borrett

5. Performance

5.1 1.50pm Performance report – month 3 108 Note Les Borrett

6. Risk Register

6.1 2pm Risk register 121 Approve Kash Pandya

7. Forward planning

7.1 2.10pm Meeting planner 131 Discussion Chair

Any other business

Date of next meetings:

13 November 2019 8 January 2020

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NELCA JCC - Acronyms List

ACRONYM MEANING

A&E Accident & Emergency

APMS Alternative Provider Medical Services (a type of Primary care contract)

AQP Any qualified provider

BAF Board Assurance Framework

Bart's / BHT Barts Health NHS Trust

BHRUT Barking, Havering and Redbridge University Hospitals NHS Trust

BMA British Medical Association

CAS Clinical Assessment Service

CCG Clinical Commissioning Group

CCU Critical Care Unit

CEG Clinical Effectiveness group

CEPN Community Education Provider Network

CHP Community Health Partners

CIL Construction Industry Levy

CPD Continuing Professional Development

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUINs Commissioning for Quality and Innovation (Payment Framework)

CSU Commissioning Support Unit

CYP Children and Young People

DES Direct Enhanced Service

DoH/ DH Department of Health

DoPM Department of Psychological Medicine

DToC/ DToCs Delayed Transfers of Care

ED Emergency Department

ELFT East London Foundation Trust

ELHCP East London Health and Care Partnership

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ELHCP ODG East London Health and Care Partnership Operational Delivery Group

EMIS web Egton Medical Information Systems (System that records patient consults)

EPCS Extended Primary Care Service

EPCT Extended Primary Care Team

EPR Electronic Patient Record

ETTF Estates and Technology Transformation Fund

FOI Freedom of Information

GB Governing Body

GIA Gross internal area

GLA Greater London Authority

GMC General Medical Council

GMS General Medical Services (a type of Primary care contract)

GP General Practitioner

HBPoS Health Based Places of Safety

HEE Health Education England

HLP Healthy London Partnership

HMT Her Majesty's Treasury

HUH The Homerton University Hospital NHS Foundation Trust

IAPT Increasing Access to Psychological Therapy

ICP Integrated care partnership

IG Information Governance

IMT Information Management and Technology

INEL Inner north east London

IPS Individual placement and support schemes

ITU Intensive Therapy Unit

IUC Integrated urgent care

JCC Joint Commissioning Committee

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPI Key Performance Indicator

LAP Local Area Partnership

LAS London Ambulance Service

LAs Local Authorities

LBN London Borough of Newham

LBWF London Borough of Waltham Forest

LCFS Local Counter Fraud Specialist

4


LD SAF Learning Disability Self-Assessment Framework

LEB London Estates Board

LEDU London Estates Development Unit

LES Local enhanced service

LMC Local Medical Committee

MoLCV Medicines of limited clinical value

MOU Memorandum of Understanding

MPIG Minimum Practice Income Guarantee

NAFO Newham Alternative Funding Option

NCCG Newham Clinical Commissioning Group

NDPP National diabetes prevention programme

NEL North East London

NELCA North East London Commissioning Alliance

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS PS NHS Property Services

NHSE NHS England

NHSI NHS Improvement

NICE National Institute of Health and Care Excellence

NUH Newham University Hospital

ONEL Outer north east London

OOH Out of hours

OPD Outpatient department

OPE One Public Estate

PALS Patient Advice and Liaison Service

PCCC Primary Care Commissioning Committee

PCT Primary Care Trusts

PHE Public Health England

PMS Personal Medical Services (a type of Primary care contract)

PoLCV Procedures of low clinical value

PolCE Procedures of low clinical effectiveness

PPE Patient and Public Engagement

PPG Patient and Public Group

PREM Patient Reported Experience Measure

PROM Patient Reported Outcome Measures

PTL Patient Tracking List

5


QIPP Quality, Innovation, Productivity and Prevention

QOF Quality Outcome Framework (Assessor Validation Reports)

R&D Research & Development

RAG Red, Amber, Green

RAS Referral assessment service

RICS Royal Institute of Chartered Surveyors

RLH Royal London Hospital

ROI Return on Investment

RTT Referral to treatment

SEP Strategic Estates Plan

SMI Severe mental illness

SMW Spending Money Wisely

SPA Single Point of Access

SPR Service Program Review

STP Sustainability and Transformation Plan or Partnership

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NHS North East London Commissioning Alliance (City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs)

Voting Members

Name Title Name of organisation and nature of its business

Position Held/Nature of Interest

Type of Interest Date

Declared

Date

Updated Financial Non-financial

Professional

Non-Financial

Personal

Jane Milligan

Accountable Officer –NELCA/NEL STP

NEL Commissioning Support Unit

Partner is employed substantively

X 2014 - Present 22 July 2019

NHS England Partner on secondment to Central London Community Healthcare as Director of Primary Care Development.

X April 2019 - present

Action For Stammering Children

Partner is a Trustee for Action for Stammering Children

X Oct 2013 – Present

Stonewall Ambassador X Oct 2014 – Present

Peabody Housing Association Board

Non-Executive Director X Jan 2017 – Present

Date July 2019

Edited by Kate McFadden-Lewis, Board Secretary

Joint Commissioning Committee Register of Interests

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Ken Aswani Chair –Chair Waltham Forest CCG

Muhammad Naqvi

Joint Chair JCC & Chair Newham CCG

Woodgrange Medical practice

GP partner X 2015-present 10 March 2019

Frenford clubs for young people (registered charity/ voluntary organisation)

Trustee X 2012-present

NHC - Newham GP Federation, Woodrange practice is a shareholder

GP partner X 2015-present

Novartis Clinical Mentor X 2018-present Primary care APMS contract for GP caretaking – Dr Abiola’spractice

X March 2019-present

Anil Mehta Joint Chair JCC & Chair Redbridge CCG

Fullwell Cross Medical Centre

GP Partner X April 2013 – present

28 Feb 2019

Metropolitan Police

Forensic examiner X November 2015 – present

The Cleaning Company

Sister-in-law is the owner

X 2013 – present

NHSE GP appraiser X February 2015 – present

Healthbridge Direct

Shareholder X September 2014 – present

Fouress Enterprises Ltd

Director X 2015 – present

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Prescon Ad-hoc screening work X January 2018 – present

London Healthwise Ltd (non trading)

Director X 2009 - present

Sam Everington

Chair THCCG Bromley By Bow Partnership - based at the Bromley by Bow Centre Charity 1999

GP X 1989-present 7 March 2019

Chair of Chairs London CCGs X 2018-present East London Health Partnership (STP)

Clinical Lead X 2011- present

Tower Hamlets health and wellbeing board

Deputy chair X 2016- present

BMA Council member and Vice President

X 1989- present

Queen Mary University of London.

Fellow and Honorary Professor

X 2014- present

Tower Hamlets CCG

Wife Linda Aldous is the practice nurse Board Member

X

Bromley by Bow partnership

Wife Linda Aldous is a Partner

X

MDDUS (insurance for the GP partnership)

As a GP partners member

X 2005- present

Queens Nursing Institute

Vice President X 2017- present

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College of medicine

Vice President and Council member

X 2016- present

NHS property board

Board member X 2018- present

NHS resolution Associate Director July 2018- present

Atul Aggarwal

Chair Havering CCG

Maylands Healthcare

GP Partner X April 2013 – present

28 Feb 2019

Maylands Healthcare Ltd

Director and shareholder in on-site pharmacy

X April 2013 – present

Parkview Dental Practice

Sister is NHS dentist within Havering

X 1996 – present

Essex Medicare LLP

Part owner which owns Westland Clinic, Hornchurch. Space rented out to Inhealth (Diagnostic),Nuffield Health (Brentwood), Communitas Clinics (Dermatology & Gynaecology)

X 2014– present

Havering Health Ltd.

Shareholder. X September 2014 – present

Barking, Dagenham and Havering LMC

Co-opted member 2013 – present

Westlands Clinic (Langton dental) have an outsourced contract with

Spouse is a dentist. X May 2018-present

10


BHRUT for oral surgery.

Mark Rickets

Joint Chair JCC and Chair C&H CCG

GP Confederation Nightingale Practice is a Member

X

HENCEL I work as a GP appraiser in City and Hackney and Tower Hamlets for HENCEL

X

Homerton University Hospital NHS Foundation Trust

CCG Representative on Board of Governors – historic

X

Nightingale Practice (CCG Member Practice)

Sessional GP X

Jagan John Chair, B&D CCG

King Edwards Medical Group

GP Partner X June 2010- present

28 Feb 2019

King Edwards Medical Group

Other GPs are family members

X June 2010-present

Proactive Care - Healthy London Partnerships NHS England

Clinical Lead X Mar 2017- present

North East London Foundation Trust - Barking & Dagenham Community Cardiology Service

GPWSI in Cardiology X Aug 2018- present

Together First Limited (GP Federation)

Practice is a Shareholder

X May 2014- present

Harley Fitzrovia Health Limited

Director and Shareholder

X Jan 2018- present

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Monifieth Limited (Director and Shareholder)

X Mar 2018- present

Health 1000 Director Prime Ministers Challenge Fund Lead BHR

X Dec 2014- Nov 2018

Kash Pandya

Vice Chair JCC and Lay member B&D CCG

NHS Havering CCG

Lay member, Governance and Audit Chair

X 2013-19 26 June 2018

Redbridge CCG a Lay member governance and audit chair

X

University of Essex

Independent Audit Committee member

X 2013-19

Southend-on-Sea Borough Council


X 2016-18

Brentwood Citizen's Advice Bureau

General Advisor X 2009 – present

Essex Ministry of Justice Advisor Committee

Lay member, Governance and Audit Chair

X 2010-19

PriceWaterhouse Cooper

Son is employed as a management Consultant

X 2013 - present

Accenture Son is employed as Legal Counsel

X 2015 – present

Historic - Her Majesty's Inspector of Constabulary

Associate Inspector 2011 – January 2018

Historic - Hillcroft College for Women (Surbiton)

Council member & honorary treasurer

X May 2017 – present

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Historic - Health & Safety Executive


X May 2017 – present

Richard Coleman

Lay Member Havering CCG

BHR CCGs Brother-in-law is Independent GP on the Primary Care Commissioning Committee

X January 2017- present

13 March 2019

Price Waterhouse Cooper

Nephew is a partner X X August 2013 – present

Khalil Ali Lay Member Redbridge CCG

Dr Joseph GP practice, Collier Row

Family Doctor X April 2017 – present

13 March 2019

St Francis Hospice

Spouse is a regular donor


Cancer Research UK

Spouse is a regular donor


Sue Evans Lay Member C&H CCG

Loughton Youth Project (registered charity)

Trustee and Treasurer X October 2017 – Sept 2018

18 March 2019

Worshipful Company of Glass Sellers Charity Fund

Secretary to Trustees, X October 2017 – present

St Aubyn’s School Charitable Trust/Limited Company

Trustee and Director X October 2017 – present

Essex Advisory Committee for Justices of the Peace

Lay Member X October 2017 – July 2018

Barts Health Trust/BHRUT

Self and family are patients in the NELCA area.

X October 2017 – present

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Caroline White

Lay Member WFCCG

Red Edge Communications Ltd - Communications/journalism/PR company

Director X 2015 - present 30 July 2019

BMJ P/T employment - Senior Media Relations Executive

X August 2017 - present

Freelance Medical Journalist

X Ongoing

Medical Journalists’ Association - Executive committee post to promote the interests of medical journalists

Co- vice chair X September 2017 - present

Women of Walthamstow (WoWStow) - Local sexual health campaign group

Member X 2011 - present

Linford Road, Wood Street

PPG member X 2017 - present

Labour Party Associate Member X 2015- present

Noah Curthoys

Lay Member THCCG

Bridgenor Group Ltd

Director & Owner X June 2015 - current

11 July 2019

Northshott Consulting Ltd

Director & Owner X March 2011- current

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The Democratic Society (Belgian based NGO/charity)

Board member X July 2019 - current

The Democratic Society

Senior Partner X July 2016-June 2019

Phil Horwell Lay Member, Newham CCG

Deloitte Management consultant

X April 2019 - current

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Non-Voting Members

Name Title Name of organisation and nature of its business

Position Held/Nature of Interest

Type of Interest Date

Declared

Date

Updated Financial Non-financial

Professional

Non-Financial

Personal

Henry Black Financial Representative JCC & NEL STP

BHRUT Wife works as Deputy Director of Income and Planning at BHRUT

X Feb 2018 - Present

4 January 2019

East London Lift Accommodation Services Ltd

Director X Feb 2018 – Present

East London Lift Accommodation Services No2 Ltd

Director X Feb 2018 - Present

East London Lift Holdco No2 Ltd



Director X Feb 2018 – Present



ELLAS No3 Ltd Director X Feb 2018 - Present

ELLAS No4 Ltd Director X Feb 2018 – Present

Infracare East London Ltd


Mark Tyson Barking & Dagenham Local Authority

NIL

Mark Ansell Havering Local Authority

NIL

Adrian Loades

Redbridge Local Authority

Redbridge Living, a company 100%

Director X October 2018 - present

29 April 2019

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owned by LB Redbridge to develop housing schemes within the Borough.

Ellie Ward City of London Corporation

NIL

Gareth Wall Hackney Local Authority

NIL 21 July 2018

Linzi Roberts-Egan

Waltham Forest Local Authority

NIL 3 May 2019

Colin Ansell Newham Local Authority

Health and Care Space Newham

Director X May 2019-present

19 July 2019

Denise Radley

Tower Hamlets Local Authority

CACI Family member (Marc Radley) is a director of CACI (supplier of information and IT systems to public sector)


13 March 2019

Hertfordshire Partnership NHS Foundation Trust

Ordinary member X April 2016 – present

Fiona Smith Chief Nurse, NELCA JCC

Director & co-owner

Honesta Partners Ltd, a LLP Healthcare Consultancy company

X 1 November 2018

Spouse is also a director

Honesta Partners Ltd, a LLP Healthcare Consultancy company

X

Registered Board Nurse

NHS Newham CCG X

Charlotte Harrison

Secondary Care Consultant, NELCA JCC

Consultant Psychiatrist and Deputy Medical Director

South West London and St Georges MH NHS Trust

X May 2005 - present

13 March 2019

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An alliance of North East London Clinical Commissioning Groups City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs

NEL Joint Commissioning Committee – part 1 12.30-2.20pm Wednesday 10 July 2019

Committee Rooms, Unex Tower, 5 Station Street, Stratford, E15 1DA

Minutes

Present:

Khalil Ali Lay Member, NHS Redbridge CCG

Dr Ken Aswani (items 1 & 4.1) Chair, NHS Waltham Forest CCG

Henry Black Chief Finance Officer, NELCA

Richard Coleman Lay Member, NHS Havering CCG

Sue Evans Lay Member, City & Hackney CCG

Professor Sir Sam Everington (items 1, 2, 4.1) Chair, NHS Tower Hamlets CCG

Charlotte Harrison Secondary Care Consultant, NELCA

Phil Horwell Lay Member, Newham CCG

Dr Jagan John Chair, NHS Barking and Dagenham CCG

Jane Milligan Accountable Officer, NELCA

Dr Muhammad Naqvi (Chair) Chair, NHS Newham CCG

Kash Pandya Lay Member, NHS Barking and Dagenham CCG

Gareth Wall Local Authority Representative, Hackney

In attendance:

Les Borrett Director of Strategic Commissioning, NELCA

Navina Evans (item 4.1) Chief Executive, ELFT

Archna Mathur Director of Performance & Assurance, NELCA

Kate McFadden-Lewis (minutes) Board Secretary, NELCA

Simon Hall (items 1-4.1) Director of Transformation, ELHCP

Apologies:

Mark Ansell Local Authority Representative, Havering

Dr Atul Aggarwal Chair, Havering CCG

Noah Curthoys Lay Member, NHS Tower Hamlets CCG

Dr Anil Mehta Chair, NHS Redbridge CCG

Denise Radley Local Authority Representative, Tower Hamlets

Dr Mark Rickets Chair, NHS City & Hackney CCG

Linzi Roberts-Egan Local Authority Representative, Waltham Forest

Fiona Smith Chief Nurse, NELCA

Ellie Ward Local Authority Representative, City of London

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No. Item

1.1 Welcome, introductions, apologies Dr Muhammad Naqvi welcomed attendees to the meeting, and apologies for absence were noted as above. There were no declarations of interest.

Dr Naqvi noted that the Waltham Forest CCG Board members, Dr Anwar Khan and Alan Wells, had come to the end of their term, and thanked them for their valuable contributions to the work of the Committee. Dr Naqvi welcomed Dr Ken Aswani, the newly elected Chair of Waltham Forest CCG, to the meeting. The Lay Member representative will be identified and attend the next meeting.

1.2 Minutes of the last meeting and matters arising The minutes of the last meeting were accepted as an accurate record.

Actions update:

an update on Specialised Commissioning plans will be discussed by the Committee inSeptember

the ELHCP digital roadmap is included in the pack for information and closes off action JCC – 7.

2.1 Questions from the public

Questions from Meenakshi Sharma:

1) Could you please explain how pooling resources for the Better Care Fund leads to reduction ininequalities across NEL, in light of what appears to be substantially lower funding for BHR as compared to the other boroughs?

Answer: Allocations for the BCF are made at borough level and there is no mechanism for sharing across NEL. Each borough is able to decide to what degree health and social care budgets are placed into the BCF as long as minimum contributions are met - this should not be confused with overall funding for local services (eg Newham have opted to pool a larger amount than other boroughs)

2) You have made clear that there are no plans to close the King George A&E site, as there is a clearneed for A&E provision at the site both now and into the future but could you also please confirm that it is possible the A&E will be limited to access for the frail elderly, as indicated in the bid submitted by the ELHCP, which is now seeking alternative funding?

Answer: The proposal for a more specialist A&E dedicated to frail and elderly patients is no longer the preferred option. Recognising the broad and growing demographic pressures, the local health system is in the process of considering all options for the service model for urgent and emergency care which will best serve the whole population needs. These plans are in early stage of development and full engagement with all stakeholders will take place in due course to help shape them, including public consultation if this is appropriate.

On 29 March, the local NHS and Council Leaders shared a joint statement which said:

“We want to be very clear – the threat of closure of the Accident and Emergency unit arising from decisions in 2011 has been removed. The local population has changed significantly since 2011 and is forecast to change further, there is a clear need for Accident and Emergency provision at King George Hospital both now and into the future.

“The review of the clinical strategy of BHRUT is an important development. This will create an opportunity to consult with all stakeholders - particularly the public - on the Trust’s future clinical

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strategy. It will provide an opportunity for us all to contribute to shaping a long term vision and plan for services at King George Hospital including the Accident and Emergency unit.”

The joint statement made on 29 March still stands – nothing has changed. The proposal in the previous ELHCP bid that you refer to is not being pursued.

3.1 Development of the Long Term Plan – update Simon Hall updated the Committee on the NEL response to delivering the Long Term Plan (LTP), following the recently published guidance from NHS England/ Improvement. An initial plan will be submitted to NHSE/I by 27 September, with the final submission due 15 November 2019. A number of engagement events are planned over the next few weeks to ensure local input into the plan. In discussion the Committee noted:

i. the robust partnership working that is in place across the STP, and the many examples ofgood practice being shared across the patch

ii. the LTP as an enabler to becoming a fully integrated care systemiii. the importance of clear communication to patients, public and community on these plansiv. the strong research and development already in place in NEL and good relationship with our

AHSN (UCLPartners), as well as the innovation projects within the STP that have alreadyimproved outcomes for patients.

3.2 ELHCP Transformation Programme – update Simon Hall presented the ELHCP transformation programme update. With most of the content discussed under the previous item, the Committee noted.

4.1 East London NHS Foundation Trust – update Navina Evans presented on the Trust Strategy which has been recently reviewed, incorporating feedback and input from staff, patients and the community. The strategy document can be found on the Trust’s website here.

The Trust mission is to ‘improve the quality of life for the community we serve’, by striving to meet the four strategic objectives, underpinned by robust plans, which are regularly reviewed and monitored:

1. Population health outcomes2. The experience of care3. Staff experience4. Value – to increase our productivity, reduce waste and cut out variation in clinical practice.

Discussion points included:

i. the strong patient focus and patient and carers engagement and involvementii. the successful initiatives around workforce, including:

o close working with training institutions for mental health nursingo the QI programme, ‘Enjoying Work’, where teams run their own improvement projects

to improve morale and bring back joy in worko an initiative on reducing violence on wards, which has impacted positively on a

number of measures, including staff satisfaction and sickness levels.iii. the effective joint commissioning arrangements between the providers, local authorities and

the CCG across the three boroughs for children and young people’s mental health services,as well as initiatives beyond CAMHS, such as early intervention programmes in schools andthe community

iv. the good links and relationships with the acute providers across NEL, at all levels, from thefrontline to the executive team.

4.2 Better Care Fund update Les Borrett updated the Committee on progress on the local systems’ implementation of the national requirements of the Better Care Fund (BCF), and plans for 2019/20. Key discussion points included:

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i. that although there is clear guidance on the requirement for pooled budgets between LocalAuthorities and CCGs, with a minimum contribution amount set and specific targets to bemet, there is no maximum contribution requirement. The budgets already committed toservices from each organisation are pooled, the BCF is not ‘new’ money available tocommission new services, rather a different way of using already committed money to bettercommission joined up health and care services

ii. with the guidance for 2019-20 not yet available, there is some uncertainty around the futurearrangements for the services commissioned through the BCF.

It was agreed to discuss this again in six months’ time, with the paper to include:

comparative performance across the key BCF indicators and initiatives sharing of good practice across the patch, such as personal health budgets, continuing

healthcare and winter planning. (ACTION: LB)

5.1 Performance report – month 12 Archna Mathur presented on the month 12 performance across the STP area, highlighting that A&E performance remains the most challenging area. Key focus areas include:

i. reducing ambulance handovers, which is now an addendum to the operating planii. the national requirement of a weekly detailed PTL submission, showing patients who have

been in hospital longer than 21 days, with a focus on the harm of these extended length ofstays

iii. same day emergency care (ambulatory care).

In discussion the Committee noted that the learning from the evaluation of last winter will be embedded into the next winter plan. The main challenge remains the increasing demand on A&E, and therefore the importance of signposting patients to other services other than A&E, and other initiatives to reduce demand on A&E was noted.

The Committee suggested for inclusion in future reports; to show numbers of patients for out of area placements as well as bed days lost, and to periodically carry out brief deep dives into key areas, such as patients waiting over 52 weeks from referral to treatment, diagnostics and continuing healthcare. (ACTION: AM)

6.1 Risk Register Kash Pandya presented the NELCA JCC risk register to the Committee, highlighting the main risks and mitigating actions to deliver the NELCA priorities.

Kash Pandya then outlined the proposed changes to risk reporting, which will link to and reflect the ambitions of the Long Term Plan, as well as the required milestones to becoming an ICS. The format of the report will also change, to show more clearly how the risk score changes over time.

In discussion, Dr Jagan John raised the national pensions issue, which is having an impact on capacity in primary care as well as, potentially, workforce retention. It was agreed to ensure that this is addressed on the risk register. Khalil Ali suggested that the progress being made on the BHR recovery plan is included as an important mitigation on the financial risk, S3. (ACTION: KP/ KML)

7.1 Meeting planner: noted.

8 Any other business: None.

Date of next meeting: 12.30-2.30pm Wednesday 11 September 2019

21

ReferenceMeeting

date Minute

referenceAction Owner

Target completion date

Comment

JCC - 18 12/09/2018 5.1Commissioning Strategy 2018/19 - 2021/22:Include an overview of the unwarranted variation across NEL, how this relates to better care for patients, as well as the implementation plan for the next update to the Committee.

Les Borrett Nov-19The commissioning strategy update will form part of the STP long term plan refresh.

JCC - 24 10/07/2019 4.2

Better Care Fund update to include: • comparative performance across the key BCF indicators and initiatives• sharing of good practice across the patch, such as personal health budgets, continuing healthcare and winter planning.

Les Borrett Jan-20 On the meeting planner.

JCC - 25 10/07/2019 5.1

Performance report: include in future reports: • show numbers alongside percentages• periodically carry out brief deep dives into key areas, such as patients waiting over 52 weeks from referral to treatment, diagnostics and continuing healthcare.

Archna Mathur Sep-19

JCC - 26 10/07/2019 6.1

Risk Register:• Ensure the national pensions issue, and the impact on capacity in primary care and workforceretention, is addressed on the risk register.• Include the progress being made on the BHR recovery plan as a mitigation on the financial risk, S3.

Kash Pandya/ Kate McFadden-

LewisNov-19

NEL JCC action log 11/9/2019

Highlighted items represent a recommendation to remove from register

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Joint Commissioning Committee 11 September 2019

Title of report Mental Health – A Service Model Fit for the 21st Century

Item number 3.1

Author David Maher, Managing Director, City and Hackney CCG

Presented by David Maher

Contact for further information

David Maher

Executive summary This report provides a detailed overview of the key areas of mental health transformation taking place across north east London aligned with Five Year Forward View for Mental Health (FYFVMH) and NHS Long Term Plan (LTP) ambitions.

The NHS Long Term Plan published on 7 January 2019 commits to grow investment in mental health services faster than the overall NHS budget. This creates a new ringfenced local investment fund worth at least £2.3 billion a year by 2023/24. This will support, among other things:

• People with moderate to severe mental illness will accessbetter quality care across primary and community teams.

• Crisis care 24/7 in the community.

• Significantly more children and young people from 0 to25 years old to access timely and appropriate mentalhealth care.

Achievements to date Good progress has been made across the partnership with improved access and quality of mental health (MH) services through FYFVMH delivery areas with notable achievements as follows:

Health Based Places of Safety and NHS 111:Residents across the whole of NEL now have access to24/7 mental health crisis lines that can accept andfacilitate warm transfers from NHS 111. Operationalplans are now in place to replace use of A&E at theRoyal London as a Health Based Place of Safety, withthe expansion of dedicated s136 suites at the Homerton.

• Children & Young People (CYP) services across allareas have increased access with commitment for furtherinvestment and increased capacity across thepartnership in 2019/20

• NEL Perinatal Service now has four established serviceteams working across East London Foundation Trust(ELFT) & North East London Foundation Trust (NELFT)

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• Improving Access to Psychological Therapies (IAPT)Recovery rates: All services across north east Londonhave achieved consistently high (against nationalstandards) and/or significant improvement in the YTD

• Employment Support & Recovery: During 2019/20validated Individual Placement and Support (IPS)services will be available in all areas of north eastLondon resulting in significant increase in the number ofpeople with long term mental health problems beingsupported into paid employment.

Long Term Plan and Local Transformation Areas

Community Model: Newham, City & Hackney and Tower Hamlets have secured significant investment over two years to pilot a new model of community based care and support within primary care networks (PCNs) for people with moderate to severe mental illness.

Crisis: The ambition for MH crisis care in NEL is to provide a truly 24/7 response that is equitable across geographical areas and to all age groups by 2023/34.

Mental Health Centres of Excellence: Options will include developing a single site for inpatient services for adults of working age from City & Hackney and Tower Hamlets at Mile End Hospital, and for older adults from City & Hackney, Newham and Tower Hamlets at East Ham Care Centre.

Action required To note.

Where else has this paper been discussed?

Mental Health Steering Group

Strategic fit

Commissioningimplications

Local authority/integratedcommissioningimplications

It is anticipated that mental health plans finalised (Nov. 19) through the STP LTP process will inform system intentions.

What does this mean for local people?

East London has amongst the highest prevalence of people living with serious mental illness in the country. Whilst there has been significant improvement in health outcomes for people with mental health problems over recent years, and the quality of community and inpatient mental has improved, we know from service users and carers that there are opportunities for further improvement. We also know that the population in east London has grown and changed significantly over the last several years, and that this is set to continue, and that serious mental illness in the population has also grown. We therefore need to make sure

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that our mental health services have the right capacity in the right place to meet current and future demand.

How does this drive change and reduce health inequalities (unwarranted variation)

The organising principles for new models of community mental health care will be piloted in the inner NEL boroughs and the City with learning, best practice to be implemented in BHR and Waltham Forest in line with LTP allocation of funds:

Models will organise care around communities Dissolve barriers between primary and secondary care,

and between health care, social care and VCS services Use complexity, not risk or diagnosis, as the organising

principle for care Use an approach that minimises the likelihood of inflicting

harm or further distress, with care and treatment that is based around the person’s choice and strengths

Step up and step down care to meet a person’s complexity of needs

Deploy these new resources in a manner that aims to reduce and address inequity and inequality of access and outcomes

Aim to develop models of care that are proactive, flexible and responsive to individual needs

Understand and take a partnership approach to addressing the social determinants of serious mental ill health

Make use of community assets and resources, including VCS, online resources and personal contacts.

