Agenda – Wirral Governing Body Meeting PUBLIC SESSION – 7th October 2014 Page 1 of 3

GOVERNING BODY MEETING – A meeting in public

Tuesday 7th October 2014 Nightingale Room, OMH

2pm

AGENDA

Ref No. No Time Item Papers GB14-15/0037 1. 2.00pm PRELIMINARY BUSINESS

(Acting Chair – Dr P Naylor)

1.1 Apologies for Absence 1.2 Chair’s Announcements 1.3 Declarations of Interest 1.4 Comments/questions from

members of the public

1.5 Patient Story (Lorna Quigley)

1.6 Minutes and Action Points of Last Meeting – held on 2nd September 2014 (All)

• Matters Arising • Action Points

DRAFT GB Minutes PUBLIC MEETING 02 09

DRAFT Action Points of WCCG -PUBLIC GB M

GB 14-15/0038

2. ITEMS FOR APPROVAL 2.1 Procedures of Low Clinical

Priority (Dr S Wells) Cover

sheet_Commissioning Govering Board

report_Commissioning 2.2 Emergency Preparedness

Response Resilience (Paul Edwards) Cover sheet EPRR

reports Oct 14.docxNHS England EPRR

Assurance Letter Septe

NHS Core Standards Requirements for CSU

EPRR core standards improvement plan Wir

STATEMENT OF COMPLIANCE EPRR 20

GB 14-15/0039

3. ITEMS FOR DISCUSSION 3.1 NHS Wirral CCG response to the

‘Capability and Governance Review & Constitutional Implications (Paul Edwards & Jon Develing)

Review and Constitution cover she

Wirral CCG Review - NHS England.pdf

High level action plan in response to NHS En

Constitutional implications of the rev

GB 14-15/0040

4. ITEMS FOR INFORMATION 4.1

Quality Performance and Finance- QPF (Lorna Quigley/Mark Bakewell)

Cover Sheet Integrated Performan

Slides for GB 071014.pptx

Agenda – Wirral Governing Body Meeting PUBLIC SESSION – 7th October 2014 Page 2 of 3

Ref No. No Time Item Papers 4.2 Progress Report re: System

Resilience Plan (Andrew Cooper/Sarah Quinn) Board report cover

sheet template System Wirral SRG Plan 201415 v3.docx

System resilience summary paper Oct 2

4.3 Progress Report re: BCF (Better Care Fund) (Sarah Quinn) Board report cover

sheet template BCF O Better care fund

summary paper Oct 2 4.4 Progress Report re: Continuing

Health Care (CHC) (Iain Stewart) CHC_Provision_Cove

r_Sheet_GBB_071014CHC_Provision_Oct1

4_GB1.pdf

GB 14-15/0041

5. ITEMS FOR NOTING 5.1

5.2 5.4 5.5

Conflicts of Interest Policy (Paul Edwards) Visions 2018 Update (Jon Develing/Anna Rigby) Commissioning Plan/Commissioning Intentions (Iain Stewart) Subgroups (Ratified Minutes):

• WGPCC of 11.06.2014

• Approvals Minutes of: 27.08.2014

• Audit Minutes of: 28.05.2014

Conflicts of Interest Cover sheet Oct GB.do

Conflicts of Interest Policy September 2014

Vision 2018 Bulletin Issue 3.pdf

Commissioning_Plan_201419_ FinalDraft_C

Comissioning_Plan_2014-19_MASTER_v71

Ratified WGPCC Executive Board Minute

Approvals Ratified Minutes 27th Aug 2014

audit minutes 280514 ratified.docx

Letter to Leigh Griffin re CHC 16 09 2014.pd

CHCCC Wirral action plan Aug 2014 ver 1 0

Agenda – Wirral Governing Body Meeting PUBLIC SESSION – 7th October 2014 Page 3 of 3

Ref No. No Time Item Papers GB 14-15/0042

6. RISK REGISTER Current Risk Register To be circulated 7. ANY OTHER BUSINESS 7.1 8. End DATE AND TIME OF NEXT MEETING

Tuesday 4th November 2014 2pm – 4pm

Nightingale Room OMH Please forward any apologies to Allison.hayes@nhs.net

**Latest submission date for papers is Friday 24th October 2014**

Wirral Clinical Commissioning Group – Future Meetings 2014 Day Date Time Venue

Tuesday 2nd December 2pm – 5pm Nightingale Room Tuesday 6th January 2pm – 5pm Nightingale Room

Minutes of the WCCG –Governing Body Meeting – PUBLIC SESSION – 2nd September 2014 Page 1 of 7

WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY BOARD MEETING

Minutes of Meeting – Public Session

Tuesday 2nd September 2014 2pm

Nightingale Room, Old Market House Present: Jon Develing (JD) Interim Accountable Officer Dr P Naylor (PN) Acting Chair WCCG Mark Bakewell (MB) Chief Finance Officer Lorna Quigley (LQ) Head of Quality and Performance Dr M Green (MG) Consortium Chair

James Kay (JK) Lay Advisor (Audit & Governance, Deputy Chair) Dr H McKay (HM) GP Executive (WGPCC) Dr A Ali (AA) GP Executive (WGPCC) Iain Stewart (IS) Consortium Chief Officer (WACC) Christine Campbell (CC) Consortium Chief Officer (WGPCC) Fiona Johnstone (JF) Director of Public Health Dr J Oates (JO) Consortium Chair Dr D Jones (DJ) GP Executive (WHCC) Andrew Cooper (AC) Consortium Chief Officer (WHCC) Paul Edwards (PE) Head of Corporate Affairs

In Attendance: Allison Hayes (AJH) Executive Assistant

Karen Prior (KP) Healthwatch Wirral Richard Williams (RW) LMC Robin Baker Grant Thornton Liz Temple Murray Grant Thornton

Ref No. Minute GB14-15/0031

Preliminary Business 1.1 Apologies for absence Apologies were received from: Simon Wagener, Dr S Wells, Dr A Smethurst & Graham Hodkinson.

1.2 Chairs Announcements Chair welcomed all members to the meeting. 7 members of the public attended the meeting. 1.3 Declarations of Interest The following GP members present declared their potential for conflict of interest in the consideration of items 2.1 & 2.2 concerning the "Primary and Community Care investment” and “Prescribing incentive Scheme” Dr P Naylor (PN) Acting Chair WCCG Dr M Green (MG) Consortium Chair

Dr H McKay (HM) GP Executive (WGPCC)

Minutes of the WCCG –Governing Body Meeting – PUBLIC SESSION – 2nd September 2014 Page 2 of 7

Ref No. Minute Dr A Ali (AA) GP Executive (WGPCC) Dr J Oates (JO) Consortium Chair Dr D Jones (DJ) GP Executive (WHCC)

In view of these declarations James Kay would take the chair for discussion of items 2.1 & 2.2 in line with our Conflicts of Interest policy. 1.4 Comments/questions from members of the public There were no comments or questions from members of the public. 1.5 Patient Story LQ gave an overview of a patient’s story which highlighted potential risks associated to patients staying in a hospital environment and how the length of stay can affect a patient’s care. Members noted the contents of the patient story. 1.6 Minutes from previous meeting held on 5th August 2014. The minutes of the previous meeting held on 5th August 2014 were agreed as a true and accurate record notwithstanding grammatical/typographical errors which will be rectified. There were no matters arising. Action Points – please refer to separate Action Sheet

GB14-15/0032

2.0 Items for approval 2.1 Primary And Community Care Investment (Over 75s Scheme &Transferring Primary Care Schemes) In view of the declarations of interest, and in line with the Conflict of Interests Policy, James Kay would take the chair for this discussion: CC and AC gave an overview of the above proposals. The papers presents proposals to use two sets of resources currently unallocated within the CCG financial plan:

• over 75s resource, required to be set aside for care of over 75s, under the NHS Planning Guidance;

• resource released from discontinued Local Enhanced Services The Governing Body approved principles for use of these resources at its meeting on the 5th August. A paper was taken to the Approvals Committee on the 27th August to approve the financial commitment of resources to General Practice, in line with the CCG Conflicts of Interest Policy. Following feedback at the August Governing Body meeting, this paper includes more detail and a full version of each General Practice scheme, for Governing Body approval. The Governing Body were asked to support the proposals for use of these resources, taking into account the rationale and anticipated outcomes behind each one, and the support given by the Approvals Committee on the 27th August. Discussions took place in relation to read codes and CC clarified this for members. JK sought clarity around procurement processes and resources available in terms of staffing and

Minutes of the WCCG –Governing Body Meeting – PUBLIC SESSION – 2nd September 2014 Page 3 of 7

Ref No. Minute work place capacity. CC explained that this is an extension of a current service and, with regards to recruitment of nurses, assurances has been given by CWP that there are adequate numbers of nurses to support the service. AC informed members of the task and finish groups that have worked in collaboration with main providers in order to address this. KP sought clarity around NHS 111 and Minor Injury services being included in the proposals. AC gave an overview of how the schemes relate to primary care and how NHS 111 may link into this particularly with its use of the Directory of Service. KP also sought clarity around additional transport issues and AC explained the rational regarding this. The Governing Body supported the proposals and agreed to commission the schemes from General Practice as identified and take forward next steps on commissioning the community Dementia Liaison Nurses and the Pharmacy First scheme. 2.2 Prescribing Incentive Scheme In view of the declarations of interest James Kay would take the chair for this discussion in line with our Conflicts of Interest policy. CC provided an overview of the scheme. The proposed incentive scheme attempts to address specific areas of prescribing that are referenced within the Medicines Management QIPP plan for the CCG. It seeks to improve quality, ensure safe prescribing, and secure a return on investment for the CCG. It is scheduled to run from September 2014 – February 2014, and would be a Wirral-wide scheme open to all General Practices. The practice-based review areas will improve the practice-based systems and provide a baseline for continued practice-based review in following years to further improve practice and systems. The scheme has discernible links to Wirral CCG strategic objectives and priority work areas. The proposed scheme also contains an element of GP peer to peer review and sharing of best practice. Overall the proposed prescribing incentive scheme should provide the following outcomes:

• Increased cost effective prescribing at GP practice level. • Increased prescribing in line with national and local clinical guidelines. • Improved systems and processes at GP practice level, supporting care of people in a

safe environment; protecting from avoidable harm. • Sharing of best practice across GP peers.

The Governing Body noted that the proposal has been sent to GP practices and the feedback received. The Governing Body agreed the above scheme. 2.3 QIPP Plan The QIPP plan sets out how the CCG seeks to achieve financial balance whilst improving the quality of care across a range of transactional and transformational areas. CC gave an update of current developments in relation to QIPP. The Governing Body were asked to note the points and approve the QIPP Plan for Wirral CCG for 2014/15. In line with the Vision 2018 programme, the CCG will need to shift focus towards transformation rather than service review and redesign, and ensure that efforts are spent on priority areas that will have an impact spanning the system, rather than just in small, isolated areas.

Minutes of the WCCG –Governing Body Meeting – PUBLIC SESSION – 2nd September 2014 Page 4 of 7

Ref No. Minute JK highlighted that appropriate governance would need to be in place across Wirral organisations to effect the necessary change. Members suggested that an update in relation to Vision 2018 is brought back to a future Governing Body meeting. Members of the Governing Body approved the QIPP Plan. 2.4 Safe Guarding Adults Policy LQ gave an overview of the Safe Guarding Adults policy and sought approval to underpin the work of the Safeguarding Team. NHS Wirral CCG is committed to safeguarding. Safeguarding adults incorporates measures to reduce the likelihood of abuse and neglect occurring as well as ‘adult protection’ i.e. making effective responses to protect ‘adults at risk’ where abuse and neglect has occurred. The policy outlines the appropriate systems in place for discharging the CCGs responsibility in respect of safeguarding. The Governing Body approved the Safeguarding Adults Policy. 2.5 Complaints Policy PE provided details in relation to the recent amendments made in the complaints policy. The complaints policy is reviewed on a biannual basis as a minimum requirement. The policy is designed to ensure staff; patients and public are informed of the current complaints process for Wirral Clinical Commissioning Group. The existing policy was approved by the Governing Body in September 2013. While the principles described within the policy have not changed there has been a need to update changes to the complaints procedure since 1st April 2013, in line with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. CC suggested that an update of the complaints procedures are sent to GP practices. The Governing Body approved the Complaints Policy.

GB14-15/0033

3.0 Items for Discussion There were no items of discussion

GB14-15/0034

4.0 Items for Information 4.1 Quality Performance and Finance Report Quality Performance LQ gave a presentation on the activity performance for month 3 (June) and highlighted the positive areas and the improvements in the challenges that were originally presented. Areas included: • Family and friends • NWAS turnaround • Delivering the same sex accommodation • Diagnostic test • MRSA • Referral to treatment – NHS Constitution • Health Care Associated Infection LQ highlighted the work carried out in conjunction with the Utilisation Management team and how this has impacted on A&E performance.

Minutes of the WCCG –Governing Body Meeting – PUBLIC SESSION – 2nd September 2014 Page 5 of 7

Ref No. Minute The Governing Body noted the contents of the Quality and Performance Report. Finance Report MB provided information of the Financial performance against budgeted allocation for 2014/15 as at month 4 (July). Plan is in line with the plan however limited data available for Month 4 reporting. Points to notice are: • Planned Year to Date Surplus - £1.5.6m • Current Year to Date Surplus - £0.96m • £0.6m variance from plan (£0.6m) variance from plan, adverse movement on expenditure between month 3 (June) and 4 (July) Adverse Variances WUTH Contract position – (£1.05m) @ M3 vs. (£17.m) @ M2 Other NHS providers – notably Royal Liverpool and Broadgreen CC (£0.35m) Commissioned out of hospital - £0.376m (Increase in CHC/package costs) Prescribing – circa £0.35m adverse movement QIPP – 4/12’s of £6.9m Gap (shortfall in budgets) = £2.30m 2014/15 Key Planning Requirements

• 1% Surplus - £4.68m • 2.5% Headroom (non-recurrent resources) - £11.4m • Minimum 0.5% Contingency - CCG hold £3m vs £2.2m (0.5%) • Better Payment Practice Code • Cash Management

Forecast Outturn 2013/14 Forecast Assumptions

• Still early position in financial year, activity based contracts for month 3 (contracts) / month 2 (prescribing)

• Adverse Movement between months increases level of risk of achievement of control total but planned Forecast Surplus - £ 4.68m (1%) – remains on track

• Risks remain consistent with plan around main expenditure areas • WUTH, • Prescribing, • Commissioned Out of Hospital Care, • QIPP Gap

Other Issues • Hosting Arrangements • Discussions held with Cheshire & Merseyside Commissioning Support Unit with regards

to ceasing of arrangements relating to Isle of Man commissioner and use of CCG Ledger • Continuing Healthcare • Restitution /Previously Unassessed Period of Care (PUPoC)Provision claims progressing

slowly JK sought an explanation regarding the over performance of the WUTH contract and how this links to the delivery of the QIPP plan. MB provided assurance about the delivery of the plan.

Minutes of the WCCG –Governing Body Meeting – PUBLIC SESSION – 2nd September 2014 Page 6 of 7

Ref No. Minute The Governing Body noted the financial report as at month 4 (July). Information Governance The purpose of the report is to update the Wirral Clinical Commissioning Group with Information Governance performance, and to demonstrate that the correct support and programmes of work are underway to meet the Information Governance Toolkit Requirements by 31st March 2015. MB provided an overview of the Information Governance performance and asked the Governing Body to:

• Receive the July IG Toolkit Baseline submission scores. • note the current position and receive the 2014/15 Work Plan • commit to support compliance with the Information Governance Toolkit, in preparation of

the March 2015 submission • Approve the changes to the IG Strategy and supporting policies.

The Governing Body acknowledged the report and the work undertaken by Suzanne Crutchley and approved the changes to the IG strategy and supporting policies. 4.2 Wirral CCG Annual Audit Letter The Annual Audit Letter summarises the key findings arising from the work that Grant Thornton carried out at NHS Wirral Clinical Commissioning Group (the CCG) for the year ended 31 March 2014. Robin Baker and Liz Temple Murray provided an overview of the Audit. The audit work plan involved:

• auditing the CCG's 2013/14 accounts (section two), and • assessing the CCG's arrangements for securing economy, efficiency and effectiveness in

its use of resources (section three). The audit conclusions provided in relation to 2013/14 were follows:

• Financial statements opinion – An ‘unqualified’ opinion on the CCG's financial statements on 6 June 2014, confirming a true and fair view of the CCG's financial position as at 31 March 2014 and of net expenditure recorded for the year.

• Regularity opinion - An ‘unqualified’ regularity opinion. • Value for money (VfM) – A ‘non-standard’ value for money conclusion • It should also be noted that the Annual Report was presented at the CCG’s Governing

Body on 3rd June 2014, a meeting that was held in public The Governing Body noted the content of the Audit report and thanked Robin and Liz for their work. 4.3 WHCC consortia Update Each Consortium has been asked to prepare a report on a quarterly basis detailing how it has contributed to key CCG priorities. AC gave an update and reported the activities undertaken by Wirral Health Commissioning Consortium since their last submission. The report demonstrates to patients, stakeholders and the public the range of innovative activities taking place at a Consortium level, and the contribution made to the overall CCG Strategic plan and priorities through the Consortia and their member practices. The Governing Body noted the contents of WHCC report and gave thanks to the consortia for their work.

Minutes of the WCCG –Governing Body Meeting – PUBLIC SESSION – 2nd September 2014 Page 7 of 7

Ref No. Minute

GB14-15/0035

5.0 Items for Noting 5.1 Service Level Agreement (SLA) Between Wirral CCG & CSU LQ provided an update regarding the SLA between Wirral CCG and the CSU (Commissioning Support Unit) The paper provided the Governing body with:

• An update regarding the progress made to date transfer of services from the commissioning support unit (CSU) to the CCG.

• Progress to date regarding the agreement of the Service Level Agreement and Key Performance Indicators (SLA, KPI) between the CCG and CSU.

The Governing Body were asked to support the work that the CCG are undertaking in addressing the issues highlighted and to support the update of the CCG risk register to reflect the potential risks identified within the paper. The Governing Body noted the report and supported the recommendations. 5.2 Subgroups (ratified minutes for noting)

• QPF meeting of 29.07.2014 – noted. The Governing Body noted the reports of the above subgroups.

GB14-15/0036

6.0 Risk Register PE gave an overview of the current risk register and all items were reviewed and noted today.

7.0 Any other Business There were no other items of business. Chair thanked members for their attendance. The Board meeting ended at 15:40pm.

8.0 Date and Time of Next Meeting The date and time of the next meeting is Tuesday 7th October 2014 at 2pm – 5pm in the Nightingale Room, OMH please contact Allison.hayes@nhs.net with any apologies or agenda items.

Board meeting ended at: 15:40pm.

Draft Action Points – Wirral Clinical Commissioning Group, Governing Body Meeting - PUBLIC SESSION – 02.09.2014 1/1

Wirral Clinical Commissioning Group

Governing Body

Draft Action Points re Meeting of 2nd September 2014 (Public Session)

Duncan Room, OMH 2pm

Outstanding Actions from: 5th August 2014

Topics Discussed Item Number/Ref Action Points Responsibility Action Target date

• • • • New Actions from: 2nd September 2014

Topics Discussed Minute Action Points Responsibility Action Target date

Minutes and Action Points of the last meeting

• AJH/PE to rectify grammatical errors • AJH • 07.10.2014

Agenda Items for next meeting / Decisions to note for next meeting / Date & time of next meeting

The date of the next meeting is Tuesday 7th October 2014 at OMH, Duncan Room. Agenda items and apologies are to be sent to: Allison.hayes@nhs.net

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Report on Proposed Changes to Commissioning Policies (also known as Procedures of Lower Clinical Priority – PLCP)

Agenda Item: 2.1 Reference: GB14-15/0038 Report to: Governing Body Meeting Date: 7th October 2014

Lead Officer: Sue Wells

Contributors: Clare Grainger

Governance: Link to Commissioning Strategy

1. Rigorously developed and agreed care pathways working

together with patients to secure their help, understanding, ownership and support of the needed changes

2. Commissioned services which have a sound evidence base 3. Provides greater equality of access to all

Link to current strategic objectives

• Enhance the quality of life for people with long term conditions

• Helping people to recover from episodes of ill health or following injury

• Ensuring people have a positive experience of care

Summary: The purpose of this report is to • To provide an overview of the process undertaken to update the

Commissioning Policies • To present the final policy to the Governing Body for approval • The most important changes or decisions in the consultation were

regarding: IVF, Interventional treatments for Varicose Veins, Penile Implants and Diabetes/Continuous Glucose Monitoring, though many others were involved.

Recommendation:

To Approve x

To Note

Comments The Governing Body are asked to consider whether the CCG should adopt and put into practice the updated policy but with the recommended exceptions and amendments noted in tables 7.2 to 7.4 If the Governing Body chooses to adopt the updated policy, the CCG has two options:

1. Put the new policy into practice as soon as possible, or 2. Phase in over a period of time to reduce the financial impact

Next Steps:

Following this review, it was agreed that the approved policies would be shared with GPs and providers, embedded into contracts with all local trusts and performance-managed to monitor compliance

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This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

Available financial impact figures are detailed in section 8 and appendices 5 and 6. If the recommendations are adopted the procedures will remain under continuous review.

Value For Money Through applying latest clinical evidence to procedures it will enable new treatments to be available with higher success rates and replace those offering reduced clinical benefit. New procedures will also reduce unnecessary delays in authorizing treatment which can happen when a treatment is subject to an ‘individual funding request’ (IFR). The revised policy would enable clinicians to clearly identify when this is necessary. There will be no decrease in other areas to pay for the policy changes.

Risk There is a risk that expectancy will be set with future policy reviews.

Legal The Commissioning Support Unit (CSU) was commissioned to take legal advice and ensure any risks or legal implications were negligible?

Workforce There has been substantial clinical and provider engagement and consultation to address the potential changes and identify any impact. These are detailed in section 3 and 4 and appendix 3 of the report. There is expected to be negligible impact on the workforce.

Equality & Human Rights

A full equality analysis report is detailed in appendix 4 and section 5 of the report. The CSU have revised the policy to mitigate any potential negative impact that was identified.

Patient and Public Involvement (PPI)

Patients and public have been engaged and consulted as part of the NICE guideline development and as part of the formal engagement and consultation that has informed the report. Full details are in section 3 of the report and appendix 3.

Partnership Working

The report provides evidence of partnership and collaborative working across the Cheshire and Merseyside CCG’s to try to align the process with the assistance of the CSU. Wirral CCG were particularly pro-active in pushing to achieve an alignment and agreement on the proposals.

Performance Indicators

There isn’t a performance indicator related to this overarching work. The new draft policy does not introduce any new contracts therefore currently commissioned services will continue to be monitored with standard procedures already established.

Do you agree that this document can be published on the website? (If not, please note that it may still be subject to disclosure under Freedom of Information - Freedom of Information Exemptions

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This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome Procedures of Low Clinical Priority

Item no. 2.6 Clinical Strategy Group (CSG)

12.11.13 Briefing and discussion

Commissioning Policy Review

Item no. 2.5 Operational Team Meeting

28.1.14 CSU presentation

Procedures of Low Clinical Priority Commissioning Policy Review

Item no. 2.1 Extraordinary Clinical Strategy Group

23.1.14 Briefing and discussion highlighting consultation

AOB Clinical Strategy Group

11.2.14 Highlighting consultation had started

Public Engagement & Consultation Activity – Commissioning Policies Review

Item no. 55 Families and Wellbeing Policy and Performance Committee

8.4.14 The Chair indicated to Members that if they had any further comments to add to the review, they could do so online. RESOLVED: That (1) the report be noted; and (2) Ms Curtis from CSU be thanked for her informative presentation.

PLCV Item no. 2.3 Extraordinary Clinical Strategy Group

8.7.14 Members voted to agree recommended position but escalated to Operational team meeting for clarification on some areas

Procedures of Low Clinical Priority – contentious issues

Item no. 4.1 Operational Team Meeting

15.7.14 Members agreed to CSG recommendations

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Officer.

GOVERNING BODY BOARD REPORT

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Report Title Report on Proposed Changes to Commissioning Policies (also known as Procedures of Lower Clinical Priority – PLCP)

Lead Officer Dr. Sue Wells

Recommendations The Governing Body are therefore asked to consider whether the CCG should adopt and put into practice the updated policy but with the recommended exceptions and amendments noted in tables 7.2 to 7.4 If the Governing Body chooses to adopt the updated policy, the CCG has two options:

1. Put the new policy into practice as soon as possible, or 2. phase in over a period of time to reduce the financial impact

1. INTRODUCTION 1.1 Historically commissioning policies across Cheshire and Merseyside were developed centrally through

association and support by CISSU (CISSU project managed the production of Cheshire and Merseyside procedures of limited clinical value); this document was due for review in 2012.

1.2 CCGs agreed that the individual funding request process (IFR) service provided by NHS Cheshire and

Merseyside Commissioning Support Unit (CSU) applied the inherited policies of CCGs, of which the majority were out of date or requiring a review.

1.3 This position review provided a real opportunity to consider the value and economy in all CCGs agreeing

to be part of a common process to develop a comprehensive suite of commissioning policies based on latest National Institute of Clinical Excellence (NICE) guidance and clinical best practice.

1.4 In mid-2013 the CSU were commissioned to undertake a review of the policy on behalf of the Clinical

Commissioning Groups across Cheshire and Merseyside. This review covered 12 Clinical Commissioning Groups, 2.5 million population, 420 GP Practices and 74 individual treatment/service lines.

1.5 The main policy draft changes were on updating the guidance based on new evidence and adding new

services/treatments/procedures that have come on stream since the old policy was adopted

1.6 Following this review, it was agreed that the approved policies would be shared with GPs and providers, embedded into contracts with all local trusts and performance-managed to monitor compliance.

1.7 This paper is to provide the Governing Body with details of the process undertaken to arrive at the updated policy and for the Governing Body to approve the final policy.

1.8 Please see appendix 1 and 2 for the full draft policies.

2. REVIEW PROCESS 2.1 A seven-stage approach was developed and agreed and followed the format below:

Stage 1 Policy stimulation - practice or evidence Stage 2 Evidence review Stage 3 Pre Equality Impact Assessment Stage 4 Production of a potential policy for CCG primary approval Stage 5 Engagement- patients, carers, members of the public, referrers and providers Stage 6 Review consultation findings, final approval by CCG and full Equality Impact Assessment Stage 7 Policy Implementation and monitoring

GOVERNING BODY BOARD REPORT

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2.2 A full evidence review was undertaken by CSU considering NICE guidance and the most up to date

clinical evidence base. This has been supported by Public Health who undertook independent reviews in a number of areas.

2.3 Following this review CSU developed draft policies for consultation. A colour-coded key chart was devised to provide and support an easier understanding of the 37 specialties (and 99 treatments/procedures) within the revised ‘draft’ policy document, to denote whether the NICE or national guidance was recommending major, moderate or no change to the status quo :

Key Description Speciality / Clinical Area

Red Important Changes

7.1. Infertility Services 20.3 Interventional treatments for Varicose Veins 19.2 Penile (Penis) Implants

Amber Criteria Changes 21.1 BotulinumToxin 11.3 Mental Health 14.1 Oral Surgery – extraction of wisdom teeth 16.5 Plastic and Cosmetic Surgery 17.1, 17.2 - Respiratory Services 18.2, 18.3, 18.18, 18.19 Trauma and Orthopaedics

Green Minor word or no changes made

1.1 Weight Management (Bariatric) Surgery 2.1 Complementary Therapies (including Homeopathy) 3.1, 3.2, 3.4 Dermatology 5.2, 5.3, 5.4, 5.5. 5.7 Ear, Nose and Throat 8.1 Gastroenterology 9.1, 9.2 General Surgery 10.1 Gynaecology 13.1,13.2, 13.3, 13.8 Ophthalmology 16.1, 16.2, 16.3, 16.4, 16.6, 16.7, 16.8, 16.9, 16.10, 16.11, 16.12, 16.13, 16.14, 16.16, 16.17, 16.18 Plastic and Cosmetic Surgery 18.15, 18.17, 18.20, 18.21, 18.22, 18.23 - Trauma and Orthopaedics

GOVERNING BODY BOARD REPORT

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Dark Blue

New - Important Change*

4.1 Diabetes - Continuous Glucose Monitoring

Mid Blue

New - Moderate Change*

3.3 Dermatology 6.1 Equipment (Lycra suits) 12.1, 12.2, 12.3 Neurology 13.5 Ophthalmology 14.3 Oral Surgery 16.8 Plastic and Cosmetic Surgery 18.1, 18.4, 18.5, 18.6, 18.7, 18.8, 18.9, 18.10, 18.11, 18.12, 18.13, 18.14, 18.16, 18.22 Trauma and Orthopaedics 19.1, 19.4, 19.5, 19.6 Urology 20.1, 20.2 Vascular Services

Light Blue

New - Minor Impact*

5.1, 5.6, 5.8 Ear, Nose and Throat 9.3 General Surgery 11.1,11.2, 11.4, 11.5 Mental Health 13.4, 13.6, 13.7 Ophthalmology 14.2 Oral Surgery 15.1 Paediatrics 18.23, 18.24, 18.25, 18.26 Trauma and Orthopaedics 19.3 Urology

3. PUBLIC CONSULTATION 3.1 The National Institute of Clinical Excellence (NICE) guidelines are already determined; the premise of the

consultation exercise was to ask key stakeholders if they felt that the respective CCGs should consider NICE guidance when forming a decision for procedures of low clinical priority. NICE guidance is not mandatory. Cheshire and Merseyside Clinical Commissioning Groups wanted to ensure that local patients, carers and members of the public were aware of NICE guidance and to gauge opinion in respect of the guidance when forming policy on procedures of low clinical priority.

3.2 The need for formal consultation (90 days) was agreed for all 12 CCGs in January 2014. 10 CCGs began the process on 6th January and 9 closed their consultation on 7th April, NHS Knowsley CCG extended their

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consultation for a further 10 days until 17th April. NHS Wirral CCG and NHS Liverpool CCG started their process later and closed on 30th April and 3rd June respectively.

3.3 This collaboration consultation across the Cheshire and Merseyside footprint resulted in 5,827 people

visiting the CSU website, 535 people completing the survey and 72 public events taking place during the formal consultation period.

3.4 The consultation was widely publicised across Wirral during the 90-day formal consultation process;

targeting patient groups, third sector, and general public alongside NHS staff and providers. The full list of engagement activities is listed in appendix 2 of the report. In addition to the Wirral-focussed engagement captured in the matrix, there was regional and national engagement undertaken by the CSU on behalf of all CCG’s; including protected groups, clinical leads, pharmacists, dentists and optometrists (via NHS England). The CSU can provide that information separately.

3.5 Wirral CCG undertook a robust consultation which resulted in a total of 253 responses to the online survey,

the highest response rate for any CCG and nearly half of the total responses overall. There was a relatively equal distribution of response from across all age ranges with the highest number being between the range of 65+. In addition, 27% were between the age of 45-54, 22% between the age of 55-64, 15% ranged from 35-44 and 8% were aged 24-34. The majority of the respondents stated that they were commenting generally and not on a specific area of the consultation. Of the 253 responses, 50% agreed with the proposals and 50% disagreed. There were no specific trends identified in the feedback and a significant number of responses did not pertain to the actual draft policy. A few comments pertained to a gap in the current pathway for bariatric patients in relation to CBT, however, this did not form part of the survey questions. Please see appendix 3 for the full consultation report.

4 CLINICAL ENGAGEMENT 4.1 Reviewing and developing commissioning policies required multi-disciplinary input and was recognised as

being a very complex process. The review would take account of 99 individual treatment lines classed as procedures of low clinical priority. Engagement with clinicians within NHS Wirral CCG is detailed in the engagement audit trail within the consultation report in appendix 3. Clinical engagement included:

• Briefing paper and discussion with clinical leads in the Senior Management Team Operational

meetings (December 2013). CSU presentation (January 2014) • Reports and discussions at the Clinical Strategy Group (November 2013, January, February and

July 2014) • Draft policy, and briefing sent to all GP practice managers and GPs from the CCG Chief Clinical

officer (December 2013) with link to dedicated email address for clinical feedback • CSU presentation at Wirral GP Commissioning Consortium GP Forum (December 2013) • CSU presentations at Commissioning Consortia Clinical forums (January 2014) • Consultation sent to all GP practices (March 2014) • Alignment and development meetings (throughout)

4.2 In addition, engagement has taken place with providers of healthcare services, including:

• Provider briefing sent from CSU (December 2014) • Details of proposed changes and the consultation process were sent to all providers (January 2014) • CSU facilitated Provider invited briefing events (January 2014) • Consultation sent to all provider engagement leads to distribute (April 2014) • Details of the consultation were sent to identified Wirral Clinical leads for treatments where there

were recommended important changes e.g. varicose veins, subfertility (March 2014)

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5. EQUALITY IMPACT ASSESSMENT 5.1 A full equality impact assessment was undertaken to ensure adherence to the Equality Duty 2010. In order

to identify potential equality impacts the full NICE guidelines were reviewed, in the first instance to identify particular procedures that effect particular protected characteristics. Once this was identified then a specialist team with clinicians looked at the detail of the change, many changes were simply procedural or ‘better medicine’ meaning there would be ‘no clinical difference from the patient’s perspective’. However, there were a number of changes that seemed significant enough that may have an ‘equality impact’ and of which interested parties may need to comment. The report examined where this was the case and ensured relevant engagement was undertaken e.g. due to the high number of proposed changes to areas that could disadvantage the transgender community the CSU established a focus group to capture opinions from the transgender community.

5.2 The equality analysis report is available in appendix 4. In summary the report recommends accepting the

NICE guidance and consulting with interested parties incorporating their views into decision making to ensure that Wirral CCG are compliant with the Public Sector Equality Duty.

5.3 As a result of the equality analysis and engagement a number of changes were made to the draft policy

that is now appended.

6. POST-CONSULTATION PROCESS 6.1 Following the conclusion of each CCG’s 90-day formal consultation process a number of activities took

place: • A structured approach to handling patient and public feedback was adopted in order to ensure all

views were considered. All survey data for each CCG was compiled into a report • All clinical feedback was considered and collated to inform the policy. • Provider feedback was considered and collated to inform the policy. • A Clinical Commissioning Group Position Meeting took place to promote discussion between CCGs,

and seek agreement to a single policy across all Cheshire & Mersey CCGs, taking into consideration the patient, carer and public feedback, alongside feedback which has been received from clinicians and providers.

• The final draft policy was provided to CCGs on 2nd July 2014, and each CCG asked to formally consider at their Governing Body whether it would like to adopt the updated policy.

7. RECOMMENDATIONS 7.1 Wirral CCG called a meeting of the Clinical Strategy Group (CSG), with representation from QIPP (Quality

Innovation Productivity Prevention) clinical leads across Wirral to specifically review the final draft policy alongside the consultation feedback and equality analysis report. The CSG were asked to vote on a template provided by the CSU to capture their recommended position in relation to the final draft policy based on clinical grounds. The CSG’s vote on Wirral’s recommended position is detailed in table 7.2 to 7.4 below. Table 7.2 Wirral CCG position on statements that the CSU proposes to remove

No. Title Agreement CSG Feedback/Comment

1. Removed statement on bariatric surgery/pathways Yes

Tier 3 commissioned by CCG

2.

Removed statement on Extraction of impacted Wisdom Teeth

Yes

3. Removed statement on Orthodontics Yes

4. Removed statement on Treatments for Obstructive Sleep apnoea/hypopnoea syndrome in Adults (OSAHS)

Yes

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Table 7.3 – Wirral CCG Position on statements that the CSU proposes to change – do we agree?

