tuesday 11th april 2017 at 2.30pm boardroom, the...

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NHS LIVERPOOL CLINICAL COMMISSIONING GROUP

GOVERNING BODY TUESDAY 11th APRIL 2017 AT 2.30PM

BOARDROOM, THE DEPARTMENT

AGENDA Part 1: Introductions and Apologies 1.1 Declarations of Interest All 1.2 Minutes and action points from the meeting Attached

on 14th March 2017 All 1.3 Matters Arising All Part 2: Updates 2.1 Feedback from Committees: Report no: GB 25-17

Primary Care Commissioning Committee – Dave Antrobus 21st March 2017

Finance Procurement & Contracting Committee Dr Nadim Fazlani - 28th March 2017

Quality Safety & Outcomes Committee – Dave Antrobus 4th April 2017

2.2 Feedback from Liverpool Safeguarding Children Report no: GB 26-17 Board – 29th March 2017 Jane Lunt

2.3 Chief Officer’s Update Verbal Katherine Sheerin 2.4 Public Health Update Verbal Dr Sandra Davies 2.5 Feedback from Health & Wellbeing Board Verbal 23rd March 2017 Dr Nadim Fazlani

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Part 3: Performance 3.1 Finance Update February 2017 – Month 11 Report no: GB 27-17

Tom Jackson

3.2 CCG Corporate Performance Report April 2017 Report no: GB 28-17 Stephen Hendry

Part 4: Strategy and Commissioning 4.1 Operational Financial Plan Update 2017/18 and Report no: GB 29-17 2018/19 Financial Years Tom Jackson Part 5: Governance 5.1 Emergency Preparedness Resilience & Response Report no: GB 30-17

Annual Report 2016/17 Ian Davies 5.2 MIAA Review of Liverpool, South Sefton and Report no: GB 31-17

Southport & Formby CCG’s Quality Assurance Jane Lunt Processes for Liverpool Community Health (LCH)

6. Questions from the Public

7. Date and time of next meetings: Tuesday 9th May 2017 at 2.30pm Boardroom, The Department

For Noting: Primary Care Commissioning Committee – 20th December 2016 Finance Procurement & Contracting Committee – 21st February 2017 Quality Safety & Outcomes Committee – 7th March 2017

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Report no: GB 25-17 NHS LIVERPOOL CLINICAL COMMISSIONING GROUP

GOVERNING BODY

TUESDAY 11TH APRIL 2017

Title of Report Feedback from Committees Lead Governor Dr Nadim Fazlani, Dr Rosie Kaur, Dave Antrobus,

Prof, Maureen Williams Senior Management Team Lead

Cheryl Mould, Primary Care Programme Director, Tom Jackson, Chief Finance Officer, Jane Lunt, Head of Quality/Chief Nurse, Katherine Sheerin, Chief Officer

Report Author(s)

Cheryl Mould, Primary Care Programme Director, Tom Jackson, Chief Finance Officer, Jane Lunt, Head of Quality/Chief Nurse

Summary The purpose of this paper is to present the key issues discussed, risks identified and mitigating actions agreed at the following committees: Primary Care Commissioning Committee – 21st

March 2017 Finance Procurement & Contracting Committee -

28th March 2017 Quality Safety & Outcomes Committee – 4th April

2017 This will ensure that the Governing Body is fully engaged with the work of committees, and reflects sound governance and decision making arrangements for the CCG.

Recommendation That Liverpool CCG Governing Body: Considers the report and recommendations from the

committees

Relevant Standards or targets

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PRIMARY CARE COMMISSIONING COMMITTEE TUESDAY 21 MARCH 2017 AT 10AM to 12PM

BOARDROOM THE DEPARTMENT

A G E N D A Part 1: Introductions and Apologies 1.1 Declarations of Interest All 1.2 Minutes and actions from previous meeting on

20TH December 2016 All 1.3 Matters Arising CHLARC Evaluation PCCC 01-17 Part 2: Updates 2.1 Primary Care Support Services Verbal

Tom Knight

2.2 Feedback from Sub-Committees: PCCC 02-17

• Medicines Optimisation Sub-Committee PCCC 02a-17 January/February 2017 Peter Johnstone

• Locality Workshops PCCC 02b-17

Jacqui Waterhouse Part 3: Strategy & Commissioning 3.1 Transformation of Primary Care PCCC 03-17

(General Practice Forward View) Dr Rosie Kaur 3.2 Primary Care & Prescribing Budget PCCC 04-17

Mark Bakewell 3.3 Liverpool l Quality Improvement Scheme PCCC 05-17

(GP Specification 2017/2018) Dr Rosie Kaur Cheryl Mould

3.4 TB Enhanced Service Update PCCC 06-17

Jacqui Waterhouse

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3.5 Prescribing Cost Reduction Plan 2017-18 PCCC 07-17 Peter Johnstone

Part 4: Performance

No Items

Part 5: Governance No items 6. Any Other Business ALL 7. Date and time of next meeting:

Tuesday 18th April 2017 Formal Meeting Boardroom, The Department

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LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: Primary Care Commissioning Committee

Meeting Date: 21st March 2017 Chair: Dave Antrobus Vice Chair: Katherine Sheerin

Key issues:

Risks Identified: Mitigating Actions:

1. Primary Care Support Services.

• That local improvements are not recognized across all services.

• Review of the local stakeholder group to ensure appropriate reporting arrangements are in place.

• Practice survey to be sent to Lead

Officer and Chair of Audit Committee NHS England.

2. Transformation of Primary Care

(General Practice Forward View).

• That the CCG cannot deliver the transformation agenda due to financial and workforce challenges.

• That the CCG does not have a detailed

communications and engagement plan.

• Ensure through the General Practice Further View Programme Board that the CCG receives/applies for all funding opportunities including technology, workforce and training.

• Task & Finish Group set up to ensure

effective communication and engagement plan is in place.

• Regular updates are provided at

Primary Care Commissioning Committee.

3. Primary Care – Prescribing Budget

• That we do not achieve financial balance across the Primary Care budgets.

• That the Prescribing Cost Reduction

Plan is not achieved.

• Regular meetings/monitoring between Finance and Primary Care Team are in place to review budget.

• Detailed reporting arrangements in

place and updates provided against planned values to Primary Care Commissioning Committee.

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• Additional staff resources allocated to prescribing.

• Project plan developed with key

milestones and trajectories and regular monitoring arrangements in place.

Recommendations to NHS Liverpool CCG Governing Body:

1. To note the issues, risks and mitigating actions. 2. To highlight to the Governing Body that the GP Specification is part of the Partners Priority Programme (PPP) Evaluation for

Change which is supported by CLAHRC

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FINANCE, PROCUREMENT AND CONTRACTING COMMITTEE

TUESDAY 28TH MARCH 2017 AT 10AM ROOM 2, THE DEPARTMENT, LEWIS’S BUILDING

RENSHAW STREET L1 2SA Part 1: Introductions and Apologies 1.1 Declarations of Interest All 1.2 Minutes and action points from the meeting Attached

on 21st February 2017 All 1.3 Matters Arising All

Part 2: Updates 2.1 Financial Recovery & Oversight Group Update FPCC 13-17 Mark Bakewell Part 3: Performance 3.1 Finance Update February 2017 – Month 11 FPCC 14-17 Tom Jackson Part 4: Strategy and Commissioning

4.1 Contract Update March 2017 - Month 10 2016/17 FPCC 15-17

Derek Rothwell

4.2 Operational Financial Plan Update 2017/18 and FPCC 16-17 2018/19 Financial Years Mark Bakewell

4.3 Interim Provider Policy (Update) FPCC 17-17 Derek Rothwell Part 5: Governance

5.1 End of Year Assessment of CCG IAF FPCC 18-17 Quality of Leadership Indicator, Good Tom Jackson Financial Leadership

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5.2 Information Governance Update FPCC 19-17 Peter Case-Upton 6. Date and time of next meeting:

Tuesday 25th April 2017 Room 3 at 10am to 12.30pm The Department, Lewis’s Building, L1 2SA.

FOR NOTING: Financial Recovery & Oversight Group minutes/Agenda summary from September 2016 to March 2017

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LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: Finance Procurement &

Contracting Committee

Meeting Date: 28th March 2017

Chair: Dr Nadim Fazlani

Key issues:

Risks Identified: Mitigating Actions:

1. LCCG Interim provider Policy required updating

• Policy was due for review and needed updating to reflect LCCG procurement process operational experience / lessons learned from recent APMS interim provider procurements

• Policy updated and approved by FPCC for use for future LCCG Interim provider requirements. Policy to be reviewed in 12 months.

2. Finance Update as per M11 reporting (February) with regards to delivery of NHS England Business Rules

• Number of risks as identified within the papers – increased activity in contract expenditure, prescribing , CHC, delivery of financial recovery plan measures

• Mitigations actions identified to deliver Business Rules requirements.

• Continued monitoring of forecast

outturn assumptions until the end of the financial year in order to ensure delivery

3. Operational Financial Plan Update 2017/18 and 2018/19

• Resource and Expenditure Assumptions for the respective financial years and required cash releasing savings for 2017/18 financial year as per these assumptions (£25.2m) with an element remaining unidentified (£1.5m)

• Development of robust monitoring regarding cash releasing efficiency savings plan for respective financial years.

• Progression of SMT discussions with

regards to identification of additional cash releasing mitigations to address unidentified savings gap.

Recommendations to NHS Liverpool CCG Governing Body:

1. To note the key issues and risks.

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QUALITY SAFETY AND OUTCOMES COMMITTEE TUESDAY 4TH APRIL 2017 3PM TO 5PM

BOARDROOM THE DEPARTMENT

A G E N D A

Part 1: Introduction & Apologies 1.1 Welcome & Introductions ALL 1.2 Declaration of Interests ALL 1.3 Minutes and Actions from 7th March 2017 Chair

1.4 Matters Arising Part 2: Updates 2.1 CCG Safeguarding Quarterly Report QSOC 17-17

Helen Smith Part 3: Strategy & Commissioning 3.1 Anti-Microbial Strategy Update QSOC 18-17

Alison Thompson 3.2 CHC/IPA Quality Report QSOC 19-17

Jane Lunt/ Lorraine Norfolk

Part 4: Performance 4.1 Early Warning Dashboard QSOC 20-17

Denise Roberts

4.2 Review of the Walton Centre (Deep Dive) QSOC 21-17 Alison Thompson

4.3 Outstanding Action from Joint Targeted Inspection QSOC 22-17 Dr Margaret Goddard

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Part 5: Governance

5.1 MIAA Report on Patient Engagement QSOC 23-17

Jane Lunt

5.2 Complaints, PALS and MP Enquires 20 December QSOC 24-17 2016 – 23 March 2017 Sallyanne Hunter

5.3 Liverpool Health Economy Utilisation of Patient QSOC 25-17 Opinion Platform – 2016/17 Kelly Jones

Date & Time of next meeting Tuesday 2nd May 2017 3pm to 5pm Boardroom, The Department

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LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: Quality, Safety & Outcomes C’tee Meeting Date: 4th April 2017 Chair: Dave Antrobus Key issues: Risks Identified: Mitigating Actions: 1. Safeguarding Quarterly Report shows

that Mersey Care and Liverpool Community Health’s performance re meeting safeguarding requirements has deteriorated.

• Children and vulnerable adults not appropriately safeguarded by Trust staff via their work.

• Contract Performance Notice to be issued to Mersey Care.

• Support and challenge work to

continue with Liverpool Community Health – with review.

• Letters outlining CCG position re need

for improvement by Trusts to be sent out.

• Review through CQPGs.

2. Mersey Internal Audit Agency (‘MIAA’) Report on Patient Experience judgement is “Limited Assurance”.

• Patient Engagement not as effective within the CCG as it could be.

• Action Plan in place – to be completed by June 2017 with oversight by Quality Safety & Outcomes Committee.

3. Continuing Healthcare (‘CHC’) Quality Assurance Framework for recording and maintaining standards in delivery of CHC (Continuing Healthcare Audit Tool ‘CHAT’ )

• CCG QIPP Programme for 17/18 identifies CHC as a key component.

• Lack of data to inform current position

• CHAT provides baseline for current position.

• CHAT enables oversight of quality of

CHC.

• CHAT enables benchmarking to support delivery of QIPP

Recommendations to NHS Liverpool CCG Governing Body: 1. Note the issues and the actions to mitigate risks.

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Report no: GB 26-17

NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY


Title of Report Feedback from the Liverpool Safeguarding

Children’s Board (‘LSCB’) 29th March 2017 Lead Governor Jane Lunt, Head of Quality/Chief Nurse

Senior Management Team Lead

Jane Lunt, Head of Quality/Chief Nurse

Report Author

Hayley McCulloch, Designated Nurse Safeguarding Children

Summary The purpose of this paper is to present the key issues discussed, risks identified and mitigating actions agreed at the Liverpool Safeguarding Children’s Board on 29th March 2017 This will ensure that the Governing Body is fully engaged with the work of the Safeguarding Boards and reflects sound governance and decision making arrangements for the CCG.

Recommendation That Liverpool CCG Governing Body: Considers the reports and

recommendations from Liverpool Safeguarding Children’s Board

Relevant Standards or targets

The Assurance & Accountability Framework 2015 – NHS England.

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LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: Liverpool Safeguarding Children’s Board (‘LSCB’)

Meeting Date: 29th March 2017 Chair: Audrey Williamson, Independent Chair

Key issues: Risks Identified: Mitigating Actions: 1. Alternative Education Provision (‘AEP’):

which now equates to over 500 young people, demonstrating a considerable increase over 5 years.

• Health provision to young people with AEP settings for physical and emotional health needs.

• CCG Designated Nurse to meet with Liverpool Community Health and Public Health to identify clear pathway for this cohort.

2. Liverpool Suicide Review: Review undertaken by independent reviewer due to the perceived high number of deaths by suicide in Liverpool. Findings were consistent with national picture. Half Day stakeholder event focused on challenges with provision of Tier 3 / 4 Children & Adolescents Mental Health Services (‘CAMHS’).

• Provision of Tier 3/Tier 4 CAMHS provision.

• Report forwarded to Lead commissioner to consider in development of services.

• Added to Agenda of Health Sub

Group and Safeguarding meeting for consideration and action.

3. Safeguarding Children with Disabilities: National Working Group report tabled which identified an inconsistent picture across 36 of 146 LSCBs related to SEND Ofsted requirements.

• Potential SEND Ofsted inspection within Liverpool

• Work underway by Liverpool CCG by allocated lead with demonstratable progress

Recommendations to NHS Liverpool CCG Governing Body: 1. To note the issues, risks and mitigation.

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Report no: GB 27-17


TUESDAY 11th APRIL 2017

Title of Report Finance Update February 2017 – Month 11

Lead Governor Tom Jackson Chief Finance Officer


Tom Jackson Chief Finance Officer

Report Author Mark Bakewell Deputy Chief Finance Officer

Summary This paper summarises the CCG’s financial performance for the month of February 2017 (Month 11) to the Governing Body and contains details regarding

a) Financial Performance in respect of delivery of NHS England Business Planning Rules particularly regarding in-year surplus position and treatment of non-recurrent headroom

b) Assessment of risk to the delivery of forecast surplus position given current / required mitigating actions as identified within Financial Recovery Plan as shared with NHS England

Recommendation That Governing Body :

• Notes the current financial position and risks associated with delivery of the forecast outturn position.

• Notes the stated assumptions

regarding proposed recovery

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solutions to deliver the required business rules based on current forecast outturn assumptions

Relevant standards/targets

Financial Duties NHS England Business Rules

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FINANCIAL PERFORMANCE UPDATE – MONTH 11 (FEBRUARY) 2016/17

1. PURPOSE

The purpose of this report is to provide the Governing Body with an update on the CCG’s financial performance within the 2016-17 financial year.

2. RECOMMENDATIONS

That the Governing Body:

Notes the current financial position and risks associated with

delivery of the forecast outturn position. Notes the stated assumptions regarding proposed recovery

solutions to deliver the required business rules based on current forecast outturn assumptions.

3. FINANCIAL POSITION SUMMARY AT MONTH 11 Month 11 financial reporting suggests that the CCG remains on track to deliver required NHS England Business Planning Rules as per the table below, albeit subject to a number of risks as outlined within this document.

Although there have been a number of movements within the reporting period, the overall forecast outturn remains in line with requirements of 1% surplus plus additional 1% held in reserves (as non-recurrent headroom) as per section 4 of this report.

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*With regards to the non-recurrent headroom reserve of £8.362m (1%), the CCG has recently received instruction from NHS England to release this reserve within month 12 reporting and is therefore confirmed to be included within the cumulative reported forecast outturn surplus of £16.4m. Due to the level of financial risk identified within the financial year, a ‘financial recovery’ plan is being closely monitored by the Financial Recovery Oversight Group (FROG), supporting both the delivery of the 2016/17 forecast outturn position and reviewing planning assumptions for future years given the challenging nature of the CCGs financial position.

4. BUSINESS RULES BACKGROUND

Discussions with NHS England during October 2016 resulted in a change of approach to the CCG’s reporting of Business Rules in respect of its surplus position compared to its original planned values with a revised target of a 1% surplus (£8.017m (rather than £14.4m (1.7%)) and, the re-establishment of the non-recurrent headroom (1%) £8.362m. This resulted in a revised targeted cumulative surplus position of £16.4m, this being consistent with delivery NHS England Business Planning Rules for the financial year but different to original CCG Plan submission (£14.4m) and again to NHS England Expectations (Circa £22m)

Year to Date Forecast

(£k) (£k)

Variance Variance

ACUTE 5,536 6,513

COMMUNITY HEALTH SERVICES 577 703

CONTINUING CARE 1,647 1,688

MENTAL HEALTH 46 86

OTHER PROGRAMME TOTAL EXCLUDING 410 (556)

OTHER NON RECURRENT RESERVE 0 0

OTHER COMMISSIONING RESERVE 1,865 2,034

OTHER QUALITY PREMIUM PROGRAMME (800) (873)

PRIMARY CARE (324) (1,270)

CORPORATE (1,796) (1,915)

7,160 6,410

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The table below shows the relative movement between months comparing the relative elements of business planning rules at each point in the reporting cycle of the financial year Cumulative Surplus In –Year Surplus /

(Deficit) Non recurrent

Headroom Plan* £14.4m – 1.7% 0 £8.362m* (1%) Month 1-4 £14.4m – 1.7% 0 £8.362m (1%) Month 5 £14.4m – 1.7% 0 £8.362m (1%) Month 6 £14.4m – 1.7% 0 0 Month 7** £16.374m - 2%*** £1.9m 0.3% £8.362m (1%) Month 8** £16.374m - 2%*** £1.9m 0.3% £8.362m (1%) Month 9** £16.374m - 2%*** £1.9m 0.3% £8.362m (1%) Month 10** £16.374m - 2%*** £1.9m 0.3% £8.362m (1%) Month 11** £16.374m - 2%*** £1.9m 0.3% £8.362m (1%) * The operational plan for 2016/17 - ‘Liverpool CCG – Financial Plan 2016/17’ paper taken to the Governing Body meeting on 12 April 2016, referred to a return to NHS England business rules and the reduction of the 2016/17 planned surplus to 1% to reflect transformation investment intentions and increasing cost pressures. The CCG was advised by NHS England in early April 2016 that an increased level of drawdown on centrally held funds to the CCG as a result of the reduction could not be accommodated. Consequently, the final plan submission for 2016/17 showed a 1.7% planned surplus. The plan narrative indicated that this was predicated by the retention of the 1% non-recurrent funds internally to the CCG. ** CCG received confirmation from the Area Team that the Non Recurrent set aside headroom will not leave the CCGs accounts and will support the year end position. The targeted cumulative surplus £16.374m therefore consists of 1% business rules surplus plus retained 1 % non-recurrent headroom (see *** below re corresponding values) ***Determination of 1% surplus and 1% headroom are on different calculations as per below methodology

• 1% Surplus = 1% of Total Allocation (including Non-Recurrent and Running Costs) less Primary Care

• 1% Non-Recurrent = 1% of Recurrent Allocation (including Primary Care) 5. FINANCIAL PERFORMANCE

The below sections summarise the key information regarding Month 11 (February) 2016/17 reporting position for NHS Liverpool Clinical Commissioning Group

Month 11 Reporting - Financial Performance Key Information

The CCG is monitored against a number of ‘business rules’ as per NHS England planning guidance, with particular regards to delivery of

• planned surplus (minimum of 1%), • establishing a contingency (of at least 0.5%) • and the availability of at least 1% headroom (non-recurrent)

within the annual planning process.

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The table below describes the CCG’s self-assessed performance against financial performance and statutory measures (regarding resource and cash limits) given the information contained within this report.

Delivery of surplus remains subject to risks / mitigations as outlined in below section but on the basis of delivery self assessment is as indicated above

a) Revenue Resource Limit and Planned Expenditure

The resources available to the CCG within the 2016/17 financial year are described within the table below; these include the CCG’s programme (recurrent and non-recurrent) and running cost allocations and also the amount delegated by NHS England for CCG commissioning of Primary Care (GP practices)

Statutory Duties

Q1 Q2 Q3 Q4 YTD

Revenue Resource Limit

Cash Limit

Better Payment Practice Code

Financial Performance (Business Rules)

Q1 Q2 Q3 Q4 YTD

Surplus

Provider Contract Performance

Running Cost Allowance

1% Non-Recurrent

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£000 Total Notified Allocation 769,888 Total Non-Recurrent Allocation 24,238 Primary Care Co Commissioning 66,357 Revenue Resource Limit (Programme) 860,483 Running Costs Allocation 10,617 Total Allocation 871,100

A breakdown of the CCG’s non-recurrent resources within the 2016/17 financial year can be found below

b) 2016/17 Year to Date Position as at Month 11 (February)

The CCG is currently reporting a year to date over performance of £7.16m against budgeted expenditure as at February 2017. This is partly due to the changes described in the revision to the 1% surplus figure as at Month 7 (and subsequent changes to the

Other Non-Recurrent Allocations2016-17

£000's

Return of Prior Year Surplus 14,427GP Access 44Vanguard Funding 914Additional MH 309Public Health 16IM&T 5,000TB Funding 16CAMHS 129Vanguard Funding 251 Local Evaluation Funding for Walton Neuro network 37Charge Exempt Oversee Visitors 85Community Development Fund - Perinatal Mental Health 554Quality Premium Awards 2015-16 873ACC - Neuro Network Vanguard Q4 Funding 605ACC - Neuro Network Vanguard 3rd Qtr local evaluation 38CYP WL & WT Reduction - 2nd Tranche 129Non recurrent allocation to mitigate impact of NHS PS move to market rents 719CYP IAPT Backfill - Jan/Feb 92Total 24,238

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planned 1.7% surplus figure) with the resulting impact of the 1% headroom being excluded from the year to date / forecast outturn financial position as per NHS England instructions. The resulting movement from a forecast outturn surplus position of £14.4m to £8.017m is an in-year deficit position of £6.4m, of which the pro-rata year to date deficit would be £5.87m if all expenditure were in line with plan (excluding headroom which will be released into the CCG position at a point to be determined by NHS England within the financial year) NHS Ledger / Reporting Restriction prevent adjustment of planned surplus position with ledger to the revised £8.017 figure (excluding headroom) However, a combination of factors including budget profiling (e.g. 1% headroom held in M12) and operational performance pressures against planned levels, increase the year to date over performance to £7.16m as per the table below and with a full cost centre breakdown included in Appendix One for further analysis.

Year to Date Position - Key Variances and Exceptional Items

Detailed Year to Date performance positions are included within Appendix One of this Report

i. Acute Expenditure

Annual Budget£'000

Year to date Budget£'000

Year to date Actual £'000

Year to date Variance

£'000

ALLOCATION Total (871,100) (798,486) (798,486) 0

ACUTE TOTAL 418,162 383,930 389,467 5,536COMMUNITY HEALTH SERVICES TOTAL 94,354 86,598 87,175 577CONTINUING CARE TOTAL 29,918 27,873 29,520 1,647MENTAL HEALTH TOTAL 83,931 77,033 77,079 46OTHER TOTAL 40,079 28,129 29,604 1,475PRIMARY CARE TOTAL 179,612 164,668 164,344 (324)

PROGRAMME TOTAL 846,056 768,231 777,187 8,956

RUNNING COSTS TOTAL 10,617 9,733 7,937 (1,796)

EXPENDITURE TOTAL 856,673 777,964 785,124 7,160

TOTAL (14,427) (20,522) (13,362) 7,160

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The overall Acute Contracts expenditure position is currently £5.5m over planned levels as at February 2017 as per the table below

The performance position being due to an ‘acute’ contract performance position of £5.2m as can be seen by the table below, pressures of £0.8m in Non-Contracted Activity offset by slippage on Winter Resilience and high cost drugs of £0.4m

Annual

Budget Budget Actual Variance

£'000 £'000 £'000 £'000

PROGRAMME ACUTE ACUTE COMMISSIONING 414,272 380,364 385,579 5,215

PROGRAMME ACUTE COLLABORATIVE COMMISSIONING 0 0 0 0

PROGRAMME ACUTE END OF LIFE 0 0 0 0

PROGRAMME ACUTE HIGH COST DRUGS 335 307 190 (118)

PROGRAMME ACUTE NCAS/OATS 3,231 2,962 3,726 765

PROGRAMME ACUTE WINTER RESILIENCE 324 297 (29) (326)

ACUTE TOTAL 418,162 383,930 389,467 5,536

Category Cost centre

Year to date

ACUTE COMMISSIONINGBudget Actual Variance Variance

£'000 £'000 £'000 %

R LIV/BRG UNI HOSP NHST 183,761 184,786 1,025 0.56%AINTREE UNI HOSP NHS FT 71,169 72,436 1,267 1.78%LIVP WOMENS NHS FT 35,955 37,211 1,255 3.49%ALDER HEY CHILDRENS FT 25,884 27,746 1,862 7.19%NW AMBUL SVC NHST 18,792 19,174 382 2.03%ST HEL/KNOWS TEACH NHST 16,984 18,382 1,398 8.23%SPIRE HEALTHCARE LTD 11,240 11,117 (124) -1.10%LIVP HRT/CHST HOSP NHS FT 5,582 5,884 302 5.41%NON CONTRACT 4,686 4,743 56 1.20%WALTON CENTRE NHS FT 1,828 1,992 164 8.96%SOUTHPORT/ORMSKIRK NHST 937 900 (37) -3.99%WIRRAL UNIV TEACH HOSP NHS FT 797 1,304 507 63.60%ONE TO ONE LTD 624 617 (7) -1.11%WARRINGTON/HALTON NHSFT 548 490 (58) -10.62%WRIGHT/WGN/LEIGH NHS FT 358 193 (166) -46.24%COUNTESS OF CHESTER FT 225 237 12 5.30%C MANC UNI HOS NHS FT 218 372 154 70.55%FAIRFIELD INDEPENDENT HOSPITAL 202 175 (26) -13.02%RENACRES HOSPITAL 194 200 6 2.89%SALFORD ROYAL NHSFT 188 260 73 38.64%UNI HOSP SMAN NHS FT 188 217 29 15.62%OTHER SAVINGS 0 (2,858) (2,858) 0.00%

TOTAL ACUTE COMMISSIONING 380,364 385,579 5,215

Year to date

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The month 11 finance information reflects activity information received to date (based on Month 10 Activity (January).

ii. Community Expenditure

The ‘net’ ‘community health services’ expenditure position is currently over planned levels by £0.6m as at February 2017.

Activity based community contracts performance (Spa Medica, AQP Physio and Podiatry contracts) being the main reason for the increased expenditure with a £1.3m over performance against planned levels with and additional cost pressures in Intermediate / Palliative Care of £0.4m and £0.2m, respectively. The table below provides relevant information of contract performance in this area

Budget£'000

Actual £'000

Variance£'000

PROGRAMME COMMUNITY HEALTH SERVICES COMMUNITY SERVICES 74,575 68,469 69,798 1,330

PROGRAMME COMMUNITY HEALTH SERVICES CARERS 302 277 319 42

PROGRAMME COMMUNITY HEALTH SERVICES HOSPICES 3,837 3,471 3,443 (29)

PROGRAMME COMMUNITY HEALTH SERVICES INTERMEDIATE CARE 10,054 9,291 9,691 400

PROGRAMME COMMUNITY HEALTH SERVICES LONG TERM CONDITIONS 5,352 4,882 3,548 (1,334)

PROGRAMME COMMUNITY HEALTH SERVICES PALLIATIVE CARE 234 208 371 163

PROGRAMME COMMUNITY HEALTH SERVICES WHEELCHAIR SERVICE 0 0 5 5

COMMUNITY HEALTH SERVICES TOTAL 94,354 86,598 87,175 577

Year to dateAnnual Budget£'000


Budget Actual Variance

£'000 £'000 £'000

LPOOL COMM HC NFT - SLA 61,703 62,588 885

AINTREE UNI HOSP NHS FT - Diabetes 3,342 3,342 0

LPOOL COMM HC NFT - Anticoag 1,223 1,302 79

SPECSAVERS HEARCARE LTD 866 866 0

LPOOL COMM HC NFT - Podiatry 707 725 17

SPAMEDICA 321 688 367

BPAS 215 322 107

OTHER 90 99 9

LPOOL COMM HC NFT - 15/16 I&E 0 319 319

STROKE ASSOCIATION 0 211 211

PRIORY MEDICAL CENTRE 0 110 110

INJURY CARE CLINICS LTD 0 97 97

WIRRAL COMM NFT 0 93 93

BOOTS HEARINGCARE LTD 0 28 28

LPOOL COMM HC NFT - Interpreter 0 12 12

LCC (LCH Contract Income CEDAS) 0 (1,004) (1,004)

COMMUNITY TOTAL 68,469 69,798 1,330

COMMUNITY SERVICES

Year to date

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These are offset against cost savings of £1.3m against Digital Programme, as agreed through the financial recovery process.

iii. Continuing Care

Continuing Care costs are over budget by £1.6m as per the table below with increases in expenditure against planned level being mainly due to increases in CHC Adult Fully Funded care packages (£1.7m year to date) and in Funded Nursing Care (£0.4m year to date) due to in year increases in charges as previously notified.

iv. Mental Health

Mental Health year to date expenditure remains in line with budget as per the table below

Budget£'000

Actual £'000

Variance£'000

PROGRAMME CONTINUING CARE CHC ADULT FULLY FUNDED 20,242 18,593 20,329 1,736

PROGRAMME CONTINUING CARE CHC ADULT JOINT FUNDED 2,508 2,299 2,361 61

PROGRAMME CONTINUING CARECONTINUING HEALTHCARE ASSESSMENT & SUPPORT

358 328 298 (30)

PROGRAMME CONTINUING CARE CHC CHILDREN 2,491 2,693 2,210 (483)

PROGRAMME CONTINUING CARE FUNDED NURSING CARE 4,319 3,959 4,321 362

CONTINUING CARE TOTAL 29,918 27,873 29,520 1,647



Budget£'000

Actual £'000

Variance£'000

PROGRAMME MENTAL HEALTH MENTAL HEALTH CONTRACTS 65,916 60,489 60,440 (49)

PROGRAMME MENTAL HEALTH CHILD AND ADOLESCENT MENTAL HEALTH 1,644 1,539 2,552 1,014

PROGRAMME MENTAL HEALTH DEMENTIA 223 204 238 34

PROGRAMME MENTAL HEALTH LEARNING DIFFICULTIES 4,104 3,762 4,363 600

PROGRAMME MENTAL HEALTH MENTAL CAPACITY ACT 116 106 106 0

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - ADULTS 5,358 4,912 4,609 (303)

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - ADVOCACY 181 166 166 0

PROGRAMME MENTAL HEALTHMENTAL HEALTH SERVICES - COLLABORATIVE COMMISSIONING

85 78 78 0

PROGRAMME MENTAL HEALTHMENTAL HEALTH SERVICES - NOT CONTRACTED ACTIVITY

264 242 174 (68)

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - OLDER PEOPLE 4,880 4,473 3,355 (1,118)

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - OTHER 1,160 1,062 998 (64)

MENTAL HEALTH TOTAL 83,931 77,033 77,079 46



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The significant variances within the breakeven position include an overspend in CAMHS expenditure of £1.0m, and increases in Learning Difficulties expenditure of £0.6m.

This is offset by a large underspend in Mental Health Older people of £1.1m (due to delayed start and reduced costs for the Care Home and Home First schemes) and Mental Health Adults £0.3m

v. Other Programme (including Reserves)

Other Programme costs are over budget by £1.5m, largely due to impact of Commissioning – Non Acute (Better Care Fund) and the Commissioning Reserve overspends of £1.0m and 1.9m respectively. This is offset by year to date underspends in Quality Premium, Programme Projects and NHS111.

Further information is included within the forecast outturn section with regards to ‘Other Programme’ expenditure including relative position on earmarked / non-recurrent reserves.

vi. Primary Care

Primary Care costs are below budgeted year to date expenditure by £0.3m as per the below table due to a combination of underspending against planned levels in Prescribing of £1.4m (which is based on the 10 months actual costs (April – January 2017) and net underspends on

Budget£'000

Actual £'000

Variance£'000

PROGRAMME OTHER COMMISSIONING - NON ACUTE 12,840 11,549 12,648 1,099

PROGRAMME OTHER COMMISSIONING RESERVE (2,034) (1,865) 0 1,865

PROGRAMME OTHER COUNSELLING SERVICES 1,000 917 626 (290)

PROGRAMME OTHER NON RECURRENT PROGRAMMES 300 275 47 (228)

PROGRAMME OTHER NON RECURRENT RESERVE 8,362 0 0 0

PROGRAMME OTHER PATIENT TRANSPORT 3 3 16 13

PROGRAMME OTHER PROGRAMME PROJECTS 1,618 1,483 1,156 (327)

PROGRAMME OTHER REABLEMENT 3,758 3,444 3,354 (90)

PROGRAMME OTHER RECHARGES NHS PROPERTY SERVICES LTD 6,035 4,846 5,542 696

PROGRAMME OTHER EXCEPTIONS & PRIOR APPROVALS 3,188 2,922 2,873 (49)

PROGRAMME OTHER SAFEGUARDING 1,011 927 890 (37)

PROGRAMME OTHER NHS 111 1,563 1,434 1,165 (269)

PROGRAMME OTHER QUALITY PREMIUM PROGRAMME 873 800 0 (800)

PROGRAMME OTHER CLINICAL LEADS 1,563 1,393 1,286 (107)

OTHER TOTAL 40,079 28,129 29,604 1,475



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Commissioning schemes and Primary Care IT, offset by a £0.3m overspend on Local Enhanced Services.