Impact on finance, performance and quality

Work is currently underway to analyse the baseline and transformation funding allocations indicated through to 20123/24 within the NHSE Mental Health Implementation guidance. The process aligned with the LTP submission process will provide triangulation of local investment with activity, trajectories and workforce growth requirements.

Risks The ELHCP Mental Health Programme operates a dedicated Mental Health Assurance function. This includes two-weekly meetings with representation from all CCGs. The MH Assurance Group identifies risks and monitors mitigating action plans. The main areas of risk identified for oversight are as follows:

1. Workforce – recruitment and retention need to mitigate issues. Failure to recruit in outer London Boroughs leads to a failure to achieve access targets

2. Finance needed to secure investment in workforce to achieve access rates during 2019/20.

3. Timescales: Pace and scale of change requires rapidly developing partnerships requiring uncertainty to be embraced within matrix working arrangements while achieving better outcomes for patients

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Mental Health in North East London: A Service Model Fit for the 21st Century

Introduction

East London has amongst the highest prevalence of people living with serious mental illness in the country. Whilst there has been significant improvement in health outcomes for people with mental health problems over recent years, and the quality of community and inpatient mental has improved, we know from service users and carers that there are opportunities for further improvement.

We also know that the population in east London has grown and changed significantly over the last several years, and that this is set to continue, and that serious mental illness in the population has also grown. We therefore need to make sure that our mental health services have the right capacity in the right place to meet current and future demand. Improving mental health services is a critical foundation of the NHS Long Term Plan.

It is one of the seven key building blocks of a new service model for the 21st Century NHS. Alongside maintaining focus on delivery of the Five Year Forward View for Mental Health priorities. 1

Our headline ambition is to deliver ‘world-class’ mental health care, when and where children, adults and older people need it. The NHS Long Term Plan (LTP) published on 7 January 2019 commits to grow investment in mental health services faster than the overall NHS budget. This creates a new ringfenced local investment fund worth at least £2.3 billion a year by 2023/24. Further, the NHS made a new commitment that funding for children and young people’s mental health services will grow faster than both overall NHS funding and total mental health spending. This will support, among other things:

• People with moderate to severe mental illness will access better quality care acrossprimary and community teams, have greater choice and control over the care theyreceive, and be supported to lead fulfilling lives.

• Significantly more children and young people from 0 to 25 years old to access timely andappropriate mental health care. NHS-funded school and college-based Mental HealthSupport Teams will also be available in at least one fifth of the country by 2023.

• We will expand perinatal mental health care for women who need specialist mentalhealth care during and following pregnancy.

• The NHS will provide a single-point of access and timely, age-appropriate, universalmental health crisis care for everyone, accessible via NHS 111.

1 The Five Year Forward View for Mental Health priorities include: Children and young people’s mental health services; perinatal mental healthservices; improving access to psychological therapies; early intervention services, crisis care, and physical health and employment of people with serious mental illness; suicide prevention.

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The priorities of the Five Year Forward View for Mental Health (FYFVMH) did not address the whole system and left gaps which the NHS Long Term Plan (LTP) addresses. The last two years of the FYFVMH overlap with the first two years of the LTP, maintaining a focus on sustainably delivering the FYFVMH. This is reflected in priorities for mental health in London and areas for place based focus across the NEL partnership.

Achievements to Date Good progress has been made across the partnership with improved access and quality of NHS mental health (MH) services through FYFVMH delivery areas which include the following achievements: Children & Young People (CYP)

• CYP services across all areas have increased access with commitment for further investment and increased capacity across the partnership in 2019/20

• Crisis Support: NELFT Interact / Home Treatment model is the ‘Gold Standard’. Interact provides highly specialist outreach crisis support for CYP. The team will see CYP anywhere i.e. public park, cafe, home, school, etc. The young person will receive support from the same clinician throughout their time with Interact. Plans to start developing in ELFT footprint within STP

• Mental Health Support in Schools: Tower Hamlets Trailblazer with learning to inform further work across the partnership.

• Digital: Kooth is a digital mental health support service. It gives children and young people easy access to an online community of peers and a team of experienced counsellors. Access is free of the typical barriers to support: no waiting lists, no thresholds, no cost and complete anonymity.

• Kooth is available as an open access universal offer to all BHR and Waltham Forest residents. City & Hackney, Newham and TH now plan to implement.

• Reviewed crisis pathways and identified gaps in order to develop equitable service provision across the STP

• Submitted successful bid to NHSE for funding in order to reduce waiting times and waiting lists on the Emotional and behavioural pathways, of which all participating CCG areas achieved the agreed target in reduction on these pathways

NEL Perinatal Service

• Four established service teams working across East London Foundation Trust (ELFT) & North East London Foundation Trust (NELFT)

• Referrals taken from across STP footprint from mental health services, Primary care, Midwives, Obstetricians, Local Authority, Health visiting, and universal services. In addition, women can Self refer in the NELFT catchment

Improved Access to Psychological Therapies (IAPT)

• IAPT services provide evidence based therapies for people with anxiety and depression and are provided across north east London by NELFT, ELFT and Homerton.

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• Recovery rates: All services across north east London have achieved consistently high (against national standards) and/or significant improvement in the YTD.

• Service Expansion: Increased investment in 2019/20 will ensure further expansion of IAPT services to include treatment for more people with physical long term conditions

• Digital: ELHCP have centrally coordinated a block arrangement to make Silvercloud online services available across north east London. This includes over 30 self-help and therapeutic programmes via a library of engaging programmes is accessible via a flexible, user-friendly online platform.

Employment Support & Recovery

• IPS (Individual Placement and Support) supports people with severe mental health difficulties into employment. It involves intensive, individual support, a rapid job search followed by placement in paid employment, and time-unlimited in-work support for both the employee and the employer.

• IPS services are currently being launched in Waltham Forest, City & Hackney, Redbridge having secured national funding. IPS is already available to Tower Hamlets and Newham residents. During 2019/20 validated IPS services will be available in all areas of north east London resulting in significant increase in the number of people with long term mental health problems being supported into paid employment.

• Research showed IPS clients were twice as likely to gain employment (55% v. 28%) and worked for significantly longer and individuals who gained employment had reduced hospitalisation

Severe Mental Illness (SMI) Health Checks

• According to latest data collected by NHSE there are 20,629 patients with SMI in NEL eligible to receive an annual physical health check. To achieve the 60% FYFV target 12,377 patients will need to receive the check in 19/20 and 20/21. For the period March 2018 - April 2019 the aggregate performance across NEL was 42.8% which suggests that we are making significant progress towards meeting the 60% national target.

Long Term Plan and Local Transformation Areas Mental Health services will need to be radically redesigned with partners and communities to deliver the LTP and MH Act Review. The LTP sets a framework for Integrated Care Systems (ICSs) to work with their partners to prioritise Children and Young People’s (CYP) MH, and system wide sustainability by addressing, both the complex needs of those living with severe and enduring mental illness (SMI) in the community, and when they are need crisis and acute care. By prioritising prevention, sustainability and integration the opportunity will be created to expand access to specific safe and high quality Mental Health services.

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Community Mental Health Service Transformation We already have mature Enhanced Primary Care Services (EPCS) for people with SMI in City & Hackney, Tower Hamlets and Newham (inner north east London); which have promoted better outcomes and reduced caseloads in secondary care by 19%. The PCNs in this sub-system are also on a journey to maturity, with substantive work well underway to develop infrastructure. Following a successful bid for wave 1 CMH transformation funding this year, we are excited to be launching our programme of redesign in 2019/20. Waltham Forest, Barking & Dagenham, Havering and Redbridge have already begun developing their approach to Enhanced Primary Care for people with SMI in readiness for the wider transformation piece to come; and we are committed to sharing knowledge and expertise as a partnership to facilitate this process. The vision for community mental health services centres on the following key features:

Dissolved barriers between ‘primary’ and ‘secondary’ mental health services Support dictated by complexity of need rather than diagnosis Population health management approaches; addressing the totality of residents’ needs in

a multi-disciplinary and multi-agency way Services that are embedded within neighbourhoods / communities; enriched by

community assets and peer support Differentiated offers for 18-25s, older adults, and people with personality disorders Moving towards a referral-less approach to assessment and support

Diagram1: Design Principles

Mental Health Centres of Excellence

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The LTP emphasises in particular the need to improve the quality and capacity of community mental health services for people with serious mental illness and the need to improve the therapeutic environment for inpatient services. Across City & Hackney, Newham and Tower Hamlets, health and care partners are working to respond to local and national priorities for developing mental health services. In addition to our existing plans to deliver the Five Year Forward View for Mental Health priorities, we have a significant transformation programme underway to further improve community services, organised around primary care networks, and intend to consider options for the development of inpatient services. Whilst we are at an early stage in considering options for inpatient services, options will include developing a single site for inpatient services for adults of working age from City & Hackney and Tower Hamlets at Mile End Hospital, and for older adults from City & Hackney, Newham and Tower Hamlets at East Ham Care Centre. It is our aim that people who require inpatient services have the very best support and treatment, in the very best of environments. Future proposals will be required to demonstrate how it will deliver:

Improved service user experience and outcomes Improved staff experience Community neighbourhood and crisis services that will support people to remain at

home, through more preventative integrated services, including with primary and social care

An inpatient clinical model that promotes high-quality treatment and support that addresses peoples mental, physical and psychosocial needs, and supports them to return home as quickly as possible

An improved and modern therapeutic environment, in line with the expectations of the NHS Long Term Plan

Operational effectiveness and value.

NEL Community Crisis Care Offer First and foremost, the ambition for MH crisis care in NEL is to provide a truly 24/7 response that is equitable across geographical areas and to all age groups by 2023/34. Our crisis response will seek to de-escalate crisis by responding pro-actively to patient needs sooner, and closer to home, thus enabling treatment in the least restrictive environment possible.

We will build on the successes of our 24/7 MH Crisis Lines, which successfully enable warm transfers from NHS 111, and will increase support to the London Ambulance and Metropolitan Police Services through the development of Street Triage, SIM and ambulance call centre co-location.

While we aim to reduce demand on A&E departments through our CRHTTs and the development of community crisis alternatives, we will also seek to ensure that residents of all ages with both physical and mental health needs who require treatment in an acute setting receive the wraparound support they need from CORE 24 compliant psychiatric liaison services.

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Through remodelling our approach to community mental health services, as well as our crisis offer, we hope to provide early help to residents in such a way that reduces the need for Mental Health Act (MHA) assessments and detentions. However, should our residents enter crisis and require detention under s136, our Health Based Places of Safety will represent fit-for-purpose spaces that promote dignity; staffed by a dedicated and well-trained workforce

Mental Health Citizen Leadership Group

Our first annual East London Mental Health Summit held in May 2019 was centred around a citizens panel which highlighted key areas on improvements required from a citizen and patient perspective. This included a commitment to develop a co-production programme of work covering the NEL partnership and led by ELFT and NELFT in collaboration with the ELHCP Mental Health Steering Group. We now have a structure in place and indicative workplan as illustrated below:

NEL Community Crisis Care

CORE 24 Liaison Services

24/7 High Fidelity CRHTTs

Community alternatives and peer support

Mental Health in Ambulances

& 111

Health Based Places of

Safety (away from A&E)

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Mental Health Programme Delivery Plan The programme will be undergoing further review aligned with the final Long Term Plan submission and mental health priorities for 2020/21 and beyond. The indicative high level deliverables we are working on are as highlighted below: By the end of 2019/20

Improve CYP productivity working with trusts CYP workforce planning and risk mitigation Online therapy increases access rates by at least 2% in each CCG All areas have established Long Term Conditions (LTC) IAPT services Investment and staffing trajectory to reach 30% IAPT access rate signed off between

CCGs and providers NEL suicide prevention strategy signed off and completed by all partners by Oct 2019 All FYFVMH standards achieved across all service areas.

By the end of 2020/21

Scoping and redesign of 0-25 pathways All CCGs in NEL will have 24/7 CRHTTs which meet NHSE high fidelity standards All acute hospitals in NEL will have psychiatric liaison services in place that meet CORE

24 standards We will develop a crisis alternative in Newham, and expand the offer in Tower Hamlets

and City & Hackney We will have staffing for all our Health Based Places of Safety that represents a well-

trained and dedicated workforce (distinct from the teams staffing our MH acute services) IAPT Staff recruitment and retention drive leads to full staff compliment for BHR

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All CCGs to be delivering their 60% health check targets by the end of 2020/21, which will set us up to meet the increasing trajectories up to 2023/24.

IPS employment support; Recruitment & Staffing: Posts to be filled; Team at full compliance

Integrate IPS with other MH services i.e. Recovery College, JCP

By the end of 2023/24

The ELHCP Mental Health Steering Group will work closely with London Ambulance Service colleagues to translate upcoming national implementation guidance into the local NEL system, seeking guidance from local A&E Delivery Boards and Crisis Concordat Partnership Boards on the appropriate model of delivery

We will develop crisis alternatives in Waltham Forest and BHR Our ambition is to support all CCGs within our region to build confidence and capacity

within primary care to enable the integration of community mental health services with PCN MDTs by 2023/24.

Mental Health Programme Governance We will build on the successes of our STP Mental Health Programme to deliver these ambitions, utilising our robust assurance framework to monitor and ensure progress against key milestones. Our current programme structure and accountability framework is illustrated in the diagram below:

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34

Mental Health Long Term Planning

Overview

35

Mental Health in the Long Term Plan Our headline ambition is to deliver ‘world-class’ mental health care, when and where children, adults and older people need it.

The NHS Long Term Plan published on 7 January 2019 commits to grow investment in mental health services faster than the overall NHS budget. This creates a new ringfenced local investment fund worth at least £2.3 billion a year by 2023/24. Further, the NHS made a new commitment that funding for children and young people’s mental health services will grow faster than both overall NHS funding and total mental health spending. This will support, among other things:• Significantly more children and young people from 0 to 25 years old to access timely

and appropriate mental health care. NHS-funded school and college-based Mental HealthSupport Teams will also be available in at least one fifth of the country by 2023.

• People with moderate to severe mental illness will access better quality care acrossprimary and community teams, have greater choice and control over the care theyreceive, and be supported to lead fulfilling lives.

• We will expand perinatal mental health care for women who need specialist mentalhealth care during and following pregnancy.

• The NHS will provide a single-point of access and timely, age-appropriate, universalmental health crisis care for everyone, accessible via NHS 111.

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Key LTP Ambitions at a Glance

345,000 more CYP will access help via NHS funded mental

health services and school or college-based Mental Health

Support Teams

Provide better community mental health support to 370,000

people with SMI via new and integrated models of primary

and community care

24,000 additional women will access specialist perinatal mental health services. The

period of care will be extended from 12 months to 24 months

post-birth

Anyone experiencing mental health crisis will be able to call NHS 111 and have 24/7 access to the mental health support

they need

380,000 more people will access NICE-approved IAPT services

each year

Reduced length of stay in units with a long length of stay

meeting the national average of 32 days

Ensure that the parts of England most affected by rough sleeping

will have better access to specialist homelessness NHS

mental health support

Expand the existing suicide reduction programme to all

STPs in the country

Expand geographical coverage of NHS services for people with

serious gambling problems

37

Our response to the LTP• We have already started engaging with our stakeholders and local people with the East

London Mental Health Summit held in early May with key themes to feed into the STPlong term planning event in June at Stratford Town Hall

• The follow up event on 15 July with people participation leads, peer workers from ELFT and NELFT has shaped 8 key areas of patient focus. This panel will meet quarterly.

• We have undertaken a lead provider review of all investments committed for 2019/20triangulating workforce expansion and OP trajectories

• We have agreed to focus our work on the LTP response at local level, and will need localclinicians to lead as we progress.

• We will need to ensure that there is local ownership of our response, and will agree keycommunications messages accordingly

• We will be expected to have one ICS for NEL, but will need to describe how this will workas the first part of our submission

• Whilst we will be expected to have a level of consistency of approach across our ICS, thePlace (borough/city) will be our key delivery unit

38

• Mixed life outcomes for peoplewith SMI and CMD

• Opportunities exist to developmore coherent approaches toprevention and recovery

• Access and waiting times forservices vary across NEL

• Opportunities exist to improveconsistency of care and reduceemergency readmissions

• Scope to deliver more care inNEL in the community

• NEL population is due to growby 12.9% over the next 5 years

• Our area has the highest levelof MH need in the country

• Demand growth will placesignificant pressure on MHservices

Prevention: Improve population mental health and wellbeing

1

• Population-based approach to mental health,tackling wider determinants, reducing inequalitiesand managing demand

• Step change in delivering self-care andpreventative, personalised approaches withincommunity based models

Mental health priorities

Access: Improveaccess and quality2 • Deliver FYFV for mental health and LTP ambition

• Expansion of CYP, IAPT, Perinatal, Crisis andIPS services

Sustainability: Ensure services have the right capacity to manage increasing demand

3

• Strengthened community capacity withdevelopment of community integrated mentalhealth models building on EPC in inner Boroughs– build capacity in BHR and Waltham Forest todevelop enhanced primary MH care

Integration: Primary and Secondary care step down/step up –physical health/SMI

4

• Improved physical health of people with mentalhealth problems and vice versa

Children & YoungPeople5

• Health and social care integration within LTPplanning cycle

Delivering sustainable mental health services as part of a whole health and social care system, placing mental health and wellbeing at the heart of new neighbourhood based models of care and delivering the Long Term Plan ambitions for mental health

Mental Health Programme 2019/20

LOCAL PRIORITIES CO-PRODUCED CITIZEN

PERSPECTIVES Mental Health Summit May 19

1. FIRST CONTACT2. WAITING TIMES3. STIGMA4. CULTURAL

SENSITIVITY &INEQUALITIES

5. INFORMATION,COMMUNICATION

6. EARLIERINTERVENTION

7. WHOLE FAMILYSUPPORT

8. PEER SUPPORT9. CO-PRODUCTION

24/7 mental health crisis support for all ages andan increase in the provision of alternative forms ofcrisis support in communitiesExpansion, increased investment – trailblazers inschools

Delivery Groups

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Key themes for further development

First Contact

Reduced Waiting Times

Peer Support

Cultural Needs

Reducing Stigma

Whole Family

Support

Info and Comms

Early Access To Help

CO-PRODUCED WHOLE PERSON

CARE Citizens’ Panel: Mental Health Summit9 May 2019, Toynbee Hall

Join the conversation! [email protected]@eastlondonhcp

40

Next Steps • Modelling of MH investment, workforce and activity through to 2023/24• Develop longer term vision, supporting narrative and robust delivery plans for mental

within integrated systems• July - Aug – NHSE ‘Comprehensive Mental Health Implementation Plan’• A comprehensive mental health implementation plan ‘appendix’ – including funding and activity trajectories and workforce

profiles• An analytical tool which apportions the national figures for activity and workforce to each STP/ICS population size. This aims to

support Regional teams and ICS/STPs in translating the national model into a local ambition.• A breakdown of the funding in baselines and available transformation funding• Key Lines Of Enquiry for Regional teams to use to support systems to identifying their level of maturity for mental health

delivery, to inform development plans• Indicative opportunities for VCSE and expert by experience leadership and involvement (incl. peer support)• Principles for the assurance of plans, including local partner sign off expectations• Additional guidance for Advancing Health Equalities in MH and Co-production and Mental health• A MH in ICS Maturity Matrix• For areas where new models are to be piloted, intensive engagement to support development and testing of models on a

local footprint.

STPs should also refer back to existing 5 Year Forward View plans to inform future direction

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Summary of implementation framework for mental health commitments in the NHS Long Term Plan

Fixed Flexible Targeted

Perin

atal

• At least 66,000 women in total accessing specialist perinatal mental health services by 2023/24 • Maternity Outreach clinics in all STPs/ICSs by 2023/24 [following a piloting phase in select sites commencing in 2020/21]

• Extended period of care from 12-24 months in community settings, and increasedavailability of evidence-based psychological therapies by 2023/24

• Evidence-based assessments for partners offered and signposting where required by 2023/24

NA

CYP

• 345,000 additional CYP aged 0-25 accessing NHS funded services [by 2023/24] (in addition to theFYFVMH commitment to have 70,000 additional CYP accessing NHS Services by 2020/21)

• Achievement of 95% CYP Eating Disorder standard in 2020/21 and maintaining its delivery thereafter

• 100% coverage of 24/7 crisis provision for CYP which combine crisis assessment, brief responseand intensive home treatment functions by 2023/24 (see also Mental Health Crisis]

• Comprehensive 0-25 support offer in all STPs/ICS’ by 2023/24 [drawing from a menu ofevidence-based approaches to be made available in 2020]

• Mental Health Support Teams (MHSTs) tobetween a quarter and a fifth of the country by 2023/24

IAPT

• A total of 1.9m adults and older adults accessing treatment by 2023/24• IAPT Long Term Conditions Service in place (maintaining current commitment) year-on-year• Proportionate increase in access for Older People (65+) year-on-year

• NA • NA

SMI

• 390,000 people with SMI receiving physical health checks by 2023/24• 55,000 people with SMI accessing Individual Placement and Support Programme by 2023/24• Delivery of the Early Intervention in Psychosis standard:

• Achieve 60% EIP Access Standard by 2020/21 and maintaining its delivery thereafter• Achieve 95% Level 3 EIP NICE- Concordance by 2023/24

• New and integrated models of primary and community care across approximately 50% ofprimary care networks (in 100% of STPs/ICS’) by 2023/24 [drawing from a menu ofapproaches to be made available in 2020/21, following testing commencing in 2019/20]

• NA

Cris

is

• 100% coverage of 24/7 age-appropriate crisis care via NHS111 by 2023/24; in line with CYPcrisis provision (see also CYP Mental Health)

• 100% coverage of 24/7 adult Crisis Resolution and Home Treatment Teams operating in line withbest practice by 2020/21 and maintaining coverage to 2023/24.

• 70% of Liaison Mental Health Teams achieving ‘Core-24’ standard by 2023/24

• Complementary crisis-care alternatives in place in each STP/ICS by 2023/24 [drawingfrom a menu of approaches to be made available in 2019]

• 100% roll-out of programme for mental health and ambulances including: mental healthtransport vehicles, training for ambulance staff and the introduction mental healthprofessionals in clinical assessment services [national / regional development work willtake place in 2019/20 with more detailed information on implementation becomingavailable in 2020]

• NA

Ther

apeu

tic

Inpa

tient

NA • Improved therapeutic offer to reduce average length of stay in all in adult acute inpatientmental health settings to less than 32 days, by 2023/24

• NA

Suic

ide

and

bere

avem

ent

NA NA • Localised suicide reduction programme rolled-out across all STPs/ICS’ by 2023/24

• Suicide bereavement support services across all STPs/ICS’ by 2023/24

Prob

lem

ga

mbl

ing

NA NA • Establishing a total of 15 new NHS clinics forspecialist problem gambling treatment by 2023/24

Rou

gh

slee

ping NA NA • Funding at least 20 areas to deliver new

mental health provision for rough sleepers by 2023/24

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Joint Commissioning Committee

11 September 2019

Title of report WEL surgical strategy and initial engagement

Item number 3.3

Author Jon Hibbs, Director of Communications and Engagement, Barts Health NHS Trust

Presented by Chris Neill, Executive Director of Commissioning and Performance and Deputy Managing Director, NHS North East London Commissioning Alliance

Contact for further information Jon Hibbs

Executive summary

This reports details the proposed narrative on which Barts Health NHS Trust and commissioners would like to engage staff, the public and key stakeholders over the coming weeks and months. The proposals build on the agreement (through Transforming Services Together and other initiatives) to develop centres of sub-specialist expertise (surgical hubs). The expectation is that this engagement exercise forms part of the process of developing a regional response to the NHS Long Term Plan.

Action required Note.


Barts Health Executive; WEL System Joint Leadership meeting Informal discussions with CCG colleagues and system-wide

colleagues. The draft strategic intent on which this narrative is based has

been discussed widely with Barts Health surgical colleagues and key stakeholders.

WEL Board - July

Strategic fit

Commissioning implications Local authority/integrated

commissioning implications

The proposals develop already agreed strategies (e.g. Transforming Services Together) and commitments made in the original case for Barts Health. The outcomes will inform the regional 10 year Long Term Plan.

The narrative sets the context of the wider WEL Long Term Plan aspirations.

The engagement plan dovetails with the wider WEL Long Term Plan engagement – with commissioners leading on key external stakeholders (supported where necessary by Barts Health) and with Barts Health leading on engaging with staff and specific external stakeholders (supported where necessary by commissioners).


Surgery saves lives, but is also complex and risky. Patients get the best possible treatment if surgeons perform large numbers of operations of the same sort.

The scientific evidence indicates that centralising surgery improves outcomes, reduces variations in clinical standards, and shortens the time patients spend in hospital. Reduction in variation across the Trust to match our lowest performing site with our best in terms of length of stay, clinical incidents and

43


readmission rates would see a greater than 5% improvement in our most variable specialties.

Pre and post-operative consultations would continue at patients’ ‘local’ hospitals, but some patients would have to travel further for their operation. Nevertheless, the distance between hospitals is c5-7 miles; and we expect to reduce the number of short-notice cancellations. These benefits, coupled with shorter lengths of stay may mean that patients and their families actually travel shorter distances to get better treatment than now.

The proposals would support the Trust’s commitment to develop the overall quality of each of its hospitals – strengthening Emergency Departments and maternity units at Newham, Whipps Cross and The Royal London.

Consolidating surgery would also benefit staff, by strengthening rotas that are currently stretched owing to workforce shortages, and improve our research capabilities.


See patient benefits section The proposals reduce existing inequalities by improving the best

surgery available in the Trust, and then enabling all patients to access this surgery.


None for engagement phase.

Risks Risk of not developing improved surgical specialities include:

• Existing inequalities continue

• Trust surgical outcomes does not improve

• Patient volumes are not managed

• Trust efficiencies are not met

• Continued difficulties in recruiting staff

Risk of implementing existing proposal

• Insufficient engagement to ensure all issues have been winnowed out (hence proposed engagement).

Poor implementation – mitigated by proposal to develop high-quality implementation plans once an agreed position is taken.

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Sustaining Safe and Compassionate Care:the next ten years

This is brought to you by:

Barts Health NHS TrustNewham CCG

Tower Hamlets CCGWaltham Forest CCG

45

Sustaining Safe and Compassionate care246

Sustaining Safe and Compassionate care 3

Contents

How can we improve services for our patients? 4

Transforming health and care across north east London 5

Reshaping surgery services within the Barts Health group 7

What this might mean for our hospitals 10

What this might mean for our patients and staff 11

Next steps 11

Pagenumber

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How can we improve services for our patients?

People have a passion for their local health services. It’s a passion we all share. The reality of an NHS that is available to all and free at the point of use is in our national DNA. Everyone who works in the healthcare system wants to protect and enhance NHS services for the benefit of the patients that use them.

Yet the NHS cannot stand still. Demand for healthcare is rising, not only because the population is growing but also because we have higher expectations. Medical and technological advances mean we are all living longer. We also expect to be treated according to the best that modern clinical science can offer, in a timely manner regardless of where we live or the hospital we use.

So across the country, NHS hospitals and health organisations are exploring how they can better work together to improve care, outcomes and patient experience, and make the most of our resources and expertise. This is a long-term project, thinking ahead to how the NHS can grow over the next ten years to offer better services and improve lives.

Within north east London, the bodies representing GPs and hospitals are looking at improving outpatient appointments, urgent and emergency care, and centres of excellence in surgery, neuro-rehabilitation, and mental health. None of this is particularly new: many local proposals for adapting services to cope with an expanding population were set out in the Transforming Services Together programme three years ago. However, with national agreement on the direction of travel in the NHS Long-Term Plan, it is time to start making positive changes that will benefit patients locally.

This document sets out some early thinking for Waltham Forest, Newham, and Tower Hamlets, the core areas served by the Barts Health group of hospitals. We are committed to ensuring that the rationale for any change is explained clearly, that any specific proposals are subject to appropriate public engagement and consultation, and that decision-making is transparent. We want to hear about what you think of these ideas.

From the outset we want to make clear we are not in the business of closing hospitals. Indeed, we are planning to build a brand new hospital to improve on the existing facilities at Whipps Cross. Demand for emergency, urgent, and maternity care is higher in north east London than anywhere else in the country.