CCG Position No. Title Yes/No CCG Likely Position

1. Continuous Glucose Monitoring

NO

DISAGREE - If patient fits all criteria; Individual Funding Request (IFR) not required

2.

Cataracts Yes

Agree with draft with Appendix 1 guide for local use. Remove

‘medically fit’ as optomertrists cannot determine this.

3. Lycra Suits Yes

Agree with draft. IFR required. Further information required from consulting with patient groups

4. Penile implants NO

DISAGREE. If patient meets criteria, no IFR required.

Currently provided on Wirral for those patients who meet the criteria (very small numbers).

5. Varicose Veins NO DISAGREE. Follow NICE Guidance. But develop a template regarding level of symptoms. Financial Impact.

6. Homeopathy NO

DISAGREE. Agree all other complimentary therapies. Wirral wishes to continue commissioning Homeopathy at present.

For future review.

7. Psychological Distress Yes

Agree

8. Botox Yes Agree

9. Infertility

Yes

Follow NICE Guidance re numbers of cycles and 40-42. Smoking to be removed as can’t police. Childlessness no change. Surrogacy no, IFR would be required. Agreed GP

pre-conception and referral pathway. Financial impact. 10 Hip & Knee Surgery Yes And continue with local referral guidelines

Table 7.4 Wirral CCG position on Unchanged Statements - confirming that you are happy to continue to adopt the following unchanged statements No. Title Yes/No CSG Comment/Feedback

1. Surgical Laser therapy for Viral Warts (excluding Genital Warts) from secondary care providers

Yes

2.

Surgical Remodelling of External Ear Lobe Yes

3. Use of Sinus X-ray Yes

4. Rhinoplasty - Surgery to Reshape the Nose Yes

5. Surgery of Laser Treatment of Rhinophyma Yes

6. Gastro-electrical Stimulation Yes

7. Surgery for Asymptomatic Gallstones & Lithotripsy for Gallstones

Yes

8. Surgical Procedures – for the Treatment of Heavy Menstrual Bleeding & Hysterectomy & D&C (Dilatation and curettage)

Yes

9. Inpatient Care for treatment of Chronic Fatigue Syndrome (CFS)

Yes

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10.

Private Mental Health (MH) Care - Non-NHS commissioned services including Psychotherapy, Adult Eating Disorders, General In-patient Care, Post-Traumatic Stress & Adolescent Mental Health

Yes

11. Bobath Therapy Yes

12. Trophic Electrical Stimulation for Facial/Bells Palsy

Yes

13. Upper Lid Blepharoplasty - Surgery on the Upper Eyelid

Yes

14. Lower Lid Blepharoplasty - Surgery on the Lower Eyelid

Yes

15. Surgical Treatments for Xanthelasma Palpebrum (fatty deposits on the eyelids)

Yes

16. Coloured (Irlens) Filters for treatment of Dyslexia

Yes More evidence required

17. Intra ocular telescope for advanced age-related macular degeneration

Yes

18. Surgical removal of Chalazion or Meibomian Cysts

Yes

19. Cranial Banding for Positional Plagiocephaly Yes

20. Mastopexy - Breast Lift Yes 21. Surgical Correction of Nipple Inversion Yes

22. Surgical treatment for Pigeon Chest Yes

23. Surgical revision of Scars Yes

24. Laser Tattoo Removal Yes

25. Apronectomy or Abdominoplasty(Tummy Tuck) Yes

26. Other Skin Excisions/ Body Contouring Surgery e.g. Buttock Lift, Thigh Lift, Arm Lift (Brachioplasty)

Yes

27. Treatments to correct Hair Loss for Alopecia Yes

28. Hair Transplantation Yes

29. Treatments to correct Male Pattern Baldness Yes

30. Liposuction Yes

31. Rhytidectomy - Face or Brow Lift Yes

32.

Treatments for Snoring. Soft Palate Implants and Radiofrequency Ablation of the Soft Palate, Sodium Tetradecyl Sulfate (STS) Injection or snoreplasty’ & Uvulopalatoplasty and Uvulopalatopharyngoplasy

Yes

33. Bone Morphogenetic Proteins, Dibotermin alfa & Eptotermin alpha

Yes

34. Palmar Fasciectomy /Needle Faciotomy For Dupuytren’s Disease. Radiotherapy & Collagenase injections

Yes Suggest the removal of ‘age’ in criteria; should be based on functionality

35. Hip Arthroscopy for Femoro–Acetabular Impingement

Yes

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36. Surgical Removal of Bunions/ Surgery for Lesser Toe Deformity

Yes Subjective

37. Treatment of Tendinopathies, Extracorporeal Shock Wave Therapy & Autologous Blood or Platelet Injection

Yes

38. Circumcision NO DISAGREE. Local need on Wirral to

prevent inappropriate surgical techniques. Continue to commission

but requires review. 39. Reversal of Male Sterilisation Yes

40. ESWT (Extracorporeal Shockwave Therapy) for Prostadynia or Pelvic Floor Syndrome

Yes

41. Hyperthermia Treatment for Prostadynia or Pelvic Floor Syndrome

Yes

42. Surgery for Prostatism Yes

43. Chelation Therapy for Vascular Occlusions Yes 7.5 The CSG felt that there were a number of areas that required further input from the CCG – where they

disagreed with NICE guidelines or where they sought clarification around which services were currently commissioned. The CSG recommendations were therefore taken to the Senior Managers Operational Team Meeting on 15th July 2014 for members to consider, highlighting the areas in table 7.6 below. (Page and item numbers refer to draft commissioning policy document)

Table 7.6

Item no.

Page/104

comment

3.1 Continuous glucose monitoring

10 IFR not needed if all criteria met NB pt comments

11.5 cataract 33/76/100 Follow NICE support use of template 5.1 Lycra suits 22 More info needed 17.2 Penile implants 70 currently commissioned ?no IFR if criteria

met 18.3 Varicose veins 72/93 Follow NICE but financial impact 1.1 Complementary therapies 7 Wirral commissions homeopathy at present 6.1 fertility 25 NICE guidelines. financial impact 16.18 Hip and Knee 61 Local guidelines 16.26 Tendinopathies 68 17.1 circumcision 69 Currently commissioned for religious/cultural

to prevent unsafe surgery

7.7 The Operational Group Members were satisfied that the recommendations made by the CSG represented the views of the CCG and that the consensus was to follow NICE guidelines with the exception of homeopathy as a currently commissioned service.

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8 FINANCIAL IMPACT 8.1 The CSG recommendations were made on clinical grounds. The financial impact and ability of the CCG to

fund any approved changes from the existing budget have been considered separately. 8.2 The CSU were limited in their ability to quantify the financial impact of all the procedures because they

apply to a low number of patients, but they were able to confirm that continuous glucose monitors are approximately £3000 each and the NICE costing template was used to estimate costs for fertility treatment and varicose veins as the procedures that had the most material implications. It is important to note that these costing templates are only estimates and subject to variation.

8.3 The Varicose Veins NICE costing template, detailed in appendix 5, indicates that the local estimated

assumption of net resource impact in adopting the revised NICE guidelines is approximately £4K per annum.

8.4 The Subfertility NICE costing template, detailed in appendix 6, indicates that the local estimated

assumption of financial impact in adopting the revised NICE guidelines is approximately £166K in year 1, rising to £272K in year 3 before falling to a recurrent cost of £117K when the new policy has been fully implemented. The costing template is detailed in appendix 5.

8.5 The recommendation is to proceed with funding changes based on CSG recommendations to take into

account the long time since the procedures have been reviewed. However it is on the basis that the procedures would therefore remain under more constant review.

9 CONCLUSION 9.1 The majority of Cheshire and Merseyside CCGs have not shared their recommendations in advance and

have not yet deliberated their specific policy changes and it is therefore possible that there will be local variation. However the recommendations in this paper should provide assurance that Wirral CCG has applied the latest clinical evidence to commissioning plans.

9.2 The Governing Body are therefore asked to consider whether the CCG should adopt and put into practice

the updated policy but with the recommended exceptions and amendments noted in tables 7.2 to 7.4. If the Governing Body chooses to adopt the updated policy, the CCG has two options: 1. Put the new policy into practice as soon as possible, or 2. Phase in over a period of time to reduce the financial impact

10 APPENDICES

No. Title of Appendix 1 Final Draft Policy – Cheshire & Merseyside Commissioning Policy – web-link:

https://www.wirralccg.nhs.uk/Downloads/DRAFT%20Commissioning%20Policy%20Criteria.pdf 2 Final Draft Policy – Cheshire & Merseyside Subfertility – web-link:

https://www.wirralccg.nhs.uk/Downloads/Draft%20Subfertility%20Policy.pdf 3 Wirral CCG Consultation report – web-lnk:

https://www.wirralccg.nhs.uk/Downloads/Wirral%20CPR%20Consultation%20Report.pdf 4 Equality Analysis Report – web-link:

https://www.wirralccg.nhs.uk/Downloads/Equality%20Anaylsis%20Report.pdf 5 Varicose Vein Implementation Costings 6 Subfertility Implementation Costings

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APPENDIX 5 – Varicose Vein Cost Assumptions

Costing Template

Notes Unit cost

£ Units Total cost £

Total population selected 329,647 Selected population who are 18 and over 262,524

Prevalence of varicose veins 65,631 Number of varicose vein interventional procedures per annum 162

Current practiceCurrent practice of treatment

Number of outpatient consultant-led first attendances specialising in vascular surgery £156 162 £25,199Number of surgery interventional procedures per annum £908 84 £76,000

Number of endothermal ablation interventional procedures per annum £624 57 £35,613Number of ultrasound-guided foam sclerotherapy interventional procedures per annum £315 21 £6,550

Number of outpatient consultant-led follow-up attendances specialising in vascular surgery £93 21 £1,931

£145,292Future practice

Future practice of treatmentNumber of outpatient consultant-led first attendances specialising in vascular surgery £156 162 £25,199

Number of surgery interventional procedures per annum £908 8 £7,336Number of endothermal ablation interventional procedures per annum £624 113 £70,188

Number of ultrasound-guided foam sclerotherapy interventional procedures per annum £315 41 £12,909Number of outpatient consultant-led follow-up attendances specialising in vascular surgery £93 41 £3,806

Increase in referrals by 25%Increase in number of outpatient consultant-led first attendances specialising in vascular surgery as

a result of increased referrals to vascular services£156 40 £6,300

Increase in number of surgery interventional procedures per annum as a result of increased referrals to vascular services

£908 2 £1,834

Increase in number of endothermal ablation interventional procedures per annum as a result of increased referrals to vascular services

£624 28 £17,547

Increase in number of ultrasound-guided foam sclerotherapy interventional procedures per annum as a result of increased referrals to vascular services

£315 10 £3,227

Increase in number of outpatient consultant-led follow-up attendances specialising in vascular surgery as a result of increased referrals to vascular services

£93 10 £952

£149,298

Net resource impact £4,005

Cost for selected population using standard NICE assumptions

NHS Wirral CCG

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APPENDIX 6. Sub Fertility Implementation Costings

Notes Costs over time using standard NICE assumptionsYear 1 Year 2 Year 3 Year 4 Year 5

1 Rate of progression towards full implementation 40% 80% 100% 100% 100%Cost in each year £142,331 £284,661 £355,826 £355,826 £355,826

2 Rate of progression towards full implementation 33.3% 33.3% 33.3% 0% 0%Cost in each year £146,138 £193,534 £217,232 £0.00 £0.00

3 Rate of progression towards full implementation 100% 100% 100% 100% 100%Cost in each year -£4,127 -£4,127 -£4,127 -£4,127 -£4,127Total costs 284,341 474,068 568,931 351,699 351,699

Costs over time using local assumptionsYear 1 Year 2 Year 3 Year 4 Year 5

Rate of progression towards full implementation 40% 80% 100% 100% 100%Cost in each year £53,101 £106,201 £132,752 £132,752 £132,752

Rate of progression towards full implementation 33.3% 33.3% 33.3% 0% 0%Cost in each year £128,820 £146,502 £155,344 £0.00 £0.00

Rate of progression towards full implementation 100% 100% 100% 100% 100%Cost in each year -£15,731 -£15,731 -£15,731 -£15,731 -£15,731Total costs 166,189 236,973 272,364 117,021 117,021

Notes1 It is assumed that the recommendations on access criteria for IVF will take 3 years to implement.2

3 It is assumed that the recommendations on embryo transfer strategies will be fully implemented in the first year.

A non-recurrent cost is expected from the reduction in time spent trying to conceive spontaneously from 3 years in the 2004 guideline to 2 years in the 2012 guideline. In the year the new recommendation is implemented the people who have been trying to conceive for 2 years and the people who have been trying to conceive for 3 years would both become eligible to receive IVF treatment. It is assumed that centres will not have the capacity to provide IVF cycles to this increased number of people in 1 year, so the service and cost has been spread over 3 years.

Incremental annual cost of access criteria for IVF

Non-recurrent cost of access criteria for IVF

Embryo transfer strategies

Incremental annual cost of access criteria for IVF

Non-recurrent cost of access criteria for IVF

Embryo transfer strategies

£0

£100,000

£200,000

£300,000

£400,000

£500,000

£600,000

Year 1 Year 2 Year 3 Year 4 Year 5

£0

£50,000

£100,000

£150,000

£200,000

£250,000

£300,000

Year 1 Year 2 Year 3 Year 4 Year 5

Governing Body Meeting 07.10.2014 1/3

Emergency Planning, Response and Resilience (EPRR) – Compliance Report

Agenda Item: 2.2 Reference: GB14 -15/0038

Report to: Governing Body Meeting Date: 7th October 2014

Lead Officer: Paul Edwards, Head of Corporate Affairs

Contributors: Laura Wentworth, Corporate Support Officer Roger Booth, Senior Resilience Manager, Cheshire & Merseyside Commissioning Support Unit

Governance: Link to Commissioning Strategy

NHS Wirral CCG has a number of duties in relation to EPRR and this paper aims to provide assurance to the Governing Body of its statement of compliance against the required areas of NHS England’s core standards for EPRR.

Link to current strategic objectives

5 - Ensuring people are treated and cared for in a safe environment and protected from avoidable harm

Summary: The statement of compliance and action plan are completed against the required areas of NHS England’s core standards for EPRR, of which the CCG has self-assessed as demonstrating the Full compliance level against the core standards.

Recommendation:

To Approve

To Note X

Comments

Not applicable.

Next Steps:

The Governing Body are asked to note the contents of these reports.

Governing Body Meeting 07.10.2014 2/3

This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

In addition to the costs of the emergency planning and resilience service which has been commissioned from the CSU, consideration may need to be given to the contents of this report and also to the CCG’s Business Continuity Plan, in terms of any resources required to continue to implement the plan.

Value For Money Not applicable.

Risk Whilst the delivery and operation of the on call facility may encounter initial instances of lack of knowledge or experience for on call staff, this has been addressed by additional training for key staff during 2012/13, as further detailed within this report.

Legal Legal issues may arise from incidents where Department of Health guidance is not followed and may take the form of a civil action or under another statue (e.g. Corporate Manslaughter and Corporate Homicide Act 2007) and can be made against the CCG or individuals.

Workforce The on call staff may be required to be away from their day job for periods of time during the extent of any emergency, and this may impact to a degree on the day to day work of the CCG.

Equality & Human Rights

Equality and Diversity protected characteristics have been and will continue to be considered throughout the process of developing actions, policies and procedures in Wirral CCG complying with the Civil Contingencies Act 2004 and the Department of Health Emergency Planning Response and Resilience requirements. There is currently no impact identified which would provide inequality.

Patient and Public Involvement (PPI)

Patients or public have not been involved in determining the EPRR requirements of the CCG.

Partnership Working

Partnership working is evidenced via the CSU attendance at Local resilience Forum Groups in Cheshire and Merseyside which allows interactions with all multi agency partners.

Performance Indicators

Reports to the Governing Body will provide updates against the elements of EPRR undertaken on behalf of Wirral CCG by CSU.

Do you agree that this document can be published on the website? (If not, please note that it may still be subject to disclosure under Freedom of Information - Freedom of Information Exemptions

Governing Body Meeting 07.10.2014 3/3

This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome

Emergency Planning,

Response and Resilience (EPRR) –

Compliance Report

Governing Body 7th October 2014

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Officer.

TO: EPRR Accountable Officers Dear Colleague, RE: 2014/15 Emergency Preparedness, Resilience and Response (EPRR) assurance

process The Local Health Resilience Partnership (LHRP) has recently completed the 2013 / 2014 assurance process for NHS-funded members of the LHRP. Thank you for your support in this process. The 2014/15 EPRR Assurance Process is based on the revised core standards (previously sent out but also attached). To comply with the national requirements the LHRP requests that you:

1) Undertake a self-assessment against the revised core standards identifying the level of compliance for each standard (red, amber, green);

2) Submit an action plan addressing any areas of improvement required (template enclosed);

3) Complete the statement of compliance (enclosed) identifying the organisation’s

overall level of compliance - full, substantial, partial, non;

4) Present the above outcomes to your board or through appropriate governance arrangements where the board has delegated their responsibility for EPRR;

5) Submit the board paper to the LHRP (by email to by 14th November 2014.

Following receipt of your submission, we may request evidence against specific standards but do not expect all evidence identified in your self-assessment to be submitted. The LHRP chair and co-chair will consider submissions during the week of 17th November. Feedback / action plan will be fed back to accountable officers during the first week in December.

Our Ref: JD/MC/EPRR Assurance 20th August 2014

Cheshire, Warrington & Wirral Area Team

Quayside Wilderspool Park Greenalls Avenue

Stockton Heath Warrington

WA4 6HL

Email address: jim.deacon@nhs.net Telephone number: 01138 251 866

Where organisations’ board meeting dates do not fit with these timescales, the LHRP chair will consider the paper in advance of the board meeting with confirmation from you, as the AEO, of the date the board will consider the paper and assurance that any changes to the overall compliance level will be communicated to us as the LHRP co-chairs. Please feel free to contact us if you have any queries relating to this process. Yours sincerely

Andrew Crawshaw Director of Operations and Delivery Cheshire, Warrington & Wirral Area Team NHS England

Dr Rita Robertson Director of Public Health Warrington Borough Council

Cheshire, Warrington and Wirral Local Health Resilience Partnership Co-Chairs

NHS Core Standards Requirements for Wirral CCG – September 2014

CORE STANDARD - DUTY CLARIFYING INFORMATION EVIDENCE OF ASSURANCE Evidence Available Governance

1.Organisations have a director level accountable emergency officer who is responsible for Emergency Preparedness, Resilience & Response (EPRR) (including business continuity management)

None • Ensuring accountable emergency officer's commitment to the plans and giving a member of the executive management board and/or governing body overall responsibility for the Emergency Preparedness Resilience and Response, and Business Continuity Management agendas • Having a documented process for capturing and taking forward the lessons identified from exercises and emergencies, including who is responsible. • Appointing an emergency preparedness, resilience and response (EPRR) professional(s) who can demonstrate an understanding of EPRR principles. • Appointing a business continuity management (BCM) professional(s) who can demonstrate an understanding of BCM principles. • Being able to provide evidence of a documented and agreed corporate policy or framework for building resilience across the organisation so that EPRR and Business continuity issues are mainstreamed in processes, strategies and action plans

The Accountable Officer has this responsibility and is supported operationally by the Head of Corporate Affairs

2. Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to Emergency Preparedness, Resilience & Response (EPPR) (including details of training and exercises and past incidents) and improve response.

Lessons identified from your organisation and other partner organisations. NHS organisations and providers of NHS funded care treat Emergency Preparedness, Resilience & Response (EPPR) (including business continuity) as a systematic and continuous process and have procedures and processes in place for updating and maintaining plans to ensure that they reflect: - the undertaking of risk assessments and any changes in that risk assessment(s) - lessons identified from exercises, emergencies and business continuity incidents - restructuring and changes in the organisations - changes in key personnel - changes in guidance and policy.

Annual work programme developed by Cheshire and Merseyside Commissioning Support Unit (CMCSU) on behalf of the CCG and taken to Governing Body. Organisation assurance framework reviewed at Governing Body. Emergency Planning professional accessed via CMCSU.

3. Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response.

Arrangements are put in place for emergency preparedness, resilience and response which: • Have a change control process and version control • Take account of changing business objectives and processes • Take account of any changes in the organisations functions and/ or organisational and structural and staff changes • Take account of change in key suppliers and contractual arrangements • Take account of any updates to risk assessment(s) • Have a review schedule • Use consistent unambiguous terminology,

Business Continuity and Incident Response plans in place which includes the CCG policy and version control and annual review arrangements (to be reviewed Autumn 2014) CMCSU provide advice, support, training and annual reports and reviews of plans/ Plans held on intranet, staff validation exercise undertaken

• Identify who is responsible for making sure the policies and arrangements are updated, distributed and regularly tested; • Key staff must know where to find policies and plans on the intranet or shared drive. • Have an expectation that a lessons identified report should be produced following exercises, emergencies and /or business continuity incidents and share for each exercise or incident and a corrective action plan put in place. • Include references to other sources of information and supporting documentation

across the organisation. • That there is an appropriate budget and staff resources in place to enable the organisation to meet the requirements of these core standards. This budget and resource should be proportionate to the size and scope of the organisation.

and facilitated by CMCSU. Requirements for debriefs included in plans. Monthly brief sent to CCG by CMCSU.

4.The accountable emergency officer will ensure that the Board and/or Governing Body will receive as appropriate reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the organisation, significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standard.

None Annual report to Governing Body. Issues from the EPRR risks would be taken to governing body. CMCSU provides an annual report on EPRR which is reviewed at Governing Body.

Duty To Assess Risk 5. Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver it's functions.

Risk assessments should take into account community risk registers and at the very least include reasonable worst-case scenarios for: • severe weather (including snow, heatwave, prolonged periods of cold weather and flooding); • staff absence (including industrial action); • the working environment, buildings and equipment (including denial of access); • fuel shortages; • surges and escalation of activity; • IT and communications; • utilities failure; • response a major incident / mass casualty event • supply chain failure; and • associated risks in the surrounding area (e.g.

Being able to provide documentary evidence of a regular process for monitoring, reviewing and updating and approving risk assessments • Version control • Consulting widely with relevant internal and external stakeholders during risk evaluation and analysis stages • Assurances from suppliers which could include, statements of commitment to BC, accreditation, business continuity plans.

CCG plans updated annually and any additional threats and risks incorporated Risk take into account within the Business Continuity plan the areas contained in clarifying information section. Any local risks additional to generic risks would be identified within the plans, there are none CMCSU representative attends Local Health Resilience Partnership (LHRP) and sub groups and Local Resilience

COMAH and iconic sites) There is a process to consider if there are any internal risks that could threaten the performance of the organisation’s functions in an emergency as well as external risks eg. Flooding, COMAH sites etc.

• Sharing appropriately once risk assessment(s) completed

Forum (LRF) groups on behalf of CCG. Corporate Risk Register assessed and national risk register considered. Threats to CCG identified within the Business Impact Analysis.

6. There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), and national risk registers.

CMCSU representative attends Local Health Resilience Partnership (LHRP) and sub groups and Local Resilience Forum (LRF) groups on behalf of CCG.

7. There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with your organisation and relevant partners.

Risks considered within CCG and cascaded appropriately. Risks affecting external agencies cascaded via LHRP and LRF representation.

Duty to maintain BC and IR plans 8. Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity. Have arrangements for (but not necessarily have a separate plan for) some or all of the issues in the next column (organisation dependent) (NB, this list is not exhaustive):

Incidents and emergencies (Incident Response Plan (IRP) (Major Incident Plan) corporate and service level Business Continuity (aligned to current nationally recognised BC standards) Severe Weather (heatwave, flooding, snow and cold weather) Pandemic Influenza Fuel Disruption Surge and Escalation Management (inc. links to appropriate clinical networks e.g. Burns, Trauma and Critical Care) Infectious Disease Outbreak Evacuation Utilities, IT and Telecommunications Failure

Relevant plans: • demonstrate appropriate and sufficient equipment (inc. vehicles if relevant) to deliver the required responses • identify locations which patients can be transferred to if there is an incident that requires an evacuation; • outline how, when required (for mental health services), Ministry of Justice approval will be gained for an evacuation; • take into account how vulnerable adults and children can be managed to avoid

Business Continuity (BC) and Incident Response (IR) plans in place which conform to NHS Core standards and ISO 22301 for BC. All plans mentioned within requirements where appropriate are contained within the IR and BC planning. Part of NHS England command and control structure to respond to Major Incidents

admissions, and include appropriate focus on providing healthcare to displaced populations in rest centres; • include arrangements to co-ordinate and provide mental health support to patients and relatives, in collaboration with Social Care if necessary, during and after an incident as required; • make sure the mental health needs of patients involved in a significant incident or emergency are met and that they are discharged home with suitable support • ensure that the needs of self-presenters from a hazardous materials or chemical, biological, nuclear or radiation incident are met. • for each of the types of emergency listed evidence can be either within existing response plans or as stand alone arrangements, as appropriate.

9. Ensure that plans are prepared in line with current guidance and good practice which includes:

Aim of the plan, including links with plans of other responders • Information about the specific hazard or contingency or site for which the plan has been prepared and realistic assumptions • Trigger for activation of the plan, including alert and standby procedures • Activation procedures • Identification, roles and actions (including action cards) of incident response team • Identification, roles and actions (including action cards) of support staff including communications • Location of incident co-ordination centre (ICC) from which emergency or business continuity incident will be managed • Generic roles of all parts of the organisation in relation to responding to emergencies or business continuity incidents • Complementary generic arrangements of other responders (including acknowledgement of multi-agency working) • Stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes • Contact details of key personnel and relevant partner agencies • Plan maintenance procedures (Based on Cabinet Office publication Emergency Preparedness, Emergency Planning, Annexes 5B and 5C (2006)

Elements required from the clarifying information box contained within the Incident Response and the Business Continuity Plans Note : -ICC contained within corporate offices

10. Arrangements include a procedure for determining whether an emergency or business continuity incident has occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the deployment of resources or acquiring additional resources.

Enable an identified person to determine whether an emergency has occurred - Specify the procedure that person should adopt in making the decision - Specify who should be consulted before making the decision - Specify who should be informed once the decision has been made (including clinical staff)

Contained within plans including triggers. Mutual aid considered in plans.

11. Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical.

Decide: - Which activities and functions are critical - What is an acceptable level of service in the event of different types of emergency for all your services - Identifying in your risk assessments in what way emergencies and business continuity incidents threaten the performance of your organisation’s functions, especially critical activities

Prioritised functions within plans as part of BIA. Further work on BIA being undertaken at present in respect of risk reduction objectives and tasks. Improvement plan submitted to NHS England.

13. Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content

CCG staff involved in BIA process, Validation exercise and staff familiarisation undertaken

14. Arrangements include a debrief process so as to identify learning and inform future arrangements

Explain the de-briefing process (hot, local and multi-agency, cold)at the end of an incident.

Debrief Process Included in plans.

Command and Control 15. Arrangements demonstrate that there is a resilient single point of contact within the organisation, capable of receiving notification at all times of an emergency or business continuity incident; and with an ability to respond or escalate this notification to strategic and/or executive level, as necessary.

Organisation to have a 24/7 on call rota in place with access to strategic and/or executive level personnel

Explain how the emergency on-call rota will be set up and managed over the short and longer term.

On call system in place.

16. Those on-call must meet identified competencies and key knowledge and skills for staff.

NHS England published competencies are based upon National Occupation Standards .

Training is delivered at the level for which the individual is expected to operate (ie operational/ bronze, tactical/ silver and strategic/gold). for example strategic/gold level leadership is delivered via the 'Strategic Leadership in a Crisis' course and other similar courses.

Training undertaken by on call staff. Further training required by some staff who have been unable to attend previous sessions.

17. Documents identify where and how the emergency or business continuity incident will be managed from, ie the

This should be proportionate to the size and scope of the organisation.

Arrangements detail operating procedures to help manage the ICC (for example, set-up, contact

Command centre within plan, decision logging included in plan.

Incident Co-ordination Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist .

lists etc.), contact details for all key stakeholders and flexible IT and staff arrangements so that they can operate more than one control/co0ordination centre and manage any events required.

18. Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident.

Decision logging included in plan

19. Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response.

Sample sitreps and crips in plan.

Duty to communicate with public 22. Arrangements demonstrate warning and informing processes for emergencies and business continuity incidents.

Arrangements include a process to inform and advise the public by providing relevant timely information about the nature of the unfolding event and about: - Any immediate actions to be taken by responders - Actions the public can take - How further information can be obtained - The end of an emergency and the return to normal arrangements Communications arrangements/ protocols: - have regard to managing the media (including both on and off site implications) - include the process of communication with internal staff - consider what should be published on intranet/internet sites - have regard for the warning and informing arrangements of other Category 1 and 2 responders and other organisations.

Have emergency communications response arrangements in place • Be able to demonstrate that you have considered which target audience you are aiming at or addressing in publishing materials (including staff, public and other agencies) • Communicating with the public to encourage and empower the community to help themselves in an emergency in a way which compliments the response of responders • Using lessons identified from previous information campaigns to inform the development of future campaigns • Setting up protocols with the

Communications within the CCG via communications support from CMCSU. NHS England communications would support out of hours Input. CCG website is updated internally.

media for warning and informing • Having an agreed media strategy which identifies and trains key staff in dealing with the media including nominating spokespeople and 'talking heads'. • Having a systematic process for tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes. • Being able to demonstrate that publication of plans and assessments is part of a joined-up communications strategy and part of your organisation's warning and informing work.

23. Arrangements ensure the ability to communicate internally and externally during communication equipment failures

Have emergency communications response arrangements in place • Be able to demonstrate that you have considered which target audience you are aiming at or addressing in publishing materials (including staff, public and other agencies) • Communicating with the public to encourage and empower the community to help themselves in an emergency in a way which compliments the response of responders • Using lessons identified from previous information campaigns to inform the development of future campaigns • Setting up protocols with the

Other systems in place, mobile telecoms, email, laptops, iPads available.

media for warning and informing • Having an agreed media strategy which identifies and trains key staff in dealing with the media including nominating spokespeople and 'talking heads'. • Having a systematic process for tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes. • Being able to demonstrate that publication of plans and assessments is part of a joined-up communications strategy and part of your organisation's warning and informing work.

Information Sharing – Mandatory requirements

24. Arrangements contain information sharing protocols to ensure appropriate communication with partners.

These must take into account and include DH (2007) Data Protection and Sharing – Guidance for Emergency Planners and Responders or any guidance which supersedes this, the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 ‘duty to communicate with the public’, or subsequent / additional legislation and/or guidance.

Attendance at or receipt of minutes from relevant Local Resilience Forum(s) / Borough Resilience Forum(s) meetings, that meetings take place and membership is quorate. • Treating the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership as strategic level groups • Taking lessons learned from all resilience activities • Using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to consider policy initiatives

Information sharing protocol in place with Cheshire and Wirral providers.

• Establish mutual aid agreements • Identifying useful lessons from your own practice and those learned from collaboration with other responders and strategic thinking and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to share them with colleagues • Having a list of contacts among both Cat. 1 and Cat 2. responders with in the Local Resilience Forum(s) / Borough Resilience Forum(s) area

Co-operation 25. Organisations actively participate in or are represented at the Local Resilience Forum (LRF) (or Borough Resilience Forum in London if appropriate)

None Attendance at or receipt of minutes from relevant Local Resilience Forum(s) / Borough Resilience Forum(s) meetings, that meetings take place and memebership is quorat. • Treating the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership as strategic level groups • Taking lessons learned from all resilience activities • Using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to consider policy initiatives • Establish mutual aid agreements • Identifying useful lessons from

CMCSU represents on LRF and sub groups.

26. Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the CCA

None CMCSU attends LHRP and sub groups and LRF and sub groups on behalf of CCG. All issues communicated to CCG

27. Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained.

NB: mutual aid agreements are wider than staff and should include equipment, services and supplies.

Via command and control and NHS England.

30. Arrangements demonstrate how organisations support NHS England locally in discharging its EPRR functions and duties

None Via command and control and CCG roles agreement document.

33. Arrangements are in place to ensure attendance at all Local Health Resilience Partnership meetings at a director level

None LHRP attended by CSU representative responsible for EPRR on behalf of the CCG

your own practice and those learned from collaboration with other responders and strategic thinking and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to share them with colleagues • Having a list of contacts among both Cat. 1 and Cat 2. responders with in the Local Resilience Forum(s) / Borough Resilience Forum(s) area

Training and Exercising 34. Arrangements include a training plan with a training needs analysis (TNA) and ongoing training of staff required to deliver the response to emergencies and business continuity incidents

• Staff are clear about their roles in a plan • Training is linked to the National Occupational Standards (NOS) and is relevant and proportionate to the organisation type. • Training is linked to Joint Emergency Response Interoperability Programme (JESIP) where appropriate • Arrangements demonstrate the provision to train an appropriate number of staff and anyone else for whom training would be appropriate for the purpose of ensuring that the plan(s) is effective • Arrangements include providing training to an appropriate number of staff to ensure that warning and informing arrangements are effective

Taking lessons from all resilience activities and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership and network meetings to share good practice

• Being able to demonstrate that people responsible for carrying out function in the plan are aware of their roles

• Through direct and bilateral collaboration, requesting that other Cat 1. and Cat 2 responders take part in your exercises

• Refer to the NHS England guidance and National Occupational Standards For Civil

TNA carried out in 2013. A further TNA to be carried during autumn 2014 to identify additional training following the training already carried out by CMCSU

Training linked to NOS

Joint Emergency Services Interoperability Programme (JESIP) familiarisation to be sought from NWAS and Police.

35. Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work.

• Exercises consider the need to validate plans and capabilities • Arrangements must identify exercises which are relevant to local risks and meet the needs of the organisation type and of other interested parties. • Arrangements are in line with NHS England requirements which include a six-monthly communications test, annual table-top exercise and

Training for role as on call ongoing. Exercises instigated by LHRP and LRF attended by CCG as appropriate. Training programme contained

live exercise at least once every three years. • If possible, these exercises should involve relevant interested parties. • Lessons identified must be acted on as part of continuous improvement. • Arrangements include provision for carrying out exercises for the purpose of ensuring warning and informing arrangements are effective

Contingencies when identifying training needs.

• Developing and documenting a training and briefing programme for staff and key stakeholders

• Being able to demonstrate lessons identified in exercises and emergencies and business continuity incidentshave been taken forward

• Programme and schedule for future updates of training and exercising (with links to multi-agency exercising where appropriate)

• Communications exercise every 6 months, table top exercise annually and live exercise at least every three years

within annual report from CMCSU.

36. Demonstrate organisation wide (including on call personnel) appropriate participation in multi-agency exercises

None Attendance at multi agency exercises where appropriate. Attendance at exercises as appropriate. Public Health exercise attended.

37. Preparedness ensures all incident commanders (on call directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation.

None To be put into place. CMCSU has records of training attended to date. Communications exercises undertake regularly.

EPRR Core Standards Improvement Plan 2014/15

Page 1 of 1

Trust: Wirral Clinical Commissioning Group

Core standard reference

Core standard description Improvement required to achieve compliance Action to deliver improvement Deadline

11

Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical

Assessment of the risk reduction objectives and tasks identified in the business Impact Analysis following completion of the update to the plan.

Assessment and update to the risk reduction objectives Oct 2014

16 Those on-call must meet identified competencies and key knowledge and skills for staff

Further training needs analysis (TNA) to be circulated and further training to be delivered

Cheshire & Merseyside Commissioning Support Unit will circulate additional TNA and schedule additional training

March 2015

34

Arrangements include a training plan with a training needs analysis and on-going training of staff required to deliver the response to emergencies and business continuity incidents

Further TNA to be carried out .Joint Emergency Services Interoperability Programme (JESIP) familiarisation to be sought

All on call personnel to have received appropriate training and familiarisation

March 2015 and ongoing

37

Preparedness ensures all incident commanders (on call directors and managers) maintain a continuous personal development portfolio (PDP) demonstrating training and/or incident /exercise participation.