*The prescribing position may need to be reviewed again in Month 12 due to ongoing conversations with NHS England regarding the treatment of prescribing stock adjustments and application of a consistent approach with other CCG’s across the North of England.

vii. Running Costs

Running costs are showing an under spend against planned levels of £1.8m for the year to date. This is mainly due to the Running cost reserve not being utilised in line with financial plan assumptions as per the table below and is currently being reviewed in preparation for year-end financial statements.

c) Forecast Outturn Position as at Month 11 (February)

Budget£'000

Actual £'000

Variance£'000

PROGRAMME PRIMARY CARE CENTRAL DRUGS 65 59 61 2PROGRAMME PRIMARY CARE COMMISSIONING SCHEMES 3,520 3,222 2,699 (523)PROGRAMME PRIMARY CARE LOCAL ENHANCED SERVICES 18,738 17,176 17,469 292PROGRAMME PRIMARY CARE OUT OF HOURS 4,278 3,922 3,891 (31)PROGRAMME PRIMARY CARE OXYGEN 872 799 788 (11)PROGRAMME PRIMARY CARE PRESCRIBING 87,543 80,248 78,895 (1,353)PROGRAMME PRIMARY CARE PRIMARY CARE IT 2,470 2,264 2,079 (185)PROGRAMME PRIMARY CARE PRC DELEGATED CO-COMMISSIONING 62,127 56,977 58,462 1,485

PRIMARY CARE TOTAL 179,612 164,668 164,344 (324)



Budget Actual Variance

£'000 £'000 £'000

ADMINISTRATION CORPORATE ADMINISTRATION & BUSINESS SUPPORT 810 743 677 (66)

ADMINISTRATION CORPORATE BUSINESS INFORMATICS 1,121 1,026 852 (174)

ADMINISTRATION CORPORATE CEO/ BOARD OFFICE 2,259 2,070 2,194 124

ADMINISTRATION CORPORATE COMMISSIONING 686 629 625 (4)

ADMINISTRATION CORPORATE COMMUNICATIONS & PR 139 127 114 (13)

ADMINISTRATION CORPORATE CONTRACT MANAGEMENT 738 676 691 15

ADMINISTRATION CORPORATE ESTATES AND FACILITIES 200 183 302 119

ADMINISTRATION CORPORATE FINANCE 1,025 940 861 (79)

ADMINISTRATION CORPORATE HUMAN RESOURCES 0 0 0 0

ADMINISTRATION CORPORATE INNOVATION FUND 0 0 0 0

ADMINISTRATION CORPORATE OPERATIONS MANAGEMENT 0 0 0 0

ADMINISTRATION CORPORATE STRATEGY & DEVELOPMENT 54 50 49 (1)

ADMINISTRATION CORPORATE CORPORATE COSTS & SERVICES 1,922 1,762 1,572 (190)

ADMINISTRATION CORPORATE GENERAL RESERVE - ADMIN 1,663 1,527 0 (1,527)

CORPORATE COSTS TOTAL 10,617 9,733 7,937 (1,796)

Year to date

Category Cost CentreAnnual Budget£'000

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535353

The CCG is currently reporting a balanced position against its revised forecast outturn position of £8.017m surplus as per the table below.

In line with the changes to CCG financial reporting as described earlier (regarding surplus and headroom) this results in a deterioration of the surplus position from £14.4m and results in an in-year deficit position of £6.410m (excluding 1% headroom but upon release will support delivery of £16.4m cumulative surplus).

Forecast outturn assumptions are generated predominantly based on the respective pro-rata year to date positions and include adjustments for additional intelligence / information where known. Included within the forecast outturn position include the expectations of delivery of financial recovery plan solutions as described below and with no material deterioration in other activity based expenditure areas (e.g. remaining activity based contracts, prescribing, continuing healthcare, packages etc) compared to the Month 11 forecast outturn position. Key Variances and Exceptional Items

i. Acute Contracts

Annual Forecast ForecastBudget Outturn Variance£000's £000's £000's

RESOURCE ALLOCATION -871,100 -871,100 0

ACUTE 418,162 424,675 6,513

COMMUNITY HEALTH SERVICES 94,354 95,057 703

CONTINUING CARE 29,918 31,606 1,688

MENTAL HEALTH 83,931 84,018 86

OTHER PROGRAMME (INC RESERVES) 40,079 40,684 605

PRIMARY CARE 179,612 178,342 (1,270)

TOTAL PROGRAMME COSTS 846,056 854,381 8,325

TOTAL RUNNING COSTS 10,617 8,702 (1,915)

TOTAL EXPENDITURE 856,673 863,083 6,410

TOTAL (14,427) (8,017) 6,410

2016/17

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The net ‘acute’ commissioning forecast outturn position as at Month 11 is a £6.51m over performance as per the table below and broadly reflects the year to date performance position.

Acute contract performance are forecast to be over planned levels by £6.0m with additional overspends on Non Contracted Activity £0.8m offset by other underspends of £0.1m on High Cost Drugs and £0.2m on Winter Resilience funding.

The main contract forecast over performance areas are as per the table below with the following contracts having a fixed outturn position reducing financial risk for year end forecasting purposes. Royal Liverpool and Broadgreen University Hospitals NHS trust Aintree University Hospitals NHS Foundation Trust Liverpool Womens NHS Foundation Trust Alder Hey Childrens NHS Foundation Trust Wirral University Teaching Hospitals NHS Foundation Trust

Annual

Budget Outturn Variance

£'000 £'000 £'000

PROGRAMME ACUTE ACUTE COMMISSIONING 414,272 420,308 6,036

PROGRAMME ACUTE COLLABORATIVE COMMISSIONING 0 0 0

PROGRAMME ACUTE END OF LIFE 0 0 0

PROGRAMME ACUTE HIGH COST DRUGS 335 216 (119)

PROGRAMME ACUTE NCAS/OATS 3,231 3,981 750

PROGRAMME ACUTE WINTER RESILIENCE 324 170 (154)

ACUTE TOTAL 418,162 424,675 6,513


Forecast

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The forecast position includes an assumption that the financial recovery solutions are delivered as per the financial recovery plan.

ii. Community Health Contracts

The net ‘community health’ commissioning forecast outturn position as at Month 11 is a £0.7m underspend against planned levels as per the table below

This underspend consists of contract over performance of £1.51m, pressures on intermediate / palliative care of £0.66m and a favourable position across long term conditions / digital of £1.38m.

With regards to Community Health Services contracts, these are over planned expenditure by £1.51m, with over performance in Liverpool

Annual


£'000 £'000 £'000

R LIV/BRG UNI HOSP NHST 200,287 201,405 1,118

AINTREE UNI HOSP NHS FT 77,537 78,920 1,382

LIVP WOMENS NHS FT 38,669 40,028 1,359

ALDER HEY CHILDRENS FT 28,236 30,305 2,069

NW AMBUL SVC NHST 20,796 21,238 442

ST HEL/KNOWS TEACH NHST 18,755 20,430 1,675

SPIRE HEALTHCARE LTD 12,262 12,167 (95)

LIVP HRT/CHST HOSP NHS FT 6,089 6,373 283

NON CONTRACT 4,898 4,783 (115)

WALTON CENTRE NHS FT 2,017 2,197 180

SOUTHPORT/ORMSKIRK NHST 1,022 980 (42)

WIRRAL UNIV TEACH HOSP NHS FT 712 1,331 619

ONE TO ONE LTD 683 674 (9)

WARRINGTON/HALTON NHSFT 598 533 (65)

WRIGHT/WGN/LEIGH NHS FT 386 218 (169)

COUNTESS OF CHESTER FT 246 257 11

C MANC UNI HOS NHS FT 238 403 165

FAIRFIELD INDEPENDENT HOSPITAL 220 191 (29)

RENACRES HOSPITAL 212 218 6

SALFORD ROYAL NHSFT 205 280 75

UNI HOSP SMAN NHS FT 205 238 33

OTHER SAVINGS 0 (2,858) (2,858)

TOTAL ACUTE COMMISSIONING 414,272 420,308 6,036

Forecast

ACUTE COMMISSIONING

Annual


£'000 £'000 £'000

PROGRAMME COMMUNITY HEALTH SERVICES COMMUNITY SERVICES 74,575 76,089 1,514

PROGRAMME COMMUNITY HEALTH SERVICES CARERS 302 302 0

PROGRAMME COMMUNITY HEALTH SERVICES HOSPICES 3,837 3,747 (89)

PROGRAMME COMMUNITY HEALTH SERVICES INTERMEDIATE CARE 10,054 10,503 449

PROGRAMME COMMUNITY HEALTH SERVICES LONG TERM CONDITIONS 5,352 3,969 (1,383)

PROGRAMME COMMUNITY HEALTH SERVICES PALLIATIVE CARE 234 446 212

PROGRAMME COMMUNITY HEALTH SERVICES WHEELCHAIR SERVICE 0 0 0

COMMUNITY HEALTH SERVICES TOTAL 94,354 95,057 703


Forecast

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Community, Spa Medica, Stroke Association and Priory Medical contracts as per the table below.

iii. Continuing Care

Continuing Care, Health Packages (Fully / Joint Funded) and Funded Nursing Care costs are forecasted over budgeted levels by £1.7m, this is predominantly as a result of in year pressures driven by increases to domiciliary care costs. A year end agreement has been reached with Liverpool City Council with regards to outstanding invoice issues in this area including areas of the Better Care Fund.

iv. Mental Health Contracts

The net ‘mental health’ commissioning forecast outturn position as at Month 11 (February), is £0.1m over performance, with regards to commitments against CAMHS and Learning Disabilities over and above planned expenditure levels being offset by underspending in Older People services.

Annual


£'000 £'000 £'000

LPOOL COMM HC NFT - SLA 67,200 68,210 1,010

AINTREE UNI HOSP NHS FT - Diabetes 3,640 3,640 0

LPOOL COMM HC NFT - Anticoag 1,335 1,421 86

LPOOL COMM HC NFT - Podiatry 772 772 0

SPECSAVERS HEARCARE LTD 945 945 0

SPAMEDICA 350 750 400

BPAS 235 376 141

OTHER 99 70 (29)

LPOOL COMM HC NFT - 15/16 I&E 0 319 319

STROKE ASSOCIATION 0 232 232

PRIORY MEDICAL CENTRE 0 120 120

INJURY CARE CLINICS LTD 0 106 106

WIRRAL COMM NFT 0 93 93

BOOTS HEARINGCARE LTD 0 28 28

LPOOL COMM HC NFT - Interpreter 12 12

LCC (LCH Contract Income CEDAS) 0 (1,004) (1,004)

COMMUNITY TOTAL 74,575 76,089 1,514

COMMUNITY SERVICES

Forecast

Annual


£'000 £'000 £'000

PROGRAMME CONTINUING CARE CHC ADULT FULLY FUNDED 20,242 21,936 1,694

PROGRAMME CONTINUING CARE CHC ADULT JOINT FUNDED 2,508 2,585 78

PROGRAMME CONTINUING CARECONTINUING HEALTHCARE ASSESSMENT & SUPPORT

358 328 (30)

PROGRAMME CONTINUING CARE CHC CHILDREN 2,491 2,331 (160)

PROGRAMME CONTINUING CARE FUNDED NURSING CARE 4,319 4,425 106

CONTINUING CARE TOTAL 29,918 31,606 1,688


Forecast

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v. Other Programme (including Reserves) The reserves held by the CCG are as per the below table.

Reserves February (M11)

January (M10)

December (M9)

1% Non-recurrent (*1) 8,362 8,362 8,362 Commissioning Reserve (*2 ) (2,034) (2,082) (2,082) Running Costs (*3) 1,663 1,663 1,663 Total 7,991 7,943 7,943

The assumptions regarding utilisation of reserves are as per the below

1) 1% Non-recurrent Reserve – to be released in Month 12 Reporting

as confirmed by NHS England

2) As per below table with regards to budget and forecast outturn position of commissioning reserve including treatment of NPFIT allocation in relation EPR contract discussions

Budget Forecast

Outturn Variance

NPFIT £5.0m £0m (£5.0m) Other In Year Budget Adjustments (including 1% non-recurrent reserves

(£7.034m) £7.034m

(£2.034m) £0m £2.034m 3) Not required as per financial planning assumptions vi. Primary Care

Annual


£'000 £'000 £'000

PROGRAMME MENTAL HEALTH MENTAL HEALTH CONTRACTS 65,916 65,843 (73)

PROGRAMME MENTAL HEALTH CHILD AND ADOLESCENT MENTAL HEALTH 1,644 2,807 1,163

PROGRAMME MENTAL HEALTH DEMENTIA 223 260 37

PROGRAMME MENTAL HEALTH LEARNING DIFFICULTIES 4,104 4,658 554

PROGRAMME MENTAL HEALTH MENTAL CAPACITY ACT 116 116 0

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - ADULTS 5,358 5,044 (314)

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - ADVOCACY 181 181 0

PROGRAMME MENTAL HEALTHMENTAL HEALTH SERVICES - COLLABORATIVE COMMISSIONING

85 85 0

PROGRAMME MENTAL HEALTHMENTAL HEALTH SERVICES - NOT CONTRACTED ACTIVITY

264 212 (51)

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - OLDER PEOPLE 4,880 3,697 (1,183)

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - OTHER 1,160 1,116 (45)

MENTAL HEALTH TOTAL 83,931 84,018 86


Forecast

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Planned expenditure in Primary Care is forecast to be underspent by £1.3m by the end of the financial year as per the table below and consists of primary care and prescribing performance positions.

The forecast outturn position for Prescribing currently stands at a £1.23m under performance against planned levels at the end of the financial year, however this remains subject to confirmation of treatment of stock adjustments and consistency with other CCG’s across the North of England as per the year to date reporting position The forecast position is based upon 10 months actual costs and includes an element of savings as per the financial recovery savings section which will require monitoring until the end of the financial eyar. The co-commissioning forecast is £1.12m above planned levels with underspends against a number of other primary care areas including primary care IT, and locally commissioned schemes.

d) Financial Recovery As previously reported, the delivery of the planned surplus position will depend on a combination of solutions as identified within the financial recovery plan and no material movement from the month 11 forecast outturn assumptions. The CCG commenced a review of its expenditure during quarter 2 of the 2016/17 financial year and led to the development of phase one of the financial recovery plan approach as per the below section. Phase One Phase One of the financial recovery process was initially anticipated to generate £6.5m of expenditure reductions within the financial year. The

Annual


£'000 £'000 £'000

PROGRAMME PRIMARY CARE CENTRAL DRUGS 65 67 2

PROGRAMME PRIMARY CARE COMMISSIONING SCHEMES 3,520 2,999 (521)

PROGRAMME PRIMARY CARE LOCAL ENHANCED SERVICES 18,738 18,348 (390)

PROGRAMME PRIMARY CARE OUT OF HOURS 4,278 4,246 (32)

PROGRAMME PRIMARY CARE OXYGEN 872 855 (17)

PROGRAMME PRIMARY CARE PRESCRIBING 87,543 86,308 (1,235)

PROGRAMME PRIMARY CARE PRIMARY CARE IT 2,470 2,268 (202)

PROGRAMME PRIMARY CARE PRC DELEGATED CO-COMMISSIONING 62,127 63,251 1,124

PRIMARY CARE TOTAL 179,612 178,342 (1,270)


Forecast

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forecast position as at month 11 is as per the table below with delivery of £6.18m included within the outturn position

Phase Two

The table below shows the additional solutions considered as part of Phase 2 of the 2016/17 financial recovery process.

These additional solutions identified an additional £1.15m of potential expenditure reductions based on information as at the end of February 2017 and again are included within the forecast outturn position.

SCHEME NAME LeadSavings Planned

£

Savings Forecast -

M11 Reporting

% of forecast achieved

16/17 Plan Phase 1Acute activity - Referral and Outpatient Reviews C Mould

300,000 - 0%

Prescribing Expenditure 'FEP' C Mould500,000 473,889

95%

Programme Expenditure Digital agenda T Woods1,000,000 750,000

75%

Review of Healthcare packages K Lloyd 240,000 - 0%

Programme Expenditure Physical Activity C Hill

750,000 750,000 100%

Winter Resilience Funding I Davies 160,000 160,000 100%

Grants Programme - Year 2 requirements T Woods

370,000 370,000 100%

Inhaler Project T Woods 42,000 42,000 100%

CLARC Contributions T Woods 300,000 300,000 100%

Excess Treatment CostsT Woods

90,000 80,000 89%

GP Specification Recovery C Mould 348,000 348,000 100%

Primary Care IT (Gold standard) C Mould 87,000 87,000 100%

16/17 CQUINS J Lunt 1,000,000 1,357,858 136%

Care Homes Model implementation T Woods 750,000 863,089 115%

Falls/Stroke T Woods 400,000 400,000 100%

Vacancy Freeze/Secondments/Fixed term/Clinical sessions

I Davies/ C Hill 200,000 200,000

100%

Total 6,537,000 6,181,836

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d) Risks

There remain a number of risks to delivery of the CCG forecast outturn position and its ability to deliver against NHS England Business Planning Rules for the 2016/17 financial year.

• No Material Movement in Month 11 Forecast Outturn

Assumptions • Release of the 1% Non-Recurrent Headroom • Agreed phasing of EPR Programme amongst partners • Agreement with Liverpool City Council with regards to the

Better Care Fund and other outstanding invoices

Summary of CCG Financial Risks to delivery In order to deliver the planned surplus position, the below table shows the level of mitigations required at each relevant reporting point within the financial year and have been equivalent to the requirements of the financial recovery plan at each of the relevant stages.

Planning Gap

Month 6 £3.4m Increase to 1% + 1% £2.0m Month 7 Acute Contracts £1.6m Other Net Month 7 Movements £0.4m

SCHEME NAME LeadSavings Planned

£

Savings Forecast -

M11 Reporting

% of forecast achieved

SMT reviews All SMT3,000,000 730,000

24%

Contract Challenges D Rothwell 350,000 140,000 40%

Demand Management T Woods 350,000 80,000 23%

Acting as One K Sheerin 100,000 0 0%

Provider Contracts T Jackson 500,000 0 0%

Prescribing Expenditure C Mould700,000 200,000

29%

Outturn Assumptions T Jackson 1,000,000 0 0%

Review Contract Agreements D Rothwell 1,000,000 0 0%

Unidentified All SMT 400,000 0 0%Total 7,400,000 1,150,000

16/17 Plan Phase 2

Page 21 of 28

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Month 7 £7.4m

(£5.4m like for like on basis of £14.4m surplus)

Acute Contracts (Royal M7 & NCA’s) £1.1m Mental Health Packages £0.4m Quality Premium (15/16) (£0.8m) Month 8 £8.1m Month 9 £8.1m

Month 10 Review of Outturn Assumptions

Planning Gap Month 9 £8.1m

Other Month 10 FOT Changes £0.5m Less NPFIT Allocation Assumptions -£4.6m Less LCC Invoice Resolution -£4.0m Month 10 £0m Month 11 £0m

The CCG financial outturn position assumes that the full value of phase 1 and 2 recovery plan elements are delivered, assumptions as per above are actioned and that there are no further adverse movements in forecast outturn positions beyond the month 11 reporting position. 6. STATEMENT OF FINANCIAL POSITION

The table below shows the statement of financial position for the CCG as at February 2017 including relevant assets and liabilities.

Feb-17 Jan-17 £ £ Total Non-Current Assets 0 Cash 2,473,993 16,824 Accounts Receivable 9,125,723 13,462,456 Current Assets 11,599,718 13,479,280 TOTAL ASSETS 11,599,718 13,479,280

Accounts Payable 42,261,506 64,232,494 Total Current Liabilities 42,261,506 64,232,494 Retained Earnings incl. In Year -30,661,790 -50,753,214 Total Taxpayers Equity -30,661,790 -50,753,214 TOTAL EQUITY + LIABILITIES 11,599,716 13,479,280

Cash Target

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The target for the month of February 2017 was not achieved, the target is based on the 1.25% year end cash holding requirement however this is not a mandatory national target in year. The higher cash position was due to late cash receipts end from Liverpool local authority.

a) Better Payment Practice Code

Under the Better Payments Practice Code (BPPC), CCG’s are expected to pay 95% of all creditors within 30 days of the receipt of invoices.

The February 17 year to date figure shows that this target was achieved for NHS and NON NHS for Values and NON NHS for Number of invoices.

The target for February 17 on NHS (number) was achieved at 95.62% (Jan17 94.35%), but still not for the year to date due to the impact of prior months, as previously reported. Action to improve performance has been implemented and it is anticipated that the target for 2016/17 should be achieved, however this is subject to an exceptional performance in March and the outcome of a retrospective review of the BPPC performance.

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Cash Target

Target

Actual

Page 23 of 28

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7. STATUTORY REQUIREMENTS (only applicable to strategy &

commissioning papers)

7.1 Does this require public engagement or has public engagement been carried out?

Not Applicable

7.2 Does the public sector equality duty apply?

Not Applicable

7.3 Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most:

Economic /Social / Environmental wellbeing

Not Applicable 7.4 Taking the above into account, describe the impact on

improving health outcomes and reducing inequalities

Not Applicable 8. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY

Supports the achievement of Statutory Financial Duties. 9. CONCLUSION

The purpose of this report is to provide the Governing Body with an update on the CCG’s financial performance against its planned surplus and elements of business planning rules for 2016/17, particularly regarding the amendments in respect of 1% non-recurrent headroom.

Tom Jackson Chief Finance Officer 31st March 2017

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Appendix One – Year to Date Budget Performance as at February 2017

Annual Year to Date (£) Forecast (£)

Budget (£) Budget Actual Variance Outturn Variance

ALLOCATIONS CONFIRMED CONFIRMED -804,743,000 -737,658,812 -737,658,812 0 -804,743,000 0

ALLOCATIONS POTENTIAL POTENTIAL -66,357,000 -60,827,250 -60,827,250 0 -66,357,000 0

ALLOCATIONS ALLOCATIONS -871,100,000 -798,486,062 -798,486,062 0 -871,100,000 0

PROGRAMME ACUTE ACUTE COMMISSIONING 414,272,151 380,364,110 385,579,460 5,215,350 420,308,345 6,036,194

PROGRAMME ACUTE NCAS/OATS 3,231,000 2,961,739 3,726,438 764,699 3,981,000 750,000

PROGRAMME ACUTE END OF LIFE 0 0 0 0 0 0

PROGRAMME ACUTE COLLABORATIVE COMMISSIONING 0 0 0 0 0 0

PROGRAMME ACUTE HIGH COST DRUGS 335,000 307,450 189,806 -117,644 215,657 -119,343

PROGRAMME ACUTE Winter Resilience 324,000 297,000 -29,140 -326,140 170,000 -154,000

418,162,151 383,930,299 389,466,564 5,536,265 424,675,002 6,512,851

PROGRAMME COMMUNITY HEALTH SERVICES

COMMUNITY SERVICES 74,575,291 68,468,516 69,798,406 1,329,890 76,089,464 1,514,173


INTERMEDIATE CARE 10,053,871 9,290,936 9,690,651 399,715 10,503,149 449,278


PALLIATIVE CARE 234,196 208,236 371,381 163,145 446,365 212,169


WHEELCHAIR SERVICE 0 0 4,627 4,627 0 0


CARERS 302,051 276,876 319,082 42,206 302,051 0


HOSPICES 3,836,530 3,471,468 3,442,796 -28,672 3,747,036 -89,494


LONG TERM CONDITIONS 5,351,930 4,881,982 3,547,633 -1,334,349 3,968,536 -1,383,394

94,353,869 86,598,014 87,174,576 576,562 95,056,601 702,732

PROGRAMME CONTINUING CARE FUNDED NURSING CARE 4,319,398 3,959,441 4,320,998 361,557 4,425,074 105,676

PROGRAMME CONTINUING CARE CHC ADULT FULLY FUNDED 20,242,000 18,592,900 20,329,332 1,736,432 21,936,343 1,694,343

656565

PROGRAMME CONTINUING CARE CHC CHILDREN 2,490,623 2,693,039 2,210,198 -482,841 2,330,941 -159,682

PROGRAMME CONTINUING CARE CONTINUING HEALTHCARE ASSESSMENT & SUPPORT

358,000 328,164 298,329 -29,835 328,162 -29,838

PROGRAMME CONTINUING CARE CHC ADULT JOINT FUNDED 2,507,583 2,299,214 2,360,663 61,449 2,585,153 77,570

29,917,604 27,872,758 29,519,519 1,646,761 31,605,673 1,688,069

PROGRAMME MENTAL HEALTH CHILD AND ADOLESCENT MENTAL HEALTH

1,643,756 1,538,703 2,552,246 1,013,543 2,806,578 1,162,822

PROGRAMME MENTAL HEALTH LEARNING DIFFICULTIES 4,104,404 3,762,402 4,362,664 600,262 4,658,064 553,660

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - OTHER

1,160,363 1,061,794 998,106 -63,688 1,115,627 -44,736

PROGRAMME MENTAL HEALTH MENTAL HEALTH CONTRACTS 65,915,580 60,488,747 60,440,135 -48,612 65,842,553 -73,027

PROGRAMME MENTAL HEALTH DEMENTIA 222,949 204,373 237,933 33,560 259,622 36,673

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - ADVOCACY

181,011 165,924 165,927 3 181,011 0

PROGRAMME MENTAL HEALTH MENTAL CAPACITY ACT 116,000 106,333 106,333 0 116,000 0

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - COLLABORATIVE COMMISSIONING

85,000 77,916 77,916 0 85,000 0

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - NOT CONTRACTED ACTIVITY

263,572 241,609 173,636 -67,973 212,434 -51,138

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - ADULTS

5,358,323 4,911,620 4,609,100 -302,520 5,043,919 -314,404

PROGRAMME MENTAL HEALTH MENTAL HEALTH SERVICES - OLDER PEOPLE

4,880,175 4,473,494 3,355,085 -1,118,409 3,696,767 -1,183,408

83,931,133 77,032,915 77,079,081 46,166 84,017,575 86,442

PROGRAMME OTHER EXCEPTIONS & PRIOR APPROVALS 3,188,000 2,922,348 2,873,481 -48,867 3,091,787 -96,213

PROGRAMME OTHER COMMISSIONING - NON ACUTE 12,839,722 11,549,162 12,647,725 1,098,563 13,906,014 1,066,292

PROGRAMME OTHER REABLEMENT 3,757,616 3,444,478 3,354,128 -90,350 3,658,702 -98,914

PROGRAMME OTHER NHS 111 1,562,521 1,434,188 1,165,162 -269,026 1,124,042 -438,479

PROGRAMME OTHER PATIENT TRANSPORT 3,000 2,750 15,807 13,057 16,626 13,626

PROGRAMME OTHER RECHARGES NHS PROPERTY SERVICES LTD

6,035,284 4,845,993 5,541,784 695,791 6,076,284 41,000

PROGRAMME OTHER QUALITY PREMIUM PROGRAMME 873,000 800,250 0 -800,250 0 -873,000

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PROGRAMME OTHER SAFEGUARDING 1,011,051 926,802 890,221 -36,581 972,598 -38,453

PROGRAMME OTHER CLINICAL LEADS 1,562,980 1,392,925 1,285,871 -107,054 1,443,980 -119,000

PROGRAMME OTHER PROGRAMME PROJECTS 1,618,099 1,483,260 1,156,453 -326,807 1,261,003 -357,096

PROGRAMME OTHER COUNSELLING SERVICES 1,000,000 916,663 626,402 -290,261 688,923 -311,077

PROGRAMME OTHER NON RECURRENT PROGRAMMES 300,000 275,000 46,583 -228,417 82,050 -217,950

NON RECURRENT RESERVE 8,362,100 0 0 0 8,362,100 0

PROGRAMME OTHER COMMISSIONING RESERVE -2,034,481 -1,864,941 0 1,864,941 0 2,034,481

40,078,892 28,128,878 29,603,619 1,474,741 40,684,108 605,216

PROGRAMME PRIMARY CARE PRC DELEGATED CO-COMMISSIONING

62,127,026 56,977,042 58,461,992 1,484,950 63,250,688 1,123,662

PROGRAMME PRIMARY CARE PRESCRIBING 87,543,000 80,248,211 78,895,168 -1,353,043 86,308,310 -1,234,690

PROGRAMME PRIMARY CARE OUT OF HOURS 4,278,256 3,921,733 3,890,814 -30,919 4,245,763 -32,493

PROGRAMME PRIMARY CARE OXYGEN 871,507 798,886 787,639 -11,247 854,844 -16,663

PROGRAMME PRIMARY CARE CENTRAL DRUGS 64,632 59,246 61,402 2,156 66,773 2,141

PROGRAMME PRIMARY CARE PRIMARY CARE IT 2,470,000 2,264,164 2,078,802 -185,362 2,267,966 -202,034

PROGRAMME PRIMARY CARE COMMISSIONING SCHEMES 3,520,144 3,222,412 2,699,284 -523,128 2,999,402 -520,742

PROGRAMME PRIMARY CARE LOCAL ENHANCED SERVICES 18,737,786 17,176,294 17,468,688 292,394 18,348,228 -389,558

179,612,351 164,667,988 164,343,789 -324,199 178,341,974 -1,270,377

ADMIN CORPORATE ESTATES AND FACILITIES 200,000 183,330 301,866 118,536 329,700 129,700

ADMIN CORPORATE INNOVATION FUND 0 0 0 0 0 0

ADMIN CORPORATE OPERATIONS MANAGEMENT 0 0 0 0 0 0

ADMIN CORPORATE COMMISSIONING 686,008 628,802 625,023 -3,779 679,973 -6,035

ADMIN CORPORATE COMMUNICATIONS & PR 139,171 127,465 114,255 -13,210 119,900 -19,271

ADMIN CORPORATE STRATEGY & DEVELOPMENT 54,328 49,798 49,283 -515 54,367 39

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ADMIN CORPORATE FINANCE 1,025,214 939,609 860,815 -78,794 940,095 -85,119

ADMIN CORPORATE HUMAN RESOURCES 0 0 0 0 0 0

ADMIN CORPORATE ADMINISTRATION & BUSINESS SUPPORT

809,687 742,694 676,943 -65,751 740,102 -69,585

ADMIN CORPORATE CEO/ BOARD OFFICE 2,258,559 2,070,367 2,194,024 123,657 2,394,134 135,575

ADMIN CORPORATE CONTRACT MANAGEMENT 738,208 675,834 690,949 15,115 781,112 42,904

ADMIN CORPORATE BUSINESS INFORMATICS 1,120,796 1,026,161 851,691 -174,470 946,021 -174,775

ADMIN CORPORATE CORPORATE COSTS & SERVICES 1,922,074 1,761,931 1,572,216 -189,715 1,716,663 -205,412

ADMIN CORPORATE GENERAL RESERVE - ADMIN 1,662,955 1,527,266 0 -1,527,266 0 -1,662,955

10,617,000 9,733,257 7,937,063 -1,796,194 8,702,068 -1,914,932

I+E Position 856,673,000 777,964,109 785,124,211 7,160,102 863,083,000 6,410,000

Month 11 position -14,427,000 -20,521,953 -13,361,851 7,160,102 -8,017,000 6,410,000

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Report no: GB 28-17


TUESDAY 11th APRIL 2017

Title of Report CCG Corporate Performance Report April

2017 Lead Governor Dr Nadim Fazlani


Ian Davies, Chief Operating Officer

Report Author Stephen Hendry, Senior Operations and Governance Manager

Summary The purpose of this paper is to report to the Governing Body the areas of the CCG’s performance in terms of its delivery of key NHS Constitutional measures, quality standards/performance and financial targets for January 2017 and February 2017.

Recommendation That Liverpool CCG Governing Body: Notes the performance of the CCG in

the delivery of key national performance indicators and the recovery actions taken to improve performance;

Determines the level of assurances given in terms of mitigating actions where risks to CCG strategic objectives are highlighted.


CCG Improvement and Assessment Framework 2016/17; Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21; NHS England/NHS Improvement “Strengthening Financial Performance & Accountability in 2016/17”

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CCG CORPORATE PERFORMANCE REPORT (FEBRUARY 2017)

1. PURPOSE

The purpose of this paper is to report to the Governing Body the areas of the CCG’s performance in terms of its delivery against key NHS Constitutional measures, NHS Planning Guidance 2016/17, quality standards/performance and targets for January 2017 and February 2017. 2. RECOMMENDATIONS That Liverpool CCG Governing Body: Notes the performance of the CCG in the delivery of key national

performance indicators and the recovery actions taken to improve performance;

Determines if there are acceptable levels of assurances given in terms of mitigating actions where risks to CCG strategic objectives are highlighted.