So there are no plans for changes to A&E or maternity services at our hospitals. Instead, we are working together to plan ways of improving these and other services. We are embarking on this exciting journey over the next few years determined that the destination will be faster access, higher quality healthcare, better experiences, and ultimately better outcomes, for our patients.

Dr Ken AswaniChair, Waltham Forest

Mr Stephen EdmondsonChair, Surgery Clinical Board

Professor Sir Sam EveringtonChair, Tower Hamlets

Dr Alistair ChesserGroup Chief Medical Officer

Dr Muhammad NaqviChair, Newham

For Clinical Commissioning Groups For Barts Health NHS Trust

Signed:

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Transforming health and care across north east London

More than one million people live in inner north east London, a number which is expected to increase rapidly over the next decade. Many of us live unhealthy lives and experience poor physical and mental health, such as obesity, cancer, heart disease and dementia. Our life expectancy is lower than the London average. We are a culturally rich and diverse population; but overall we are more deprived than the rest of the capital. We also tend to rely too much on emergency services, resulting in late diagnosis of illness and variable access to care outside hospitals.

The NHS and other public bodies that provide health and social care within the boroughs of Newham, Tower Hamlets, Waltham Forest, and also Hackney and the City of London, are working together to tackle these challenges so that services are co-ordinated between GPs, social care, community and hospital services.

Much of this care is delivered in the community at a local level, but some is provided across a wider footprint. Our hospitals provide local acute services across local authority boundaries, together with specialist services for all of them, and some regional and national services as well. So under the umbrella of the East London Health and Care Partnership, organisations are collaborating on a series of cross-cutting programmes to transform health and care services and improve outcomes.

One group of partners is focusing on four specific areas within the NHS Long-Term Plan. Much of this work is about providers, GPs and primary care services coming together to organise services more effectively. We are exploring different models of care for outpatients to improve patient experience and reduce the need for hospital visits. We are reviewing urgent care pathways to make services more co-ordinated, thereby both improving outcomes for patients and reducing unnecessary attendances in emergency departments. We also want to improve the health and care of rough sleepers and homeless people.

Finally, we are exploring how providers can collaborate more closely, and organise clinical services more effectively, to meet the challenges of the future. Together the Barts Health group, Homerton University Hospital NHS Foundation Trust, and both the East London NHS Foundation Trust and the North East London Foundation Trust (which provide mental health and community services), are committed to working with staff, stakeholders, patients, and the public to develop lasting and innovative solutions that will benefit everyone who works, lives in, or visits this part of London.

In particular, the partners are reviewing the opportunities for meeting future demand for surgical, neuro-rehabilitation and mental health services run by the Barts Health group, Homerton University Hospital NHS Trust and the East London NHS Foundation Trust.

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Working together to support excellence in clinical servicesa) SurgeryThere are examples of excellence in surgery across north east London, typically where there are large numbers of patients being treated in one place, such as the heart centre at St Bartholomew’s, or the bariatric centre for obese patients at Homerton. Yet other surgical services are dispersed and have lower volumes, resulting in variable quality and outcomes. This affects their ability to attract staff and undertake research.

Clinicians are reviewing surgical services at Homerton and across the Barts Health group to identify opportunities for working in partnership to improve quality and outcomes. Their endeavours are based on the proven concept of centres of excellence, where different types of surgical activity (including complex work) are undertaken in one place. More details of emerging findings from the Barts Health group follows in the next section.

b) Mental healthDemand for mental health services is also growing, with more referrals for specialist treatment and increasing hospital admissions. The NHS Long-Term Plan suggests the way forward is organising community services around GPs, delivering more preventative support for people at risk of mental health problems, and better co-ordinated care for people with complex mental and physical health needs.

Locally, one element of this “mental health in the neighbourhoods” approach includes an option to develop Mile End hospital as a centre of excellence for inpatient psychiatric services for people living in Tower Hamlets and elsewhere. Concentrating staff and expertise on one site would give patients access to the best care in a therapeutic setting. In turn, this focus of expertise would seek to work with community outpatient services based at the hospital and involve and support peripatetic staff in the community.

c) Neuro-rehabilitationClinicians at Homerton and Barts Health are also reviewing what improvements could be made for patients recovering from traumatic brain injury. This is a major cause of death and disability in people under 40, and tends to be clustered in deprived areas. Appropriate rehabilitation is crucial, and the evidence suggests the best outcomes are achieved through a mixture of specialist rehab within three months of injury and services in the community.

Commissioners are therefore considering ways of ensuring the most critically-ill patients can get rapid access to acute rehabilitation at The Royal London major trauma centre, while also improving access to rehab at Homerton hospital and in the community. These local services would improve outcomes for patients and reduce their long-term care needs.

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Reshaping surgery services within the Barts Health group

We are committed to retaining A&E and maternity services at each of our three main local hospitals, The Royal London, Newham and Whipps Cross. As a group, we are the biggest provider of emergency care in the country, and we deliver more babies than any other trust. Yet we recognise there are opportunities for our four hospitals to work more effectively together and to bring some treatments together into single centres.

The principle of developing centres of excellence to improve quality and reduce waiting times across the health system was endorsed in the Transforming Services Together programme in 2016. Our recent improved CQC ratings and exit from quality special measures means that the time is now right to make further progress with developing outstanding surgical services for our patients.

We believe there are opportunities within the Barts Health group to re-organise surgery in order to greatly improve patient access, outcomes and experience. We also recognise that we need to work with other providers, primary care and patients to ensure that any decisions take into account the views of a range of key stakeholders and contribute positively to a stronger, more joined-up healthcare system.

Why change? Our local population is growing faster than the national average. The growth in the last few years is equivalent to a city the size of Carlisle. Our hospitals now see about 450 more patients a day than seven years ago. We have absorbed the extra demand, developed new models of care, and reduced the length of time people spend in hospital. According to national benchmarks, the Trust is already judged efficient. Yet we will need to manage demand from a projected 17% population increase over the next decade, including addressing any inequity in access to care.

Meanwhile, tremendous advances continue to be made in medical care. The traditional way in which hospitals are organised has often not kept pace with changes in medical practice, or the expectations of patients. Surgery in particular is increasingly specialised. The 350 surgeons working for the Barts Health hospitals are divided into more than 20 different specialties. Outcomes are often excellent, and our death rates are lower than the national average. Waiting times for planned operations have also reduced, though with 85% treated within the national standard there is still room for improvement. However there are also unwarranted variations in standards between hospitals, and the ever-present challenge of recruiting and training enough high-calibre staff. These challenges limit our ability to ensure mortality rates are even lower, and provide excellent experiences and outcomes for every single patient who arrives at one of our hospitals.

Centres of excellenceSurgery saves lives, but is also complex and risky. Patients get the best possible treatment if surgeons perform large numbers of operations of the same sort. The scientific evidence indicates that centralising surgery improves outcomes, reduces variations in clinical standards, and shortens the time patients spend in hospital. For example, experts from the national Getting It Right First Time programme reviewed surgical services across a number of providers, and recommended closer networking and developing higher-volume centres in many specialities.

Clinicians tell us that over the next ten years we should develop a network of specialist centres of surgical excellence that reflect local need and the clinical expertise within each host hospital. It makes sense to organise our world-class surgical services so that more patients benefit from access to the very best care when they most need it.

Model centres of excellence already exist in the Barts Heart Centre at St Bartholomew’s Hospital and the major trauma centre at The Royal London Hospital.

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As a group, we can potentially offer our patients faster access to more centres of excellence than any one hospital, while maintaining local facilities for urgent and emergency care. Consolidating surgery would also benefit staff, by strengthening rotas that are currently stretched owing to workforce shortages, and improve our research capabilities.

Barts Heart CentreEurope’s largest cardiac centre opened in in May 2015, bringing staff and services from three sites to purpose-built facilities at St Bartholomew’s Hospital. Today more heart patients are treated faster, achieving better health outcomes than ever before.

> We treat over 7,500 patients every month. This includes a 50% rise in people receiving new heart valves through a minimally invasive technique (via an artery in the leg), avoiding open heart surgery

> We offer seven-day emergency and specialist cover for patients whose hearts have stopped. Response to heart attacks is quicker, with 9 out of 10 patients receiving treatment to re-open blocked arteries within the national standard. Almost all cardiac patients are now tested within six weeks of referral by a GP.

> The service is more efficient, halving the proportion of procedures cancelled (to 4%) and reducing average length of stay in hospital by 10%. We are on track to meet our ambition to save a thousand lives a year.

The Royal London Hospital major trauma centre (MTC)

This is a specialist centre with an international reputation for caring for some of the most seriously injured patients across London. The first dedicated major trauma unit in the UK, it sits at the heart of the North East London and Essex Trauma Network set up in response to the 7 July 2005 terror attacks.

The MTC has emergency operating theatres available 24/7 and is home to London’s Air Ambulance charity.

> Over the last decade the capital’s mortality rate from major trauma fell 20%> In the last five years, the number of people who bleed to death from injury within 24

hours halved because blood products were immediately available> All 12 people brought to the unit immediately after the 2017 London Bridge terror

attack survived.

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Some other considerations

Any proposals for change in future need to take account of investment decisions already taken. For example, the Royal London Hospital is not only the major trauma centre for the area; it also hosts a specialist children’s hospital, a regional Hyper Acute Stroke Unit, emergency neurosurgery facilities and an outstanding dental hospital.

As well as the cardiac centre at St Bartholomew’s, the hospital hosts specialist thoracic and cancer services. Newham Hospital recently opened a pioneering £7m children’s centre and is investing £5m in improving operating theatres. A revamped £9m maternity unit will open at Whipps Cross Hospital in 2020, even as we work with local partners on developing ambitious plans for a brand new hospital as the centre-piece of an integrated health and care campus for the community.

We are working with colleagues in primary care to prevent illness, to treat people at home (or close to it) wherever possible, and to integrate services so patients move seamlessly and quickly between different parts of the health We need to take advantage of new technologies and working practices that will enable, for instance, fewer visits to hospitals. For instance, a first outpatient appointment could be arranged through Skype and the diagnostic scan and pre-assessment appointment arranged for the same day, this would reduce the number of required visits to hospital and speed up the time taken to surgery. Meanwhile, we are working with other partners in the wider healthcare system. For example, we are discussing the development of a shared neurosurgical service with Barking, Havering and Redbridge NHS Trust. And we are exploring the benefits of a shared NHS pathology service for blood and tissue tests with neighbouring trusts at Homerton, Lewisham, and Greenwich.

Proposals from our cliniciansTaking all these factors into account, our surgeons believe that specialist surgical activity should be concentrated on one site where possible, in order to support the creation of centres of excellence. They identified a dozen key surgical service groupings, and mapped their clinical co-dependencies. This suggests clear, emerging surgical identities for each of the Barts Health hospitals.

> Whipps Cross could become a centre of excellence for surgery relevant to the care of the elderly. This is in line with the Trust’s aspiration that the hospital becomes renowned for the integrated treatment and care of frail and older people within it’s catchment area.

> Newham could host centres of excellence for routine day-case surgery and also specialist women’s surgery, building on its existing skills in obstetrics and orthopaedics. Expanding these services would absorb planned surgery from the Royal London and therefore reduce the risk of routine operations being delayed by complex or emergency surgery.

> In addition to the major trauma centre, The Royal London could become a centre of excellence for all complex, multi-specialty services, including a bespoke centre for the treatment of abdominal and pelvic conditions, and inpatient surgery for children and young people.

> St Bartholomew’s would continue in its role as a world-leading provider of cardiac and thoracic surgery and a specialist cancer centre.

> Alongside these surgery changes, we would continue to develop community-based services at Mile End Hospital to create a diagnostic and walk-in medical hub, providing the majority of outpatient chronic pain procedures and cancer diagnostics.

These emerging hospital identities are not mutually exclusive. Whipps Cross and Newham will continue to serve their local communities, as the first port of call for urgent and emergency care, and for many routine medical interventions.

Just because Whipps Cross hosts a centre of excellence for the elderly would not stop its doctors and nurses caring for - and operating on - children when needed, for example. As Newham develops a specialist identity as a day-case centre, surgeons on day duty would continue to perform general operations to support the emergency department where necessary.

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What this might mean for our hospitals

Our surgeons perform about 95,000 operations a year. The gradual changes we are considering would mean that in ten years’ time a proportion would be undertaken in around a dozen new centres of excellence in our hospitals rather than at their current locations. At each hospital, some existing surgery activity would move elsewhere in the group, while other activity would move in. Yet most would continue as now.

As we develop specific proposals and implementation plans we would work with colleagues in primary care and with patient groups to ensure patient experiences and patient pathways are at the forefront of our designs.

Creating a specialist centre in one place does not mean downgrading services. For example, The Royal London – home to our specialist children’s hospital – could be the designated centre for inpatient surgery on children and young people. But a lot of routine paediatric surgery that doesn’t require an overnight stay would move to Whipps Cross, while some extra paediatric day cases will be performed at Newham.

However surgery is only one aspect of what hospitals do. For example, our surgeons make up about one-third of all consultants. Most of the day-to-day hospital business of providing safe and compassionate care will continue as normal. The adoption of a distinct surgical identity for each hospital would not overshadow the bigger picture of how they serve their local communities.

At Whipps Cross, for example, we are already talking to clinicians, staff, patients and local community representatives about what services a brand-new acute hospital should offer in order to serve the local population, alongside other health, care and wellbeing facilities on a redeveloped site. This is a long-term project ultimately dependent on capital investment from the government, but the work of establishing a health and care strategy will influence how we shape the existing hospital in the short-term.

At Newham, our surgeons suggest that in due course it should become our expert centre for women’s and maternity surgery, but also a leading provider of ambulatory surgery. The range of day-case surgery done at the hospital could include plastic surgery, vascular surgery, hernia repairs and other common conditions. This would expand on services currently available and bring new services to the site, thereby increasing the overall amount of surgery undertaken at Newham.

Doing more at Newham would free up space at our other hospitals, so patients are treated more quickly, and there is less likelihood of cancelling routine surgery. It would also enable Newham residents to have more routine surgery closer to home. And as the hospital consolidates the reputation it already has for orthopaedic day cases, the occasional local emergency requiring overnight general surgery would be taken straight by ambulance to The Royal London major trauma centre for immediate expert attention.

Overall, the changes would reflect the needs of the younger population the hospital serves. They complement Newham’s vision of the hospital as a modern centre of urban healthcare for diverse communities whose members are often deprived and sometimes transient.

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What this might mean for our patients and staff

As we move towards greater specialisation of surgery at our hospitals, some patients will have to travel further for an operation than they do now. Of course, many patients already travel for specialist treatment at St Bartholomew’s or The Royal London. Each of the Barts Health group of hospitals lies within 30 minutes of each other by car, or an hour by public transport. Any inconvenience arising from creating centres of excellence is balanced against the benefits of faster treatment, better outcomes, and an improved patient experience.

However, for those patients who have surgery, the operation is only one part of their journey through the hospital. All outpatient appointments, before and after a procedure, would remain local. A typical clinical pathway involves seven steps, six of which would continue to take place in the local hospital. And for many patients, the seventh will be local too, because the surgical centre of excellence will be in their local hospital.

In addition, we anticipate that over the next ten years changes within the Barts Health group of hospitals will be synchronised with the transformation taking place across outpatients, primary care, and community services. There will be more virtual appointments and one-stop clinics. Referral and diagnosis before surgery, and follow-up afterwards, would remain local, with more care delivered remotely. The net impact across all change would be to move care closer to home.

At all our hospitals, surgical centres of excellence would create the volume and variety of work to attract and retain top-quality clinicians, so addressing staff shortages and enabling the group to provide more consultant-led care to our patients.

Next steps

The vision set out here cannot be delivered just by changing how surgery is organised. We need to strengthen research and academic work - so that patients can benefit from the latest scientific developments. We should also continue to build wider, and stronger, partnerships with other providers and primary and community care providers, bringing our combined knowledge together to develop outstanding care for every patient, whichever hospital or primary care facility they arrive at. We must improve data and digital capabilities, particularly focusing on sharing activity, outcome and cost data between partners.

We are developing our ideas based on research and experience. We are engaging with staff, stakeholders, patients and the public to inform the wider debate on the future shape and scope of NHS healthcare services across north east London. In due course, we would expect to consult as appropriate on any specific plans for service change.

Meanwhile, the collaborating partners will submit proposals for inclusion in the NHS Long-Term Plan for the area, being drawn up by the East London Health and Care Partnership. As we do this, we want feedback from staff, patients, service users, stakeholders and the public on some key questions. We want to hear what you think about these ideas. Please click here to give your views.

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BH99

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Designed and produced by the Barts Health Communications team in conjunction with the WEL joint clinical commissioning group

© Copyright Barts Health NHS TrustMMXIX

Switchboard: 020 3416 5000 www.bartshealth.nhs.uk

This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. For more information, speak to your clinical team.

এই তথ্যগুলো সহজে পড়া যায় অথবা বৃহৎ প্রিন্টের মত বিকল্প ফরম্যাটে পাওয়া যাবে, এবং অনুরোধে অন্য ভাষায়ও পাওয়া যেতে পারে। আরো তথ্যের জন্য আপনার ক্লিনিক্যাল টিমের সাথে কথা বলুন।

Na żądanie te informacje mogą zostać udostępnione w innych formatach, takich jak zapis większą czcionką lub łatwą do czytania, a także w innych językach. Aby uzyskać więcej informacji, porozmawiaj ze swoim zespołem specjalistów.

Macluumaadkaan waxaa loo heli karaa qaab kale, sida ugu akhrinta ugu fudud, ama far waa weyn, waxana laga yabaa in lagu heli luuqaado Kale, haddii la codsado. Wixii macluumaad dheeraad ah, kala hadal kooxda xarunta caafimaadka.

Bu bilgi, kolay okunurluk veya büyük baskılar gibi alternatif biçimlerde sunulabilir, ve talep üzerine Alternatif Dillerde sunulabilir. Daha fazla bilgi için klinik ekibinizle irtibata geçin.

ہک اسیج ،ںیہ یتکس اج یک بایتسد ںیم سٹیمراف لدابتم تامولعم ہی یھب ںیم ںونابز لدابتم رپ تساوخرد روا ٹنرپ اڑب ای ناسآ ںیم ےنھڑپ تاب ےس میٹ لکنیلک ینپا ،ےیل ےک تامولعم دیزم ۔ںیہ یتکس وہ بایتسد۔’ںیرک

Large print and other languagesFor this leaflet in large print, please speak to your clinical team.

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Appendix 1

Sustaining Safe and Compassionate Care: the next ten years - engagement plan

We are seeking to ensure proposals by the Surgery Clinical Board of the Barts Health group are fully aligned with commissioning expectations and have input from other key stakeholders. We will engage widely with staff, patients and the public.

Narrative We aim to agree the text of a public-friendly document (co-branded with WEL clinical commissioners) that will be the core script for engaging staff, stakeholders and public. This will make the case for centres of surgical excellence at Barts Health in the context of local healthcare system transformation plans. The document will highlight the direction of travel and give examples, without being a comprehensive blueprint. It is not a consultation but a local contribution to the work of developing a formal system response to the NHS Long Term Plan. Once agreed, we will use it to develop a range of communications materials to engage different audiences, and make arrangements to capture their feedback. A steering group representing the Trust and its commissioning partners will coordinate a detailed plan of activity, including any public meetings as appropriate.

Key responsibilities Commissioners (supported by Trust staff) engage general external stakeholders (including Save

our NHS, Health Scrutiny Boards and Health and Wellbeing Boards) on the plan as part of their engagement to develop the 10 year Long-Term Plan.

Trust (supported by commissioners where appropriate) engages with internal stakeholders e.g. surgical staff (meetings), patient groups, wider Trust staff (Take 5, Teamtalk), Whipps Cross community engagement and proposed public meeting) and specific audiences e.g. Royal College of Surgeons.

Overarching timeline

August (Engage): Presentations, issue of a narrative leaflet, meetings etc. September (Engage): Continue engagement

18 Sept: INEL/ONEL JOSC 27 Sept: Submission of initial draft Long-Term Plan to NHS England

October (Agree): Consider responses and comments from engagement, including sector-wide joint working. Ensure agreement of any recommendations at the Surgery Partnership Board and Clinical Strategy Project Group etc. November (Submit)

15 Nov: Refreshed and final version of Long-Term Plan to NHS England

Trust-level detailed activities – internal This is the key focus for the Trust. Engaging with staff and aligning our engagement with the Trust’s People Strategy so that we inform and engage. Staff views are essential if we are to ensure the proposals are well supported, the best they can be, and once agreed, are able to be implemented efficiently and effectively.

Upload commissioner and Trust narratives on intranet and Trust/site newsletters and email updates (e.g. Take5 and Teamtalk)

Investigate whether further surgical staff meetings would be beneficial or drop-in sessions for staff in the hospitals

‘Piggy-back’ on existing meetings with leaders, staff and patients e.g. Whipps Cross redevelopment patient groups; surgical and other team meetings.

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Trust-level detailed activities – key partners and external stakeholders Upload commissioner and Trust narratives on the Trust website and incorporate messages into

newsletters and email updates for patient groups and other key stakeholders. In agreement with the INEL CCG team we will work to develop targeted communications where there are opportunities

Healthwatch meeting. 14 August. Surgery leads will engage with Royal College of Surgeons Work in partnership with commissioners to engage Healthwatch organisations, Health and Wellbeing

Boards etc.

Commissioner engagement activities Borough based partnerships. Directors of integrated commissioning, working with the CCGs will engage with:

Hackney Transformation Board Tower Hamlets Together Newham Health and Well Being Partnership Waltham Forest Better Care Together.

Commissioners will (as required) engage with MPs, CVSs, LMCs, Health and Wellbeing Boards, Primary Care Networks, Healthwatch organisations etc.

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11 September 2019

Title of report Child Sexual Assault & Abuse Hub in north east London

Item number 4.1

Author Siobhan Hawthorne, Newham CCG Senior Commissioning Manager Maternity and Child Health

Presented by Chris Neill, Executive Director of Commissioning and Performance and Deputy Managing Director, NELCA

Contact for further information Siobhan Hawthorne, Newham CCG, Senior Commissioning Manager Maternity and Child Health: [email protected].

Executive summary

In January 2018 a paper was presented to JCC by the Healthy London Partnership (HLP) recommending the development of a Child Sexual Assault/Abuse Hub (CSA) for NEL. The paper made the case for two elements of the HUB model.

One was the procurement of an emotional support service (ESS) to work with children and young people (CYP) who had made disclosures of CSA that did not meet the criteria for the Haven sexual abuse referral centres.

The second was to develop a model for CSA clinics for the medical assessment and treatment of CYP staffed by a rota of paediatricians from across NEL who have the required experience to deliver this care.

This purpose of this paper is to provide an update on both those elements.

The contract for the emotional support service was awarded to Barnardo’s to provide the ‘Tiger Light’ model of trauma informed therapy and support. The service was mobilised 1st April and is already meeting targets for delivery across the seven NEL STP boroughs.

Barts Royal London Hospital has implemented a weekly clinic for CSA medicals supported by the Barnardo’s service. However, it has not been possible to develop the second clinical Hub in ONEL, largely due to very limited current and future paediatric capacity and expertise. This paper is requesting approval in principle for moving to a one site model of CSA medicals paid for on a block contract with costs shared across the 7 STP boroughs. This will enable equity of access for CYP across NEL, a clinic that meet quality standards plus workforce development and succession planning to ensure sustainability This proposal is in line with NHS long term plan priorities and will enable NEL to evidence best practice in child sexual assault services and may also support us to bid for new national funding flagged in the LTP. This approach will also support NEL to increase and enhance our focus on CYP at risk of or involved with youth offending, as the links between child criminal exploitation and child

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sexual exploitation are well established. Children known to gangs are at 23% greater risk of sexual exploitation, increasing to 40% for girls. CSA services are therefore well placed to identify, signpost, and refer CYP for gang related support.1

Action required 1. To agree in principle to the development of a one site model for the CSA clinic funded on a block contract basis in line with the contract for the emotional support service (2019/20 to 2021/22) for £60,390 pa

2. To agree that the RLH Hub can accept referrals from the seven CCGs that make up the NEL STP.

3. To note the progress made on developing and implementing the emotional support service.


Previously at the NEL commissioning alliance meeting in January 2018.

Strategic fit

Commissioning implications

Local authority/integrated commissioning implications

This paper has commissioning implications for the seven NEL STP CCGs.


Improved and timely access for CYP to child sexual assault services meeting standards of best practice.

Improved outcomes for children and young people.


Current provision is inequitable across NEL. Agreeing the recommendations will improve both the equity of access to services and the quality of service for CYP and their families across NEL. It will also enable workforce and succession planning, thereby future-proofing CSA services at a NEL system level.


Development of the CSA model of care will in the longer term help reduce pressure on CAMHS services as CYP affected by CSA will have received more timely clinical and emotional support.

Risks If agreement cannot be reached there are risks:

1 That services will revert to the previous model of delivery which was ‘ad hoc’ and carried significant clinical and quality risk with paediatricians working in isolation and seeing small numbers of cases.

2 Workforce development and succession planning will not be addressed, as there will continue to be limited training opportunities with those trained being unable to maintain competencies (20 cases per year).

3 Access to medical assessment for CYP who have experienced CSA will be limited and potentially non-existent in outer NEL boroughs.

1 The characteristics of gang associated children and young people, technical report, February 2019, the Children’s Commissioner for England

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Introduction and background

1. Introduction 1.1 This paper provides an update on progress made in North East London to provide a child sexual abuse

and assault (CSA) Hub modelled on the Lighthouse which was funded as a pilot for 2 years by MOPAC2 funding and the recommendations from the 2015 review by NHSE and MPAC of pathways for young people following sexual assault. 3 It includes recommendations regarding the development of a one site CSA pediatric hub at Royal London Hospital able to take referrals from the seven NEL boroughs.

2. Background and context 2.1 The NEL Commissioning Alliance approved a business case for the development of a child sexual abuse hub in January 2018. This proposed the realignment of CSA paediatric provision across the NEL STP footprint into two medical clinics and funding for an early emotional support service for CYP) being seen for CSA paediatric assessment. 2.2 The development of this model was a recommendation from A Review of the pathway following sexual assault in London 2015 commissioned by MOPAC and NHS England which estimated there are 12,500 children aged 11 to 17 years who experienced contact sexual abuse in the past year. The report concluded that there was poor identification, limited support and high thresholds and waiting lists for CAMHS for those children who have experienced sexual abuse. Costs of child sexual assault are estimated by NSPCC to be in the region of £3.2 billion per year. 2.3 Recent data from the MPS Crime Reporting Information System (CRIS) for 2018/19 shows that in NEL STP there were 721 acute CSA reports (within 8 days or less of the assault) and 705 historical cases (over 8 days) with the majority of victim being girls aged over 13. 2.4 The paediatric provision in NEL represented a significant clinical and quality risk with paediatricians working in isolation and seeing small numbers of cases, a lack of adequate facilities and equipment, and no succession or workforce planning. 1.5 The business case4 provided the evidence base and assurance that the proposed model of

emotional support offered alongside paediatric medical care reduces the need for specialist support later. In short, the summary of evidence in that paper included the following:

CSA is strongly linked to negative psychological outcomes There is an emerging evidence base for effective interventions which reduces symptoms Interventions within 4-6 weeks of a trauma or disclosure has been shown to decrease development

of long term post traumatic disorders. Recent policy studies and NICE guidance call for such interventions for emotional support In international studies, there are high lifetime costs associated with CSA Early intervention could reduce the need for long-term CAMHS support The costs of CAMHS care exceed the cost of early emotional support The costs attributable to even a small number of serious cases associated with later suicide far

outstrip the costs of an emotional pathway service.

2.6 The principles of the CSA Hub paediatric provision were: Dual examination with opportunities for training and peer review Weekly clinic across the sector to ensure timely access to paediatric assessment for CYP and

families Provision from an inner and outer London site to support accessibility across a large geographical

area with access for CYP regardless of borough.

2 The London Mayor’s office for policing and crime 3 https://www.england.nhs.uk/london/wp‐content/uploads/sites/8/2015/03/review‐pathway‐cyp‐londonreprot.pdf 4 CSA |HUB in NE London: summary business case, Healthy London Partnership: January 2018

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Provision of an emotional support service, provided across the 7 boroughs. This was to be procured through competitive tender. The service would see CYP and, where appropriate, their families at the clinic for an initial assessment and offer of emotional support and advocacy in a community setting. Funding for the service was agreed at £299,342 for a three-year contract period across the seven CCGs.