All on call personnel to be required to keep details of training in a PDP

PDP requirement to be circulated to on call CCG staff Ongoing

STATEMENT OF COMPLIANCE EPRR 2014/15

Wirral Clinical Commissioning Group has undertaken a self-assessment against required areas of the NHS England Core Standards for EPRR v2.0).

Following assessment, the organisation has been self-assessed as demonstrating the Full compliance level (from the four options in the table below) against the core standards.

Compliance Level Evaluation and Testing Conclusion

Full The plans and work programme in place appropriately address all the core standards that the organisation is expected to achieve.

Substantial The plans and work programme in place do not appropriately address one or more the core standard themes, resulting in the organisation being exposed to unnecessary risk.

Partial The plans and work programme in place do not adequately address multiple core standard themes; resulting in the organisational exposure to a high level of risk.

Non-compliant The plans and work programme in place do not appropriately address several core standard themes leaving the organisation open to significant error in response and /or an unacceptably high level of risk.

Where areas require further action, this is detailed in the attached core standards improvement plan and will be reviewed in line with the Organisation’s EPRR governance arrangements.

I confirm that the above level of compliance with the core standards has been or will be confirmed to the organisation’s board / governing body.

________________________________________________________________

Signed by the organisation’s Accountable Emergency Officer

07/10/2014 ____________________________ Date of board / governing body meeting Date signed

WCCG Governing Body Meeting 05.11.2013 1/3

NHS Wirral CCG response to the ‘Capability and Governance Review’

Agenda Item: 3.1 Reference: GB 14-15/0039

Report to: Governing Body

Meeting Date: 7th October 2014

Lead Officer: Jon Develing, Interim Accountable Officer

Contributors: Paul Edwards, Head of Corporate Affairs

Governance: Link to Commissioning Strategy

To be a high performance, high reputation organisation with ambition. To reduce waste and inefficiency and duplication within the patient journey and between partners.

Link to current governing body Objectives

To ensure that the CCG is a fully constituted organisation, in order to undertake fully its statutory requirements

Summary: NHS England’s ‘Capability and Governance Review’ in relation to NHS Wirral CCG has made a number of key recommendations and these have been fully accepted by the CCG. As a result, a high level action plan has been developed in response and this is included here together with the Review summary issued by NHS England. A number of the recommendations directly relate to the CCG’s constitution and a significant degree of change is required to that document to address the concerns highlighted by the Review. In line with the guidance from NHS England entitled ‘Procedures for Clinical Commissioning Group Constitution Change, Merger or Dissolution’ (May 2013), the CCG has an opportunity to update its constitution at two yearly submission dates and is currently aiming to submit a revised constitution at the next submission date in November 2014. This latter part of this report presents an overview of proposed key changes to the constitution in response to the Review and it is envisaged that the full revised constitution will be presented to November 2014 Governing Body.

Recommendation: To Approve

To Note x

Comments

Next Steps: Revised constitution to be presented at Governing Body November 2014

WCCG Governing Body Meeting 05.11.2013 2/3

This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

The Review indicates a need for a single approach to planning and strategy. This should facilitate a stronger financial management and control. The CCG Constitution describes the Quality, Performance and Finance Committee and its role in overseeing financial performance and this will be retained as part of the Constitutional amendment process.

Value For Money The Review and Action Plan highlight the need to improve the effective use of staffing resources by moving to a more cohesive, single Wirral structure. The CCG Constitution describes the functions of the CCG, including ensuring robust financial stewardship and efficient services and this will be retained as part of the Constitutional amendment process.

Risk The CCG Constitution ensures that the CCG is a fully constituted organisation, in order to undertake fully its statutory requirements. In addressing the concerns of the review, that Action Plan should improve organisational stability and mitigate risk through a single planning and delivery process.

Legal The CCG Constitution outlines how the CCG carries out its statutory duties. The process for amendment includes consideration of the requirement for legal advice and the CCG intends to seek legal advice before submission of amendments to NHS England.

Workforce The Action Plan indicates the need for a change to the CCG’s staffing structures and this will be implemented using appropriate consultation processes.

Equality & Human Rights

The impact assessment required by NHS England will be completed as part of the application process

Patient and Public Involvement (PPI)

The impact assessment required for constitutional change includes patient involvement and this will be undertaken as part of the development of the amended constitution

Partnership Working

The CCG Constitution describes that membership of the Governing Body and other committees. These include representation from partner organisations such as Wirral Local Authority and Healthwatch.

Performance Indicators

N/A

Do you agree that this document can be published on the website? (If not, please note that it may still be subject to disclosure under Freedom of Information - Freedom of Information Exemptions

WCCG Governing Body Meeting 05.11.2013 3/3

This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome Changes to the CCG Constitution

GB 14-15/008 2.1

Governing Body 6th May 2014 Decision deferred pending further consultation

Changes to the CCG Constitution

GB 13-14/045 4.5

Governing Body 5th November 2013

Approved

Changes to the CCG Constitution

GB 13-14/039 4.5

Governing Body 1st October 2013

Noted

Changes to the CCG Constitution

GB13-14/014 2.1

Governing Body 4th June 2013 Approved

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Director/Officer.

5th September 2014

Dear colleague

RE: NHS Wirral CCG – Capability and Governance Review 2014

I am writing to you with regard to the recent review into capability and governance at Wirral

Clinical Commissioning Group which was carried out by NHS England.

In order to inform you of the findings of the review I have detailed below an over view of:

The Wirral CCG

Background to the review

Need for the review

Recommendations from the review

Next step recommendations

The Wirral CCG response

We will ensure that all stakeholders including yourself are kept fully informed and up to

date as the recommendations are taken forward however, should you have any questions

or require any further information at the current time, please contact Kirsty McBride on

kirsty.mcbride@nhs.net

Yours Sincerely

Alison Tonge

Director

Cheshire, Warrington & Wirral Area Team

NHS England

Cheshire, Warrington and Wirral

Quayside

Wilderspool Business Park

Greenalls Avenue

Stockton Health

Warrington

WA4 6HL

About Wirral Clinical Commissioning Group (CCG)

NHS Wirral CCG serves a population of approximately 330,000 across the Wirral

Peninsula. There are both rural areas and industrialised areas within 60 square miles,

with significant variation in life expectancy.

During the first three quarters of 2013/14 the CCG was fully assured against the CCG

Assurance Framework with performance at or near required national standards, however

performance against the four hour A&E standard deteriorated markedly in the fourth

quarter of 2013/14 and has remained well below standard.

Financial performance of the CCG is in line with national expectations and it achieved

the required 1% surplus in 2013/14 and is planning to achieve this in 2014/15.

A distinctive feature of the NHS Wirral CCGs profile is that its 58 member practices form

three Consortia or Divisions within the CCG in a mosaic pattern rather than being based

on discrete populations.

NHS England has been working closely with NHS Wirral CCG for some time to assure

that the CCG discharges its functions as there were concerns particularly in relation to:

• The leadership and development of the whole system strategy,

• Delivery of A&E and Urgent Care, and

• Relationships with stakeholders.

Background to the review

In May 2014 the Governing Body of the CCG requested support from NHS England

whilst a review was undertaken of the CCG. At this time both the Chair and the Chief

Clinical Officer (CCO) of the CCG agreed to voluntarily step aside from their roles whist

the review was conducted.

The purpose of this capability and governance review is to ensure that NHS Wirral CCG

can fully discharge its functions, with a core focus on:

• Governing Body capability,

• Governance, (including the structure and constitution of the CCG), and

• Senior leadership capability.

N.B. The terms of reference exclude any human resources process, which are a matter

for the CCG.

The review is based on 34 individual interviews with members of the CCG Governing

Body, the CCG Senior Leadership Team and stakeholders as well as a review of key

documents. The review team were also directly approached by a small number of

people who wished to contribute their views and were included in the review process.

The review was carried out by:

John Bewick OBE NHS England

Colin Mcllwain NHS England

The review took place over a six week period commencing 16th June 2014

Need for the review

A review into the capability and governance of the CCG was deemed necessary on the

basis of:

1. The current state of CCG progress on strategy development,

2. The need to ensure delivery of service standards today, and

3. Relationships with stakeholders.

Review findings

The CCG has fundamental organisational design characteristics which are manifesting

themselves in all three areas of concern above. These are:

• Three CCG Consortia being mosaics of like-minded practices rather than

discrete population based commissioning areas.

• The CCG Governing Body being constituted around proportionate representation

from Consortia.

• No substantive CCG membership forum across the whole CCG.

• The managerial resource of the CCG being significantly invested in servicing the

relatively autonomous functioning of Consortia.

• The relatively complex governance arrangements for decision making which

derive from the Consortia structure.

The increasingly challenging financial environment has exposed these characteristics as

being problematic for the CCG in discharging its functions.

All CCG Governing Body members and senior staff interviewed for this review largely

recognised the problems manifesting from the CCG’s original design. There is an

encouraging consistency of views about the need to develop the CGG and free it from

its own history to better serve the population of Wirral. However, progress in addressing

these issues has not happened at the pace needed.

The review found that the CCG has been working within, and increasingly not coping

with, a set of organisational arrangements which are not fit for purpose. This has caused

increasing difficulties in operating strategically, ensuring delivery today and sustaining

relationships with stakeholders.

The review therefore found that the capability and governance issues in NHS Wirral

CCG to be primarily related to the CCG not moving at sufficient pace to pro-actively

develop itself as an organisation and get ahead of the challenges it now faces.

The review also found that the Governing Body, under the leadership of the Governing

Body Chair is largely aware of the need to develop the CCG but has not shown the

necessary capability to assure the development of the CCG to discharge its functions.

The Governing Body has expressed concern about how the organisation presently

works but has not overseen the necessary processes of development to address those

concerns.

The Governing Body itself is considered not to have had adequate development to fulfil

its role. There is no substantive development programme in place for the Governing

Body. The Chief Clinical Officer (CCO) considers that the development of the Governing

Body is primarily the lead responsibility of the Governing Body Chair.

The Chief Clinical Officer recognised the challenges of the organisation's original design,

and proposed incremental shifts away from the Consortia design to more CCG wide

arrangements, but considered that an organisational review would distract too much

from the work of today and would set the CCG back significantly. The CCO also felt

change needed to come up from the membership rather than be top down.

Taken together, the CCG Chair and CCO do not demonstrate the necessary close

working agreement about what needs to change in the CCG, by when, to develop the

CCG, nor how the necessary leadership for this work would be provided between the

two roles. The review notes that ongoing relationship between the Chair and the CCO

has impacted the ability of the organisation to make progress.

The review concludes that it is unlikely that the CCG will sustainably improve its strategic

and delivery position without undertaking a fundamental review of its constitution and

organisational structure, and its arrangements for member practice and public and

patient engagement. The main issues the CCG may wish to consider in that review are

set out below.

Recommendations from the review

1. To improve its leadership and development of the whole system strategy

a) Review the Consortia structure of the CCG to reflect the need to have whole

Wirral approaches to strategic issues and within that strong connection to

geographical communities coherent with partner commissioners.

b) Review the constitution of the CCG to reflect the need to strengthen ownership of

strategic direction across the membership of the CCG.

c) Review the senior leadership structure to better harness the CCG’s overall

management resource to strategic development.

d) Secure increased programme management capability to develop and take

forward a complex whole system strategy.

e) Strengthen the senior management presence in the Senior Leadership Team of

the CCG capable of taking an overall leadership role internally and externally on

strategic development issues.

2. To improve its delivery of A&E and urgent care

a) Review the present Consortia structure to strengthen common approaches to

meeting the urgent care needs of the whole population while retaining sensitivity

to local variation in need.

b) Develop an urgent care strategy that addresses all of the elements of the urgent

care system in social, primary, community and secondary care services.

c) Revise CCG governance arrangements to strengthen the Governing Body's

capability to corporately assure that investments in urgent care are evidence

based and consistently assessed using common criteria across the CCG.

d) Secure a programme management resource capable of developing an urgent

care strategy with commissioning partners and managing the resultant change

programmes to enable present and potential providers to engage effectively.

e) Review the working relationships with Wirral University Teaching Hospital NHS

Foundation Trust (WUTH) at senior leadership, operational and clinician to

clinician level between the CCG and the Trust to agree a framework for how the

two organisations will work together – along with the other organisations in Wirral

– to develop and implement the urgent care strategy and to reflect it in future

commissioning plans.

4. To improve relationships with stakeholders

a) Secure further external facilitation of relationship development while trust across

organisations and individuals is strengthened and to enable knowledge and skill

transfer within Wirral of leading whole system strategic developments can take

place.

b) Address the unclear governance of delegated authority, programme

management and the weak engagement of member practices in whole system

strategy through Consortia arrangements as outlined in relation to leadership and

development of the whole system strategy.

4. To improve its Governing Body capability

a) Establish an organisational development programme for the CCG Governing

Body to enable it to oversee the changes that Governing Body members have

indicated are needed to the organisation’s structure and governance.

b) Develop the capability of the Governing Body to fully discharge its ongoing

assurance role.

5. To improve governance

a) Urgently consult its membership and then submit an application to NHS England

to amend its constitution with regard to the eligibility of the Chair and the Chief

Clinical Officer roles to remove the inconsistency and contradiction within the

constitution so that both roles can then be occupied on a secure constitutional

basis.

b) Consider a fundamental review of its constitution including how it engages with

its membership in the work of the CCG and whether there should be

engagement arrangements below the level of the CCG and if so what these

should be and how they relate to populations and geographies within Wirral.

c) As part of any review of its constitution consider the composition of its Governing

Body and consult its membership on the method of identifying the Chair and GP

representatives on the governing body.

d) Undertake a development programme with its Governing Body members that

includes providing greater clarity over decision making arrangements, individual

roles and responsibilities and the collective assurance role of the Governing

Body.

e) Review its arrangements for engaging with practices as providers alongside the

review of its constitution.

6. To improve its senior leadership capability

a) Review the structure of the CCG Senior Leadership Team to reflect the proposed

review of the CCG structure and governance, with particular consideration of:

strengthening the very senior strategic management capability of the

CCG;

securing a strategic programme management capability;

securing a corporate capability in investment appraisal and evaluation;

and

strengthen the coordination of CCG capability through the development of

the CCGs business planning function.

b) Review the CCG leadership of organisational development capability, supported

by a revised OD plan that includes development priorities for the Governing Body

and the whole of the CCG’s staffing capacity.

c) Bring together the managerial resource in the central and three Consortia teams

to make more effective use of the CCG’s capacity.

Next step recommendations

1. The review recommends that the CCG agrees a time and task limited action plan

with the Area Team to address the recommendations of this review.

2. The Area Team should agree appropriate external support to that process in

agreement with the CCG and support the associated review of the CCG’s

constitution and organisational structure.

3. The CCG should remain as assured with support until that action plan is

discharged in full.

Wirral CCG response to the review

Wirral CCG welcomes the publication of NHS England’s capability and governance

review and accepts its recommendations.

The review makes a number of recommendations which focus on the development of a

new constitution and improving the effectiveness of the CCG as a commissioner of

health care for the people of Wirral.

The CCG has already made good progress in many of the areas covered by the

recommendations and is pleased to see that this is recognised by NHS England. A more

detailed action plan is being developed so as to consolidate this work.

In line with the recommendations the support from NHS England will continue. Therefore

Jon Develing, Regional Director of Operations and Delivery (NHS England North) will

remain as the Interim Accountable Officer so as to oversee this action plan.

The report has been shared with the Chair and Chief Clinical Officer; the CCG will

discuss this with them in due course.

Wirral CCG continues to work closely with patients, carers and the public to continuously

improve health services and reduce health inequalities across the Wirral.

ENDS

High level action plan in response to NHS England’s Governance and Capability Review

Introduction

NHS England’s ‘Governance and Capability Review’ has now concluded (see Appendix A) and makes a number of recommendations aimed at strengthening the CCG and addressing the issues raised. In summary these are:

• To improve its leadership and development of the whole system strategy

• To improve its delivery of A&E and urgent care • To improve relationships with stakeholders • To improve its Governing Body capability • To improve governance • To improve its senior leadership capability

High level response

The CCG has developed a high level action plan that addresses each of these recommendations and also acknowledges that the CCG has already made significant progress in these areas. This is shown overleaf.

Next steps

A more detailed action plan, with timescales, will be developed and the process for amending the CCG constitution will continue in line with NHS England guidance.

Recommendation

The Governing Body is asked to note the action plan in response to the recommendation of the ‘Capability and Governance Review’. The Governing Body should also note the next section which deals with the specific implications for the CCG’s constitution.

Recommendation CCG Response Progress to Date

To improve its leadership and development of the whole system strategy

• Develop a single unified CCG demonstrated by a new constitution and new Governing Body composition

• Strengthen senior leadership capability and capacity resulting from the new Governing Body composition and also an internal staff restructure that addresses the consortia arrangements

• Interim arrangements to be maintained whilst CCG is assured with the support of NHS England

• Signed Year end position, annual accounts, letter of compliance with Auditors annual report and WUTH contract

• Significantly improved relationships with Providers and Local Authority

• Engagement process begun with members and LMC

To improve its delivery of A&E and urgent care

• Develop whole system strategic approach linked with the System Resilience Group (SRG) and the new constitution.

• Develop Urgent Care Strategy and Recovery Plan.

• Develop a provider engagement plan

• Improved A&E performance in the last 3/52 and an agree recovery plan

• Revised urgent care working group now SRG

• Improved relationships • Urgent Care Conference

18/09/14

To improve relationships with stakeholders

• Develop a forum for clinicians to inform strategy development

• Further improve senior relationships through the Vision 2018 process

• Develop an integrated communications strategy

• New Vision 2018 framework • System wide engagement • Integrated communications via

the Vision 2018 programme • New constitution under

development

To improve its Governing Body capability

• Development of a new CCG constitution so as to reflect the needs of patients on the Wirral

• Develop a program of development for the new Governing Body post November constitution approval

• Roles on the Governing Body will be a mixture of elected and appointed

• Governing Body will become more strategic so as to provide a unified vision for Wirral

• Sought GP views on possible options for constitution changes

• Sought staff engagement of same • Researched Best practice for

model constitutions • Internal committee structure

being reviewed • Exploring governing body

development opportunities with external partners (The CCG will work with North West Leadership Academy to develop a development programme for Governing Body)

To improve governance • Consult membership on a new vision for Wirral CCG

• Develop a new CCG Constitution so as to remove current inconsistency regarding consortia arrangements

• Develop a new Wirral wide GP Membership Council and a Provider Forum

• Sought GP views on possible options for constitution changes.

• Developing an integrated communication and engagement plan.

• Started the impact assessment for constitutional change

To improve its senior leadership capability

• Develop a new CCG structure clinically and operationally aligned

• Become a learning organisation that is able to respond to best practice with a commitment to Organisational Development

• Begun consultation with staff and member practices

• Centralised consortia staff into a single corporate function

• Alignment of work plans to CCG strategic objectives

Constitutional Implications Of the Capability and Governance Review

Introduction The purpose of this report is to outline the constitutional implications arising from the Capability and Governance Review. Summary of key issues from the review with constitutional impact

• Consortia arrangements are not discrete, mosaic in nature and not population based

• Managerial resource invested in servicing relatively autonomous functioning of consortia that has led to fragmentation

• Governing Body is constituted from representation that reflects the fragmented, mosaic consortia arrangements

• Lack of cohesive strategic approach to commissioning resulting from consortia arrangements

• Current practice engagement arrangements via consortia are ‘weak’ and hence there is a need for new approach to member engagement

• Separate arrangements not in place for engaging with practices as providers • Complex and unclear governance arrangements for decision making resulting

from consortia arrangements • Need for urgent review of the composition of the Governing Body, including

the methods of identifying GP representatives and the Chair The proposed areas of amendment: In addressing the fundamental problems resulting from the consortia and governance arrangements highlighted by the review, there are number of areas that require immediate change:

• Methods for determining clinical leaders • Governing Body Composition • Membership and clinical engagement methods • Governance arrangements

In addition to the evidence provided from the CCG 360 degree survey, LMC survey of members and the review itself, the CCG has utilised a number of sources to inform the amendments

• Other ‘best practice’ constitutions • NHS England advice • Member practice engagement events • GP Consortia forums • Patient Forums • Local Medical Committee • CCG staff briefings and feedback

Methods of determining clinical leaders There are advantages and disadvantages with an election and appointment process. Election is more likely to maintain the ownership of the member practices and ensure the leaders are responsive to their members. Appointments are more likely to ensure the leaders have the right skills, competencies and attributes.

Whilst there are diverse views on this issue there is overwhelming support for the development of a model that provides a balance between election and appointments based on skills, knowledge and experience.

With that in mind, it is suggested that a model is adopted that fulfils both of those requirements.

The Chair and Medical Director/Assistant Chair will be elected posts. Each role will have a defined job description and person specification outlining duties, expectations and skill-set criteria. Additionally, the Chair will be approved or accredited through any stipulated assessment process, including any required by NHS England within 3 months of taking office. The tenure for these posts will be four and three years respectively so as to provide continuity.

Those who meet the defined criteria and are also a GP (partner or salaried) on the performers’ list and working substantively in a Wirral practice, will be eligible to stand for election.

Each practice will be balloted (as members of the CCG are practices, not individuals), with a weighting based on list size (based on multiples of 2500 registered patients, where 1-2500 would be 1 vote, 2501-5000, would be 2 votes and so on).

For both roles, the candidate with the largest number of votes will be elected to the position.

The Governing Body defines a further 4 GP Clinical Lead Posts, which mirror the key work-streams of the CCG. These also reflect the Joint Strategic Needs Assessment and the Vision 2018 `for a healthier Wirral` programme.

• Primary Care • Unplanned Care • Planned Care • Long Term Conditions

Given the future challenges and opportunities faced by Primary Care it is suggested that the Lead Primary Care post also adopts an elected process. The CCG would work with the Local Medical Committee in ensuring all election processes are robustly conducted.

For the remaining posts in Unplanned Care, Planned Care and Long Term Conditions, as these require specific skills, interest and experience these will be selected through a process of assessment and interview against agreed job

descriptions and specifications. For each of these posts, along with the Primary Care lead post, it is suggested that the have a three year tenure so as to ensure equity between the elected and appointed posts.

To ensure an open and transparent process, member involvement and probity, it is suggested that the Local Medical Committee, Lay Person and an external assessor are part of the panel assessment process.

In addition to these posts so as to provide stronger assurances it is further proposed that two additional positions are developed. An additional GP role, elected by the Membership Council and an independent Registered Nurse who would be appointed in the same way as the Secondary Care Doctor. The CCG would be supportive of involving the Local Medical Committee in the appointment of the Registered Nurse. Both roles add to the independent assurance challenges at Governing Body.

Board Composition (Clinical)

Governing Body composition Other constitutions reviewed demonstrated a mix of approaches to Governing Body membership. Wirral Practice membership feedback favoured a strong clinical influence and hence the balance of representation is towards clinical members, with a view that the posts identified below should all be held by GPs currently working in Wirral practices.

This is balanced by statutory requirements to have additional clinicians on Governing Body such as a Secondary Care Doctor and a Registered Nurse. There are currently also two statutory Lay Members (one acting as a patient champion and one leading on audit and governance) and it is further proposed that an additional Lay Member is recruited to provide additional assurance. As a result the managerial posts on the Governing Body are in a voting minority. These managerial posts are reflective of the functions of the CCG. Also in attendance at the Governing Body will be a representative from Healthwatch and a representative from the Local Medical Committee, to provide further external assurance and scrutiny. In summary: Clinical (where a requirement of the post)

• Chair (GP) • Medical Director (GP) • Clinical Lead Planned Care (GP) • Clinical Lead Unplanned Care (GP) • Clinical Lead Long Term Conditions (GP) • Clinical Lead Primary Care (GP) • Membership Council Representative (GP) • Director of Quality and Patient Safety (Registered Nurse) • Registered Nurse • Secondary Care Doctor

Managerial (clinicians can occupy these roles, but not a requirement of the post)

• Accountable Officer • Director of Commissioning • Chief Financial Officer • Director of Corporate Affairs

Lay Representation

• Audit and Governance • Patient Champion • Additional Lay Member

In attendance

• Director of Public Health • Director of Adult Social Services • Local Medical Committee • Healthwatch

Membership and clinical engagement methods

The development of a clinical senate as new approach to wider clinical engagement

• The Clinical Senate will provide the opportunity for clinicians to establish a multidisciplinary group in influence and driving forward service transformation.

• The Clinical Senate will ensure that improved health outcomes for the population of the Wirral are underpinned by a focus on quality and safety.

• In developing a truly integrated approach to the provision of health care, the Clinical Senate will contribute to the delivery of the CCG’s strategic and operational plans whilst providing clinical ownership of the objectives of the CCG.

• The Clinical Senate will provide a clinical perspective on provider and primary care performance, guiding how issues could be remedied whilst ensuring any improvement requirement are from within a perspective of maintaining quality and safety.

• Its key duties will be to:

Inform commissioning reform in the areas of:

Major clinical strategic areas including clinical service planning and reform, models of care and service delivery

Strategies to improve patient care by improving the integration of services to patients across all settings of care

Identifying relevant innovations, emergent best practice and research findings in healthcare to inform future strategies

Strategies to support the transformation of health and social care services to reduce the growth in hospital demand

Influence clinical excellence when developing:

Strategies to implement clinical guidelines and standards Strategies to improve the safety quality, efficiency and sustainability of

clinical services and prevention strategies Strategies to improve the professional links between partners

organisations and professional groups

Recommend:

The Senate will discuss and make recommendations on key clinical issues as determined by the work plan of the group or as requested by the Governing Body

The development of a Membership Council to create a Wirral Wide practice engagement forum

Membership Council will be a forum whereby member practices can come together to discuss and inform key commissioning issues. The principles behind the Members Council meeting are:

• To work effectively with GPs, including sessional and locum GPs, to feed the

practice’s views into commissioning decisions. • To facilitate relationships with Governing Body members and member

practices • To give voice to member practices by ensuring members are engaged,

informed and empowered to participate. • To seek advice and views of practice members of Wirral CCG • To represent their practice’s views and act on behalf of the practice • Facilitate communication between members and the CCG Governing body • To shape the culture of Wirral CCG • Driving forward improvements in the services for patients, carers,

communities

The development of a GP Provider Forum

This forum will be where GP practices can meet to discuss issues regarding GP practices in their roles as providers. This will be led by the GP Executive for Primary Care and would focus on issues such as implementation of enhanced services and other local schemes, Primary Care workforce issues, and other topical issues.

With the development of co-commissioning this forum is seen as a critical part of the new architecture.

Local sensitivity in commissioning

It is proposed that the 4 managerial ‘Heads’ within the CCG Commissioning structure will act as named link staff to 4 geographic MP constituencies. This will give practices a route to engage with the CCG in presenting local issues in their local communities. It is further suggested that practice managers, practice nurses and patient engagement groups will also operate on this basis so as to retain local sensitivity, share best practice and reflect variation of need.

The 4 managers will also regularly attend Neighbourhood Constituency meetings in these geographic areas to both inform commissioning, brief local residents and build partnerships with other agencies such as Police and Fire and Rescue.

From a planning perspective, the commissioning teams responsible for planning and delivery will ensure these local perspectives are taken into account when developing specifications that might require differential models that reflect and address health inequalities.

This addresses the call from members to develop local sensitivity without the need for bureaucracy and will need to develop and mature over time.

This will be an early consideration for the new GP Membership Council.

Governance arrangements There are four principle roles for any govenring body be it NHS or Industry. These are Accountability, Foresight or Vision, Strategy and Management. The table below applies this to the new CCG consitiution so as to provide members with a perspective of how future roles and influences will fit with the decion making process.

Accountability ForesightDevelopment of Values Development of Shared VisionDevelopment of Principles Identification of Key StakeholdersTransparency Future Scenario PlanningTesting Value for Money Identifications of InfluencesPolicy Making Sensitivity CheckingAssurances Local Engagement with PracticesCCG Audit Committee Clinical SenateApprovals Committee GP Membership CouncilGP Membership Council Local Medical Council

Communication Sensitising

Development of business Plan Making Best use of ResourcesAllocate Resources Priority SettingAudit Investments Targeted Resources sensitivityFinical Controls Clinical SenateValue for Money Developing New InitiativesImplementation RedesignRemuneration Committee Quality & Performance CommitteeProvider Forum Provider Forum

Management Strategy

Overview, Shaping, Thinking (GP Council / Clinical Senate)

Implementation (CCG Management - Operationalisation `Do`)

Valu

e Pr

otec

tion

(Ass

urna

ces f

rom

Gov

erni

ng B

ody)

Adding Value (Pt Groups / Clinical Senate / LM

C)

Implementation

Envisioning

Impact Assessment In line with the guidance from NHS England entitled “Procedures for Clinical Commissioning Group constitution change, merger or dissolution” (May 2013), the CCG will also engage with key stakeholders and patients in order to comply with the impact assessment. The CCG will also seek legal advice on the revised constitution prior to submission. Recommendation These constitutional amendments are a result of careful and considerate engagement and reflective of the urgent need for change. It is now recommended that these are incorporated into a revised constitution for consideration by the CCG Governing Body and submission to NHS England. Jon Develing Interim Accountable Officer

Integrated Performance and Finance Report Agenda Item: Reference:

Report to: Governing Body Meeting Date:

October 2014

Lead Officer: Mark Bakewell, Lorna Quigley

Contributors: CCG and CSU Finance and Business Intelligence teams

Governance: Link to Commissioning Strategy

Sound financial control is essential to the Clinical Commissioning Group (CCG) strategy and is directly linked to the delivery of the CCG Commissioning and Operational Plan for the financial year. Ensuring that services that the CCG commission for the population comply with patient’s rights under the NHS constitution.

Link to current governing body Objectives

To achieve financial control total with sound financial management. To ensure that providers achieve strong performance against national targets.

Summary: This report updates the Governing Body on; • Activity & Performance for Month 4 • Financial performance against budgeted allocation for

2014/15 as at Month 5 (August)

Recommendation: To Approve

To Note

Comments

Next Steps: Continuation of performance monitoring through the remainder of the financial year

This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

The report sets out the financial performance within the CCG for 2014/15 financial year

Value For Money

All expenditure plans are subject to an ongoing value for money review.

Risk The report details the key risks and how these will be monitored in year as part of the reporting process

Legal Legal advice is sought on issues as and when required.

Workforce The financial plan includes budgeted “running costs” expenditure and is reflective of the respective workforce implications in these areas

Equality & Human Rights

Plans will consider as appropriate the equality impact assessment for proposals within the budgeted expenditure

Patient and Public Involvement (PPI)

Budgets include funding to ensure continued involvement of patients and public in CCG decisions. Patient choice is a right under the constitution in relation to referral for treatment.

Partnership Working

The CCG works with a number of NHS Trusts and the Local Authority on a number of its commissioning budgets.