3. BACKGROUND The CCG is held to account by NHS England for corporate performance against delivery of key indicators as defined in the CCG Improvement and Assessment Framework 2016/2017. The new framework supports the NHS Planning Guidance for 2016/17 and aligns key objectives and priorities for the NHS for the financial year; linking heavily to Sustainability and Transformation Plans (STP) and the ‘triple aim’ of improving the health and wellbeing of the population. Under the Improvement and Assessment Framework 2016/17 CCGs will be rated in 29 areas (underpinned by 60 indicators) which are located in four domains:

• Better Health - how the CCG is contributing towards improving the health and wellbeing of its population and ‘bending’ the demand curve;

• Better Care - care redesign, performance of constitutional standards and outcomes;

• Sustainability - how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends;

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• Leadership - assesses the quality of the CCG’s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity (for example in managing conflicts of interest)

For the first time patients are now able to view their CCG’s ratings on the ‘myNHS’ website (part of the NHS Choices web resource). Ultimately, the CCG has to be assured that the services we commission are delivering the required NHS Constitutional and quality standards and meet the local system priorities for 2016/17. This is largely achieved through the now well established governance frameworks and committee structures in place which monitor performance and provide assurances to the Governing Body that key risks to strategic objectives and operational delivery continue to be effectively managed.

The reporting of quarterly indicators and analysis against key NHS/Public Health/local outcomes to the Governing Body will continue in 2016/17 with the aim of aligning reporting requirements and measurements with the key Healthy Liverpool Programme (HLP) areas of transformation. Due to the way in which these indicators are currently measured, reporting for the majority of these data sets will be on a quarterly and/or annual basis, by exception or as and when key data is made available. The timing of some data flows continue to impact on corporate reporting schedules and this report updates the Governing Body with a combination of performance data from January 2017 and up to the end of February 2017. Headline commentary is provided below to draw the Governing Body’s attention to specific areas of performance which represent risks to delivery, and to the relevant assurances on internal control measures in place to mitigate those risks. 4. BETTER CARE DOMAIN - NHS CONSTITUTIONAL MEASURES

NHS Liverpool CCG is committed to ensuring that performance against constitutional measures and outcomes is consistently and rigorously maintained. Although not all of the indicators within the ‘Better Care domain’ will be reflected in the Corporate Performance Reports for 2016/17, NHS England aims to develop operational support tools to support CCGs (and NHS England’s local teams) to identify trends,

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https://www.nhs.uk/service-search/Performance/Search

outliers and enable a more thorough analysis of the CCG Improvement Assessment Framework (CCG IAF) indicators which will form an integral part of future reporting. 4.1 Elective Access & Waiting Times During 2016/17 achievement of ‘recovery milestones’ for access standards is a priority. Standards relating to A&E and ambulance waits, referral to treatment, 62-day cancer waits (including securing adequate diagnostic capacity) along with mental health access standards account for four of the nine National ‘must dos’ which every local system is expected to achieve for the financial year. 4.1.1 Good Performance – Referral to Treatment (52 Weeks)

Indicator Narrative Referral to Treatment Incomplete pathway (52 Weeks)

Mandate: no-one waits more than 52 weeks to receive treatment from the date of referral There were 0 (zero) Liverpool CCG patients reported to be waiting over 52 weeks in February 2017. For the year-to-date, a total of four Liverpool CCG patients have been reported as waiting over 52 weeks (although it should be emphasised that all of these patients have now been treated). There were 0 (zero) patients reported to be waiting over 52 weeks at provider catchment level (latest available data is for January 2017).

Assurance on CCG Control Measures Liverpool CCG will continue to robustly monitor any breaches which occur against the 52 week RTT standard.

4.1.2 Good Performance - Diagnostic Waiting Times

Indicator Narrative Diagnostics - % patients waiting 6 weeks or more for a diagnostic test

Percentage of patients waiting 6 weeks or more for a diagnostic test Mandate: no-one waits more than 6 weeks for a diagnostic test from the date of referral In February 2017, Liverpool CCG has achieved the 1% standard with performance at 0.75%. This is a much improved position on the January 2017 performance of 2.67%. As at February 2017, there were 58 patients waiting over 6 weeks, 7 of which were over 13 weeks.

RED

TREND

GREEN

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YTD (April to January) the CCG is fractionally above the 1% standard with performance at 1.066% At provider catchment level, the latest published data available is for January 2017. The Royal Liverpool Hospital failed to achieve 1% standard in January 2017 with performance at 4.521%, although is an improvement in performance on December 2016 (5.55%). As at January 2017, in total, there were 195 patients that waited longer than the standard (14 of these patients waited over 13 weeks). Capacity issues, particularly in endoscopy are cited as the main issues in achievement of the diagnostics target Liverpool Women’s Hospital also failed the diagnostics target in January with performance at 1.379%. In total there were 8 patients that waited longer than the standard. All breaches were in ‘urodynamics’ and are due to lack of capacity and are within ‘cystometeries’. Aintree also again failed to achieve 1% standard in January with performance at 1.41%. In total, there were 62 patients that waited longer than the standard. 6 of these were over 13 weeks. All of these patients were in endoscopy All other Liverpool Providers achieved the standard in December 2016.

4.1.3 Areas for Improvement - Patients waiting 18 weeks or less from referral to hospital treatment (Incomplete Pathways)

Indicator Narrative Referral to Treatment Incomplete pathway (18 Weeks – 92% target)

The 2016/17 Planning Guidance includes a commitment to improve on and maintain the NHS Constitutional Standard which stipulates that over 92% of patients on non-emergency pathways do not wait in excess of 18 weeks from referral to treatment (including patient choice). This is also one of the National ‘must dos’ for 2016/17 and a key component of how the local system will deliver the Government’s mandate to NHS England in 2016/17; reducing unwarranted variation between CCG referral rates to better manage demand. During February 2017, the 92% standard was missed again with performance at 90.79% and as such gives the CCG an overall ‘red’ rating against this key constitutional measure. This is also a further decline in performance from January’s

RED

TREND

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position of 91.3%. As at February 2017 there were 2646 patients waiting over 18 weeks, 191of these were waiting over 36 weeks. Specialties with the largest volumes of long waiters (+18 weeks) were General Surgery (528), Trauma & Orthopaedics (476) and Ophthalmology (495) Performance since July 16 has consistently fallen below the national standard of 92% Analysis of the number of incomplete pathways shows that since April 2016 the number of active waiters has reduced by 2,824 from 31,560 to 28,736 in Feb 17 but the number of patients waiting over 18 weeks has remained fairly flat and as such performance has suffered.

Liverpool CCG’s cumulative YTD performance currently stands at 91.68% When comparing Liverpool CCG against its core city peers, for January 2017, Liverpool CCG was ranked 11th out of 15 core cities. Liverpool CCG performance was 91.3%. The peer average was 92.3% with the best performing CCG achieving 95.5% and the worst 87.4%.

89.5%

90.0%

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91.0%

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LCCG incomplete pathways - No of waiters and performance against national standard

waiters over 18 weeks waiters under 18 weeksLCCG performance national standard

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At provider catchment level, the latest published data that is available is January 2017. The Royal Liverpool Hospital failed to achieve 92% standard in January 2017 with performance at 88.9 - a slight improvement in performance on December 2016 performance of 89.7%. This equates to 2950 patients waiting over 18 weeks for treatment. The five specialties which have continued to experience the poorest performance against the standard continue to be challenged (i.e. General Surgery (82.4%), T&O, (80.9 %) and Oral Surgery (82%)) Overall, issues affecting the Trust’s performance are as previously reported which include large numbers of medical outliers who are ready for discharge, cancellations of elective admissions due to the escalation status of the hospital and particularly long waits for highly specialist services. The long diagnostic waits (particularly in endoscopy) are also having an impact on the achievement of the overall RTT standard. Aintree University Hospital also failed to achieve the 92% standard in January 2017 with performance at 91.5%, although this does represent an improvement on the December 2016 performance of 89.2%. As at January 2016 there were 1324 patients waiting over 18 weeks for treatment. Specialties such as Dermatology (9%), Ophthalmology (82.7%) and Oral Surgery (74.8%) continue to show the poorest performance.

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% within 18 weeks National target

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All other Liverpool Providers are achieving the 92% standard in January 2017 Nationally the performance for January 2017 is 89.9%.

Assurance on CCG Control Measures The Royal Liverpool has undertaken a comprehensive ‘demand and capacity’ modelling exercise across a number of specialities, with the findings of this work stream due to be presented to the Trust’s Executive Team imminently (early April 2017). The findings will also be shared with the CCG once finalised, although early indications have shown the need for redesign of OPD activity in some specialities which the CCG will support in terms of any transformation work required. As reported last month the Trust has taken advantage of the additional funding offered by NHS England for waiting list validation and additional capacity for General Surgery, although issues with regards to securing cover under the Clinical Negligence Scheme for Trusts (CNST) for Trauma & Orthopaedics (T&O) prevented this work from being undertaken (the T&O specialty is also participating in a ‘scheduling’ pilot). The CCG is working closely with the provider to both monitor progress and support the weekly reporting process to NHS England. The additional activity is focussed primarily on those specialities which have faced the sternest capacity challenges and patients are being offered alternative providers where it is considered to be clinically appropriate. Other notable actions which are now underway include the following:

• Ophthalmology – engagement with the Local Optical Committee Support Unit to directly commission post-surgical follow up for routine cataract patients within the community by community optometrists. Liverpool CCG has supported the development of a business case for an additional consultant post which will focus on the Cataract Pathway;

• A business case to increase gastroenterology capacity was presented to the Trust Executive Team at the end of March 2017. Although confirmation of approval has not yet been communicated (at the time of writing) this would increase to three session days and two session Saturdays for colorectal, which is impacting on general gastro.

The most recently reported figures show that an additional 35 general surgical cases have been operated on and 273 patients have been removed from the overall waiting list through validation. The Royal Liverpool continues to discuss options for additional capacity via the private sector for a number of specialties and diagnostic tests to improve performance against the constitutional targets. With the recent decisions around the receipt of the STP money no longer being dependent upon elective performance, the central steer seems to be that providers should now be concentrating on AED performance and Cancer waiting times, which reduces the pressure that CCGs can apply to providers who fail the RTT target without removing the constitutional right to treatment within 18 weeks.

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4.2 Cancer Waiting Times 4.2.1 Good Performance – Cancer Measures (6 out of 9)

Indicator Narrative Cancer Waiting Times

In January 2017, the CCG achieved 6 out of the 9 of cancer standards and performance remains positive, with achievement in month and YTD

• % Patients seen within two weeks for an urgent GP referral for suspected cancer. Liverpool CCG achieved 95.74% against a target of 93%

• % of patients seen within 2 weeks for an urgent referral for breast symptoms. Liverpool CCG achieved 98.18% against a target of 93%

• % of patients receiving definitive treatment within 1 month of a cancer diagnosis. Liverpool CCG achieved 97.41% against a target of 96%

• % of patients receiving subsequent treatment for cancer within 31 days (Surgery Liverpool CCG achieved 100% against a target of 94%. At Provider catchment level, Aintree (88.89%) and Liverpool Heart & Chest (87.50%) failed to meet the standard.

• % of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening Service. Liverpool CCG achieved 92.86% against a target of 90%

• % of patients receiving treatment for cancer within 62 days – upgrade their priority. Liverpool CCG achieved 86.96% against a local target of 85%. At provider catchment level, Liverpool Heart and Chest failed the local standard with performance at 55.56%. This equates to 2 patient breaches of the standard

4.2.2 Areas for Improvement – Cancer Measures (3 out of 9)

Indicator Narrative Cancer Waiting Times

Liverpool CCG narrowly failed to achieve three of the nine Cancer standards and is showing as ‘red’ against the following areas:

• % of patients receiving subsequent treatment for cancer within 31 days (drug treatment); Liverpool CCG achieved 97.06% against a target of 98%. This equates to two patient breaches of the standard. At provider catchment level, Aintree failed to meet the standard with performance at 96.3%.

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• % of patients receiving subsequent treatment for

cancer within 31 days (radiotherapy treatment. Liverpool CCG achieved 91.84% against a target of 94%. This equates to 4 patient breaches, all of which occurred at Clatterbridge Centre for Oncology.

• % of patients receiving 1st definitive treatment for cancer within 2 months (62 days). Liverpool CCG achieved 83.53% against a target of 85%. This equates to 14 patient breaches of the indicator.

In terms of the year-to-date position the CCG is currently 86.17% and is as such is achieving the 85% target. At provider catchment level, a number of Trusts failed to meet the standard in January 2017: Aintree failed to meet the standard with performance at 78.81% (12.5 patient breaches). Liverpool Heart & Chest also failed to meet the standard with performance at 81.82% (3 patient breaches). The three breaches at the provider did not relate to Liverpool CCG patients and an analysis into root causes identified that the breaches were due to late referral from providers outside of the Liverpool catchment area and included complex pathways, incomplete diagnostics and patient choice respectively as causal factors. LHCH has engaged with the ‘late referring’ trusts and an action plan for improvement has been developed. Liverpool Women’s Hospital failed to meet the standard with performance at 82.76% (2.5 patient breaches). Analysis of the breaches identified that they occurred as a result of late referrals to LWH from providers outside of the Liverpool areal. Liverpool Women’s has developed an action plan and is providing clinical leadership and support to late referring trusts.

Assurance on CCG Control Measures Performance at Aintree continues to be challenging, particularly in urology where a biopsy equipment failure occurred in December 2016. Although this issue is now resolved, it had continued to impact on performance in January 2017. Liverpool CCG will continue to engage with South Sefton CCG around Aintree performance and recovery date.

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4.3 Urgent & Emergency Care 4.3.1 Areas for Improvement - Ambulance Waits

Indicator Narrative Ambulance Response Times (‘Red’ Response Rates)

Ambulance activity has remained high up to the end of February 2017, with some further volatility in activity levels experienced during the month. Overall incident growth in the city slightly increased and was 0.8% above plan in-month, comparing very favourably with overall North West growth in-month of 5.4%. Red activity was similarly marginally above plan by 0.9%, with the North West significantly higher at 7.5% above plan in the month. Performance in February 2017 has remained significantly challenged as a result of ‘Red’ demand, patient acuity and continued hospital turnaround delays, although some early signs of improvement in the latter are being seen, it is not yet sustained. Liverpool performance remains challenged with none of the three national targets met in-month, although cumulatively (year-to- date) ‘Red 1’ performance is being met: February 2017:

• Red 1: 8-minute response 68.44% against 75% target (remains above North West performance of 64.71%);

• Red 2: 8-minute response 67.37% against 75% target (remains above North West performance of 60.96%);

• All Reds: 19-minute response 90.89% against 95% target (remains above North West performance of 88.38%)

Despite the higher than planned number of incidents the service continues to make good progress in reducing conveyance to hospital, with the following February performance seen in Liverpool: 'Hear & Treat' is at 12.88%; 'See & Treat' at 21.61% and 'See & Convey' at 65.51% of incidents.

Assurance on CCG Control Measures There is no doubt that performance continues to be disappointing with the three national performance measures not being met, a situation mirrored across most of England. Demand across the North West for the emergency ambulance service continues to be at levels previously not seen and significantly above the previous annual average growth of circa 2.5%. The actual distance from the national targets for performance in the city, i.e. the time after the national targets at which they are met is as follows. In February 2017 we saw the following performance ‘tails’ (Jan 2017 comparative figures in brackets) Red 1 in January was met at 9mins 10secs (8mins 35secs); Red 2 at 9mins 15secs (9mins 15secs); and ‘all Reds’ A19 at

RED

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28mins (29mins). The length of these performance ‘tails’ are closely monitored to assess the impact of any worsening performance.

4.3.2 Areas for Improvement: Percentage of patients admitted, transferred or discharged from A&E within 4 hours

Indicator Narrative A&E Waits - % of patients who spend 4 hours or less in A&E (cumulative) 95% threshold

*CCG performance is calculated based on CCG A&E mapping table produced by NHS England. Provider activity described relates to Royal Liverpool Hospital, Liverpool Women’s Hospital, Alder Hey Children’s Hospital and Aintree Hospital. ** Performance of “Type 1” and “all types” is seen as the consistent measure of overall A&E performance

Liverpool CCG continues to fail the A&E target with January 2017 performance showing that 87.75% of patients spent less than 4hrs in A&E against the national standard of 95% (all Types). January 2017 performance does, however show a small improvement on the December 2016 performance of 87.08% The 2016/17 year-to-date position for LCCG currently stands at 91.12%. At provider catchment level the Royal Liverpool Hospital (86.4%) and Aintree University Hospital (79.2%) both failed the 95% threshold (all Types) in January 2017.

Liverpool Women’s Hospital (95.4%) and Alder Hey (97.3%) both achieved the monthly target in January 2017. Despite a recent dip in performance, Alder Hey has recovered its position during January 2017 and is now achieving both monthly and year-to-date. Performance of “Type 1” and “all types” is seen as the consistent measure of overall A&E performance. Analysis of Type 1 enables a closer focus on the site specific performance but challenges in terms of performance at a specific site can often be masked by the agreed inclusion of Type 2 (Trust specific) and 3 activity (e.g. Walk-in Centre services). The Royal Liverpool includes both ‘Type 2’ and ‘Type 3’ performance whilst Aintree Hospital includes ‘Type 3’ in its reporting. Alder Hey, however, counts Type 1 performance only. In terms of the year-to-date picture for Liverpool Trusts who report Type 1 activity, The Royal Liverpool and Aintree both continue to fail the 4-hour performance against Type 1 activity, as illustrated in the table below:

RED

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Nationally for the month of January 2017, six out of 139 providers achieved the Type 1 performance standard of 95%. National performance for January was 77.6 % for Type 1 and 85.1% for ‘all types’. When comparing Liverpool Trusts against providers within the core cities for A&E (all types), Alder Hey and Liverpool Women’s Hospital rank amongst the top performing providers, ranking 2nd and 3rd respectively out of 16 peers. The Royal Liverpool ranks 8th and Aintree 13th. The peer average is 87% with the best performing provider achieving 98.3% and the worst 73.1% When comparing Type 1 A&E performance across the ‘core’ cities, Alder Hey ranks 2nd out of 15 peers, whilst the Royal Liverpool ranks 14th and Aintree 15th (bottom). The peer average is 80.3% with the best performing provider achieving 98.3% and the worst 58.2% (Aintree)

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ospitals Bristol…

A&E 4 hour performance (type 1): Jan 17: Liverpool providers and core city providers

% in 4 hours or less (type 1) National Standard

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Type 1 Type 2 Type 3Total

performance.Alder Hey Childrens Hospital 95.1% 95.1%Aintree Hospital 69.2% 100.0% 84.2%Liverpool Womens Hospital 98.0% 98.0%Royal Liverpool Hospital 72.6% 99.8% 100.0% 89.3%

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Assurance on CCG Control Measures Although the urgent care system continues to be under pressure, achievement of the 4hr A&E target remains a priority. The findings of the Emergency Care Improvement Programme (ECIP) system diagnostic, which encompassed both Acute Trusts have been formally received by the CCG were presented at the February 2017 CCG Governing Body meeting. As a result of the ECIP diagnostic a concordat agreement is place, agreed by all system partners, which will continue to support delivery of sustainable improvement in performance. Responsibility for implementation and oversight of the action plan linked to this concordat agreement falls under the remit of the North Mersey AED Delivery Board. The main areas of focus for the action plan include:

• System leadership; • Assessment prior to admission; • Doing ‘today’s work today’, and; • Discharge to assess

Maintaining the ‘system-wide’ focus, all partners continue to explore actions to relieve service pressures and enable consistent flow throughout hospitals. This included the CCG taking steps to commission additional capacity in Intermediate Care, ‘rapid response’ Community Equipment provision and domiciliary provision during 2016/17. As previously reported to the Governing Body, 4-hour AED performance is very much a ‘symptom’ of whole system pressures and solutions therefore lie in that whole system working together to transform the way in which urgent and emergency care is both perceived and used by the public. Through the AED Delivery Board and with the support of ECIP the CCG aims to make sustainable performance improvements in 2017/18 through ‘acting as one’ and changing the way in which our services are provided and delivered, this includes the system wide response to the Urgent and Emergency Care requirements set out within ‘Next Steps on the NHS 5 year forward view’ which will see the CCG working with partners through the AED Delivery Board to:

• Put in place a comprehensive front-door primary care streaming within A&E departments by October 2017, in line with the nationally mandated model;

• Ensure implementation of the recommendations of the Ambulance Response Programme by October 2017, freeing up capacity for the service to increase their use of Hear & Treat and See & Treat, thereby conveying patients to hospital only when this is clinically necessary;

• Increase the number of 111 calls receiving clinical assessment, so that only patients who genuinely need to attend A&E, or use the ambulance service, are advised to do this;

• Strengthen support to Care Homes so as to ensure that they have direct access to clinical advice, including where appropriate on-site assessment to avoid inappropriate hospital attendance or admission;

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5. BETTER CARE - MENTAL HEALTH 5.1 Good Performance – Dementia Diagnosis

Indicator Narrative Estimated Dementia Diagnosis: % of people aged over 65

For February 2017 the CCG continues to achieve the measure with performance reported at 75.3% against the 70% target. Performance throughout 2016/17 continues to be above the 70% target.

5.1.2 Good Performance – Early Intervention in Psychosis (EIP)

Indicator Narrative Proportion of people experiencing first episode psychosis (FEP) or an “at risk mental state” that wait 2 weeks or less to start a NICE recommended package of care

For February 2017, Liverpool CCG achieved 71.43% of patients who were treated within 2 weeks of referral for first episode psychosis to start a NICE recommended package of care against the 50% standard. Although the CCG remains compliant, this does represent quite a sharp decline in performance when compared to January 2017 (87.5%). The decline is primarily due to the small numbers of people accessing the service with a ‘first episode’ of psychosis and some of this cohort failing to enter treatment in the reporting period (which can impact on performance). To put this into context, for February 2017 5/7 people met the standard as opposed to 7/8 in January 2017. Delays in entering treatment can be due to the nature of psychosis; assessment can often be prolonged, especially with people who are mistrustful and reluctant to engage. At provider level Mersey Care achieved 76.5% against the 50% standard (latest available data is January 2017). In terms of the national picture, the January 2017 position for the proportion of people treated within 2 weeks was 76.2%. Analysis of Liverpool CCG patients who were still waiting in February 2017 (incomplete pathways) shows that there were 86.3% people waiting over 2 weeks. This equates to 38 out of 44 people who are still waiting to start treatment and who had already waited over 2 weeks. At Mersey Care 75.4% of patients were identified as waiting over two weeks (as at the end of January 2017). This equates to 46

GREEN

TREND

GREEN

TREND

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out of 61 people waiting to start treatment and who had already waited over 2 weeks Nationally the percentage of people who were still waiting over 2 weeks at the end of January was 46.9%

5.1.4 Good Performance – Improving Access to Psychological Therapies (IAPT) 6-week and 18-week Referral to Treatment

Indicator Narrative % of patients who received their first treatment appointment within 6 weeks **National data

National data for December 2016 for the percentage of patients who received their first treatment appointment within 6 weeks of referral is 93.22% against a target of 75%. Performance throughout 2016/17 is on an upward trajectory and is significantly above the 75% target The year-to-date position currently stands at 87.21%

% of patients who received their first treatment within 18 weeks **National data

National data for December 2016 for percentage of patients who received their first treatment within 18 weeks of referral is 97.46% against a target of 95%. Performance over the last 5 months has improved significantly with the CCG achieving the 95% target. Year-to-date performance is currently at 93.79% (just under the 95% target).

GREEN

TREND

GREEN

TREND

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5.1.5 Areas for Improvement - IAPT Access & Recovery (Quarterly Measures)

Indicator Narrative IAPT (Access) -% of people who receive psychological therapies (Quarterly Measure 3.75%) Data reported in the dashboard relates to national quarterly performance data.

National performance for Quarter 3 (Oct to Dec) 2016/17 shows that Liverpool CCG remains significantly below the target of 3.75% with performance at 2.36%. This is also a decline in performance on the Q2 position of 2.7%. Due to the publication of national data being several months behind, this indicator is also monitored using local data supplied by the provider in order to provide a more current position. Based on local data for the latest rolling quarter (Dec Jan and Feb 2017) the CCG remains below the standard of 3.75% with performance currently reported at 2.08%.

IAPT (Recovery) - % of people who finish treatment having attended at least two treatment contacts and are moving to recovery **National data

National performance for Quarter 3 (Oct to Dec) 2016/17 shows that Liverpool CCG remains below the 50% target with performance at 32.8%. This is also a decline in performance on the Q2 position of 34.2%. Due to the publication of national data being several months behind, this indicator is also monitored using local data supplied by the provider in order to provide a more current position. Based on local data for the latest rolling quarter (Dec Jan and Feb 2017) the CCG remains below the standard of 50% with performance at 30.46%.

Assurance on CCG Control Measures The action plan produced as a result of the IAPT Intensive Support Team (IST) ‘deep dive’ of the service continues to be robustly monitored by Liverpool CCG to ensure that the numerous recommendations are implemented, with the focus of the action plan now shifting towards increasing access and ongoing sustainability. Good progress has been made in clearing the waiting list (which at the end of February 2017 stands at 658, a reduction of approximately 2,500 since October 2016). Long waits are intrinsically linked to poor recovery rates although these rates should start to improve as the interim patient cohort completes treatment.

RED

TREND

RED

TREND

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6. CLINICAL QUALITY, PATIENT SAFETY AND ENSURING A POSITIVE EXPERIENCE OF CARE Commissioning high quality, person-centred, safe and effective healthcare for the people of Liverpool is a key priority for the CCG. In line with the recommendations of the National Quality Board (NQB) the CCG’s Quality, Safety and Outcomes Committee has established a Quality ‘Early Warning Dashboard’ to provide the CCG with a robust system which identifies issues and risks relating to patient quality and safety at the earliest opportunity. The dashboard covers all NHS Trusts within the Merseyside area and includes Risk Profiles for each organisation issued by the Care Quality Commission (CQC) and Monitor Risk and Financial Ratings. Where risks or themes are identified they will be actively managed through established CCG governance arrangements and overseen by the Quality, Safety and Outcomes Committee, relevant Clinical Performance and Quality Group Meetings and through collaborative commissioning arrangements with other Merseyside CCGs. This section of the report summarises key performance areas of the NHS Outcomes Framework in Domain 4 (ensuring that people have a positive experience of care and Domain 5 - treating and caring for people in a safe environment and protecting them from avoidable harm. 6.1 NHS Outcomes Framework Domain 4 – Ensuring people have a positive experience of care 6.1.1 Areas for Improvement

Indicator Narrative Mixed sex accommodation breaches

One (1) breach of the mixed sex accommodation indicator was reported during February 2017 (reported by Liverpool Heart & Chest Hospital). The year-to date-position for Liverpool CCG for 2016/17 is 10 mixed sex accommodation breaches against a plan of 0. At provider level there were six breaches reported in February 2017, all by Liverpool Heart & Chest Hospital

Assurance on CCG Control Measures Liverpool CCG continues to robustly monitor any breaches of the Mixed Sex Accommodation indicator at Trust CPQG meetings.

RED

TREND

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6.2 NHS Outcomes Framework Domain 5 – treating and caring for people in a safe environment and protecting them from avoidable harm. 6.2.1 Areas for Improvement - MRSA

Indicator Narrative Incidence of Healthcare Acquired Infections – MRSA Monthly plan tolerance of 0; Annual plan of 0 for 2016/17

Year to date April to February 2017 there have been 11 reported incidences of MRSA assigned to Liverpool CCG. The breakdown of MRSA cases assigned to Liverpool CCG is illustrated in the following table

Liverpool Providers Zero (0) new cases have been reported in February 2017. For the year-to-date (Apr – Feb 2016/17) a total of 7 cases of MRSA have been reported at Liverpool providers. These have occurred at Royal Liverpool (2), Alder Hey (2), The Walton Centre (1) and Aintree (2).

Assurance on CCG Control Measures The Post Infection Review (PIR) of the ‘Non-Trust apportioned’ MRSA case reported in February 2017 (Aintree Hospitals) identified no lapses of care and is currently awaiting decision by NHS England following arbitration. The Zero tolerance objective remains in place and all cases of MRSA BSI are subjected to a robust Post Infection Review (PIR) which aims to identify the root cause and any lapses in care that have contributed to the case. The Quality, Safety and Outcomes Committee will be assured that robust Post Infection Reviews are completed for each with clear learning and action plans developed. An example of learning is being taken forward by a GP Clinical Lead who is reviewing EMIS to enable the documentation and identification of MRSA status where there has been an episode of bacteraemia.

Liverpool CCG Apr May Jun Jul Aug Sep Oct Nov Dec Jan FebYTD Total

Trust Apportioned 0 0 0 0 2 0 0 0 1 2 0 5

Non Trust Apportioned 2 0 0 1 0 0 0 1 1 0 1 6

Total 2 0 0 1 2 0 0 1 2 2 1 11

RED

TREND

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6.2.3 Areas for Improvement – C.difficile

Indicator Narrative Incidence of Healthcare Acquired Infections – C.difficile Annual plan of 138 for 2016/17

There were 9 new cases of C.diff reported in February 2017 for Liverpool CCG against a monthly plan of 11. This brings the year to date position to 151 against the year-to-date plan of 127. At provider level, 9 new cases of C.diff were reported during February 2017 across the Liverpool providers: Royal Liverpool and Broadgreen Hospital –there have been 50 reported cases of C.diff against the year-to-date plan of 40. This is a significant increase on the same period in 2015/16 where the provider reported 28 incidences of C.diff. Aintree Hospital - year-to-date there have been 43 reported cases of C.diff against the plan of 42. This is below the numbers reported during the same period in 2015/16 where the provider reported 48 incidences. Alder Hey year-to-date there has been one reported cases of C.diff against the YTD plan of 0. Liverpool Heat and Chest - year-to-date there have been three reported cases of C.diff against the plan of four. Walton Centre year-to-date there have been nine reported cases of C.diff against a zero tolerance plan.

Assurance on CCG Control Measures Robust Root Cause Analysis reviews of C.diff cases continue to be conducted at provider level. The Aintree CDI Appeals Panel upheld two appeals in March 2017 relating to Liverpool CCG patients (i.e. the Trust’s appeal against these cases were agreed with and totals adjusted accordingly). The CCG continues its multifactorial approach to all Health Care Associated Infections (HCAI) and the HCAI programme lead has recently developed a revised RCA tool which is currently being piloted with the aim of identifying and disseminating lessons learned (particularly to Primary Care Quality Groups). Where two or more CDI cases occur in Liverpool GP practices within the same financial year a post infection review meeting will be carried out and led by the CCG. Additional work streams also continue to be implemented with the aim of supporting shared learning and understanding across providers. The trajectory presented does not account for the number of cases where a review has been completed and an appeal lodged. For an appeal to be upheld there has to be clear evidence that there were no lapses in care; where this is agreed cases are ‘separated’ from the numbers and a revised total applied.

RED

TREND

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7. CARE QUALITY COMMISSION INSPECTIONS/ISSUES/NOTICES Where providers are not meeting essential standards, the CQC has a range of enforcement powers to protect the health, safety and welfare of people who use the service (and others, where appropriate). When the CQC propose to take enforcement action, the decision is open to challenge by the provider through a range of internal and external appeal processes. 7.1 CQC Inspections of Liverpool GP Practices The following reports have been published by the Care Quality Commission into the public domain during March 2017: 7.1.2 Dr P L Gupta – Overall Rating ‘Good’ (Re-inspection) The CQC carried out an announced inspection of the practice in March 2016 following which it received an overall rating of ‘Good’, but required improvements for Safety. An announced and ‘focussed’ follow-up inspection took place on 22nd February 2017 to ensure the required improvements had been made since the original inspection. The inspection team were satisfied that the practice had put in place suitable guidance, policies and procedures for staff for the protection of vulnerable people and had made improvements to the recording of, and learning from significant events. As a result of the actions taken the practice was rated as ‘Good’ for providing a safe service. The full inspection report can be downloaded from: http://www.cqc.org.uk/sites/default/files/new_reports/AAAG3399.pdf 8. SUSTAINABILITY - CCG FINANCIAL POSITION Due to the changing need and complexity of financial reporting requirements the CCG Financial Position is now issued as a separate report.

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http://www.cqc.org.uk/sites/default/files/new_reports/AAAG3399.pdf

9. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers) This section is not applicable to the CCG Corporate Performance Report. 10. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY The report provides evidence of the progress being made across the health economy in terms of CCG and local provider performance against NHS Constitutional/National Indicators and Outcomes Measures. The report highlights whether local providers are contributing to overall financial sustainability by measuring performance against activity, quality and value for money and individual contractual requirements. 11. CONCLUSION Where performance is at variance to plan action is underway with Trusts to deliver corrective action to improve performance with contractual levers utilised to support improvements. These improvements are actively led by CCG Clinicians.