Progress on developing the model

3. Emotional support service 3.1 Barnardo’s won the tender for the emotional support service with their evidenced based ‘Tiger Light’ model. The service was mobilized on the 1st April 2019 and immediately began taking referrals. 3.2 The service provides 6-8 sessions of support including trauma-informed early help, advocacy and case management, and symptom management, with safe and appropriate onward referral when necessary. The support is provided directly to the child/young person and/or their safe parent/carer as appropriate with referrals coming from local MASH5 teams. Social workers can refer directly to Barnardo’s if the young person or their family does not want a medical assessment or refer via the CSA medical Hub. Where possible CYP will be seen for a first ESS appointment at the same time as the medical assessment. 3.3 Evidentially the emotional support service aims to provide early help, reduce the development of long-term mental health conditions such as PTSD, and thereby minimise the need for long-term support from CAMHS. 3.4 The service is fully staffed with 1.7 wte practitioners and a part time team manager. Monitoring data is submitted monthly with a breakdown of referrals by CCG. Between April and end of July the service has received 28 referrals from across the 7 boroughs and is already meeting their monthly targets. It is too early to identify any trends or outcomes from the service. However, the service collects outcome data for all service users and also undertakes a service user outcome evaluation. 4. Paediatric Hubs 4.1 The original business case had proposed the establishment of 2 paediatric hubs -one for outer north east London probably based at Wood Street, Waltham Forest and one at Royal London Hospital. The preferred model being 3 weeks of 4-week cycle based at Barts Health site (Royal London Hospital) and the 4th at Wood Street. Within this model it was envisaged that the seven boroughs would contribute paediatric time to creating a sector-wide paediatric rota, staffing a weekly CSA Hub clinic, 48 weeks of the year. CYP would have open access at either clinic. 4.2 Operating a model in this way would meet standards of best practice for two paediatricians to be present and improved referral and access to the emotional support service at the time of the medical appointment. It would also enable training and support to paediatricians not currently able to provide this care and provide enough cases a year for them to maintain their competencies. Payment for the two clinics would be either through an amended PBR which had not been fully agreed at the time for RLH or within the existing block contract if seen at the NELFT clinic. 4.3 Subsequent work to implement the above model identified a number of issues that required a reassessment of the two site model. The most significant being is the number of trained pediatricians in NEL with capacity to support a two site model clinic- a problem that is London wide. 4.4 The rota developed to support a two site model required NELFT to provide 192 hours of pediatric time a year which equates to 18 hours per month. Further discussion with NELFT pediatricians currently providing CSA examinations and the Director of Integrated Care for NELFT identified that currently NELFT have a very small number of paediatricians qualified to undertake CSA medicals who do not have the capacity to support the Hubs as required.

5 Multi‐agency safeguarding hubs – essentially the front door for all children’s safeguarding enquiries.

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4.5 Additionally paediatricians from both Barts and NELFT have raised logistical issues with a service offered across two sites operated by different organisations using different ICT systems, plus a concern about ‘chain of evidence’ arrangements which are not available in a community setting and which therefore could impact on the outcome of any criminal proceedings. Currently NELFT paediatricians offering appointments on an ad hoc basis take any evidence to the laboratories themselves. Both these issues would need to be addressed before moving to a two site model. 4.6 NELFT have committed to provide CSA medicals on an ad hoc basis while the model is finalised, so there is some level of service in ONEL, however this will not continue indefinitely and they intend to serve notice at some near point in the future.

5. Royal London Hospital hub 5.1 Progress has been made on the establishment of the weekly clinic at RLH led by the consultant paediatrician with support from Bart’s paediatricians and a paediatrician from the Homerton. The clinic also has the potential to offer training places, which will in time, increase the number of paediatricians trained and able to meet the necessary competencies of 20 contacts a year across the sector. 5.2 Referrals into the Hub have been agreed for Newham, Tower Hamlets and Hackney and come via the MASH services in those boroughs. The Barnardo’s practitioners support the clinic so CYP and their families receive a holistic service. 5.3 Activity data from the RLH Hub shows that in the 4 months from the clinic starting on April 1st there have been 32 referrals into the service with 28 CYP seen by a clinician by end of July. The main referring boroughs are Hackney and Tower Hamlets however there have also been referrals from Newham and Waltham Forest. 5.4 It is worth noting that we are currently the only STP outside of NCL, which has separate MOPAC funding, to have established a weekly clinic alongside emotional support so are leading the way in this regard. Some of the other London Boroughs have commissioned emotional support services but have been unable to secure agreement from NHS Trusts to provide a regular clinic. This will place NEL in a good position to apply for any additional funding from MOPAC at the end of the pilot in NCL. The NHS long term plan has also indicated that there will be provision in selected areas.

6 Finance

6.1 Activity in the RLH Hub is currently paid on the standard outpatient tariff, however there has been a recognition from the outset of this work that this is not a true reflection of the cost of providing a clinic of this complexity- a first appointment for CSA can take over an hour and requires more than one Paediatrician in attendance, best practice also requires a play specialist to work with younger children. 6.2 Across London there is no agreement on what would constitute an appropriate tariff and no guidance as yet from NHSE. 6.3 In order to come to a position on what would be an appropriate tariff commissioners requested that Barts provide a financial assessment of the cost of providing the clinic plus we reviewed the (limited) tariff information available from the Havens and UCLH which had been providing City and Hackneys CSA service – the UCLH tariff dates from 2009/10 so will have increased significantly. 6.4 Barts have requested a block contract rather than PBR to pay for the clinic on the basis of sharing risk and ensuring longer term sustainability. Clinical supervision and peer review/emotional support for paediatricians has also been included to improve retention of clinicians willing to work in this field and dedicated time from a play specialist for younger patients. With the limited information available regarding costs of similar clinic the Barts proposal compares favourable.

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UCLH 2009/10 tariff Haven -2018/19 Barts 19/20 proposed cost per

clinic paid on a block £708 -1st medical appointment £1,443 –1st medical appt ,

advocacy and follow up appt £915 for 1st appointment and follow up6 Based on 66 new referrals and block cost of £60,390 p.a.

The standard outpatient tariff for 2019/20 is s £232 per appointment which is one paediatrician plus MDT and an appointment of approximately 30 minutes. For a CSA appointment we would expect to pay the equivalent of 2-4 appointments as a first medical is at least one hour with 2 paediatricians plus a follow up MDT appointment at £152. This totals £618 to £1,080. The outpatient tariff costs also do not include provision for psychological/peer support for paediatricians or a dedicated play specialist which is best practice for younger patients. Provision also needs to be made for potential court reports and appearances which are estimated as required for about 18% of cases.7 Below is a summary of the business case and costings submitted by Barts 6.5 Proposal:

Weekly clinic on a 4-week cycle based at Barts Health site (48 weeks) (Royal London Hospital Paediatricians across sector staff a joint rota; ownership of clinic rota is held by Barts Health for

the clinics at their site Clinical accountability and governance held by provider of clinic that the CYP attends

regardless of borough Clinic supported on site by Emotional Support service provided by Barnardo’s Dedicated Hospital play specialist and administrative support in place along with capacity for

court responsibilities.

6.6 Capacity A weekly clinic would allow for 2 new patients or 1 new and 2 follow up patients to be seen. Historically the proportion of children requiring follow up is approximately 50% and this is reflected in the proposed capacity, with follow up slots being available monthly rather than weekly. However the management of these slots will be fluid to meet the needs of the child or young person. The clinic would be staffed by a rota of paediatricians who would prospectively cover annual / study to ensure the clinic can be delivered 48 weeks a year. 6.7 Staffing Each weekly clinic will require the following staffing to meet the clinical and quality standards required. The emotional support service is in addition to this.

Per clinic

Consultant Paediatrician 1.5PA

Consultant Paediatrician 1 PA

Hospital Play Specialist 0.1WTE In addition to the clinic provision, it is imperative that clinical supervision and peer review is built into the service. Monthly provision for the team will ensure an opportunity to discuss cases and ensure a level of emotional support. The provision for this is detailed below. 6 7 NHSE: CSA Hub Toolkit v 2.0: Health in Justice programme: 28 March 2017.

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Per year Consultant Paediatrician (assuming 6 on rota) 144 hours Hospital Play Specialist 24 hours Psychologist 24 hours

Overall provision for the service is outlined below.

Per Year Rate Total Consultant Paediatrician 624 hours 84 £52,416Hospital Play Specialist 216 hours 28 £6048Psychologist 24 hours 49 £1176Equipment-colposcopy maintenance. £750 Total £60,390

If costs are allocated evenly across the seven CCGs this equates to £8,630 per year. Costs and allocations per CCG would be reviewed at 6 and 12 months to ensure fairness of funding arrangements. There is agreement with Barts that paediatric time provided by another NHS Trust, as currently provided by the Homerton, would be reimbursed annually to that CCG. NELFT Paediatricians have expressed an interest in training if this was agreed they could then contribute to the rota with reimbursement to the appropriate CCG.

7. Conclusion and recommendation 7.1 NEL has made good progress on implementing the recommendations of the 2015 CSA review. The emotional support service is fully mobilised across the STP and supports the clinic at RLH plus there is a weekly clinic that meets standards of best practice and supports succession and workforce planning. NEL is the only STP area that has managed to achieve this, aside from NCL. This will place us in good stead should there be an opportunity to apply for additional funding through MOPAC once the Lighthouse pilot comes to an end. The NHS Long term Plan has indicated the development of service to address children with who have experienced sexual assault but are not reaching the attention of Sexual Assault Assessment Centre’s (Havens)8 i.e. more historic cases of sexual assault or abuse that is outside the forensic window. 7.2 However the current situation with CSA provision is inequitable across the STP with CYP from three CCGs being referred to a clinic that meets best practice standards for CSA both in terms of medical provision and access to play specialists. CYP from the other boroughs can only access an ‘ad hoc’ clinic that sees a very small number of CYP every year. Providing an ‘ad hoc’ clinic does not meet the required standards for a CSA service in terms of access to emotional support alongside the clinic, play specialists and peer support and review nor does it enable the ongoing training and development of paediatricians to undertake this work. There is the additional risk that NELFT will cease providing this in the near future as key paediatrician is close to retirement. 7.4 Allowing referrals from the 7 STP CCGs into RLH Hub will help address this inequity plus it will also support workforce and succession planning. This may, in the longer term, enable the development of an ONEL clinic as long as ICT and ‘chain of evidence’ arrangements can be addressed. 7.5 Travel from some parts of ONEL into RLH may be more difficult for some CYP however this is something we could monitor over time and potentially identify strategies to address. As the young person’s social worker is also expected to attend the medical appointment, CYP will have support to travel. As a point of comparison children under 13 for acute “forensic” CSA are seen at the Haven in Camberwell and those over 13 are seen at Whitechapel. 7.6 The service will need to be monitored closely as capacity and therefore wait times may become an issue however increased paediatric training will help resolve this. Commissioners have agreed quarterly 8 https://www.longtermplan.nhs.uk/wp‐content/uploads/2019/01/nhs‐long‐term‐plan‐june‐2019.pdf accessed 06/08/2019

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activity monitoring from Barts for the clinic and will developed associated contractual documentation such as a service specification and KPIs. 7.7 Should a decision be made not to support this model; it is likely that Barts will also return to an ad hoc model. As discussed above, this means service’s will not:

Meet standards of good clinical practice Enable a holistic offer of emotional support offered alongside medical assessment Support workforce development and succession planning Ensure equity of offer to CYP across the STP.

Recommendations:

4. To agree in principle to the development of a one site model for the CSA clinic funded on a block contract basis in line with the contract for the emotional support service (2019/20 to 2021/22) for £60,390 pa

5. To agree that the RLH Hub can accept referrals from the 7 CCGs that make up the NEL STP 6. To note the progress made on developing and implementing the emotional support service.

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11 September 2019

Title of report North east London Evidence Based Interventions policy

Item number 4.2

Author Alison Glynn, Deputy Director, Transformation Delivery

Matt Henry, Senior Transformation Delivery Manager

Presented by Les Borrett, Director of Strategic Commissioning

Contact for further information Les Borrett, [email protected]

Executive summary

The following paper provides a summary of the outcomes of the engagement exercise undertaken on Aligning Commissioning Policies in north East London and the resulting recommendations made by the project’s Clinical Reference Group. The paper includes a ‘You said, We did’ section which will be cascaded to stakeholders and participants in the engagement. Embedded in the document is the new policy which has been named the North East London Evidence Based Interventions Policy.

Next steps

The proposed policy is being taken through CCG Governing Bodies for sign off. It is planned that the policy and associated business case will be taken to the BHR Board on 25 September, WEL Board on 26 September, and the City & Hackney Board on 27 September 2019.

Once the policy has been signed off, as per the national contract, one month’s notice will be issued to all Providers, along with implementation guidance, on 1 October 2019 for implementation from 1 November. Systems will be set up to monitor the policy. Wherever possible, this will be automated to reduce workload for clinicians. Coding of local policies to be reviewed by clinical coder and code to be shared with Providers. Guidance for patients, GPs and clinicians will be issued along with the policy ready for implementation on 1 November 2019.

Action required Note the engagement outcomes and resulting recommendations and make any final comments on the policy embedded in the document.


N/A

Strategic fit



This aligns with the NELCA Commissioning Strategy in that it would introduce a common policy across the whole of north east London and ensure policies adopted across north east London are evidence based and in line with the latest clinical guidance and the National Evidence Based Interventions and the London Choosing Wisely Programmes

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Ensures they will have access to the same access to treatments across the seven north east London boroughs and brings our local policy in line with London and National work to ensure that our people have access to the same treatments as those in London and England

Ensures the treatment they receive is evidence based Ensures that they are being treated in line with latest clinical

guidance.


Drives change as it ensures treatment is being provided in line with latest clinical guidance, this allows treatment that wasn’t previously available to now be available or brings the standard of practice up which will drive change.

Reduces inequalities and unwarranted variation as it ensures our patients all now have access to the same treatments.


Financial Impact

Whilst money is a factor, it isn’t the main reason for doing this. It’s about making sure we are making the most effective use of public money to commission the most appropriate healthcare services for local people.

Performance Impact

This would have a nominal effect on RTT i.e. Surgical capacity created.

Quality Impact

Ensures policy is up to date with the latest clinical guidance.

Risks

1. It will take time for clinicians to understand the new policy, inherent risk that GP’s or consultants may seek prior approval or IFR for procedures under old policy or not be aware of new policy and treat without complying with process. Will be mitigated by CCGs, IFR and prior approvals team raising awareness of the new new policy through communications and training with primary and secondary care prior to implementation . Sessions with clinicians will be set up as part of the implementation to ensure they are aware of the changes. Audit will also help for those treatments that are undertaken outside of policy criteria.

2. For one policy to be adopted across seven CCGs, the BHR, WEL and City & Hackney CCG boards need to sign off the policy. There is a risk that one or more boards may not sign off. This risk has been mitigated by ensuring that the Clinical Reference Group who developed this policy had representation from each of the local systems.

3. Risk that if only one policy can be in place, if local systems wish to update their policy going forward, all three systems will need to be on board and in agreement with any proposed changes.

4. Risk that savings will not be realised where north east London CCGs are an associate. For financial values attributed to associates, within the NHS standard contract there is a specific service condition (29.21) which states the following with regard to prior approval

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schemes: the Commissioners must have regard to the burden which Prior Approval Schemes may place on the Provider. ‘The Commissioners must use reasonable endeavours to minimise the number of separate Commissioner-specific Prior Approval Schemes in relation to any individual condition or treatment.’ If providers have a host commissioner with a different list of IFR or prior approval policies they will likely apply their host commissioner policy even for north east London patients. The effect of which is not quantifiable. However most of the providers in London will have the majority of procedures from both national and London Choosing Wisely policies in their contract, other policies are also similar. So the effect is likely not material on the numbers stated, but true value is not quantifiable.

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North East London Evidence Based Interventions Policy Engagement Outcome

1.0 Introduction

The following paper provides a summary of the outcomes of the engagement exercise undertaken on Aligning Commissioning Policies in north East London and the resulting recommendations made by the project’s Clinical Reference Group. The paper includes a ‘You said, We did’ section which will be cascaded to stakeholders and participants in the engagement. Embedded in the document is the new policy which has been named the North East London Evidence Based Interventions Policy.

Members are asked note the engagement outcomes and resulting recommendations and

Members are asked to make any final comments on the policy embedded in the document.

2.0 Background and Context

In May 2019, we asked local people to tell us what they thought about plans to change our commissioning policies in Barking and Dagenham, City and Hackney, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest. These list specific treatments, procedures and interventions the NHS funds, and who is eligible to have them.

During six weeks of engagement process we spoke to around 600 individuals by hosting or attending around 30 events and received around 230 responses from individuals and organisations including:

Patient Engagement Forums Older Peoples Reference Group meetings Age UK meetings Local Medical Councils GP Protected Learning Time Events Council for voluntary services Patient Participation Groups Patient Workshops Patient Events Health scrutiny committees

Information was published on Clinical Commissioning Group (CCG) websites which included an easy read format, a patient friendly version of the engagement document, a clinical version of the engagement document, an equality impact assessment and a quality impact assessment along with a questionnaire to collect responses.

CCG communications teams distributed communications to local GPs, CCG staff, MPs, Health Watch, patient reference groups, hospitals, councils and the north east London Citizen’s Panel., tweets regarding

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the programme were sent from CCG corporate accounts. Information on the proposals was also included in staff newsletters, practice bulletins and GP practice portals and sent to local optical committees.

Chief Medical Officers from Barts, BHRuT, Homerton, ELFT, NELFT, Moorfields were contacted and asked to disseminate information via their networks to ensure feedback from consultants on the proposals could be captured.

Feedback given at events, via email and in questionnaires have been analysed and this feedback was presented to the Clinical Reference Group who discussed potential changes to the overall policy and to specific treatments.

We are grateful to all those who have contributed and helped us refine and strengthen our proposals. We have benefitted from a rich array of suggestions and insights which have helped shape the proposed north east London Evidence Based Interventions policy (embedded in Appendix A – page 4).

3.0 You said, we did

The following is a summary of recurring themes that were received either in questionnaires or at events and the actions the Alliance is taking as a result. This summary will be published on CCG websites and distributed to clinicians, patients and the public who took part in the engagement exercise.

1. Concerns about the criteria for hip and knee replacements and whether it unfairly targeted older people and could undermine clinical judgement

We have conducted an audit which showed that clinicians were following the proposed pathway and there would be no real impact on clinical practice from making this change, so GPs agreed to remove hip and knee replacements from the policy.

2. Suggestions were made for patients to be involved throughout the process in the future.

We are keen to learn from this engagement which is the first we’ve done as North East London Commissioning Alliance and we will look at how we can involve patients more in the design and implementation of services.

3. "The proposed policy does not state any exclusions for mental health patients"

Mental health is often a factor in patients seeking treatment or surgery. There are no universally accepted and objective measures of psychological distress, so it is difficult to include such factors when setting clinical thresholds for agreeing when a particular treatment is effective or needed.

We believe it is generally better to provide support, such as therapy, to treat the mental health need, but if a clinician thought there were exceptional mental health reasons why a patient needed treatment, they could apply through the individual funding request process explaining why this is an exceptional case.

Our GPs considered the feedback received and felt it was important the policy was altered to make clear that if mental health affects people’s ability to function then it should be considered for funding, provided there is evidence of the patient having received psychological treatment prior to the procedure. The policy has now been updated to reflect this.

4. Cancer - "It is unclear whether all (or just selective policies) are not applicable to patients who have or have survived cancer.”

We have always been clear that this does not apply to patients with confirmed or suspected cancer. GPs have updated the policy to include a statement to clarify that that cancer patients will be excluded where the treatment sought is in relation to their cancer care.

5. "The documentation is too clinical and not clear"

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The nature of a document like this is that it is clinical, as it was developed in line with the latest national clinical guidance. Recognising this, we produced an easy read version but will consider how we might involve patients in ensuring documents are easy to understand in future work.

6. "NICE guidance says you can't use visual acuity to determine whether cataract removal should be carried out"

We have sought advice from clinicians at our local hospitals including Moorfields, a specialist eye hospital, and they all support the policy. This means that all patients in London will get the same access to cataract surgery.

7. "The questionnaire needs to be improved, hard for people to reference back to main document constantly to answer"

The complexity of what we were proposing meant that the questionnaire was complicated and we will test future questionnaires with local people before they are finalised.

8. If patient are unable to access these treatment, what are the alternatives? We will make sure all clinicians know how to apply the policy asking them to consider the overall health and wellbeing of the patient and to ensure that, where appropriate, referrals are made to talking therapies and support services available through social prescribing link workers.

9. Clinicians fed back that they were concerned that this might add an additional administrative burden to their already busy workloads

Further to this feedback, work has commenced to simplify and automate the process using special software to reduce the administrative burden for clinicians.

4.0 Procedure level decisions following public engagement

The Clinical Reference Group was established in September 2018. It is made up of GPs and commissioners from each of the CCGs in north east London and was tasked with developing the single policy across north east London. As part of the development of the draft policy and the engagement process, advice was sought from clinicians in Barts Health, Barking Havering and Redbridge University Trust, Homerton University Hospital Trust, Moorfields Eye Hospital and independent sector providers across north east London. In the main, clinicians were supportive of the individual policy changes. We received some requests for clarification and challenge on some of the clinical criteria.

These comments were combined with the feedback from patients and the public and presented to the project’s Clinical Reference Group on 9 August 2019. This group considered the feedback alongside guidance from NHS England and the London Choosing Wisely Programme and used it to amend and clarify elements of the policy.

Appendix B sets out a summary of the procedure level decisions made at the Clinical Reference Group which will form the basis of the recommendations we will be making to CCG Governing Bodies.

5.0 Next Steps

The draft policy will now be taken through CCG Governing bodies in September for sign off and to East London Health Care Partnership Joint Commissioning Committee and Clinical Senate.

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If the policy is agreed, notice will be issued to hospital trusts and independent sector providers along with guidance on 1 October 2019.

Systems will be set up to monitor the policy. Wherever possible, this will be automated to reduce workload for clinicians.

Coding of local policies to be reviewed by clinical coder and code to be shared with Providers.

Guidance for patients, GPs and clinicians will be issued along with the policy ready for implementation on 1 November 2019.

A review of the policy will be undertaken 12 months from the date of implementation.

APPENDIX A

Final Policy

NEL EBI 2019-2020_CRG_DRA

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APPENDIX B

Procedure Decision made

The following Injections for non-specific low back pain :

Facet joint injections Adopt NHS England policy to ensure consistency of approach for patients and clinicians.

Therapeutic medial branch blocks Adopt NHS England policy but provide clarity that diagnostic medial branch blocks continue to be funded as per NICE guidance

Intradiscal therapy Adopt NHS England policy to ensure consistency of approach for patients and clinicians.

Prolotherapy Adopt NHS England policy to ensure consistency of approach for patients and clinicians.

Trigger point injections with any agent, including botulinum toxin

Adopt NHS England policy to ensure consistency of approach for patients and clinicians.

Epidural steroid injections for chronic low back pain or for neurogenic claudication in patients with central spinal canal stenosis

Adopt NHS England policy to ensure that consistency of approach for patients and clinicians.

Any other spinal injections not specifically covered above


Surgical interventions for snoring in the absence of obstructive sleep apnoea


Chalazia removal Adopt NHS England policy to ensure consistency of approach for patients and clinicians.

Haemorrhoidectomy Adopt NHS England policy to ensure consistency of approach for patients and clinicians.

Shoulder Decompression Adopt NHS England policy but with a review in March 2020 if anticipated guidance has an impact.

Interventional treatments for back pain : Epidurals, Spinal Decompression, Discectomy, Epidurolysis, spinal fusion surgery

Adopt London policy to ensure consistency of approach for patients and clinicians.

Lumbar disc replacement surgery Adopt London policy to ensure consistency of approach for patients and clinicians.

Acupuncture Clarify that acupuncture is not routinely funded as an isolated intervention

Ozone discectomy Adopt London policy to ensure consistency of approach for patients and clinicians.

Cataract Surgery Adopt London policy to ensure that consistency of approach for patients and clinicians.

Hip arthroplasty Remove from policy following feedback and audit results showing compliance with good practice

Knee arthroplasty Remove from policy following feedback and audit results showing compliance with good practice

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Laser surgery for short sightedness Adopt proposed local policy following support from local clinicians

Functional electrical stimulation (FES) for foot drop

Adopt proposed local policy

Abdominal wall hernia management and repair Adopt proposed local policy

Bariatric Surgery Adopt proposed policy in line with NICE guidance

Pinnaplasty/Otoplasty Adopt proposed policy following feedback from local clinicians

Rhinoplasty/Septoplasty/Rhinoseptoplasty Adopt proposed policy following feedback from local clinicians

Dupuytren’s contracture release Adopt NHS England policy to ensure that consistency of approach for patients and clinicians.

Female breast reduction Adopt NHS England policy to ensure consistency of approach for patients and clinicians

Grommets for glue ear in children Adopt NHS England policy to ensure consistency of approach for patients and clinicians

Trigger Finger Adopt NHS England policy to ensure consistency of approach for patients and clinicians

Dilation & Curettage (D&C) for heavy menstrual bleeding in women

Adopt NHS England policy to ensure consistency of approach for patients and clinicians

Surgical treatment of carpal tunnel syndrome Adopt NHS England policy to ensure consistency of approach for patients and clinicians

Repair of split ear lobes Adopt NHS England policy to ensure consistency of approach for patients and clinicians

Herbal medicines Adopt NHS England policy to ensure consistency of approach for patients and clinicians

Treatment for scarring and skin hyper- or hypo- pigmentation

Adopt proposed local policy

Sympathectomy for severe hyperhidrosis Adopt proposed local policy

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APPENDIX C

The following is an analysis of the questionnaires that were received either electronically or on paper. These graphs demonstrate the reach that the engagement exercise achieved and the level of support for the proposed changes.

1. Overall response to proposed NEL EBI Policy

2. Response based on Gender

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3. Response based on Ethnicity

4. Response based on Age

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DRAFT_V16

North East London

Evidence Based Interventions Policy Procedures not routinely funded (Individual Funding Requests (IFR)) or requiring prior approval

Barking & Dagenham, City & Hackney, Havering, Newham, Redbridge, Tower Hamlets, Waltham Forest Clinical Commissioning Groups (North East London (NEL) CCGs)

Version: 1.0

Date of publication: Mar‐19

Document details

Document reference NEL Evidence Based Interventions Policy version 1.0

Document category Clinical Policy

Date of publication Mar‐19

Approved By

VERSION 16

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Background The NEL Evidence Based Interventions Policy (NEL EBI) is a list of treatments/interventions that are only

funded by the NHS when a patient meets certain clinical threshold criteria. This policy applies to adult

patients aged 18 and over only, unless specified otherwise in the body of text within each policy.

Policy development is an on‐going process resulting from the publication of new evidence regarding

clinical effectiveness. Policy reviews will be undertaken in response to NICE Guidance/Guidelines, health

technology assessments etc.

NEL EBI Policy is a clinically led and evidence based programme. In developing the NEL EBI, we have

taken into account clinical advice from local clinicians, national clinical evidence and guidelines i.e. NICE.

A network of clinicians from all seven North East London CCGs have been involved in the development

of this policy and in reviewing and updating specific sections.

We know that some procedures are currently carried out on patients, where the evidence for

intervention is not strong and more conservative approaches to the management of conditions would

be more appropriate and present less risks than surgical intervention. We need to ensure that in making

decisions on how we fund treatments, that our patients realise the best clinical and quality outcomes.

Having a policy to govern these procedures that is adhered to will ensure that patients do not undergo

unnecessary surgical interventions or procedures where clinical evidence is not strong or where in some

cases carries significantly greater risk and cost, than alternative treatment options. Adherence to an

effective policy will also ensure that surgical capacity is available for those patients that really need a

procedure to be carried out that is supported by clinical evidence.

We need to continue to prioritise those services that deliver the greatest health gain for local people. By

ceasing to make some services routinely available and putting in place stricter criteria for accessing

other services, we believe that will be able to protect the most important services so that they can be

available when people need them whilst at the same time continuing to live within our financial means.

To achieve this aim, we will ensure the current NEL EBI Policy is:

1. Consistently applied across the seven North East London Clinical Commissioning Groups (Barking &

Dagenham, City & Hackney, Havering, Newham, Redbridge, Tower Hamlets, and Waltham Forest) to

avoid any postcode related inequity or inequality.