Performance Indicators

The plan reflects the planned achievement of statutory financial duties and patient’s rights under the NHS constitution

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This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name

Reference Submitted to Date Brief Summary of Outcome

QPF Updates Quality, Performance and

Finance Committee

30th September

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this

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“Your partner in a healthier future for all”

Finance & Performance Update to Governing Body Meeting

7th October 2014

“Your partner in a healthier future for all”

NHS Wirral CCG 14-15 Q1 14-15 Q2 14-15 Q3 14-15 Q4CCG Dashboard 2014/15

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

MRSA - Incidence of HCAI YTD 0 0 0 0 0 ####### ####### ####### ####### ####### ####### ####### #######C. difficile - Incidence of HCAI YTD 8 13 16 23C. difficile - YTD Ceiling 4 11 15 19

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

RTT admitted 90% 93.2% 93.6% 93.8% 91.8%RTT non-admitted 95% 97.4% 97.5% 97.1% 95.5%RTT incompletes 92% 94.9% 95.1% 94.5% 93.4%RTT 52+ week waiters 0 1 1 3 1

Diagnostics Diagnostics - 6 weeks+ <1% 3.7% 3.0% 0.9% 1.1% - 2 week wait 93% 97.4% 97.2% 95.6% 96.1% - Breast symptom 2 week wait 93% 96.0% 90.4% 95.9% 96.9% - 31 day first definitive treatment 96% 97.5% 98.1% 98.8% 97.3% - 31 day subsequent treatment - surgery 94% 100.0% 95.7% 92.6% 97.6% - 31 day subsequent treatment - drug 98% 100.0% 98.1% 100.0% 100.0% - 31 day subsequent treatment - radiotherapy 94% 100.0% 100.0% 96.8% 100.0% - 62 day standard 85% 80.9% 85.1% 91.9% 81.7% - 62 day screening 90% 100.0% 91.3% 86.7% 94.1% - 62 day upgrade n/a 88.0% 73.9% 78.6% 83.7%

Mixed Sex Mixed-sex accommodation breaches 0 1 1Mental Health CPA follow up within 7 days 95%

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

- Total elective (YTD) 4,080 8,152 12,438 16,870 - Total elective plan (YTD) 4,217 8,454 12,481 16,900 16,900 16,900 16,900 16,900 16,900 16,900 16,900 16,900 - Non-elective (YTD) 3,977 8,097 12,001 16,247 - Non-elective plan (YTD) 3,653 7,433 11,085 14,863 14,863 14,863 14,863 14,863 14,863 14,863 14,863 14,863 - Outpatients (YTD) 7,467 14,828 22,755 30,955 - Outpatients plan (YTD) 7,866 15,738 23,248 31,471 31,471 31,471 31,471 31,471 31,471 31,471 31,471 31,471 - GP referrals (YTD) 5,035 10,325 15,515 21,087 - GP referrals plan (YTD) 5,091 10,195 15,058 20,387 20,387 20,387 20,387 20,387 20,387 20,387 20,387 20,387

Q1 Q2 Q3 Q4

Cancer - 31 day

Health Outcomes Framework/Every one Counts

Safe environment and protecting from avoidable harm

NHS Constitution

RTT

Cancer - 2 week

Cancer - 62 day

97.5%

Other - Activity & Efficiency

“Your partner in a healthier future for all”

NHS Constitution -4 hour A&E

Category Outcome indicator

Baseline Preferred Outcome

Quarter 1 Performance

July 2014 Comment

Patients seen within 4 hours of attending

Arrowe Park 95% Higher 88.5% 89% As the WIC is on site this is a combined target

Arrowe Park (WIC)

95% Higher

99.7% 99.9%

Combined total

95% Higher

91.1%

91.5%

Victoria Central Hospital walk in Centre

95% Higher

99.7% 99.8%

Eastham Walk in Centre

95% Higher

99.7% 99.9%

“Your partner in a healthier future for all”

Friends and Family (in patient)

Acute Trusts: Friends and Family Test scores Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

Wirral University Teaching Hospital NHS FT 66 59 68 71 67 67 69 65 70 77 73 73Mid Cheshire Hospitals NHS FT 71 68 77 74 75 68 76 73 78 75 74 75The Clatterbridge Cancer Centre NHS FT 86 91 89 84 86 97 89 93 95 95 93 90East Cheshire NHS Trust 87 77 77 78 77 73 79 82 82 74 78 80Countess of Chester Hospital NHS FT 78 83 82 82 77 80 83 82 82 80 80 73Warrington & Halton Hospitals NHS FT 76 77 82 75 71 78 81 79 76 74 81 76#N/A#N/A#N/A#N/A#N/A

Acute Trusts: Friends and Family Test response rates Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

Wirral University Teaching Hospital NHS FT 20.6% 24.7% 21.5% 21.4% 31.3% 21.3% 23.3% 30.1% 21.2% 26.6% 44.6% 33.5%Mid Cheshire Hospitals NHS FT 30.2% 25.5% 33.7% 42.4% 32.7% 39.3% 45.9% 42.3% 45.6% 45.9% 49.8% 44.5%The Clatterbridge Cancer Centre NHS FT 49.1% 51.0% 42.7% 56.1% 38.8% 49.4% 31.8% 53.8% 50.5% 47.4% 60.8% 32.8%East Cheshire NHS Trust 18.8% 48.4% 39.2% 30.8% 34.1% 33.4% 33.3% 26.1% 30.1% 41.5% 21.0% 24.2%Countess of Chester Hospital NHS FT 44.9% 41.0% 36.0% 33.8% 47.1% 38.9% 34.6% 31.8% 32.9% 26.4% 45.9% 25.6%Warrington & Halton Hospitals NHS FT 13.2% 31.6% 35.8% 29.5% 27.9% 29.5% 43.8% 27.5% 27.3% 26.8% 34.6% 32.2%#N/A#N/A#N/A#N/A#N/A

“Your partner in a healthier future for all”

Friends and Family (A&E)

Accident and Emergency: Friends and Family Test scores Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

Wirral University Teaching Hospital NHS FT 23 16 46 34 49 79 90 90 89 89 86 89Mid Cheshire Hospitals NHS FT 55 56 58 59 58 66 59 63 69 68 65 55East Cheshire NHS Trust 45 54 49 58 56 60 53 46 55 44 52 52Countess of Chester Hospital NHS FT 69 53 55 57 57 49 48 64 51 57 60 53Warrington & Halton Hospitals NHS FT 20 46 48 42 35 42 45 39 42 35 41 40#N/A#N/A#N/A

Acccident and Emergency: Friends and Family Test response rates

Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

Wirral University Teaching Hospital NHS FT 17.8% 19.9% 22.1% 25.1% 21.2% 27.0% 25.3% 21.6% 26.9% 28.3% 19.9% 26.3%Mid Cheshire Hospitals NHS FT 14.7% 12.1% 17.7% 14.2% 15.4% 21.4% 18.4% 18.1% 22.8% 21.3% 21.0% 20.4%East Cheshire NHS Trust 24.9% 24.7% 20.4% 24.1% 21.3% 23.0% 20.7% 21.1% 21.6% 19.2% 18.7% 20.4%Countess of Chester Hospital NHS FT 21.9% 38.8% 14.9% 19.5% 13.4% 12.6% 15.9% 18.3% 19.0% 17.4% 21.2% 21.1%Warrington & Halton Hospitals NHS FT 4.4% 24.9% 29.6% 21.8% 19.9% 18.7% 15.1% 18.5% 23.1% 18.5% 20.8% 19.5%#N/A#N/A#N/A

“Your partner in a healthier future for all”

Friends and Family Ante natal

Maternity: Friends and Family Test Question 1 scores Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 50 69 74 90 87 80 83 91 94Mid Cheshire Hospitals NHS FT 64 61 53 42 61 42 65 73 61 60East Cheshire NHS Trust 81 85 62 77 71 86 75 76 75 82Countess of Chester Hospital NHS FT 50 100 100 0 100 100 71Warrington & Halton Hospitals NHS FT 100 64 80 80 77 77 73 61 42 50#N/A#N/A#N/A

Maternity: Friends and Family Test Question 1 response rate Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 0.0% 8.8% 6.1% 26.1% 12.8% 29.1% 12.7% 28.7% 33.7% 12.7%Mid Cheshire Hospitals NHS FT 4.6% 11.6% 13.2% 11.0% 14.8% 10.4% 22.2% 15.8% 16.6% 16.3%East Cheshire NHS Trust 10.9% 15.1% 27.9% 76.9% 74.3% 42.6% 31.4% 52.1% 30.9% 31.8%Countess of Chester Hospital NHS FT 0.0% 0.0% 1.8% 0.0% 1.5% 1.6% 1.1% 2.3% 1.1% 4.0%Warrington & Halton Hospitals NHS FT 3.2% 43.5% 14.0% 13.4% 5.4% 12.0% 13.4% 45.0% 35.7% 3.6%#N/A#N/A#N/A

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Friends and Family- Birth

Maternity: Friends and Family Test Question 2 scores Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 84 100 90 89 91 82 99 81 82 79Mid Cheshire Hospitals NHS FT 50 64 87 79 93 100 68 57 89 74East Cheshire NHS Trust 100 85 75 80 83 96 84 92 85 81Countess of Chester Hospital NHS FT 84 84 91 86 83 92 79 90 94 89Warrington & Halton Hospitals NHS FT 60 72 79 78 63 80 74 65 81 73#N/A#N/A#N/A

Maternity: Friends and Family Test Question 2 response rate Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 7.4% 17.8% 17.4% 16.2% 24.2% 25.5% 30.5% 33.5% 27.7% 24.3%Mid Cheshire Hospitals NHS FT 3.5% 4.3% 18.1% 12.3% 13.4% 6.7% 12.9% 14.0% 11.6% 9.7%East Cheshire NHS Trust 1.7% 19.9% 33.7% 58.6% 35.3% 16.5% 24.3% 54.9% 34.0% 21.6%Countess of Chester Hospital NHS FT 17.2% 16.3% 16.9% 8.8% 20.7% 27.3% 16.5% 27.2% 28.5% 15.5%Warrington & Halton Hospitals NHS FT 12.5% 44.9% 33.3% 6.4% 18.0% 37.6% 43.7% 48.9% 48.9% 31.4%#N/A#N/A#N/A

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Friends and family –post natal ward

Maternity: Friends and Family Test Question 3 scores Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 79 93 72 86 97 81 94 92 73 77Mid Cheshire Hospitals NHS FT 50 27 70 67 91 76 63 62 70 55East Cheshire NHS Trust 66 80 74 88 74 100 87 79 80Countess of Chester Hospital NHS FT 84 84 88 59 72 86 68 82 82 76Warrington & Halton Hospitals NHS FT 47 69 75 68 74 74 67 59 74 62#N/A#N/A#N/A

Maternity: Friends and Family Test Question 3 response rate Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 15.2% 13.7% 21.3% 16.2% 31.2% 28.2% 30.5% 28.7% 20.8% 23.8%Mid Cheshire Hospitals NHS FT 3.3% 4.2% 9.4% 23.6% 15.1% 24.6% 20.8% 18.9% 24.2% 21.2%East Cheshire NHS Trust 0.6% 21.1% 36.1% 57.3% 43.4% 12.0% 11.8% 57.7% 29.9% 20.1%Countess of Chester Hospital NHS FT 16.4% 15.5% 24.3% 8.4% 18.8% 26.1% 15.8% 26.4% 28.0% 15.5%Warrington & Halton Hospitals NHS FT 12.9% 47.7% 41.2% 12.4% 33.5% 43.3% 41.0% 51.5% 49.5% 34.5%#N/A#N/A#N/A

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Friends and Family-Post natal community

Maternity: Friends and Family Test Question 4 scores Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 73 50 97 88 100 100 96Mid Cheshire Hospitals NHS FT -40 63 74 46 64 56 79 30East Cheshire NHS Trust 77 88 92 79 80 77 88 80 87Countess of Chester Hospital NHS FT 100 100 100 83 100Warrington & Halton Hospitals NHS FT 29 88 82 73 65 77 100 78 67#N/A#N/A#N/A

Maternity: Friends and Family Test Question 3 response rate Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Wirral University Teaching Hospital NHS FT 0.0% 6.8% 4.1% 14.1% 7.4% 9.5% 4.3% 10.9%Mid Cheshire Hospitals NHS FT 2.1% 0.0% 15.6% 17.6% 16.0% 18.0% 19.8% 16.4% 10.3%East Cheshire NHS Trust 8.3% 9.5% 15.8% 53.9% 54.8% 44.8% 35.8% 40.8% 52.8%Countess of Chester Hospital NHS FT 0.0% 0.0% 0.0% 0.0% 0.5% 0.6% 1.2% 3.4% 1.2%Warrington & Halton Hospitals NHS FT 4.6% 33.6% 18.2% 21.1% 14.4% 17.6% 6.7% 14.8% 8.5%#N/A#N/A#N/A

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2014/15 Key Planning Requirements

• 1% Surplus - £4.68m • 2.5% Headroom (non-recurrent resources) - £11.4m • Minimum 0.5% Contingency

– CCG hold £3m vs £2.2m (0.5%)

• Better Payment Practice Code • Cash Management

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Year to Date (Month 5) – Financial Performance Planned Year to Date Surplus - (£1.95m) Current Year to Date Surplus - (£1.24m) * Activity based contracts for month 4 (contracts) / month 3 (prescribing)

Key Issues • WUTH Contract Position – (£1.7m) under @ M4 vs [(£1.05m) @ M3

(£1.7m) @ M2] • Other NHS Providers – Notably Royal Liverpool and Broadgreen (£0.42m)

over • Commissioned Out of Hospital - £0.678m (In Month increase in CHC /

Package costs) • Prescribing £0.16m over performance (in month improvement £0.1m) • QIPP Gap 5/12 - £2.6m (of £6.3m)

(£0.7m) variance from plan, In Month over performance position has held

between Month 4 (July) and 5 (August)

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Forecast Outturn 2014/15 Forecast Assumptions • Planned Forecast Surplus - £ 4.68m (1%) – remains deliverable but not

without risk an • Risks remain consistent with plan around main expenditure areas

– WUTH (variation away from outturn as per QIPP assumptions) – Prescribing, – Commissioned Out of Hospital Care, – QIPP Gap

• YTD position reflect challenges of forecast delivery

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QIPP Plan 2014/15 £ m

Original QIPP Planning Assumptions (4.1)

Updates to financial planning assumptions 0.2 Includes Prescribing / Contract Settlements

Vascular Activity Shift Risk (WUTH NEL Block) (2.2) Specialist Commissioning Impact - Resource Transfers (1.0) - Risk Management 14/15 (0.4) Resource Utilisation (Demand Mgt / Restitution) 1.2

As at Month 5 (6.3)

Offset by Anticipated WUTH Contract Underperformance 2.5 Includes QIPP Schemes, Impact of PLCP and C2C

Contingency (Full Value £3m) 3.0

Planning Gap (0.8) To be met by

Other Underperformance / Slippage / Vascular Activity

Assumes all other budgets breakeven

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Self Assessment at Month 5 (August) 2014/15

No. IndicatorPrimary /

Supporting Indicator

Self Assessment Month 3 (June

2014)

Self Assessment Month 4 (July

2014)

Self Assessment Month 5

(August 2014)

1 Underlying recurrent surplus Primary Green Green Green2 Surplus - year to date performance Primary Green Amber Amber 3 Surplus - full year forecast Primary Green Green Green4 Management of 2% NR funds within agreed processes Supporting Green Green Green5 QIPP ** - year to date delivery Primary Amber / Green Amber / Green Amber / Green6 QIPP ** - full year forecast Primary Amber / Green Amber / Green Amber / Green

7 Activity trends - year to date SupportingIndicator - Not yet

AvailableIndicator - Not yet Available

Indicator - Not yet Available

8 Activity trends - full year forecast SupportingIndicator - Not yet

AvailableIndicator - Not yet Available

Indicator - Not yet Available

9 Running costs Primary Green Green Green10 Clear identification of risks against financial delivery and mitigations Primary Green Green Green

11This covers internal and external audit opinions, and an assessment of the timeliness and quality of returns Supporting TBC - Green TBC - Green TBC - Green

12 Balance sheet indicators including cash management and BPCC Supporting TBC - Amber / Green TBC - Green TBC - Green

13 Financial plan meets the 2014 surplus planning requirement Supporting Green Green Green

Financial performance

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Other Performance Indicators Cash Management

– Balance as at the end of the August £69k

Better Payment Practice Code

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Other Issues • Hosting Arrangements

– Discussions held with Cheshire & Merseyside Commissioning Support Unit with regards to ceasing of arrangements relating to Isle of Man commissioner and use of CCG Ledger

• Continuing Healthcare Restitution – New Guidance suggests future financial year top-slice to

support national shortfall on risk share basis

Governing Body WCCG 07.10.2014 1/3

System Resilience Plan September 2014

Agenda Item: 4.2 Reference: GB14-15/0040

Report to: Governing Body Meeting Date: 7th October 2014

Lead Officer: Sarah Quinn, Commissioning Manager

Contributors: Lorna Quigley, Head of Performance Andrew Cooper, Vision 2018 Programme Manager for Unplanned Care Angela Denny, Performance Analyst

Governance: Link to Commissioning Strategy

BCF links to all 3 Vision 2018 programmes and the cross cutting integration board

Link to current strategic objectives

1 Prevent people from dying prematurely 2 Enhance the quality of life for people with long term conditions 3 Helping people to recover from episodes of ill health or following injury 4 Ensuring people have a positive experience of care 5 Ensuring people are treated and cared for in a safe environment and protected from avoidable harm

Summary: This paper summarises the current progress in the development of the system resilience group and the system resilience plan. Work undertaken to date has secured £2.4 million system resilience funding from NHS England.

Recommendation:

To Approve

To Note X

Comments

Next Steps:

System resilience group will continue to meet on a monthly basis and implement the work plan and the current version of the system resilience plan will continue to develop over the next few months.

Governing Body WCCG 07.10.2014 2/3

This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

£2.4 million system resilience funding has been secured from NHS England to support system resilience plan projects between October 2014 and March 2015.

Value For Money Each of the schemes within the plan have been assessed for VFM and will be monitored on a monthly basis to ensure they are delivering against expected benefits.

Risk There is a risk that the funded schemes will not deliver the expected benefits and ultimately the impact on 4 hour target performance required. This has been mitigated by monthly monitoring of KPIs and payment of funding to the providers involved in the schemes on a monthly basis.

Legal

Workforce The majority of the system resilience projects require investment in and recruitment of additional staff across a range of staff groups.

Equality & Human Rights

Patient and Public Involvement (PPI)

Partnership Working

The system resilience plan for Wirral has been developed in conjunction with all members of the system resilience group including Wirral University Teaching Hospitals NHS FT, Wirral Community NHS Trust, Cheshire and Wirral Partnership NHS FT, Wirral Council and the North West Ambulance Service.

Performance Indicators

Performance indicators are in place for each scheme and will be monitored on a fortnightly basis in the urgent care recovery plan meetings and on a monthly basis in the system resilience group.

Do you agree that this document can be published on the website? (If not, please note that it may still be subject to disclosure under Freedom of Information - Freedom of Information Exemptions

Governing Body WCCG 07.10.2014 3/3

This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome System resilience plan

System Resilience Group

16th September 2014

Approved and amendments requested to be made prior to submission to NHS England

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Officer.

NHS Wirral CCG

Operational Resilience and Capacity Plan

2014/15

Draft agreed with:

Wirral University Teaching Hospital NHS FT

Wirral Community NHS Trust

Cheshire and Wirral Partnership NHS FT

Wirral Council

To be agreed with:

North West Ambulance Service

Version 2

22nd September 2014

1. Introduction

1.1 NHS England, Monitor, the NHS Trust Development Agency and the Association of Directors of Adult Social Services have recently published a joint guidance document to support planning for operational resilience during 2014/15. This guidance covers both urgent and planned care and measures to support the changes which will arise through the Better Care Fund.

1.2 The guidance sets out best practice requirements across planned and urgent and emergency care that each system should reflect in their local plan and the evolution of Urgent Care Working Groups (UCWGs) into System Resilience Groups.

1.3 System Resilience Groups are to become the forum where capacity planning and operational delivery across the health and social care system is co-ordinated.

1.4 This guidance also requires the Wirral health and social care economy to publish a System Resilience Plan, signed by all members

of the System Resilience Group.

1.5 The guidance makes clear that resilience needs to be delivered while maintaining financial balance and that there can be no trade-off between finance and performance.

1.6 The paper also refers to the work being undertaken by local systems this year setting the ground work for the longer term changes to strategic and operational delivery that will be brought about by outputs from the Urgent and Emergency Care Review. It states ‘the review and its proposals will have a clear impact on the operations of UCWGs within local systems’. Phase 2 of this review is expected to report in the Autumn of 2014.

1.7 Wirral CCG is currently in the process of developing an urgent care strategy as part of the Vision 2018 programme, to set out a strategy over 5 years and respond to the findings of the national Urgent and Emergency Care Review.

2. Local reviews of the unplanned care system

2.1 Wirral CCG has recently commissioned 2 key reviews from the Greater Manchester Commissioning Support Unit (GMCSU), the utilisation management review and a point prevalence review.

2.2 The WUTH, along with partners from across the economy have also undertaken two “perfect days” to work with clinical teams to understand the issues with the system and patient pathways that are causing delays. A further “perfect day” will be held in November to test some of the changes that have been put in place as a result of this initiative.

2.3 The Wirral has now completed a “deep dive” with the North West Ambulance Service (on 18th September) and lessons learned from this will feed in to the development of plans going forward. There is already a significant focus on putting services in place to support the ambulance service in 2015/16 Better Care Fund plans.

2.4 The recovery plan arising from these reports and the perfect day initiative is now in place and has been signed off by all Director leads from key health and social care economy partners. Please see Appendix 1 for completed recovery plan.

3. Wirral Urgent Care Conference

3.1 An urgent care conference was held on 18th September 2014, led by the Accountable Officer of the CCG and the Chief Executive of WUTH. Over 100 representatives from primary care, WUTH, WCT, CWP, DASS, patient groups were brought together to hear about the level of challenge that that Wirral economy is facing in urgent care now and into the future.

3.2 There were also presentations from areas of best practice in acute medicine and primary care; and plenary sessions to discuss some of the key challenges and brain storm solutions.

3.3 A summary of key actions from this conference include: • Development of a voluntary sector ‘showcase’ • Focus on making cross-organisational barriers invisible • Development of a ‘consistent offer’ to patients for unplanned care • Development of a comprehensive Directory of Service that is user-friendly for

clinicians • Redesign of Single Point of Access to offer senior clinician triage • Joined up I.T across the system’

3.4 It was agreed at the end of the conference that a task and finish group would be set

up to ensure that these actions were taken forward linking in with existing groups.

3.5 The outputs from the working groups at the conference also affirmed that the current direction of travel with the development of the Urgent Care Vision and the work plans for the next 1-2 years, are focused in the right areas and delivery now needs to be the priority.

4. System Resilience Group

4.1 The Wirral System Resilience Group (WSRG) is a whole system network

designed to bring together multiple stakeholders from across Wirral. It enables all parts of the local health and social care system to co-develop strategies and collaboratively plan safe, efficient services for patients. On an annual basis the WSRG is responsible for recommending the approval of, updating and monitoring the Wirral System Resilience Plan and ensuring the actions it contains deliver the required level of performance improvement.

4.2 The proposed Terms of Reference of the have been drafted and agreed by the first meeting of the WSRG on 16th September and feedback is being received from partners. The group builds on those of the predecessor Urgent Care Working Group and take into account guidance to expand the group’s remit to cover elective care and to extend the membership of the group to include public health and the independent and voluntary sectors.

4.3 The Draft Terms of Reference includes the following proposed membership:

Commissioners • Chairman of the WSRG will be the Chairman of the CCG • CCG Interim Accountable Officer • CCG Planned and Unplanned Care Clinical Leads • CCG Head of Performance • Planned and Unplanned Care CCG Commissioning Leads

• Director of Adult Social Services • Public Health representative • NHS England representative

Providers Nominated representatives (clinical and / or managerial) from: • Wirral University Teaching Hospital NHS FT • Wirral Community NHS Trust • Cheshire and Wirral Partnership NHS FT • North West Ambulance Service • Local Pharmaceutical Committee representative • Independent sector • Voluntary sector • Healthwatch

4.4 The WSRG agreed a number of actions at the first meeting on 16th September 2014,

which are noted in the action plan section below (section 6). 5. Summary Capacity Plans and Current Performance

5.1 Monthly capacity plans and performance to date are shown in detail (month on month) in Appendix 3 and are summarised below:

2014/5 Plan Q1 Plan Q1 Activity

Q1 Variance Q1 2013/4

Referrals 93886 23389 24049 +2.8% +2.0% (GP) Outpatients 144948 36113 35147 - 2.7% +2.6% (GP) Elective 50106 12481 12438 - 0.3% - 6.4% (GP) A&E 113398 28272 29727 +4.9% +2.8% Non Elective 44443 11085 12001 + 8.3% +5.1% (GP)

5.2 Feedback from ECIST on the WSRG plan highlighted the need for the Wirral economy to understand capacity and demand on an overall strategic basis across planned and unplanned care; and also in relation to capacity across key staff groups. The WSRG agreed on 16th September to add a review of system capacity and demand to its work plan (see section 6).

5.3 The ECIST review also highlighted the need to understand and have systems in place to monitor capacity and demand on a daily / weekly basis to ensure that actions can be taken in response to rising demand at the time that it is occurring.

5.4 Daily teleconferences are now taking place across the economy, chaired by the CCG and attended by key operational managers from WUTH, WCT, CWP and DASS. To support this daily discussion, the CCG has developed a template which is required to be filled in by each partner on a daily basis prior to the teleconference.

5.5 Operational actions are agreed from this meeting and followed up the same day to ensure they have been implemented. If issues are not resolved then they are escalated to Directors on call.

5.6 It is now confirmed that the economy is using the predictive tool provided by the Greater Manchester Commissioning Support Unit on a daily basis to predict admissions and discharges; and that this is playing a key part in both bed management within the acute trust and the daily economy teleconferences.

5.7 Key recurring issues from teleconferences were reported back to the first meeting of the WSRG and this will continue to be a standing item.

5.8 Further work is planned to: • Review economy wide escalation plans and trigger points and feedback to the

next meeting on 21st October 2014 (a task and finish group has been convened to undertake this task)

• This review will include assessment of operational actions for increasing staffing capacity as per ECIST recommendations

• Review and revise daily information collected on dashboard and used in daily teleconferences to assess pressures across the system, including primary care

6. System Resilience Group Work Plan

6.1 Summary of actions agreed at the first meeting of the WSRG:

• Review lessons learned, economy wide escalation plans and trigger points and feedback to the next meeting on 21st October 2014 (a task and finish group across partners has been convened to undertake this task)

• Receive a regular report on progress with the development of the daily

teleconferences and key recurring themes and issues

• Review and revise daily information collected on dashboard and used in daily teleconferences to assess pressures across the system

• Develop a strategic performance dashboard and a draft of this will be

available for review at the next meeting on 21st October 2014

• Explore how links and regular communications can be developed with the West Cheshire SRG and report back to the next meeting on 21st October 2014

6.2 In addition WSRG plans to review the following areas and consider on 21st October

2014 how and when those reviews will take place:

• A review of capacity and demand across the economy for planned and unplanned care, including specific reference to staffing capacity is required (in addition to the operational actions that have already been put in place).

• Assessment of current plans (urgent care recovery plan and system resilience plans) against national priorities in response to ECIST recommendations that the current plans do not adequately address all areas. This will include how plans will support ambulance turnaround and patient safety.

• In addition to the above actions undertake a review of planned care system including:

o Access Policy against national rules and guidance in October o RTT policy and training plan o Sub specialty analysis of elective capacity and demand o ‘Right size’ outpatient, diagnostic and admitted waiting lists, in line with

demand profile, and pathway timelines (see IMAS Capacity and demand tools)

o local application of RTT rules o RTT validation for 2013/14 o Areas of good practice for referral management o Provision of choice

An initial report on the developments required to integrate planned care into the WSRG will be given at the next meeting on 21st October 2014 but further work will be required beyond this.

6.3 WSRG is integrating its work plan into Wirral’s Vision 2018 programme to ensure that

all programmes and projects are managed and evaluated in a consistent way, in line with the vision and strategy that has been agreed by all partner organisations and towards the 3 overarching priority areas of unplanned care, planned care and long term conditions.

6.4 All projects within the system resilience plan will be monitored via the Vision 2018 Programme Management Office under the unplanned and planned care workstreams and evaluation will be completed to assess investment and delivered outcomes for each initiative.

6.5 While this system is fully developed the urgent care recovery plan and regular fortnightly review meetings with all partners (chaired by the CCG) will continue to monitor the delivery of key actions.

6.6 WSRG has reviewed Wirral’s position against all areas of best practice set out in the

operational and resilience planning guidance. In addition to these areas, the Cheshire, Warrington and Wirral Local Area Team have also benchmarked the Wirral economy against additional areas of best practice for urgent care. As highlighted above in 6.2 this review will now be extended to include the detailed against national priorities highlighted by ECIST (see Appendix 8).

7. Next steps

7.1 The WSRG will now need to:

• Agree finalised terms of reference the next meeting on 21st October 2014

• Undertake the tasks as set out in the outline work plan summarised in section 6, which highlights tasks to complete for the next meeting on 21st October 2014

• Consider the key outstanding actions following feedback from ECIST review of plans how they will be addressed and by when

• Continue to monitor and update the system resilience and capacity plan monthly

over the winter period up to March 2015, including receipt of monthly reports on implementation of the urgent care recovery plan, system resilience plans and outcomes delivered for the investment made (via the Vision 2018 PMO structure)

Appendices

Appendix 1: Agreed urgent care recovery plan for the Wirral health and social care economy, (17th September version)

Appendix 2: Activity Plans and Current Performance

Appendix 3: Non elective system resilience plan

Appendix 4: Elective system resilience plan

Appendix 5: Lessons learned from winter 2013/14

Appendix 6: Escalation planning (currently under review)

Appendix 7: New system for daily teleconferences for WSRG

Appendix 8: Areas of best practice for elective and non elective care

Appendix 1: Wirral health and social care economy urgent care recovery plan

Final UCRP - 17th Sep 14 V3.docx

Appendix 2: Non Elective and Elective Activity Plans and Current Performance

Referrals

Referrals Month

2013/14 Actuals 2014/15 Plan 2014/15 Actuals Activity vs Plan Variance

Activity vs Plan % Variance

GP Year on Year Var %

Other Year on Year Var %

GP Referrals

Other Referrals

GP Referrals

Other Referrals

All Referrals

GP Referrals

Other Referrals

All Referrals

GP Var

Other Var

All Var

% Var GP

% Var Other

% Var All

April 5394 2909 5091 2815 7906 5035 2826 7861 -56 11 -45 -1.1%

0.4% -0.6%

-6.7% -2.9%

May 4973 3082 5104 2826 7930 5290 2949 8239 186 123 309 3.6% 4.4% 3.9% 6.4% -4.3% June 4850 2790 4863 2690 7553 5189 2760 7949 326 70 396 6.7% 2.6% 5.2% 7.0% -1.1% July 5338 2836 5329 2947 8276 August 4868 2487 4868 2692 7560 September 4977 2672 5094 2817 7911 October 5413 2842 5326 2947 8273 November 4692 2574 4630 2560 7190 December 4327 2637 5325 2947 8272 January 5208 3137 5094 2818 7912 February 4664 2708 4630 2560 7190 March 5079 2859 5095 2818 7913 Year to Date

15217 8781 15058 8331 23389 15514 8535 24049 456 204 660 3.0% 2.4% 2.8% 2.0% -2.8%

Full Year

59783 33533 60449 33437 93886

Elective

Elective Month

2013/14 Actuals 2014/15 Plan 2014/15 Actuals Activity vs Plan Variance

Activity vs Plan % Variance

GP Year on Year Var %

Other Year on Year Var %

Elective Ordinary

Elective Daycase

Elective Ordinary

Elective Daycase

All Elective Elective Ordinary

Elective Day Case

All Elective El Ord Var

El DC Var

All Var % Var Ord

% Var DC

% Var All

April 761 3341 749 3468 4217 618 3462 4080 -131 -6 -137 -17.5% -0.2% -3.2% -18.8% 3.6% May 721 3324 759 3478 4237 745 3327 4072 -14 -151 -165 -1.8% -4.3% -3.9% 3.3% 0.1% June 749 3163 716 3311 4027 726 3560 4286 10 249 259 1.4% 7.5% 6.4% -3.1% 12.6% July 777 3576 788 3631 4419 August 673 3136 723 3317 4040 September

691 3435 749 3469 4218

October

811 3830 789 3628 4417

November

827 3597 681 3156 3837

December

643 3204 787 3625 4412

January

708 3830 753 3470 4223

February

734 3341 680 3157 3837

March 709 3875 753 3469 4222 Year to Date

2231 9828 2224 10257 12481 2089 10349 12438 -135 92 -43 -6.1% -0.3% -6.4% 5.3%

Full Year

8804 41652 8927 41179 50106

Outpatients

Out patients Month

2013/14 Actuals 2014/15 Plan 2014/15 Actuals Activity vs Plan Variance

Activity vs Plan % Variance

GP Year on Year Var %

Other Year on Year Var %

Out patients

GP Written Referrals Seen

Out patients

GP Written Referrals Seen

Total Out patients

Out patients

GP Written Referrals Seen

Total Out patients

OP Var

Seen Var

All Var

% Var OP

% Var Seen

% Var All

April 7547 4229 7866 4351 12217 7467 4053 11520 -399 -298 -697 -5.1% -6.8% -5.7% -1.1% -4.2% May 7606 4262 7872 4359 12231 7361 3915 11276 -511 -444 -955 -6.5% -10.2% -7.8% -3.2% -8.1% June 7017 3957 7510 4155 11665 7927 4424 12351 417 269 686 5.6% 6.5% 5.9% 13.0% 11.8% July 8100 4455 8223 4552 12775 August 7162 3862 7513 4158 11671 September 7943 4336 7865 4351 12216 October 8746 4879 8222 4551 12773 November 7986 4403 7150 3955 11105 December 7511 4277 8219 4546 12765 January 7938 4337 7862 4349 12211 February 7178 3950 7149 3955 11104 March 7765 4345 7863 4352 12215 Year to Date

22170 12448 23248 12865 36113 22755 12392 35147 -493 -473 -966 -2.1% -2.7% 2.6% -0.4%

Full Year

92499 51292 93314 51634 144948

A&E

A&E Activity Trajectories A&E Attendances - All types

2013/14 Forecast Outturn 115712

2014/15 Total 2% Reduction forecast 113398

Q1 14/15 plan Q1 (yr/365*91days) 28272

Q1 Actual Activity 2014/15 29727 forecast for yr (Q1 * 4) 118909 Plan Variance Q1 2014/15 Over 1455 Forecast Plan Variance Q1 14/15 Over 4.9% Plan Variance 14/15 - forecast yr over 5511 Forecast Plan Variance 14/15 over 4.9%

13/14 comparison 3197 Variance 13/14 to current over 2.8%

Non Elective

Non Elective Month

2013/14 Actuals 2014/15 Plan 2014/15 Actuals Activity vs Plan Variance

Activity vs Plan % Variance

GP Year on Year Var %

Non Elective

Non Elective

All Non Elective

Non Elective

All Non Elective

GP Var

All Var

% Var GP

% Var All

April 3909 3653 3653 3977 3977 324 324 8.9% 8.9% 1.7% May 3940 3780 3780 4120 4120 340 340 9.0% 9.0% 4.6% June 3566 3652 3652 3904 3904 252 252 6.9% 6.9% 9.5% July 3829 3778 3778 August 3729 3775 3775 September 3561 3652 3652 October 3876 3776 3776 November 3950 3652 3652 December 4259 3773 3773 January 4070 3773 3773 February 3573 3407 3407 March 4013 3772 3772 Year to Date

11415 11085 11085 12001 0 12001 916 0 916 8.3% 8.3% 5.1%

Full Year 46275 44443 44443

Appendix 3

Wirral non elective & elective system resilience plans

See template attached below:

Wirral op-res-cap-plan-temp

Appendix 4

North West Ambulance Service system resilience plan

See template attached below:

(Item 4-2-2) - NWAS op-res-cap-plan-temp

Appendix 5

Lessons learned from winter 2013/14

The attached paper was received and noted by the Wirral Urgent Care Working Group on

Urgent Care Working Group Evaluation repo

Appendix 6

Escalation Planning 2013/14 (currently under review)

The attached paper was agreed by the Urgent Care Working Group on:

Winter Planning 2013 v8.doc

Appendix 7

New system for Wirral economy daily teleconferences

The attached paper was agreed by the Urgent Care Working Group on:

Teleconferences proposal v1.doc

Appendix 8: Review of best practice

Elective areas of best practice Planning

• Review and revise access policy

• Develop and implement RTT training programme

• Carry out annual analysis of capacity and demand

Building on existing work

• Build upon any capacity mapping that is currently underway Pathway redesign

• Ensure that all specialties understand elective pathways for common referral reason / treatment plans

• Ensure that “patient choice” and patient rights under the NHS constitution are

communicated

• Right size outpatient diagnostic and admitted waiting lists Measurement

• Review local application of RTT rules

• Pay attention to RTT data quality

• Put in place clear and robust performance management arrangements

• Ensure supporting KPIs are well established Governance

• Provide assurance during quarter 2 2014/15 at Board level on implementation of the above.

Non elective areas of best practice Planning

• Discharge planning

• Avoiding inappropriate delays in A&E

• Working with ambulance services

• Unscheduled care

• Flu planning

• Maintaining or improving financial performance

• Manage referrals effectively Patient experience

• Right care, right time, right place

• Children’s services

• Mental health services Chronic conditions and home care Caring for patients with chronic conditions Planning for care home residents

Best practice and national priorities reviewed by LAT

Wirral position

RAT model In plans to be implemented

RAID model In plans to be implemented

Hear&Treat and See&Treat Already in place

Access to primary care in A&E

Already in place

7-day cross-system working In plans to be implemented

Facilitating and minimising delayed discharge

In plans to be implemented

Commissioning alternatives for high-risk patients, and appropriate data-sharing

The development of integrated teams in the community on the Wirral includes a project to implement risk stratification, which is currently being developed and will be rolled out by the end of October 2014. Currently the model covers both high and medium risk tiers. Until the development of the tool is complete it is not possible to report the exact % of the population this will cover, but it will be available in October when the tool development is complete.

Preventing admissions from residential and nursing homes

A care homes steering group across the CCG, Council and other partner organisations has recently been formed to map all current projects to prevent admissions and support care homes on Wirral. Once this mapping exercise is complete a work plan will be agreed for key workstreams to be implemented.

Detailed report on national priorities highlighted by ECIST review:

1. Initiatives to reduce length of stay by expediting discharge (weekend discharge rounds; enhanced transport; home from hospital support; expedited take-out medicines (TTOs); additional juniors on rounds; daily ward rounds 7/7 on all wards; discharge to assess schemes; trusted assessor schemes etc).

2. 7-day working and extended hours (into the evening), not just by doctors but also relevant supporting players (therapists, social care assessors, mental health, imaging, hospital pharmacy etc)

3. Focused initiatives to prevent admissions from residential and nursing homes (see recent British Geriatrics Society guidance on care home medicine)

4. A focus on ambulance services: including reducing queuing at emergency departments, creating capacity to deal with surges, improving the response to GP urgent conveyance requests and see/hear and treat.

5. Schemes that are aimed at early senior review, including in emergency departments, acute medical

NHS WIRRAL CCG

System Resilience Update Background 1. NHS England, Monitor, the NHS Trust Development Agency and the Association of Directors

of Adult Social Services have published a joint guidance document to support planning for operational resilience during 2014/15. This guidance covers both urgent and planned care and measures to support the changes which will arise through the Better Care Fund.

2. The guidance sets out best practice requirements across planned and urgent and emergency care that each system should reflect in their local plan and the evolution of Urgent Care Working Groups (UCWGs) into System Resilience Groups.

3. System Resilience Groups are to become the forum where capacity planning and operational delivery across the health and social care system is co-ordinated.

4. This guidance also requires the Wirral health and social care economy to publish a System Resilience Plan, signed by all members

of the System Resilience Group.