Stephen Hendry Senior Operations & Governance Manager

3rd April 2017

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APPENDIX 1 – LIVERPOOL CCG CORPORATE PERFORMANCE DASHBOARD 2016/17

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YTD

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

RAG G G G G G G G G G G G

Actual 95.252% 95.725% 94.31% 95.19% 94.89% 97.31% 96.06% 97.59% 97.50% 95.74% 95.9%

Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

RAG G G G G R R G G G G G

Actual 94.286% 94.444% 93.40% 97.04% 92.78% 92.18% 95.56% 96.33% 96.06% 98.18% 95.0%

Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%


Actual 97.549% 98.837% 98.84% 97.57% 98.85% 99.09% 97.62% 98.96% 98.90% 97.41% 98.349%

Target 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00%


Actual 96.296% 100.00% 100.00% 100% 96% 100% 100% 100% 95.65% 100% 98.87%

Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00%

RAG G G R G G R G G G R G

Actual 100.00% 100.00% 97.56% 100% 100% 93.59% 98.65% 100% 100% 97.06% 95.62%

Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%

RAG G G R G G G G G G R G

Actual 96.552% 96.364% 91.30% 100% 95.30% 97.40% 95.52% 98.98% 100% 91.84% 96.80%

Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00%

RAG R R G R G G G G G R G

Actual 82.979% 83.133% 86.36% 84.06% 88.16% 87.21% 89.47% 88.63% 88% 83.53% 86.17%

Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

RAG G G R G G G R G G G G

Actual 95.455% 100.00% 80.00% 100% 100% 90.91% 88.89% 90.91% 100% 92.86% 94.53%

Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

RAG G G R G R G G G G G G

Actual 100.00% 100.00% 80.00% 88.89% 83.30% 100% 100% 87.50% 87.50% 86.96% 91.057%

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

Liverpool CCG - Performance Dashboard 2016-17

1170: % of patients receiving subsequent treatment for cancer within 31 days -Drug Treatments31-Day Standard for Subsequent Cancer Treatments (Drug Treatments)

26: % of patients receiving subsequent treatment for cancer within 31 days -Surgery31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Surgery)

539: % of patients receiving 1st definitive treatment for cancer within 2 months -62 daysThe % of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer

25: % of patients receiving subsequent treatment for cancer within 31 days -Radiotherapy Treatments31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Radiotherapy)

1516 and 1617 Trend

2016-17

Cancer Waiting Times191: % Patients seen within two weeks for an urgent GP referral for suspected cancer The percentage of patients first seen by a specialist within two weeks when urgently referred by their GP or dentist with suspected cancer

Preventing People from Dying Prematurely

535: % of patients receiving definitive treatment within 1 month of a cancer diagnosis The percentage of patients receiving their first definitive treatment within one month (31 days) of a decision to treat (as a proxy for diagnosis) for cancer

17: % of patients seen within 2 weeks for an urgent referral for breast symptomsTwo week wait standard for patients referred with 'breast symptoms' not currently covered by two week waits for suspected breast cancer

Metric Q1 Q2 Q3 Q4

541: % of patients receiving treatment for cancer within 62 days upgrade their priority% of patients treated for cancer who were not originally referred via an urgent GP/GDP referral for suspected cancer, but have been seen by a clinician who suspects cancer, who has upgraded their priority.

540: % of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening ServicePercentage of patients receiving first definitive treatment following referral from an NHS Cancer Screening Service within 62 days.

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YTD


RAG G G G G G R R R R R G

Actual 85.92% 87.00% 79.60% 82.02% 80.40% 72.68% 67.83% 69.23% 67.21% 70.63% 75.737%

Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00%

RAG G G R R R R R R R R R

Actual 75.38% 77.20% 73.40% 67.61% 73.02% 66.50% 68.13% 66.70% 63.53% 67.87% 69.752%

Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00%

RAG R G R R R R R R R R R

Actual 94.94% 95.10% 92.80% 91.06% 94.71% 92.62% 91.59% 89.89% 87.92% 90.06% 91.957%

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

RAG G

Actual 96.44%

Target 95.00%

RAG

Actual

Target 15.00%

RAG

Actual

Target 50.00%

RAG G G G G G G G G G G

Actual 76.15% 81.20% 81.50% 87.20% 90% 91.94% 90.76% 92.98% 93.22% 87.21%

Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00%

RAG R R R R A G G G G R

Actual 87.16% 90.00% 89.90% 93.10% 94.6% 96.77% 96.64% 98.25% 97.46% 93.79%

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

RAG G G G G G G G G G G G G

Actual 73.8% 74.5% 75.0% 75.7% 76.10% 76.50% 76.50% 76.36% 75.95% 74.90% 75.30% 75.3%

Target 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70%

RAG G G R G G G G G G G G G

Actual 55.50% 55.50% 41.60% 57.15% 62.50% 61.50% 57.14% 75% 61.54% 87.5% 71.43% 61.417%

Target 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%


50.0%

1516 and 1617 Trend

2016-17

E.A.3: % of people who receive psychological therapies - Access

Ambulance

R

Metric Q1 Q2 Q3 Q4

32.8%

3.75% 3.75% 3.75% 3.75%

2.36%

R R R

95.00% 95.00% 95.00% 95.00%

98.113% 96.36% 94.62%

G G

Early Intervention in Psychosisearly intervention in Psychosis waiting times: The proportion of people experiencing first episode psychosis (FEP) or an “at risk mental state” that wait two weeks or less to start a NICE-recommended package of care.

Dementia DiagnosisEstimated diagnosis rates

50.0%

R R

E.H.1 - A2: % of patients who received their first treatment appointment within 18 weeks of referral

Helping People to Recover from Episodes of Ill Health or Following Injury

E.H.1 - A1: % of patients who received their first treatment appointment within 6 weeks of referral50.0% 50.0%

R

1887: Category A Calls Response Time (Red1) Number of Category A (Red 1) calls resulting in an emergency response arriving at the scene of the incident within 8 minutes

1889: Category A (Red 2) 8 Minute Response Time Number of Category A (Red 2) calls resulting in an emergency response arriving at the scene of the incident within 8 minutes

546: Category A calls responded to within 19 minutes Category A calls responded to within 19 minutes

E.A.S.2: % of people who finish treatment having attended at least two treatment contacts and are moving to recovery - Recovery

2.90% 2.70%

IAPT

34.8% 34.2%

Enhancing Quality of Life for People with Long Term ConditionsMental Health138: Proportion of patients on (CPA) discharged from inpatient care who are followed up within 7 days The proportion of those patients on Care Programme Approach discharged from inpatient care who are followed up within 7 days

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YTD


RAG R R G G R G R R G R R R

Actual 2 2 0 0 2 0 1 1 0 1 1 10

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

RAG R R G G R G R R G R R R

Actual 0.15 0.14 - - 0.15 - 0.08 0.08 0 0.07 0.1 0.65

Target 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

RAG G G A A R R R R R R R R

Actual 92.9% 92.6% 92.0% 92% 91.70% 91.28% 91.19% 91.60% 90.91% 91.30% 90.79% 91.68%

Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00%

G R G G R R G R G G G R

Actual 0 1 0 0 1 1 0 1 0 0 0 4

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

RAG G G G G G R G G R R G R

Actual 0.476% 0.509% 0.464% 0.53% 0.99% 1.04% 0.41% 0.82% 3.02% 2.67% 0.75% 1.066%

Target 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%

RAG R R R R R R R R R R R R

YTD 2 2 2 3 5 5 5 6 8 10 11 11

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

RAG R R R R R R R R R R R R

YTD 18 33 49 67 79 93 107 120 131 142 151 151

Target 11 22 34 46 58 70 82 94 105 116 127 138 82

RAG R R G R R R R R R R R

Actual 90.87% 91.31% 92.10% 91.93% 91.18% 90.37% 90.10% 88.53% 87.08% 87.75% 91.124%

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%


1516 and 1617 Trend

2016-17

Metric Q1 Q2 Q3 Q4

Ensuring that People Have a Positive Experience of Care

Treating and Caring for People in a Safe Environment and Protect them from Avoidable HarmHCAI

1291: Referral to Treatment RTT (Incomplete) Percentage of patients waiting at period end (RTT) for incomplete pathways (Commissioner)

Referral to Treatment (RTT) & Diagnostics

1812: Mixed Sex Accommodation - MSA Breach Rate MSA Breach Rate (MSA Breaches per 1,000 FCE's)

EMSA1067: Mixed sex accommodation breaches - All Providers No. of MSA breaches for the reporting month in question for all providers

431: 4-Hour A&E Waiting Time Target (Monthly Aggregate for Total Provider) % of patients who spent less than four hours in A&E (Total Acute position from Unify Weekly SitReps)

Accident & Emergency

2004: Referral to Treatment RTT - No of Incomplete Pathways Waiting >52 weeks The number of patients waiting at period end for incomplete pathways >52 weeks

24: Number of C.Difficile infections Incidence of Clostridium Diffici le (Commissioner)

497: Number of MRSA Bacteraemias Incidence of MRSA bacteraemia (Commissioner)

1828: % of patients waiting 6 weeks or more for a diagnostic test The % of patients waiting 6 weeks or more for a diagnostic test

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APPENDIX 2 – LIVERPOOL CCG PROVIDER PERFORMANCE DASHBOARD 2016/17

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Period Target

ROYAL LIVERPOOL

AND BROADGREEN

UNIVERSITY HOSPITALS NHS TRUST

AINTREE UNIVERSITY

HOSPITAL NHS

FOUNDATION TRUST

ALDER HEY CHILDREN'S

NHS FOUNDATIO

N TRUST

LIVERPOOL HEART AND

CHEST HOSPITAL

NHS FOUNDATIO

N TRUST

LIVERPOOL WOMEN'S

NHS FOUNDATION

TRUST

LIVERPOOL COMMUNITY

HEALTH

MERSEYCARE NHS TRUST

THE WALTON CENTRE

SPIRE LIVERPOOL

Jan-17 93% 95.41% 94.61% 100.00% 99.00% 100.00%

Jan-17 93% 97.42% 96.88%

Jan-17 96% 96.55% 97.41% 100.00% 100.00% 96.55% 100.00%

Jan-17 98% 100.00% 96.30%

Jan-17 94% 100.00% 88.89% 100.00% 87.50% 100.00% 100.00%

Jan-17 94%

Jan-17 85% 85.85% 78.81% 81.82% 82.76% 100.00%

Jan-17 90% 94.60% 100.00% 100.00%

Jan-17 85% 100.00% 74.36% 55.56% 100.00%

Provider Performance Dashboard 2016-17

% of patients receiving treatment for cancer within 62 days upgrade their priority% of patients treated for cancer who were not originally referred via an urgent GP/GDP referral for suspected cancer, but have been seen by a clinician who suspects cancer

% of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening Service Percentage of patients receiving first definitive treatment following referral from an NHS Cancer Screening Service within 62 days.

% of patients receiving 1st definitive treatment for cancer within 2 months -62 daysThe % of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer

% of patients receiving subsequent treatment for cancer within 31 days -Radiotherapy Treatments31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Radiotherapy)

% of patients receiving subsequent treatment for cancer within 31 days -Surgery31-Day Standard for Subsequent Cancer Treatments where the treatment function is (Surgery)

% of patients receiving subsequent treatment for cancer within 31 days - Drug Treatments31-Day Standard for Subsequent Cancer Treatments (Drug Treatments)

% of patients receiving definitive treatment within 1 month of a cancer diagnosisThe percentage of patients receiving their first definitive treatment within one month (31 days) of a decision to treat (as a proxy for diagnosis) for cancer

% of patients seen within 2 weeks for an urgent referral for breast symptoms Two week wait standard for patients referred with 'breast symptoms' not currently covered by two week waits for suspected breast cancer

2005: % Patients seen within two weeks for an urgent GP referral for suspected cancer The % of patients first seen by a specialist within two weeks when urgently referred by their GP or dentist with suspected cancer

Preventing People from Dying PrematurelyCancer Waiting Times

Metric

949494

of 28

Period Target

ROYAL LIVERPOOL

AND BROADGREEN


AINTREE UNIVERSITY

HOSPITAL NHS

FOUNDATION TRUST


NHS FOUNDATIO

N TRUST

LIVERPOOL HEART AND

CHEST HOSPITAL

NHS FOUNDATIO

N TRUST

LIVERPOOL WOMEN'S

NHS FOUNDATION

TRUST

LIVERPOOL COMMUNITY

HEALTH


THE WALTON CENTRE

SPIRE LIVERPOOL

Q3 2016-2017

95% 95.70%

Jan-17 50% 76.90%

Feb-17 0 0 0 0 6 0 0 0 0 0

Feb-17 0 0.0 0.0 0.0 5.1 0.0 0.0 0.0 0 0.0

Jan-17 1.00% 4.521% 1.411% 0.00% 0.22% 1.379% 0.00% 0.50% 0.00%

Jan-17 92.00% 88.92% 91.50% 92.36% 92.36% 92.56% 96.00% 94.70%

Jan-17 0 0 0 0 0 0 0 0

Jan-17 0 0 0 0 0 0 0

Q3 2016-2017

10% 7% 17% 0% 0% 0%


Helping People to Recover from Episodes of Ill Health or Following Injury

early intervention in Psychosis waiting times: The proportion of people experiencing first episode psychosis (FEP) or an “at risk mental state” that wait two weeks or less to start a NICE-recommended package of care.

Cancelled OperationsUrgent Operations cancelled for a 2nd time Number of urgent operations that are cancelled by the trust for non-clinical reasons, which have already been previously cancelled once for non-clinical reasons.

Referral to Treatment RTT - No of Incomplete Pathways Waiting >52 weeks The number of patients waiting at period end for incomplete pathways >52 weeks

% of patients waiting 6 weeks or more for a diagnosic test The % of patients waiting 6 weeks or more for a diagnosic test

Referral to Treatment RTT (Incomplete) Percentage of patients waiting at period end (RTT) for incomplete pathways (Provider)

Referral to Treatment (RTT) & Diagnostics

Proportion of patients on (CPA) discharged from inpatient care who are followed up within 7 days

Enhancing Quality of Life for people with long term conditionsMental Health

Ensuring that People Have a Positive Experience of CareEMSAMixed sex accommodation breaches No. of MSA breaches for the reporting month in question for all providersMixed Sex Accommodation - MSA Breach Rate MSA Breach Rate (MSA Breaches per 1,000 FCE's)

Early Intervention in Psychosis

% of Cancellations for non clinical reasons who are treated within 28 days Patients who have elective ops cancelled, on or after the day of admission (Inc. day of surgery), for non-clinical reasons to be offered a binding date within 28 days, or treatment to be funded at the time and hospital of patient’s choice.

Metric

959595

of 28

Period Target

ROYAL LIVERPOOL

AND BROADGREEN


AINTREE UNIVERSITY

HOSPITAL NHS

FOUNDATION TRUST


NHS FOUNDATIO

N TRUST

LIVERPOOL HEART AND

CHEST HOSPITAL

NHS FOUNDATIO

N TRUST

LIVERPOOL WOMEN'S

NHS FOUNDATION

TRUST

LIVERPOOL COMMUNITY

HEALTH


THE WALTON CENTRE

SPIRE LIVERPOOL

Jan-17 95.00% 86.4% 79.2% 97.3% 97.1%

Jan-17 7,521 6,896 4,829 0

Jan-17 (YTD) 197,314 136,454 48,366 10,668

Jan-17 0 2 34 0 0

Feb 17 (YTD) Local 2 2 2 0 0 0 0 1 0

Feb 17 (YTD) Local 50 43 1 3 0 0 0 9 0

Treating and Caring for People in a Safe Environment and Protect them from Avoidable Harm


MRSAHospital Acquired Infections

Number of MRSA Bacteraemias Incidence of MRSA bacteraemia (Provider)

CdifficileNumber of C.Difficile infections Incidence of Clostridium Difficile (Provider)

12 Hour Trolley waits in A&E Total number of patients who have waited over 12 hours in A&E from decision to admit to admission

A&E Attendances: Type 1 Number of attendances Type 1 A&E depts

A&E Attendances: All Types Number of attendances at all A&E depts

Accident & Emergency 4-Hour A&E Waiting Time Target (Monthly Aggregate for Total Provider) % of patients who spent less than four hours in A&E (Total Acute position from Unify Weekly SitReps)

Metric

969696

Report no: GB 29-17



Title of Report Operational Financial Plan Update

2017/18 and 2018/19 Financial Years Lead Governor Tom Jackson

Chief Finance Officer Senior Management Team Lead

Tom Jackson Chief Finance Officer

Report Author Mark Bakewell Deputy Chief Finance Officer

Summary The paper provides further detailed information with regards to the relevant elements of the CCG Resource Assumptions and Expenditure Plans for 2017/18 and 2018/19 financial years. This paper provides an update to the strategic planning assumptions for the that was presented to the CCG Governing Body on the 14th March 2017 Based on resources available, the paper includes an assessment of planned expenditure levels in order to deliver the required business rules with subsequent risks / mitigation for the respective financial periods.

Recommendation That the Liverpool CCG Governing Body: Notes the Resource & Expenditure

Assumptions in respective financial years

Notes the implications of the delivery of ‘Business Rules’ in 2017/18 & 2018/19 financial years and

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979797

subsequent Cash Releasing Savings requirements that will require detailed monitoring on a monthly basis

Approves Delegation of Budgets to Senior Management Leads (with subsequent delegation to next level of hierarchy as appropriate) with sign off achieved before the start of financial year.

Approves submission of final financial planning returns on this basis to NHS England with identified risks and mitigations as identified within this paper.


Financial Duties NHS England Business Rules

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OPERATIONAL FINANCIAL PLANS

2017/18 & 2018/19

1. PURPOSE The purpose of this document is to update the Governing Body on the operational financial plans in respect of delivering the required CCG financial position for the 2017/18 and 2018/19 financial years in line with NHS England Business Planning Rules. The document includes the relevant resource, expenditure and Cash Releasing Efficiency Savings (CRES) required in order to achieve delivery of these Rules. This follows the Strategic Financial Planning Paper presented to the CCG Governing Body on the 14th March 2017 which provided further information on background, context to the CCG’s financial position. 2. RECOMMENDATIONS

That Liverpool CCG Governing Body: Notes the Resource & Expenditure Assumptions in respective

financial years Notes the implications of the delivery of ‘Business Rules’ in

2017/18 & 2018/19 financial years and subsequent Cash Releasing Savings requirements that will require detailed monitoring on a monthly basis

Approves Delegation of Budgets to Senior Management Leads (with subsequent delegation to next level of hierarchy as appropriate) for the 2017/18 financial year.

Approves submission of financial planning returns on this basis to NHS England with identified risks and mitigations as identified within this paper.

3. NHS ENGLAND BUSINESS RULE REQUIREMENTS The key requirements of business rules for CCGs for 2017/18 and 2018/19 are as per below: i) CCGs are required to deliver a minimum cumulative 1 percent

underspend in 2017/18 and 2018/19.

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ii) all CCGs are required to aim for an ‘in-year’ breakeven position, with expectations set for the minimum level of improvement in deficit CCGs;

iii) As in previous years, CCGs should plan for 1% non-recurrent

spend with an amendment to the commitments within these expenditure plans as per below:

0.5% to be uncommitted and held as risk reserve (see above);

and 0.5% immediately available for CCGs to spend non recurrently,

to support transformation and change implied by STPs; iv) As was the case for 2016/17 and previous years, CCGs should

also plan for 0.5% contingency to manage their in-year pressures and risks;

Application of Business Rules for Liverpool CCG i) Liverpool CCG is currently forecasting a £16.4m cumulative surplus

in 2016/17 equivalent to 2% surplus (based on 1% surplus + release of 1% non-recurrent) which is in excess of the stated 1% ‘Business Rule’ in 2016/17.

ii) In effect for CCGs in this surplus position (applicable to Liverpool

CCG) the business rule therefore increases from 1% as stated to 2%.

Business Rules delivery in accordance with an ‘in-year’ break even position would therefore assume a surplus requirement of £16.4m in 2017/18 (equivalent to 16/17 position).

iii) 1% Non-Recurrent Headroom Requirement of £8.549m for 2017/18

(£8.699m in 18/19) 0.5% uncommitted: 2017/18 £4.275m, 2018/19 £4.349m 0.5% local investment*: 2017/18 £4.275m, 2018/19 £4.349m iv) 0.5% Contingency: 2017/18 £4.525m, 2018/19 £4.625m Summary of Surplus Positions for Liverpool CCG Business rule requirements therefore of an ‘in-year’ break even position and ‘like for like’ treatment of uncommitted non-recurrent headroom mean that potentially an additional 0.5% surplus could be expected of

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the overall CCGs financial position (should the same treatment be applied in 17/18 as in 16/17), increasing the cumulative surplus from £16.4m to £20.6m (circa 2.5%) Again on a like for like basis for 2018/19, should the same methodology be applied this would again increase the CCG surplus position from £20.6m to £25.0m (circa 3%) The Chart and Table below provides a summary of Surplus positions for Liverpool CCG in respective financial years

2016/17 2017/18 2018/19

£m £m £m

Cumulative (Surplus) / Deficit (16.379) (20.654)* (25.003)* In Year (Surplus) / Deficit (1.952) (4.275) (4.349) Allocation Growth (%) 2.43% 1.62% 1.59%

* Based on NHS England Business Rule Expectations for 2017/18 & 2018/19 4. 2017-18 CCG DETAILED FINANCIAL PLAN ASSUMPTIONS RESOURCES The ‘in-year’ resource limit assumptions for the CCG are as per the below table for the relevant financial years.

Revenue Resource Limit

2017/18 £ 000’s

2018/19 £ 000’s

Recurrent 865,497 880,361

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

-5.0

0.0

5.0

10.0

15.0

20.0

25.0

2016/17 2017/18 2018/19

Allocation Growth

Surplus / (Deficit) Position

£m

Financial year

Cumulative (Surplus) / Deficit In Year (Surplus) / Deficit Allocation Growth (%)

Page 5 of 34

101101101

Non-Recurrent 2,491 1,467 Total In-Year allocation 867,988 881,828

Recurrent Resources are as per the below table with supporting information as per notes below

2017/18 £ 000’s

2018/19 £ 000’s

a) Programme Baseline Allocation 782,388 794,814 b) Primary Care Co-Commissioning 72,547 75,041 c) Running Cost Allocation 10,562* 10,506* Total Notified Allocation 865,497 880,361

* Running Cost Allowances reduce for 2017/18 and 2018/19 financial years compared to 2016/17 in line with formula adjustments Non-Recurrent Resources Non-Recurrent Resources are as per the below table

Other non-recurrent allocation

2017/18 £000’s

2018/19 £000’s

a) IM&T 4,000 3,000 b) IR Changes (2,941) (2,988) c) HRG4+ changes 1,432 1,455 Total 2,491 1,467

5. EXPENDITURE ASSUMPTIONS CCG Expenditure Plans for 2017/18 have been calculated on the basis of the following assumptions with specific amendments made as required

• 2016/17 Forecast Outturn Based on (Quarter 3 Information) • Reversal of Non-Recurrent items • Generic Inflation / Efficiency Factors (as per table below)

2017/18 2018/19 Tariff Uplift +2.1% (£12.6m) +2.1% (£13.0m) Tariff Efficiency

-2.0% £11.3m -2.0% £11.7m

Prescribing Uplift

+5.3% £4.8m +4.4% £4.4m

• Acting As One Contract agreement (Block Contract)

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102102102

i) 2016-17 Forecast Outturn ii) +1% growth for each of the next 2 years iii) Shared plan for delivery of ‘Must Dos’ iv) Implementation of HRG4+ & Identification Rules (IR) v) Treatment of penalties / sanctions vi) Delivery of LDS transformation milestones

• Non- Acting As One Contracts

i) 2016-17 Forecast Outturn iv) Implementation of HRG4+ & Identification Rules (IR) The impact of these planning assumption for the 2017-18 financial year is as per the below table

Expenditure £ 000’s Acute 421,872 Mental Health 86,717 Community 94,480 Continuing Care 35,239 Local Primary Care Investment & Prescribing 119,570 Other Programme 42,722 Delegated Primary Care 68,940 Total Programme Costs 869,541 Business Rule Requirements (not included above)

Non-Recurrent Headroom 8,549 Running Costs 10,454 Contingency 4,525 Total Costs 893,068 Surplus / (Deficit) (25,167)

This results in a £25.17m gross deficit position when comparing available ‘in-year’ resource allocations to expenditure requirements and requirements to deliver NHS Business Rules. This £25.2m deficit is before Cash Releasing Savings assumptions for 2017-18 financial year as described in section 6 and also excludes 0.5% contingency held and 0.5% non-recurrent headroom risk reserve as per national instructions. Details of expenditure against each of these categories are included within appendices 1 to 9 of this paper and will form the basis for delegation to budget holders and respective sign off for the 2017-18 financial year.

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103103103

6. CASH RELEASING EFFICIENCY SAVINGS (CRES) Plans developed to date by the CCG with regards to Cash Releasing Efficiency Savings (CRES) are as per the table below. An initial CRES plan was shared with the GB in March 2017 which at that time had a financial gap of £8.1m. The plan was further developed following instructions from the Governing Body to review all areas of discretionary spend, which included the Voluntary and Charitable Sector; Healthy Liverpool Programme; Digital; General Practice Specification and Enhanced Services; and Better Care Fund Schemes. All areas of discretionary spend were formally reviewed using a Decision Tree Analysis Tool which facilitated prioritisation of schemes on their impact in delivering cost savings to the health economy, in line with the demand management priority area within the Healthy Liverpool Programme. This process also took into account the national priority ‘must do’ areas and the Public Sector Equality Duty (PSED) with Equality Impact Assessments (EIA) undertaken. The process, and outputs from the process, were reviewed by the Governing Body at the March Governing Body Development Session and approved. This led to classification of schemes into four areas:

1) Schemes that would continue as planned; 2) Schemes that would continue but be modified in some form; 3) Schemes that had a commitment in 2017/18 but would be

discontinued, with notice provided as per their agreement; 4) Schemes with no commitment in 2017/18 that would be

discontinued with effect from 31/3/17.

Delivery of these plans would result in an unidentified Cash Releasing Savings gap of £1.55m heading into the 2017-18 year, notwithstanding the risk of delivery against the £23.6m already identified. Detailed Monitoring of Cash Releasing Planning Assumptions will be required within the financial year and will be reported to Finance, Procurement and Contracting Committee and Governing Body on a monthly basis.

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Scheme 17-18 Value

Non Acting as One Contracts (2,000) LD Out of Area (215) Prescribing (6,985) CHC Package Costs (860) Primary Care (2,000) Voluntary / 3rd Sector Expenditure (1,889) CAMHS (922) Healthy Liverpool (100) Digital IT- Phase 1 (556) Digital IT- Phase 2 (400) Digital IT- Phase 3 (945) Imerseyside (100) GP IT (147) Joint Funded Packages Reductions (292) IC Spot Purchase / Intermediate Care Plans (709) STARS / CHC (433) EOL CHC (CG / KM / JOSPICE) (128) Care Home Scheme (600) Healthy Lung (161) Self Care Living Well (19) Living Well – Alcohol (25) Winter Resilience (128) Reduction in Better Care Fund Contribution / Demand Led

(4,000)

(23,614) CRES Plans (23,614) CRES Required as at 170317 (25,167) Unidentified 1,554

As per above CRES values, using the alternative segmentation approach (as described in Strategic Financial Planning paper as presented to the Governing Body) would result in below planned budget values

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105105105

Pot A Base Expenditure 17/18 CRES 17/18 Budgets

a) Business Rules 30,466 0 30,466

b) Acting As One 492,055 0 492,055

522,521 0 522,521

Pot B Base Expenditure 17/18 CRES Revised

Expenditure

a) Healthcare Contracts 82,274 (2,336) 79,938

b) Prescribing 94,437 (6,985) 87,452

c) Continuing HealthCare (Adults & Children) 30,011 (1,421) 28,590

d) Other Contract Agreements 7,218 (409) 6,809

e) Primary Care 71,078 (2,000) 69,078

f) Running Costs & Property Services 17,541 0 17,541

g) Packages of Care 6,776 (292) 6,484

309,335 (13,443) 295,892

Pot C Base Expenditure 17/18 CRES Revised

Expenditure

a) Voluntary / 3rd Sector Expenditure 7,246 (1,743) 5,504

b) Healthy Liverpool 2,401 (880) 1,521

c) Projects & non-recurrent 622 0 622

d) Digital IT 4,402 (1,901) 2,501

e) Better Care Fund 29,112 (4,725) 24,387

f) Local Enhanced Services and GP Spec 15,191 0 15,191

g) Child & Adolescent Mental Health 2,238 (922) 1,316

61,212 (10,171) 51,042

Total 893,068 (23,614) 869,455

Cash Releasing Savings Gap (25,167) 23,614 (1,554)

7. BETTER CARE FUND In the absence of formal planning guidance with regards to the Better Care Fund arrangements for 2017-18, work is progressing to agree draft arrangements between the CCG and Liverpool City Council, Further information is included in Appendix 10 on draft expenditure plans for the 2017-18 financial year that will support delivery of objectives. The below table provides headline values with regards to draft proposals still being considered by the senior management leads

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Liverpool CCG Baseline Expenditure £ 000’s

STARS 1,157 Hospice Provision 2,368 Other Voluntary Sector 1,071 Digital Expenditure 1,375 Enhanced Care Home Model 504 Older Peoples Service 1,700 Community Equipment Provision 4,770 Specialist Rehabilitation 1,295 Total CCG Baseline 14,241

Liverpool CCG Payments to Liverpool City Council £ 000’s

Support for Carers 302 Care Act 1,729 Protection of Social Care 7,577 Reablement Provision 10,640 Intermediate Care Provision 4,170 CCG Joint Funded Packages (Demand Led) 4,756*

TeleHealth 350 Total CCG Baseline 29,527

* Demand Led Expenditure, subject to fluctuation – includes CCG responsibilities regarding Section 117, complex needs and Mental Health Rehabilitation costs. Requires agreement regarding approach to risk sharing as part of revised Section 75 agreement

Better Care Fund £ 000’s Baseline Expenditure 14,241 Contribution to Liverpool City Council Services 24,770

CCG Demand Led Expenditure 4,756 Total CCG Baseline 43,768 CCG Minimum Contribution 39,911*

* Awaiting guidance regarding minimum 2017/18 contribution - value as per 16/17 information 8. RUNNING COSTS Based on planning assumptions the CCG would be within its running cost allowance as per the below table for the 2017-18 financial year.

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Further information is included in Appendix 9 on detailed expenditure plans for the 2017-18 financial year

Running Cost Allowance 2017-18 £10.562m Running Cost Expenditure £10.454m Running Cost (Surplus) / Deficit (£0.108m)

9. 2017-18 FINANCIAL PLAN SUMMARY The below table summarises the overall CCG plan for the 2017-18 financial year (inclusive of delivery of required Cash Releasing savings of £25.2m) that would deliver NHS England Business Rules for the financial year.

Category 2017/18

Recurrent £ 000’s

2017/18 Non-Recurrent

£ 000’s

2017/18 Total

£000’s Acute 424,037 (4,294) 419,744 Community Health 91,512 91,512 Continuing Care 33,218 33,218 Mental Health 84,290 84,290 Other 42,671 6,785 49,455 Primary Care 179,316 179,316 Running costs 10,454 10,454 Grand Total 865,411 2,491 867,988

The below table summarises the Savings required by heading on the basis of delivery of £25.16m savings within the financial year and the remaining unidentified ‘CRES’ of £1.552m is achieved.

Category 2017/18 CRES

£ 000’s

2017/18 Total Expenditure (Including CRES)

£000’s Acute (2,128) 419,744

Community Health (2,968) 91,512

Continuing Care (2,021) 33,218

Mental Health (2,427) 84,290

Other (4,874) 49,455

Primary Care (Including Prescribing) (9,194) 179,316

Running costs 10,454

Unidentified CRES (1,552) (1,552) Grand Total (25,167) 867,988

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10. 2018-19 FINANCIAL PLAN Initial Planning Assumptions for 2018-19 are based on following assumptions • Delivery of NHS England Business rules as per relevant sections of

this report • Allocation growth as per national allocations for CCG programme,

running costs, and delegated primary care • Recurrent 17-18 budgets rolled forward as basis for 2018-19 plans • Assumptions as per below table 2018/19

% change 2018/19 £ value

Tariff Inflation 2.1% (£13.1m) Tariff Efficiency (2.0)% £11.7m Allocation Growth 1.59% CCG / 3.44%

PC £14.9m

Prescribing Inflation / Growth

4.4% £4.7m

Contracts (inc Acting as one)

+ 18/19 tariff +1% growth

£4.3m

Continuing Healthcare 3% £1.0m • Acting as One Contract Implications for 2018-19 financial years • Continuation of Better Care Fund arrangements as per 17-18 draft

plan

The above assumptions would result in planned programme and running cost expenditure values as per the below table for the 2018-19 financial year for the CCG.

Expenditure £ 000’s Acute 423,435

Mental Health 85,087

Community 92,842 Continuing Care 34,429 Local Primary Care Investment & Prescribing 115,041

Other Programme 35,836

Delegated Primary Care 71,434

Total Programme Costs 871,318

Business Rule Requirements (not included above) Non-Recurrent Headroom 8,699

Running Costs 10,397

Contingency 4,625

Total Costs 881,828

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Further work is required to develop Cash Releasing Assumptions in 2018/19 as growth assumption would need to be tested within the 2017/18 financial year but are predicted to be lower than the 17/18 requirements of £25.2m (2.9%) due to front loading of cash releasing savings in order to achieve NHS England Business Rules.

11. STATUTORY REQUIREMENTS (only applicable to strategy &


Does this require public engagement or has public engagement been carried out? Any proposals for disinvestment that arise from the requirement to deliver savings to meet NHS business rules will be subject to consultation with affected providers, service users and public. Any savings proposals that impact patients with regard to prescribing policy would also be subject to public engagement and consultation. Does the public sector equality duty apply? Yes/no. Yes. The process to review expenditure would comply with the CCG’s disinvestment policy, which takes into account the public sector equality duty prior to any decision being taken Explain how you have/will maximise social value in the proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most: Economic /Social / Environmental wellbeing The review process will take into account the impact of decisions on economic, social and environmental wellbeing. Taking the above into account, describe the impact on improving health outcomes and reducing inequalities The review process will endeavor to mitigate the impact on improving health outcomes and reducing inequalities. 12. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY Supports the achievement of the CCG’s Statutory Financial Duties.