2. Presented using unambiguous language, which is easy for clinicians and patients to interpret.

3. Regularly reviewed, updated and reissued using the most up to date and validated evidence base.

4. Effectively and consistently communicated to health care professionals within the footprint.

5. An open and transparent process, adhering to local governance policies.

Where possible, references to the evidence/ guidelines underpinning individual clinical policies have

been added to the relevant sections. However, it should be noted that an assumption is made that if

National guidelines are updated that would impact upon this policy they will be taken into account

when assessing eligibility for a particular treatment. Obtaining funding approval and due process.

There are two main routes by which funding can be sought and obtained as outlined below:

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Funding for any of the procedures or interventions contained in this policy will be subject to (a) if an

exceptional case is made through an individual funding request (IFR) OR (b) prior approval. Further

details are described below:

Prior Approval ‐ This means the CCG will fund treatment if the patient meets the stated clinical

threshold for care. Before the procedure is undertaken Prior Approval must be sought and obtained. A

GP or Consultant must seek approval for an individual before treatment is carried out. In the majority of

cases this will be requested by the treating clinician with the exception of the following procedures

where the GP will have more information regarding the patient’s clinical condition.

Tonsillectomy (page 12)

Chalazia removal (page 9)

Abdominal wall hernia management and repair (page 25)

IFR (Not routinely funded) ‐ The statement “NEL CCGs will not routinely fund” means it is primarily a

commissioning decision not to routinely fund. In these circumstances a clinician may still request

funding for that treatment but this will only be approved if an Individual Funding Request (IFR) proves

exceptional clinical need and is approved by the IFR panel (Please refer to IFR Policy).

A copy of the relevant IFR policy can be obtained from the IFR team by contacting the following:

For City and Hackney, Newham, Tower Hamlets and Waltham Forest:

Email: nelcsuwelc‐[email protected] or Tel. 020 3688 1290

For Barking and Dagenham, Havering and Redbridge:

Email: nelcsubhr‐[email protected] or Tel. 020 3688 1290

Exceptional cases must have exceptional clinical circumstances supported by robust clinical evidence.

We have defined exceptionality as an unusual clinical factor (or factor affecting the clinical condition)

about the patient that suggests that they are:

Significantly different to the general population of patients with the condition in question

Likely to gain significantly more benefit from the intervention than might be expected from the average

patient with the condition

The fact that a treatment is likely to be effective for a patient is not, in itself, a basis for exceptionality. If

a patient's clinical condition matches the 'accepted threshold indicators' for a treatment that is not

funded, their circumstances are not, by definition, exceptional.

Any procedures carried outside of the funding governance arrangements outlined above will be subject to challenge and carries a significant risk of non‐payment to the provider.

Performance monitoring arrangements

Performance measures and audits will be used to monitor provider activity. These will be carried out as

instructed by individual CCGs. Any procedures carried out that are not in line with this policy will be

investigated and, where appropriate, challenged for non‐payment.

Prior Approval and IFR – Any procedures carried outside of the funding governance arrangements

previously outlined will be subject to challenge and carries a risk of non‐ payment to the provider

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Retrospective audits ‐ The frequency, scope and depth for the said audits will be agreed with providers who will be given appropriate notice pending any such audits and or reviews. All providers will be asked

to clarify any activity or procedure codes that fail to comply with those set out within the policy. These

will be subject to challenge as is relevant and where appropriate challenged for non‐payment.

Coding; CCGs and Providers will work collectively to agree, maintain and review coding as required to

support policy implementation.

All providers will be asked to clarify any activity or procedure codes that fail to comply with those set

out within the policy. These will be subject to challenge as is relevant and where appropriate challenged

for non‐payment

Equality statement NEL CCGs have a duty to have due regard for the need to reduce health inequalities in access to health

services and health outcomes achieved as detailed in the Health and Social Care Act 2012. NEL CCGs

have committed to ensuring equality of access and non‐discrimination, irrespective of age, gender,

disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy

and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions,

NEL CCGs will have due regard to the different needs of protected equality groups, in line with the

Equality Act 2010. This document is compliant with the NHS Constitution and the Human Rights Act

1998. This applies to all activities for which they are responsible, including policy development, review

and implementation.

NEL CCGs have completed an Equality Impact Assessment (EIA) and Full Quality Impact Assessment

(fQIA) for this policy update.

Exclusions to this policy The policy does not apply to the following:

Patients diagnosed with cancer or suspected of having cancer: diagnoses should be dealt with via a

two‐week wait referral and NOT via an Individual Funding Request (IFR) or Prior Approval (PA)

application.

Policies may also not apply to those patients that have survived cancer where there is a different

commissioning pathway in place, e.g. breast reconstruction post cancer. Patients will only be

excluded where the treatment sought is in relation to their cancer pathway.

If Mental Health affects functionality then it should be considered for funding. Although in such cases there should be evidence of the patient having received psychological treatment prior to the procedure.

Children (aged under 18) unless otherwise stated within individual treatment/intervention policy.

Emergency or urgent care.

Where NHS England commission the service as part of specialist commissioning arrangements.

If a clinician considers the need for referral/treatment on clinical grounds outside of the Prior

Approval (PA) criteria, please refer to the CCG Individual Funding Request policy for further

information.

In relation to the above exclusions, the provider should be able to demonstrate the clinical need as part

of the payment verification process.

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Implementation time scales This policy will be used to assess all patients being referred for assessment or treatment from 01 November 2019.

The NEL EBI will be reviewed one year from the date of implementation. A formal Clinical Review Group (CRG) will

be reinstated and the Nationally mandated policies will be adopted without further consultation.

Category 1 Procedures: Individual funding request (IFR) This list includes procedures that are not routinely commissioned by NEL CCGs, and therefore funding is only

available through an IFR panel. Only IFR applications that demonstrate clear clinical exceptionality will be

processed. Please refer to the local IFR policy for further guidance before completing an application form.

Procedures Speciality Page No. Face lifts and brow lifts (rhytidectomy) Dermatology & Skin 6 Hair transplantation Dermatology & Skin 6 Repair of split ear lobes Dermatology & Skin 6 Tattoo removal Dermatology & Skin 6 Treatment for hair loss (alopecia) Dermatology & Skin 6 Treatment for scarring and skin hyper‐ or hypo‐ pigmentation Dermatology & Skin 6 Laser surgery for short sightedness Ophthalmology 7 Surgical interventions for snoring in the absence of obstructive sleep apnoea

Respiratory 13

White cell apheresis Haematology 13 Breast augmentation Breast 14 Breast lift (mastopexy) Breast 14 Male breast reduction (gynaecomastia) Breast 14 Injections for non‐specific low back pain Orthopaedics 16 Knee arthroscopy for patients with osteoarthritis Orthopaedics 16 Lumbar disc replacement Orthopaedics 16 Ozone discectomy Orthopaedics 16 Spinal fusion for non‐radicular back pain Orthopaedics 16 Cholecystectomy for asymptomatic gall stones Abdominal Surgery 22 Excess skin excision from buttocks, thighs and arms Bariatric surgery 22 Liposuction Bariatric surgery 22 Surgery to correct divarification (or diastasis) of the abdominal rectus muscle

Bariatric surgery 22

Cosmetic genital procedures (labiaplasty – excluding Female Genital Mutilation (FGM) (refer to circumcision category 2 prior approval policy)

Gynaecology/Urology 23

Dilation & curettage (D&C) for heavy menstrual bleeding in women Gynaecology/Urology 23 Double balloon enteroscopy for diagnostic purpose Gynaecology/Urology 23 MRI guided ultrasound (MRgFUS) for uterine fibroids Gynaecology/Urology 23 Non‐medical circumcision Gynaecology/Urology 23 Reversal of female sterilisation and reversal of vasectomy Gynaecology/Urology 23 Sacral nerve stimulation for faecal and urinary incontinence Gynaecology/Urology 23 Varicocele Gynaecology/Urology 23 All treatments for vascular lesions General Surgery 25 Manual therapies (osteopathy – outside of an MSK integrated service) Physiotherapy 27 Ketogenic diet for epilepsy Medicine 27 Acupuncture Alternative therapy 27 Herbal medicines Alternative therapy 27 Homeopathy Alternative therapy 27 * Appendix A provides more clinical guidance for category 1 – IFR procedures.

** See breast reduction and correction of breast symmetry

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Category 2 Procedures: Prior Approval (PA) Procedures Speciality Page No. Excision of skin and subcutaneous lesions Dermatology & Skin 6 Hair epilation Dermatology & Skin 7 Keloid and other scar revision Dermatology & Skin 8 Cataract surgery Ophthalmology 8 Chalazia removal Ophthalmology 9 Surgery on the upper or lower eyelid (blepharoplasty) Ophthalmology 10

Grommets for glue ear in children ENT 10 Pinnaplasty/otoplasty (correction of prominent or bat ears) ENT 11

Rhinoplasty/Septoplasty/Rhinoseptoplasty (surgery to reshape the nose)

ENT 11

Surgical treatment of chronic sinusitis ENT 12 Tonsillectomy ENT 12 Breast reduction and correction of breast symmetry Breast 14 Nipple inversion Breast 15 Removal / revision of breast augmentation Breast 15 Bunion surgery (Hallux Valgus) Orthopaedics 16 Dupuytren's contracture release Orthopaedics 16 EXOGEN bone healing Orthopaedics 17 Functional electrical stimulation (FES) for foot drop Orthopaedics 17

Ganglion excision Orthopaedics 17 Interventional treatments for back pain Orthopaedics 18

Shoulder decompression Orthopaedics 20 Surgical treatment of carpal tunnel syndrome Orthopaedics 20 Sympathectomy for severe hyperhidrosis (palmar, plantar, axillary)

Orthopaedics 21

Trigger finger Orthopaedics 21 Bariatric Surgery Bariatric surgery 23 Bartholin’s cysts Gynaecology/Urology 23 Circumcision Gynaecology/Urology 23 Hysterectomy for menorrhagia (heavy menstrual bleeding) Gynaecology/Urology 24

Abdominal wall hernia management and repair General surgery 25 Abdominoplasty General surgery 26 Haemorrhoidectomy General surgery 26 Varicose veins General surgery 27 Botulinum toxin (not cosmetic) Other 28 Open MRI Other 29

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Detailed Procedure Criteria Guidance

Dermatology & Skin

Category 1 Procedures: Individual funding request (IFR) Face lifts and brow lifts (rhytidectomy) Hair transplantation Repair of split ear lobes Tattoo removal Treatment for hair loss (alopecia) Treatment for scarring and skin hyper‐ or hypo‐ pigmentation

Category 2 Procedures: Prior Approval (PA)

Excision of skin and subcutaneous lesions Criteria

This policy refers to the following benign lesions when there is diagnostic certainty and they do meet the criteria listed below: • benign moles (excluding large congenital naevi) • solar comedones • corn/callous • dermatofibroma • lipomas • milia • molluscum contagiosum (non‐genital) • epidermoid & pilar cysts (sometimes incorrectly called sebaceous cysts) • seborrhoeic keratoses (basal cell papillomata) • skin tags (fibroepithelial polyps) including anal tags • spider naevi (telangiectasia) • non‐genital viral warts in immunocompetent patients • xanthelasmata • neurofibromata With prior approval, NEL CCGs will fund benign skin lesions which are listed above when one of the following criteria are met: 1. The lesion is unavoidably and significantly traumatised on a regular basis with evidence of this causing

regular bleeding or resulting in infections such that the patient requires two or more courses of antibiotics (oral or intravenous) per year

OR 2. The lesion causes regular pain OR 3. The lesion is obstructing an orifice or impairing field vision OR 4. The lesion significantly impacts on function e.g. restricts joint movement OR 5. The lesion causes pressure symptoms e.g. on nerve or tissue OR 6. If left untreated, more invasive intervention would be required for removal OR 7. Facial viral warts OR 8. Facial spider naevi in children causing significant psychological impact

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Lipomas on the body > 5cms, or in a sub‐facial position, with rapid growth and/or pain. These should be referred to Sarcoma clinic. The following are outside the scope of this policy recommendation: • Lesions that are suspicious of malignancy should be treated or referred according to NICE skin cancer guidelines. • Any lesion where there is diagnostic uncertainty, pre‐malignant lesions (actinic keratoses, Bowen disease) or lesions with pre‐malignant potential should be referred or, where appropriate, treated in primary care. • Removal of lesions other than those listed above. Referral to dermatology or plastic surgery: • The decision as to whether a patient meets the criteria is primarily with the referring clinician. If such lesions are referred, then the referrer should state that this policy has been considered and why the patient meets the criteria. • This policy applies to all providers, including general practitioners (GPs), GPs with enhanced role (GPwer), independent providers, and community or intermediate services.

Hair epilation Criteria

With prior approval, NEL CCGs will fund hair epilation when either criteria 1(a) or criteria 1(b) AND 2 are met: 1(a). Have undergone reconstructive surgery leading to abnormally located hair‐bearing skin to the face, neck or upper chest (areas not covered by normal clothing) OR 1(b). Are undergoing treatment for pilonidal sinuses to reduce recurrence for patients who do not meet these criteria AND 2. Confirmation that the patient has not had more than six NHS/private treatments in the past In the event that NHS funding is agreed up to a maximum of six treatments. Additional information An IFR application will ONLY be considered (for facial, neck or upper chest areas not covered by normal clothing) on completion of the relevant section explaining for the benefit of the IFR panel why the patient differs from the cohort of similarly hirsute patients such that they are likely to gain more health benefit from depilation which is not available to other similar patients.

Because NEL CCGs do not fund maintenance treatment for hirsuitism, it is not considered appropriate to commission an intervention whose effects are likely to be transitory and psychological distress would be likely to recur. Severe hirsuitism due to an endocrine disorder may be referred to an endocrinology department but this is not an indication for NHS funding of epilation. NEL CCGs will fund radiosurgery for the treatment of symptomatic trichiasis.

Keloid and other scar revision Criteria

NEL CCGs will not fund surgical procedures to re‐fashion keloid scars for cosmetic purposes. With prior approval, NEL CCGs will fund symptomatic keloid scars when one of the following criteria are met: 1. Interferes with physical function

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OR 2. Causes pain or itchiness for six months and is unrelieved by standard medication Additional information Corticosteroid injections and Haelan tape should be considered the first line treatment for keloid scars. The aim of injections and tape is to improve the appearance of the scar. Patients should be informed of the need to wear the tape for 12 hours daily for at least three months. Patients should be informed that having surgery on a scar will in itself leave a new scar that will take up to two years to improve in appearance. If surgery is used to treat a hypertrophic scar, there is a risk that the scarring may be worse after the surgery. Low‐dose, superficial radiotherapy may reduce the recurrence rate of hypertrophic and keloid scars after surgery. Because of the possibility of long‐term side effects, it is only reserved for the most serious cases. IFR applications should be submitted for this intervention describing the clinical exceptionality in any case.

Ophthalmology

Category 1 Procedures: Individual funding request (IFR)

Laser surgery for short sightedness


Cataract surgery Criteria

This policy relates to cataract surgery only, as described in detail below. The policy does not apply to:

Patients with confirmed or suspected malignancy

Patients with acute trauma or suspected infection

Children under the age of 18 With prior approval, NEL CCGs will fund cataract surgery when both of the following criteria are met: 1. Patient has a best corrected visual acuity of 6/9 or worse in either the first or second eye AND 2. Patient has impairment in lifestyle such as substantial effect on activities of daily living, leisure activities,

and risk of falls Additional information All patients should be given the opportunity to engage with shared decision making at each point in the pathway to cataract surgery (e.g. optometrists, GPs, secondary care), to ensure they are well informed about the treatment options available and personal values, preferences and circumstances are taken into consideration.

Surgery is also indicated for management of cataract with coexisting ocular comorbidities. A full list of these ocular comorbidities can be found below.*

Where patients have a best corrected visual acuity better than 6/9, surgery should still be considered where there is a clear clinical indication or symptoms affecting lifestyle. For NHS treatment to be

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provided, there needs to be mutual agreement between the provider and the responsible (i.e. Paying) commissioner about the rationale for cataract surgery prior to undertaking the procedure).

*List of ocular comorbidities

Glaucoma

Conditions where cataract may hinder disease management or monitoring, including diabetic and other retinopathies including retinal vein occlusion, and age related macular degeneration; neuro‐ophthalmological conditions (e.g. visual field changes); or getting an adequate view of fundus during diabetic retinopathy screening

Occuloplastics disorders where fellow eye requires closure as part of eyelid reconstruction

Corneal disease where early cataract removal would reduce the chance of losing corneal clarity (e.g. Fuch's corneal dystrophy or after keratoplasty)

Corneal or conjunctival disease where delays might increase the risk of complications (e.g. cicatrising conjunctivitis)

Severe anisometropia in patients who wear glasses

Posterior subcapsular cataracts

Chalazia removal Criteria

With prior approval, NEL CCGs will fund incision and curettage (or triamcinolone injection for suitable candidates) of chalazia when one of the following criteria have been met: 1. Has been present for more than six months and has been managed conservatively with warm compresses,

lid cleaning and massage for four weeks OR 2. Interferes significantly with vision OR 3. Interferes with the protection of the eye by the eyelid due to altered lid closure or lid anatomy OR 4. Is a source of infection that has required medical attention twice or more within a six month time frame OR 5. Is a source of infection causing an abscess which requires drainage OR 6. If malignancy (cancer) is suspected e.g. Madarosis/recurrence/other suspicious features in which case the

lesion should be removed and sent for histology as for all suspicious lesions

Surgery on the upper or lower eyelid (blepharoplasty) Criteria

With prior approval, NEL CCGs will fund surgery on the upper or lower eyelid when one of the following criteria are met: 1. Impairment of visual field(s) in the relaxed, non‐compensated state where visual field test results show that

eyelids impinge on visual fields reducing them to 1200 laterally and 400 vertically OR 2. Patients who have severe headache as a result of frontalis muscle overaction when trying to overcome

brow ptosis, upper eyelid ptosis or excess dermatochalasis should be allowed corrective surgery Additional information These procedures should only be carried out in the ophthalmology department under the care of an oculoplastic surgeon.

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NEL CCGs will not fund ptosis repair, upper eyelid blepharoplasty and brow lift for cosmetic reasons. This will include corrective surgery for patients who are dissatisfied with the cosmetic appearance post‐surgery of any of the procedure mentioned above.

Ears, Nose & Throat (ENT)


Grommets for glue ear in children Criteria

The NHS should only commission this surgery for the treatment of glue ear in children when the criteria set out by the NICE guidelines are met. With prior approval, NEL CCGs will fund grommets for glue ear when criteria 1, 2 and 3 are met. Or exclusively when either 4(a) or 4(b) are met: 1. All children must have had specialist audiology and ENT assessment AND 2. Persistent bilateral otitis media with effusion for at least three consecutive months AND 3. Hearing level in the better ear of 25‐30dbHL or worse averaged at 0.5, 1, 2 & 4kHz OR exclusively in one of the following circumstances 4(a). Exceptionally, healthcare professionals should consider surgical intervention in children with persistent bilateral OME with a hearing loss less than 25‐30dbHL where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant OR 4(b). Healthcare professionals should also consider surgical intervention in children who cannot undergo standard assessment of hearing thresholds where there is clinical and tympanographic evidence of persistent glue ear and where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant Additional information This guidance does not apply to children with Down’s Syndrome or Cleft Palate, who may be offered grommets after a specialist Multi‐Disciplinary Team (MDT) assessment in line with NICE guidance. It is also good practice to ensure glue ear has not resolved once a date of surgery has been agreed, with tympanometry as a minimum. For further information, please see: https://www.nice.org.uk/Guidance/CG60. The risks to surgery are generally low, but the most common is persistent ear discharge (10‐20%) and this can require treatment with antibiotic eardrops and water precautions. In rare cases (1‐2%) a persistent hole in the eardrum may remain, and if this causes problems with recurrent infection, surgical repair may be required (however this is not normally done until around 8‐10 years of age).

Pinnaplasty/otoplasty (correction of prominent or bat ears) Criteria

With prior approval, NEL CCGs will fund pinnaplasty/otoplasty when all of the following criteria are met: 1. The patient is under the age of 18 at the time of referral for significant prominent or bat ears AND 2. Where the prominence measures >30mm (using the measuring guide below)

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Measuring guide One of the most consistent methods for measuring the degree of prominence is the helical‐mastoid (H‐M) distance. Typically, the H‐M distance is 18‐20 mm. As the H‐M distance increases, the ear is perceived to be increasingly prominent. Measure from the posterior aspect of the Helix. Prominence = H‐M distance > 20mm Pinnaplasty/otoplasty will only be considered in patients who have a >30mm prominence, unless there are other considerations e.g. in helping to retain hearing aids. In which case an IFR application would be required clearing setting out the patient’s clinical exceptionality.

Rhinoplasty/Septoplasty/Rhinoseptoplasty (surgery to reshape the nose) Criteria

Rhinoplasty, commonly known as a ‘nose job’, is a plastic surgery procedure for correcting and reconstructing the form, restoring the functions, and aesthetically enhancing the nose by resolving nasal trauma (blunt, penetrating, blast), congenital defect, respiratory impediment, or a failed primary rhinoplasty.

a) Rhinoplasty, Septoplasty and Septorhinoplasty are not routinely commissioned for cosmetic reasons.

b) Rhinoplasty, Septoplasty and Septorhinoplasty are restricted for non‐ cosmetic/other reasons. The CCG will fund this treatment if the patient meets the following criteria:

Documented medical problems caused by obstruction of the nasal airway AND all conservative treatments have been exhausted. OR

Correction of complex congenital conditions e.g. Cleft lip and palate For the purposes of this eligibility criteria, a medical problem is defined as a medical problem that continually impairs sleep and/or breathing. This means (for patients who DO NOT meet the above criteria or require the procedure for cosmetic reasons) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

Surgical treatment of chronic sinusitis Criteria

ENT referral is appropriate for suspected:

Complications, e.g. periorbital infection or suspected sinonasal tumour. Surgical treatment of chronic sinusitis is not routinely funded by NEL CCGs and will only be considered for funding, with prior approval, where all of the following criteria are met: 1. Recurrent or chronic sinusitis of uncertain cause AND 2. Unremitting or progressive facial pain AND 3. A trial of intranasal corticosteroids of three months in duration has been ineffective AND 4. A significant anatomical abnormality

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Additional Information Evidence Base: NHS Clinical Knowledge Summaries advise a trial of intranasal corticosteroids for three months for treatment in the first instance. Sinus puncture and irrigation has a poor diagnostic yield, and carries the risk of secondary contamination. Only short‐term benefit seen in patient refractory to medical management treated with balloon catheter dilation of sinus ostia.

Tonsillectomy Criteria

The NHS should only commission this surgery for treatment of recurrent severe episodes of sore throat when the following criteria are met, as set out by the Scottish Intercollegiate Guidelines Network (SIGN) guidance and supported by ENT UK commissioning guidance. With prior approval, NEL CCGs will fund tonsillitis when criteria 1 and 2 and one of criteria 3(a) or 3(b) or 3(c) are met: Section 1 1. Sore throats are due to acute tonsillitis AND 2. The episodes are disabling and prevent normal functioning AND 3(a). Seven or more, documented, clinically significant, adequately treated sore throats in the preceding year OR 3(b). Five or more such episodes in each of the preceding two years OR 3(c). Three or more such episodes in each of the preceding three years There are a number of medical conditions where episodes of tonsillitis can be damaging to health or where tonsillectomy is required as part of the on‐going management. In these instances tonsillectomy may be considered beneficial at a lower threshold than this guidance after specialist assessment. In these instances with prior approval, NEL CCGs will fund surgery when one of the following criteria are be met: Section 2 1. Acute and chronic renal disease resulting from acute bacterial tonsillitis OR 2. As part of the treatment of severe guttate psoriasis OR 3. Metabolic disorders where periods of reduced oral intake could be dangerous to health OR 4. PFAPA (Periodic fever, Apthous stomatitis, Pharyngitis, Cervical adenitis) OR 5. Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous Additional information Further information on the SIGN guidance can be found here: http://www.sign.ac.uk/assets/sign117.pdf Please note this guidance only relates to patients with recurrent tonsillitis. This guidance should not be applied to other conditions where tonsillectomy should continue to be funded, these include: • Obstructive Sleep Apnoea / Sleep disordered breathing in Children • Suspected Cancer (e.g. asymmetry of tonsils)

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• Recurrent Quinsy (abscess next to tonsil) • Emergency Presentations (e.g. treatment of parapharyngeal abscess) It is important to note that a national randomised control trial is underway comparing surgery versus conservative management for recurrent tonsillitis in adults which may warrant review of this guidance in the near future.

Respiratory


Surgical interventions for snoring in the absence of obstructive sleep apnoea

Haematology


White cell apheresis

Breast Category 1 Procedures: Individual funding request (IFR)

Breast augmentation Breast lift (Mastopexy) Male breast reduction (gynaecomastia)


Breast reduction and correction of breast symmetry Criteria

Section 1: Bilateral breast reduction With prior approval, NEL CCGs will fund bilateral breast reduction when all of the following criteria are met: 1. The woman has received a full package of supportive care from their GP such as advice on weight loss and

managing pain AND 2. In cases of thoracic/ shoulder girdle discomfort, a physiotherapy assessment has been provided AND 3. Breast size results in functional symptoms that require other treatments/interventions (e.g. intractable

candidal intertrigo; thoracic backache/kyphosis where a professionally fitted bra has not helped with backache, soft tissue indentations at site of bra straps)

AND 4. Breast reduction planned to be 500gms or more per breast or at least four cup sizes AND 5. Body mass index (BMI) is <27 and stable for at least 12 months AND

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6. Women must be provided with written information to allow them to balance the risks and benefits of breast surgery

AND 7. Women should be informed that smoking increases complications following breast reduction surgery and

should be advised to stop smoking AND 8. Women should be informed that breast surgery for hypermastia can cause permanent loss of lactation

Section 2: Unilateral breast reduction This treatment is considered for asymmetric breasts as opposed to breast augmentation if there is an impact on health as per the criteria above. Surgery will not be funded for cosmetic reasons. With prior approval, NEL CCGs will fund unilateral breast reduction when all of the following criteria are met: 1. A difference of 150 ‐ 200gms size as measured by a specialist AND 2. Body mass index (BMI) is <27 and stable for at least 12 months Additional information Resection weights, for bilateral or unilateral (both breasts or one breast) breast reduction should be recorded for audit purposes. This recommendation does not apply to therapeutic mammoplasty for breast cancer treatment or contralateral (other side) surgery following breast cancer surgery, and local policies should be adhered to. The Association of Breast Surgery support contralateral surgery to improve cosmesis as part of the reconstruction process following breast cancer treatment. Gynaecomastia: Surgery for gynaecomastia is not routinely funded by the NHS. This recommendation does not cover surgery for gynaecomastia caused by medical treatments such as treatment for prostate cancer.

Nipple inversion Criteria

Nipple inversion may occur as a result of an underlying breast malignancy and it is essential that this be excluded. With prior approval, NEL CCGs will fund surgical correction of nipple inversion when the following criteria is met: 1. The inversion has not been corrected by correct use of a non‐invasive suction device after three months of

use. Additional information Idiopathic nipple inversion may be corrected by the application of sustained suction. Commercially available devices are available from major chemists or online without prescription. Best results are seen where this is used correctly for up to three months.

Removal / revision of breast augmentation Criteria

Removal With prior approval, NEL CCGs will fund removal of breast implants when one of the following criteria are met for patients who have undergone cosmetic augmentation mammoplasty: 1. Breast disease OR 2. Implants complicated by recurrent infections OR

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3. Implants with capsule formation that is associated with severe pain OR 4. Implants with capsule formation that interferes with mammography OR 5. Intra or extra capsular rupture of silicon gel‐filled implants Revision With prior approval, NEL CCGs will fund reinsertion of new breast implants when criteria 1 and one of criteria 2(a) or 2(b) are met: 1. The original implant insertion was funded by the NHS AND 2(a). The patient would still be eligible for breast implant under NEL CCGs commissioning policies breast augmentation OR 2(b). The patient would still be eligible for breast implant under NEL CCGs commission policy for correction of asymmetry NEL CCGs will not contribute funding to procedures funded privately, irrespective of whether part of that procedure involves removal of breast implants.