5. The guidance makes clear that resilience needs to be delivered while maintaining financial balance and that there can be no trade-off between finance and performance.

Introduction

2. This paper sets out a summary of progress to date with the development of the Wirral System Resilience Group and Operational Resilience and Capacity Plan.

Summary of progress to date

3. The first Wirral System Resilience Group (WSRG) was held on 16th September 2014, chaired by the Wirral CCG chair, Dr Pete Naylor.

4. Draft terms of reference were discussed and will be finalised at the next meeting on 21st October 2014.

5. The new WSRG intends to build on the work of the Urgent Care Working Group but now also includes planned care.

6. WSRG considered the Wirral Operational Resilience and Capacity plan on 16th September and approved it once requested amendments were made.

7. The plan includes proposals for a range of schemes to be implemented over winter (October 2014 to March 2015) to support delivery of both the 4 hour target and the 18 week target.

8. This plan was submitted as required to NHS England on 19th September.

9. Following review by NHS England Wirral CCG were informed that system resilience funding to the tune of £2.4 million would be released to support the delivery and improvement in performance against the 4 hour target.

Next steps

10. The next steps include:

• Continue to develop the system resilience group and implement the work plan • Continue to develop the operational resilience and capacity plan as this work plan

is progressed • Work with providers to implement and monitor system resilience schemes

] Recommendations

11. The CCG Governing Body is asked to note the progress to date with the development of the system resilience group and operational resilience and capacity plan.

Sarah Quinn Commissioning Manager

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Better Care Fund Submission October 2014 Update

Agenda Item: 4.3 Reference: GB14-15/0040

Report to: Governing Body Meeting Date: 7th October 2014

Lead Officer: Sarah Quinn, Commissioning Manager

Contributors: Jacqui Evans, Head of Transformation, DASS Louise Morris, Senior Accountant Peter Tomlin, Integration Programme Manager Sheena Hennell, Commissioning Manager Anna Rigby, Vision 2018 Programme Manager Damien Boden, Performance Analyst, Wirral Council Lucy Jones, Accountant, Wirral Council

Governance: Link to Commissioning Strategy

BCF links to all 3 Vision 2018 programmes and the cross cutting integration board

Link to current strategic objectives

1 Prevent people from dying prematurely 2 Enhance the quality of life for people with long term conditions 3 Helping people to recover from episodes of ill health or following injury 4 Ensuring people have a positive experience of care 5 Ensuring people are treated and cared for in a safe environment and protected from avoidable harm

Summary: This paper summarises current progress with the development of the Better Care Fund, provides all the latest papers submitted to NHS England for the September submission and gives a summary of initial feedback from the national BCF assurance team.

Recommendation:

To Approve

To Note X

Comments

Next Steps:

Formal feedback on the Wirral BCF submission is expected from NHS England by the end of October 2014 CCG and Council commissioning teams are working on an implementation plan and with Vision 2018 Programme leads to ensure that the programmes and projects are set up and monitored via the new Programme Management Office.

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This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

The CCG is required to create a pooled budget with Wirral Council in 2015/16. The BCF proposal sets out the agreed use of this money to deliver the greatest benefit to the economy and meeting all the national requirements for BCF.

Value For Money Each of the 25 schemes within the BCF have been or are in the process of being assessed for value for money (depending on the level of development of the scheme) and the current view on return on investment is summarised in the modeling spreadsheet.

Risk The BCF narrative submission sets out and scores a number of risks associated with the BCF proposal.

Legal The CCG is required to set up a section 75 agreement with Wirral Council for the 2015/16 pooled budget. It is expected that national guidance will be given on this.

Workforce There are significant workforce implications within the schemes in the BCF, for example the development of integrated care coordination teams requires staff to work in multidisciplinary teams and be co-located. There is also a requirement for the implementation of 7 day working which will have a significant impact on staff.

Equality & Human Rights

This is being completed for each BCF scheme depending on the stage of development.

Patient and Public Involvement (PPI)

Patient and public involvement has been completed as part of the Vision 2018 programme.

Partnership Working

The BCF programme of work is being completed jointly with Wirral Council. There has also been significant provider engagement as part of the second submission as our major providers were required to sign off the return (see Annex 2s)

Performance Indicators

A BCF scorecrard has been developed which monitors both nationally required indicators and local indicators on a monthly basis.

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This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome BCF Update Joint Strategic

Commissioning Group

21st August 2014

Approved

BCF Update

Vision 2018 Programme

Managers Group

5th September 2014

Noted

BCF Update Joint Strategic Commissioning

Group

16th September 2014

Approved

BCF Update Vision 2018 Implementation

Group

16th September 2014

Noted

BCF submission

Health and Wellbeing Board

17th September 2014

Approved

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Officer.

NHS Wirral CCG and Wirral Council October 2014

NHS WIRRAL CCG and WIRRAL COUNCIL

Better Care Fund: October 2014 Update Background

1. The Better Care Fund (BCF) is explicitly intended to facilitate the integration of Health and social Care systems at a local level. The Health and Wellbeing Board has a critical role in influencing and monitoring progress in relation to integration, it has a key role in signing off submissions.

2. NHS Wirral Clinical Commissioning Group (CCG) and Wirral Council were required to re-submit a final ‘Better Care Fund’ plan for 2015 / 2016 to NHS England on 19 September 2014, following approval by the Wirral Health and Wellbeing Board on 17 September, explaining how they intend to improve local services.

Introduction

3. This paper sets out a summary of the current progress with the development of the Wirral Better Care Fund, including informal feedback on the latest submission from the national BCF assurance team

4. Attached is the full BCF submission that was approved at the Wirral Health and Wellbeing Board on 17th September 2014.

Summary of current progress

5. Following original submissions in April 2014, NHS England advised they would be requesting further detailed work nationally, in response to feedback received from the LGA, Department of Health and Acute Trusts. On 11 July 2014, Andrew Ridley made clear his intentions regarding a ‘pay for performance’ framework.

6. Revised high level guidance was circulated on 25 July 2014, with revised full guidance and the documents being used on 18 August 2014.

7. The new guidance specifically required the following:

• Finance: Plans must balance to total settlement (Minimum £28,009,000 locally).

• National Conditions: Details requested on the implementation of the Care Act, including assurance funding comes from CCG allocation.

• Non Elective Admissions:

National expectation of a minimum 3.5% reduction target. Nationally mandated payment by results attached.

• Other Outcomes &Measures:

Revision of baseline data from 2012/13 to 2013/14 These outcomes are not linked to performance payment.

• Scheme Specifications:

An individual annex to be submitted alongside BCF templates demonstrating impact of each scheme.

• Provider Commentary:

An individual annex to be submitted to allow each local provider to comment on deliverability of plans.

NHS Wirral CCG and Wirral Council October 2014

8. NHS Wirral Clinical Commissioning Group (CCG) and Wirral Council (WBC) have agreed through Vision 2018, with key providers, a level of ambition of 15% reduction in emergency admissions over three years.

9. NHS Wirral CCG and WBC have agreed with key partners that all operational plans would align to the level of ambition by April 2015.

10. In order to redesign services and achieve the 15% reduction in emergency admissions, NHS Wirral CCG and WBC have recommended 25 schemes, under four themed areas:

• Early Intervention and Prevention

• Keeping people in their local communities

• Step up / Step down services

• Mental Health, including drug and alcohol services.

11. Revised guidance clarifies the performance related element, focussing on delivery of the

reduction in non-elective admissions, 5% for 2015 / 2016. Payment will be related to delivery of the target. Potential funding will be held to mitigate the impact of non delivery and acute pressure.

September BCF submission

12. The Wirral Health and Wellbeing Board approved the latest submission for the Wirral BCF on 17th September 2014 which was submitted to NHS England on 19th September.

13. Informal feedback from the national BCF assurance team suggests that they consider the Wirral submission to be strong, the narrative was coherent, they were impressed by the scale of ambition on non-elective reduction and picked out provider engagement as being strong compared to other areas. They also noted that they will consider using the Wirral modelling summary template nationally for the next round of submissions.

Next steps

14. The next steps include:

• Formal feedback on the Wirral BCF submission is expected from NHS England by the

end of October 2014

• CCG and Council commissioning teams are working on an implementation plan and with Vision 2018 Programme leads to ensure that the programmes and projects are set up and monitored via the new Programme Management Office.

Recommendations

15. The CCG Governing Body is asked to note the current progress with the Wirral Better Care Fund Proposals.

Sarah Quinn Commissioning Manager

NHS Wirral CCG and Wirral Council October 2014

Jacqui Evans Head of Transformation, Wirral Council

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Continuing Healthcare Provision

Agenda Item: 4.4 Reference: GB14-15/0040

Report to: Governing Body Meeting Date:

Lead Officer: Iain Stewart, Chief Officer, Wirral Alliance Consortium

Contributors:

Governance: Link to Commissioning Strategy

Enhance the quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Ensuring people have a positive experience of care Ensuring people are treated and cared for in a safe environment and protected from avoidable harm

Link to current governing body Objectives

Summary: Service performance issues identified with CHC service from Cheshire & Mersey Commissioning Support Unit (CMCSU). Action plan received from CSU. Operational management decision taken to issue notice of service failure letter to CSU.

Recommendation: To Approve

To Note √

Comments Work is currently continuing on a CHC service assessment being undertaken by Mersey Internal Audit Agency (MIAA) which will be available for the November Governing Body meeting

Next Steps: CCG management team to collate outcome of MIAA assessment and prepare a proposal for addressing the service delivery of the CHC service.

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This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

Expenditure on Continuing Healthcare (CHC) packages continues to rise year on year due to an increase in the shift of care into the community for patients with complex care needs. The current year forecast for 2014/15 is a c£2m overspend against the CHC budget. A key element of the CHC Framework is the review of care packages to ensure the current care needs are being met and where appropriate, packages of care be reasonably adjusted. In the absence of regular reviews the CCG is unable to achieve best value for money against the use of its financial allocations.

Value For Money The CCG is not as informed as it needs to be via performance reporting and assurance on procurement processes, and as such cannot determine best value for money against the use of its financial allocations.

Risk Along with the financial risks (see above),the current CHC service delivery is creating the potential for clinical and safeguarding risks, due to the backlog of annual reviews of patients’ care packages.

Legal The CCG has a legal duty to achieve financial balance. The failure to commission high quality, best value services that will likely lead to budgetary overspends, will impact on this statutory requirement.

Workforce The CHC service is currently commissioned as an “end to end” service from the CSU. Over the past several months, CCG staff have increasingly been drawn into operational issues; complaints handling and performance reporting matters. It is unrealistic to absorb the responsibilities of an end to end service into an extremely lean CCG workforce.

Equality & Human Rights

The CCG must be mindful of its priority to ensure people are treated and cared for in a safe environment and protected from avoidable harm. Whilst the current performance issues exist within the CHC service commissioned from the CSU, the CCG must take action to assure itself that patients in receipt of CHC packages continue to be supported appropriately with their current care needs.

Patient and Public Involvement (PPI)

The increasing number of complaints received from patients and families about aspects of the CHC service (mainly delays in decision-making) represents involvement albeit a negative experience for those patients. The formation of a service user forum in conjunction with the existing CHC Forum could yield improvements in service experience.

Partnership Working

The CCG is part of a pan-Cheshire/Wirral approach to assessing CHC service delivery from the CSU with a view to sharing learning points and identifying opportunities for improvement.

Performance Indicators

Overall service delivery is not meeting agreed standards.

Do you agree that this document can be published on the website? (If not, please note that it may still be subject to disclosure under Freedom of Information - Freedom of Information Exemptions

This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

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Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome Verbal update Minutes Quality

Performance & Finance Committee

26th August 2014

Risk identified on financial spend and service performance matters

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Director/Officer.

Produced by Iain Stewart, Chief Officer, Commissioning Lead for Continuing Healthcare

NHS Wirral CCG

Continuing Healthcare provision Background

1. When the CCG was established in April 2013 it determined that a CHC service would be commissioned from the Commissioning Support Unit (CSU) as part of a wider Service Level Agreement covering a full range of support functions (e.g. Finance, Business Intelligence, Contracting etc). The service specification agreed, encompasses all aspects of a CHC service and is described by the CSU as an “end to end service”, meaning the CCG should only expect to have minimal involvement in operational and managerial aspects of the day to day delivery of the service.

2. It became clear during 2013 that increasing instances of operational and managerial issues were being presented to the CCG to resolve. It was also clear that processes for requesting funding authorisation for high cost packages or increases to existing packages of care, appeared un-co-ordinated, reactive and rushed, resulting in pressure on the CCG to approve high value cost proposals without a reasonable time to seek assurances that the proposals represented value for money and that all procurement options had been considered in determining the care package costs.

3. The CCG established a monthly CHC Forum as a means of enabling the

opportunity for the CSU provider colleagues to meet with the commissioner and discuss operational matters, planning considerations for changes in CHC payment rates; focus on greater explanation on processes used and improving knowledge about joint funded care packages developed in conjunction with Wirral Department of Adult Social Services.

4. As part of the current interim management arrangements within the CCG, the

interim Chief Operating Officer reviewed the current level of complaints received to-date on CHC-related issues. She identified serious failings in both the delay in responses and the overall content quality of responses, when finally provided to complainants. To-date, two complainants have written to the Parliamentary Health Ombudsman as a result of dissatisfaction with their responses.

Introduction

5. This paper updates Governing Body on recent key operational decisions taken by the management team to attempt to address current service matters and follows on from the issue identified in the Quality, Performance & Finance Committee on 26th August 2014 and subsequently included in the CSU Service Level Agreement update provided to Governing Body meeting on 2nd September 2014.

Produced by Iain Stewart, Chief Officer, Commissioning Lead for Continuing Healthcare

Current Issues identified

6. On 21st August 2014, the CCG met with senior managers from the CSU to discuss a range of concerns regarding the current service delivery and requested an action plan from the CSU. Key concerns were;

- Backlog of annual reviews (which increases the risk of safeguarding matters arising due to lack of updated clinical assessment and financial implications of care package costs)

- Performance reporting not adequate to inform the commissioner of key aspects of the service

- Speed of response in relation to patient queries about CHC eligibility decision-making and subsequent quality of complaint response letter content.

In response the CSU has provided an outline action plan to address the areas of concern raised (see Appendix 1).

7. A Due Diligence Review of the existing service has been completed on behalf

of the CCG (as part of a wider commission of work in conjunction with the Cheshire CCGs) and highlights a general failure to deliver the service in line with the service standards expected locally and nationally.

8. The CCG, along with the Cheshire CCGs has taken the decision to withdraw this service from the CSU on the basis of a failure to deliver the service in line with the agreed specification. Further concerns relate to the nature of complaints received from members of the public and timeliness of monitoring of care being received. A notice of service failure letter was sent to the CSU on 16th September 2014 (Appendix 2 refers).

9. The CCG continues to hold the CSU to account for on-going delivery of the

current service.

10. The Governing Body is asked to note the operational decision taken by the management team.

CHC/COMPLEX CARE FOR WIRRAL CCG – ACTION PLAN AUGUST 2014

Wirral CCG has shared concerns with CSU regarding four key elements of the CHC/Complex Care Service. The action plan below describes briefly our understanding of the issues and outlines the steps that will be taken to address these issues or provide further information for discussion with the CCG.

There was also an agreement to provide a comprehensive CHC/Complex Care report for the October 2014 CCG Board Meeting. It is proposed that this will be provided by September 22/23rd. Please confirm if this date is suitable.

Complaints: 1. Final draft responses lack an understanding of the key question/issue raised by the

complainant, do not have sufficient empathy and are too defensive. CCG would like to enable broader range of staff to understand complaints/disputes/restitution and the different requirements associated with each. There has in the past been a long delay in responding to complaints.

2. It was noted the CCG have 4 (long running) CHC complaints with the Ombudsman. It is

expected that the CCG will be asked to explain why the complainants faced delays through the process (of initial CHC delivery and in responding to the complaint raised).

Actions already taken

3 The immediate actions taken as a result of conversation between The Assistant Interim Accountable Officer at Wirral CCG and Head of Business Solutions at CMCSU are detailed below.

a) The CSU Head of Governance reviewed draft responses to create an analysis of

gaps in our capability b) The CSU complaints team are using responses approved by Assistant Interim

Accountable Officer as models for future responses c) Reinforced the meetings between complaints and CHC team so that there is a

regular focus for complaints which relate to current CHC cases d) Checked the process for review of all CHC complaints is still in place led by the Head

of Service for CHC e) Recognition of the need for regular review and/or training within the CSU for all those

staff handling complaints focussing how we have the discussion with the patient to understand their expectation and desired outcome from their complaint

f) Confirmation to the complaints team as to how the CSU CHC team share the workload for responding to complaints depending on what the nature of the complaint and the status of the request i.e. a. Current CHC case b. Dispute c. Retrospective case post 1/4/13 d. Retrospective case pre 1/4/13

4 From the observations of the above we will review the way the responses explain NHS CHC responsibility and accountability and use of plain English; with the intent of helping staff and CCG colleagues understand the arrangements, and differences for CHC, FNC, Disputes and CHC legacy claims.

5 A further internal action plan for delivery by the end of September with assistance being

provided by the CSU Service Transformation team is set out below:

Actions to be taken

A. Diagnostic of complaints 1/9/13 to 31/8/14 B. Summarise numbers and trends of complaints for CHC C. Interviews with CSU Business Solutions Locality leads to establish their

perceptions of the difficulties the CSU has with delivering excellence for complaints that relate to CHC & write up their views

D. Interviews with 3 Heads of Client Operations ( Debbie Fairclough; Phil Meakin; Paul Turner) to establish their perceptions of the difficulties the CSU has with delivering excellence for complaints that relate to CHC & write up their views

E. Interview Paul Butler and Jill Edwards who lead on inputs to all ‘legacy’ complaints and Anne Thompson Head of Governance /Debbie Invernizzi Centre Manager to pick up on their recent learning from involvement in delivery of complaints responses & write up their views

NOTE. CCG staff are not being interviewed as they have previously described their views on the process and difficulties and we do not want to impose on their time. If any further views are available they will be fed into review.

F. Summarise ‘evidence collated’; scope the issues and write a project plan which describes the actions that need to be undertaken – this may include actions for several CSU teams; CCGs, and other parties

G. Produce collateral , from existing resources which explains the difference between the different ‘routes’ that the CHC framework/DH guidance allows for complaints – current CHC cases; Disputes, retrospective cases after 1/4/13; retrospective cases before 1/4/13

H. Identify resources needed and oversee implementation of plan

Costs:

6 CCG believes CHC costs are escalating and that there is a high conversion rate for CHC. There appear to be a high number of high cost cases. CCG wants to understand reasons and whether Wirral is different from other areas. CCG would like assurance that authorisation process is being followed in all cases.

Actions to be taken

Taking into consideration the limited accuracy of historic data, the CHC/Complex Care Team together with Finance will:-

I. Analyse patient data on Broadcare to understand high cost patients and where possible benchmark against other CCGs locally, regionally and nationally.

J. Analyse Fast track referrals to establish whether they are valid palliative care cases. (Wirral CCG has a higher number of fast track referrals than any other CCG in Cheshire and Wirral.)

K. Analyse domiciliary cases to establish trends (where data permits) and impact of District Nursess withdrawing service via case studies.

L. Benchmark CHC/Complex Care (incl joint funded cases) in Wirral CCG against other CCGs locally, regionally and nationally particularly in respect of conversion rates, costs, numbers per 10,000 weighted population and trends around activity, cost and volume.

M. Describe the authorisation process including delegated authorities and a process to provide assurance to CCGs CSU is adhering to it.

CHC/FNC review backlog:

7 CCG wants to understand extent of backlog, reasons it has occurred, risks associated with it and plan of action to address.

Actions to be taken N. CSU will provide up to date data that details the current position regarding the backlog of

both CHC and FNC reviews and that at the point of transition from PCT to CCG. O. Based on the CSU’s Service Proposition document shared with CCGs in March 2014

further commentary will be provided detailing reasons why the backlog has occurred, options to address the problem together with associated risks.

Legacy Restitution:

8 CSU has provided a monthly update report detailing progress but CCG would like to understand more detail on progress to date, financial and activity projections and associated risks.

Actions to be taken P. Provide data on revised projections of both the number of claims that will progress to

decision panel, the potential claims payable and the resource required to undertake the activity.

Q. Provide information and options on the timescales for addressing the increased number of claims expected to progress to decision panel.

R. Meet CCG Director of Finance to review the above information. S. Agree further actions relating to legacy restitution.

Yvonne Lochhead Head of Continuing Healthcare and Complex Care Cheshire and Merseyside Commissioning Support Unit 25th August 2014

Chair: Dr Phil Jennings Chief Clinical Officer: Dr Abhi Mantgani

NHS Wirral Clinical Commissioning Group Old Market House

Hamilton Street Birkenhead

Wirral CH41 5AL

Tel: 0151 651 0011

WICCG.InTouch@nhs.net

Our Ref: JD

16th September 2014 Leigh Griffin Acting Managing Director Cheshire and Merseyside CSU Dear Leigh Notice of Service Failure: Continuing Healthcare, Complex Care, Funded Nursing Care We are writing formally to lodge our concerns regarding failure of the Continuing Healthcare, Complex Care and Funded Nursing Care service, provided to Cheshire and Wirral CCGs, as part of the 2014/15 Service Level Agreement. For the purposes of this letter we will refer to CHC in its broadest sense, covering CHC, Complex Care and FNC.

As you are aware we commissioned an independent Due Diligence Review of this service, a draft of which has been shared with the CSU and yourself for review and comment. Comments have been received from the CSU; however, evidence has not been provided that justifies a change to the findings of this report. The report has confirmed that there is an urgent need to re-commission the CHC service due to clinical quality, safety and governance concerns.

Whilst it is recognised that the CSU has inherited some legacy issues from PCT’s, the CSU has failed to address these during the last 2 years, and the service has therefore continued to experience substantial challenges that continue to impact on the operational performance of the CHC service. This review has highlighted a number of critical failure risks and issues associated with the service which we have summarised below:-

1. CHC Service Performance

The CSU is failing to deliver a comprehensive CHC service as outlined in the SLA for 2014/15. Levels of performance in key areas do not meet the national KPI targets and due to the significant workload pressures experienced by the service, and subsequent prioritisation of resources, means that 3-month and 12-month reviews are de-prioritised (see table 1 overleaf) because “they represent a financial rather than a clinical risk”. The CSU data supplied shows there are over 200 reviews (CHC and FNC) outstanding more than 12 months and some patients could be waiting up to 24 months before a review. Not only does this pose a potential financial risk to the CCGs, but there is also a potential clinical risk to patients. This has been raised as a particular concern by the CHC clinical teams.

Interim Chair: Dr Pete Naylor

Interim Accountable Officer: Mr Jon Develing

2. Clinical Leadership and Direction

There is a distinct lack of clinical strategic leadership and a lack of a transformational operating style that is essential in order to develop a continuous quality improving service. There is little evidence of strategic direction or of a strategic development plan showing actions taken to improve the service going forward. We would expect, given the level of clinical risk associated with this service, that the CSU would have in place an appropriate clinical director, operating at Board level, who could provide the clinical oversight, leadership and assurance required when managing such a service.

3. Capability and Capacity Issues

These issues have been widely acknowledged and recognised as a critical issue. Long-term sickness absence has and continues to be one of the major issues affecting the management of the service and operational delivery. The service is failing to meet its statutory targets and key performance indicators, and services are under significant pressure despite the CHC teams carrying a high workload and working significantly long hours to maintain service delivery.

Additional resources have been requested by the CSU to manage operational pressures in the service; however, we have seen no supporting evidence or case for the additional resource requests. This has been requested on behalf of CCGs and is still awaited. We would expect such a case to provide evidence as to the increases in activity and complexity of cases and also a plan with timescales as to how the additional resources will be used to reduce the operational pressures and stabilise the service.

Interim Chair: Dr Pete Naylor

Interim Accountable Officer: Mr Jon Develing

We recognise the operational challenges the service has faced, particularly in relation to complex, long-term sickness absence and are concerned about the lack of appropriate HR support to manage these long-standing, complex issues, which are detracting clinical staff from direct patient contact, and therefore adding to the operational issues experienced by the service.

It has also been acknowledged that statutory and mandatory training compliance has been adversely affected by the workload pressures on the operational teams, difficulties accessing some of the modules and completion of some modules not being recorded on the system. From the data provided by the CSU, 43.5% of staff still need to complete the required training to demonstrate compliance.

4. Governance and Assurance

We have serious concerns regarding quality assurance, in terms of delivering the service to the required quality standard, and in accordance with the National Framework for CHC and FNC. We are exposed to areas of clinical, safety and financial risk where reporting is weak and where there is no credible data/ information to provide us with the appropriate assurance.

5. Financial Management and Control

Understanding the financial risks and developing the ability to effectively forecast risk has been a critical area of concern. There has been little or no evidence that the service is organised and delivered to support the proactive management of CHC/ FNC costs to commissioners – which have showed signs during Q1 14/15 of spiraling out of control. Specifically, in the latter half of 13/14 there was instances of high cost cases incurring significant spend which were only identified towards the end of the financial year.

6. Performance Reporting

Financial, contracting and locality reports have been produced and issued, however, these have failed to assure the CCGs about the performance of the service, are lacking the level of data accuracy and completeness required, and have poorly supported CCG’s from a performance / business Intelligence perspective.

We recognise the inherited legacy position and the work that the CSU has undertaken to reconcile a significant number of datasets and to establish more robust performance reporting via Broadcare. The draft report produced for Eastern Cheshire CCG is a significant improvement from previous reports and is a good platform upon which to build the performance reporting function delivered through Broadcare. The issue of credible information and data remains a concern and priority for the CCGs.

Summary and Conclusion

The CHC service delivered by C&M CSU has been reactive rather than proactive, failing to deliver against national KPIs. There is a distinct lack of assurance, and concerns have been raised regarding the robustness of financial data, poor financial forecasting as well as inconsistent performance reporting and significant data quality issues. In relation to the latter, it should be noted that the data quality issues have, largely resulted from inherited legacy systems and processes that the CSU is continuing to work to resolve.

Interim Chair: Dr Pete Naylor

Interim Accountable Officer: Mr Jon Develing

Despite the significant challenges faced by the locality teams, it should be noted that the locality teams are highly thought of by the CCGs and have managed to sustain the operational elements of the service during testing circumstances.

Given the areas of concern identified, and the information supplied by the CSU, it is our view that without a fundamental change to the way in which the service is currently undertaken, there will be no significant improvement in the delivery of these services or addressing of our concerns. Only by triggering a change in ownership, accountability and taking direct control of the service will we feel confident that we will be able to drive service improvements aligned to our commissioning intentions, mitigate risk, and deliver value for money services for the patients we serve.

We now request the formal transfer of the locality teams (CHC and FNC), specialist nurses and their associated administrative support with effect from 31 January 2015. South Cheshire CCG will host the service on behalf of Cheshire and Wirral CCGs. We also request that the CSU establishes urgent measures to ensure the stability of the Continuing Health Care service, prior to transition to the Clinical Commissioning Groups at the end of January 2015. We also request that the CSU provides ongoing assurance that a stabilised state has been established, that reduces any clinical risk to patients.

As part of Phase 2 CCGs will be reviewing associated support (contracting, quality and finance) for those of us who commission these services from the CSU.

With kind regards Yours sincerely

Jon Develing Interim Accountable Officer Wirral CCG

Conflicts of Interest Policy – September 2014 Governing Body – 7th October 2014

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Conflicts of Interest Policy Agenda Item: 5.1 Reference: GB 14-15/0041 Report to: Governing Body

Meeting Date: 7th October 2014

Lead Officer: Paul Edwards, Head of Corporate Affairs

Contributors: Laura Wentworth, Corporate Support Officer

Governance: Link to Commissioning Strategy

Link to current governing body Objectives

The conflict of interest policy is reviewed on an regular basis. The policy is designed to ensure all staff work impartially, protect against accusations of corruption, uphold the principles of the NHS constitution (including Nolan principles), uphold the reputation of Wirral CCG, promote openness and comply with the requirements of the Bribery Act 2010.

Summary: The existing policy was approved by the Governing Body in March 2013. While the principles described within the policy have not changed there is a need to update it to reflect the changes in structure and personnel that have been implemented since its approval. The Terms of Reference for the Approvals Committee have also been updated and are amended within this policy.

Recommendation: To Approve To Note Comments

Next Steps: Agree amendments to the policy & the updated Terms of Reference for the Approvals Committee.

Conflicts of Interest Policy – September 2014 Governing Body – 7th October 2014

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This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

Failure to disclose direct financial benefits could damage the reputation of the CCG.

Value For Money Not applicable.

Risk Robust governance arrangements are essential for the CCG to operate effectively and these include a policy on conflicts of interest. The CCG needs to continue to make decisions in and open and transparent manner and put in place arrangements for dealing with any conflicts of interest.

Legal Failure to adopt clear governance policies calls in the question the validity of the CCG decision making process which could lead to challenge including judicial review. The policy also describes requirements necessary to satisfy the Bribery act 2010

Workforce This policy is available to all staff on the Intranet and folders within the shared drive.

Equality & Human Rights

These policies and procedures will be applied equally to all staff covered and in accordance with the CCG’s Equality and Diversity Policy.

Patient and Public Involvement (PPI)

Both the policy and the accompanying register of interests are publicly available on the CCG website and are necessary to demonstrate to the public that the CCG is upholding its duties as a public sector organisation.

Partnership Working

Not applicable.

Performance Indicators

Not applicable.

Do you agree that this document can be published on the website? (If not, please note that it may still be subject to disclosure under Freedom of Information - Freedom of Information Exemptions

Conflicts of Interest Policy – September 2014 Governing Body – 7th October 2014

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This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome Conflict of Interest Policy

Governing Body June 2013 Approved amendments

Conflict of Interest Policy

Governing Body August 2014

Updated TOR for Approvals Committee to be reflected within the policy

Conflict of Interest Policy

Governing Body October 2014

Updated policy and TOR with Approvals Committee

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Director/Officer.

Conflicts of Interest Policy Page 1 of 3

CONFLICTS OF INTEREST POLICY

First issued by/date

Issue Version

Purpose of Issue/Description of Change Planned Review Date

Jul 2012 4 Reviewed in line with planned review date and amended TOR for Approvals Committee included

July 2016

Named Responsible Officer:- Head of Corporate Affairs

Approved by Governing Body

Date

Policy file: General Policy Impact Assessment Screening Complete - July 2012 Full impact Assessment Required - No

Policy No. POL012

Key Performance Indicators:

1. an annual audit of declarations of interest from the Governing Body, Consortia Board Members, Senior Managers and staff graded 8a and above;

2. an annual audit of declarations of gifts and hospitality from all staff; 3. reminder articles to staff about this policy and the importance of compliance

with it are to be issued at least twice a year; 4. an annual report of the findings of the audits described above will be

presented to the Audit Committee and the Governing Body.

Conflicts of Interest Policy Page 2 of 3

Conflicts of Interest Policy

Contents Page 1. Introduction 3

2. Purpose of the Policy 3

3. Scope 3

4. Defining a Conflict of Interest 4

5. Direct and Indirect Financial Conflicts 4

6. Non Financial or Personal Conflicts 5

7. Conflict of Loyalties 5

8. Professional Codes, Standards, Guidance and Law 5

9. Applying Guidance to the local context 8

10. Register of Interests 8

11. Declaration of Interests 9

12. Role of the Chair 9

13. Approvals Committee 9

14. Personal: Hospitality, Gifts and Sponsorship 10

Appendices

Appendix A References 12

Appendix B Code of Conduct Template 13

Appendix C Declaration of Interests Proforma 15

Appendix D Personal Benefit Declaration Proforma 18

Appendix E Approvals Committee Terms of Reference 19

Appendix F Impact Assessment Screening Tool 23

Appendix G Dissemination and Training Plan 25

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1. Introduction 1.1 Good governance is critical in the design and operation of a Clinical

Commissioning Group (CCG) in order that it acts transparently, manages conflicts of interest and has the proper checks and balances in place to provide assurance that decisions are taken in ways that protect patients’ best interests, promote continuous improvements in quality and provide assurance that public money is well managed.

1.2 Governance arrangements need to combine the public accountability of an organisation responsible for improving quality and outcomes, and spending public money wisely, with the flexibility, culture and ways of working of a member-led organisation.

1.3 All staff have a personal responsibility to make sure that they are not placed in a position which risks, or appears to risk, a conflict between their private interests and their NHS duties or allegations of their official position.

2. Purpose of the policy 2.1 This policy is intended to:

• Ensure staff are aware of the need to act impartially in all of their work

• Protect all staff against the possibility of accusations of corruptive practice

• Uphold the established principles of business conduct within the NHS and the public sector

• Uphold the reputation of NHS Wirral CCG and its staff in the way it conducts its business

• Ensure staff do not contravene the requirements of the Bribery Act 2010

• Uphold the principles of openness

• Uphold the Nolan Principles (the 7 principles of Public Life) 2.2 This policy will describe the types of conflict of interest that might face

professionals involved in the CCG and highlight how conflicts of interest will be managed to mitigate against conflicts of interest.

3. Scope 3.1 This policy applies to all employees and appointed individuals who are

working for Wirral Clinical Commissioning Group (CCG), members of Wirral CCG, persons serving on committees and other decision-making groups and members of Wirral CCG Governing Body and its committees.

3.2 It applies to all areas in support of the organisation’s business objectives both clinical and corporate.

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4. Defining a Conflict of Interest 4.1 A conflict of interest can be defined as: “a set of conditions in which

professional judgement concerning a primary interest (such as patients’ welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain)” or a situation in which “one’s ability to exercise judgement in one role is impaired by one’s obligation in another”. Please note that these lists are not exhaustive and members of staff should declare an interest if they are in any doubt as to whether it should be recorded.

4.2 Holding of a primary care contract is not deemed as requiring a declaration unless that provider provides additional services outside of the core contract.

4.3 Within the CCG conflicts may arise as a result of individuals having:

• A direct financial Interest

• An indirect financial interest

• Non financial or personal interests

• Conflicts of loyalty 5. Direct and Indirect Financial Conflicts 5.1 A clear conflict of interest arises when an individual involved in taking or

influencing the decisions of an organisation could receive a direct financial benefit as a result of the decisions being taken. Examples include:

• Holding an office or shares in a private company or business, or a

charity or voluntary organisation that may do business with the NHS. • The implementation or alteration of an existing incentive scheme that

provides financial rewards to practices such as Local Enhanced Services or Prescribing Incentive Schemes

• Decisions which may alter the working conditions of clinicians such

as length of working hours or days of operation. 5.2 An indirect financial interest arises when a close relative of a director or

other key person benefits from a decision of the organisation. As healthcare providers as well as commissioners, individual healthcare professionals sitting on the Governing Body of the CCG (and their family members or business partners) may have commercial interests in organisations that their commissioning group is already purchasing from or that could potentially bid/offer to provide services that the group might procure and fund. The positions which might create real or perceived conflict due to financial interest include:

Conflicts of Interest Policy Page 5 of 3

• partnership (for example, in a general practice which will benefit from a proposal) or employment in a professional partnership, for example, limited liability partnership

• directorships, including non-executive directorships held in private

companies or PLCs

• ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS

• shareholdings in organisations likely or possibly seeking to do

business with the NHS

• any connection with a voluntary or other organisation contracting to provide NHS services

• research funding/grants that may be received by an individual or

their department/company. 6. Non Financial or Personal Conflicts 6.1 These occur where directors or other key persons receive no financial

benefit, but are influenced by external factors such as gaining some other intangible benefit or kudos, for example, through awarding contracts to friends or personal business contacts.