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13. CONCLUSION

The purpose of this report is to provide the Governing Body with an update on the detailed financial plans with regards to delivery of business planning rules for 2017/18 and 2018/19 financial years. Based on the respective resource and expenditure assumptions and subsequent required cash releasing efficiency savings required, the CCG faces a challenging year ahead with close monitoring of budgetary performance as per the appendices within this paper. Tom Jackson Chief Finance Officer 31st March 2017

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Appendices 2017-18 Planned Expenditure 1) Acute Contract Expenditure 2) Community Contracts Expenditure 3) Mental Health Contracts Expenditure 4) Continuing Healthcare & Funding Nursing Care Expenditure 5) Delegated Primary Care 6) Prescribing 7) Other Primary Care 8) Other Commissioning 9) Running Costs 10) Better Care Fund Information 11) Budgeted Expenditure by Senior Management Lead

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1) Acute Contracts Category Cost Centre Number Cost centre Description Senior Management

Lead Detail 2017/18

Total Acute

553571

Acute Commissioning Derek Rothwell Royal Liverpool 198,073,249

Acute Acute Commissioning Derek Rothwell Aintree 78,702,455

Acute Acute Commissioning Derek Rothwell Liverpool Women's 42,582,691

Acute Acute Commissioning Derek Rothwell Alder Hey 28,498,536

Acute Acute Commissioning Ian Davies North West Ambulance Service 21,019,021

Acute Acute Commissioning Derek Rothwell St Helens and Knowsley Hospitals 20,719,654

Acute Acute Commissioning Derek Rothwell Spire - Liverpool 11,439,633

Acute Acute Commissioning Derek Rothwell Liverpool Heart and Chest 6,491,705

Acute Acute Commissioning Derek Rothwell The Walton Centre 2,957,681

Acute Acute Commissioning Derek Rothwell Wirral Teaching 1,131,435

Acute Acute Commissioning Derek Rothwell Southport and Ormskirk 1,032,057

Acute Acute Commissioning Derek Rothwell One to One 550,499

Acute Acute Commissioning Derek Rothwell Non-Core Contracts 546,479 *2

Acute Acute Commissioning Derek Rothwell Warrington and Halton 505,434

Acute Acute Commissioning Derek Rothwell Central Manchester 355,175

Acute Acute Commissioning Derek Rothwell Wrightington, Wigan And Leigh 316,332

Acute Acute Commissioning Derek Rothwell Salford Royal 272,507

Acute Acute Commissioning Derek Rothwell Fairfield 236,907

Acute Acute Commissioning Derek Rothwell South Manchester 195,079

Acute Acute Commissioning Derek Rothwell Countess Of Chester 194,137

Acute Acute Commissioning Derek Rothwell Ramsay (Renacres) 167,854

Acute 553616 Non-Contracted Activity Derek Rothwell Non-Contracted Activity 3,449,446

Acute 553631 Winter Resilience Ian Davies Winter Resilience Funding 42,500

Acute 553606 High Cost Drugs Derek Rothwell Various 263,544

Acute TOTAL 419,744,009

*1 Relates to application of Identification Rules (CCG Allocation adjustment on a non-recurrent basis) *2 Cash Releasing Savings Assumptions Requires Apportionment across non-acting as one contracts

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2) Community Contracts Category Cost Centre Number Cost Centre Description Senior Management

Lead Detail 2017/18 Total

Community Health

553736

Palliative Care Cheryl Mould Healthy Lung 40,000

Community Health Palliative Care Tony Woods Sunflowers - Grant 4,907

Community Health Palliative Care Tony Woods Crossroads - Grant 4,280

Community Health

553711

Community Services Tony Woods Lpool Comm HC NFT 59,836,739

Community Health Community Services Tony Woods LCC (LCH Contract Income Cedas) (1,004,000)

Community Health Community Services Tony Woods Aintree Uni Hosp NHS FT- Diabetes 3,680,533

Community Health Community Services Tony Woods LCH Podiatry 779,994

Community Health Community Services Tony Woods Anti coagulation Services (Royal) 1,569,218

Community Health Community Services Tony Woods Royal Liverpool Community (Non-Core) 2,642,633

Community Health Community Services Tony Woods Alder Hey Community Services (Non-Core) 2,247,720

Community Health Community Services Tony Woods Specsavers Hearcare Ltd 955,404

Community Health Community Services Tony Woods Spamedica 758,258

Community Health Community Services Jane Lunt BPAS 328,578

Community Health Community Services Tony Woods Stroke Association 234,554

Community Health Community Services Tony Woods Injury Care Clinics Ltd 220,400

Community Health Community Services Tony Woods Other 216,356

Community Health 553716 Carers Dyanne Aspinall LCC/BCF Carer Breaks 302,051

Community Health

553721

Hospices Tony Woods STARS Activity 1,157,000

Community Health Hospices Tony Woods Marie Curie - Main Hospice 1,733,968

Community Health Hospices Tony Woods Marie Curie - Phone Line 17,718

Community Health Hospices Tony Woods Marie Curie - Lymphodema Service 84,084

Community Health Hospices Tony Woods Marie Curie - Lymphodema Garments 79,796

Community Health Hospices Tony Woods Marie Curie - Pharmacy 245,093

Community Health Hospices Tony Woods Marie Curie - Oxygen 28,024

Community Health Hospices Tony Woods Woodlands - Main Hospice 633,693

Community Health Hospices Tony Woods Woodlands - Grant / Outreach 114,787

Community Health Hospices Tony Woods Woodlands - Pharmacist 10,571

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Community Health Hospices Tony Woods Woodlands - Drugs, O2, Lymphodema 56,403

Community Health

553726

Intermediate Care Dyanne Aspinall BUPA - Arncliffe Court 75,600

Community Health Intermediate Care Dyanne Aspinall BUPA - Mersey Parks (Sefton Unit) 189,000

Community Health Intermediate Care Dyanne Aspinall Speke H/C - Medical Cover @ Middleton Court 9,000

Community Health Intermediate Care Dyanne Aspinall Speke H/C - Medical Cover @ Arncliffe Court 36,000

Community Health Intermediate Care Dyanne Aspinall Brownlow - Medical Cover @ various 196,550

Community Health Intermediate Care Dyanne Aspinall Dom Care Packages - Acute Wards 1,417,617

Community Health Intermediate Care Dyanne Aspinall LCC Social Workers Support 27,000

Community Health Intermediate Care Dyanne Aspinall Reablement - Granby Hub 2,558,039

Community Health Intermediate Care Dyanne Aspinall Reablement- Sedgemoor Hub 3,051,865

Community Health Intermediate Care Dyanne Aspinall Reablement - Venmore Hub 2,670,172

Community Health Intermediate Care Dyanne Aspinall IC Spot purchase 1,116,108

Community Health Intermediate Care Dyanne Aspinall Reablement Social Work team 460,553

Community Health Intermediate Care Dyanne Aspinall Integrated Discharge Team Whiston 103,133

Community Health 553731 Digital Tony Woods Digital Programme 2,622,333

Community Health Total 91,511,732

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3) Mental Health Contracts Category Cost Centre Number Cost centre Description Senior Management

Lead Detail 2017/18

Total

Mental Health

553556

Mental Health - Others Dyanne Aspinall 2 year recurrent income stream 16/17 & 17/18 (28,775)

Mental Health Mental Health - Others Dyanne Aspinall Counselling - Action for Blind People 12,500

Mental Health Mental Health - Others Dyanne Aspinall Compass - Counselling 25,000

Mental Health Mental Health - Others Dyanne Aspinall Compass - Anger Management 2,083

Mental Health Mental Health - Others Dyanne Aspinall The Reader Organisation 2,083

Mental Health Mental Health - Others Dyanne Aspinall Sth Lpl CAB - Advice on Prescription Service 581,693

Mental Health Mental Health - Others Dyanne Aspinall PSS grant - Umbrella Project 26,643

Mental Health Mental Health - Others Dyanne Aspinall Counselling - Sign Health 27,542

Mental Health Mental Health - Others Dyanne Aspinall Counselling Services - Bereavement 23,214

Mental Health Mental Health - Others Dyanne Aspinall S12 Claims 250,000

Mental Health

553551

Mental Health Services - Older people Dyanne Aspinall 1 to 1 fees @ Paisley Court - Care UK 61,381

Mental Health Mental Health Services - Older people Dyanne Aspinall £5 p/h allocation for 75's+ 504,791

Mental Health Mental Health Services - Older people Dyanne Aspinall Community Geriatrician 58,987

Mental Health Mental Health Services - Older people Dyanne Aspinall Paisley Court - Care UK 1,580,084

Mental Health

553546

Mental Health - NCAs Dyanne Aspinall OATS - Penine Healthcare 58,115

Mental Health Mental Health - NCAs Dyanne Aspinall Military Veterans IAPT 64,346

Mental Health Mental Health - NCAs Dyanne Aspinall NCA Inpatients - Other Areas 62,227

Mental Health Mental Health - NCAs Dyanne Aspinall Patient Drugs 5,205

Mental Health Mental Health - NCAs Dyanne Aspinall OBDS & Phlebotomy 11,746

Mental Health 553541 Mental Health Services - Liverpool MH Consortium Dyanne Aspinall Liverpool MHC - Grant funding 7,168

Mental Health 553536 Mental Health Services - Advocacy Dyanne Aspinall Shap Ltd - Community Wellbeing 90,687

Mental Health

553531

Mental Health Services - Adults Dyanne Aspinall BCF - Out of city resettlement 296,855

Mental Health Mental Health Services - Adults Dyanne Aspinall Supported Accommodation for Complex

Substance Misuse 1,000,000

Mental Health Mental Health Services - Adults Dyanne Aspinall Social Care Support for Home First 1,900,000

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Mental Health Mental Health Services - Adults Dyanne Aspinall Mental Health S117 contribution 20,000

Mental Health Mental Health Services - Adults Dyanne Aspinall Recharge Sefton Council (64,952)

Mental Health Mental Health Services - Adults Dyanne Aspinall BCF 1,729,880

Mental Health Mental Health Services - Adults Dyanne Aspinall Ladders of Life - Care & Support Services 86,366

Mental Health Mental Health Services - Adults Dyanne Aspinall Womens Health - Info & Support Funding 17,133

Mental Health Mental Health Services - Adults Dyanne Aspinall IMAGINE - Outreach Project 28,222

Mental Health Mental Health Services - Adults Dyanne Aspinall IMAGINE - Daily Rates (£290pp) 105,956

Mental Health Mental Health Services - Adults Dyanne Aspinall IMAGINE - Mainstream Bridge building

service 99,655

Mental Health Mental Health Services - Adults Dyanne Aspinall Other Private Care home Patients 240,119

Mental Health Mental Health Services - Adults Dyanne Aspinall LCC - Amethyst Close 23,000

Mental Health Mental Health Services - Adults Dyanne Aspinall LCC - Complex Cases 1,125,793

Mental Health Mental Health Services - Adults Dyanne Aspinall LCC - rehab Cases - S117 1,978,279

Mental Health Mental Health Services - Adults Dyanne Aspinall Middleton St George 355,818

Mental Health Mental Health Services - Adults Dyanne Aspinall Priestwood Residential 72,072

Mental Health Mental Health Services - Adults Dyanne Aspinall First Initiatives 20,156

Mental Health Mental Health Services - Adults Dyanne Aspinall Alternative Futures- Abbeydale Drive -

Annual Grant 127,402

Mental Health Mental Health Services - Adults Dyanne Aspinall Alternative Futures- Support @ Sunbeam

Place 27,380

Mental Health Mental Health Services - Adults Dyanne Aspinall PSS Day Care 140,949

Mental Health

553501

Mental Health Contracts Derek Rothwell Cheshire And Wirral Partnership 134,238

Mental Health Mental Health Contracts Derek Rothwell Lancashire Care 141,315

Mental Health Mental Health Contracts Derek Rothwell 5 Boroughs 636,682

Mental Health Mental Health Contracts Derek Rothwell IAPT (Merseycare) 4,979,094

Mental Health Mental Health Contracts Derek Rothwell Mersey Care 60,017,331

Mental Health Mental Capacity Act Dyanne Aspinall Mental Capacity Act Funding - LCC/BCF 116,000

Mental Health 553521 Learning Difficulties Jane Lunt Joint funded IAT patients awaiting reference 94,469

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Mental Health Learning Difficulties Jane Lunt Autism Initiative (new line Month 8) 40,555

Mental Health Learning Difficulties Jane Lunt LCC insight 25,000

Mental Health Learning Difficulties Jane Lunt The Priory / Recovery First 959,014

Mental Health Learning Difficulties Jane Lunt St Marys 350,553

Mental Health Learning Difficulties Jane Lunt Equilibrium Healthcare 290,072

Mental Health Learning Difficulties Jane Lunt Cambrian Healthcare 13,315

Mental Health Learning Difficulties Jane Lunt Medicines recharge 5,272

Mental Health Learning Difficulties Jane Lunt Partnerships in Care (exMHC) 28,399

Mental Health Learning Difficulties Jane Lunt Mental Healthcare UK 653,683

Mental Health Learning Difficulties Jane Lunt Four Seasons Healthcare 192,474

Mental Health Learning Difficulties Jane Lunt Lighthouse Healthcare (Acorn) 969,429

Mental Health Learning Difficulties Jane Lunt Brothers of Charity 70,691

Mental Health Learning Difficulties Jane Lunt Alternative Futures 411,220

Mental Health 553511

Dementia Dyanne Aspinall Chinese Wellbeing (work with 5 BAME community groups) 20,634

Mental Health Dementia Dyanne Aspinall Non-Pharm Initiative/Post Diagnostic Support (Altzeimer's Society) 5,824

Mental Health Dementia Dyanne Aspinall Altzeimer's Society Liverpool Support 12,650

Mental Health

553506

Child and Adolescent Mental Health Jane Lunt CAMHS Waiting List (NR funding 16/17) 129,000

Mental Health Child and Adolescent Mental Health Jane Lunt CYP IAPT MoU from NHS England (123,750)

Mental Health Child and Adolescent Mental Health Jane Lunt CYP IAPT (ADHD + PSS) 123,750

Mental Health Child and Adolescent Mental Health Jane Lunt Bal of 16/17 Transformation Monies (129,000)

Mental Health Child and Adolescent Mental Health Jane Lunt ND support for MH hubs - Advanced

Solutions 76,254

Mental Health Child and Adolescent Mental Health Jane Lunt Bullying - LCC 10,000

Mental Health Child and Adolescent Mental Health Jane Lunt CORC - CORC LTD 3,000

Mental Health Child and Adolescent Mental Health Jane Lunt ADHD - ADHDF 81,121

Mental Health Child and Adolescent Mental Health Jane Lunt Refugee & Asylum Seekrs PSS 137,844

Mental Health Child and Adolescent Mental Health Jane Lunt GP Champs - YPAS/Brownlow Hill Practice 70,367

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Mental Health Child and Adolescent Mental Health Jane Lunt Therapeutic and Counselling Service - YPAS 780,329

Mental Health Child and Adolescent Mental Health Jane Lunt Young Carers - Barnadoes 25,000

Mental Health Child and Adolescent Mental Health Jane Lunt Participation and Engagement/Voices in

Partnership Project - MYA 21,247

Mental Health Child and Adolescent Mental Health Jane Lunt Mental Health Promotion and Training - MYA 112,525

Mental Health Child and Adolescent Mental Health Jane Lunt Contribution toward YOS Management Post 14,592

Mental Health Child and Adolescent Mental Health Jane Lunt Snr Project Mgr Transformation Monies 32,568

Mental Health Total 84,289,568

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4) Continuing Healthcare & Funded Nursing Care Category Cost Centre Number Cost Centre Description Senior Management


Continuing Care Funded Nursing Care Jane Lunt Health Funded Nursing Care costs from LCC 6,183,595

Continuing Care Funded Nursing Care Jane Lunt Health Funded Nursing Care costs from Wirral BC 17,288

Continuing Care Funded Nursing Care Jane Lunt Health Funded Nursing Care costs from Sefton BC 156,960

Continuing Care CHC Children Jane Lunt Looked after children (income) (7,164)

Continuing Care

553686

Continuing Healthcare Assessment & Support Jane Lunt 2016/17 Nurse Assessment SLA (CSU) 365,514

Continuing Care CHC Children Jane Lunt Bereavement Service 3,333

Continuing Care CHC Children Jane Lunt Zoe's Place 2,708

Continuing Care CHC Children Jane Lunt PERSONAL HEALTH BUDGET (New m8) 2,899

Continuing Care CHC Children Jane Lunt Occ Therapy Staff 320,000

Continuing Care CHC Children Jane Lunt Community patients' Saturation Monitors & ventilation equip Alder Hey 13,651

Continuing Care CHC Children Jane Lunt Looked after children 75,343

Continuing Care CHC Children Ian Davies Primary Care GPs in AED @ Alder Hey 405,510

Continuing Care CHC Children Jane Lunt Children's JIMG - Alder Hey Equip 29,356

Continuing Care CHC Children Jane Lunt Neuro pathways-occ therapy sensory processing disorder pilot 80,000

Continuing Care CHC Children Jane Lunt Communication, Augmentative, Assistive Technology (CAAT) - LCC 15,000

Continuing Care CHC Children Jane Lunt Breastfeeding peer support programme - LCC 38,000

Continuing Care CHC Children Jane Lunt Children's JIMG -LCC 1,728,093

Continuing Care CHC Children Jane Lunt Claire House end of life 3,250

Continuing Care CHC Children Jane Lunt YP Healthline - MYA 5,217

Continuing Care CHC Children Jane Lunt Claire House emergency respite 9,583

Continuing Care

553684

CHC Joint Funded Jane Lunt Remaining Recharge budget (70,832)

Continuing Care CHC Joint Funded Jane Lunt Care of others in Various Locations 1,152,573

Continuing Care CHC Joint Funded Jane Lunt Wirral Borough Council 24,075

Continuing Care CHC Joint Funded Jane Lunt Complex Needs Recharges from Liverpool City Council 1,652,178

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Continuing Care CHC Joint Funded Jane Lunt Heroncare 58,561

Continuing Care CHC Joint Funded Jane Lunt Castletrock 160,547

Continuing Care CHC Joint Funded Jane Lunt Active Assistance 34,479

Continuing Care CHC Joint Funded Jane Lunt Paisley Court 124,293

Continuing Care CHC Joint Funded Jane Lunt Vancouver House 42,706

Continuing Care

553682

CHC Adult Fully Funded Jane Lunt Prescribed Continuing Care Equipment 86,515

Continuing Care CHC Adult Fully Funded Jane Lunt PHB payments 592,897

Continuing Care CHC Adult Fully Funded Jane Lunt Private Continuing Healthcare Support & Care 507,437

Continuing Care CHC Adult Fully Funded Jane Lunt Private Continuing Healthcare Support & Care 19,389,069

Continuing Care CHC Adult Fully Funded Jane Lunt Prescribed Continuing Care Equipment 15,206

Continuing Care Total 33,217,842

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5) Delegated Primary Care & Local Enhanced Services Category Cost Centre Number Cost centre Description Senior Management


Primary Care Co Commissioning Cheryl Mould Other - GP Services 3,921,662

Primary Care Co Commissioning Cheryl Mould QOF 6,591,066

Primary Care Co Commissioning Cheryl Mould Enhanced Services 763,297

Primary Care Co Commissioning Cheryl Mould Other Premises costs 754,427

Primary Care Co Commissioning Cheryl Mould Primary Care NHS Property Services Costs - GP 4,388,294

Primary Care Co Commissioning Cheryl Mould Premises cost reimbursements 2,205,185

Primary Care Co Commissioning Cheryl Mould Other List-Based Services (APMS incl.) 5,792,353

Primary Care Co Commissioning Cheryl Mould General Practice - PMS 2,730,856

Primary Care 553678 Co Commissioning Cheryl Mould General Practice - GMS 41,793,404

Primary Care 553651 Local Enhanced Services Cheryl Mould GP Practices 15,191,473

Primary Care Total 84,132,017

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6) Prescribing & Oxygen Category Cost Centre Number Cost centre Description Senior Management


Primary Care

553671

Prescribing Cheryl Mould Charges from CSU 7,692

Primary Care Prescribing Cheryl Mould FP47 Prescribing 1,097,928

Primary Care Prescribing Cheryl Mould BSA Prescribing 85,299,997

Primary Care 553666

Oxygen Cheryl Mould Trafford CCG 8,242

Primary Care Oxygen Cheryl Mould BSA Home Oxygen 861,474


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7) Other Primary Care Category Cost Centre Number Cost centre Description Senior Management


Primary Care

553676

Primary Care IT Tony Woods Wifi Spark 9,572

Primary Care Primary Care IT Tony Woods Phone Lines - Business Continuity 24,667

Primary Care Primary Care IT Tony Woods Misc GP IT 80,000

Primary Care Primary Care IT Tony Woods Sunquest ICE 30,690

Primary Care Primary Care IT Tony Woods EGTON Arrivals / Envisage 99,116

Primary Care Primary Care IT Tony Woods Community Of Interest Network (COIN) Licences 349,553

Primary Care Primary Care IT Tony Woods SMS 17,008

Primary Care Primary Care IT Tony Woods EMIS Search & Reports 30,634

Primary Care Primary Care IT Tony Woods EMIS Extended Services 64,000

Primary Care Primary Care IT Tony Woods EMIS GPSoC / Vision Support 15,000

Primary Care Primary Care IT Tony Woods IM SLA 1,327,721

Primary Care 553661 Out of hours Ian Davies Out of Hours Services 4,356,885

Primary Care 553646 Commissioning Schemes Cheryl Mould Pay & Non-Pay 1,327,361


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8) Other Commissioning Category Cost Centre Number Cost Centre Description Senior Management Lead Detail 2017/18

Total Other Commissioning

553808

Safeguarding Jane Lunt Mobiles 165 Other Commissioning Safeguarding Jane Lunt Contribution towards SAR Independent

Chair - LCC 8,000

Other Commissioning Safeguarding Jane Lunt Improving Maternity Experience recharge - Halton CCG 50,536

Other Commissioning Safeguarding Jane Lunt Multi Agency Safeguarding Hub (MASH) - LCC 150,000

Other Commissioning Safeguarding Jane Lunt Early Help - LCC 159,066 Other Commissioning Safeguarding Jane Lunt LSAB - LCC 64,000 Other Commissioning Safeguarding Jane Lunt LSCB - LCC 100,000 Other Commissioning Safeguarding Jane Lunt City Safe Post - LCC 7,500 Other Commissioning Safeguarding Jane Lunt Safeguarding recharge - Halton CCG 340,124 Other Commissioning Safeguarding Jane Lunt Safeguarding Support 165,252 Other Commissioning 553801 Re-charges NHS Property

Services Tom Jackson Re-charges NHS Property Services 5,795,000

Other Commissioning

553791

Programme Projects Jane Lunt Other costs 2,242 Other Commissioning Programme Projects Jane Lunt Merseyside Play Action Group 5,833 Other Commissioning Programme Projects Tony Woods Comp maintenance 37,800 Other Commissioning Programme Projects Tony Woods Health & Social Care Informatics iM

Service - Mersey Care 677,030

Other Commissioning Programme Projects Tony Woods CCG IT Comp Maint - Mersey Care 168,156 Other Commissioning Programme Projects Katherine Sheeran Advancing Quality 178,346 Other Commissioning 553786 Patient Transport Ian Davies Patient Transport 10,000 Other Commissioning

Non Recurrent Reserves Tom Jackson Non Recurrent Reserves 12,549,350 Other Commissioning

553776

Non Recurrent Programmes Tony Woods Other research expenditure 27,525 Other Commissioning Non Recurrent Programmes Tony Woods CLAHRC 270,265 Other Commissioning Non Recurrent Programmes Tony Woods Pay costs 59,624 Other Commissioning 553809 NHS 111 Ian Davies Non-Pay Costs 1,376,120 Other Commissioning 553807

Healthy Liverpool Carole Hill Healthy Liverpool Programme 974,985

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Other Commissioning 553766 Social Grants Tony Woods Social Grants 200,000 Other Commissioning 553762 Commissioning Reserve Tom Jackson Earmarked Reserve 16,363,926 Other Commissioning

553756

Commissioning - Non Acute Dyanne Aspinall Oak Vale gardens re additional GP sessions. 85,569

Other Commissioning Commissioning - Non Acute Dyanne Aspinall Protection of Social Care 6,000,000 * Other Commissioning Commissioning - Non Acute Dyanne Aspinall LCC - Liquid Logic 140,000 Other Commissioning Commissioning - Non Acute Dyanne Aspinall LCC - Services @ Bradbury Fields 34,709 Other Commissioning Commissioning - Non Acute Dyanne Aspinall LCC - Data Information & sharing 163,680 Other Commissioning Commissioning - Non Acute Dyanne Aspinall LCC - QA & Safeguarding 383,625 Other Commissioning Commissioning - Non Acute Dyanne Aspinall LCC -Care Brokerage Services 130,938 Other Commissioning Commissioning - Non Acute Dyanne Aspinall LCC - Joint Investments Peripatetic

Services 235,290

Other Commissioning Commissioning - Non Acute Dyanne Aspinall Oak Vale Gardens - Equipment 39,600 Other Commissioning Commissioning - Non Acute Dyanne Aspinall Oak Vale Gardens - Contract Beds 1,170,000 Other Commissioning 553812 Clinical Leads Cheryl Mould GP Practices 1,211,322 Other Commissioning Total 49,369,253

* Subject to variation pending finalisation of 2017-18 Better Care Fund Arrangements

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9) Running Costs Category Cost Centre Number Cost Centre Description Senior Management Lead Detail 2017/18

Total Running costs 555251 Admin & Business Support Ian Davies Pay & Non-Pay 1,153,321

Running costs 555266 Business Informatics Derek Rothwell Pay & Non-Pay 1,119,355

Running costs 555271 CEO/Board office Ian Davies Pay & Non-Pay 2,065,038

Running costs Commissioning Cheryl Mould Pay & Non-Pay 731,026

Running costs 555301 Communications & PR Ian Davies Pay & Non-Pay 105,404

Running costs 555311 Contract Management Derek Rothwell Pay & Non-Pay 774,596

Running costs 555316

Corporate Costs Ian Davies Pay & Non-Pay 881,590

Running costs Corporate Costs Derek Rothwell Midlands & Lancs CSU 866,829

Running costs 555346 Estates & Facilities Ian Davies Non-Pay 496,900

Running costs 555351 Finance Tom Jackson Pay & Non-Pay 1,011,971

Running costs 555401 Operations Management Dyanne Aspinall Pay & Non-Pay 441,322

Running costs 553441 Quality Jane Lunt Pay & Non-Pay 806,330

Running costs Total 10,453,682

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10) Better Care Fund (Draft) 2017-18 BCF Ref Scheme Title 17-18

STARS STARS 1,157,000

STARS Total 1,157,000

Hospices Marie Curie 1,733,968

Woodlands 633,693

2,367,661

Other Voluntary Sector Altzeimer's Society Liverpool Support 12,650

Post diagnostic Support 5,824

Chinese Wellbeing 20,634

The Reader Organisation 2,083

Compass - Anger Management 2,083

Compass - Counselling 25,000

Counselling - Action for Blind People 12,500

Counselling - Sign Health 27,542

Counselling Services - Bereavement 23,214

PSS grant - Umbrella Project 26,643

Sth Lpl CAB - Advice on Prescription Service 581,693

IMAGINE - Mainstream 99,655

IMAGINE - Outreach Project 28,222

Womens Health 17,132

Ladders of Life - Care & Support Services 86,366

Shap Ltd - Community Wellbeing 90,686

Crossroads - Grant 4,280

Sunflower - Grant 4,907

1,071,114

Digital Programme Philips Healthcare Contract 800,000

Community Provision of teleheath 575,167

1,375,167

Enhanced Care Homes Care Home Service Development 504,791

Older Peoples Services Paisley Court 1,641,465

Community Geriatrician 58,987

Community Equipment Store Equipment Provision 4,770,247

Specialist Rehab Oak Vale - Contract Beds 1,170,000

Oak Vale - Equipment 39,600

85,569

Specialist Rehab Total 1,295,169

LCCG Baseline 14,241,601 Support For Carers Provision of Carers Breaks 302,051

Support for Carers Total 302,051

Care Act Care Act Assessment 799,000

Adult Safeguarding Board 62,000

Armed Force Disregard 20,000

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Support of Health & Social Care Mental Health Clients 67,658

Residential & Nursing fee Uplift 507,222

IMHA service 107,000

Advice & Support to access care 167,000

Care Act Total 1,729,880

Protection of Social Care LCC - Amethyst Close 23,000

Mental Capacity Act 116,000

Care Brokerage 130,938

Mental Health S117 contribution 20,000

BCF - Out of city resettlement 296,855

Joint Investments Peripatetic Services 235,290

QA & Safeguarding 383,625

Data Information & sharing 163,680

Services @ Bradbury Fields 34,709

Liquid Logic 140,000

Examine Your Options (Insight) 33,674

Protection of Social Care 6,000,000

Protection of Social Care 7,577,771

Reablement Provision Sedgemoor Hub 2,558,039

Venmore Hub 3,051,865

Granby Hub 2,670,172

Reablement Social Work team 460,553

Home First (Social Care) Support 1,900,000

Reablement Total 10,640,629

Intermediate Care Provision BUPA - Arncliffe Court (Until 31/07/17) 75,601

BUPA - Mersey Parks Sefton Unit - (Until 31/07/17) 189,000

Speke H/C - Medical Cover @ Middleton Court 9,000

Speke H/C - Medical Cover @ Arncliffe Court 18,000

Medical Cover @ Riverside 18,000

Brownlow - Medical Cover @ various 196,550

LCC Social Workers Support 27,000

Intermediate Care Spot Purchase 1,116,108

Dom Care Packages - Acute Wards 1,417,617

Integrated Discharge Team Whiston 103,133

Supported Accommodation for Complex Substance Misuse 1,000,000

Intermediate Care Total 4,170,009

Joint Funded Packages Joint Funded Packages – Mental Health S117 1,978,279

Joint Funded Packages- Complex Needs 1,125,793

Joint Funded Packages MH rehab 1,652,178

Joint Funded Packages Total 4,756,250

Tele-Health (LCCG & LCC) Telehealth Joint Contract Payment 350,000

LCCG Contribution to LCC 29,526,590

Liverpool CCG Better Care Fund 2017/18 43,768,191

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10) Planned Expenditure by Senior Management Lead

Senior Management Lead

2017/18 Total £000 ‘s

Carole Hill 975 Cheryl Mould 174,893 Derek Rothwell 467,352 Dyanne Aspinall 33,949 Ian Davies 31,912 Jane Lunt 40,469 Katherine Sheeran 178 Tom Jackson 35,806 Tony Woods 82,453 Grand Total 867,988

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Report no: GB 30-17



Title of Report Emergency Preparedness Resilience &

Response Annual Report 2016/17

Lead Governor Dr Nadim Fazlani


Ian Davies, Chief Operating Officer

Report Author Joanne Davies, Corporate Services Manager (EPRR & Governance)

Summary The purpose of this paper is to present an overview to the Governing Body with regards to the EPRR activities undertaken by the CCG during 2016/17.

Recommendation That Liverpool CCG Governing Body: Acknowledges the CCG’s internal and

multi-agency work to ensure compliance with The Civil Contingencies Act and NHS England requirements.


National Core EPRR Standards (NHS England).

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EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE (EPRR) ANNUAL REPORT 2016/17

1. PURPOSE The paper introduces to the Governing Body the ongoing work carried out by the CCG both internally and externally with multi-agency partners.

2. RECOMMENDATIONS The Governing Body is asked to acknowledge the work completed to ensure compliance with the Civil Contingencies Act. 3. BACKGROUND This is the annual report to the Governing Body regarding EPRR as required by the NHS Emergency Preparedness Framework and the NHS England Core Standards for EPRR. The CCG needs to be able to plan for, and respond to, a wide range of incidents and emergencies that could affect health or patient care. These could be anything from severe weather to an infectious disease outbreak or a major transport accident. Under the Civil Contingencies Act (2004), NHS organisations and sub-contractors must show that they can deal with these incidents while maintaining services to patients. This work is referred to in the health service as ‘emergency preparedness, resilience and response’. To ensure accountability in this area, each CCG has a nominated Accountable Emergency Officer (AEO) and a Deputy. The CCG’s AEO is the Chief Officer, and the Deputy AEO is the Chief Operating Officer. The CCG is meeting the duties set out in legislation and associated statutory guidelines, as well as addressing other issues identified by way of risk assessments, such as the Merseyside Community Risk Register. In its role as a Category 2 responder, the CCG is acting in accordance with the Civil Contingency Act 2004, the Health and Social Care Act 2012 and all other relevant national policy and guidance as issued by the Department of Health. The role of the CCG, in terms of EPRR, is to:

• Ensure contracts with provider organisations contain relevant EPRR (including business continuity) elements.

• Support NHS England in discharging its EPRR functions and duties locally through membership of the Local Health and Resilience

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Partnership (LHRP), both at strategic level and on the Health Response Group.

• Provide a route of escalation for the LHRP should a provider fail to maintain necessary EPRR capacity and capability. Provider self-assessment issues will be escalated through the LHRP to ensure a collaborative solution with our health partners.

• Fulfil the responsibilities as a Category 2 Responder under the Civil Contingencies Act 2004 and the appropriate NHS EPRR guidance such as the NHS Core Standards for EPRR. This includes maintaining business continuity plans and an incident response plan for the CCG. Being represented on the LHRP (either on our own behalf or through representation by the CSU Business Continuity and EPRR Manager). The Chief Operating Officer represents the CCG on the LHRP. The Corporate Services Manager (Governance & EPRR) represents the CCG on the Health Response Group.

• Seek assurance that provider organisations are delivering their contractual obligation by monitoring through a process of self-assessment with provider EPRR colleagues.