Orthopaedics Category 1 Procedures: Individual funding request (IFR)

Autologous chondrocyte (cartilage) implantation Injections for non‐specific low back pain Knee arthroscopy for patients with osteoarthritis Lumbar disc replacement Ozone discectomy Spinal fusion for non‐radicular back pain


Bunion surgery (Hallux Valgus) Criteria

With prior approval, NEL CCGs will fund bunion surgery where one of the following criteria are met: 1. Significant pain on walking not relieved by chronic standard analgesia OR 2. Deformity such that fitting adequate footwear is difficult OR 3. Overlapping or underlapping of adjacent toe(s) OR 4. Hammer toes OR 5. Recurrent or chronic ulceration OR 6. Bursitis or tendinitis of the first metatarsal head

Dupuytren's contracture release Criteria

Treatment is not indicated in cases where there is no contracture, and in patients with a mild (less than 20°) contractures, or one which is not progressing and does not impair function.

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With prior approval, NEL CCGs will fund intervention/treatment in the form of (collagenase injections, needle fasciotomy, fasciectomy and dermofasciectomy) when one of the following criteria are met: 1. Finger contractures causing loss of finger extension of 30° or more at the metacarpophalangeal joint or 20°

at the proximal interphalangeal joint OR 2. Severe thumb contractures which interfere with function With prior approval, NEL CCGs will fund, in line with NICE Guidance, collagenase when 1 or 2(a) and 2(b) of the following criteria are met: 1. Participants in the ongoing clinical trial (HTA‐15/102/04) OR 2. Adult patients with a palpable cord if: (a) there is evidence of moderate disease (functional problems and metacarpophalangeal joint contracture of 30° to 60° and proximal interphalangeal joint contracture of less than 30° or first web contracture) plus up to two affected joints AND (b). needle fasciotomy is not considered appropriate, but limited fasciectomy is considered appropriate by the treating hand surgeon.

EXOGEN bone healing Criteria

With prior approval, NEL CCGs will fund EXOGEN ultrasound bone healing system when the following criteria are met: 1. Long bone fractures that have failed to heal after nine months (non‐union)

NICE Guidance MTG12

Functional electrical stimulation (FES) for foot drop Criteria

With prior approval, NEL CCGs will fund initiation or continuation of treatment when one of the following criteria are met: The patient will have objectively demonstrated that the use of FES is still clinically appropriate by: Initiation 1. Foot drop which impedes gait and evidence that this is not satisfactorily controlled using ankle‐foot

orthosis OR Continuation 2. Gait improvement from its use

Ganglion excision Criteria

Section 1: Wrist ganglia With prior approval, NEL CCGs will fund wrist ganglia excision when 1 and 3 or 2 and 3 of the following criteria are met: 1. No treatment unless causing pain or tingling/numbness or concern (worried it is a cancer) OR

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2. Aspiration if causing pain, tingling/numbness or concern AND 3. Surgical excision only considered if aspiration fails to resolve the pain or tingling/numbness and there is

restricted hand function Section 2: Seed ganglia that are painful With prior approval, NEL CCGs will fund seed ganglia that are painful when one of the following criteria are met: 1. Puncture/aspirate the ganglion using a hypodermic needle OR 2. Surgical excision only considered if ganglion persists or recurs after puncture/aspiration Section 3: Mucous cysts With prior approval, NEL CCGs will fund mucous cysts when one of the following criteria are met: 1. No surgery should be considered unless recurrent spontaneous discharge of fluid OR 2. Significant nail deformity

Interventional treatments for back pain Criteria

This policy relates to interventional treatments for back pain only as described in detail below and relates to people aged 18 and over For many patients, consideration of such treatments only arises after conservative management in primary care or specialist musculoskeletal services. The following exclusions apply:

Children (aged under 18)

Patients thought to have/have cancer (including metastatic spinal cord compression)

Patients with neurological deficit (spinal cord compression or cauda equina symptoms), fracture or infection

In ordinary circumstances, funding for interventional treatments for back pain is available for patients who meet the following criteria. Section 1: Epidurals With prior approval, NEL CCGs will fund interventions for epidurals when criteria 1 and 2 and one of 3(a) or 3(b) are met: 1. The patient has radicular pain consistent with the level of spinal involvement AND 2. The patient has moderate‐severe symptoms that have persisted for 12 weeks or more AND either one of the following: 3(a). The patient has severe pain and advice, reassurance, analgesia and manual therapy ideally part of community Musculoskeletal (MSK) service has been undertaken. (Evidence that disc prolapses get better on their own) AND/OR 3(b). The MRI scan (unless contraindicated) shows pathology concordant with the clinical diagnosis. A maximum of three epidural injections, within a 12 month period with objective with functional benefit demonstrable with each injection, will be funded

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For patients with persisting symptoms after three injections, re‐approval of treatment with epidural injections will be needed through the IFR panel. This may be older/frailer patients who derive medium term benefit but are unsuitable for or unwilling to have surgery. Medial branch blocks, sacroiliac joint injections and subsequent medial branch radiofrequency lesioning (facet joint denervation) or sacroiliac joint radiofrequency denervation are only funded if performed in a Pain Service with a multidisciplinary team approach, only to be performed by doctors trained in Biopsychosocial Assessment. Section 2: Spinal decompression With prior approval, NEL CCGs will fund interventions for spinal decompression when all of the following criteria are met: 1. The patient has radicular/claudicant leg pain consistent with the level of spinal involvement AND 2. The MRI scan (unless contraindicated) shows one or more areas of spinal stenosis whereby the pathology is

concordant with the clinical diagnosis AND 3. The patient has shown no sign of improvement despite conventional therapy for one year Section 3: Discectomy With prior approval, NEL CCGs will fund interventions for discectomy when both of the following criteria are met: 1. The patient has radicular pain consistent with the level of spinal involvement AND 2. The patient has shown no sign of improvement despite conventional therapy for 12 weeks Section 4: Epidurolysis (See also NICE IPG 333) With prior approval, NEL CCGs will fund interventions for epidurolysis when all of the following criteria are met: 1. The patient has late onset radiculopathy post spinal surgery AND 2. MRI Gadolinium‐enhanced or dynamic epidurogram (unless contraindicated) findings are concordant to

show adhesive radiculopathy AND 3. Conservative management and epidural injections have failed The specialist applying for funding must confirm that they are trained in the technique. Subsequent epidurolysis treatments will require an IFR approval, including information about the nature and duration of benefit from initial treatment. Spinal Fusion Spinal fusion surgery is not routinely funded for non‐radicular back pain Lumbar Disc Replacement Lumbar disc replacement surgery is not routinely funded Acupuncture

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Acupuncture for back pain is not routinely funded but can continue to be provided as part of existing physiotherapy packages of care. Ozone Discectomy Ozone discectomy is not routinely funded

Shoulder decompression Criteria

With prior approval, NEL CCGs will fund arthroscopic subacromial decompression when:

1. The Arthroscopic subacromial decompression is for pure subacromial shoulder impingement Arthroscopic subacromial decompression for pure subacromial shoulder impingement should only offered in appropriate cases. To be clear, ‘pure subacromial shoulder impingement’ means subacromial pain not caused by associated diagnoses such as rotator cuff tears, acromio‐clavicular joint pain, or calcific tendinopathy. Non‐operative treatment such as physiotherapy and exercise programmes are effective and safe in many cases. For patients who have persistent or progressive symptoms, in spite of adequate non‐operative treatment, surgery should be considered. The latest evidence for the potential benefits and risks of subacromial shoulder decompression surgery should be discussed with the patient and a shared decision reached between surgeon and patient as to whether to proceed with surgical intervention.

Surgical treatment of carpal tunnel syndrome Criteria

Mild cases with intermittent symptoms causing little or no interference with sleep or activities require no treatment. Cases with intermittent symptoms which interfere with activities or sleep should first be treated with:

Corticosteroid injection(s) (medication injected into the wrist: good evidence for short (8‐12 weeks) term effectiveness)

OR Night splints (a support which prevents the wrist from moving during the night: not as effective as

steroid injections) With prior approval, NEL CCGs will fund surgical treatment for carpal tunnel syndrome when one of the following criteria are met: 1. The symptoms significantly interfere with daily activities and sleep symptoms and have not settled to a

manageable level with either one local corticosteroid injection and/or nocturnal splinting for a minimum of eight weeks

OR 2. A permanent (ever‐present) reduction in sensation in the median nerve distribution OR 3. Muscle wasting or weakness of thenar abduction (moving the thumb away from the hand)

Nerve Conduction Studies if available are suggested for consideration before surgery to predict positive surgical outcome or where the diagnosis is uncertain.

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Sympathectomy for severe hyperhidrosis (palmar, plantar, axillary) Criteria

With prior approval, NEL CCGs will fund sympathectomy when criteria 1(a) and 2 are met or 1(b) and 2 are met: 1(a). Significant focal hyperhidrosis and a one to two month trial of aluminium salts (under primary care supervision to ensure compliance) has been unsuccessful in controlling the condition OR 1(b). Significant focal hyperhidrosis and intolerance of topical aluminium salts despite reduced frequency of application and use of topical 1% hydrocortisone AND 2.All of the following conservative therapies have been tried and found to be unsuitable or unsuccessful:

treatment of underlying anxiety if it is an exacerbating factor

referral to a dermatologist for modified topical therapy

prescription of oral anticholinergics (which block the effect of the nerves that stimulate the sweat glands)

iontophoresis (for palmar or plantar hyperhidrosis) or botulinum toxin injections (for axillary hyperhidrosis)

Sympathectomy is an established intervention for this condition BUT should be considered only after all other non‐invasive non‐surgical treatment options have been tried and failed. Additional Information Compensatory sweating following sympathectomy is common and can be worse than the original problem. Patients should be made aware of this risk.

Trigger finger Criteria

Mild cases which cause no loss of function require no treatment or avoidance of activities which precipitate triggering and may resolve spontaneously. Cases interfering with activities or causing pain should first be treated with:

one or two steroid injections which are typically successful (strong evidence), but the problem may recur, especially in diabetics

OR splinting of the affected finger for 3‐12 weeks (weak evidence) With prior approval, NEL CCGs will fund trigger finger surgery when one of the following criteria are met: 1. The triggering persists or recurs after one of the above measures (particularly steroid injections) OR 2. The finger is permanently locked in the palm OR 3. The patient has previously had two other trigger digits unsuccessfully treated with appropriate

nonoperative methods OR 4. Diabetics Surgery is usually effective and requires a small skin incision in the palm, but can be done with a needle through a puncture wound (percutaneous release).

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Treatment with steroid injections usually resolve troublesome trigger fingers within one week (strong evidence) but sometimes the triggering keeps recurring. Surgery is normally successful (strong evidence), provides better outcomes than a single steroid injection at one year and usually provides a permanent cure. Recovery after surgery takes two to four weeks. Problems sometimes occur after surgery, but these are rare (<3%).

Abdominal Surgery Category 1 Procedures: Individual funding request (IFR)

Cholecystectomy for asymptomatic gall stones

Bariatric Surgery Category 1 Procedures: Individual funding request (IFR)

Excess skin excision from buttocks, thighs and arms Liposuction Surgery to correct divarification (or diastasis) of the abdominal rectus muscle


Bariatric Surgery Criteria

With prior approval, NEL CCGs will fund bariatric surgery when all of the following criteria are met:

They have a BMI of 40 kg/m2 or more, OR between 35 kg/m2 and 40 kg/m2 and other significant diseases (type 2 diabetes or high blood pressure) that could be improved if they lost weight AND

All appropriate non‐surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss AND

The person has been receiving or will receive intensive management in a tier 3 service AND

The person is generally fit for anaesthesia and surgery AND

The person commits to the need for long term follow up For further details see NICE clinical guidance CG189: https://www.nice.org.uk/guidance/cg189/chapter/1‐recommendations

Gynaecology/Urology Category 1 Procedures: Individual funding request (IFR)

Cosmetic genital procedures (Labiaplasty – excluding Female Genital Mutilation (refer to circumcision category 2 prior approval policy) Dilation & curettage (D&C) for heavy menstrual bleeding in women Double balloon enteroscopy for diagnostic purpose MRI guided ultrasound (MRgFUS) for uterine fibroids Non‐medical circumcision Reversal of female sterilisation and reversal of vasectomy Sacral nerve stimulation for faecal and urinary incontinence Varicocele

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Bartholin’s cysts Criteria

With prior approval, NEL CCGs will fund the surgical treatment of Bartholin’s cysts which cause one of the following:

1. Significant pain OR 2. Have become infected requiring anti‐biotic treatment on at least two separate occasions

Circumcision Criteria

With prior approval, NEL CCGs will fund circumcision when one of the following criteria are met: 1. Phimosis seriously interfering with urine flow and/or associated with recurrent infection OR 2. Paraphimosis OR 3. Suspected cancer or balanitis obliterans OR 4. Congenital urological abnormalities when skin is required for grafting and interference with sexual activity

in adult males OR 5. Recurrent, significantly troublesome episodes of infection beneath the foreskin OR 6. To restore functional anatomy after female circumcision to facilitate childbirth where mutilation renders

this hazardous

Female circumcision (Female Genital Mutilation) is prohibited under the Prohibition of Female Circumcision Act 1995.

Hysterectomy for menorrhagia (heavy menstrual bleeding) Criteria

Based on NICE guidelines [Heavy menstrual bleeding: assessment and management [NG88] Published date: March 2018], hysterectomy should not be used as a first‐line treatment solely for heavy menstrual bleeding. It is important that healthcare professionals understand what matters most to each woman and support her personal priorities and choices. With prior approval, NEL CCGs will fund hysterectomy when criteria 1 and 3(a), 3(b) and 3(c) are met or 2 and 3(a), 3(b) and 3(c) are met: Hysterectomy should be considered only when: 1. Where other treatment options have failed OR 2. Where other treatment options are contradicted OR 3a. there is a wish for amenorrhoea (no periods) AND 3b. the woman (who has been fully informed) requests it AND 3c. the woman no longer wishes to retain her uterus and fertility

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NICE guideline NG88 1.5 Management of HMB: When agreeing treatment options for HMB with women, take into account: the woman's preferences, any comorbidities, the presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis, other symptoms such as pressure and pain. With prior approval, NEL CCGs will fund treatment for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis when one of the following criteria are met:

1. Consider an LNG‐IUS (levonorgestrel‐releasing intrauterine system) as the first treatment for HMB in women with: no identified pathology or fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity or suspected or diagnosed adenomyosis.

OR 2. If a woman with HMB declines an LNG‐IUS or it is not suitable, consider the following pharmacological treatments: non‐hormonal: tranexamic acid, NSAIDs (non‐steroidal anti‐inflammatory drugs), hormonal: combined hormonal contraception, cyclical oral progestogens. Be aware that progestogen‐only contraception may suppress menstruation, which could be beneficial to women with HMB. OR 3. If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to specialist care for: investigations to diagnose the cause of HMB, if needed, taking into account any investigations the woman has already had and alternative treatment choices, including: pharmacological options not already tried, surgical options: second‐generation endometrial ablation, hysterectomy. OR 4. For women with submucosal fibroids, consider hysteroscopic removal Treatments for women with fibroids of 3 cm or more in diameter Consider referring women to specialist care to undertake additional investigations and discuss treatment options for fibroids of 3 cm or more in diameter. If pharmacological treatment is needed while investigations and definitive treatment are being organised, offer tranexamic acid and/or NSAIDs. Advise women to continue using NSAIDs and/or tranexamic acid for as long as they are found to be beneficial. For women with fibroids of 3cm or more in diameter, take into account the size, location and number of fibroids, and the severity of the symptoms and consider the following treatments: pharmacological: non‐hormonal: tranexamic acid, NSAIDs, hormonal: LNG‐IUS, combined hormonal contraception, cyclical oral progestogens, uterine artery embolization, surgical: myomectomy, hysterectomy. Be aware that the effectiveness of pharmacological treatments for HMB may be limited in women with fibroids that are substantially greater than 3cm in diameter. Prior to scheduling of uterine artery embolisation or myomectomy, the woman's uterus and fibroid(s) should be assessed by ultrasound. If further information about fibroid position, size, number and vascularity is needed, MRI should be considered. [2007] Consider second‐generation endometrial ablation as a treatment option for women with HMB and fibroids of 3cm or more in diameter who meet the criteria specified in the manufacturers' instructions. If treatment is unsuccessful: consider further investigations to reassess the cause of HMB, taking into account the results of previous investigations and offer alternative treatment with a choice of the options described in recommendation.

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Pretreatment with a gonadotrophin‐releasing hormone analogue before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus.

General Surgery Category 1 Procedures: Individual funding request (IFR)

All treatments for vascular lesions


Abdominal wall hernia management and repair Criteria

With prior approval, NEL CCGs will fund abdominal wall hernia management and repair when one of the following hernias are diagnosed: 1. Symptomatic hernias (i.e. hernias causing pain) OR 2. Irreducible hernias OR 3. All femoral hernias OR 4. Spigelian hernias OR 5. Inguinal hernias extending to scrotum OR 6. Incisional hernias with small defects OR 7. Hernias at risk of strangulation ‐ small neck OR 8. Symptomatic umbilical hernias

Abdominoplasty Criteria

With prior approval, NEL CCGs will fund abdominoplasty following significant weight loss after bariatric surgery when criteria 1 is met or when criteria 2(a) and 2(b) are met: Section 1: Following weight loss 1. Following non bariatric surgery weight loss have a stable BMI of less than 27 Kg/m2 for at least 24 months OR 2(a). Following post bariatric surgery weight loss have a stable BMI of less than 27 Kg/m2 for at least 24 months AND 2(b).Had their surgery at least two years previously With prior approval, NEL CCGs will fund abdominoplasty following significant weight loss after natural weight loss when one of criteria 3(a), 3(b) or 3(c) are met: Section 2 have severe functional problems from excessive abdominal skin folds as defined as: 3(a). Severe difficulties with daily living (i.e. walking, dressing, toileting) which have been formally assessed, and for which abdominoplasty will provide a clear resolution OR

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3(b). Documented evidence of clinical pathology due to excess overlying skin e.g. recurrent infections or intertrigo which has led to ulceration requiring four or more courses of antibiotics in the 24 month period of stable weight OR 3(c). Where overhanging skin makes it impossible to maintain care of stoma bags

Haemorrhoidectomy Criteria

Often haemorrhoids (especially early stage haemorrhoids) can be treated by simple measures such as eating more fibre or drinking more water. If these treatments are unsuccessful many patients will respond to outpatient treatment in the form of banding or perhaps injection. With prior approval, NEL CCGs will fund haemorrhoidectomy when one of the following criteria are met: 1. Do not respond to the non‐operative measures outlined above OR if the haemorrhoids are more severe 2. Recurrent grade 3 or grade 4 combined internal/external haemorrhoids with persistent pain or bleeding OR 3. Irreducible and large external haemorrhoids In cases where there is significant rectal bleeding the patient should be examined internally by a specialist.

Varicose veins Criteria

Intervention in terms of, endovenous thermal (laser ablation, and radiofrequency ablation), ultrasound guided foam sclerotherapy, open surgery (ligation and stripping) are all cost effective treatments for managing symptomatic varicose veins compared to no treatment or the use of compression hosiery. For truncal ablation there is a treatment hierarchy based on the cost effectiveness and suitability, which is endothermal ablation then ultrasound guided foam, then conventional surgery. With prior approval, NEL CCGs will fund varicose veins when one of the following criteria are met: 1. Symptomatic * primary or recurrent varicose veins OR 2. Lower limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous

insufficiency OR 3. Superficial vein thrombophlebitis (characterised by the appearance of hard, painful veins) and suspected

venous incompetence OR 4. A venous leg ulcer (a break in the skin below the knee that has not healed within two weeks) OR 5. A healed venous leg ulcer. *Symptomatic: “Veins found in association with troublesome lower limb symptoms (typically pain, aching, discomfort, swelling, heaviness and itching).” [NICE CG 168] For patients whose veins are purely cosmetic and are not associated with any symptoms do not refer for NHS treatment. Refer people with bleeding varicose veins to a vascular service immediately. Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable.

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Physiotherapy Category 1 Procedures: Individual funding request (IFR)

Manual therapies (osteopathy – outside of an MSK integrated service)

Medicine Category 1 Procedures: Individual funding request (IFR)

Ketogenic diet for epilepsy

Alternative therapy Category 1 Procedures: Individual funding request (IFR)

Acupuncture Herbal medicines Homeopathy

Other Category 2 Procedures: Prior Approval (PA)

Botulinum toxin (not cosmetic) Criteria

NEL CCGs will not fund the use of Botulinum Toxin for cosmetic treatments. Botulinum Toxin applications in oculoplastics With prior approval, NEL CCGs will fund the use Botulinum A by an oculoplastics specialist when one of the following criteria are met: Section 1: Entropion Botox will be commissioned by NEL CCGs for patients with INVOLUTIONAL entropion who meet one of the following criteria: 1. Have a corneal ulcer/keratopathy secondary to entropion OR 2. Where surgery is contraindicated due to medical co‐morbidities not warranting cessation of

anticoagulation OR 3. Patient with advanced dementia, who is not fir for surgery under local, with or without sedation or

general anaesthesia

Section 2: Corneal Ulcer/lagophthalmos With prior approval, NEL CCGs will fund corneal ulcer/lagophthalmos by an oculoplastics specialist when one of the following criteria are met: Botox will be commissioned by NEL CCGs for patients with corneal ulcer/ lagophthalmos who: 1. Have a corneal ulcer due to facial palsy and lagophthalmos to induce a protective ptosis OR 2. Have a corneal ulcer due to lagopthalmos secondary to eyelid retraction, trauma or proptosis to induce a

protective ptosis

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Botox treatment may need to be repeated after three to six months. Prior approval is not required for the following treatments: Blepharospasm Botulinum A toxin is routinely funded and does not require prior approval for the treatment of blepharospasm. For palmar or plantar hyperhidrosis, other procedures such as iontophoresis appear to be more effective and have fewer side effects and should be considered as initial treatment. Botulinum A toxin is routinely funded and does not require prior approval for: 1. spasticity, hand and wrist disability associated with stroke, hemofacial spasm, spasmodic torticollis 2. severe hyperhidrosis, overactive bladder syndrome Botulinum B toxin is routinely funded and does not require prior approval for: 1. spasmodic torticollis 2. as alternative to Botulinum toxin A in presence of antibodies to Botulinum A. Botulinum A will also be approved for treatment of migraine for patients who meet the criteria described in NICE TA 260: 1.1 Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with

chronic migraine (defined as headaches on at least 15 days per month of which at least eight days are with migraine) that has not responded to at least three prior pharmacological prophylaxis therapies and whose condition is appropriately managed for medication overuse.

Botox treatment needs to be repeated after six to nine months. 1.2 Treatment with botulinum toxin type A that is recommended according to 1.1 should be stopped in people whose condition: is not adequately responding to treatment (defined as less than a 30% reduction in headache days per month after two treatment cycles) or has changed to episodic migraine (defined as fewer than 15 headache days per month) for three consecutive months.

Open MRI Criteria

Claustrophobic patients Most patients with claustrophobia can be successfully scanned using a conventional MRI scanner. With prior approval, NEL CCGs will fund open MRI when 1(a) and 2 or 1(b) and 2 of the following criteria are met: 1(a). The patient has failed to tolerate a conventional scan using feet first OR 1(b). Oral sedation approaches as appropriate AND 2. Confirm that no other diagnostic tests are suitable. If more serious health problems preclude sedation, this will need to be detailed Obese patients Patients who are too large to fit within a conventional MRI scanner should be referred by a secondary care clinician to a bariatric MRI service.

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Appendix A This appendix provides more clinical guidance for treatments for category 1 procedures (IFR) through either the

work of London Choosing Wisely or the National Evidence Based Interventions.


Injections for non‐specific low back pain Criteria

Spinal injections of local anaesthetic and steroid should not be offered for patients with non‐specific low back pain. For people with non‐specific low back pain the following injections should not be offered:

Facet joint injections

Therapeutic medial branch blocks

Intradiscal therapy

Prolotherapy

Trigger point injections with any agent, including botulinum toxin

Epidural steroid injections for chronic low back pain or for neurogenic claudication in patients with central spinal canal stenosis

Any other spinal injections not specifically covered above Radiofrequency denervation can be offered according to NICE guideline (NG59) if all non‐surgical and alternative treatments have been tried and there is moderate to severe chronic pain that has improved in response to diagnostic medical branch block. Epidurals (local anaesthetic and steroid) should be considered in patients who have acute and severe lumbar radiculopathy at time of referral. Alternative and less invasive options have been shown to work e.g. exercise programmes, behavioural therapy, and attending a specialised pain clinic. Alternative options are suggested in line with the National Back Pain Pathway. For further information, please see: https://www.nice.org.uk/guidance/ng59

Dilation & curettage (D&C) for heavy menstrual bleeding in women Criteria

D&C should not be used for diagnosis or treatment for heavy menstrual bleeding in women because it is clinically ineffective. UIltrasound scans and camera tests with sampling of the lining of the womb (hysteroscopy and biopsy) should be used to investigate heavy periods. Medication and intrauterine systems (IUS) should be used to treat heavy periods. NICE guidelines recommend that D&C is not offered as a treatment option for heavy menstrual bleeding. There is very little evidence to suggest that D&C works to treat heavy periods and the one study identified by NICE showed the effects were only temporary. D&C should not be used to investigate heavy menstrual bleeding as hysteroscopy and biopsy work better. Complications following D&C are rare but include uterine perforation, infection, adhesions (scar tissue) inside the uterus and damage to the cervix.

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Knee arthroscopy for patients with osteoarthritis Criteria

Arthroscopic knee washout (lavage and debridement) should not be used as a treatment for osteoarthritis because it is clinically ineffective. Referral for arthroscopic lavage and debridement should not be offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking. More effective treatment includes exercise programmes (e.g. ESCAPE pain), losing weight (if necessary) and managing pain. Osteoarthritis is relatively common in older age groups. Where symptoms do not resolve after non operative treatment, referral for consideration of knee replacement, or joint preserving surgery such as osteotomy is appropriate.

Surgical interventions for snoring in the absence of obstructive sleep apnoea Criteria

It is on the basis of limited clinical evidence of effectiveness, and the significant risks that patients could be exposed to, this procedure should no longer be routinely commissioned in the management of simple snoring. Alternative Treatments There are a number of alternatives to surgery that can improve the symptom of snoring. These include: • Weight loss • Stopping smoking • Reducing alcohol intake • Medical treatment of nasal congestion (rhinitis) • Mouth splints (to move jaw forward when sleeping) In two systematic reviews of 72 primary research studies there is no evidence that surgery to the palate to improve snoring provides any additional benefit compared to other treatments. While some studies demonstrate improvements in subjective loudness of snoring at 6‐8 weeks after surgery; this is not longstanding (> 2years) and there is no long‐term evidence of health benefit. This intervention has limited to no clinical effectiveness and surgery carries a 0‐16% risk of severe complications (including bleeding, airway compromise and death). There is also evidence from systematic reviews that up to 58‐59% of patients suffer persistent side effects (swallowing problems, voice change, globus, taste disturbance & nasal regurgitation). It is on this basis the interventions should no longer be routinely commissioned.

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11 September 2019

Title of report Month 3 Performance Report

Item number 5.1

Author Archna Mathur, Director of Performance & Assurance, NELCA

Presented by Archna Mathur, Director of Performance & Assurance, NELCA

Contact for further information

Archna Mathur, Director of Performance & Assurance, NELCA

Executive summary

The paper outlines the performance headlines as at M3 201920 (or latest position where available) and provides an update on the Operating Plan Performance trajectories for 2019/20. Key points for JCC to note:

A&E Performance August YTD

Barts Health: 87.19% vs 88.75% trajectory with Newham with the most significant performance shortfall against trajectory 88.07% vs 92.41% trajectory (4.34% variance) WX 88.57% vs 88.75% trajectory (exceeding trajectory by 3.82%) and RLH 84.59% vs 88.38% trajectory. (4.16% shortfall)

BHRUT: 79.9% vs 88.41% trajectory (8.51% variance) Homerton: 95.77% vs 95.45% trajectory.

RTT Performance May

Barts achieved 84.55% vs 85.8% trajectory with a PTL size of 88,773 (727 pathways within plan).

The May position on > 52 ww was 21 vs 17 trajectory. BHRUT achieved 82.67% vs 82.3% trajectory with a PTL size of

40,494 (above plan of 38,596 by 1898) The May position on > 52 ww was 29 vs trajectory of zero. Homerton achieved 96.1% vs 95.1% trajectory with a PTL size of

19,791 (within plan by 291) The key focus is on reduction of the > 52 ww at Barts Health and

BHRUT with weekly tracking of the unvalidated position, more robust operational processes to understand breach reasons and outsourcing where feasible. The NEL Demand and Capacity Group has reviewed the year end position and is assessing the risks to the 19/20 delivery of the key elective programme deliverables.