6.2 Even if the individuals leading a CCG do not have commercial or other

direct interests in particular services or providers, they are likely to have long-standing professional relationships with colleagues to whom they may have allegiances as peers, and with whom they have developed particular ways of working over a period of time. Personal conflicts could therefore exist when decisions are being taken that would affect such relationships in some way.

7. Conflict of Loyalties 7.1 Decision-makers may have competing loyalties between the organisation to

which they owe a primary duty and some other person or entity. For healthcare professionals, this could include loyalties to a particular professional body, society or special interest group, and could involve an interest in a particular condition or treatment due to an individual’s own experience or that of a family member.

Conflicts of Interest Policy Page 6 of 3

8. Professional Codes, Standards, Guidance and Law 8.1 The existence of and need to manage conflicts of interest is clearly not a

new issue for the NHS and the healthcare professionals working in it, and there are various existing sets of guidance, policy and law on which the CCG can draw. These include: Nolan Principles The Nolan Committee’s Seven Principles of Public Life should underpin our approach to conflicts of interest. These are:

• Selflessness Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends.

• Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties.

• Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

• Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

• Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

• Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

• Leadership Holders of public office should promote and support these principles by leadership and example.

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General Medical Council (GMC) Medical practitioners also have professional guidance to adhere to which is published by the GMC in the ‘Good Medical Practice Guidance’. With regards to conflict of interest it states:

• You must act in your patients’ best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat or refer patients. You must not offer such inducements to colleagues. (para. 1.74)

• If you have financial or commercial interests in organisations

providing healthcare or in pharmaceutical or other biomedical companies, these interests must not affect the way you prescribe for, treat or refer patients. (para. 2.75)

• If you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must tell the patient about your interest. When treating NHS patients you must also tell the healthcare purchaser. (para. 3.76)

Additionally the GMC produces specific guidance for doctors working in management roles, such as Governing Body Members, where it states:

• You must declare any interest you have that could influence or be

seen to influence your judgement in any financial or commercial dealings you are responsible for. In particular, you must not allow your interests to influence:

i. the treatment of patients

ii. purchases from funds for which you are responsible

iii. the terms or awarding of contracts

iv. the conduct of research

The Bribery Act 2010 The Bribery Act 2010 replaces the fragmented and complex offences at common law, and in the Prevention of Corruption Acts 1889-1916. This broadly defines the two sections:

• Two general offences of bribery – 1) Offering or giving a bribe to induce someone to behave, or to reward someone for behaving, improperly and 2) requesting or accepting a bribe either in exchange for acting improperly, or where the request or acceptance is itself improper;

• The new corporate offence of negligently failing by a company or limited liability partnership to prevent bribery being given or offered by an employee or agent on behalf of that organisation.

Conflicts of Interest Policy Page 8 of 3

Any suggestion or suspicion of corruption or fraudulent practice should be reported to the Local Counter Fraud Specialist – as detailed in the Countering Fraud and Corruption Policy, Strategy and Guidance Notes Code of Conduct: Managing conflicts of interest where GP practices are potential providers of CCG-commissioned services The template in appendix B sets out the factors on which our CCGs will assure ourselves, our Approvals Committee and Governing Body and be ready to assure our local local community, Health and Wellbeing Board and auditors – when commissioning services that may potentially be provided by GP practices. The setting out of these factors in a consistent and transparent way as part of the planning process, enables us to seek and encourage scrutiny and enables our local community and Health and Wellbeing Board to raise questions if they have concerns about the approach being taken. The template is based on guidance from the NHS National Commissioning Board in October 2012 and has been adopted for use by our Approvals Committee – see below.

9. Applying Guidance to the local context 9.1 Members of the Governing Body, delegated sub-committees and those

holding specific roles within the CCG agree to embody the Nolan Principles during their work on behalf of the CCG. The same members will be held accountable for their actions and the Chair of the Governing Body will take ultimate responsibility for this task.

10. Register of Interests 10.1 The CCG will maintain a register of interests for members of the Governing

Body. This will be a publicly available document. The register will be updated whenever necessary and at least annually as an agenda item of the Governing Body.

10.2 The Audit Committee will review the register of declared conflicts of interest on an annual basis. This register may be subject to requests under the Freedom of Information Act 2000 and published in an annual report or other publication. Additionally, the register may be subject to review by the Local Counter Fraud Specialist as part of proactive detection activity and during referred investigations. The Register of Interests is updated six monthly and is held by the Corporate Support Officer. A copy of the most recent register is also available on the public facing website:

https://www.wirralccg.nhs.uk/About%20Us/Whos-Who.htm

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11. Declaration of Interests 11.1 A standing agenda item for ‘Declarations of Interest’ will feature on the

agenda of every Governing Body and Sub Committee meeting of the CCG. Where a perceived conflict of interest exists for a meeting member they would be expected to declare that interest again at the start of a meeting even if the conflict has been included in the register of interests. Governing Body members are not expected to reiterate all potential conflicts of interest contained within the register routinely at every meeting.

11.2 Declarations of Interest should be submitted to the Head of Corporate

Affairs on the Declaration of Interests Proforma (see appendix B) 12. Role of the Chair 12.1 Once a conflict of interest has been identified it is the responsibility of the

Chair of the meeting to determine, by committee discussion if necessary, the extent to which the individual(s) can further contribute to the meeting. Depending on the nature of the conflict the chair will decide whether to:

• permit contribution, as conflict considered immaterial to discussion

• exclude from any discussion on the specific item • exclude from any vote on the specific item

• exclude from the room during any discussion or vote on the specific

item 12.2 Once a decision has been made it will be recorded for the minutes of the

meeting. 12.3 When the conflict of interest relates to the Chair, an alternate Chair without

such a conflict of interest will stand in. In the case of the Governing Body the Lay Member with portfolio for Governance and Audit will chair that item of discussion in the meeting.

13. Approvals Committee 13.1 In situations where there are insufficient decision makers available after

exclusion of those with relevant interests to enable effective decision making or management action, the matter will be conveyed to the Approvals Committee.

13.2 The purpose and role of the Approvals Committee is to scrutinise and

approve, with or without conditions or reject commissioning decisions where a potential conflict of interest has been identified for the GP membership of the CCG Governing Body or Consortia Boards. This will help the CCG to ensure and demonstrate to its stakeholders that all of its commissioning decisions are made selflessly, fairly, transparently and with independent scrutiny.

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13.3 The Approvals Committee reports to the Governing Body, and its terms of reference have been established and approved by the Governing Body.

13.4 The Approvals Committee terms of reference including its membership are

described in the attached Appendix E: 14. Personal: hospitality, gifts and sponsorship 14.1 Under the Prevention of Corruption Act 1916, any money, gift or

consideration received by an employee in public service from a person or organisation holding or seeking to obtain a contract will be deemed by the courts to have been received corruptly unless the employee proves to the contrary. Guidance from the Audit Commission and the Nolan Committee reiterated the importance and continued applicability of the legislation to all those involved in work for public bodies.

14.2 Some approaches may be at a personal level where an individual member, director, or employee receives hospitality, a gift, or sponsorship from a company or an individual. All CCG staff are required to record the receipt of hospitality, gifts or sponsorship, seeking prior approval where required by this policy.

14.3 All hospitality, gifts and sponsorship accepted or declined should be declared to the Secretary to the Board/Chief Operating Officer using the form supplied, as Appendix C.

14.4 In cases of doubt, advice must be sought from your line manager and in no case must the value of the gift exceed £25 limit without prior approval of the Accountable Officer.

Hospitality 14.5 Hospitality, provided it is normal and reasonable in the circumstances, may

be accepted but must always receive prior approval; retrospective recording in the register is not acceptable.

14.6 Modest incidental hospitality (e.g. refreshments) may be accepted without

prior approval; modest incidental meals in the course of working visits may also be accepted provided the value of the meals do not exceed the cost that would otherwise be reimbursable by the NHS as an employer.

Casual gifts 14.7 The Register must be used for declaring all hospitality offered, but

excluding small items such as pens and calendars not exceeding £25 in value. However, gifts should be declared if several small gifts worth a total of over £100 are received from the same or closely related source in a 12 month period.

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14.8 It is also acceptable to receive other small value items, for example from a patient or relative in appreciation of the treatment and care received, or seasonal items, if it is made clear to the offerer that it is accepted on behalf of the Consortium or Practice (and indeed is shared with colleagues), or is to be donated to the organisation’s Charitable Fund.

14.9 Any other offers of personal gifts should be politely declined. Cash 14.10 Under no circumstances must anyone to whom this policy applies accept

personal gifts of cash, even below the £25 threshold. It is permissible for staff to accept cash donations to the organisations charitable funds, subject to a receipt being issued and the cash being banked through the organisations cash office.

Sponsorship 14.11 Commercial sponsorship for staff attendance at relevant conferences and

courses is acceptable, but only where permission is sought in advance from your line manager. The CCG must be satisfied that acceptance will not compromise purchasing decisions in any way.

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APPENDIX A - REFERENCES BMA Ensuring Transparency and Probity Available at http://www.lmc.org.uk/article.php?group_id=2182 Bribery Act 2010 Available at http://www.legislation.gov.uk/ukpga/2010/23/pdfs/ukpga_20100023_en.pdf GMC good practice guidance Available at http://www.gmc-uk.org/guidance/good_medical_practice.asp ‘Managing conflicts of interest in clinical commissioning groups Available at http://www.england.nhs.uk/wp-content/uploads/2013/04/ccg-conflict-int-guide.pdf Nolan report Available at http://www.archive.official-documents.co.uk/document/parlment/nolan/nolan.htm

Prevention of Corruption Act 1916 Available at http://www.legislation.gov.uk/ukpga/1916/64/pdfs/ukpga_19160064_en.pdf

Standards for members of NHS boards and governing bodies in England. 2012. Council of Healthcare Regulatory Excellence http://www.professionalstandards.org.uk/docs/psa-library/november-2012---standards-for-board-members.pdf?sfvrsn=0 ‘Towards Establishment: creating responsive and accountable clinical commissioning groups’ Available at http://www.england.nhs.uk/wp-content/uploads/2012/09/towards-establishment.pdf

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APPENDIX B

NHS Wirral Clinical Commissioning Group Approvals Committee Template Date of Approvals committee: Insert date Scheme title: Consortia : Lead Officer: Procurement route: Source of Resource: Total Value: Duration of scheme: What authority exists at what level in the Scheme of Delegation for this scheme? Describe scheme: Précis here and attach detail. How does the scheme deliver good or improved outcomes and value for money – what are the estimated costs and the estimated benefits? How does it reflect the CCG’s commissioning priorities? How have you determined a fair price for the service? How have you involved the patients in the decision to commission this service? What range of partner health professionals have been involved in designing the proposed service?

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What range of potential providers have been involved in considering the proposals? How does the proposal support the priorities of the CCG strategy? [When a joint health and wellbeing strategy is in place it should also be referenced here]. What are the proposals for monitoring the quality of the service? What systems will there be to monitor and publish data on referral patterns? Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers which are publicly available? Why have you chosen this procurement route? If AQP: How will you ensure that patients are aware of the full range of qualified providers from whom they can choose? If Single Tender from GP Provider - What steps have been taken to demonstrate that there are no other providers that could deliver this service? In what ways does the proposed service go above and beyond what GP practices should be expected to provide under the GP contract? What assurances will there be that a GP practice is providing high-quality services under the GP contract before it has the opportunity to provide any new services? Other information

□ Approved

□ Approved with conditions

□ Referred back to ______________________ for revision □ Rejected

Conflicts of Interest Policy Page 15 of 3

APPENDIX C

REGISTER OF INTERESTS YEAR 2014-2015

Please indicate which group/committee to which you are a member by placing a X in the box below:- Governing Body Meeting Quality, Performance & Finance Committee Clinical Strategy Group/QIPP Team Wirral Alliance Commissioning Consortium Wirral Health Commissioning Consortium Wirral GP Commissioning Consortium Audit Committee I have read and understood the CCG Conflict of Interest Policy and hereby declare the following interests:- DIRECT FINANCIAL INTEREST (if you have no interests in this category, state ‘NONE’) INDIRECT FINANCIAL INTEREST (if you have no interests in this category, state ‘NONE’) NON-FINANCIAL OR PERSONAL INTEREST (if you have no interest in this category, state ‘NONE’) CONFLICT OF LOYALTIES (if you have no conflict in this category, state ‘NONE’) Signature: ………………………………………………………………………………………………………………… Name (please print): Date:

Conflicts of Interest Policy Page 16 of 3

Guidance Note for Completion of the declaration form

This form must be completed by all members of NHS Wirral CCG Governing Body and updated as interests change or new interests are identified. It should also be completed by any employees or other persons serving on NHS Wirral CCG subcommittees or decision making groups. Recognised interests that must be declared include: 1. directorships, including non-executive directorships held in private companies or public limited companies (with the exception of those of dormant companies) 2. ownership or part ownership of companies, businesses or consultancies which may seek to do business with the CCG 3. significant share holdings (more than £25,000 or 1% of the nominal share capital) in organisations which may seek to do business with the CCG 4. membership of or a position of trust in a charity or voluntary organisation in the field of health and social care 5. receipt of research funding / grants from the CCG 6. interests in pooled funds that are under separate management (any relevant company included in this fund that has a potential relationship with the CCG must be declared) 7. formal interest with a position of influence in a political party or organisation 8. current contracts held with the CCG in which the individual has a beneficial interest 9. any other employment, business involvement or relationship or that of a spouse or partner that conflicts, or may potentially conflict with the interests of the CCG. Where individuals are unsure whether a situation falling outside of the above categories may give potential for a conflict of interest they should seek advice from the Head of Corporate Affairs or Corporate Support Officer.

Conflicts of Interest Policy Page 17 of 3

APPENDIX D

Personal Benefit Declaration Any offers of hospitality, personal gifts (other than inexpensive items, such as pens/calendars etc.) and sponsorship should be declared. Gifts of over £25 in value and offers of hospitality and sponsorship should be authorised by your line manager and for gifts, personal hospitality or sponsorship over the value of £200, authorisation from the Accountable Officer must be sought; Authorisation must be PRIOR to acceptance.

Name:

Job title:

Consortium: Telephone number

Details of the benefit Name of organisation or individual providing benefit

Nature and purpose of benefit

Date

Estimated value

Other information

Decision of person offered benefit Declined Accepted If accepted, please have this form authorised by your line manager Signed Date Authorisation by Line Manager/Accountable Officer (Limit is £200 – larger sums must be authorised by the Chief Executive) Yes No Reason for non authorisation

Name of Manager declining

Conflicts of Interest Policy Page 18 of 3

Signature Date Please submit this form to Head of the Corporate Affairs, NHS Wirral CCG, for inclusion In the Hospitality, Gifts and Sponsorship Register

Conflicts of Interest Policy Page 19 of 3

APPENDIX E – APPROVALS COMMITTEE TERMS OF REFERENCE

NHS Wirral Clinical Commissioning Group Approvals Committee

Terms of Reference

1) Introduction An essential feature of the reforms introduced by the Health and Social Care Act (2012) is that Clinical Commissioning Groups should be able to commission a range of community based services to improve quality and outcome for patients. Clinical Commissioning Groups can also make payments to GP practices for “promoting improvements in the quality of primary medical care (e.g. reviewing referral and prescribing) To help them manage potential conflicts of interest associated with such commissioning decisions, the NHS Commissioning Board has issued guidance, a Code of Conduct and an associated decision making template. These documents are designed to help Clinical Commissioning Groups demonstrate that they are acting fairly and transparently and that members will always put their duty to patients before any personal financial interest. The Governing Body of NHS Wirral Clinical Commissioning Group (the CCG) and the Boards of the constituent Wirral GP, Wirral Health and NHS Alliance Consortia (the Consortia ) have a majority of GP members. It is anticipated that situations will arise where a conflict of interest may exist for these members when considering commissioning decisions by the CCG or Consortia. In such cases where all or most of the GPs on a decision making body could have a material interest in a decision, there is specific advice in the above mentioned Code of Conduct. In essence the advice is to ensure that GPs and other practice members who may have a potential conflict are excluded from the decision making process. In following this advice it is therefore necessary to implement an additional mechanism to support the Governing Body in making these commissioning decisions. The Governing Body has previously agreed through its Conflict of Interest Policy that this additional mechanism should be an Approvals Committee. Pending full authorisation of the CCG by the NHS National Commissioning Board, committee structures and other organisational arrangements are made on an interim basis. The tenure of the Interim Approvals Committee therefore will be until the 31st March 2013 when a substantive Approvals Committee will be established. The Interim Approvals Committee (the Committee) is established in accordance with the CCG’s Constitution, Standing Orders, Scheme of Delegation and Conflicts of Interest policy. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the Constitution and Standing Orders. The Committee has no executive powers other than those specifically delegated in these Terms of Reference.

Conflicts of Interest Policy Page 20 of 3

2) Purpose The purpose and role of the Committee is to scrutinise and approve with or without conditions and/or reject commissioning decisions where a potential conflict of interest has been identified for the GP membership of the CCG Governing Body or Consortia Boards. This will help the CCG to ensure and demonstrate to its stakeholders that all of its commissioning decisions are made selflessly, fairly, transparently and with independent scrutiny.

3) Membership

• Chair (Lay Member, Lead for Governance and Audit) - voting • Lay Member (Patient Champion) - voting • Lay Advisor (Audit Committee Lay Advisor) - voting • Lay Advisor (Audit Committee Lay Advisor) - voting • Patient Member - voting • Head of Quality & Performance / Corporate Nurse - voting • Director of Public Health - voting • Chief Finance Officer - non voting • Consortia Chief Officers - non voting

Should it be required the Chair of the meeting will have a casting vote. The CCG Chair and/or Chief Clinical Officer may attend to advise where appropriate. Any governing body member who is not a member of the Committee may attend as a non-voting observer with the prior agreement of the Chair of the Committee. The meetings will be chaired by the Lay Member (Governance and Audit) in the absence of whom the meeting will be chaired by the Lay Member (Patient Champion) or if he is unavailable by one of the other Lay Advisors or Patient Member. Attendance (in a non-voting capacity) will also be expected from the the Head of Corporate Affairs who will make arrangements to ensure that the Committee is supported administratively. Duties in this respect will include taking minutes of the meeting and providing appropriate support to the Chairman and committee members.

4) Quorum A quorum will be three voting members (including at least one of the two of the Lay Member/ Advisors, and at least one of the Director of Public Health / Head of Quality & Performance (Corporate Nurse). The other members would constitute of at least two of the other members (including Consortia Chief Officers or Chief Finance Officer)

5) Frequency and notice of meetings

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The Committee will meet when required to consider proposals coming from the governing body or consortia boards after the Governing Body Chair has deemed that commissioning decisions are unable to be reached in the governing body or consortia board due to potential conflicts of interests for members of those bodies. Consortia Boards may refer directly to the Approvals Committee when they identify a potential Conflict of Interest and are encouraged to do so. The Approvals Committee are authorised by the CCG Governing Body exceptionally to call in for review and scrutiny, commissioning decisions made by either the Consortia Boards or Governing Body when they believe there may be a potential for unresolved conflicts of interest in the commissioning process. Agendas and papers will be sent out 7 days before the meeting is held. Action points will be sent out within 48 hours of the meeting occurring. Full minutes will be available within 2 weeks of the meeting. To ensure there is minimum delay within the process, a monthly schedule of meetings of the Committee will be arranged over a 12 month schedule. If no proposals are received within 7 days of the scheduled meeting date, that meeting will not take place.

6) Remit and responsibilities of the Committee The Committee will review and reach an agreement on all matters relating to the commissioning of health services in circumstances where the Governing Body or Consortia Board cannot do so without independent scrutiny due to potential conflicts of interest. The Committee may approve with or without further conditions, reject or refer back to the originating body for further development, any proposal reviewed and not approved.

7) Relationship with the Governing Body

The minutes of the Committee shall be formally recorded by the Committee Secretary and submitted to the Governing Body. The Chair of the Committee shall draw to the attention of the Governing Body any issues that require disclosure to the full Board, or require executive action. The Committee will produce an annual report on the decisions it has taken and submit for the Board’s consideration.

8) Policy and best practice In order to facilitate the achievement of good governance, the Committee is authorised to:

• Seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.

• Use of the amended version of the NHS Commissioning Board Conflicts of Interest Template when gathering information about commissioning proposals to help support its decision making.

• Obtain outside legal or other independent professional advice and/or secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

Conflicts of Interest Policy Page 22 of 3

• Use core national criteria when assessing clinical decisions and ensure that commissioning proposals support the strategic intentions of the CCG

9) Conduct of the Group

When discharging functions delegated to it by the Governing Body the Approvals Committee, and its individuals members must:

• Conduct its business in accordance with Nolan’s Seven Principles of Public Life.

• Ensure that any relevant national guidance is adhered to.

These Terms of Reference shall be reviewed annually by the Governing Body, with recommendations made for any amendments in line with development requirements. Date Agreed: August 2014 Review Date: August 2015

Conflicts of Interest Policy Page 23 of 3

APPENDIX F - IMPACT ASSESSMENT SCREENING TOOL 1. Initial Screening Process

1.1 Title of the policy/procedure/function/service Conflict of Interest Policy 1.2 Directorate/Department Governing Body 1.3 Name of the person responsible for this Equality Impact Assessment Helen Jones 1.4 Date of Completion July 2012 1.5 Aims and Purpose of this policy/procedure/function/service The aim is to provide guidance to all employees regarding what constitutes a conflict of interest in relation to their official position as an NHS employee. 1.6 Is this a new or existing policy/procedure/function/service New 1.7 Examination of Available Evidence – Tick evidence used

Census Data for UK _

Census Data for London _

Census Data for Local Authority Area _

Trust Workforce Data _

Trust Patient Data _

National Patients Survey _

Trust Patients Survey _

Complaints Summaries _

Other Internal Research/Survey/Consultation/Audit (please list)

Other External Research/Survey/Consultation/Audit (please list)

BMA Ensuring Transparency and Probity Bribery Act 2010 GMC good practice guidance ‘Managing conflicts of interest in clinical commissioning groups ‘Managing conflicts of interest. Technical Appendix 1. The Nolan report Prevention of Corruption Act 1916

Conflicts of Interest Policy Page 24 of 3

Standards for members of NHS boards and governing bodies in England. 2012. Council of Healthcare Regulatory Excellence ‘Towards Establishment: creating responsive and accountable clinical commissioning groups’ What is the summary of the available evidence? It is an offence under the Prevention of Corruption Acts 1906 and 1916 for an employee to corruptly to accept any inducement or reward for doing or refraining from doing anything in their official capacity; or corruptly showing favour, or disfavour in the handling of contracts. This policy sets the CCG’s professional expectations in the work environment and encourages transparency in dealing with external organisations or negotiating contracts. Employees are required to declare any interests to the Governing Body Secretary. 1.8 Does the evidence indicate that there is, or is the potential to be any significant impact on anyone or any group in relation to the following equality strands? No

Strand Yes/No/Insufficient Data

Justified Yes/No

Ethnicity/Race No N/A Disability No N/A

Gender/Sex No N/A Religion/Belief No N/A

Sexual Orientation No N/A Age No N/A

Human Rights No N/A If further evidence is required to complete this section, take steps to obtain to before

proceeding with the assessment. If the review of evidence indicates that there is a significant unjustified impact, a Full Equality Impact Assessment must be carried out.

1.9 No further evidence Required. Skip to Section 5. √ 1.10 Full Equality Impact Assessment required. No

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To ensure the residents of Wirral enjoy the best quality of life possible, being supported to make informed

choices about their own care, and being assured of the highest quality services.

Vision 2018 bulletin Issue 3

Contents

General Update .......................................................................................................... 1

Programme & Governance Structure ......................................................................... 1

The Engagement with People Group ......................................................................... 2

Next Steps .................................................................................................................. 2

Vision 2018 in action - meet Mike: ............................................................................. 3

General Update

It may have been the holiday season but the pace has been quickening for Vision 2018! If you haven’t already done so, have a look at the new Vision 2018 pages on the CCG website: www.wirralccg.nhs.uk/vision2018. They are packed with background information about the challenges facing the NHS and local government, and how Vision 2018 aims to address them. There are details of how we are already implementing some of the changes people have suggested we make to improve their experience of health and social care services, links to resources to help you lead a healthier lifestyle, and information about how you can get involved. We’re also going to add a ‘Q&A’ section – watch this space! Programme & Governance Structure Welcome to Terry Whalley, who has joined the CCG to lead Vision 2018 on a placement from the NHS Leadership Academy (as part of the national Fast-track Executive Development programme). His placement is being funded by the Leadership Academy until March 2015, and is a fantastic opportunity for us to make use of Terry’s skills and experiences from outside the NHS as we move into the next critical phases of Vision 2018. Terry will lead the Vision 2018 Programme Management Office and direct the efforts of all the programmes of work within Vision 2018. Work-streams As described in the previous bulletin, we have established a new shape to Vision 2018 which allows us to focus our efforts on 3 key areas; Planned Care,

2

Unplanned Care and Long Term Care. We have also a number of enabling work-streams, for example Integration Adults, which focuses on the development of integrated teams, services and systems to provide coordinated care for people aged over 18. We have done more work to ensure we have really clear strategic outcomes defined for Vision 2018 - these are now being refined and will be shared in the next bulletin. Each of the work-streams is now developing a detailed definition of scope to ensure its aims and objectives are linked back to these strategic outcomes. This will enable a clear description of how those work-streams will enable benefits that will ultimately improve health outcomes for the people of Wirral together with their experience of health care. At the same time, balancing quality and value to improve the efficiency of services delivered will be the third major consideration for each work-stream. In addition to considering these longer term changes, each of the work-streams is now also considering the things that can be done quickly to start to make a real difference in 2015. It is important that we balance the need to re-imagine health and wellbeing in 2018 and consider how best we achieve this future state vision with the need to make real and practical improvements to the services we have today. It is this balance that the Vision 2018 team is now focused on achieving. We’ll bring you more on this in next month's bulletin. The Engagement with People Group continues to provide invaluable input into how we engage with people about Vision 2018, ensuring we engage with ALL Wirral communities. This group includes representatives from many community groups and networks across Wirral. If you would like to join, please get in touch. Next Steps

A series of ‘patient characters’ are currently being developed. Based on real life stories, these will illustrate how different people will benefit from the changes Vision 2018 will bring (see Mike’s story below). They will also enable those involved in developing patient pathways to have an understanding of the impact that different pathway options could have on the patient. Vision 2018 posters and leaflets are also being produced, to help inform Wirral residents about some of the key challenges and proposals. Furthermore Vision 2018 will be presented at a number of events over the coming months. These include International Older People’s Day (1st October) and Youth Voice Conference (16th October). More details to follow on the website.

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Vision 2018 in action - meet Mike: Mike is a 61 year old widower, who lives in Tranmere. He is unemployed (following redundancy), smokes and had COPD. He frequently goes to A & E and gets admitted to hospital because he forgets to take his medications. He struggles to manage household tasks, isn’t sleeping well and has recently lost weight. He also suffers from breathlessness, constant coughing and tiredness. Previously:

Mike would have seen his GP for support, been given medication and referred

for tests for his breathlessness, constant coughing and tiredness.

His condition may have deteriorated because his management of his health

hasn’t changed, leading to hospital admissions.

If he doesn’t start to manage his health, Mike may die earlier than necessary.

What happens to Mike under Vision 2018:

Mike sees his GP because he is struggling to cope with the loss of his wife

and is smoking more.

His GP contacts the Integrated Care Co-ordination Team , which identifies

local support to help Mike to give up smoking, and to meet with other people

who have suffered bereavement.

A care plan is developed and implemented, including:

A pharmacist to review Mike’s medication with him, and plan how to

treat future flare ups

A dietician to help Mike manage his medication and diet

Assistive Technology and telehealth so his condition can be monitored

remotely

Mental Health practitioner support to help Mike in coping with his loss

Benefits advice in managing finances since his redundancy

Mike goes on to be a peer mentor, helping other people with similar

experiences.

If you have any questions about Vision 2018, or would like to get involved, please contact WICCG.InTouch@nhs.net or 0151 651 0011

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Commissioning Plan 2014-19 – Final Draft

Agenda Item: 5.4 Reference: GB14-15/0041

Report to: Governing Body Meeting Date:

Lead Officer: Iain Stewart, Chief Officer, Wirral Alliance Consortium

Contributors:

Governance: Link to Commissioning Strategy

Preventing people from dying prematurely Enhance the quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Ensuring people have a positive experience of care Ensuring people are treated and cared for in a safe environment and protected from avoidable harm

Link to current governing body Objectives

Summary: NHS Wirral CCG has developed its strategic plan for the healthcare of the Wirral population describing how the health needs of the population today and into the future will be met through the commissioning (planning and buying) of high quality, best value health services. The strategic plan covers the period 2014-2019 and sets out the fundamental changes required for how services must be delivered in order to meet the on-going challenge of an ageing population, living longer with long-term medical conditions coupled with a worsening life expectancy gap dependent upon where someone is born on Wirral, whilst planning for reducing financial allocations over the next five years. The CCG has also produced its 2 year Operational Plan 2014-16 which effectively commences the journey to achieving the stated aims and objectives of the strategic plan by 2019. The Operational Plan is constructed on key characteristics of a successful, sustainable health care system;

- wider primary care, provided at scale - modern model of integrated care - access to the highest quality urgent and emergency care - a step change in the productivity of elective care

This Commissioning Plan sets out to describe the commissioning intentions of the CCG that will be undertaken in order to support

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the priority plans between 2014-19. The CCG will apply the following principles in its commissioning approach;

- Cost = price - Patients versus Spells - Transitional relief - Delivery - Integration (where it makes sense to do so) - Move from an over “medicalised” model to rewarding

innovation - Making best use of quality payments - Use of health economy CQUINs to drive transformation - Consideration of savings impact – Provider Cost

Improvement Programmes versus Health System savings

- More robust evaluation alongside contract monitoring

These principles are designed to support and achieve the transformation of local health services which will remain high quality and value for money, and provided in an improved cohesive and integrated way so as to enable innovation to meet rising healthcare demands with increasing financial challenges. The CCG knows what health outcomes it wishes to achieve for Wirral patients and it knows which priority plans it wishes to action in order to achieve those outcomes.

Recommendation: To Approve

To Note √

Comments Work is currently continuing on the development of an agreed single model of Urgent Care provision for the Wirral health economy.

Next Steps: Further refinement to commissioning intentions to support contracting for 2015/16 and stepped progress in the description of an agreed single model of urgent care provision for Wirral. Commissioning Plan for 2014-19 to be approved by Governing Body at November 2014 meeting.

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This section is an assessment of the impact of the proposal/item. As such, it identifies the significant risks, issues and exceptions against the identified areas. Each area must contain sufficient (written in full sentences) but succinct information to allow the Board to make informed decisions. It should also make reference to the impact on the proposal/item if the Board rejects the recommended decision. What are the implications for the following (please state if not applicable): Financial

The continuing pressure on CCG allocations and the implementation of the Better Care Fund (pooled budgets) requires targeted and robust commissioning actions to secure the full range of high quality, best value local health services to meet the increasing health needs of the Wirral population.

Value For Money An ageing population with associated long-term co-morbidities provides the challenge to the CCG to ensure the available financial allocations for health services are placed into commissioned services that offer high quality outcomes and best value investment. Innovative ways of service delivery; a focus on the integration of service provision; and increased joint commissioning with Social Care commissioners are approaches that the CCG must pursue in order to continue to meet the stated health system challenges.

Risk The Better Care Fund (pooled budgets) is a significant proportion of the CCG financial allocation and its use for social care that derives a health benefit must deliver both transactional and transformational outcomes that equal the historic healthcare activity costs where the CCG has traditionally spent its allocation across mainstream health providers. A poorly executed Better Care Fund will represent a significant risk to the CCG and local health economy.

Legal The CCG has a legal duty to achieve financial balance. The failure to commission high quality, best value services that will likely lead to budgetary overspends, will impact on this statutory requirement.

Workforce This Commissioning Plan will necessitate a requirement to ensure the current CCG workforce continue to be readily skilled and capable to implement the full range of work-related activities generated by the commissioning intentions.

Equality & Human Rights

Any change to commissioned services must be undertaken in consideration of not impairing/worsening patients’ rights. The considerations and recommendations in this document are designed to continue the securing of healthcare services that meet the current health needs of the Wirral population, based upon agreed evidenced CCG objectives and supported by data from the Joint Strategic Needs Assessment (JSNA).

Patient and Public Involvement (PPI)

Further to the involvement by local patients and public in the development of the CCG Strategic Plan, informed by the iterative Joint Strategic Needs Assessment, this Commissioning Plan is a clinical and managerial response to operationalize the achievement of the stated strategic objectives.

Partnership Working

The progress of Vision 2018 and the development of key programme scopes have informed the compilation of this Commissioning Plan and those programme scoping summaries are included as appendices within the Plan. Engagement with Providers through the contract monitoring process has informed and directed the key commissioning intentions included in this Plan.

Performance Indicators

The agreed CCG Strategic Plan outcomes along with NHS Outcomes Framework and NHS Constitutional standards form the performance framework for this Commissioning Plan to help achieve.

Do you agree that this document can be published on the website? (If not, please note that it may still be subject to disclosure under Freedom of Information -

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Freedom of Information Exemptions This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path ie. other papers that are directly related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome

Private Business The Board may exclude the public from a meeting whenever publicity (on the item under discussion) would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution. If this applied, items must be submitted to the private business section of the Board (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960). The definition of “prejudicial” is where the information is of a type the publication of which may be inappropriate or damaging to an identifiable person or organisation or otherwise contrary to the public interest or which relates to the provision of legal advice (for example clinical care information or employment details of an identifiable individual or commercially confidential information relating to a private sector organisation). If a report is deemed to be for private business, please note that the tick in the box, indicating whether it can be published on the website, must be changed to a x. If you require any additional information please contact the Lead Director/Officer.

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2014 – 2019 Commissioning Plan

September 2014 – Final Draft v1

Page 2

Contents

1) Introduction ................................................................................................................................................................. 3

2) Commissioning Programmes ................................................................................................................................... 5

2.1 Wider primary care, provided at scale .............................................................................................................. 5

2.2 Model of modern integrated care ...................................................................................................................... 7

2.3 Access to the highest quality urgent and emergency care ......................................................................... 10

2.4 Step change in the productivity of elective care ........................................................................................... 12

2.5 Better Care Fund ............................................................................................................................................... 14

2.6 Outcomes Framework Indicators .................................................................................................................... 15

2.7 NHS Constitution standards ............................................................................................................................. 18

Appendices ................................................................................................................................................................ 19

Appendix 1 – NHS Outcomes Framework Indicators ......................................................................................... 19

Appendix 2 – Vision 2018 Summary Programme Documents .......................................................................... 20

Appendix 3 – Potential Years of Life lost from causes considered amenable to healthcare by Disease group. ......................................................................................................................................................................... 23

Appendix 4 – QIPP Plan 2014 / 15 ........................................................................................................................ 25

Appendix 5 – Urgent Care Strategy ...................................................................................................................... 41

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1) Introduction

NHS Wirral CCG has developed its strategic plan for the healthcare of the Wirral population describing how the health needs of the population today and into the future will be met through the commissioning (planning and buying) of high quality, best value health services. The strategic plan covers the period 2014-2019 and sets out the fundamental changes required for how services must be delivered in order to meet the on-going challenge of an ageing population, living longer with long-term medical conditions coupled with a worsening life expectancy gap dependent upon where someone is born on Wirral, whilst planning for reducing financial allocations over the next five years.