4. EPRR POLICY AND PLANS NHS Liverpool CCG has in place an Incident Response Plan and Business Continuity Plan which are subject to regular review on at least an annual basis and which are tested through an annual desktop exercise. Specific ‘risk’ plans are developed as required with a severe weather response plan and pandemic influenza plan now in place. 5. MERSEYSIDE LOCAL HEALTH RESILIENCE PARTNERSHIP

(LHRP) The LHRP is primarily a strategic ‘executive’ forum for organisations in the local health sector (providers, commissioners and public health) that facilitates health sector preparedness and planning for emergencies at Local Resilience Forum (LRF) level, in our case Merseyside and is led by NHSE. The LHRP also supports the NHS, Public Health England (PHE) and local authority (LA) representatives on the LRF in their role to represent health sector EPRR matters. The LHRP strategic meetings are supplemented by an operational group that is made up of EPRR practitioners / leads. During the last twelve months the LHRP has focussed upon a variety of issues including: pre-hospital trauma care, power loss, including lessons learnt from several significant incidents; the junior doctors industrial action; planning for body storage in the event of excess deaths; a post Ebola debrief led by PHE; and accommodation plans for secure mental health services. The LHRP strategic

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meetings are attended by the CCG Chief Operating Officer and the operational group by officers from the governance team. 5.1 LHRP PRACTITIONERS GROUP The LHRP Practitioners Group ensures delivery of the LHRP strategy. This includes carrying out the EPRR assurance process, organising and delivering training and exercises, developing and reviewing health related MRF plans, ensuring health is appropriately represented at MRF events and exercises, carrying out post incident debriefs and is the forum for all health EPRR related matters. The Group meets every two months and also creates working groups to produce specific deliverables, such as pandemic influenza plans. The Senior Operations and Governance Manager represents NHS Liverpool CCG on this group. 5.2 MERSEYSIDE LOCAL RESILIENCE FORUM (MRF) The MRF is the forum for multi-agency emergency planning in Merseyside and is usually Chaired by the Chief Constable, it delivers the requirements of multi-agency emergency planning and preparedness as outlined by the Civil Contingencies Act 2004. NHS England represents health at the LRF. However, specific deliverables required by the MRF are actioned by the LHRP Practitioners Group, such as producing a mass casualty plan. The LHRP is also committed to ensuring the appropriate health organisations, including Liverpool CCG, play their appropriate part in MRF organised multi-agency training and exercising events. 5.3 LIVERPOOL RESILIENCE GROUP (LRG) The LRG brings together the emergency services, utility / infrastructure, local authority, health and other key partners to co-ordinate emergency planning and response on a city footprint, as well as sharing intelligence and best practice. The forum recognises the unique challenges and complexity of city life and the opportunities for joint working and shared learning During the last twelve months the group has focussed upon a variety of issue including: flood resilience, including lessons learnt from last winter, including Cumbria; the development of a local risk catalogue to complement the work of the LRF; event planning across the city; major public infrastructure works; cyber resilience and security; counter terrorism; and the introduction of revised city centre public information zones for use in the event of a major incident. The groups Vice Chair is the CCG Chief Operating Officer.

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5.4 SAFETY ADVISORY GROUP & NON-LICENSABLE SAFETY ADVISORY GROUP (SAG & NLSAG)

The purpose of the SAG and NLSAG is to deliver to the public a safely planned and organised event; that meets all the statutory obligations under relevant legislation; that meets the standards of safety applied to all public events in the City of Liverpool, and to review and agree recommendations made at Joint Agency Planning Meetings The Senior Operations and Governance Manager represents the CCG at the SAG and NLSAG meetings and cascades event information to the local Trusts when there is, or is potential for, impact upon local health services. 5.5 QUARTERLY LIVERPOOL EPRR LEADS MEETING ESTABLISHED The purpose of this meeting is for Liverpool EPRR Leads from the CCG, NWAS, LCC and local provider Trusts, to meet on a quarterly basis to share intelligence and to discuss city events that may have an impact on the provision of local health services. This operational forum provides the opportunity to share experiences at the city level across the key health partners. 6. EPRR ASSURANCE 6.1 NHS LIVERPOOL CCG EPRR ASSURANCE NHS Liverpool CCG is required to and has undertaken a self-assessment against the NHS England Core Standards for EPRR. Following self-assessment, and in line with the definitions of compliance, the organisation has declared itself as demonstrating Substantial Compliance against the EPRR Core Standards. This is based on a process of self-assessment and the production of a work plan to address any gaps. The cyclical nature of EPRR means there will always be actions required in the plan, e.g. to exercise and review, however no significant areas of none compliance with the standards was identified in 2016/17. 6.2 PROVIDER EPRR ASSURANCE Under the NHS EPRR guidance CCGs are required to assure themselves that their commissioned services have plans in place to respond to, and recover from, emergencies. As a continuing part of this assurance process, all Trusts had to provide submit a self-assessment against the NHS England Core Standards for EPRR. A summary of their level of compliance is shown below.

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NHS England EPRR Core Standards Assurance 2016/17

Provider

Compliance Level

Alder Hey Children’s NHS Foundation Trust Substantial

Liverpool Heart and Chest Hospital Full

Liverpool Community Health NHS Trust Substantial

Liverpool Women's Hospital NHS Trust Partial

Royal Liverpool and Broadgreen University Hospital Trust Substantial

NHS England has an annual process of auditing core standards for EPRR of all trust providers (excluding GPs/ Pharmacies etc.). To prevent duplication of work by Trusts, their compliance is submitted directly to NHS England and the results are shared with the CCG. As part of the NHS England review process they will conduct a review of the LWH EPRR improvement plan, in light of their partial compliance prior to the EPRR Assurance Process for 2017-18 and the subsequent findings will be shared with the CCG. It should be noted that in the case of LWH as their self-assessment was submitted a number of months ago progress has already been made against a number of the actions and they are currently in the process of putting together a work plan to address the outstanding items and they will be submitting a further EPRR Core Standards self-assessment later this year to NHSE. 7. EPRR TRAINING AND EXERCISING 7.1 NORTH MERSEY ON-CALL ROTA STAFF The Senior Managers that are part of the North Mersey On-Call rota, shared across Liverpool, Sefton and Southport & Formby CCGs are invited to attend relevant training arranged by the Business Continuity and EPRR Manager at the Midlands and Lancashire CSU (previously The North West CSU). Four members of the Liverpool CCG on-call rota have attended Tactical Command Training that was run during 2016. 7.2 CCG STAFF During 2016/17 NHS Liverpool CCG has worked with multi-agency partners in the planning of numerous large scale events including the Rock ‘n’ Roll Marathon Series, Sound City, International River Festival, LIMF (Liverpool International Music Festival), Liverpool Pride, Liverpool Triathlon, Fusion Music Festival etc. to ensure comprehensive plans for the events were

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developed with adequate medical provision available. There were no significant health or health service related impacts arising from these events and through the subsequent de-brief process lessons where appropriate have been learnt and will be applied to future event planning. Liverpool City Council has developed a new web based Major Events Planner to assist in both awareness raising and co-ordination for the numerous events happening across the city each year. Key staff within the Corporate Services Team have access to this new tool (along with other multi-agency partners) to record key events taking place in the city. This planner gives a broad overview of the number (and scale) of events taking place at any one time. The Chief Operating Officer has participated in the following EPRR updates / training during 2016/17:

• JESIP Commander Training. • Cyber Threat & Resilience Awareness: North West Organised Crime

Unit (Regional Cyber Crime Unit). The process for risk rating and disseminating event documentation across the NHS providers in the city has been mapped out so that any member of staff can forward it to the relevant organisations for their information and for bringing to the attention of on-call staff. In this role the CCG acts in a leadership and co-ordination role for NHS resources. Due to the high volume of EPRR meetings where CCG representation is required, the recurring meetings have been tabulated with a lead and deputy identified for each. The CCG carried out a business continuity table top exercise in June 2016. The exercise highlighted areas of additional work (e.g. the creation of a utilities action card for use during a business continuity incident) required to ensure the business continuity plan can be as robust as possible. The Corporate Services Manager (EPRR & Governance) is working to fully populate the CCG’s page on Resilience Direct. (Resilience Direct is a fully accredited and secure information-sharing platform for Emergency Responders. It allows for real time information to be shared across all organisational and geographic boundaries). The Chief Operating Officer continues as the Vice Chair of the Liverpool Resilience Action Group (LRAG) that provides a focus for city wide EPRR strategic and operational planning, covering a wide variety of threats and risks from terrorism through to adverse weather and major public events.

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8. GUIDANCE The following guidance has been released during the course of 2016/17:

• Cold Weather Plan – this was issued in October 2015 and in November 2016 confirmation was received that the content of the plan remained the same for this financial year and that the cold weather alerts scheme will again run from November to March. The CCG reviewed the content of the plan and ensured actions were taken locally to comply with the guidance.

• Heatwave Plan – this was issued in May 2016 and the hot weather alerts scheme runs from June to September each year. The CCG reviewed the content of the plan and ensured actions were taken locally to comply with the guidance. Assurance was also obtained from our providers that they too were meeting the requirements of the plan. Three new resources have been developed nationally to support this plan: ‘Beat the Heat’ poster; ‘Beat the Heat’ supporting leaflet and a ‘Beat the Heat’ keep cool at home checklist.

• NHS England released guidance on 3rd February 2017 on the roles and responsibilities of CCGs in preparing for and responding to an influenza pandemic. The CCG pandemic influenza plan has been reviewed to ensure it incorporates this information.

• NHS England Core Standards for Emergency Preparedness, Resilience and Response – this was issued in July 2016. The aim of the core standards is to clearly set out the minimum EPRR standards expected of NHS organisations and providers of NHS funded care. In addition, the standards also:

o enable agencies across the country to share a common purpose and to co-ordinate EPRR activities in proportion to the organisation’s size and scope; and

o provide a consistent cohesive framework for self-assessment, peer review and assurance processes.

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9. STATUTORY REQUIREMENTS (only applicable to strategy & commissioning papers)

This section is considered to not be applicable as this is a performance paper. 10. DESCRIBE HOW THIS PROMOTES FINANCIAL SUSTAINABILITY The provision of effective business continuity and incident response arrangements supports the finances of the CCG. 11. CONCLUSION The Governing Body can be assured that the CCG takes its responsibilities for EPRR and Business Continuity very seriously and has put into place the necessary infrastructure and plans to ensure that it is able to discharge its statutory and wider NHS and citywide obligations in an effective and professional manner.

Joanne Davies Corporate Services Manager (EPRR & Governance)

March 2017

Ian Davies Chief Operating Officer

March 2017

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Report no: GB 31-17

NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERING BODY


Title of Report MIAA review of Liverpool, South Sefton and

Southport & Formby CCG’s quality assurance processes for Liverpool Community Health (LCH)

Lead Governor Jane Lunt Head of Quality/ Chief Nurse


Jane Lunt Head of Quality/Chief Nurse

Report Author Jane Lunt Head of Quality/Chief Nurse

Summary The purpose of this paper is to update the Liverpool CCG Governing Body of the outcome of the joint review undertaken by MIAA regarding the assurance on quality of services – specifically focusing on Liverpool Community Health

Recommendation That the Liverpool CCG Governing Body: Notes the contents of this paper outlining

the outcome of the review Notes the actions to be undertaken


NHS Outcomes Framework 16/17: Domains 1-5

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MIAA REVIEW OF LIVERPOOL, SOUTH SEFTON AND SOUTHPORT & FORMBY CCG’S QUALITY ASSURANCE

PROCESSES FOR LIVERPOOL COMMUNITY HEALTH (LCH)

1. PURPOSE The purpose of this paper is to update the Liverpool CCG Governing Body of the outcome of the joint review undertaken by MIAA regarding the assurance on quality of services – specifically focusing on Liverpool Community Health. 2. RECOMMENDATIONS

That the Liverpool CCG Governing Body: Notes the contents of this paper outlining the outcome of the

review Notes the actions to be undertaken

3. BACKGROUND Liverpool Community Health (LCH) was rated as ‘Requires Improvement’ by CQC in February 2014. At this point the trust was in the process of becoming a Foundation Trust. In February 2015, the LCH Board made a decision to step out of this process and NHSI began a process to transact the services provided by LCH into new providers as LCH would not be able to continue to provide services. Throughout this time period, Liverpool CCG in conjunction with South Sefton and Southport & Formby CCGs has had arrangements in place to oversee quality of services and associated quality improvements. Due to the number of commissioners involved, a Collaborative Forum was established to enable commissioners to, where possible, act collectively and also to support effective communication. During this time period, there has been much interest in the quality of services, and the pace of improvement, from a number of sources. LCCG has been subject to a number of Freedom of Information requests (FOIs) and MP letters requesting information about the transaction process and the quality of services.

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An MP with a nearby constituency has taken a particular interest in the trust and the progress of the transaction, culminating in a Parliamentary Adjournment in July 2016, where a request was made for a public inquiry, or at least an independent clinical review, into patient harm associated with the leadership failings at Liverpool Community Health NHS Trust between 2010 and 2014. This has led to a Clinical Review led by Dr. Bill Kirkup CBE currently being undertaken. The first phase has focused on the trust (LCH) and key staff members, and will move to commissioners in early March. As preparation for this, and to collate and analyse evidence to be submitted, MIAA were commissioned to undertake a review of governance and processes used by the 3 CCGs, and determine whether they were fit for purpose with regard to the CCGs statutory duties, and to take reasonable steps to confirm that providers are delivering services to patients of the appropriate quality. This report will be submitted to the review as part of the evidence pack. The review was completed in February 2017 and is attached (Appendix 1). 4. OUTCOME OF REVIEW Overall there is ‘significant assurance’. Whilst there are some weaknesses in the design/ and or operation of controls which could impair the achievement of the objectives of the system, function of process, their impact would be minimal or unlikely to occur. The review looked at 3 areas; firstly external facing quality activities, secondly, internal CCG quality activities and lastly, each CCG self- assessed the control position as at April 2013. An action plan will be prepared to undertake the 5 recommended actions, the majority of which need completing by the end of April 2017. 5. STATUTORY REQUIREMENTS (only applicable to strategy &


5.1 Does this require public engagement or has public engagement been carried out? Yes / No

i. If no explain why

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ii. If yes attach either the engagement plan or the engagement report as an appendix. Summarise key engagement issues/learning and how responded to.

5.2 Does the public sector equality duty apply? Yes/no.

i. If no please state why ii. If yes summarise equalities issues, action taken/to be

taken and attach engagement EIA (or separate EIA if no engagement required). If completed state how EIA is/has affected final proposal.

5.3 Explain how you have/will maximise social value in the

proposal: describe the impact on each of the following areas showing how this is constructed to achieve the most:

a) Economic wellbeing b) Social wellbeing c) Environmental wellbeing

5.4 Taking the above into account, describe the impact on

improving health outcomes and reducing inequalities 6. DESCRIBE HOW THIS PROMOTES FINANCIAL

SUSTAINABILITY Not applicable. 7. CONCLUSION

The MIAA review indicates ‘significant assurance’ with respect to assurance processes on quality of services commissioned with 5 recommendations which require completion largely by the end of April 2017. This report will form part of the evidence submission for the clinical review led by Dr. Bill Kirkup. It should be noted that although the focus of the review was LCH, the processes are utilised for all Trusts for which LCCG is the coordinating commissioner, and therefore the findings can be applied to all trust processes. This report has wider impact than first apparent and assures QSOC, and ultimately the Governing Body, that the systems, processes and governance for quality monitoring are robust.

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The report has also been considered by the Audit Committee on 17th February 2017 and the Quality Safety & Outcomes Committee on 7th March 2017. Jane Lunt Head of Quality/Chief Nurse 27/02/17

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Assurance on Quality of Services

Commissioned Review

Assignment Report 2016/17

South Sefton, Southport & Formby and Liverpool CCGs

QSOC 14-17

GB 31-17 Appendix 1

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Assurance on Quality of Services Commissioned

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Contents

1. Introduction

2. Executive Summary

3. Findings, Recommendations and Action Plan

Appendix A: Terms of Reference

Appendix B: Assurance Definitions and Risk Classifications

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1. Introduction, Background and Objective

There has been significant focus from the Regulators and other Government bodies

with regard to the quality of services provided to Patients by Liverpool Community

Health NHS Trust (LCH).

In particular, the CQC issued critical reports in 2013 and 2014. This led to LCH ceasing

its plans to progress to Foundation Trust status and to NHS Improvement beginning a

transaction process for new Providers to take on the services provided by LCH. This

will mean that LCH will cease to operate with effect from April 2017.

The CCGs (LCCG, SSCCG & SFCCG) are confident in the robustness of their current

quality oversight control mechanisms of Providers but seek independent assurance

over these controls. In addition, an analysis is sought of whether there are any lessons

learned for the CCGs during the period that they have commissioned services from LCH

(April 2013 to date).

The main objective of the audit was to provide assurance that the CCGs (LCCG, SSCCG

& SFCCG) internal processes are fit for purpose with regard to the CCGs statutory duties

to take reasonable steps to confirm that Providers are delivering services to Patients to

the appropriate quality.

2. Executive Summary

There are some weaknesses in the design and/or operation of controls which could

impair the achievement of the objectives of the system, function or process. However,

either their impact would be minimal or they would be unlikely to occur.

Significant Assurance

The following provides a summary of the key themes:

OVERALL SUMMARY AND CONCLUSION

There are three quality related forums in place at a regional level hosted by NHS

England (Cheshire and Mersey) which are not specific to an individual Provider. These

are the Quality Surveillance Group, CCG Chief Nurses’ meetings and the Quarterly

Assurance Meetings with each CCG which includes Quality matters. Liverpool, South

Sefton and Southport & Formby CCGs were able to demonstrate participation in these

forums. Management also highlighted that there is regular communication with the

CQC.

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Quality related forums are also in place at Provider level and we were provided evidence

of the operation of the Commissioner Collaborative Forum, Contract Review meeting

and Clinical Quality Performance Group for LCH. Other quality review mechanisms

specific to LCH were also demonstrated including the holding of a Risk Summit, the

preparation of a Quality Risk Profile and the performance of a full day Quality Visit.

Engagement with Patients was noted as being secured for all Providers through: GP

Clinical Leads, CCG Programme Managers, the Patient and Advice Liaison Service,

Locality meetings, Engagement and Patient Experience Groups, Patient Opinion Web

site and the complaints/comments sections on the CCG web sites.

Within each CCG, Quality matters for all Providers are monitored through the respective

Governing Bodies and Quality Committees with evidence being seen of items related

to LCH being covered at these forums. Dedicated Quality teams are in place at each

CCG under the leadership of a Chief Nurse which includes a Serious Incident reporting

process and employee feedback mechanisms notably through whistleblowing policies.

Given the various forums in place and parties involved in the management of Quality it

is important that the responsibilities of the CCGs are formalised as part of the three

lines of defence model in order to provide clarity in more detail than the statutory

guidance. The CCGs should then ensure that the matters they are responsible for

monitoring (as part of their second line of defence role) are confirmed as being in place

at each Provider on an annual basis.

The detailed findings and conclusions section which follows sets out the comments

above in more detail and explains the documents reviewed and discussions held during

the audit. There are also comments from Management with regard to their self-

assessment of the current control environment compared with that in place when the

CCGs were formed in 2013.

DETAILED FINDINGS AND CONCLUSIONS

Objective 1: External Facing Quality Activities

Overview

This section of the audit examined the quality related control mechanisms that are in

place with regard to the interfaces that the CCGs have with: Liverpool Community

Health (LCH); NHS England; the Care Quality Commission (CQC); and through

engagement with Patients. CCG Management explained the forums in place and the

interfaces for each area as detailed in the following sections.

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Liverpool Community Health (LCH)

There is a 2016-17 contract in place dated 1 April 2016 between LCH and NHS Liverpool

CCG (LCCG) as Co-ordinating Commissioner. Review of the contract confirmed that a

signed copy is held and that quality requirements are referred to in Schedule 4.

Management also explained that the supporting CCGs have a separate contract with

LCH and the signature page signed extracts from this contract were also reviewed. It

is also noted that LCCG are the Co-ordinating Commissioner for the Serious Incident

process.

Contract performance for LCH is monitored through the monthly contract review

meeting (CRM). The papers for the 7th November 2016 meeting were reviewed and the

attendees confirmed as being LCH and LCCG management. Quality aspects were

included on the agenda through inclusion of agenda items on the 13th October 2016

Clinical Quality and Performance Group feedback and the Integrated Performance and

Quality report for April-September 2016.

The primary forum for monitoring quality aspects in relation to LCH is the monthly Joint

Clinical Quality Performance Group (CQPG) meeting. The minutes and action log

arising from the 13th October 2016 meeting were reviewed and it was confirmed that

attendees included the LCCG Chief Nurse and the SS/SF Deputy Chief Nurse.

The CRM and the CQPG report to the LCH Commissioner Collaborative Forum (CF).

Review of the Terms of Reference for the forum confirmed that joint oversight of

Quality improvement was included within the purpose of the CF and that the

membership comprised: LCCG, SS/SF CCG, NHS England (Cheshire & Mersey), Liverpool

City Council, Sefton Council and the Trust Development Authority (NHS Improvement).

The forum meets monthly and the 3rd November 2016 meeting papers were reviewed

from which it was noted that the agenda included CQPG meeting agenda setting.

Attendees at the meeting included both Chief and Deputy Chief Nurses from LCCG and

SS/SF CCG as well as NHS Improvement.

CCG Management explained that a GP Clinical Lead is assigned to each Provider (so

can be contacted by local GPs with their concerns) and also attends the Commissioner

Collaborative Forum and the CQPG.

CCG Management highlighted that a Risk Summit for LCH was held in August 2014 in

light of the specific risks highlighted by the CQC inspection and this was confirmed by

review of the meeting minutes arising. The Risk Summit is the meeting that, if the risks

are agreed and accepted by partners, sets in train the remedial work to mitigate and

reduce the risks with follow up of agreed actions through the CQPG and Collaborative

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Forums. Discussions also highlighted that a Quality Risk Profile for LCH was undertaken

in July 2016 (led by CCG Management) following concerns raised by the February 2016

CQC inspection. Review of the profile showed that it covered 75 risk areas with 10

being rated as very high which should be followed up through the CQPG and

Collaborative Forums.

It was also highlighted that, as part of a range of quality surveillance processes used to

monitor LCH, a full day Quality Visit took place on 17th August 2015 to all 3 Wards

providing bed based intermediate care facilities. Review of the resultant report

confirmed that the visit was undertaken by representatives from NHS England and both

the Chief and Deputy Nurses from LCCG and SS/SF CCG. Whilst good practice points

were highlighted, there were also a number of improvement points noted. CCG

Management has confirmed that the action plan arising was monitored at subsequent

CQPG meetings. Management also explained that this type of visit has not been

repeated on the basis that the nature of the work done was similar in nature to what

the CQC would perform on an audit visit as well as the CCG not having the resource to

conduct such reviews on a regular basis. In addition, SS/SF CCG Management

highlighted that more recent LCH related visits include attending a Bootle District Nurse

team meeting and shadowing a Health visiting team. It was discussed that a ‘softer’

approach to monitoring is used rather than a formal Quality visit by, for example,

touring updated ward facilities.

NHS England

Review of the Clinically-led commissioning fact sheet (the Health and Social Care Act

2012) highlighted that the core duties of CCGs include “securing continuous

improvements in the quality of services commissioned”. However, the CCGs in their

(‘second line of defence’) oversight role can only be expected to exercise certain

monitoring activities but there needs to be clarity between all parties with regard to

expectations. A summary quality checklist should be developed of the control

mechanisms that the CCGs monitor at Providers within the context of their oversight

role. This should be shared and ideally agreed with the CQC and NHS England as being

the key matters which the CCGs should be expected to monitor in this role. The

checklist should be completed by the CCGs at the start of the contract with any new

Provider and annually thereafter.

NHS England (Cheshire & Mersey) hold a Quarterly Assurance meeting with each CCG.

Review of the papers for the 9th September 2016 meeting with LCCG confirmed that

Quality mechanisms were included within the Leadership section (Appendix 1 of

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Papers). Review of the papers for the 13th September 2016 meeting with SS/SF CCG

confirmed that the Chief Nurse was an attendee at the meeting.

NHS England (Cheshire & Mersey) hold a meeting with CCG Chief Nurses once every

two months. The papers from the 19th September 2016 meeting were reviewed and it

was noted that this meeting agenda included a presentation by the LCCG and SS/SF

CCG Chief Nurses on lessons learned from the March 2016 Capsticks Report on LCH.

One of the lessons learned was that there was a fragmented commissioning system

particularly post NHS reforms and this was addressed by, for example, formation of the

Commissioner Collaborative Forum noted above. The report also included

recommendations with regard to: Clarification of Director remits on Quality; Quality

Governance Arrangements; and Incident Reporting. A copy of the LCH action plan

tracker for the Capsticks recommendations as at May 2016 was reviewed and is was

noted that the status on all actions was reported as ‘complete’ or ‘on track’. Discussions

also highlighted that the CCG Chief Nurses have one to one meetings with the NHS

England (Cheshire and Mersey) Director of Nursing.

NHS England (Cheshire & Mersey) hold a Quality Surveillance Group (QSG) meeting

once every two months. The 1st December 2016 meeting papers were reviewed and it

was noted that the Deputy Chief Nurses from LCCG and SS/SF CCG were in attendance.

Other attendees included representatives from CCGs, CQC, Healthwatch, NHS

Improvement, Local Councils and Public Health England North West as well as NHS

England. CCG Management highlighted that, now that the Group covers both Cheshire

and Mersey, the QSG covers matters by exception only. Discussions indicated that this

approach is being kept under review by Management to avoid the risk of relevant issues

not coming to light.

CQC

CCG Management highlighted that the CQC Central communications team send the

CCGs a list of announced visits to Providers and that the CCGs have the opportunity to

feedback to the CQC with any comments. This could include highlighting any areas of

concern at Providers to be visited. Discussions also highlighted that the CQC usually

contact the CCGs prior to each Provider review starting to obtain current views from

the CCGs. This was confirmed by review of two examples provided by SS/SF CCG of

newsletters to GP Practices where patients were encouraged to provide an on-line

opinion on Providers subject to forthcoming CQC visits. Liverpool CCG should check

whether the equivalent content is in their Newsletters to GP Practices. If this is not the

case then inclusion should be considered.

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Implementation of actions arising from the CQC visits to LCH in 2014 and February

2016 are being formally tracked and this was confirmed through review of the 3rd

November 2016 CF papers and the minutes from the 13th October 2016 CQPG meeting.

Engagement with Patients

CCG Management highlighted that GP Clinical Leads work with LCH day to day and see

any issues from their own Patient’s perspective as a clinical commissioner but also in

their provider role as a General Practitioner. CCG Management also explained that CCG

Programme Managers who develop services have contact as well with LCH (eg. walk-in

centres, virtual ward developments) and that the Patient and Advice Liaison Service

(PALS) is available to Patients and is publicised at Provider premises including LCH.

Discussions highlighted that a member of the SS/SF CCG Quality Team is allocated to

attend the four Locality Meetings where quality issues with providers can be raised.

Review of the Minutes for the 22nd November 2016 Central Locality meeting confirmed

that the meetings are Chaired by a GP and that GPs/Practice Managers from local

surgeries are in attendance as well as SS/SF CCG representatives. At LCCG, the LCCG

Primary Care team have a representative at the three Locality meetings and bring back

any quality issues to the LCCG Quality team. Review of the minutes from the 18, 19, 20

October 2016 meetings for the LCCG Local Clinical Workshops highlighted that 53 GP

Practices were represented. CCG Management also highlighted that any relevant

points from Locality meetings are included on the LCCG and SS/SF CCG Quality

Committee agendas (see below).

We noted that Healthwatch are part of the LCCG and SS/SF CCG Engagement and

Patient Experience Groups (EPEG) which are Chaired by a lay member, and that the

EPEG is a sub-Committee of the Quality Committee at the CCGs and the lay member

sits on the Quality Committee. The 13th July 2016 minutes from the joint EPEG for SS/SF

CCG were reviewed and it was noted that this included a presentation from LCH

management on how they are collecting and using patient experience feedback.

Review of the minutes from the 29th November 2016 LCCG EPEG highlighted that, under

the Complaints Key Issues report, the LCH MP Enquiries came through for re-assurance

around the process.

Review confirmed that details of how patients can make a complaint on the Liverpool

CCG web site are relatively straightforward to find by going to ‘contact us’ and then

‘comments and complaints’. Details are also noted on the South Sefton and Southport

& Formby CCG web sites. However, checking of this facility on both web sites

highlighted that this can only be found by searching on ‘complaints’ rather than by

going through the main menus. CCG Management should investigate the feasibility of

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amending the South Sefton and Southport & Formby CCG web site functionality to

make it similar to Liverpool CCG for complaints. CCG Management highlighted that

the Chief Nurses at LCCG and SS/SF CCG are actively involved in the review of

complaints received.

We noted that Liverpool CCG have commissioned a Patient Opinion web site where

Patients can put their comments (both compliments and complaints). The site was

reviewed and noted as being referenced off the Liverpool CCG site (‘contact us’ then

‘comments and complaints’). Management explained that the LCCG Communications

Team monitor the site for any matters which require follow up. It was also highlighted

that the site is not fully implemented because not all Trusts are in agreement with the

need for the site. Consideration should be given to making usage of the Patient

Opinion web site one of the clauses within the contracts between the CCG and relevant

Providers.

It was also noted that LCCG and SS/SF CCG have introduced ‘Aristotle’ which is a

business intelligence application provided by Midlands and Lancashire Commissioning

Support Unit to aid ‘drill-down’ of intelligence at a locality and practice level.

Objective 2: Internal CCG Quality Activities

Overview

This section of the audit examined the quality related control mechanisms that

are in place within Liverpool CCG (LCCG), South Sefton CCG and Southport &

Formby CCG (SS/SF CCGs). The management of Quality is a combined operation for

South Sefton and Southport & Formby CCGs. As such, the phrase ‘both CCGs’ within

this section refers to LCCG and SS/SF CCGs.

CCG Resource

Management explained that both CCGs have an in-house Quality team (LCCG: 9

colleagues, SS/SF CCG: 7 colleagues) each headed by a Chief Nurse who reports to the

Chief Officer and including Deputy Chief Nurses. Discussions highlighted that the

Safeguarding Teams in each CCG have close links with both Quality teams and that

LCCG act as the co-ordinating Commissioner for 7 Trusts each of which have a CQPG

meeting once every 6 to 8 weeks.

LCCG job descriptions were reviewed for the Chief Nurse, Deputy Chief Nurse, Quality

and Performance Manager and the Quality and Safety Manager. Job descriptions for

SS/SF CCG were reviewed for the Chief Nurse, Deputy Chief Nurse, Programme Quality

and Performance Manager and the Quality and Safety Manager. Either Quality or

Patient Safety was highlighted in all job descriptions reviewed. CCG Management

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highlighted that the LCCG Chief Nurse job description needs updating and that the

SS/SF CCG job descriptions for the Chief Nurse and Deputy Chief Nurse are currently

being reviewed as part of the Agenda for Change process. The updates should be

completed as soon as possible.

CCG Quality Team Management

LCCG Management explained that the Chief and Deputy Nurses cover for each other

and plan holidays so that one of them is in work. Discussions also highlighted that

regular team meetings and workload planning is in place.

SS/SF Management explained that the Chief Nurse, Deputy Chief Nurse and Head of

Vulnerable People can cover for each other in the event of holidays and other

commitments. Discussions also highlighted that there is a programme of one to ones

and team meetings with the Chief and Deputy Nurses located in the same office as

other colleagues in the Quality team to aid communication. The 2nd November 2016

team meeting agenda and prior meeting actions were reviewed and it was noted that

the Quality Team Risk Register was included (see below re LCCG).

Quality Committee

The LCCG Quality, Safety and Outcomes Committee papers were reviewed for the 1st

November 2016 meeting. It was noted that the LCCG Chief Nurse was in attendance

and that coverage included the LCH Quality Risk Profile mentioned above and a Serious

Incidents Overview agenda item. Management explained that there is no specific paper

from the Chief Nurse because there are a number of agenda items on Quality matters.

Review of the agenda highlighted that prior meeting actions are included together with

a risk register update which is analysed by Provider including coverage of LCH.

The SS/SF CCG Joint Quality Committee papers were reviewed for the 16th November

2016 meeting. The SS/SF Chief Nurse was noted as a member with a 100% attendance

record. LCH is included with regard to reporting on the 27 LCH open serious incidents.

The Paper from the Chief Nurse to the Committee was reviewed and it was noted that

there was a section on Continuing Healthcare. Review of the agenda highlighted that

prior meeting actions are included.

Governing Body

The LCCG Quality, Safety and Outcomes Committee (QSOC) submit a report to the

Governing Body meetings based on a summary reporting template for Sub-

Committees. The 8th November 2016 papers were reviewed and it was noted that the

QSOC report included reference to LCH with regard to the risk to services provided

during the transaction process. Management highlighted a potential concern on

papers to the LCCG Governing Body being ‘light’ on quality matters and may wish to

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compare with the reporting approach of other CCGs. However, the format of the paper

was in line with that of other Sub-Committees and covered a summary of key issues,

risks and mitigating actions. As such, material matters should be highlighted to the

Governing Body under the current format.

SS and SF CCGs issue a report from the Chief Officer to the respective Governing Bodies.

The reports to the July 2016 Governing Bodies were reviewed and it was noted that

there was coverage of LCH with regard to the Capsticks report and the most recent

CQC inspection results.

Both CCGs issue an Integrated Performance Report to their respective Governing

Bodies. The LCCG report reviewed issued to the November 2016 Governing Body

included coverage of LCH in the Provider Performance Dashboard. The November

2016 report reviewed for SS and SF CCGs included a LCH Quality Overview section.

Serious Incidents Reporting Process

Both CCGs have a Serious Incident reporting process to their respective Quality

Committee meetings and LCCG take the lead on Serious Incident reporting through

their role as Lead Commissioner. The Serious Incident reports to the November 2016

meetings were reviewed and the content with regard to LCH was noted as being

primarily related to pressure ulcers.