Diagnostics (DM01) Performance May (< 1%)

Barts Health did not achieve the DM01 standard for May with 2.41% with particular challenges in MRI capacity.

BHRUT did not achieve the DM01 standard for May with 10.04% against a trajectory of 6.5%. Main challenges are in non -obstetric ultrasound and endoscopy.

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Cancer (855 standard)

Barts achieved 84.96% BHRUT achieved 76.21% Homerton achieved 89.29%

CHC (Continual Health Care) assessments completed within 28 days

At Q1 2019/20 NEL STP performance was 65.6%, an improvement on the previous quarter but below the 80% target. 5/7 CCGs achieved the target, exceptions were Havering 59% and R4dbridge 58.3%

CHC Assessments in the acute setting (< 15% target)

STP level performance at Q1 2019/20 was 8.9%, achieving the <15% maximum target.

NHS 111, Of calls triaged, % of Ambulance dispatches

In June -19, NEL (LAS provider) % Ambulance dispatches was 9% compared to 11% at London level

NHS111 % Calls Closed as Self-care

In June-19, NEL (LAS provider) performance of calls closed as self-care / Consult and Complete was 27% compared to 25% in May. NEL did not achieve the standard of 33%. Mental Health latest Performance

CYP Access

NEL STP performance at Q1 2019/120 was 113.2% achieving the Q1 target.

Indicative data for June suggests 3 CCGs on track to achieve the Q1 CYP access target, Havering, Tower Hamlets and Waltham forest, B&D, C&H, Newham and Redbridge are currently under performing against Q1 plan.

IAPT Access Rate

NEL STP’s access rate performance in Q1 was 5.1%, achieving the 4.8% operating plan target. Local indicative data shows C&H, Newham and tower Hamlets are on track to achieve IAPT access for Q1, performance challenged in the three BHR CCGs and Waltham Forest.

IAPT Recovery

NEL STP’s recovery rate performance at Q1 was 53.7%, achieving the 50.2% standard. Local indicative 3 months rolling position for June suggests 6/7 CCGs achieving the Q1 operating plan target, with the exception B&D CCG.

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Dementia

NEL STP performance for June 19 was 69.3%, ahead of the 66.7% standard. Only B&D and Havering fell short of the target by 14 and 86 patients respectively.

Transforming Care (Reducing reliance on inpatient care for people with learning disabilities) STP level position at May 19 (Q4) showed 30 adults with learning

disabilities in receipt of inpatient care, 27 below Q1 57 target. This is a shared CCG/specialised commissioning indicator.

Inner north east London reported 15 adults in receipt of inpatient care during Q1, 22 below 37 plan with spec comm. accounting for 67%.

Outer north east London reported 15 adults in receipt of inpatient care during Q1, 5 below 20 plan.

Action required The JCC is asked to note this report.


This paper has been discussed at the NELCA SMT meeting on the 27 August 2019

Strategic fit



Commissioning Implications:

Underperformance against constitutional standards creates a case for change in the way in which services are commissioned and how both elective and non elective demand is planned and managed by commissioners and primary care.

Local Authority/integrated commissioning implications:

As above with implications specifically for integrated commissioning around urgent care, reducing lengths of stay, commissioning of care home capacity for example.


Local people will be aware of how services that are commissioned to meet their needs around quality, safety and access perform, and the processes in place to provide assurance


The performance report highlights national standard performance which means that all services across England are measured in the same way for equitable delivery.


The performance report highlights where increases in activity could be driving commissioning costs e.g. A&E attendances or unplanned admissions, with the consequence of under performance against a national standard. If a performance standard is not delivered, this could impact on patient quality e.g. waiting times for outpatient appointments or planned surgery, resulting in the need to ensure processes are in place gain assurance on patient safety and minimising the risk of clinical harm. Equally, if performance standards are met, then the impact on patient outcomes will be seen e.g. delivery of the 62 day cancer standard driving improving early diagnosis and one year survival.

Risks Current risks are insufficient improvement to consistently deliver 18 weeks, reduction in over 52 week waiters, A&E standards, diagnostic access times and consistent delivery of Mental health standards

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NEL STP Performance Report

Monthly report - M3 2019/20

Produced by NEL POD Performance team V9Last updated: 08-08-2019 111

Data sources

Acute Indicators Data SourceFrequency of Update

Data typeMonth

reportedData Type Publication date

Monthly Delayed Transfer of Care NHS England Monthly Overall Provider May-19 Published 11/07/2019

Cancer Waiting Times (CWT) NHS England/NHS Digital MonthlyOverall Provider Commissioner based

May-19 Published 09/07/2019

RTT NHS Digital Monthly Overall Provider May-19 Published 11/07/2019

Diagnostics NHS Digital Monthly Overall Provider May-19 Published 11/07/2019

A&E NHS England Monthly Overall Provider Jun-19 Published 11/07/2019

Ambulance Handover HAS portal Daily Overall Provider Jun-19 Published 19/07/2019

% CHC Assessments in an Acute Setting NHS Digital Monthly Commissioner Based Q1 2019/20 CCG reported data 15/07/2019

% Referrals completed within 28 days NHS Digital Monthly Commissioner Based Q1 2019/20 CCG reported data 15/07/2019

Minors Breaches Trust Data Monthly Provider and Site Level Jun-19Trust Unvalidated Site level

dataNA

LOS > 21 days Long Stays Dashboard Monthly NHS Improvement Analytics Hub Jun-19 Published 11/07/2019

111 CallsNHS England/NHS DigitalTrust data Monthly Provider Jun -19 Published and Trust 11/07/2019

FDS NHS Digital Monthly Provider /Commissioner May-19 Shadow reporting 17/07/2019

The NEL STP performance report uses the latest published data available at time this report was produced. The period the data refers to, publication dates and data sources are detailed in the tables below.

Mental Health Indicators Data SourceFrequency of Update

Data typeMonth

reportedData Type Publication date

IAPT Access and Recovery Rates NHS Digital Monthly Commissioner based Jun-19 (Provisional) CCG local data 18/07/2019

CPA 7 day follow-up & Gatekeeping NHS Digital Quarterly Commissioner based Mar-19 (Q4) Published 10/05/2019

Children and Young Person’s Access Rate NHS Digital Monthly Commissioner based Jun-19 (Provisional) CCG local data 24/07/2019

Early Intervention in Psychosis (EIP) NHS Digital Monthly Commissioner based Jun-19 Published 8/08/2019

Dementia Estimated Diagnosis Rate NHS Digital/NHS England Monthly Commissioner based Jun-19 Published 11/07/2019

Inappropriate Out of Area Placements NHS Digital Monthly Commissioner based Apr-19 Published 11/07/2019

SMI Physical Healthchecks NHS Digital SDCS return Quarterly Commissioner based Q1 2019/20 CCG SDCS submission 15/07/2019

Eating Disorders NHS Digital Quarterly Commissioner based Q1 2019/20 Published 8/08/2019

IP care for people with learning disabilities. TPMO report Monthly Commissioner based May-19 CCG & spec comm data 6/08/2019

Patients on GP LD Register receiving AHC NHS Digital Quarterly Commissioner based Q4 2018/19 Published 5/07/2019

Children’s Wheelchair Equipment NHS Digital Quarterly Commissioner based Q1 2019/20 Published 31/07/2019

112

Executive Summary

Sustained Improvement(>3months)

Recent Improvement Areas of Particular Concern Issues

The following metrics remainedon track with sustainedachievement of targets acrossthe STP for three months orlonger.

• Mental Health IAPT WaitingTimes (recovery)

• Mental Health Dementia• MH EIP waiting times• CHC assessments in acute

setting (at STP level)

Five metrics either improved further ormaintained recent improvement

• Minor breaches: remains in the improvingcategory for Jun-19 with 99.4%.Performance is consistently above 99%(albeit June saw a very minor drop inperformance compared to May-19 99.5%).

• Diagnostics: NEL STP performance of 4.15% in May-19. A 0.34% improvement against Apr-19 performance of (4.49%). This improvement is driven by better performance across all three NEL Providers.

• MH CYP Access: NEL STP reported aprovisional position of 13.2% for Q12019/20 in line with Q1 operating plantrajectory.

• IAPT Access: NEL STP access rateperformance in Jun-19 (provisional) was5.1%, meeting the Q1 4.8% operating plantarget. 3/7 CCGs met target.

Continued improvement noted for:

• LOS: NEL STP achieved the length of stayambition in Jun-19 reporting a week 12position of 387 patients waiting >21 daysagainst a trajectory of 408.

One metric showed a deterioration which movedthem down a performance category:

The following metrics remain in the lowestcategory, ‘not improving’:

• RTT: In May-19, NEL achieved 85.64%. ThePTL position is 1,939 over plan for NEL STP;driven by BHRUT (2,353 pathways) and HUH(291 pathways). The volume of 52ww in May-19 at BHRUT (29) and Barts (21) againsttrajectory remains a risk. Provisional data forJun-19 indicates 20 breaches at BHRUT, 16 atBarts and zero at HUH.

• LAS Handovers: In Jun-19, NEL STP handoverswithin 30 minutes was 89.0% in Jun-19 (aminor improvement on May’s performance).There were six 60 minute breaches reportedin Jun-19; whereas in May there were noreported 60 minute breaches. QueensHospital is the predominant driver of 30 and60 minute breaches for the STP.

• A&E 4 hour: NEL STP A&E performance inJun-19 was 84.34%, 4.06% below STPtrajectory.

• Serious Mental Illness Physical Healthchecks:During Q1 2019/20, 40.1% NEL STP patientson GP SMI register received all six physicalhealthchecks, below the 50% Q1 target. OnlyCity and Hackney CCG achieved this target.

• CHC completed within 28 days: For Q119/20, NEL STP performance was 65.6%,below the 80% target. 5/7 CCG achievedtheir local recovery trajectories, withHavering (59%) and Redbridge (58.3%)blow their trajectories. BHR CCGsaccounted for 84% of the total reported 28day pathway breaches across NEL for Q119/20.

• MH Inappropriate Out of Area Placements:NEL STP reported a total of 670 days in Apr-19, compared with 580 days in Mar-19. Thisincrease was mainly at B&D and WalthamForest CCGs reflecting demand pressuresand low bed capacity at NELFT

• DTOC: NEL STP average bed days lost toDTOCs in May-19 was 118, above thetarget of 69. The position deterioratedfrom Apr-19 position of 111.

• Cancer 62 day: The Cancer standard wasnot achieved this month at an STP levelfollowing many months of compliance.BHRUT is the key driver to under-performance.

• NHS 111: performance for % calls answeredwithin 60 seconds dipped to 91.7% against95% standard. However, NEL STPperformance is above the London average.

Summarises the key issues from this months STP Performance Report; identifies key changes from previous month’s report including changes between the categories of performance achievement on the next slide.

4Key: GREEN: Sustained Improvement >than 3mths LIGHT GREEN: Recent Improvement RED: Denotes areas of Particular Concern BURGUNDY: Denotes areas where issues persists

113

Currently compliant against trajectory/performance standard but performance at risk AT RISK (2)

Mental Health Dementia

Mental Health IAPT Access

Mental Health CYP Access

Mental Health IAPT recoveryTransforming Care

IP reduction Learning Disabilities

14 - 1 p 1 p 4 - 1 p

NEL STP performance during Jun-19 was 69.3%, delivering above the 66.7% national standard.

NEL STP’s access rate performance in Jun-19 (provisional) was 5.1%, meeting the target. 3/7 CCGs met target.

NEL STP 2019 May (provisional) performance was 13.2%, in line with Q1target of 13.2%.

NEL STP IAPT recovery rate performance in Jun-19 (provisional) was 53.7%, above the 50% standard. 6/7 CCGs achieved the standard.

NEL STP level position at May-19 showed 30 adults with learning disabilities (LD) in receipt of inpatient care, 27 within the NHSE target of 57.

ELHCP STP Executive Performance update – M3 2019/20

Performance On Track against trajectory/ performance standard ON-TRACK (1)

Mental Health EIP waiting time

5 -

NEL STP achieved the waiting times element of EIP across 7 of 7 CCGs in Jun-19 reporting 87.3%, delivering on the operating plan 2019/20 target of 56%.

Not compliant and performance trajectory deteriorating /not improving NOT IMPROVING (4)

Elective Care RTT

CHC 28 dayU&ECDTOC

A&E 4 Hour Wait LAS Handovers

Mental Health SMI Physical Healthcheck

NHS 111

14 - 11 - 4 - 3 - 3 - 4 q 1 q

NEL STP achieved 85.64% in May-19. The NEL PTL position is 1939pathways over-plan for the month, mainly driven by BHRUT (2,353 pathways over-plan) and HUH (291 pathways over-plan).

STP level performance during Q1 19/20 was 65.6%, below the 80% target.

NEL STP average bed days lost to DTOCs was 118 in May-19; exceeding the revised NEL STP target of (69)and a deterioration on Apr-19

NEL STP A&E performance in Jun-19 was 84.34%, 4.06% below STP trajectory.

NEL STP performance deteriorated by 1.77% from the previous month driven by a drop in performance across all NEL Providers.

NEL STP performance against the 30 minute handover threshold was 89.0% in Jun-19, a 0.7% improvement from the previous month.

In Jun-19 for NEL STP the number of 30 min LAS handover breaches was 1,506, up from 1,315 in May-19.

During Q1 2019/20,40.1%. NEL STPpatients on GP SMIregister received allsix physicalhealthchecks, belowthe 50% Q1 target.

In Jun-19, NEL reported 91.% of calls answered within 60 seconds; a deterioration compared to 95.8% in May-19 and below the 95%standard. NEL’s % calls abandoned within 30 seconds was achieved with 1.0%.

Performance improving but not yet on track IMPROVING (3)

Minors BreachesLOS >21 Days Diagnostics

2 - 3 - 1 p

NEL STP achieved 99.4% in Jun-19 – a minor decrease on 99.5% reported the previous month.

NEL STP reported 148 breaches in Jun-19, anincrease from 141 reported in May-19 with a decrease in the volume of attendances.

NEL STP achieved the trajectory for Jun-19 (week 12) with a position of 387 against a trajectory of 408. All trusts were compliant with trajectory for Jun-19.

NEL STP improved but remained non-compliant in May-19 against the diagnostics DM01 standard at 4.15%, above the national standard of 1%.

The improvedposition seen this month at STP levelwas driven by improvements in DM01 performance across all three NEL Providers.

Issu

es

/ A

ctio

n /

Mit

igat

ion

Diagnostics Elective Care RTT Mental Health

NEL STP deterioration in performance was driven by a Barts Health (2.41% driven predominantly by MRI) and deterioration at BHRUT (10.04%) against the 1% Standard. BHRUT DMO1 trajectory forecasts delivery in Sept-19. Barts is currently implementing a MRI recovery action plan and forecasts return to compliance at modality in Aug-19. Barts are running evening and weekend lists and outsourcing to Inhealth to mitigate backlog and support recovery. A business case is being taken to the Trust’s investment steering committee for resource to support recovery and options for outsourcing in the locality are being explored.BHRUT has worked up recovery actions for the challenged modalities and provide weekly DM01 reporting which is discussed at the planned care programme board and at CRG. BHRUT’s financial position is having a significant impact on overall delivery.

NEL STP performance remains challenged across Barts Health and BHRUT. At Barts Health the number of 52ww remained static at 21 in May same as in April. The PTL for May-19 was 88,695 pathways, delivering below the plan (89,400) for the month. Provisional data indicates the Trust is on track to deliver the operating plan expectation for Jun-19 of no more than 89, 000 pathways on the PTL and fewer than 17 pathways >52ww.BHRUT achieved 82.67% in May-19, narrowly missing the trajectory of 82.3% for the month.At month end, the PTL was 40,494 up from 39,575 in Apr-19 and 1,898 above the plan of 38,596 for M2 of 19/20. Significant risk in the number of patients waiting over 52+ ww as position albeit marginally improved to 29 this month and unvalidated data indicates June-19 is circa 20.

IAPT access and recovery rates have shown an overallimprovement across the STP during Q1 2019/20 basedon indicative data. BHR recovery plans are in place,with oversight through STP MH Assurance Group.CYP Access Rate: NEL 2018/19 final position following national refresh exercise was 29.8% (2.2 percentage points below 32% target). CCG level recovery plans are in place to support delivery during 2019/20. CYP overall STP level performance at Q1 2019/20 is in line with Q1 trajectory.

URGENT AND EMERGENCY CARE

ELELCTIVECARE

CANCER/DIAGNOSTICS

PRIMARYCARE

MENTAL HEALTH TRANSFORMING CARE

Key: Number of consecutive months that performance is in assigned category.

Arrows denote movement between categories.qp , no change -

114

SRO: Archna Mathur Urgent and Emergency Care: Out of Hospital

How are we performing?

KPI ELHCP Site/ CCG

NHS111

% Calls answered within 60 seconds

95% standard

• In Jun-19, NEL (LAS provider) performance for % calls answered within 60 seconds deteriorated to 91.7% from 95.8% the previous month. This represents a variance of (-4.2%). NEL performance is above the London performance average of (85.4%) for Jun-19.

NHS111

% Calls abandoned after 30 seconds

< 5 =% standard

• In Jun-19, NEL (LAS provider) % calls abandoned within 30 seconds achieved the standard with 1.0% from 0.4% in May-19. London’s position in Jun-19 worsened to (2.6%).

NHS111Of calls triaged, % of Ambulance dispatches

• In Jun-19, NEL (LAS provider) % Ambulance dispatches was 9.0% from 8.6% in May-19. London’s position in Jun-19 (11.0%) remained marginally stable.

NHS111% Calls Closed as Self-care

Standard 33%

• In Jun-19, NEL (LAS provider) performance of calls closed as self-care / Consult and Complete was 27%, compared to May-19 position of 25%. NEL did not achieve the standard of 33%.

What are our key issues impacting delivery?

Theme Issue description and root cause Mitigation Owner/ lead Resolution date

1. 111 Performance Call answering standard and call abandonment standards have been met. The percentage of closed calls as self-care continues to improve, however remains below the national standard of 33%.

The LAS performance improvement plan is now delivering the required trajectories.

LAS March 2020

115

SRO: Archna Mathur Urgent and Emergency Care: CHC


KPI NEL STP Site/ CCG Tables and graphs

% CHC assessments taking place in acute setting: <15%

STP level performance during Q1 2019/20 was 8.9%, achieving the <15% maximum target.

• 6/7 CCGs achieved the Q1 2019/20 agreed NHSE local recovery trajectory target. The exception was City and Hackney: 23.1% (9/39 breaches).

% CHC referrals completed within 28 days of a positive checklist decision: >80%

STP level performance during Q1 2019/20 was 65.6%, below the 80% target.

• 5/7 CCGs achieved the Q1 2019/20 agreed NHSE local recovery trajectory target. The two exceptions were Havering: 59% and Redbridge: 58.3%.

• The BHR CCGs accounted for 84% of the totalreported 28 day pathway breaches across NELduring Q1 2019/20.



1 CHC Asst in an acute setting

Hospital process issues with out of area hospitals not being part of local decision to admit pathways. Limited access to nursing home capacity within the North East Inner London CCGs.

In Jun-19, NEL CHCs agreed recovery trajectories with NHSE which will beused to assess local CCG performance during 2019/20. Thesetrajectories show achievement of the location and 28 day target acrossall 7 CCGs by end of Q4 2019/20.Work has been undertaken with leads to develop a detailedunderstanding of the causes of underperformance to inform targetedaction planning and service improvement. A standard breach reportingtemplate has been developed and is in use by NEL CHC Commissionersto support monthly and quarterly national reporting to NHSE. NEL CHCimprovement group has been established to share good practice andintegrate services where required.

Local CCG commissioning lead.

Q4 2019/20

2 CHC Asst with a checklist in 28 days

Process delays in obtaining / providing completedpaperwork to facilitate timely and effective decisionmaking by panel, and social service engagement(notably in BHR).

Local CCG commissioning lead.

% CHC referrals completed within 28 daysCCG Recovery trajectory

Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q1 2019/20

Barking and Dagenham 70.4% 72.0% 51.3% 64.2% 66.9% 65%-69.9%

Havering 81.6% 60.3% 60.3% 65.6% 59.0% 65%-69.9%

Redbridge 66.0% 53.2% 54.9% 58.0% 58.3% 60%-64.9%

City and Hackney 81.6% 64.9% 73.8% 72.5% 78.8% 70%-74.9%

Newham 73.2% 75.7% 88.6% 92.0% 60.0% 60%-64.9%

Tower Hamlets 71.9% 45.7% 54.8% 36.8% 87.5% 78%-79.9%

Waltham Forest 76.7% 88.9% 92.0% 97.0% 94.6% 80.0%

North East London STP 74.9% 65.4% 60.6% 64.3% 65.6%

Tolerance level (80%) 80% 80% 80% 80% 80%

Q1 2019/20 Performance RAG rated against NHSE agreed 2019/20 recovery trajectory.

QUARTERLY ACTUALS

% CHC assessments in an acute setting CCG Recovery trajectory

Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q1 2019/20

Barking and Dagenham 3.4% 12.2% 12.5% 3.1% 8.8% 15.0%

Havering 1.8% 20.0% 15.0% 9.0% 5.2% 15.0%

Redbridge 4.2% 10.3% 14.0% 5.5% 8.2% 15.0%

City and Hackney 54.3% 71.0% 26.3% 10.8% 23.1% 15.0%

Newham 43.8% 47.1% 17.6% 26.1% 6.5% 40%- 49.9%

Tower Hamlets 38.2% 42.4% 22.2% 26.7% 20.7% 35%-39.9%

Waltham Forest 15.6% 18.1% 14.3% 10.0% 10.8% 15.0%

North East London STP 17.7% 25.9% 16.0% 10.6% 8.9%

Tolerance level (<15%) 15% 15% 15% 15% 15%

Q1 2019/20 Performance RAG rated against NHSE agreed 2019/20 recovery trajectory.

QUARTERLY ACTUALS

116

SRO: Archna Mathur Cancer 62 day


KPI ELHCP Site/ CCG Tables and Graphs

Cancer 62 day

National standard 85%

As of Apr-19, the 62-Day standard is now measured on referral and treatment breach reallocation, in line with the new guidance.

• NEL STP failed to achieve the Cancer 62 Day standard in May-19 with a performance of (81.53%). This was down 4.76% when compared to Apr-19 performance.

• There was a total of 254.5 cases in NEL this month and 207.5 were treated in time. This means that there were 47.0 breaches treated outside of the 62 Days standard in NEL this month.

Two of the three NEL STP providers were non- compliant against the 62 day Urgent GP referral standard in May-19.

• BHRUT achieved (76.21%) with a 10.15% deterioration on last month

• Bart's achieved (84.96%) with a 1.74% deterioration on last month

• Homerton achieved (89.29%) with a 4.80% Improvement on last month.

Homerton returned to a compliant position this month following non compliance in April 2019.



1. BHRUT BHRUT's position for M2 was adversely impacted by an increasing Cancer PTL and increase in number of breaches across a number of tumour sites with Urology accounting for 35% of breaches seen this month. Performance for June is expected to meet the required target of 85%

Weekly SRO Touch point meetings and Monthly tripartite RTT escalation meetings.

BHRUT/ CCG July-19

2. BH There was a half breach allocated to the Trust from Southend Hospital in error; a letter has been sent to Southend Hospital Trust to remedy this. The reporting portal will be re-opened in December to allow validation of previous month’s reporting.

Barts Health will be revising the upload of data for May when the portal reopens in December 2019 and will be submitting a compliant position for the month.

BH Dec-19

NEL Providers May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19

BHRUT 86.00% 90.70% 85.13% 86.97% 85.94% 86.76% 87.90% 89.25% 85.35% 86.36% 87.07% 86.36% 76.21%

Barts Health 87.90% 86.10% 85.65% 86.75% 86.24% 86.73% 88.45% 87.01% 86.67% 85.86% 85.25% 86.70% 84.96%

Homerton 98.40% 88.70% 69.49% 84.48% 87.23% 91.38% 88.89% 87.23% 89.13% 91.49% 91.94% 84.48% 89.29%

NEL STP Providers 88.10% 88.50% 83.67% 86.63% 86.27% 87.23% 88.24% 88.01% 86.20% 86.68% 86.89% 86.29% 81.53%

117

SRO: David Maher Mental Health

ST


1 IAPT Access and Recovery Rate

• Whilst improvements in performance haveoccurred BHR CCG remains challenged, inpart due to staffing and recruitment issues.However B&D services appear morechallenged than others, the reasons for thisare not , as yet, fully understood.

• BHR: joint CCG/NELFT action plan in place to support delivery on access and recovery rate,trajectory agreed with commissioners to achieve 19.3% access by year end 19/20 withperformance weighted to Q2 onwards. Investigation into variance between BHR CCGs required.

• Local commissioners across NEL are working with providers to improve uptake rates by marketinglocal services, and explore scope for improved productivity in order to achieve the 2019/20national access ambition target of 22%.

CCG commissioning leads.

Q2 2019/20


KPI ELHCP Site/ CCG Tables and graphs

IAPT Access Rate

National target: 5.5% by Q4 2019/20

All NEL CCGs will be assessed against agreed 2019/20 operating plan trajectories

NEL STP’s access rateperformance at Q12019/20 was 5.1%,achieving the 4.8%operating plan target.3/7 CCGs Q1 target

• Local indicative data for June 2019 suggests that City &Hackney (C&H), Newham, and Tower Hamlets are on track toachieve the IAPT access rate target at Q1 2019/20.

• Performance remains challenged at the three BHR CCGs, andWF CCG.

IAPT Recovery Rate

National standard: 50%

All NEL CCGs will be assessed against agreed 2019/20 operating plan trajectories

NEL STP’s recoveryrate performance atQ1 2019/20 was53.7% achieving the50.2% operating plantarget. 6/7 CCGsachieved Q1 target

• Local indicative 3 month’s rolling position for June 2019suggests that 6/7 CCGs achieved Q1 operating plan target. Theexception was Barking and Dagenham reflecting variability inmonthly activity.

IAPT Access rate (Rolling 3 mths) Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19

Q1 2019/20

operating plan

trajectory

Barking and Dagenham 3.72% 3.77% 4.14% 3.97% 3.90% 3.80% 4.75%

City and Hackney 5.41% 5.43% 5.76% 5.82% 5.89% 6.12% 4.94%

Havering 4.06% 3.75% 4.06% 4.00% 4.00% 4.10% 4.75%

Newham 5.12% 4.88% 5.07% 5.01% 5.01% 5.08% 4.75%

Redbridge 3.26% 3.21% 3.66% 3.59% 3.76% 4.14% 4.75%

Tower Hamlets 3.81% 4.90% 6.10% 6.76% 7.25% 6.82% 4.94%

Waltham Forest 4.88% 4.43% 4.97% 4.65% 4.85% 4.82% 4.94%

NEL STP 4.40% 4.42% 4.91% 4.93% 5.06% 5.10% 4.84%

NHSE standard 4.75% 4.75% 4.75%

Data source: NHS Digital

Published data Local data

2019/20 perf. measured against local trajectory

IAPT Recovery rate (Rolling 3 mths) Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19Q1 operating

plan trajectory

Barking and Dagenham 47.0% 48.0% 51.7% 47.3% 51.1% 47.1% 50.0%

City and Hackney 58.7% 57.7% 57.0% 58.0% 58.5% 61.0% 50.6%

Havering 46.0% 48.0% 53.0% 56.3% 57.2% 58.2% 50.3%

Newham 50.0% 50.0% 52.0% 53.3% 53.9% 51.9% 50.1%

Redbridge 47.3% 46.0% 49.0% 53.7% 53.7% 51.7% 50.1%

Tower Hamlets 47.3% 50.7% 52.0% 51.7% 51.3% 52.4% 50.1%

Waltham Forest 54.7% 54.0% 55.0% 53.7% 54.2% 53.7% 50.1%

NEL STP 50.1% 50.6% 52.8% 53.4% 54.3% 53.7% 50.2%

National Standard 50.0% 50.0% 50.0%

Data source: NHS Digital

Published data Local data

2019/20 perf. measured against local trajectory

118


Theme Issue description and root cause

Mitigation Owner/ lead Resolution date

1 CYP Access Rate

• Under reporting of CYP access rate data by mental health and third sector providers due to data capture/ reporting technical and process issues.

.

• Local joint commissioner/provider recovery plans are in place to support delivery of the CYP Access target. Plans are reviewed and signed off through the NEL 5YFV Mental Health Assurance Group.

• B&D and Redbridge variance investigated and action plan produced including actions on staff training, recording, offering planned contacts and improved processes.

Local CCG commissioning leads.