The CCG has also produced its 2 year Operational Plan 2014-16 which effectively commences the journey to achieving the stated aims and objectives of the strategic plan by 2019. The Operational Plan is constructed on key characteristics of a successful, sustainable health care system;

- wider primary care, provided at scale - modern model of integrated care - access to the highest quality urgent and emergency care - a step change in the productivity of elective care

The CCG has a duty to continue to improve local services in line with agreed national outcomes as detailed with the NHS Outcomes Framework indicators (see Appendix 1).

In 2014/15 and 2015/16 the CCG will focus upon improving its relative performance on the following indicators:

• Emergency admissions for alcohol-related disease • Emergency readmissions within 30 days of discharge from hospital • Emergency admissions for children with lower respiratory tract infections

The NHS Constitution affords patients in the NHS the legal expectation that certain national standards are achieved.

As such, in 2014/15 and 2015/16 the CCG will focus on improving its performance against the following standards:

• RTT waiting times for non-urgent consultant-led treatment • A&E waits • Diagnostic test/waiting times

The CCG will apply the following principles in its commissioning approach;

- Cost = price - Patients versus Spells - Transitional relief - Delivery - Integration (where it makes sense to do so) - Move from an over “medicalised” model to rewarding innovation

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- Making best use of quality payments - Use of health economy CQUINs to drive transformation - Consideration of savings impact – Provider Cost Improvement Programmes versus

Health System savings - More robust evaluation alongside contract monitoring

These principles are designed to support and achieve the transformation of local health services which will remain high quality and value for money, and provided in an improved cohesive and integrated way so as to enable innovation to meet rising healthcare demands with increasing financial challenges.

The CCG knows what health outcomes it wishes to achieve for Wirral patients and it knows which priority plans it wishes to action in order to achieve those outcomes. This Commissioning Plan sets out to describe the commissioning intentions of the CCG that will be undertaken in order to support the priority plans between 2014-19.

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2) Commissioning Programmes

2.1 Wider primary care, provided at scale

WHAT HOW WHEN OUTCOMES PLANS INTENTIONS 2014/15 2015/16 2016/17 2017/18

1 Proactive

coordination of care for complex patients and those with a long term condition.

• New local GP contract offer

• Mapping of community services to inform primary care communities

• Support practices to maximise uptake of the Unplanned Admissions DES

• Primary Care staff to be part of the integrated care MDT meetings to plan care for the most complex

* *

2 Address physical, mental health and social care needs holistically.

• New local GP contract offer

• New Primary Care Mental Health service in place

• Mapping of community services to inform primary care communities

• Commission community mental health nurses to work alongside primary care clinicians as part of integrated teams

*

3 Fast and responsive access to care to reduce emergency admissions.

• Improving access to GP practice care

• Primary care communities fully formed

• Review of GP OOH

• Define an agreed model of Primary Care at scale

• Develop the agreed model into working proposal

• Implement the agreed model

• Review working model

• Renew BME Health Link Worker Service

• Review BME Health Link service as part of all 3rd sector services

*

* *

* *

*

4 Promote health and well-being and offer rapid access to diagnosis.

• Training needs analysis of primary care staff, and up-skilling programme

• Launch of new community phlebotomy service with faster access for those requiring urgent appointments

• All warfarin monitoring to move into the community

• Investment in general practice for review of over 75s with caring responsibilities, and those who are housebound and / or live alone

* * *

*

5 Support patients and cares to manage their own health and well-being.

• Accountable clinician for over 75’s

• Investment in General Practice to keep a register of carers and to undertake regular

*

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reviews of elderly carers

• Commission Alzheimer’s Society Dementia Advisor to offer advice and support to carers of those with dementia

*

6 Ensure consistent

high quality / safe and effective care.

• Training needs analysis of primary care staff, and up-skilling programme

• Primary Care outcomes scorecard

• Develop a quality dashboard for General Practice

• Revised specification for GP OOH to ensure a more accessible and a high quality service

• Put into place a system for GP Practices to report serious incidents and soft intelligence on patient experience

• Work with NHS England to explore co-commissioning of primary care contracts, with a focus on improved quality and reduced bureaucracy for General Practices

*

*

*

*

The current central tenet for the CCG in relation to commissioning primary care is focused upon the quality of primary care. In order to achieve all of the stated strategic plan outcomes the CCG will need to quickly move to working with NHS England in the co-commissioning of primary care in one of the 3 categories of interest:

• Category A – Greater involvement • Category B – Joint commissioning • Category C – Delegated authority

“Wider Primary Care, delivered at Scale” will be defined and agreed by the CCG and its constituent member practices by March 2016 with full implementation of the agreed model by April 2017.

Page 7

2.2 Model of modern integrated care

WHAT HOW WHEN OUTCOMES PLANS INTENTIONS 2014/15 2015/16 2016/17 2017/18

7 Reduce non elective

admissions and care home placements.

• Integrated care co-ordination teams in place

• Shared care planning

• Commission a single integrated gateway via one telephone number for public & professionals to access

* 8 Reduction in length

of stay and therefore hospital beds.

• Integrated care co-ordination teams in place

• Shared care planning

• Commission a care co-ordination model of care with named clinician / professionals for patient contacts

* 9 Increased

Community capacity for integrated care services.

• Pooled budgets • Commissioning for

Outcomes

• Alignment of ICCTs to local authority neighbourhoods (akin to parliamentary constituencies)

• Development of pooled budgets to support the commissioning requirements of the ICCTs

• Agree Integrated Service Specification

• Develop Alliance Contracting model of governing specification

• Implement alliance contract in shadow form

• Analyse impact on outcomes

• Implement integrated alliance contract

*

*

*

* *

* *

10 Increased number of people managed in integrated service.

• Redesign of children’s pathways

• Care closer to home

• Produce a single consistent set of referral, screening assessment and planning documentation

• Provision of an 8am-8pm, 7 day service, integrated with out of hours services

*

*

11 Increase in coordinated care.

• Single gateway • Care coordination in

the community • Electronic Shared Care

Record for all • Single assessment and

referral • Integrated care co-

ordination teams in place

• Shared care planning • Care closer to home

• Commission a care co-ordination model of care with named clinician / professionals for patient contacts

• Incorporate the voluntary, community and faith sector services into the ICCTs to promote support to patients from community assets.

*

*

12 Ensure a consistent high quality, safe and effective care.

• Electronic Shared Care Record for all

• Appointment of jointly funded management roles *

Page 8

to oversee performance and service delivery of each ICCT

• Establishment of an alliance contracting model to share risks and manage competing demands of cost improvement

*

A Wirral Integrated Commissioning Plan is paramount in enabling the rapid move towards integrated health and social care. The advent of the Better Care Fund (BCF) offers the opportunity to pool resources and jointly commission a range of services that deliver better value for money and productivity. By March 2015, an agreed integrated service specification and an associated alliance contracting model will be in place. During 2015/16, the alliance contracting model will be applied in shadow form in order to inform robust analyses and impact on agreed outcomes from 2016 onwards; an integrated alliance contract for service provision will be jointly commissioned. The CCG is committed to developing a model of integrated care through the establishment of 4 Integrated Care Co-ordinated Teams (ICCTs). The model of care can be summarised as the following pathway:-

• One number to call - A single integrated gateway that the public and professionals have access to through one number, staffed by health clinicians and social care professionals who through discussion with the referrer will establish if the need being referred is urgent or can be responded to in a planned way, and whether the need is primarily a health or social care need.

• Telling your story once - A single set of referral, screening, assessment and care planning documentation will be used throughout the pathway that, once consent from the patient has been obtained, health and social care professionals have access to and can contribute to. There will be specialist assessments required, but the core information required for referrals will have been collected, reducing the need for separate referral processes and repeatedly collecting the same basic information from patients.

• One person to co-ordinate your care – A care co-ordinator model of working where the

patient has a named clinician / professional as their contact point, who works as part of an integrated team. The care co-ordinator does not do everything, but they ensure a multi-agency plan is in place and they co-ordinate the care. Once support is in place the case is closed / the patient discharged, but it is this care co-ordinator the patient goes back to, as they know them, if they need further support in the future (so once you are known to the system you don’t need to start again).

• One message – a single culture of helping people to help themselves, self-managing their care and seeking support from community assets before statutory services will be supported by all organisations and at each point on the pathway. The voluntary, community and faith sector will be part of the integrated teams, promoting local, informal support as part of the care plan to support people who require care.

Page 9

• Local services close to home – the care will be co-ordinated through an integrated local neighbourhood team, and health and social care services delivered by the Council, CWP, Community Trust and WUTH will be aligned to these neighbourhoods. The neighbourhoods are Wallasey, Birkenhead, South Wirral and West Wirral. GP surgeries will be clustered to align to these areas, as primary care plays a pivotal role in delivering integrated care. The local integrated teams are configured on the same footprint as the public service boards, creating the opportunity for further alignment and partnership working with organisations who have aligned to these neighbourhoods; the police, fire and rescue service, housing providers, work and pensions service, job centre, the voluntary, community and faith sector, one stop shops and anti-social behaviour teams.

• Support when you need it – The integrated teams include the arrangers and providers of

the care as well as the clinicians / practitioners who co-ordinate the plan so the provision of care can be prioritised immediately. The health and social care provision will be 8.00am until 8.00pm 7 days a week, with an integrated out of hours service bringing together night nursing and emergency duty team services, so you get the same support whether something happens to you on a Friday night or a Wednesday lunch time.

• Pooled Resources – The integrated teams would be responsible for the health and social

care spend in their neighbourhood and would be able to access resources, regardless of which professional is managing the plan i.e. a nurse or therapist could commission a package of care, so no need to re-refer / pass the person on. The team would also be accountable for the budget and savings targets for their neighbourhood.

• Accountable management – the model of care has jointly appointed and funded

management posts overseeing the performance, service delivery and budget for the neighbourhood. The clinical and professional supervision required for professional bodies’ standards will continue to be provided by the employing organisations (DASS, CT, CWP, WUTH).

• Risk Sharing – each of the providers will continue to have separate contracts, but will be

brought together through an alliance contracting model to share the risks and manage the competing demands of cost improvement through co-ordinating the deployment of their organisations’ resources to meet the shared objectives set out in the Integration service specification.

Page 10

2.3 Access to the highest quality urgent and emergency care

WHAT HOW WHEN OUTCOMES PLANS INTENTIONS 2014/15 2015/16 2016/17 2017/18

13 Reduced non-

elective admissions (long and short stay).

• Single front door for urgent care on the APH site, including streaming patients back to primary care

• Ambulance pathfinder and community care plans

• Ensure successful transition and implementation of step up / step down system

• Develop a range of admission prevention services and pathways

• Apply Non-Elective Marginal rate as per PbR

• Implement Urgent Care Action Plan

• Apply zero tolerance to minor A&E breaches and re-directs

• Agree revised local tariff for AAU and shadow monitor

• Apply revised local tariff for AAU

• Incorporate Community Geriatrician role into AAU

• Reduce admissions by 15% (5% pa)

• Develop wirralwide schemes with care home providers to support admission prevention, active case management and education and training requirements.

*

* *

*

*

* *

*

*

*

*

14 Reduction in length of stay and therefore hospital beds.

• Single front door for urgent care on the APH site, including streaming patients back to primary care

• Ensure successful transition and implementation of step up / step down system

• Care Arranging Team

• Commission IMC & transitional beds covering 7 day response

• Commission brokerage function

• Dementia liaison nurses in post to support inpatient care of those with dementia and facilitate timely and appropriate discharge

*

*

*

15 Increased community capacity for urgent care services.

• Ensure successful transition and implementation of step up / step down system

• Implement a new model of urgent care hubs in the community, including medical assessment.

• Establish agreed model for urgent care Wirral

• Implement agreed model

*

*

16 Reduced conveyance to hospital by ambulance.

• Ambulance pathfinder and community care plans

• Commission a range of NWAS avoidance schemes

* 17 Reduced emergency

readmissions.

• Develop a range of admission prevention services and pathways

• Commission Wirral-wide Admissions Prevention

*

Page 11

service 18 Ensure consistent

high quality, safe and effective care.

• Implement NHS 111 and new GP out of hours service

• Redesign discharge pathways

• Redesign of children’s pathways in urgent care and the community

• Define local Directory Of Services to support requirements from NHS 111

*

A single agreed model for urgent care on Wirral will be agreed by April 2015 and fully implemented by April 2016. At the time of writing, the Wirral health economy is appraising the following model options:- Devolve all urgent care provision to primary care Devolve all urgent care provision with core GP practice hours to primary care Maintain status quo Urgent care front door and integrated community urgent care centres Fully integrated ‘Urgent Care Village’ and integrated community urgent care centres

Each option has a series of commissioning intentions associated therefore dependent upon the agreed chosen model, those respective commissioning intentions will be implemented.

Page 12

2.4 Step change in the productivity of elective care

WHAT HOW WHEN OUTCOMES PLANS INTENTIONS 2014/15 2015/16 2016/17 2017/18

19 Reduced elective

admissions (excess bed days)

• Outpatient strategy • To review AQP contracts against current patient needs

• To determine required market size to meet identified needs and commission appropriate AQP services

• Define an agreed model of Primary Care at scale

• Develop the agreed model into working proposal

• Implement the agreed model

• Review working model

• Implement Follow-up tariff for in-specialty referrals

• Apply agreed Hip & Knee referral process

• Revise specification for Drop-in ear care aural climes

• Re-open AQP window for procurement of DADs

• Procure a block contract arrangement for pathology test service

• Commission an integrated PTNS & Botox clime for bladder conditions

*

* * *

*

*

*

* *

*

*

*

20 Increased community capacity for planned care services.

• Community Hubs • 4 integrated care co-

ordination teams in place

• Care closer to home • Sufficient staffing and

estates to deliver greater proportion of planned care in the community

• Establish 4 fully operational ICCTs

• Define primary care configuration to fit with ICCTs

• System-wide estates plan

• Establish all relevant protocols for referral management between practices and ICCTs

*

*

*

*

21 Increased number of people managed in integrated services.

• Transfer of planned care into community

• Community Hubs • 4 integrated care co-

ordination teams in place and fully operational

• Establish 4 fully operational ICCTs

• Define primary care configuration to fit with ICCTs

• Establish all

*

*

Page 13

relevant protocols for referral management between practices and ICCTs

* 22 Protocols and

managed referrals.

• Appropriate referral protocols across all clinical specialties, in primary and secondary care

• Redesign of children’s pathways for planned care in the community

• Electronic Shared Care Record for all

• Rollout of Summary Care Record in all practices

• Consultant to Consultant referrals policy to be re-launched within WUTH

• Implement refreshed PLCP policy and apply non-compliance penalties

* * *

23 Ensure consistent high quality, safe and effective care.

• Appropriate referral protocols

• Electronic Shared Care Record for all

• Appropriate referral pathways

• Commissioning for Outcomes

• Rollout of Summary Care Record in all practices

• Consultant to Consultant referrals policy to be re-launched within WUTH

• Implement refreshed PLCP policy and apply non-compliance penalties

• Develop COBIC skills within key CCG staff

* * *

*

The CCG will implement alternative delivery models for elective productivity so as to be more outcome focused alongside realising 20% efficiency in elective productivity by 2018. One such model is the Prime Provider. The 20% efficiency in productivity is profiled over the next 4 years evenly at 5% per year. In order for the step change in productivity to be achieved, it is vital that the whole system of Wirral interacts and ultimately integrates around the provision of services to patients. The CCG will commission increasingly for outcomes based results, switching its emphasis away from costs / volume activity.

Page 14

2.5 Better Care Fund

WHAT HOW WHEN OUTCOMES PLANS INTENTIONS 2014/15 2015/16 2016/17 2017/18

25 Reduction in number

of bed days due to delayed transfers of care per 100k patients

• Step up Step down service

• Planned acute care

• Joint commissioning integrated services

• Development of ICCTs to support shift of outpatient activity

• Dementia Liaison nurses within hospital

• Implement RAID model through review of psychiatric liaison service

*

*

* *

*

*

*

26 Reduction in avoidable emergency admissions

• Reduce the number of people attending A&E

• Admissions Prevention service

• Care Homes schemes • Urgent Care community

centres • CPN capacity • Early on-set dementia • Falls

• Commission Admissions Prevention Service to support 7 day working

• Implement agreed single model for urgent care

• Commission range of day services to support Dementia

• Review current falls services to identify joint commissioning efficiencies

• Review joint mental health posts

* * * *

*

27 Increase in proportion of people (65 and over) still at home 91 days after discharge from hospital

• Care Arranging Team

• Commission brokerage function

• Community dementia liaison nurses

*

*

28 Reduction in permanent admissions to residential and nursing care homes

• Care Arranging Team

• Commission brokerage function *

29 Patient service user experience

• Develop community-based care of the elderly service

• Dementia shared care pathways

• Disabled Facilities Grant

• Change scope of memory assessment service

• Implement outcome of joint review of CAMHS, ABI, ARBD, & EOD

*

*

30 Percentage of care packages commenced within initial contact with agency

• Joint careers strategy • Investment in social

care community services

• Pooled resources • Increase capacity

of domiciliary care services

*

*

Page 15

2.6 Outcomes Framework Indicators

WHAT HOW WHEN OUTCOMES PLANS INTENTIONS 2014/15 2015/16 2016/17 2017/18

31 Securing additional

years of life for the people of England with treatable mental and physical health conditions.

• Increase cancer screening rates

• Preventing ill-health, ensuring more timely diagnosis of ill-health, and supporting wider action to improve community health and wellbeing.

• Potential years of life lost (PYLL) from causes considered amenable to healthcare

• Under 75 mortality rate from cardiovascular disease

• Under 75 mortality rate from respiratory disease

• Under 75 mortality rate from cancer

• Health-related quality of life for people with long-term conditions

• Review, update and commission best practice services for : Cardiovascular, Respiratory, Cancer, Stroke to impact on PYLL

* * *

32 Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions.

• Improve recovery rates for primary care mental health

• Increase diagnosis rates for dementia

• Improve clinical outcomes for patients with at least one long-term condition

• Increase immunisation rates for vulnerable groups

• Achieve equity of access to physical healthcare for those with a learning disability or a mental illness

• Increase the uptake of NHS Health Checks

• Under 75 mortality rate from cardiovascular disease

• Under 75 mortality rate from respiratory disease

• Under 75 mortality rate from cancer

• Health-related quality of life for people with long-term conditions

• Procure new PCMH service with minimum recovery rate of 50% in Year 1 rising to 65% by Year 3 and Entering Treatment proportion of 15% by Year 1 rising to 20% by Year 3

• Invest in Dementia services within general practices to achieve diagnosis rates 60%/65%/70%/75%

• Establish a shared care worker for mental health to act as caseworker/service navigator

• Extend NHS Health checks to specifically include SEMI patients

• Determine specific metrics for SEMI patients accessing prevention services such as smoking cessation and vaccinations

• Commission integrated learning disability pathway with local authority

* * * * *

*

*

*

Page 16

• Implement revised specification for psychiatric liaison

• Commission integrated ADHD & Personality Disorder Service

* *

33 Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital.

• Emergency admissions for alcohol-related liver disease

• Unplanned hospitalization for chronic ambulatory sensitive conditions (adults)

• Unplanned hospitalization for Asthma, Diabetes and Epilepsy in under 19s

• Emergency admissions for acute conditions that should not usually require hospital admission

• Emergency readmissions within 30 days of discharge from hospital

• Emergency admissions for children with lower respiratory tract infections

• Incidence of Healthcare Associated infection – MRSA Incidence of Healthcare Associated infection – C Difficile

• Implement revised AAU specification and local tariff

• Implement agreed single urgent care model

• Develop innovative practices through collaborative working with the National Centre for Infection Prevention Management (CIPM)

* *

*

*

*

34 Increasing the proportion of older people living independently at home following discharge from hospital.

• Proportion of people feeling supported to manage their condition

• Establish 4 fully operational ICCTs

• Jointly commission rehabilitation services via Better Care Fund (BCF)

*

*

*

35 Increasing the number of people with mental and physical health conditions having a positive experience of hospital care.

• Involving patients and carers more fully in managing their own health and care.

• Implement requirements of NHS Commitment to Carers

• Performance manage hospital providers to achieve on-going improving Family & Friends Test outcomes

*

*

*

*

*

36 Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community.

• Involving patients and carers more fully in managing their own health and care.

• Improvement in patient experience in A&E and acute care High rate of patient satisfaction with services in community hubs and based in their own homes

• An Improvement in Patient Reported Outcome Measures by 2018 for appropriate conditions

• Implement requirements of NHS Commitment to Carers

• Implement agreed single urgent care model

• Implement Family & Friends Test across primary care.

• Develop a framework for engagement involvement and

*

* *

*

*

Page 17

• An improvement in the experience of patients who require planned elective care.

• Patient-reported outcome measures for elective procedures – hip replacement

• Patient-reported outcome measures for elective procedures – knee replacement

• Patient-reported outcome measures for elective procedures – groin hernia

• Patient experience of GP services

• Patient experience of GP Out of Hours service Patient experience of NHS dental services

patient experience in conjunction with Wirral Healthwatch

37 Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care.

• Incidence of Healthcare Associated infection – MRSA Incidence of Healthcare Associated infection – C Difficile

• Develop innovative practices through collaborative working with the National Centre for Infection Prevention Management (CIPM)

*

Page 18

2.7 NHS Constitution standards

WHAT HOW WHEN

OUTCOMES PLANS INTENTIONS 2014/15 2015/16 2016/17 2017/18

38 RTT waiting times for non-urgent consultant-led treatment

• Commissioned services to achieve maximum target of 18 weeks RRT moving to achieving target of 16 weeks RRT by 2016.

* *

39 Diagnostic test waiting times

• Commissioned services to achieve maximum target of 6 weeks from referrals moving to achieving target of 4 weeks by 2016

* *

40 A&E waits

• Commissioned service to achieve and maintain current target of 95% moving to 98% by 2016

* *

41 Cancer waits – 2weeks wait

• Commissioned services to achieve and maintain national targets

* * * *

42 Cancer waits – 31 days

• Commissioned services to achieve and maintain national targets

* * * *

43 Cancer waits – 62 days

• Commissioned services to achieve and maintain national targets

* * * *

44 Cancelled operations

• Zero tolerance for cancellations not due to clinical reasons

* * * *

45 Mental Health – CPA

• Commission of services to achieve and maintain current target 95% moving to 98% by 2016 and 100% by 2017

* * *

46 Ambulance handovers

• Commissioned services to achieve and maintain national targets

* * * *

Page 19

Appendices

Appendix 1 – NHS Outcomes Framework Indicators The chart below shows the distribution of the CCGs on each Outcomes Framework indicator in terms of ranks. NHS Wirral CCG is shown as a red diamond. The yellow box shows the inter quartile range and median of CCGs in the same ONS cluster as this CCG. The dotted blue line is the England median. Each indicator has been orientated so that better outcomes are towards the right (light blue).

Page 20

Appendix 2 – Vision 2018 Summary Programme Documents

Programme Name: Planned Care

Programme Objectives:

Objective No

Objective Statement

1. To enable more patients to self-care

2. To ensure the patient sees the right professional first time

3. To deliver planned care in a setting close to the patients home unless their care requires specialist facilities to ensure the best outcomes

4. To improve access to diagnostic services and treatment

5. To improve outcomes of planned care

6. To ensure equity of service provision

7. To ensure the correct levels of planned care capacity are commissioned at the appropriate level of delivery e.g. Primary, secondary or tertiary care

8. To achieve a 20% improvement in productivity in planned care by 2018.

Programme Name: Unplanned Care

Programme Objectives:

Objective No

Objective Statement

Overarching Strategic Aims

• Reduce hospital emergency activity by 15 per cent • Achieve the A&E 4 hour standard • Right care, right place, right time

1. Ensure people know where to access advice to enable them to care for themselves where appropriate

2. Provision of same-day access to care when necessary (e.g. GP, Pharmacy, Dentist, Optician, community or hospital based care as required)

3. If advice or treatment is required, this should be provided where the patient presents whenever possible

4. Ensure patients have rapid access to specialist care when required

5. Ensure care is coordinated to meet the mental, physical and social needs of the individual

Page 21

6. Ensure quality and patient experience is measured and monitored to continually improve care

Programme Name: Long Term Conditions/Complex Needs Delivery programme

Programme Objectives:

Objective No.

Objective Statement

[e.g. Reducing attendances, emergency admissions at Accident and Emergency department and mortality rates within the acute hospital

1 Improve life expectancy across Wirral

2 Improve the health and social care related quality of life for people with more than 1 long term condition

3 Empower and support people to take more responsibility for their own health needs including understanding what the local community can offer as support.

4 Ensure that care is delivered in an environment best for individual needs, closer to home

5 Reduce attendance at A&E and reduce the number of people accessing care in long term care settings

6 Preventing people from dying prematurely

Programme Name: Prevention, Self Care & Community Development

Programme Objectives:

Objective No. Objective Statement

[e.g. Reducing attendances, emergency admissions and mortality at Accident and Emergency departments]

1

Community Development (Primary prevention e.g. Healthy Places)

a) Healthy, resilient, empowered and engaged communities to reduce health inequalities improve outcomes and demand on services.

b) Greater community involvement and challenge in shaping delivering of public services.

c) Healthy environments, utilising the assets within communities. 2 Prevention (Secondary prevention e.g. lifestyle services, immunisation and

vaccination programmes, screening programmes)

a) Empower and support people to take more responsibility for their own health. 3 Self Care (tertiary prevention)

a) Improve the quality of life and patient experience of people living with health issues

b) Contribute to reducing inappropriate attendances and clinically inappropriate

Page 22

admissions to A & E c) Reduce GP appointment which could be managed in a different setting

4

Workforce development

a) Remodel the role of the workforce to develop new relationships with colleagues, patients and citizens

Programme Name: Integration – Adults

Programme Objectives:

Objective No.

Objective Statement

[e.g. Reducing attendances, emergency admissions and mortality at Accident and Emergency departments]

1 Improving people’s care experience and health outcomes by commissioning services that care for people at home or in their local community

2 Reducing by 25 per cent the length of time people with a long term condition(s) stay in hospital by 2015

3 Reducing spend on long term care home placements from 3.7% to 2.1% average for the North West (ADASS/AQUA North West Utilisation Report September 2012)

4 Reducing unplanned hospital admissions by 20 per cent by 2015

Programme Name: Integration – Children’s

Programme Objectives:

Objective No.

Objective Statement

[e.g. Reducing attendances, emergency admissions and mortality at Accident and Emergency departments]

1 Transformational outcome: Children are ready for school

Aim: Children will be supported to have the best possible start in life and develop healthy lifestyle choices.

2 Transformational outcome: Young people are ready for work and adulthood

Aim: Children and Young People who need extra help to reach their potential and achieve well will be supported.

Page 23

Appendix 3 – Potential Years of Life lost from causes considered amenable to healthcare by Disease group. (Data from 2001-03 to 2010- 12) Please see the attached graphical and numerical representation of Local health economy performance when addressing the disease groups considered to be amenable to healthcare across CWW Area team. There are a number of areas where the performance to 2012 and the subsequent trend suggest an underperformance. The intention is to ensure the issues identified in the attachment are understood and ideally addressed in the current strategic and operational plans provided by the respective CCGs. Clearly the timescales for the PYLL data is long term and the attached appears to be nationally the most recent data. CCG’s however may well have more up to date information. Potential Years of Life lost from causes considered amenable to healthcare. Disease area

Eastern Cheshire

CCG

South Cheshire

CCG

Vale Royal CCG

Warrington CCG

West Cheshire

CCG

Wirral CCG

All causes. Better than National values. Extrapolated trend in line with national projection

Better than National values. Extrapolated trend in line with national projection

Better than National values. Extrapolated trend in line with national projection

Worse than National values. Extrapolated trend remains worse than national trend

Better than National values. Extrapolated trend in line with national projection

Worse than National values. Extrapolated trend remains worse than national trend

Coronary heart Disease Better than National values. Extrapolated trend in line with national projection

Better than National values. Extrapolated trend in line with national projection

Better than National values. Extrapolated trend in line with national projection

Worse than National values. Extrapolated trend remains worse than national trend

Better than National values. Extrapolated trend in line with national projection

Worse than National values. Extrapolated trend remains worse than national trend

Stroke Better than National values. Extrapolated trend in line better than national

Better than National values. Extrapolated trend in line better than national

Better than National values. Extrapolated trend in line with national projection

Worse than National values. Extrapolated trend remains worse than national trend

Better than National values. Extrapolated trend in line with national projection

Worse than National values. Extrapolated trend remains worse than national trend

Page 24

projection

projection

Pneumonia Better than National values. Extrapolated trend in line with national projection. Delivery showing significant swings.

Better than National values. Extrapolated trend in line with national projection. Delivery showing significant swings.

Better than National values. Extrapolated trend worse than national projection. Delivery showing significant swings

Worse than National values. Extrapolated trend remains worse than national trend. Delivery showing significant swings

Better than National values. Extrapolated trend worse than national projection. Delivery showing significant swings

Worse than National values. Extrapolated Trend in line diverting and worse than national trend

Amenable cancers In line with National values. Extrapolated trend in line slightly better than national projection

In line with National values. Extrapolated trend in line slightly better than national projection

Worse than National values. Extrapolated trend line worse than national trend

Better than National values. Extrapolated Trend in line with national projection

Worse than National values. Extrapolated trend line worse than national trend

Worse than National value. Extrapolated Trend line better than national trend

Other amenable Better than National values, extrapolated trend worse than national trend

Better than National values, extrapolated trend worse than national trend

Better than National values. Extrapolated Trend in line with national projection. Delivery showing significant swings.

Better than National values. Extrapolated Trend in line with national projection

Better than National values. Extrapolated Trend in line with national projection. Delivery showing significant swings.

Worse than National value. Extrapolated Trend in line diverting and worse than national trend

Page 25

Appendix 4 – QIPP Plan 2014 / 15

NHS Wirral CCG

QIPP Plan 2014/15

Page 26

What is a QIPP Plan?

During this plan we will set out what our financial challenge is for 2014/15, that is, the level of resource we need to either save, or release by being more efficient, and by undertaking programmes of work that embrace the QIPP Principles as outlined on page 2.

We will refer to this financial challenge the QIPP Gap.

For NHS Wirral CCG in 2014/15, this is currently £6.9m which is made up of £6.5m recurrently and £0.4m non-recurrently. This was originally £4.1m as per the CCG financial planning assumptions but has subsequently increased during the current financial year to its current value of £6.9m (due to updates / revisions of these planning assumptions and finalisation of contract values). The original QIPP gap was driven by increases to healthcare expenditure over the last few financial years and resulting contract agreements with healthcare providers for the 2014-15 financial year.

Pages 4 – 6 describe the current and longer term financial challenge, so that the QIPP plan for this year is not seen in isolation.

Page 7 sets out how the areas within this plan will align with other plans of the CCG – the QIPP plan is not developed in isolation.

This QIPP Plan will set out the areas in which we think as a CCG we can either avoid cost (an economic term used to describe costs that would have been incurred should you not have taken steps to avoid them), or release efficiencies, in order to bridge our QIPP gap.

Page 9 explains how we monitor these to ensure that they will achieve the impact that we anticipate, and therefore that we are on track to bridge our QIPP gap.

An overview of the individual schemes that make up the plan is provided on pages 12 - 14, along with the cost that we expect to either avoid or release through these areas. Some of the pieces of work we undertake will mean that activity will shift from one provider to another, e.g. from the hospital to services in the community.

Finally, we have identified potential risks to the delivery of the QIPP plan on page 16, and set out how we seek to mitigate these.

Page 27

Wirral CCG Financial Challenge – the next five years

There is an anticipated gap between the CCG’s financial allocation, and its anticipated expenditure. The following graph describes the gap for Wirral over the next five years, should no action be taken.

The high level financial forecast indicates that the system needs to deal with the pressures using a very different clinical and commercial model. Delivering efficiency alone will not be sufficient to meet rising costs and growth which are roughly equivalent to 30% of the original baseline 14/15 budget.

The QIPP plan starts to address this gap, but greater transformational system change will be required to address the growing pressure.

400,000,000

500,000,000

600,000,000

2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

Funding Forecast costs

Wirral health system 5 year financial challenge projection (worst case = do nothing)

£

c£140m

Page 28

The QIPP Challenge – the next five years

The CCG’s QIPP requirement for the financial years 2015-16 to 2018-19 is estimated to be circa £74m based on delivery of efficiencies through tariff, prescribing efficiencies and cash releasing savings (through transactional / transformational schemes). This is based on the CCG delivering an efficiency requirement of 4% of its available resources which is in line with NHS England planning requirements.

The CCG will need to ensure that the contract values in each of the respective years are reflective of the required net tariff values (including the required tariff efficiency in each of the respective years) and that through the targeting of its QIPP workstreams / projects to deliver the cash releasing and prescribing efficiencies as appropriate.

Page 29

What is the 2014/15 QIPP Gap?

The 2014/15 QIPP gap of £6.9m has been calculated on the following basis: £6.5m recurrent & £0.4m non-recurrent (included below as part of specialised commissioning impact)

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CCG QIPP Plans 2014-15

Page 30

The QIPP Plan is not something to be seen in the system in isolation. We must focus on the areas that we know pose the greatest challenge for us as a health economy and, by focussing time and resources in a way that is innovative,

focusses on prevention and productivity, we will make efficiencies that will contribute towards a sustainable health and social care system.

We must be mindful that the priorities of the QIPP plan are aligned with our five year Strategic Plan, our short-term Commissioning Plan, and our system-wide plan for Urgent Care.

How does this two-year QIPP Plan fit in with wider system transformation?

Vision 2018 is the plan to re-shape health services and social care in Wirral, whilst empowering people to take more

responsibility for looking after their own health.

It brings together health and social care partners to set out the vision for our health and social care system over the next five years. The work that we will do is split into three programmes

of work – planned care, unplanned care, and long term conditions and complex needs.

The principles of QIPP must be embedded in all that we do in order to make Vision 2018 a reality.

Vision 2018 Programme

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Governance in place for the development and monitoring of the Wirral CCG QIPP Plan

QIPP Review meeting (monthly)

QIPP Sponsor

Commissioning Managers

Business Intelligence and Finance

QIPP Area

QIPP Area

QIPP Area

QIPP Area

QIPP Area

There is a PMO process for consideration of any new areas for potential cost avoidance or efficiency. These are judged on the basis of alignment with strategy, and inclusion of clear, realistic outcomes.

QIPP Workstreams

Operational Team meeting (weekly)

A verbal update is given on the overall progress against the QIPP plan on a weekly basis, with any issues being reported on

an exceptional basis. If required, the Operational Team may recommend that schemes / issues are escalated to the

Quality, Performance and Finance Committee

Those staff that are involved in monitoring QIPP on a day-to-day basis meet monthly in order to highlight and resolve any issues at an operational level, and determine what

needs to be escalated, and to what level

Quality, Performance and Finance Committee (monthly)

The Quality, Performance and Finance Committee will receive the QIPP Plan dashboard on a monthly basis. The Operational Team will highlight any variance to

the QIPP Plan for discussion. The Governing Body will also receive the QIPP Plan on a monthly basis, with any issues reported on an exceptional basis.

NHS Wirral CCG Governing Body

Page 32

Monitoring Progress

Progress is monitored through a QIPP Dashboard, which RAG rates each scheme, and overall plan performance, against implementation date, planned activity shifts and financial impact – the following is an example from the 2013-14 QIPP Plan:

Longer-term QIPP Plan

Whilst this plan focusses on 2014 - 16, the CCG has embarked on ambitious programmes of transformation that will secure QIPP gains over future years. Integration

Through its Vision 2018 programme, the CCG and its health and social care partners are working towards increasing integration in both commissioning of services, and provision.