LCCG Management explained that there had been a capacity issue in coping with the

volume of Serious Incidents but that they were now in a position of being able to

analyse the incidents. As such, the resourcing levels for Serious Incident management

should be kept under review.

Discussions highlighted that both Chief Nurses are actively engaged in the review of

Serious Incidents within their respective CCGs.

CCG Employee Feedback Mechanisms

The whistleblowing policies in place at LCCG and SS/SF CCG were reviewed and it was

confirmed that the content included encouraging CCG employees to report concerns

internally in the first instance. Management also highlighted that there is an ‘open

door’ policy in place and that senior colleagues with access to Datix (and who typically

have interaction with Providers) can record incidents on this system. However, currently

there is no, for example, electronic feedback mechanism for CCG employees to provide

feedback on Provider quality experiences. Such feedback could be both critical and

complimentary. Consideration should be given to extra ways of making sure that the

knowledge within CCG employees of Quality matters at Providers is captured promptly

which could include an electronic feedback mechanism.

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Objective 3: Control Position in April 2013

CCG Management has self-assessed the current control environment compared with

that in place when the CCGs were formed in 2013.

The management detailed self-assessment highlights, in particular, that the following

current controls were not in place in April 2013: CCG announced visits to LCH (and

other Providers); NHS England Quality Surveillance Group and use of Quality Risk

Profile Tool; the LCH Commissioner Collaborative Forum (CF); CCG in-house Quality

resource was at a low level in April 2013 with some support from the Commissioning

Support Unit (CSU); and monitoring of actions from meeting forums was through prior

minutes rather than formal action trackers. Management also note that what has

improved since 2013 is the control maturity in terms of understanding and managing

risk, relationships, trust, growth/development of the key forums in place and

understanding of NHS England escalation procedures.

3. Findings, Recommendations and Action Plan

The review findings are provided on a prioritised, exception basis, identifying the

management responses to address issues raised through the review.

To aid management focus in respect of addressing findings and related

recommendations, the classifications provided in Appendix B have been applied. The

table below summarises the prioritisation of recommendations in respect of this review.

Critical High Medium Low Total

0 0 4 1 5

The detailed findings and recommendations are set out below.

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Detailed Recommendations

1. CCGs Oversight Role with Providers Risk Rating: Medium

Control design

Issue Identified - The Capsticks report recommendations included points with regard

to: Clarification of Director remits on Quality; Quality Governance Arrangements; and Incident

Reporting.

The three lines of defence model can be applied to the control of Quality at Providers with

Trust Management being the first line of defence, CCGs (as Commissioners) being part of the

second line of defence and regulators such as the CQC being part of the third line of defence.

CCGs in their oversight role can only be expected to exercise certain monitoring activities but

there needs to be clarity between all parties with regard to expectations including respective

responsibilities within the CCGs themselves.

Specific Risk – There may be duplication or omission in quality control matters if there is not

sufficient formality around the responsibilities between the three lines of defence.

Recommendation - A summary quality checklist should be developed of the control

mechanisms that the CCGs monitor at Providers within the context of their (‘second line of

defence’) oversight role.

This should be shared and ideally agreed with the CQC and NHS England as being the key

matters which the CCGs should be expected to monitor in their oversight role.

The checklist should be completed by the CCGs at the start of the contract with any new

Provider and annually thereafter. Each item on the checklist should have responsibility within

the CCGs assigned.

Management Response (Remedial Action Agreed) - As recommended.

Responsibility for Action – Jane Lunt, Head of Quality / Chief Nurse, LCCG; Debbie Fagan, Chief

Nurse and Quality Officer, SS/SF CCGs

Deadline for Action – 30 April 2017 (within CCGs); 31 July 2017 (CQC / NHS E)

2. Patient Opinion Web Site Risk Rating: Medium

Operating effectiveness

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Issue Identified - Management highlighted that Liverpool CCG have commissioned a Patient

Opinion web site where Patients can put their comments (both compliments and

complaints). The site was reviewed and noted as being referenced off the Liverpool CCG site

(‘contact us’ then ‘comments and complaints’). Management also explained that the LCCG

Communications Team monitor the site for any matters which require follow up. Discussions

also highlighted that the site is not fully implemented because not all Trusts are in agreement

with the need for the site.

Specific Risk – Liverpool CCG may not become aware of all valid compliments and complaints

from Patients on a timely basis.

Recommendation - Consider making usage of the Patient Opinion web site one of the clauses

within the contracts between the CCG and relevant Providers.

Management Response (Remedial Action Agreed) - As recommended plus an internal

review of lessons learned from the original engagement process undertaken with Trusts which

in this case was via the Healthy Liverpool Programme rather than the Quality team.

Responsibility for Action – Jane Lunt, Head of Quality / Chief Nurse, LCCG

Deadline for Action – 30 June 2017

3. Feedback from CCG Colleagues on Quality at Providers Risk Rating: Medium

Control design

Issue Identified - The CCGs have whistleblowing Policies in place which were reviewed during

the audit and encourage CCG employees to raise any concerns internally in the first

instance. Management also highlighted that there is an ‘open door’ policy in place and that

CCG employees have various ‘touch points’ with Patients and Providers including through

attendance at Locality meetings.

In terms of highlighting any quality issues with Providers before they become serious, early

warning signs are key and could come to light if a number of apparently minor points in

isolation come together to form a theme. CCG employees will have their own personal

experience of being a patient with Providers as well as that of their family and friends.

Currently there is no, for example, electronic feedback mechanism for CCG employees to

provide feedback on Provider quality experiences. Such feedback could be both critical and

complimentary.

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Specific Risk – Early warning signs of quality issues known by CCG employees may not come

to light as quickly as possible. Alternatively, the opportunity to spread good practice coming

to light through compliments may be missed.

Recommendation - Consideration should be given to extra ways of making sure that the

knowledge within CCG employees of Quality matters at Providers is captured promptly. This

could include an electronic feedback mechanism.

Management Response (Remedial Action Agreed) - As recommended. This will include

possible use of the Staff Listening Group and Floor Briefings at LCCG. It will also look at the

possibility of taking CCG Colleague feedback on an anonymous basis. At SS/SF CCGs, it will

include possible use of the Sounding Group meetings and looking at ways of promoting the

updated whistleblowing policies.

Responsibility for Action – Jane Lunt, Head of Quality / Chief Nurse, LCCG; Debbie Fagan, Chief

Nurse and Quality Officer, SS/SF CCGs

Deadline for Action – 30 April 2017

4. Notification of CQC Visits to Providers Risk Rating: Medium

Control design

Issue Identified - Examples were reviewed of two Newsletters to GP Practices from Southport

& Formby and South Sefton CCGs. The examples included details of pending CQC visits to

two Providers and a web site address was included where Patients could log their experiences

with the Providers in advance of the CQC visits. GPs were invited to publicise this in their

Practices. Liverpool CCG have not mentioned that the equivalent is included in their routines.

Specific Risk – An opportunity may be missed to obtain patient feedback which would inform

CQC visits to Providers.

Recommendation - Liverpool CCG should check whether the equivalent content is in their

Newsletters to GP Practices. If this is not the case then inclusion should be considered.

Management Response (Remedial Action Agreed) - This content is not currently within LCCG

Newsletters and the merits of inclusion going forward will be reviewed.

Responsibility for Action – Jane Lunt, Head of Quality / Chief Nurse, LCCG

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5. Complaints from Patients Risk Rating: Low

Control design

Issue Identified - Details of how patients can make a complaint on the Liverpool CCG web

site are relatively straightforward to find by going to ‘contact us’ and then ‘comments and

complaints’. Details are also noted on the South Sefton and Southport & Formby CCG web

sites. However, checking of this facility on both web sites highlighted that this can only be

found by searching on ‘complaints’ rather than by going through the main menus.

Specific Risk – Patients within South Sefton and Southport & Formby may be deterred from

making a complaint leading to potential delays in the CCGs becoming aware of valid patient

concerns.

Recommendation - Investigate the feasibility of amending the South Sefton and Southport

& Formby CCG web site functionality to make it similar to Liverpool CCG for complaints.

Management Response (Remedial Action Agreed) - As recommended.

Responsibility for Action – Debbie Fagan, Chief Nurse and Quality Officer, SS/SF CCGs


Follow-up

In light of the findings of this audit we would recommend that follow-up work to confirm the

implementation of agreed management actions is conducted within the next 12 months.

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Appendix A: Terms of Reference

The main objective of the review was to provide assurance that the CCGs (LCCG, SSCCG &

SFCCG) internal processes are fit for purpose with regard to the CCGs statutory duties to take

reasonable steps to confirm that Providers are delivering services to Patients to the

appropriate quality.

The review comprised the following sub-objectives:

1. To examine the quality related functions of the CCGs and confirm alignment with

quality duties as commissioners including collaborative arrangements that are in

place between the CCGs

2. To review the effectiveness of the internal governance systems relating to CCG

quality oversight of Providers

3. To provide assurance in relation to the CCGs oversight of Liverpool Community

Health NHS Trust (LCH) quality since April 2013 to date. This is to include the

CCGs role within the wider Quality Surveillance Process and the CCG Assurance

Process (facilitated by NHS England).

The review focused on the CCGs quality oversight mechanisms relating to Liverpool

Community Health NHS Trust (LCH) although it is expected that the controls noted during the

review and any proposed enhancements will have applicability to other Providers.

The review sought to confirm operation in practice of the current controls in place. The extent

to which these controls have been in operation since April 2013 (sub-objective 3.) was

confirmed with management by means of their self-assessment.

Limitations inherent to the internal auditor’s work

We have undertaken the review of Assurance on Quality of Services Commissioned process,

subject to the following limitations.

Internal control

Internal control, no matter how well designed and operated, can provide only reasonable and

not absolute assurance regarding achievement of an organisation's objectives. The likelihood

of achievement is affected by limitations inherent in all internal control systems. These include

the possibility of poor judgement in decision-making, human error, control processes being

deliberately circumvented by employees and others, management overriding controls and the

occurrence of unforeseeable circumstances.

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Future periods

The assessment of controls relating to the Assurance on Quality of Services Commissioned

process is that at December 2016. Historic evaluation of effectiveness is not always relevant to

future periods due to the risk that:

The design of controls may become inadequate because of changes in the operating

environment, law, regulation or other; or

The degree of compliance with policies and procedures may deteriorate.

Responsibilities of management and internal auditors

It is management’s responsibility to develop and maintain sound systems of risk management,

internal control and governance and for the prevention and detection of irregularities and

fraud. Internal audit work should not be seen as a substitute for management’s responsibilities

for the design and operation of these systems.

We shall endeavour to plan our work so that we have a reasonable expectation of detecting

significant control weaknesses and, if detected, we shall carry out additional work directed

towards identification of consequent fraud or other irregularities. However, internal audit

procedures alone, even when carried out with due professional care, do not guarantee that

fraud will be detected. The organisation’s Local Counter Fraud Officer should provide support

for these processes.

Data Protection and Freedom of Information

All documents acquired or created by us during the course of this assignment remain the

property of the client.

MIAA are, thus, considered as a data processor rather than a data controller and are not,

therefore, directly subject to the requirements of the Data Protection Act. No information

relating to this, or any other, assignment will be directly disclosed to a third party by MIAA in

response to a subject access request. Any requestor will be advised that they should approach

the client.

These principles will also be applied in respect of any request for information relating to this,

or any other, assignment under the Freedom of Information Act.

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Appendix B: Assurance Definitions and Risk Classifications

Level of

Assurance

Description

High Our work found some low impact control weaknesses which, if addressed would

improve overall control. However, these weaknesses do not affect key controls

and are unlikely to impair the achievement of the objectives of the system.

Therefore we can conclude that the key controls have been adequately

designed and are operating effectively to deliver the objectives of the system,

function or process.

Significant There are some weaknesses in the design and/or operation of controls which

could impair the achievement of the objectives of the system, function or

process. However, either their impact would be minimal or they would be

unlikely to occur.

Limited There are weaknesses in the design and / or operation of controls which could

have a significant impact on the achievement of the key system, function or

process objectives but should not have a significant impact on the achievement

of organisational objectives.

No There are weaknesses in the design and/or operation of controls which [in

aggregate] have a significant impact on the achievement of key system,

function or process objectives and may put at risk the achievement of

organisational objectives.

Risk Rating Assessment Rationale

Critical Control weakness that could have a significant impact upon, not only the

system, function or process objectives but also the achievement of the

organisation’s objectives in relation to:

the efficient and effective use of resources

the safeguarding of assets

the preparation of reliable financial and operational information

compliance with laws and regulations.

High Control weakness that has or is likely to have a significant impact upon the

achievement of key system, function or process objectives. This weakness,

whilst high impact for the system, function or process does not have a

significant impact on the achievement of the overall organisation objectives.

Medium Control weakness that:

has a low impact on the achievement of the key system, function or

process objectives;

has exposed the system, function or process to a key risk, however the

likelihood of this risk occurring is low.

Low Control weakness that does not impact upon the achievement of key system,

function or process objectives; however implementation of the

recommendation would improve overall control.

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Report Distribution

Report Distribution

Name Title Report

Distribution

Jane Lunt Head of Quality/Chief Nurse, LCCG Draft & Final

Debbie Fagan Chief Nurse & Quality Officer, SS/SF CCGs Draft & Final

Tom Jackson CFO, LCCG Final

Martin McDowell CFO, SS/SF CCGs Final

Mark Bakewell Deputy CFO, LCCG Final

Fiona Taylor Chief Officer, SS/SF CCGs Final

Katherine Sheerin Chief Officer, LCCG Final

Discussion Meeting held with

Name Title Date

Jane Lunt Head of Quality/Chief Nurse, LCCG 23 January 2017

Debbie Fagan Chief Nurse & Quality Officer, SS/SF CCGs 30 January 2017

Review Completion

Action Planned Date Actual Date

Fieldwork Starts 17-Oct-2016 26-Oct-2016

Discussion Document to Client 21-Nov-2016 14-Dec-2016

Final Report 05-Dec-2016 09-Feb-2017

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Review prepared on behalf of MIAA by

Name: Gary Baines

Title: Assistant Director

Telephone: 0151 285 4503

Email: [email protected]

Name: Adrian Poll

Title: Senior Audit Manager

Telephone: 0151 285 4521


Name: Nigel Woodcock

Title: Internal Audit Manager

Telephone: 0151 285 4556


Acknowledgement and Further Information

MIAA would like to thank all staff for their co-operation and assistance in completing this

review.

This report has been prepared as commissioned by the organisation, and is for your sole use.

If you have any queries regarding this review please contact the Audit Manager. To discuss

any other issues then please contact the Director.

MIAA would be grateful if you could complete a short survey using the link below to provide us with

valuable feedback to support us in continuing to provide the best service to you.

https://www.surveymonkey.com/r/MIAA_Client_Feedback_Survey

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https://www.surveymonkey.com/r/MIAA_Client_Feedback_Survey

170170170

NHS LIVERPOOL CLINICAL COMMISSIONING GROUP

PRIMARY CARE COMMISSIONING COMMITTEE Minutes of meeting held on Tuesday 20TH DECEMBER 2016 at 10AM

BOARDROOM, THE DEPARTMENT Present: Voting Members: Dave Antrobus (DA) Governing Body Lay Member – Patient

Engagement (Chair) Katherine Sheerin (KS) Chief Officer Prof Maureen Williams (MW) Lay Member for Governance/Deputy Chair of Governing Body Cheryl Mould (CM) Primary Care Programme Director Nadim Fazlani (NF) GP Governing Body Chair Paula Finnerty (PF) GP – North Locality Chair Dr Rosie Kaur (RK) GP Governing Body Member/Vice Chair Jane Lunt (JL) Chief Nurse/Head of Quality Tom Jackson (TJ) Chief Finance Officer Co-opted Non-voting Members: Rob Barnett (RB) LMC Secretary Moira Cain (MC) Practice Nurse Governing Body Member Sarah Thwaites (ST) Healthwatch Tina Atkins (TA) Governing Body Practice Manager Co-Opted

Member Advisory Non-voting Members: Mark Bakewell (MB) Deputy Chief Finance Officer In attendance: Colette Morris (CMo) Locality Development Manager Tom Knight (TK) Head of Primary Care – Direct Commissioning

NHS England Hannah Hague (HH) Healthy Liverpool Programme Lead: Urgent &

Emergency Care Paula Jones Committee Secretary Observing: Laura Middleton PriceWaterhouseCoopers Apologies: Dr Adit Jain (AJ) Out of Area GP Advisor

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Sandra Davies (SD) Director of Public Health Simon Bowers (SB) GP/Governing Body Clinical Vice Chair Scott Aldridge (SA) Primary Care Co-Commissioning Manager Public: 2

PART 1: INTRODUCTIONS & APOLOGIES The Chair welcomed everyone to the meeting and introductions were made. It was highlighted that the public were in attendance but any questions they wished to raise needed to be done via the public Governing Body meeting in writing.

1.1 DECLARATIONS OF INTEREST

There were none made specific to the agenda.

1.2 MINUTES AND ACTIONS FROM PREVIOUS MEETING ON

18TH OCTOBER 2016 The minutes of the 18th October 2016 were approved as accurate records of the discussions which had taken place subject to the following amendments:

• The date of the next meeting was 20th December 2016 as the November meeting was cancelled. The minutes would be changed to clarify this.

1.3 MATTERS ARISING NOT ALREADY ON THE AGENDA – Verbal

1.3.1 It was noted that all the actions from the previous meeting

were on the agenda.

1.3.2 Re Action Point Four JW clarified the matter in the minutes for item 4.1 Primary Care Performance Report in which Walton Village Medical Centre was reported as being “Good” for Safe and Caring and then “Requires Improvement” for Safe in the report submitted to the Primary Care Commissioning Committee and about which the members had asked for clarity. She noted that Walton Village Medical Centre “Required Improvement” re the domains of “safe” and “Well Led” and Walton Medical Centre was rated as “Good”. The Primary Care Team

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was working through an action plan with Walton Village Medical Centre.

The Primary Care Commissioning Committee:

Noted the issues raised under matters arising.

PART 2: UPDATES 2.1 PRIMARY CARE SUPPORT SERVICES – VERBAL

TK updated the Primary Care Commissioning:

• Work was on-going with Capita re the implementation plans for the improvement to service.

• There had been positive movement overall in most areas

but there were still causes for concern.

• Patient Data: additional staff had been recruited to meet recovery actions.

• Medical Records: there had been improvement, there were

issues nationally, new couriers were in place and a great deal of work carried out around reconfiguration but there were still issues, however not as many as before.

• Performers List – there was a significant focus on the

backlog, all GP Registrars for 2015/16 were not on the Performers List, there had been a great deal of hard work to achieve this positive result.

• Optometrists – work was on-going nationally re payments,

etc.

• Dentistry – there were Performers List issue and NHS England had looked at extending the window period for Dental registration.

• Locally NHS England had taken back GP Retention for new GPs therefore putting capacity back into Capita who would be free to concentrate on the bigger issues.

• GP Payments – there were still issues and NHS England

was working closely with the Capita Finance Team.

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• Customer Support Centre Leeds: this had now been significantly re-designed and additional assurance given by Capita about better database management and quality of information. Locally however there were still reports of dissatisfaction. Nationally 50% of calls were being resolved the same day. The comments raised by RB had been escalated to the national commissioning team around conversation with Capita being one way only and that Capital needed to be more pro active, additional offices had been opened in Blackburn.

• Supplies: this seemed stable both locally and nationally.

RB felt that the report from TK was fair and that matters were moving in the right direction, however there was great frustration among the Practice Managers and delays in payments to practices could cause severe cash flow problems. There were also issues still with the couriers that they would collect from branch surgeries but would not deliver to them. TA commented that lack of “noise” from practices did not mean that there had been improvement, there were still delays on the transfer of medical records however practices were finding ways to work around the difficulties which resulted in a higher workload. ST added that the Capital Communications Team did not respond to queries from Healthwatch. KS asked what the Primary Care Commissioning Committee role should be in this matter in keeping up the pressure on NHS England and reducing the impact on practice staff with regards to their own performance monitoring. It was noted that the CCG had already written officially to NHS England and there had been some improvement but not enough. MW expressed concern that Capita had not been creative in trying to find their own solutions to the problems. She asked if this should be referred to the NHS England Audit Committee. KS asked about involving local MPs and informing them of the difficulties practices were working under in the light of potential patient safety issues with their constituents. It was noted that Luciana Berger Chaired the Select Committee for Health. NF had a meeting with Luciana Berger in the diary for

January 2017 and would use that opportunity to raise the issue with her. TK responded that the NHS England Executive Director was leading on this. A local CCG had carried out a survey and asked if the Primary Care Team at the CCG wanted to do something similar with practices and then the responses could be

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shared which would be a useful tool. CM agreed that this should be co-ordinated by TA and the practices. TK also noted that Dr Raj Patel, Medical Director at NHS England Lancashire & Greater Manchester, was looking at the impact on patient safety. It was agreed that Liverpool CCG would feed through their concerns to him.

The Primary Care Commissioning Committee: Noted the verbal update.

2.2 FEEDBACK FROM SUB-COMMITTEES – REPORT NO: PCCC 30-16

• Medicines Management Optimisation Sub-Committee –

PCCC 30a-16 JW updated the Primary Care Commissioning Committee on

matters discussed at the meetings in November and December 2016:

Effective Use of prescribing resource – Phase One savings

extended until end of March 2017. Additional drugs had been added to the pilot programmes and rollout of Phase 2 delayed from January 2017 to April 2017.

Prescribing Rebate Scheme – this would generate £150k

per annum from Seratide.

Transfer of prescribing from Secondary Care of Irrigation Pumps – this needed to go back to being the responsibility of Secondary Care and not be prescribed by General Practice.

Governance of Non-Medical Prescribers re Liverpool

Community Health – governance process to go to Medicines Management Optimisation Sub-Committee for review and to give assurance to the CCG that appropriate measures were in place.

KS asked why only three of the nine pilot sites were to go ahead re the Phase Two savings. The response was that there would be all nine going ahead but only three at present were ready to proceed. KS asked for PJ to provide a more detailed update on

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progress at the next meeting on each Phase and where progress was up to. KS queried the issue of Irrigation Pumps. PF explained that this was mostly for patients with spinal injuries and that the expertise required was outside of the GP’s remit. KS asked about how to take the discussions forward with Secondary Care. TJ referred to the contracting process currently being undertaken for sign off before Christmas and using it for clarity on where responsibilities lay with a clinically led joint approval between Secondary Care and Primary Care re prescribing. MW pointed out the disparity of prescribing between geographical areas. RB noted that not in Liverpool, but in other areas GPs had no control over switching medication prescribed by Secondary Care i.e. from branded to generic. NF added that with high cost drugs prescribing there were clear clinical pathways which should be adhered to by Secondary Care.

• Primary Care Quality Sub-Committee – PCCC 30b-16 RK updated the Primary Care Commissioning Committee on the meeting held in October 2016:

Locality Meetings were now quarterly and attended by the

CCG Leads only not the Programme Leads. There had been two meetings focussing on hypertension and asthma and one was coming up on prescribing. Feedback from the new style meeting was very positive and GPs were well engaged.

Liverpool Quality Improvement Scheme – Minor Surgery:

Liverpool had its own Local Enhanced Service which did not align with the dermatology re-design. A full review of the current scheme was to be undertaken, this follow due processes within the CCG Governance.

Digital Roadmap – Primary Care Transformation – there

had been a well-attended members’ Event. The GP Forward View needed to signal plans for e-consultation and e-bookings.

The Primary Care Commissioning Committee: Considered the report and recommendations from the Sub-

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PART 3: STRATEGY & COMMISSIONG There were no items for discussion under this section.

PART 4: PERFORMANCE 4.1 PRIMARY CARE PERFORMANCE REPORT - REPORT NO:

PCCC 31-16 RK presented the performance report to the Primary Care Commissioning Committee and highlighted:

• General Practice Patient Survey – the Primary Care Team were working with the lower performing practices.

• E-referrals: performance was Red and was part of the

Quality Premium, to improve this work was required with the trusts, to improve their Directory of Services and slot utilisation issues. The Planned Care Team was meeting in January 2017 with all trusts and working closely with them to improve their Directory of Services.

• Access: provision of 80 appointments per 1,000 weighted

practice population per week target was met by 78 practices. Work was ongoing to produce an automated system to produce the data on appointments. It was noted that six practices were currently part of a pilot with EMIS and hopefully the automated system could be rolled out before April 2017.

• Ambulatory Care Sensitive (‘ACS’) Admissions: ‘Flu Group

was meeting and would continue to resource practices. Pulmonary Rehabilitation referrals in one practice had gone from 10% to 100% thanks to the hard work of the Primary Care Team.

• Outpatient Referrals: there had been an improvement

although there were issues with Urology. The Teledermatology pilot had not yet commenced, this should have been started before Christmas and the issue had been escalated to the Community Board.

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• Alcohol Consumption – patients being offered brief interventions due to their level of alcohol intake had decreased.

• Vaccinations and Immunisations: relatively stable, the

vaccination lead was visiting all practices to help them manage their lists.

• Medicines Management – 4 practice targets were not

achieved: monitoring of lithium levels, antipsychotics in dementia, beta blockers in asthma, thiazides in Addison’s disease. It was noted that prescribing was driven by specialist services. All patients had been reviewed in 2015-16 and primary care was unable to have a further impact on numbers. The CCG was not currently meeting the target for 5% antibiotic reduction against baseline.

KS noted that it was good to see the number of practices achieving Band A for ACS Admissions. CM added that there were 31 practices achieving Band A, it was agreed that for the next few months the focus would be on COPD and Blood Pressure so hopeful this would increase to approximately 50 practices in Band A. With regard to the Teledermatology Pilot KS agreed to chase this up with John Graham, Finance Director at the Royal Liverpool Hospital. MB referred to the Financial Recovery Plan and that it was only by March 2017 that we would be in a position to now the financial position. PF asked if “Advice and Guidance” was live now or to go live in April 2017. RK responded that it should be live now as the technology was ready but currently there was no one at the trust end to respond. JL referred to Significant Event Analysis, it was felt that this should align to the Serious Incident Reporting. RK noted that there was a new Chair for Quality Surveillance Action Group (‘QSAG’) and that she would email JL for to arrange a meeting for the new QSAG Chair with JL. MB spoke to the Primary Care Commissioning Committee about the financial performance aspect of the report:

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• Over-performance against budget variance year to date was £2.4m overall.

• Over-performance year to date on prescribing was £2.1m

although this would hopefully be reduced to £1.2m by the year end. Information held so far was up to Month 6 therefore by Month 7 we should see the impact of the prescribing schemes.

KS referred to evaluation of the GP Specification and the need to carry out an evaluation of the six years that it had been in place for over the next nine to ten months. CMo noted that this was being done as part of the Collaboration for Leadership in Applied Health Research and Care (‘CLAHRC’) and would be completed in a few months’ time.

The Primary Care Commissioning Committee: Noted the performance of the CCG in delivery of Primary

Care Medical commissioned services and the recovery actions taken to improve performance

PART 5: GOVERNANCE 5.1 RISK REGISTER – REPORT NO: PCCC 32-16

CM presented the Risk Register to the Primary Care Commissioning Committee. She noted that Mersey Internal Audit Agency had written a report looking at the accountability and responsibility of each delegated function which would form the basis of the formal Service Level Agreement to be produced in February 2017 between the CCG and NHS England which would be brought to the February 2017 formal Primary Care Commissioning Committee meeting.

The Primary Care Commissioning Committee:

Noted the content of the report and the mitigating actions

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6. ANY OTHER BUSINESS

None

7. DATE AND TIME OF NEXT MEETING Tuesday 21st February 2017 - 10am

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NHS LIVERPOOL CLINICAL COMMISSIONING GROUP FINANCE PROCUREMENT AND CONTRACTING COMMITTEE

MINUTES OF MEETING HELD ON TUESDAY 21ST FEBRUARY 2017 10AM TO 12.30PM

ROOM 3, LIVERPOOL CCG, THE DEPARTMENT, LIVERPOOL, L1 2SA

Present Nadim Fazlani (NF) Chair Katherine Sheerin (KS) Chief Officer Maureen Williams (MW) GB Member -Lay Member –

Governance/Deputy Chair Dave Antrobus (DA) GB Member – Patient Engagement Lay

Member Maurice Smith (MS) GB Member – GP In Attendance Mark Bakewell (MB) Deputy Chief Finance Officer Derek Rothwell (DR) Head of Contracts, Procurement & BI Tony Woods (TW) Programme Director Digital & Community

Care Jamie Hampson (JH) Governing Body Prescribing Clinical Lead

(item 4.1 and 4.2 only) Zafi Bisti (ZB) HR Manager (item 4.1 and 4.2 only) Paula Jones Committee Secretary (Minutes) Apologies Tom Jackson (TJ) Chief Finance Officer Tina Atkins (TA) Practice Manager Ian Davies (ID) Chief Operating Officer Part 1: Introductions and Apologies NF chaired the meeting and introductions were made and apologies were noted. He welcomed Dr Jamie Hampson who was attending to present the Catheter and Stoma Supply Management paper (4.1) and Zafi Bisti who was assisting in answering HR questions arising from the Pensions paper (4.2). For this reason these items would be taken first so that they did not need to stay for the whole meeting.

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1.1 Declarations of Interest

There were no declarations of interest made specific to the agenda.

1.2 Minutes and action points from the meeting on 24th January

2017.

The minutes of the meeting on 24th January 2017 were accepted as an accurate record of the discussions which had taken place subject to the following amendments requested by KS:

• DR was to provide a clarifying form of words to amend Matters Arising 1.3.1 Supportive and End of Life Care Service Ratification of Procurement Decision from November 2016 page 3 second paragraph around QIPP savings delivery schemes.

• From item 2.1 Telehealth Technology Service Procurement page 8 the recommendation was amended to read “to cancel the procurement award and rerun the ITT procurement. This is based on the legal advice and the risk of incurring significant legal costs”.

• From item 3.1 Finance Update December 2016 Month 9 –

page 15 second paragraph to amended to say that delivery of the required savings was a risk and that KS had sympathy with what MS was highlighting.

• From item 4.2 Contract Update Month 8 – page 20 next to

last paragraph – DR to supply a form of words to clarify use of St Helens and Knowsley Hospital services by Liverpool practices re use of out of area providers.

1.3 Matters Arising Not already on the Agenda

1.3.1 Liverpool Community Health Update: KS noted that the CCG had written to NHS Improvement expressing its concerns over the pause in the transaction process. An Extraordinary meeting of the Finance Procurement & Contracting Committee had been convened on Friday 10th

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February 2017 with only non-conflicted (i.e. not GP or practice staff) members attending to discuss the response the CCG was to make and would meet again after the meeting that day to review the process.

1.3.2 Action Point One –. Supportive and End of Life Care Service

Ratification of Procurement Decision from November 2016. DR confirmed that he had contacted the provider to ask to extend the current contract for 3 months whilst a decision was made. Patients were on a 12 week pathway. TW noted that he was still working on a QIPP Savings Report. It was noted that the February 2017 meeting had been changed from 28th February 2017 to 21st February 2017.

1.3.3 Action Point Two – Telehealth Technology Service

Procurement – DR updated the Finance Procurement & Contracting Committee that Mersey Internal Audit were now involved around the challenge to the Invitation to Tender received and the putting together a new process and evaluation panel. Lessons needed to be learnt from the original procurement process and we were working closely with the Digital Team. It was vital to ensure that information was shared equally with all parties in the process to ensure that the process was open, honest and transparent.

1.3.4 Action Point Three – it was noted that the outcome of the

Deployment of Digitally Enabled Community Services Senior Management Team discussion had been reported to Dave Horsfield.

1.3.5 Action Point Four – it was noted the Emergency Care

Improvement Programme Whole System Enquiry Visit report had been discussed at the Governing Body.

1.3.6 Action Point Five – it was noted that DR was reviewing the

use of St Helens and Knowsley out of area services by Liverpool practices.

1.3.7 Action Point Six – KS noted that she was raising the issue of

Bariatric Surgery tariff at the appropriate meetings.

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Part 2: Updates There were no items for discussion in this section. Part 3: Performance 3.1 Finance Update January 2017 – Month 10 Report No: FPCC

09-17

The Deputy Chief Finance Officer (MB) presented a paper to the Finance Procurement & Contracting Committee summarising the CCG’s financial performance for the month of January 2017 (month 10) in respect of NHS England Business Planning Rules regarding in-year surplus position and treatment of non-recurrent headroom and an assessment of the risk to the delivery of the forecast surplus position given current/required mitigating actions as identified within the Financial Recovery Plan shared with NHS England. He highlighted:

• The CCG was on track to deliver the NHS England planning rules with the delivery of the 1% surplus and 1% non-recurrent headroom totalling £16m.

• The Business Rules performance had therefore changed

slightly for the better with the CCG showing as Green for delivery of the Surplus, 1% non-current headroom and running cost allowance.

• For Month 10 an additional allocation from NHS Property

Services income had been received re the move to market rents. The second tranche of Children and Adolescents Mental Health waiting list monies had been received, as well as Vanguard funding.

• The CCG was currently reporting over performance of £7.6m

against budgeted expenditure. Acute contract performance was stable, community services were usually on a block contract or via Any Qualified Provider. Continuing Healthcare was overspent and there was over-performance

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in the Children and Adolescents Mental Health budget, increased Learning Disabilities expenditure and mental health contract provision. Local Authority costs had increased and there was an increase in volume and backlog catch up.

• Primary Care – there was over-performance in budgets

(including co-commissioning, Local Enhanced Services and GP Specification). Prescribing had held steady year to date but at the year-end a reduction was anticipated.