Q2 2019/20

SRO: David Maher Mental Health



CYP Access Rate

Operating Plan standard 2019/20, 34%

NEL STP performance at Q1 2019/20 was 13.2%, achieving the 13.2% Q1 target.

3/7 CCGs Q1 operating plan target

• Local indicative data for June 2019 suggests 3 CCGs are on track to achieve the Q1 CYP access target: Havering, Tower Hamlets, and Waltham Forest.

• 4 CCGs are currently under performing against Q1 plan: Barking and Dagenham, City and Hackney, Newham, and Redbridge.

• 2018/19 final position has been provided byNHS Digital (shown in the bottom table).

• NEL STP performance was 29.8% (2.2percentage points below 32% target). 4/7CCGs achieved the national standard.

CYP Access Performance April 2018-March 2019 published (data refresh exercise 2019)

Barking & Dagenham CCG 6331 1169 18.5%

C&H CCG 5861 2395 40.9%

Havering CCG 4972 1631 32.8%

Newham CCG 8832 3038 34.4%

Redbridge CCG 6926 1384 20.0%

Tower Hamlets CCG 4162 1815 43.6%

Waltham Forest CCG 6412 1526 23.8%

NEL STP 43496 12958 29.8%

National CYP Target 32.0%

Comment

Approx. 91% patients treated by NELFT




Approx. 54% patients treated by ELFT, 41% by Homerton

Approx. 50% patients treated by ELFT, 47% by LB Newham

Approx. 84% patients treated by ELFT

Total CYP

seen

Final CCG annual

performance (%)Organisation

Operating plan

prevalence rate

CCG

Operating plan

prevalence rate

2019/20

Operating Plan

Trajectory Q1 2019/20

Actual May-Jun19

(local data)

Barking & Dagenham 6331 14.2% 9.2%

C&H CCG 5861 16.3% 15.3%

Havering CCG 4972 14.2% 19.5%

Newham CCG 8832 15.5% 12.5%

Redbridge CCG 6926 11.1% 10.2%

Tower Hamlets CCG 4551 14.2% 16.9%

Waltham Forest CCG 6412 7.2% 11.7%

NEL STP 43885 13.2% 13.2%

National Target (34% by Q4 2019/20)

Cumulative position CYP 2019/20 data

119

SRO: TBC Transforming Care



1 Reducing reliance on inpatient care for people with learning disabilities.

SRO with performance support to identify issues and mitigations to programme delivery.

Both CCG local commissioning leads and NHSE as specialist commissioner responsible for their respective elements.

N/A



Reducing reliance on inpatient care for people with learning disabilities.

STP level position at May-19 (Q4) showed 30 adults with learning disabilities (LD) in receipt of inpatient care, 27 below Q1 2019/20 NHSE reported target of 57.

This is a shared CCG/ Specialised Commissioning indicator.

• The CCG and Specialist Commissioning data on inpatientcare for adults with learning disabilities is divided intoperformance for Inner North East London and OuterNorth East London (see table).

• Inner North East London reported 15 adults in receipt ofinpatient care during Q1 (at May-19), 22 below 37 plan.Spec Comm accounted for 67% of inpatient provisionwithin INEL.

• Outer North East London reported 15 adults in receipt ofinpatient care during Q1 (at May-19), 5 below 20 plan.Spec Comm accounted for 33% of inpatient provisionwithin ONEL.

Adults position at May-19

Commissioner Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20

INEL - CCG 10 10 10 10 10 5

INEL - Specialised Commissioning 15 10 10 10 10 10

Inner North East London TCP 25 20 20 20 20 15

Inner North East London TCP Trajectory 37

position at May-19


ONEL - CCG 10 10 10 10 10 10

ONEL - Specialised Commissioning 5 10 5 5 5 5

Outer North East London TCP 15 20 15 15 15 15

Outer North East London TCP Trajectory 20

position at May-19


Total NEL - CCG 20 20 20 20 20 15

Total NEL - Specialised Commissioning 20 20 15 15 15 15

Total North East London TCP 40 40 35 35 35 30

Total North East London TCP Trajectory 0 0 0 0 0 57

Data Source: TPMO report data provided by NHSE

120

Joint Commissioning Committee 11 September 2019

Title of report Joint Commissioning Committee Risk Register

Item number 6.1

Author Kate McFadden-Lewis and Marie Price

Presented by Kash Pandya

Contact for further information [email protected]/ [email protected]

Executive summary The report presents the NELCA Joint Commissioning Committee (JCC) risk register for review.

Good governance requires each committee to hold a risk register for its responsibilities. The paper identifies the risks currently held by the NELCA JCC and indicates the mitigating action. These cover:

S1 Robust demand and capacity planning across NEL

S2 Improving self care and demand management and increasing care closer to home

S3 Securing the future of NEL health and social care providers and commissioners

S4 Improving the commissioning of specialised care

S5 Securing local council leadership for key NEL programmes

S6 Delivery of primary care at scale

E1-3 Enabling programmes of workforce, digital and estates

AD1 Streamlined and robust assurance on system transformation and improvement plans

AD2 Integrating CSU services into CCGs where required.

The report outlines proposed changes to the JCC risk register to be agreed by the Committee.

Action required The Committee is asked to:

review the risks and mitigating action and advise on any gapsor concerns for further action

agree the proposed changes to arrangements for riskmanagement.


JCC risk group 2 September 2019

Strategic fit

Commissioning implications Local authority/integrated

commissioning implications

The risk register notes the main risks and mitigating actions to deliver the NELCA priorities. The risks should be considered and integrated into local CCG Board Assurance Frameworks where required.


The risk register sets out the key actions being implemented to address any finance, performance or quality risks.


This report highlights the main risks to deliver the NELCA priorities within the Scheme of Delegation and the actions taken to minimise the impact of those risks. It is part of making sure the work of the JCC is transparent and accountable to local people.

121


Risks This report also links to the following JCC papers being presented to this meeting that provide greater detail on the key risks and the mitigating action:

3.1 Long Term Plan submission update

4.2 Evidence Based Interventions policy – engagement outcome

5.1 Performance report

122


Current NELCA JCC Risk Register

1. The current NELCA JCC risk register is under review to reflect the move towards a NEL ICS from 2021, section below refers. In the interim, individual NEL CCGs are managing risks through their own BAF arrangements. The NELCA JCC risk register only considers the responsibilities delegated by the CCGs to the JCC and the progress being made to mitigate any resultant risks. These, including the mitigations in place, are set out at Appendix 1 to this report.

Risk register review – preparing for NEL 2021 commissioning arrangements

2. Following discussions with Audit Chairs and JCC Members, it has been agreed to keep the risk management and the risk register under review to ensure the risk arrangements are robust and embedded firmly within the ELHCP, Alliance and its member CCGs. Further work is underway, aligned to the review of NEL risk management arrangements, to improve the approach. Many of the risks identified in the register are ones that apply equally to the ELHCP as much as to NELCA. Given this, it is intended to explore how we can move potentially to a common NEL risk register while recognising the formal accountability back to respective organisations.

3. The JCC is currently only delegated some risks by the CCGs, with the bulk of the risk management

being managed through the CCG BAFs and the robust processes behind them. With the ambition to become a NEL ICS by 2021 the current JCC risk register is being reviewed and revised to ensure it reflects the key risks to the overall system, including where appropriate those related to the 2021 programme which sets out how we will get there (noting that the programme will have its own risk register covering all risks within the programme workstreams).

4. It is proposed that the format of the risk register will change to show one risk per page, and include

progress of the risk score against a trajectory, as well as clearly outlining how and where the risk is managed. This new format was agreed in principle at the July meeting and will be presented at the November 2019 meeting.

5. A ‘task and finish’ risk group which includes two audit chairs, the JCC nurse and governance staff is

now in place overseeing this work. The group has met twice and have agreed a number of principles and actions, including:

o the NEL SMT team will own the risk register and be responsible for ensuring that the risks are regularly reviewed in detail

o each risk will be assigned an SRO/ SMT lead and a sub-committee (once they are established)

o each risk will include evidence for the mitigations, and show volume indicators to show the movement of the risk score over time

o the group agreed that it would be helpful if timescales were not restricted to one year o where appropriate risks from the 2021 programme, as managed by the NEL 2021

programme board via the NEL 2021 risk register will be escalated to the JCC for consideration (in line with the risk rating methodology)

o CCG risk registers will be reviewed and compared, and a decision made on any risks that need to be escalated to the JCC register

o a common template for risk management/ BAFs across NEL will be established in the lead up to NEL 2021

o the new format risk register, process for escalating and deescalating risks, as well as risk tolerance and risk appetite will be proposed to the JCC at its November meeting.

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11 September 2019, item 6.1 - Appendix 1

Joint Commissioning Committee – Risk Register

Purpose of the report 1. The purpose of the Joint Commissioning Committee risk register is to set out the key risks to the North East London Commissioning Alliance

(NELCA) in achieving its objectives and priorities and the actions in place to manage those risks.

Background 2. The Joint Commissioning Committee has a responsibility to maintain sound risk management processes and ensure that internal control

systems are appropriate and effective and where necessary to take remedial action. It is a key part of good governance. 3. The risk review uses the standard NHS methodology that considers the likelihood of the risk alongside its severity. Both measures are scored

out of 5 (with 5 being the most likely and worst impact). The risk score takes account of the mitigating action proposed. This then gives a risk score and categorisation of:

4. The risk register is organised around the NEL corporate objectives. The JCC has set out its forward plan that includes updates on its key

strategies and programmes. The risk register will be updated each time to reflect the progress being made, as well as identifying any new risks from the consideration of its business.

5. As the JCC is a collaborative committee of all CCGs, each Governing Body must own the risk and associated mitigating action through its risk

management arrangements. The risk assessment and mitigation are set out in appendix 1. For risks that are red-rated (scored 15 or greater), CCGs should ensure that these are covered in their own risk registers and Board Assurance Frameworks.

Current Risks on the JCC Risk Register

6. Appendix 1 shows the full detail of the current JCC risks and the mitigating action. Progress on Risk Mitigation

7. A brief update on progress on the JCC risks is given below:

S1 - Robust demand and capacity planning across NEL 8. The 19/20 System Operating plan has been agreed. This aligns commissioner and provider approaches to key programme and issues and

includes a consolidated approach to system savings. This was approved through the ELHCP Executive and is available on the ELHCP website. Finance and activity continues to be managed through the ODG. The commissioning strategy will be revised as part of agreeing the ELHCP STP refresh by Oct 19. S2 - Improving self-care and demand management and increasing care closer to home

9. The NELCA prevention programme continues to deliver existing projects including stopping smoking, diabetes and TB. These have a focus on secondary prevention interventions including interest in exploring the Ottawa model on reducing smoking as adopted in Greater Manchester. As part of the NEL response to the LTP, the programme is being refreshed including developing the network / locality approach that will be a major focus for work with local communities. In addition, the LTP makes further commitments around personalisation that will assist with self-care. This will include social prescribing where we have significant good practice from Tower Hamlets, City & Hackney, Redbridge and Waltham Forest that can assist wider learning.

S3 - Securing the future of NEL health and social care providers and commissioners

10. Payment reform is on-going and developing through the wider commissioner and provider collaboration embedded in the NEL approach to integrated care and the 19/20 System Operating Plan. This will be one of the key areas considered in the refresh of the NEL STP. A risk share is in place across NEL CCGs.

S4 - Improving the commissioning of specialised care

11. The guidance is still awaited from NHSE / NHSI on the delegation of specialised commissioning and this is now anticipated to be included in the NHS Long Term Plan. There was a focus on SpecComm and provider alignment in the 19/20 System Operating Plan. There is ongoing engagement with NHSE to influence any proposals and current plans and commissioning of specialised commissioning by NHSE. S5 – Local Council Engagement

12. The main vehicle for local council involvement is through each of the integrated care systems and engagement is good. Regular updates on NELCA and ELHCP are provided to HWBBs and OSCs. Engagement with local councils is ongoing around the INEL Transformation Board (Waltham Forest, Newham, Tower Hamlets and City & Hackney). BHR has good engagement with local authorities through its integrated partnership arrangements. This involves both commissioners, providers and local councils. Local council chief executives are engaged with the ELHCP Partnership Executive and there is ongoing liaison between the Single Accountable Officer and her local MDs and local council leaders (both politicians and officers).

S6 – Primary Care at Scale

13. The focus on primary care recruitment and retention of existing and new workforce roles, such as social prescribing link workers and clinical pharmacists continues. The development of digitally enabled primary care continues to underpin patient pathways, such as urgent care providing a ‘front door’ into accessible care. A full review of all Federations has been completed using the national maturity matrix tool. This has been used to inform the best use of primary care transformation funds in 19/20 and beyond, which we have now secured. In addition, the new GP contract changes aimed at supporting the introduction of Primary Care Networks is being supported both locally and across NEL. It is aligned to the ongoing work with local GP Federations. The local PCN framework has been extended to encompass PCN development plans and population health management plans. 98% of PCNs are DES ready and becoming fully functioning PCNs with their community partners.

E1 – Workforce

14. Delivery of a number of initiatives from external funding bids continues. This includes physician associates, nursing associate apprentices, workforce support around cancer and mental health and provider collaboration on the use of bank and agency. Workforce is seen as one of the key enablers to deliver long term sustainability for NEL and will be a priority within the STP Refresh.

Risk rating Risk Score Low 1 – 3 Medium 4 – 6 High 8 – 12 Severe 15 - 25

124

E2 – Digital

15. The focus continues on the delivery of the NEL Local Health and Care Record Exemplars including clinical access, public access to care records and improving data quality. The development of a digital front door to the NHS continues with funding in place to deliver the Primary Care Digital Accelerator. E3 – Estates

16. The NEL estates strategy was published fully in October on the ELHCP website. Although no funding was secured in the Wave 4 bids, each of the NEL priority schemes are assessing potential alternative funding. It is however important to note the recent (August) positive news of capital investment secured for the St Georges Hospital site in Hornchurch, Havering. The Whipps Cross business case continues to be developed with the involvement of local stakeholders. There has been significant engagement with local councils around the NEL strategy including local briefings and presentation to the BHR and INEL Joint Overview and Scrutiny Committees.

AD1 - Streamlined and robust assurance on system transformation and improvement plans

17. There is continued discussion with regulators on the 19/20 assurance process following the integration of NHS England (commissioners) and NHS Improvement (providers). A framework is being developed for earned autonomy and this being tested in key areas such as mental health and A&E. The NEL reporting framework is now agreed and a regular rhythm established for the JCC, ELHCP Executive and NELCA chairs. This ensures much greater oversight and awareness of current performance issues. AD2 – CSU Integration

18. The NEL programme has been paused by the national team pending the outcome of an NHS England commissioned audit by Deloitte. This will allow fresh consideration of any key areas for in-housing. Until the outcome of the review is known, NEL is working with three other London STPs to develop an interim operating model to for closer and more flexible working arrangements between CSU and CCG teams.

125

Ref Category Date

added Description

Original rating

Current risk rating

Risk owner (SRO)

Escalated to CCG GBAFs

Mitigating actions Target Target date Likelihood

(1-5) Severity

(1-5)

Total Score (1-25)

Objective 1: Improving Quality of Care for local people

S1 Strategy May-18 Unless there is robust demand and capacity planning and approaches across NEL, the quality of services, health outcomes and the sustainability of both commissioners and providers will be affected negatively.

16 4 4 16 Les Borrett

N

STP reviewed and refreshed with transformation programmes to deliver on key priorities including maternity, outpatients, mental health and others. NEL focus on enablers around workforce, digital and estates

19/20 System Operating Plan agreed with review and monitoring through Operational Delivery Group.

NEL Commissioning strategy agreed at the Sep 18 JCC with further work being undertaken through engagement with local stakeholders to refine it further.

Overarching strategy will be refreshed to the NHS Long Term Plan (Nov 19).

8

31/11/19

Objective 2: Securing financial stability

S2 Strategy May-18 Unless self care and demand management is improved and high quality care offered closer to home, the pressure on services will continue with a consequent effect on performance, quality and outcomes.

12 3 4 12 Simon Hall N

STP refresh of all programme underway for Oct 19. NEL prevention programme focused on secondary

prevention programmes around smoking and diabetes. Local prevention programmes focused on boroughs and localities to allow tie into Primary Care Networks and local communities.

New personalisation programme to be developed as part of the STP Refresh that will include social prescribing drawing on the good practice in some NEL CCGs

Integrated Urgent Care continues to provide better clinical advice and signposting to reduce pressure at ED

Primary care improvement strategy to enhance capacity and quality.

8

31/03/20

S3 Strategy May-18 Unless the future of NEL health and social care providers and commissioners is secured financially there may need to be significant reductions in services with a consequent impact on health outcomes.

20 3 5 15 Henry Black Y

19/20 System Operating Plan agreed to align commissioner and provider savings schemes

Risk share mechanisms in place across NEL NEL Transformation programmes to address

demand and capacity issues Monthly monitoring at ODG meeting to consider

risk and mitigation Financial Strategy Committee manages payment

reform and other STP wide finance issues.

12

31/03/20

126

Ref Category Date

added Description

Original rating

Current risk rating

Risk owner (SRO)

Escalated to CCG GBAFs

Mitigating actions Target Target date Likelihood

(1-5) Severity

(1-5)

Total Score (1-25)

S4 Strategy May-18 Unless specialised services are aligned with current CCG commissioned services, there is a risk of duplication and inefficiencies, as well as financial pressure on NEL commissioners and providers.

9 3 3 9 Les Borrett N

Delegation of Specialised Commissioning under review as part of NHS England new arrangements with further guidance expected with Long Term Plan.

Further alignment proposed between specialised commissioning and providers as part of 19/20 Operating Plan

Ongoing SAO engagement with NHSE to influence future proposals and current (NHSE) specialised commissioning plans

6

31/03/20

Objective 3: Developing the local integrated care system

S5 Strategy Jul-18 Unless there is full engagement and involvement of local councils in developing and delivering integrated care systems and political leadership on and support of NEL-wide priorities, transformation will not be achieved fully


Approach to Integrated Care fundamental to the Refresh of the NEL STP with a focus on place-based partnerships

Regular engagement and participation through HWBB and local integration programmes

Collaborative CCG framework in development across Waltham Forest, Newham and Tower Hamlets CCGs with INEL System Transformation Board with providers and City & Hackney.

Regular NELCA / ELHCP updates provided to HWBB and OSCs

SAO and CCG leadership engaging regularly with Council leadership

6

31/03/20

Objective 4: Primary care transformation

S6 Strategy Jul-18 Unless primary care at scale organisations develop at sufficient scale and pace, the improvement in resilience and quality and the primary care role in integrated care systems will not be achieved

12 3 4 12 Ceri Jacob Partial

• STP primary care programme oversight and local delivery – being refreshed to ensure adequate plans • Governance structure with provider forum • New model of care workstream included in new PC Transformation programme with group being established • New GP contract changes relating to introduction of PCNs being supported at CCG and NELCA level and aligned to existing work on GP Federations • Primary Care Digital first programme is being established to deliver digital enabled primary care, including online and video consultations

8

31/03/20

127

Objective 5: Progressing integrated commissioning with local councils

Objective 6: Partnerships and collaboration across north east London

E1 Enablers May-18 Unless the large scale enabling programme around workforce is delivered with all providers being aligned, working collaboratively and understanding the implications of the new models of care and the new training and employment models that are required, local transformation and the drive towards integration of services will not be delivered.


Coordinated approach to establishing training capacity and placement allocations

Workforce strategy being refreshed and aligned to the resources available in each system as part of the STP Refresh

Additional resources secured from HEE, transformation funding for cancer and Mental Health programmes.

Maternity and UEC innovative flexible career options to attract and retain staff continuing.

New Models of Care, Recruitment of Physician Associates graduates, Nursing Associate Apprentice programme across secondary and Primary Care

System wide principles to increase apprentice roles and utilise the apprentice levy

Promoting careers and developing pathways into employment with schools and colleges.

6

31/03/20

E2 Enablers May-18 Unless the large scale enabling programme around technology is delivered with all providers aligned and understanding the implications of the new models of care, local transformation and the drive towards integration of services will not be delivered

12 2 4 8 Luke Readman N

Funding has been secured to deliver the One London LHCRE, key elements of the programme now need to be delivered in NEL

STP LTP response will include significant input from Digital Workstream

NHSI&E review of Digital investment underway Funding in place for Primary Care Digital

Accelerator needed to help create ‘digital front door’ to the NHS.

6

31/03/20

E3 Enablers May-18 Unless the large scale enabling programme around estates is delivered with all providers aligned and understanding the implications of the new models of care, local transformation and the drive towards integration of services will not be delivered

20 4 4 16 Henry Black N

STP refresh of deliverables planned for Sep / Oct 19

Estates Board established to oversee NEL strategy and funding bids under London Devolution

Estates strategy published and engagement programme delivered.

Following no funding under Wave 4 bids potential alternative funding is being explored.

6

31/11/19

AD1 Assurance and Delivery

May-18 Unless the assurance process with NHS England is streamlined, it will be difficult to release capacity to support delivery of local priorities and the Sustainability and Transformation Plan. Unless NEL delivers robust assurance on its improvement plans to regulators, it may lead to additional costs and a lack of control and influence over local services.

9 3 3 9

Jane Milligan/ Archna Mathur

N

NEL ICS performance and assurance framework in development following the London Regional Team Operating model for earned autonomy.

Testing of approach in place with respect to RTT delivery, mental health performance and A&E performance at BHRUT/Royal London and Whipps Cross

Reporting documentation and rhythm established for JCC, STP Executive and NELCA chairs.

Regular bi-meetings with regulators to discuss and test approach

6

30/04/20

128

Objective 7: Organisational effectiveness / organisational development

AD2 Assurance and Delivery

June-18

Unless the significant programme of in-housing from the CSU is delivered through close joint working with NELCSU; with due regard to maintaining support services before, during and after the TUPE transfers, support for clinical services, finance and control mechanisms may be compromised.

16 4 4 16

Les Borrett

(Charlotte Fry)

N

In line with the LTP, the development of ICSs and changes to the commissioning landscape in London, the commissioning support system is being reviewed under the Regional Architecture programme (comprising LITA, Once for London and an alternative model for contracting). The scope of LITA focuses on the improvement and transformation support future ICSs will need, and therefore includes HLP and the NELCSU consulting arm, as well as Right Care and clinical networks. NELCSU’s broader functions are subject to two separate processes of review under the ‘Aligned Operating Model’ for the contracting functions, and ‘Once for London’ for more generic shared functions. Work to develop this new model is ongoing under the London System Support Board (LSSB) and it is anticipated that a proposal for future oversight of the CSU will emerge later this year.

9

31/03/2020

129

Risk grading matrix

Likelihood

Rating 1 2 3 4 5

Description Rare Unlikely Possible Likely Certain

Probability <10% 10% - 24%

25% to 45%

50% - 74% >75%

Seve

rity

Rating Description

A Objectives/

projects

B Harm/injury to patients, staff

visitors & others

C Actual/potential

complaints & claims

D Service

disruption

E Staffing &

competence

F Financial

G Inspection/

Audit

H Adverse media

1 Insignificant

Insignificant cost

increase/time slippage.

Barely noticeable

reduction in scope or quality

Incident was prevented or

incident occurred and there was no

harm

Locally resolved complaint

Loss/ interruption more than 1

hour

Short term low staffing leading to reduction in quality (less than 1 day)

Small loss <£1000

Minor recommendations Rumours 1 1 2 3 4 5

2 Minor

Less than 5% cost or time

increase. Minor

reduction in quality or

scope

Individual(s) required first

aid. Staff needed <3

days off work or normal

duties

Justified complaint

peripheral to clinical care

Loss of one whole

working day

On-going low staffing levels

reducing service quality

Loss of 0.1% budget.

<£10,000

Recommendations given. Non-

compliance with standards

Local media column

2 2 4 6 8 10

3 Moderate

5-10% cost or time increase.

Moderate reduction in

scope or quality

Individual(s) require

moderate increase in care. Staff needed >3

days off work or normal

duties

Below excess claim. Justified

complaint involving

inappropriate care

Loss of more than one

working day

Late delivery of key objectives/service due to lack of staff. On-going unsafe staff levels. Small

error owing to insufficient training

Loss of more than 0.25% of budget. <£100,000

Reduced rating. Challenging

recommendations. Non-compliance with standards

Local media front page story

3 3 6 9 12 15

4 Major

10-25% cost or time increase. Failure to meet

secondary objectives

Individual(s) appear to have

suffered permanent harm. Staff

have sustained a "major injury" as defined by

the HSE

Claim above excess level.

Multiple justified complaints

Loss of more than one working week

Uncertain delivery of services due to lack of staff. Large

error owing to insufficient

training

Loss of more than 0.5% of

budget. <£500,000

Enforcement action. Low rating.

Critical report. Major non-

compliance with core standards

Local media

short term 4 4 8 12 16 20

5 Severe

>25% cost or time increase. Failure to meet

primary objective

Individual(s) died as a result of the incident

Multiple claims or single major

claims

Permanent loss of

premises or facility

No delivery of service. Critical error owing to

insufficient training

Loss of more than 1% of

budget. >£500,000

Prosecution. Zero rating. Severely critical report.

National media

more than 3 days. MP

concern

5 5 10 15 20 25

Risk Category Severe High Medium Low

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Joint Commissioning Committee and Clinical Senate meeting plan – 2019/20

Regular items:

Minutes / Action log/ Questions from the public Performance report – tailored to the agenda items and include friends and family test Future of commissioning – 2021 vision Risk register Meeting plan

Clinical Senate Joint Commissioning Committee

Month Subject / Topic Month Items

10 April

Stroke Network – developing collaborative,system wide clinical approaches across NEL

East London Prevention Program (ELoPE) –Promoting the coordination of CVD preventionacross NEL

10 April Moorfields Hospital proposals - Pre Consultation Business

Case – part II

8 May

Neurosurgery provision/reconfiguration acrossNEL

Integrated Care System & ELHCP governanceupdate

8 May

STP refresh update

Cancer Diagnostic Hub: update on patient engagement

North East London Spending Money Wisely Programme update

12 June

Stroke – Presentation of a proposed uniformstroke care pathway for NEL – Senate tocontribute support via input, feedback and nextsteps.

Neuro-Rehab – INEL STB overview ofprogramme

Spending Money Wisely – Update paper onlycirculated (no presentation)

12 June OD session – future of commissioning

Item 7.1

131


10 July Mental Health – LTP developments; senate to

input and feedback 10 July

ELFT update

Better Care Fund – update

ELHCP Transformation Programme

Update on development of LTP

o to include NELCA progress on the LTP vision

14 August LTP and London vision 14 August OD session - cancelled

11 September

Primary Care Networks – Consideration ofuniform PCN structures and governance acrossNEL that promote collaboration and integration.

NEL LTP Enabler Workstream programmeupdate: Digital Transformation.

11 September

Long Term Plan draft submission

Barts Health surgical strategy

Aligning Commissioning Policies – engagement outcome

Update on progress on the NEL child sexual abuse hubs

Mental Health Strategy- including crises intervention, suicideand veterans and Early Intervention in Psychosis

Update on LITA/HLP/CSU – part II

9 October Stroke – Strategic programme updates

Whipps Cross redevelopment progress update9 October OD session – Progress on digitalisation

13 November NEL Enabler Workstream programme update:

Workforce 13 November

HUHT update

Neurosurgery

Neuro-Rehab Level 2b business case

Social prescribing

Update on specialised commissioning

Prevention – areas for collaboration across NEL

Progress on redeveloping Whipps Cross

Health and Wellbeing Board plans

11 December Medicines Optimisation - Strategic Programmeupdates

11 December OD session – Workforce strategy

8 January NEL LTP Enabler Workstream programme

update: Infrastructure (Estates)8 January

NELFT update

Future of commissioning – update

Medicines Optimisation strategy

Better Care Fund update

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12 February

Urgent & Emergency Care - StrategicProgramme updates

0 – 25 (Children’s & Young Persons) StrategicProgramme updates

Personalisation Strategic Programme updates

12 February OD session - Primary care at scale

11 March

ELHCP Clinical Senate review:

o Terms of Reference

o Membership

o Lessons Learnt/ Future Senatedevelopments for 20/21

11 March

BHRUT update

Operating Plan 2020/21

Transforming Care

Cancer

JCC Review:

o Terms of Reference

o 2020/21 programme

JCC to be scheduled: Pathology business case Vascular Acute paediatrics Estates strategy update ICS system updates (WEL/ BHR/ C&H/ INEL) Demand management – update from demand and capacity group.

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