• Running Cost Allowance – slight under-spend due to

reserves held.

• Acute contracts – two had been fixed for the year end (Aintree and Liverpool Women’s) and the Royal had since been finalised. DR added that Alder Hey would follow shortly.

• Financial Recovery – Phase One and Phase Two savings

were required to deliver the forecast outturn position. Phase One was the Quarter 2 work with £6.5m of savings identified, Phase Two was the Quarter 3 work of an additional £7.4m of savings to deliver the £16m. Of this £1.5m had been delivered and there were no more savings which could be made.

• Financial Risks to Delivery – between Month 9 and Month 10

the planning gap had moved from £8.1m to £0 via £0.5m move in the forecast outturn position, allocation of NPFIT monies of £4.6m and Liverpool City Council invoice £4m. However this was at the expense of the 2017/18 funding planning.

• Balance Sheet – the cash target for January had been

achieved with a cash balance of £16k which was below the 1.25% target.

• Better Payment Practice Code, the target had not been

achieved for January 2017 but this should be achieved by the year end.

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MS raised the issue of highlighting at the committee the risk of the measures to achieve the forecast outturn position on the financial planning position for 2017/18. It was noted by MW that this was part of the Risk Register which was on the agenda. MB noted that the Finance paper to the Finance Procurement & Contracting Committee was a fluid document subject to constant movement and not a statement of risk. KS noted formally for the minutes that this had been discussed in detail at the private session of the Governing Body meeting on 14th February 2017. The NHS Liverpool CCG Finance Procurement & Contracting Committee: Noted the current financial position and risks associated

with delivery of the forecast outturn position, Noted the stated assumptions regarding proposed

recovery solutions to deliver the required business rules based on current forecast outturn assumptions.

Part 4: Strategy & Commissioning 4.1 Catheter and Stoma Supply Management Service Report No:

FPCC 10-17

JH gave a presentation to the Finance Procurement & Contracting Committee to accompany the paper seeking the views of the Committee on the proposed approach to address the increasing prescribing costs for Catheter and Stoma appliances. He highlighted:

• Phase 4 - Liverpool CCG Prescribing Effectiveness Plan (FEP)

• Prescribing costs for Catheter and Stoma appliances in

Liverpool were over £4M per annum rising at up to 10% per year.

• The Medicines Optimisation Sub-Committee (MOC)

proposed to remove the responsibility of prescribing these

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appliances away from General Practice into a specialist service.

• The aim was to reduce prescribing waste and provide a

review service for patients to improve quality of life.

• The service would require an initial investment of approx. £90k rising to £310k (recurrently).

• Estimated costs savings of £1M to £1.6M per annum (25%-

40%).

• This would improve quality of life for patients, small number of patients involved (around 4,000) but this represented 5% of total prescribing budget.

• Currently patients were seen by specialist nurses in hospital

and then discharged to GP practices who had no expertise or real knowledge of this area.

• Generally patients would opt for a Dispensing Compliances

Contractor for convenience and discretion of supply as they specialise in home delivery services using unmarked vehicles.

• The Medicines Management Optimisation Sub-Committee

had a preferred option (Option 3) of a two stage approach:

o Year One: have supply management follow up and

establish a comprehensive patient register. Build and maintain a register of all catheter and stoma patients

Provide a proactive service in line with patient need

Scheduled calls to patients / carers using a series of set screening questions to determine current stock levels and patient need

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Prescription requests to GPs clearly indicating the product code and quantities required for each item

Signpost / refer patients to specialist advice and support using existing services where required

o Year Two – Specialist Nurse Led Service: • Establish a programme to ensure all patients

received an annual review of their products and appliances, including house bound patients

• Direct patient access to specialist nurse advice and support where patients might be experiencing difficulties with products and appliances

• Transfer of Catheter/Stoma prescribing budget from primary care

• Issuing of FP10 prescriptions and transmission to the patient choice of CP or DAC for dispensing/delivery.

• Cost for Option 3 was Year One £72k, Year Two would

increase to recruit 2 x Band 7 Specialist Nurse Prescribers. Potential savings after five years could be around £6m and we also would have a better service.

• Advice was sought from the Finance Procurement &

Contracting Committee on how to proceed and what route to follow vis a vis procurement. Patient Engagement would also needed to be carried out.

The Finance Procurement & Contracting Committee members commented as follows:

• MW asked about the rising costs of catheter and stoma products, JH noted that this was detailed in the paper at over 10% per annum also as the population aged demand was increasing. Other CCGs such as Rotherham and Bury CCGs had taken this approach and it had worked well. It was confirmed to MW that it was whoever was providing the service who would employ the specialist nurses. MW was

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not convinced about how significant the savings would actually be. She also referred to the Exit Strategy referred to in the paper and was adamant that the service should not have the option for a two year contract extension after the three year contract came to an end. She was also concerned that this felt like privatisation as in a procurement process any organisation could tender, however JH felt that it would probably be existing staff who would provide this and as patients exercised choice in choosing the companies who supplied the products (Dispensing Compliances Contractor) this could not be viewed as a move towards privatisation.

• KS felt that for the funding involved a procurement process

was not the most practical and cost-effective way forward and that some form of Risk Sharing Agreement should be put in place. DR agreed that this was the most practical format with the use of a pilot scheme in the first instance over a couple of years.

• DA felt that this was all good in principle, his concern was

engagement with South Sefton and Southport & Formby CCGs and the lack of information received and that we needed to avoid doing something new when an existing format was already working well which we were not aware of.

• MS referred to the principles of RightCare prescribing

agenda and the need to specify outcomes desired and the need for a clinical support service. JH responded that going directly to some pharmacies and not others for advice in this area would upset other pharmacies. DR agreed that the best route was to go for a pilot with one provider.

JH agreed to go back to Southport & Formby CCG to reference their approach to this area. MW noted that she was pleased to note the potential for improvement in patient experience but given she was not completely convinced on how significant any cost savings would be, given that it had already been noted that demand was increasing as the population aged, she would like the proposal to come back to the Finance Procurement & Contracting Committee.

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The NHS Liverpool CCG Finance Procurement & Contracting Committee:

Noted that this formed part of the Prescribing Financial

Effectiveness Plan (FEP) to reduce prescribing waste Considered the options described within the attached

business case and note the level of investment required for each of these options

Provided a recommendation of a preferred option to the MOC via the pilot route but requested that the proposal be brought back with more detail..

Part 5: Governance 5.1 Auto Enrolment And Workplace Pensions Report No: FPCC

11-17

MB presented a paper to the Finance Procurement & Contracting Committee on the changes in pension regulations which now required all employers to auto-enrol all eligible workers in a workforce pension. The CCG was required to have this in place by 1st July 2017, although it had an option to delay this until 30th September 2017, given that the organisation did have a large number of staff it was recommended not to take up this delay option and comply by 1st July 2017. Auto-Enrolment also required employers to offer an alternative scheme to the workplace scheme which for public sector/NHS was the National Employment Savings Trust (‘NEST’). There were currently 138 members of CCG staff in the NHS Pension Scheme, with 20 identified as not. Of these 13 were eligible for the NHS Pension and would be auto-enrolled on 1st July 2017, 2 who were not eligible for the NHS Pension but satisfied the criteria for NEST and would be auto-enrolled into NEST on 1st July 2017 and 5 who were not eligible for either scheme as they were below the minimum qualifying earnings. The cost to the CCG was based on estimated annual salary costs of £466k (the paper was incorrect in

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stating this was the actual cost of the pension contributions) and so would be around 14% of the total salary cost of £466k per annum. MW referred to NEST and noted from personal experience that individuals could be registered for NEST and then opt out for 3 years. It was agreed by the Finance Procurement & Contracting Committee to approve the recommendations in the paper but also for a Pensions Working Group to be set up.

The NHS Liverpool CCG Finance Procurement & Contracting Committee agreed that:

The CCG did not utilise the postponement period of auto

enrolment for relevant staff groups.

The CCG did not utilise the Transitional Period for defined benefit pension schemes and delays auto enrolment until 30th September 2017.

The CCG did appoint NEST as its Auto Enrolment Alternative Qualifying Pension Scheme provider with effect from 1st July 2017.

The Alternative Pension Scheme contribution rates were set in line with the Pensions Regulator minimum percentage contribution rates.

The CCG needed to identify leads and monitor delivery of requirements through joint HR / Finance Working Group.

5.2 Finance, Contracting & Business Intelligence Risk Register

Report No: FPCC 12-17

The Finance Contracting and Procurement Committee considered the Finance, Contracting & Business Intelligence Risk Register. MB highlighted:

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• Risk F08 (successful Liverpool Community Health transaction) had been increased as a Result of the Bridgewater pause.

• Risks Removed: o F05 (internal/external financial reporting) – training now

completed and reporting arrangements being reviewed. o F11 (Compliance with Information Governance

policies) – Audit Tender completed o C11 (Contract Sign Off) – Acting as One Contract

negated tariff risk.

The Finance Procurement & Contracting Committee commented as follows:

• DA referred to the need for clarity around the initials for Dyanne Aspinall re the risks allocated her which were labelled DA. Also asked why risk C01 which referred to the transaction of Liverpool Community Health Services was not listed for removal when F08 was. MW commented that F08 was rated at 16 and she felt this was low. TW agreed that this needed to be looked at. KS commented that there were two separate risks in the transaction process, one was the financial risk and the other was the safe transaction of services and that these needed to be split with the financial risk being higher at 20 and the risk to services being correct at 16.

• KS referred to risk C04 contract sanctions with Royal

Liverpool Hospital 2015/16 and the link to C05 paying the Royal Liverpool Hospital for System Resilience Schemes. The contract offer just agreed excluded the 2015/16 numbers.

• MW asked if risk F13 reporting on the Better Care Fund

should be re-examined in the light of discussions at the Audit Risk & Scrutiny Committee. MB responded that this was all about validating the demand led activity/changes in order to authorise bill payment so had been put into the Better Care Fund agreement. More and more clarity was being obtained providing more assurance.

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The NHS Liverpool CCG Finance Procurement & Contracting Committee:

Noted the contents of this report. Considered current control measures and whether action

plans provide sufficient assurance on mitigating actions. Agreed that the risk scores accurately reflect the level of

risk that the CCG is exposed to given current controls and assurances.

Noted that the Liverpool Community Health transaction risk should be split between financial (at risk score 20) and safe transaction of services (at risk score 16) and that TW was to look into this.

6. Any Other Business

None

7. Date and time of next meeting

Tuesday 28th March 2017 Room 2 10am The Department Lewis’s Building L1 2SA.

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NHS LIVERPOOL CLINICAL COMMISSIONING GROUP QUALITY SAFETY & OUTCOMES COMMITTEE

Minutes of meeting held on Tuesday 7th March 2017 at 3pm Boardroom, The Department, Lewis’s Building

Present Dave Antrobus (DA) Chair/Lay Member Jane Lunt (JL) Head of Quality/Chief Nurse & Vice

Chair Katherine Sheerin (KS) Chief Officer Fiona Lemmens (FL) GP Governing Body Member Shamim Rose (SR) GP Governing Body Member Donal O’Donoghue (DOD) Secondary Care Clinician Rosie Kaur (RK) GP Governing Body Member In attendance Andy Woods (AW) Senior Governance Manager South

Sefton CCG (Merseyside Equality and Inclusion Service)

Kerry Lloyd (KL) Deputy Chief Nurse Julia Burrows((JB) Quality Manager Peter Johnstone (PJ) Primary Care Development Manager Mavis Morgan (MM) Patient Representative Sarah Thwaites (ST) Healthwatch Kellie Connor (KC) Quality Manager Monica Khuraijam (MK) Governing Body GP/Clinical Lead for

Spire Rachael Gosling (RG) Public Health Representative

Liverpool City Council Lynne Hill (LH) PA/Minute Taker Apologies Margaret Goddard (MG) Named GP for Safeguarding Denise Roberts (DR) Clinical Quality & Safety Manager Paula Jones (PJ) Committee Secretary

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Part 1: Introductions & Apologies

1.1 WELCOME & INTRODUCTIONS The Chair welcomed everyone to the meeting and apologies were noted. 1.2 DECLARATIONS OF INTEREST There were no declarations made specific to the agenda. 1.3 MINUTES AND ACTIONS FROM 7th FEBRUARY 2017 The minutes from the meeting held on the 7th February 2017 were approved as an accurate record of the discussions which had taken place subject to the following amendments: Page 11, 1st paragraph to read:

Going forward in the next financial year, the CCG Healthcare Acquired Infections Programme Manager was to explore the provider organisations’ use of patient satisfaction survey in relation to infection to capture patient experience to provide a quality measure.

In line with future Quality Premium requirements, the CCG will be working with providers to deliver a 10% target reduction in E-coli blood stream infection.

Page 13: 1st bullet point to read: JL noted that as Liverpool CCG was the co-ordinating commissioner for so many organisations, it was disappointing that the Trusts were having such difficulties in meeting the reporting timescales. This is a Trust specific target, rather than a target relating to Liverpool CCG performance, in line with the national timescales relating to the Serious Incident Framework (SI).

Action Point 3 to read: From item 4.1 Spire Health Care Quality Profile – JL to identify an appropriate /regular LCCG GP to attend the LWH CQPG alongside Jane Lunt.

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1.4 MATTERS ARISING NOT ALREADY ON THE AGENDA

1.4.1 Action Point One - Provider Cost Improvement Plans is on today’s agenda.

1.4.2 Action Point Two - MIAA report not yet received and will be

presented at the next available meeting (April 2017).

1.4.3 Action Point Three - amendment to the action point which should read: Spire Health Care Quality Profile – JL to identify an appropriate / regular LCCG GP to attend the LWH CQPG alongside Jane Lunt.

1.4.4 Action Point Four – Presented at today’s meeting in the Quality ‘Must Do’s’ update. Completed.

DA (Chair) suggested a change to the agenda order to enable Andy Woods (AW) to attend to present his report (QSOC 15-17). This was agreed by the Committee. Part 5: Governance 5.2 EQUALITY AND DIVERSITY LCCG ANNUAL REPORT AND

EQUALITY OBJECTIVE PLAN 2017-2020 REPORT NO: QSOC 15-17

Andy Woods (AW) presented the Equality and Diversity Annual Report and Equality Objective Plan to the Quality Safety and Outcomes Committee. That Quality Safety & Outcomes Committee is asked to: Note the Equality and Diversity Annual report (Appendix A); Note LCCGs approach to Equality Delivery Systems 2 (EDS2)

assessment (Appendix A section two);

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Approve the 3 year Equality Objectives Plan in light of the EDS2 assessment (Appendix A, section three);

Note the NHS England EDS summary Report (Appendix B); Note the workforce Equality Plan which was approved by the

Human Resource Committee in January 2017. (Appendix A, section five).

Note the CCG approach Quality Delivery System 2. AW drew the Committee’s attention to the Draft Equality Objectives plan, which is a CCG specific duty and the plan includes (Appendix A section 3), Appendix B is an NHS England Summary report. AW stated that the key issue for the Committee is the Equality Objectives Plan. AW highlighted that there is an omission in the Annual Report which relates to the grading from the Royal Liverpool Hospital. However, there were no issues to highlight. The Equality Objective Plan is detailed on page 146 onwards of the report. Engagement has taken place with organisations that represent the views of people with protected characteristics at a national, regional and local level. The following queries were raised by the Committee: Mavis Morgan (MM) highlighted page 162 and commented that the layout was confusing, queried the ticks on the page and she did not understand the colour coding. AW explained that the toolkit can be confusing to read however all CCGs have gone through a robust process in terms of the details and evidence on the Equality Plan and the LCCG is achieving on the requirements of the toolkit and progressing and improving. Concerns have been highlighted on the toolkit design at various meetings. KS stated that the information is condensed into ‘screenshots’ and the main results are on pages 144 and 145 so need to be cross referenced. KS suggested for the Governing Body that a box be put around it, so as to show what LCCG has achieved and this should make it clearer.

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Action: Andy Woods to update the Plan for the Governing

Body and put a box around those that Liverpool CCG have achieved.

KL queried area 4.2 “Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination” and how can we demonstrate we work in a culturally competent way if staff are not usually exposed to those characteristics. AW stated that we have had a HR Plan agreed at a HR Committee on the Equality Objective Plan and we are looking at bringing this area into greater focus and it being Equality Impact Assessed. AW outlined the current process for legislation and how this is filtered through the toolkit and worked through so as to align with the requirements of the Equality Act. AW reported that his team focus on the legislation and ensure it meets the EDS 2 and ensure it goes through a robust process. They are trying to improve on this, the EDS landscape does skew the information, and however, they are working through this to make it understandable and to evidence the relevant areas. MM asked if managers have appropriate Equality training. KL and KC confirmed that Equality Training is mandatory requirement. RK commented that this is a robust report, however queried what is it trying to tell us and what does “Good” look like, and is the CCG serving the diverse groups better than before. AW stated that there is a need to focus on the Equality Objective Plan, as this is where the community groups would have highlighted any issues in services. It was acknowledged that as we will be going through a difficult commissioning round, we need to ensure during our decision making processors that we do not discriminate against minority groups and that we are not leaving any groups behind, and that we have appropriate processors in place.

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KS commented that this is an Annual Report and it should describe how much progress has been made throughout the year. KS highlighted the appendices and suggested that it may be better to have Appendix 1 and 3 together (EDS) and Appendix 2 (Equality Objective Plan) separate, so that it is more understandable. Also the plan needs to reflect which organisations and groups have been included in the development of the plan. KS asked how does Liverpool CCG benchmark and where do we need to focus our energy on improvements. AW stated the key areas that need to be addressed are in the EDS and Equality Objectives and are the core gaps, for example: Effective Translation and Interpretation Culturally Competent Staff Being able to offer reasonable adjustments Day to day decision making and ensuring that funding is going to

those in priority need and taking into account the legislation. AW confirmed that the Committee is asked to approve the Equality Objective Plan and then Governing Body will be asked to approve the Annual Report once the amendments to the report have been finalised. DA highlighted page 139 and requested a change from ‘Board’ to ‘Governing Body’. This report should give reassurance to the public, however acknowledged it is difficult giving this the levels of reassurance needed when utilising a toolkit type design. MM asked if gathering information has been undertaken in a consistent manner each year. AW explained the process of gathering information and the robust legislation being followed. The appropriate organisations and groups have been approached for information and this has been approached in a consistent way. MM queried how all the organisations and groups involved will receive the outcomes of the report. AW stated that this information will be on the CCGs website and will be provided to the groups they have been working with.

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Sarah Thwaites (SW) highlighted on page 162 that the date appears to be last year’s date and requires amendment. ST highlighted the cultural competencies and assumptions at the operational level and gave some examples of the assumptions that have happened within the work place when caring for people with a disability. The Quality Safety and Outcomes Committee: AW agreed to make changes discussed prior to submission to the

Governing Body. Noted the Equality and Diversity Annual report (Appendix A); Noted LCCGs approach to Equality Delivery Systems 2 (EDS2)

assessment (Appendix A section two); Approved the 3 year Equality Objectives Plan in light of the

EDS2 assessment (Appendix A, section three); Noted the NHS England EDS summary Report (Appendix B); Noted the workforce Equality Plan which has approved by the

Human Resource Committee in January 2017. (Appendix A, section five).

Noted the CCG approach to Equality Quality Delivery System 2. Andy Woods (AW) left the meeting. Part 2: Updates 2.1 Quality Safety & Assurance Group Quarterly (QSAG) Update Peter Johnstone (PJ) gave a verbal update to the Committee and stated that the QSAG has not met prior to this meeting and will report back at the April 2017 Quality, Safety and Outcomes Committee. PJ reported that a number of complaints regarding the practices have gone to NHS England and they have forwarded on to the CCG for appropriate action. Discussion is taking place to clarify each organisations’ role and responsibility to ensure an effective process.

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SR stated that there appears to be no line of accountability and we need to know what the QSAG remit is. JL stated that other parts of the system do have a propensity to use the CCG as a backstop. The process needs clarification with NHSE however, we need to review the complaints and see what themes are coming up and how we can support practices to address or improve on those areas. KS acknowledged that the issue cannot be resolved at this Committee meeting, however we need clarity on the role and responsibilities from NHSE and need to be clear on the process and a meeting should be arranged to discuss further. KL stated that she has arranged a meeting with another a GP from West Cheshire who is looking at implementing a ‘Human Factors’ approach to SEA and has invited them to meet with Liverpool CCG and will extend the invite to SR and PJ. It is envisage that the GP will be invited to a future QSAG meeting. Action: PJ/SR/JL to meet to address the process and make it

more formal. The Quality Safety and Outcomes Committee: Noted the update; and A meeting to be arranged to explore and formalise the

arrangements Part 3: Strategy and Commissioning 3.1 PERSONAL HEALTH BUDGETS REPORT NO: QSOC 11-17 JL presented the report to the Quality Safety and Outcomes Committee highlighting that Mersey Internal Audit Agency (MIAA) report was presented to the February 2017 Audit, Risk and Scrutiny Committee. There are a number of recommendations in the report that we need to implement over the next few months to ensure that we have the correct procedures and policies in place to support us in offering Personal Health Budgets to a growing group of patients.

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Overall judgement of ‘’limited assurance” was disappointing, however gives us an opportunity to develop this in our operational plan. Personal Health Budgets (PHB) has expanded to other patient groups along with CHC patient groups and therefore we need the correct policies and procedures in place and having the support systems in place with Finance, Contracting and Quality Teams. There is an action plan in the report and JL and the Deputy Chief Finance Officer (Mark Bakewell) have responsibility for the recommendations and there are some specific references in terms of the Commissioning Support Unit (CSU) and their role. JL commented that the report is brought to Quality Safety and Outcomes Committee to be aware of and be assured that there is an action plan to implement the recommendations within the required time frame. DA commented that the Midlands & Lancashire CSU have been in place since April 2016 and it is disappointing that the policies have not been put in place in that time, in addition the deadlines to achieve this are March 2017. JL confirmed that the deadlines will be achieved and we are working with the CSU to ensure they achieve their remit. Meetings have taken place with the CSU and they are co-operating. DOD commented that lot of effort goes in to the Personal Health Budgets (PHB); however the number of people that use them is small and is therefore disappointing as we cannot get enough statistics to sufficiently review the impact of PHB. There may be an IT enabler for patients to use the PHB. KL outlined the e-market place available and would like to consider this further as a mechanism for Personal Health Budgets (PHB) and the management of the PHB finances. MM asked how patients are made aware of Personal Health Budgets. JL stated that patients that are subject to a clinical assessment for Continuing Health Care (CHC) or a new package of care is offered PHB and is at a point of contact. JL stated that a pilot is being run in Cheshire and Mersey and the impact of PHB is being assessed.

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The Quality Safety and Outcomes Committee: Noted outcome of the review; Noted the activity to implement the recommendations detailed in

the action plan. Part 4: Performance 4.1 COST IMPROVEMENT PLAN REPORT NO: QSOC 12-17 Kellie Connor (KC) updated the Quality Safety and Outcomes Committee on the Cost Improvement Plan and the mechanisms that are in place for review. The paper informs the Committee of a suggested process of CCG approval of provider cost improvement plans and to provide an update on the assurance received in 2016/17. KC explained that the planned process incorporates a number of measures within the quality schedule in the Standard NHS Contract which allows the providers to give us the assurance that it has followed a process which includes Quality Impact Assessment, it has been signed off by their Boards, and the Medical and Nursing Directors are signed up to delivering those priorities, and that they are assured that the relevant risks have been mitigated and the correct governance is in place to take forward for the next 12 months. Through the Clinical Quality Performance Groups (CQPGs) , the CCG has challenged the governance and requested that review of Cost Improvement Plans be part of the work programmes. Documentation is received and these can be reviewed and identifies what systems the Trusts have in place and can assess the impact (either negative or positive) and this can be delved into in the work programme. A check list is in place which we measure compliance against. It is in our gift to challenge the providers and that the providers are taking the correct action and the process is appropriate.

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The paper is brought to the Committee to open the discussion on whether it is the correct vehicle and is undertaking the correct processes to receive assurance. DA highlighted page 53 ‘there must be an appropriate mechanism in place to capture frontline staff concerns’. KS commented that Liverpool CCG has not got a requirement to approve the plans and this is the Trusts’ responsibility. KS stated that the CCG’s responsibility is to make sure providers have gone through that process, and then to monitor to ensure that providers are delivering, in terms of the cost improvements with no negative impact on quality and this is the work of each of the Clinical Quality Programme Groups (CQPG) and reporting up to the Quality Safety and Outcomes Committee. KS suggested there should be an endorsement by CQPGs confirming they are satisfied with the Cost Improvement Programme of each trust and then each CQPG needs to ensure it is monitored throughout the year and reported back to the Quality Safety and Outcomes Committee. KS further suggested that JL write to each provider, based upon the Acting as One contract, what we are proposing in terms of the quality assurance from the CCGs perspective of Cost Improvement Plans. Donal O’Donoghue (DOD) asked if there is a narrative for our service users and can we encourage our providers to publish details of how they spend their funds. Sarah Thwaites (ST) commented if there is a benefit in a collective shared narrative about financial pressures. Rachael Gosling (RC) asked is there an opportunity in the Acting as One contract to have an overview of what the different Cost Improvement Plans and joining up the information and to allow sharing. Action: Kellie Connor (KC) to make amendments to the

process to incorporate the suggestions of the endorsement of the CQPG and monitoring responsibilities.

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Action: Jane Lunt to write to trusts in relation to process and the Cost Improvement Plans.

The Quality Safety and Outcomes Committee: Noted the content of the report; and Agreed for KC to amend the report based on the discussions

taken place at the Quality Safety and Outcomes Committee. 4.2 BRIDGEWATER COMMUNITY NHS FOUNDATION TRUST –

CARE QUALITY COMMISSION REPORT FEBRUARY 2017 REPORT NO: QSOC 13-17

JL updated the Quality Safety and Outcomes Committee and reported that there is a one month pause of the transaction of Liverpool Community Health services and NHSI are looking at the current quality issues in terms of Bridgewater to see if this report has any material impact on this decision. The pause concludes on the 13 March 2017 and some decisions from that will determine next steps. JL tabled the Bridgewater Community Health NHS FT scores matrix and although there are 13 domains that require improvement, there are 26 domains rated as ‘Good’ and one ‘Outstanding’ domain. JL also ‘looked back’ to the previous CQC report in 2014, which was the report used as part of the Trust becoming a Foundation Trust. JL highlighted that the methodology is different between the 2 inspections so not comparing like for like, but some comparisons can be made. JL highlighted the description of the culture within Bridgewater Community Healthcare NHS FT which was reported to be open, patient focussed and staff openly commented on the quality and openness of the line management arrangements in their own organisation. This is in contrast to the CQC report of Liverpool Community Health (LCH) in 2014. In addition, Bridgewater seems to have capacity and capability to make the relevant quality changes and improvements required.

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JL attended the CQC Quality Summit for Bridgewater Community Trust, the Trust were keen to point out that two of the services where they received some criticism was a paediatric service they inherited from another organisation and took on long waiting times and they were in the process of putting this right, plus they host a standalone Community Midwifery Service which came with its own challenges and issues, and specific recommendations made to this in the report, which have been remedied. FL stated that she appreciated the visual evidence (matrix) and the expert opinion from the individuals involved in quality assurance. FL asked how the action plan for Bridgewater Community Healthcare NHS FT will be collated and what the next steps are. JL stated that Bridgewater Community Healthcare NHS FT is subject to regular CQC improvement meetings and work has begun to implement the improvements required. Bridgewater Community Healthcare NHS FT has been collating the evidence to demonstrate this to both CQC and also NHSI. FL queried if Liverpool CCG can see this evidence. JL stated that she has had contact with the Chief Nurse who is being candid, and open and honest and has stated that she is willing to share evidence. Bridgewater Community Healthcare NHS FT is being re-inspected by CQC in June 2017. ST queried if there are no further issues and Bridgewater Community Healthcare NHS FT become the preferred provider will there be a clear messages give on their fitness to provide. A question was asked re the potential impact on the current decision to award GP provider contracts to Bridgewater. This has been via a separate procurement process, and currently there is no impact of this ‘pause’ on the awarding of the contracts. Action: KS to provide a briefing update to Sarah Thwaites

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The Quality Safety and Outcomes Committee: Noted the content of the report.

Part 5: Governance

5.1 REPORT FOR MIAA REVIEWING LIVERPOOL CCG QUALITY ASSURANCE PROCESS FOR LIVERPOOL COMMUNITY HEALTH REPORT NO: QSOC 14-17

JL reported on the paper and gave some background and context with regard to Liverpool Community Health and the interest in the quality of services. This includes queries from one MP which led to a parliamentary adjournment and a request for a clinical review into Liverpool Community Health during the period of the poor quality of services. Dr Bill Kirkup has been appointed by NHS England to lead and undertake the Clinical Review and he has been working with Liverpool Community Health in recent weeks with a team of people. The Terms of Reference highlight to talk to commissioners and commissioners will be approached to provide evidence to the review. Liverpool CCG, South Sefton CCG and Southport and Formby CCG commissioned a Mersey Internal Audit Agency (MIAA) Review on the systems, processes, policies and procedures in place at that time the CCGs came in to place to date. The outcome of the review is that MIAA conclude that there were significant assurance around our systems and processes. This report will form part of the evidence submitted by the CCG to the Clinical Review. There is further significance for this report in that the systems in place for Liverpool Community Health are the same as those used for other trusts and this gives further assurance to the CCG. This will be submitted to the Q3 NHSE Assurance process as evidence. KS commented that this is an important report and should be submitted to the April 2017 Governing Body. However, the title of the report of In needs to be changed for clarity prior to submission to the Governing Body- it is currently not clear what the report is about.

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Action: Quality Safety and Outcomes Committee Agenda title to be updated to include Liverpool Community Health in the title;

Action: GB Feedback template to highlight importance of report and include Liverpool Community Health in the title;

Action: MIAA report to be presented to April 2017 Governing Body and outlining why we received significant assurance on our systems and processes.

The Quality Safety and Outcomes Committee: Noted content of the paper; and The actions detailed in the report to be undertaken.

5.2 EQUALITY AND DIVERSITY LCCG ANNUAL REPORT AND

EQUALITY OBJECTIVE PLAN 2017-2020 REPORT NO: QSOC 15-17

This item was addressed at the beginning of the meeting. 5.3 RISK REGISTER REPORT NO: QSOC 16-17 DA stated that the Governing Body have seen a PwC report that recommends that the risk register report is presented to Quality Safety and Outcomes Committee monthly, however the chair (DA) had previously suggested that the report is reviewed quarterly. DA asked for Committees view on which is correct. KL stated that the suggestions from the Corporate team were that those risks that remain static for three consecutive periods were to be reported on quarterly, and those that have an increasing risk needs to be reported monthly, as well as those that are red or significant. DA highlighted risk Aintree1 – Mortality and if there is a danger we are going backwards as the risk appears to be increasing. KL reported that Mortality rates at Aintree are a consistent agenda item at each CQPG and Dr Paula Finnerty (LCCG) and Dr Peter Chamberlain

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(SSCCG) are closely involved in the mortality work stream within the Trust itself. KL reported that the SHMI was rising as predicted due to an earlier increase in crude mortality. KC outlined that the reason it was rising is because of the similarities of a number of years ago and pneumonia was one of the factors, and that we expected the Trusts to investigate further, this has been flagged again. KL stated in relation to mortality more generally we receive flags from our own internal reporting systems and NHSE also flag up. Dr Julian Hobbs (NHSE) will be looking specifically at mortality and a commissioner event on 9th May 2017 is to consider mortality in more depth and will give another opportunity to review. FL stated that we have high levels of confidence in the systems in place for monitoring mortality for both the CCG and the provider. Discussions at CQPG are open and transparent and Dr Paula Finnerty is up to date on the mortality issues and should be invited to the June 2017 Quality Safety and Outcomes Committee. FL asked if we can reference the minutes of the CQPG or embedded the documents in the risk register. DOD suggested that there should be a way to extract the details with more clarity. JL suggested that a deep dive mortality paper should be brought to the Quality Safety and Outcomes Committee in June 2017 after to two events have taken place by NHSE. RK queried Aintree9. KS stated that this risk needs to stay on the risk register but an update on the narrative is required. DA queried page 173 AldeyHey9, nothing in risk AlderHey9 refers to the Asthma Service and the narrative does not give the reason why it has reduced. KS stated that the report describes Liverpool Community Health and the

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transfer of services to a new provider, this is not detailed on the Quality Team risk register however is on the Corporate Risk Register and needs to be cross-referenced. FL asked how the risks are reviewed within the Quality Team and how often does the Quality Team meet to discuss the risk register. KL stated that Denise Roberts spends a great deal of time reviewing and chasing the details for the risk register with different teams and risks are discussed at various CQPG meetings. DA acknowledged that the Quality Safety & Outcomes Committee had one of the best risk registers available and items are appropriately highlighted within the risk register. KL commented that there is an emerging risk on IPC at Alder Hey and this will be included on the April 2017 risk register. Action: KL Deep Dive on Mortality paper for June 2017 QSOC. Action: Dr Paula Finnerty to be invited to the June 2017

QSOC. Action: KL to update the risk register with correct narrative

for Aintree1, Aintree9 and Alderhey9. Action: JL/KL to cross check the risk register with the

Corporate Risk Register. The Quality Safety and Outcomes Committee: Noted the Risk Register.

6. ANY OTHER BUSINESS No items. 7. DATE AND TIME OF NEXT MEETING Tuesday 4th April 2017 - 3pm – 5pm

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Apologies sent • Fiona Lemmens • Rosie Kaur The quoracy for the next meeting will be checked nearer the time.

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tuesday 11th april 2017 at 2.30pm boardroom, the...

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