This will mean great transformation not only in the way that services are commissioned and delivered, but also in the way that people use services, with the following objectives:

• Seamless and timely response from integrated

teams and other appropriate services

• Single gateway and streamlined pathways which are easier for people to navigate

• Encouraging self-care and self help

• Health and social care having joint responsibility for the patient pathway by pooling budgets to reduce duplication

• Implementation of shared electronic record to improve communication

• Coordinated care plans with patient led goal setting

Unplanned Care

We know that we have a system where too many people go to A&E when this isn’t always the right place for them to be treated, and that too often people are admitted to hospital because the care offered in the community has not been accessed, or has not been the right sort of care, has not been delivered timely enough, or where the patient and family member are not sure how best to manage at home.

We must see this as a failure of the system, and this is what we must work to address.

Our strategy for unplanned care is centred on a productive system, and one that prevents rather than reacts. It describes treating people quickly within the community, offering rapid assessment to those whose conditions are more complex, through to helping the hospital to ensure a smooth journey from admission to discharge. Through this approach, we will secure efficiencies not just in year one, but over the next generation of the NHS.

Page 33

Integrated commissioning and provision, and productive and preventive

urgent care

People empowered to

take responsibility for their own

health

Sustainable health and social care

system

Page 34

Impact Assessment of each QIPP scheme

The aim of the QIPP Programme is to find efficiencies whilst at the same time improving the quality and safety of patient care. For instance, delivering services in the community rather than in an acute setting will be more cost-effective, but will also deliver a faster and more accessible service to patients.

Each scheme will therefore need to demonstrate an anticipated positive impact upon one or more of the following measures:

NHS Outcome measures – five domains, and 7 ambitions

NHS Constitution measures

These are standards that every patient, under the NHS Constitution, should expect, for instance:

- at least 90% of admitted or non-admitted patients should receive treatment within 18 weeks of referral

- at least 99% of patients should have received their diagnostic test within six weeks of referral

We will also expect each QIPP scheme to demonstrate alignment with one of the following key Characteristics of a sustainable NHS:

A completely new approach to ensuring that citizens are

fully included in all aspects of service design and change and that patients are fully empowered in their own care.

Wider primary care, provided at scale.

A modern model of integrated health and social care.

Access to the highest quality urgent and emergency care.

A step-change in the productivity of elective care (more for less).

Specialised services concentrated in centres of excellence.

Page 35

Summary of QIPP Plan 2014/15

The programmes that make up the plan for QIPP savings in 2014/15 have been divided into transactional (those generated through use of enablers and contractual levers) and transformational schemes (those with a direct impact on patient care). Through activity modelling we have estimated the anticipated financial impact of each area of work for 2014/15. A summary of intended QIPP schemes is provided for 2015/16, where further detailed modelling is required.

Recurrent Non-Recurrent Total

£ million £ million £ million

QIPP Planning Gap £6.5m £0.4m £6.9m

QIPP Delivery 2014/15

Transformational / Service Redesign QIPP £0.13m £0.13m

Transactional QIPP £4.1m £4.1m

CCG Mitigation (Contingency) £3.0m £3.0m

Total £4.23m £3.0m £7.23m

Gap (Shortfall / Surplus) (£2.27m) £2.6m £0.33m

Cost Avoidance

In addition, there is £0.7m in Prescribing Efficiency / Medicines Management that is anticipated as ‘cost avoidance’ rather than ‘cash releasing’, and therefore will further contribute towards financial balance. A focus on prescribing therefore continues to be an imperative for the CCG.

Page 36

QIPP Plan for 2014/15 – further detail

Assumed impact of transactional schemes in 2014/15

Area of Work Anticipated Financial Impact in 2014/15

Brief description of scheme

Vacant QIPP Lead posts £26,900 These are posts that have been accounted for but are currently vacant

CCG Staffing vacancies £76,300

Updated financial planning assumptions £1,516,000 These resources represent slippage against various areas within the financial plan

Underperformance on WUTH contract £2,500,000

It is anticipated that there will be underperformance against the WUTH contract due to referral management and a number of areas where activity is forecast to be lower than projected within the plan.

Total £ 4,119,200

Page 37

Taking into account both transactional and transformational impact, we therefore anticipate that with the use of contingency resources available to the CCG that we will be able to achieve the current in – year QIPP gap, but there remains a recurrent shortfall to the CCG.

There are a number of pressures within the system that will need to be operationally managed on a monthly basis in addition to monitoring progress against the QIPP schemes. The detail of these is brought to Governing Body on a monthly basis.

Assumed impact of transformational /service redesign schemes in 2014/15

Area of Work Anticipated Financial Impact in 2014/15

Brief description of scheme

Rapid Access Chest Pain Clinic £14,000 People with chest pain are risk stratified before referral to ensure that they are seen in the most appropriate place

Trial Without Catheter £50,000 Patients previously given trial without catheter in hospital ward, now done in community - combination of own home and hospital clinic

Direct Listing for Hernia £20,000 Patients are directly listed for hernia appointments where appropriate, cutting out unnecessary steps in the patient journey

Crisis Beds £30,000 Crisis beds delivered by a more cost-effective provider, whilst maintaining quality of care

Community Glaucoma treatment £13,500 Working to a more cost-effective tariff for glaucoma follow-up within the community

Total £127,500

In addition, there is the following area of cost avoidance that will contribute towards achieving overall financial balance:

Area of Work Anticipated Financial Impact in 2014/15

Brief description of scheme

Medicines Management / Prescribing Efficiency £700,000 Use of more cost-effective medications and reduction in prescribing waste

Page 38

QIPP in 2015/16 and beyond

For a sustainable system, greater efficiencies will need to be gained through transformational change, rather than non-recurrent transactional impact. Moving forwards we will need a QIPP plan that is inherently transformational, with integration of end to end services, and pathways that are truly patient-centred.

The Vision 2018 programme describes the areas for focus as follows:

Page 39

Based on this, current thinking around transformational and transactional change for 2015/16 and beyond is as follows:

Transformational We will need to have a greater focus on transformational change in order to meet the growing QIPP challenge and to ensure recurrent impact. This table gives an overview of key areas for QIPP impact from 2015 onwards

Transactional / Cost Avoidance Reduced reliance upon care packages coupled with enhanced commissioning of community provision for mental health and learning disabilities

Consultant to Consultant referrals within same patient pathway

Outpatient redesign for more streamlined and integrated patient pathways

Compliance with Procedures of limited clinical value policy

Prime provider model for Primary Care Mental Health

Application of non-elective threshold / marginal rate emergency tariff

Referral decision-making tools, e.g. hip and knee referral form Acute assessment unit tariff

Working with providers and the Local Authority to transform pathways for older people

Medicines Management / Prescribing Efficiency Efficiency in Continuing Healthcare / care package commissioning

Urgent care transformation, as per emerging urgent care strategy

Integrated commissioning through the Better Care Fund

Page 40

Risks, Concerns and Mitigation

NHS Wirral CCG has identified a number of risks to the delivery of its QIPP Plan: Risk

These risks and concerns will be mitigated through…

Mitigation Unsuccessful delivery against QIPP Plan operational management against agreed milestones

and financial plans to ensure the maintenance of sufficient headroom between size of challenge and savings identified

Insufficient governance and performance management process regular performance updates to the Quality Performance and Finance Committee, and to the Governing Body, to track delivery and ensure ability to take effective mitigating actions as appropriate

Lack of effective and meaningful engagement with key stakeholders including patients and public

the development and implementation of robust engagement strategies to include local authorities, clinicians, patients. carers and public as part of any QIPP programmes of work

Failure to develop a robust recovery plan if required the maintenance of effective and time bound monitoring processes to ensure that sufficient early warning mechanisms of any deviation from plan are in place, such that remedial action can be taken at the earliest possible opportunity

Gap in transformational schemes The Vision 2018 programme is prioritising health and social care commissioning to ensure that the focus is on transformational areas that will generate recurrent efficiencies. This is governed through a Programme Management Office function to track delivery

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Appendix 5 – Urgent Care Strategy

A Wirral-wide Urgent Care Conference was held on 18th September 2014 involving commissioners and providers to share, gather and collate clinical opinion on the Urgent Care system for Wirral. Agreement to a single model of the provision of urgent care services is required by April 2015 in order to commence the required commissioning to effect the changes in the local health system during 2015/16.

Minutes of the WGPCC Executive Board meeting – 11th June 2014 Page 1 of 7

WIRRAL GP COMMISSIONING CONSORTIUM

EXECUTIVE BOARD MEETING Minutes of Meeting

Wednesday 11th June 2014, 6.30pm

Nightingale Room, Old Market House Present: Dr Akhtar Ali (NA) GP Lead Penny Angill (PA) Practice Manager Member Christine Campbell (CC) Chief Officer Dr Simon Delaney (SD) GP Lead Dr Maria Earl (ME) GP Lead Dr Andrew Lee (AL) GP Lead Dr Hannah McKay (HM) GP Lead Dr John Oates (JO) Chair Sam Saminaden (SS) Lay Representative Eddy Shallcross (ES) Patient Council Chair In attendance: Anita Fletcher (AF) WGPCC Administrator Steve Riley (SR) CSU Medicines Management

Ref No. Minute WGPCC/EB/ 14-15/007

1.1 Apologies for absence Apologies were received from Dr Navaid Alam and Louise Morris.

1.2 Declarations of interest There were no declarations of interest made.

1.3 Public Comments/Questions There were no members of the public present.

1.4 Minutes and Action Points of the last meeting The minutes were agreed to be a true record of the meeting. Matters Arising Briefing Statement – Members were advised that a statement had been released by Wirral CCG. The Chair and Accountable Officer have temporarily stepped aside whilst a review is undertaken, led by NHS England, which is due to commence during the week of 16th June 2014. Dr Pete Naylor is Acting Chair and Jon Develing is the Interim Accountable Officer. JO explained that he is aware that different members have different levels of information. If members have any questions, JO advised that he would answer them to the best of his ability at end of this meeting. Action Points

Minutes of the WGPCC Executive Board meeting – 11th June 2014 Page 2 of 7

Ref No. Minute

WGPCC Care Homes Scheme – Action complete – JS to share the scheme evaluation with Patient Council members on Thursday 12th June 2014. Minor Injury and Illness Service Evaluation 2013-14 – Action complete – CC has explored ways to release £50k from existing financial priorities for the Consortium. This item is covered under the WGPCC Expenditure Plan Update at this meeting. Minor Injury and Illness Service Evaluation 2013-14 – Action complete – CC has deferred the decision regarding future commissioning of all three of the WGPCC Minor Injury and Illness sites to the CCG – This item is covered under the WGPCC Expenditure Plan Update at this meeting. Financial Budget 2013/14 – Action pending – LM to ensure activity data for all providers is included in future monthly reports – Due to the fact that reporting does not commence until month three or four, the full pack is not available but this information will be included going forward.

1.5 Minutes for Noting There were no ratified Governing Body meeting minutes available for noting.

1.6 Complaints, Compliments and Patient Feedback Executive Board members were advised that there is nothing specific to report on relating to services commissioned by WGPCC this month.

WGPCC/EB/ 14-15/008

2.1 WGPCC Medicines Management Approach Steve Riley attended the Executive Board meeting to introduce himself and highlight how Medicines Management have engaged with practices and how this could be improved. Feedback and thoughts were requested. One member highlighted that value of the input from their Medicines Management Practice Pharmacist. If this resource were to be lost, it would take a great deal of GP time to cover the role. Any problems that occur in practice are resolved quickly by the Medicines Management team. For the budgetary position, AA suggested that there is too much emphasis placed on cost switching medication, and would like to see more work on quality improvement. SR assured that medication would not be switched by a practice technician on cost alone; other factors are considered here, for example the quality of a product. CC added that the Medicines Management Team is working to a brief set by the CCG regarding QIPP, which includes both quality and productivity. Members were asked to send feedback directly to Steve Riley and any issues would be looked into; the team will be as flexible as possible in exploring any areas that a practice is interested in. JO suggested that supply problems with particular medication can cause problems. Members felt it would be helpful if the team could advise practices of the length of time a product would be unavailable and whether it is a local or national issue, as this has an impact on whether a patient’s repeat prescription should be amended. SR agreed to look into the possibility of resolving the timescale issues mentioned. Members were asked to consider what they would like to see included in reporting papers that are shared at meetings. PA suggested that the top 20 most expensive patients for each practice would be useful to receive.

Minutes of the WGPCC Executive Board meeting – 11th June 2014 Page 3 of 7

Ref No. Minute

Medicine waste was highlighted as an issue and members were advised that it is difficult to quantify the amount of wastage that occurs. This can be done from care home information received but is difficult to report down to practice level. It was agreed that a draft reporting pack would be put together and brought to the next meeting for members to comment if any different information is required.

WGPCC/EB/ 14-15/009

3.1 Tier 1 Gynaecology Evaluation Report Members were reminded that the Tier 1 Gynaecology Service was commissioned to provide a ‘one stop shop’ approach for female patients from WGPCC member practices has been operating for eight months. The purpose of the service is for gynaecological reasons and is not for contraceptive purposes. As the service is due for review in July 2014, it has been brought to the Board for consideration. Members were advised that the cost of the service for the eight month period is as follows: • Villa MC = £1,440 • Teehey Lane = £600 • Total £2,040 This includes payments for pessaries purchased for patients who subsequently decided not to proceed with the procedure. The cost for 38 patients to be seen in the WUTH outpatient gynaecology department would have cost practices £5,901 in total. Therefore an approximate saving of £3,861 has been made in the eight month period. Villa has suggested two consultations be funded with a fee of £25 for an initial additional consultation appointment as their experience to date had been that discussion with patients concerning intervention and treatment in the service was required before proceeding to the intervention. They have advised that they would only want to carry on the service on this basis. By having the Tier 1 service, CC explained that it has avoided costs at WUTH but has not released any costs. If members want to see the service continue, there is an amount of slippage available but if the service continues indefinitely, the Consortium may have to cap what is available and limited the number of people seen. Members were asked to consider the following: • Stop the service in August • Carry on and include the additional charge of £25. • Monitor the number of women going through the service and put a cap on this if the cost

approaches the budget that is available. Members were advised that due to the QIPP review, the service may be looked at Wirral wide. Members must decide on the future of the service at this meeting as the Executive Board does not meet again until September. The question was raised if details of practices that use the service could be obtained as it was felt only a number of practices are using the service. A proposal was made to continue funding the service until March 2015 but put a cap on activity.

Minutes of the WGPCC Executive Board meeting – 11th June 2014 Page 4 of 7

Ref No. Minute

The Executive Board agreed to continue the service until the end of March 2015 with the additional consultation appointment and agreed to the funding with a cap on activity once spend reaches the total budget available. No guarantee to be given to practices for funding beyond March 2015. Action: CD to collate and share details of practices that use the Tier 1 service. Action: The Tier 1 Gynaecology service to be brought back to the Executive Board in November 2014 or January 2015 for review.

3.2 Claim for Non-recurrent Resources There was no conflict of interest for this item as the Member Practice involved is not represented on the Executive Board. Members were advised that the report asks the Board to consider a request from a Member Practice to access non-recurrent resources that were available in 2013-14. The practice used their non-recurrent resource allocation of £22,090 for Counselling, Health Care Assistant and Acupuncture but failed to invoice the CCG by the deadline set, before the end of the financial year. Therefore no money has been accrued for this. A request was made for reimbursement due to extenuating circumstances but this request was originally turned down by CC and JO. The practice appealed this decision and as the Chair and Chief Officer made the original decision, the next stage is for consideration by the Board. Full details including email correspondence is set out in the paper. Members were advised that as the resource was not invoiced for, the money went to support the CCG bottom line and therefore was no longer available to the Consortium. The Practice has said it missed the communication due to extenuating circumstances. Appendices 1, 2 and 3 were highlighted. The practice is aware that the final decision would be made by the Executive Board. The Board was asked to consider the following:

a. There is the risk of this practice – a practice with a history of strong engagement with the Consortium and its commissioning strategies – disengaging with the Consortium, at a time when the CCG is working harder than ever to engage its Member Practices;

b. Three other practices did not submit an invoice in time, to a total of £56,214. The Consortium does not have access to this level of resource, and therefore there would need to be a particularly extenuating reason for granting reimbursement to one practice and not to others, if we are seeking to be equitable;

c. The practice has fully implemented the schemes for which it is claiming reimbursement, and can provide evidence of this.

Members were informed that there is strong engagement with this Member Practice. Members were reminded that the amount was based on the financial situation at that time but when making the decision today is must be based on the financial situation at this time. Discussions took place and it was agreed that this must be made clear the Board is supporting this case due to extenuating circumstances and the ability to honour this financially, but will not be in a position to honour any future applications. The Executive Board agreed to reimburse the Member Practice 50% of the total funding requested.

Minutes of the WGPCC Executive Board meeting – 11th June 2014 Page 5 of 7

Ref No. Minute 3.3 WGPCC Expenditure Plan Update

Members were advised that the paper set out the proposed expenditure plan for 2014/15 for Wirral GP Commissioning Consortium’s recurrent service development budget of £695,758. The paper shows the breakdown for each area within the budget. Members were reminded that there had been a large discussion at the last Executive Board meeting regarding the Minor Injury and Illness Service. This had been discussed with senior management in the CCG for consideration. Wirral GPCC is covering the commissioning responsibility and budget until the end of August 2014. A review is currently being undertaken being led by the Interim Accountable Officer, with a decision to be reached by the end of August 2014. The practice training budget has been transferred to another budget and members were informed that the money available at practice level does not change. With regards to the ECG service, figures on the number of patients who have used the service are shown in figure 3.4 of the report for information, following a request raised at the previous Executive Board meeting. One Board Member explained that it is a valued service, with very quick reporting and information. Comparison costs for the service would be useful for members to consider. Members were advised that the cost for this service is £35. There is no additional cost at the Heart Centre as this is run on a block contract. If the ECG service was stopped, this would increase waiting times at the Heart Centre. It was agreed that the ECG service should continue. An extra £11,000 would be available to put into the contingency fund due to the Member Practice only receiving 50% of the non-recurrent resource. For Primary Care Mental Health, Peninsula have agreed to a block contract for the remainder of the year, but the additional value is still required to meet the increasing complexity of the patient caseload. A query was raised as to whether this could be guaranteed, whether Peninsula would ask for more money in the future and would waiting times go up. CC advised that as it is a block contract, there would be no further costs within 2014/15. Members were advised that this would be monitored on a weekly basis and that the provider is currently meeting waiting times and DNA targets. Referrals are steady and the contract is based on average numbers received. The Board is being asked to note how the budget is broken down for the financial year 2014/15 in order for the budget to be signed off. The Executive Board approved the breakdown of the WGPCC expenditure plan for 2014/15.

WGPCC/EB/ 14-15/010

4.1 Financial Budget 2013/14 The finance update for the period 1st April 2014 to 30th April 2014 was tabled at the meeting. Members were advised that for the year ending 31st March 2014, the accounts for the first year of Wirral CCG have been audited and Grant Thornton have given an unqualified opinion which concludes the financial records and statements are fairly and appropriate presented which is good. One challenge for the CCG is to make QIPP savings for the coming year. £5 million savings have to be realised in order to achieve financial balance; although the idea is to look towards £10 million savings if possible. Members were advised that CC has been given responsibility for

Minutes of the WGPCC Executive Board meeting – 11th June 2014 Page 6 of 7

Ref No. Minute

the QIPP plan. There is a budget of £35 million for Continuing Healthcare and packages of care, the panel process for which lies with the Commissioning Support Unit. Members were advised that for some services under Peninsula Health, for example Orthopaedics the first appointment here is more expensive that at WUTH. There is a perception that practices think there is a less expensive tariff. A request was made for a breakdown of which practices send patients to these services together with tariff charges. It was agreed that tariff prices should be shared with practices. 2014/15 WGPCC Update – The total budget available to the consortium for the year is £148 million, which is based on a new “fair share” formula approach (WGPCC fair share 38.59%) of the overall amount allocated to the Consortia of £384 million. Members were advised that this is much less than the previous year. The Executive Board noted the finance update for month one.

4.2 Patient Council and Engagement Update Members were informed by ES that Healthwatch had presented at the last Patient Council meeting and would like to attend each meeting. This was agreed on the proviso that they can be asked to leave the meeting if it is deemed necessary, to discuss any private business. There was a discussion and update on the Minor Injuries and Illness Service and patients are in favour of the service. A request had been made for Simon Wagener, the Patient Representative from the Wirral CCG Governing Body, to attend the next Patient Council meeting. Good feedback was received on the Primary Care Mental Health service update. Members were advised that meetings go from strength to strength. More knowledge, good ideas and strong good views are fed into these meetings. ES was asked to write a letter to Simon Wagener on behalf of the patient group regarding concerns raised at the Patient Council on how views are represented at Governing Body meetings on the patients’ behalf, copying into the letter both AA and HM, as WGPCC representatives at Governing Body. Action: ES to write a letter as set out above.

4.3 Practice Managers’ Update Phlebotomy – Executive Board members were advised that the issues highlighted at the last Executive Board meeting still continue. A representative from the Phlebotomy service will be attending the next Practice Managers’ Forum on 10th July 2014. Practice Managers’ Workloads – There has been a reduction in the number of LES’s and some of QOF has now gone in the baseline. The question was asked if this has helped with workloads and members were advised that this is bound to help to an extent. There have been issues with inputting figures in time for deadlines due to system problems and therefore claiming can be difficult. Account Managers within the Local Area Team have a wider remit covering a number of CCGs, which has reduced engagement.

Minutes of the WGPCC Executive Board meeting – 11th June 2014 Page 7 of 7

Ref No. Minute

4.4 Items for Risk Register There were no new items to be included on the risk register.

WGPCC/EB/ 14-15/011 5. Any Other Business

GP Forum – Members were advised that Dr Clive Pleasance has stepped down as Chair of the WGPCC GP Forum with the new Chair being Dr Simon Delaney. Members thanked Dr Pleasance for all his hard work and commitment in the role of GP Forum Chair. Action: A letter to be sent to Dr Pleasance thanking him for his services as GP Forum Chair. Risk Stratification – ME asked if there were any arrangements to support practices with risk stratification. CC advised that a letter had been issued to Senior Partners and Practice Managers a few weeks ago regarding this. The DES requirements were highlighted to members. Members were informed that practices can use their own list of patients or can use the list that will be provided shortly. Action: AF to resend the risk stratification email to Practice Managers.

WGPCC/EB/ 14-15/012 6. Private Business

There was no private business discussed.

7. Date and Time of Next Meeting The date and time of the next meeting is Tuesday 16th September 2014, 6.30pm in the Nightingale Room, Old Market House, Birkenhead. Please send any apologies to Anita Fletcher on anitafletcher@nhs.net

The meeting finished at 8.15pm

1

APPROVALS COMMITTEE

Minutes of Meeting

Tuesday 27th August 2014

Room 539, 5th Floor, Old Market House Present: James Kay (JK) Lay Member (Audit & Governance), WCCG (meeting Chair)

Lorna Quigley (LQ) Head of Quality & Performance

In attendance:

Chelsea Worthington (CW) Corporate Support Admin Assistant (minute taker) Christine Campbell (CC) Chief Officer, WGPCC Andrew Cooper (AC) Chief Officer, WHCC Sylvia Cheater (SC) Audit Lay Member Bernard Halley (BH) Audit Lay Member Steve Riley (SR) Senior Prescribing Advisor

REF NO. MINUTES ACTIONS AC14-15/01

1. PRELIMINARY BUSINESS

1.1 Apologies for absence:

• Fiona Johnstone (FJ) Director of Public Health • Simon Wagener (SW) Lay Member (Patient Champion), WCGG • Mark Bakewell (MB) Chief Financial Officer, WCCG

2

REF NO. MINUTES ACTIONS JK introduced the new Lay Members to the group. Both Lay Members introduced themselves and their job roles within the CCG to the Group. Each member of the group introduced themselves and their job roles to the Lay Members also. 1.2 Declarations of interest: LQ would like to note that with regards to the over 75’s paper due to be presented by CC in this meeting. LQ advised that she has a family member that would benefit from this but LQ is looking at the wider population of 3,000. JK advised that under our Conflicts of Interest Policy he has to rule on whether to a) note, b) note and not allow the conflicted person to speak on the item or c) exclude the person from the meeting. JK ruled to a) note. CC advised committee that Harry Parsonage current Patient Rep has sadly passed away. Committee noted the loss and expressed their sympathies. JK advised that he is not sure of the process for electing a new patient rep at the current stage of the Capacity and Governance review. He suggested that this should be left as it is until the review has been completed. JK informed the committee in relation to the MIAA report on the previous 12 month’s approvals activities and their outcomes that MIAA’s report will be going to the next Audit Committee and then will come on to Approvals Committee for information. 1.3 Minutes from Previous Meeting: The minutes of 16th April 2014 were agreed as a true and accurate record with the exception of the changes noted and agreed by the committee.

AC14-15/02

2. ITEMS FOR DISCUSSION

3

REF NO. MINUTES ACTIONS

2.1 Approvals TOR JK presented the last approved TOR to the group with all amendments shown in red. Revisions have already been agreed to the document. When NHS England approve these TOR they will become the TOR the Approvals Committee will use. As we are operating under the old TOR, JK explained that the lay members here today are here as observers. JK’s intention in the future is to have 2 of the lay members to attend each Approvals Committee meeting. Action – Lay advisor title to be changed to lay member throughout the document AC pointed out that the previous minutes need to reflect that MB should be in attendance rather than present to the meeting as the TOR state that the CFO does not have the right to vote. Action – CW to check with PE with regards to the CFO being a voting member or not. BH explained that the suggested quorum for the meeting is 3 lay members. Should this not be 4? After discussion it was agreed that the quorum should stay as 3. Committee agreed they are happy with proposed changes to the TOR and that these can go to the next Governing Body Meeting. As of the November GB meeting the current lay members should be able to vote at Approvals Committee.

AC14-15/03

3. ITEMS FOR APPROVAL

4

REF NO. MINUTES ACTIONS

3.1 Prescribing incentive scheme JK explained to the committee that all items for discussion use a standard pro-forma promoted by NHS England which includes a tick box for approval. All proposals include supporting papers. CC introduced Steve Riley to the group and Lay members introduced themselves to Steve. CC explained this was a renewed scheme and that the main difference with this year’s scheme is that it embodies proposals from our internal auditors (MIAA) previously completed audit report on the prescribing scheme whereas the new scheme now reflects what MIAA have raised in the report. CC advised that this scheme goes above and beyond the GMS and PMS contracts. This scheme requires General Practices to undertake project work relating to the prescribing of various drugs, with a view to ensuring consistently high quality and cost-effective prescribing. They will also be required to undertake audits to inform future best practice. This GP prescribing incentive scheme in 14/15 aims to: •Encourage GP practices to review prescribing in key therapeutic areas which have been identified as areas of high cost for the CCG or where the practices are outliers on the QIPP report. •Improve quality of prescribing in accordance with local and national clinical guidelines. •Improve adherence to local formulary choices and decisions. •Improve cost effective prescribing in identified therapeutic areas. •Improve the practice based systems involved in the handling of hospital discharge prescriptions and outpatient letters requiring medication changes, additions or deletions. Also, identify any issues with information supplied to GP practices. •Improve the systems for the repeat ordering and prescribing of stoma / ileostomy products, reducing waste and inappropriate orders via third part appliance contractors. Developing and implementing a CCG wide approach. •Encourage sharing of best practice and peer review amongst GPs.

5

REF NO. MINUTES ACTIONS •Provide a basis for continued practice based review in following years to further improve practice and systems. CC confirmed that there has been money set aside for the scheme and this is within budgets already approved. Exploring potential sources of Conflicts of Interest It is hard to figure out an hourly rate for the scheme as this will be using time of both admin staff and GPs, it has been thought that it would be better to go by list size. BH states that in section 2 of the schedule at the end of the final section it mentions about an attendance list, and asked if there was something that can be added into that to say how we would benefit from this. SR advised that this would be tricky. This section is itself additional as a requirement to achieve final payment. BH expressed surprise at paragraph 2.1 which shows GP Practices required to modify records and discharge papers. SR responded that is routine practice. This looks at how they do it in their practice, each practice would be different. SR explained that there is currently no contractual agreement on how practices should keep this information, some may note it down and some keep only in their heads. It’s all about looking at the best process to suit each practice. SC asked if patients have been asked if they want this scheme and if they think it is going to help them? CC advised that patients as a PPG or Forum have not been advised of this scheme although individual patients will be consulted with by their GPs about their prescribing choices. SR explained that this has not gone to any patient groups.

6

REF NO. MINUTES ACTIONS JK raised the concern that patients feel more engaged when they are having a discussion rather than just being told of what is going to happen. JK suggested adding a recommendation that this is to go to patient groups and patient forums to have the discussion and for them to express their thoughts SC asked about the contract that pharmacies currently have to discuss with their patients regarding their medicine. Is this not duplication? SR explained that there is currently a review to look at patients and their medicines to ask if they know how to use it/take it/can we help you with anything etc but this is a separate NHS service and much more limited. Decision: The Committee approved the proposal with the recommendation that patient forums and patient practice groups should be advised of this scheme and then encouraged to discuss it with their members within the practice. 3.2 Improving the care of people aged 75 and over CC introduced the improving the care of people aged 75 and over. This scheme requires general practices to undertake a range of activities to improve the care of their patients aged 75 and over. The aims are: to personalize a care plan for complex patients, follow-up of patients following an early admission, review people on 10 or more medications, develop a register who are careers, or live alone, offer a health check for vulnerable people who have not visited their practice in more than 12 months and to review the dementia register to ensure that all appropriate patients have been identified. CC advised that they are asking practices to use a new information tool on local services to enhance medical imputs. The GP practices would need to be trained to use this, meds management have been secured to deliver this training.

7

REF NO. MINUTES ACTIONS The CCG have decided to put together a pack for 75s and over to help them with any further information. CC explained that she has worked with The Older People’s Parliament to develop and deliver these packs. CC explained that we have recurring money for this for years 14/15 and 15/16 within agreed budgets. CC advised that the CCG want to develop a multi-disciplinary care plan. This is what the scheme is for as current GP’s don’t have this in place. Exploring potential sources of Conflicts of Interest JK asked if we have explored different ways that this can be done? CC advised that this is the most cost efficient way this can be done as to procure elements individually would be more expensive. JK asked what happens if a GP decides that they do not want to take part in this? CC advised that if a GP does not want to participate the neighboring GP can be commissioned to provide these services. BH expressed that this was a very good paper and that he thought there should be a better review date. It says that the patients that register for the scheme should receive their pack within 3 months. JK then asked if this could be reduced to 1 week? CC explained that this would be something they could discuss; it just goes to the admin duties of the practices. BH talked about the payment for patients living alone, what is the percentage of people that are added to the register? CC explained that this would be hard to discuss as each GP practice has a different number of patients already on registers. JK advised that there needs to be something added in to the scheme that proposes a percentage increase

8

REF NO. MINUTES ACTIONS and CC advised that she would look into this. Decision: The Committee approved the proposal with the recommendations that patient forums and patient practice groups should be advised of this scheme and then encouraged to discuss it with their members within the practice, and the above noted review of deadline dates and percentage increases should be reconsidered. 3.3 Transforming primary care scheme AC presented the transforming primary care paper to the committee. The scheme requires General Practices to undertake a range of activities to improve access to and the provision of primary urgent care. The elements with the paper include:

• Accepting patients streamed from A&E who may require urgent appointment slots (telephone/face to face)

• Accepting patients redirected by ambulance service and conducting home visits within 2 hours of a referral.

• Aligning to integrated care coordination teams- attending MDT meetings for very complex cases and regularly liasing with ICCT’s for clinical discussion of patients

• The collection of data for all GP visit requests undertaken within practice and formulating a delivery plan to offer staggered and responsive visits for all urgent requests. From 1st April 2014, our aim will be for practices to adopt these delivery plans to achieve staggered and responsive home visits.

Exploring potential sources of Conflicts of Interest The summary of costing for the Transforming Primary Care Scheme is £540,00 which includes GP scheme, alignment to ICCT’s, GP visiting and patient streaming. In terms of GP streaming and GP visiting schemes, patient records currently sit with GPs, we do not have access to the records. If the ambulance team would require the records they would have to make the clinical call to the GP themselves.

9

REF NO. MINUTES ACTIONS SC asked if it would be the same for this scheme with regards to GP’s not wanting to sign up. Could neighboring practices supply the services to patients? AC confirmed that it would also apply to this scheme that is if GPs did not want to sign up then we would commission another practice. Decision: The Committee approved the proposal with the recommendations that patient forums and patient practice groups should be advised of this scheme and then encouraged to discuss it with their members within the practice.

AC14-15/04

5. ANY OTHER BUSINESS

No other business discussed.

AC14-15/05

DATE AND TIME OF NEXT MEETING

The next meeting is: Wednesday 17th September 2014 1.00 – 2.30pm Room 539, 5th Floor, Old Market House Agenda papers to chelsea.worthington@nhs.net no later than Tuesday 9th September 2014. Agenda and supporting papers will be emailed to Committee members: Wednesday 10th September 2014.

10

REF NO. MINUTES ACTIONS

S i g n e d – C h a i r P a g e 1 of 8

Audit Committee Meeting

Wednesday 28th May 2014 10.00am – 12.30pm, Room 539, Old Market House

Present: James Kay (JK) Audit Committee Chair Mark Bakewell (MB) Chief Financial Officer Liz Temple-Murray (LTM) Manager - Grant Thornton Sylvia Cheater (SC) Audit Lay Member Tracey Fisher (TF) Audit Lay Member Simon Wagener (SW) Lay Member Laura Wentworth (LW) Corporate Support Officer Bernard Halley (BH) Audit Lay Member Gordon Haworth (GH) Executive Assurance- Grant Thornton Lin Elliott (LE) Audit Manager Mersey Internal Audit Agency In Attendance: Chelsea Worthington (CW) Administrative Assistant (minute taker) Christine Campbell (CC) Consortium Chief Officer Iain Stewart (IS) Consortium Chief Officer Emma Shanks (ES) Senior Reporting Accountant

Item No.

Agenda Items

Action

GA13-14/15

PRELIMINARY BUSINESS

JK provided an update to Audit Committee members on the current situation within the CCG and provided information relating to the capability and capacity review which is currently being undertaken by NHS England. It was confirmed that the Chair and Accountable Officer have voluntarily stepped down from their posts for the next 4 weeks, whilst this review is undertaken. Jonathan Develing was introduced to the meeting as the Interim Accountable Officer and he explained his role whilst working with the CCG over the next 4 weeks to assist through the current challenges.

1.1 Apologies: Robin Baker, Andrew Cooper, Paul Edwards, Joy Hammond.

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1.2

Declarations of Interest: No declarations of interest were made.

1.3

Minutes of Previous Meeting/Action points of previous meeting held on 3rd April 2014 The minutes of the previous meeting held on 3rd April 2014 were agreed as a true and accurate record. Actions – 32- CW to speak to LQ regarding the presentation on serious incident reporting at Patient Forums and CW to then send an update regarding this action via email to Audit Committee members. 53 - LW to re-send the Assurance Framework and list of acronyms to Lay Members. 55 - MB advised that he is currently in talks with ICT regarding refreshing the policies- MB will send update to all members regarding this in due course. It was noted that the actions tracker should be updated to reflect items completed or amended.

CW LW MB

1.4 Matters Arising: No matters arising.

GA13-14/16

ITEMS FOR DISCUSSION

2.1

Review of CCG annual accounts MB explained current position of annual account process at this time and that respective CCG / audit teams are still working through final amendments in line with member’s comments and the national guidance. MB thanked the Finance Team and the Corporate Team for their hard work over the past few months in completion of this report. It was noted that any amendments to the document need to be agreed before the final version is submitted to Governing Body on June 3rd for their approval. The final deadline for this report to be uploaded to ‘sharepoint’ is midday on Friday 6th June. MB advised that there are discussions in place with regards to who will sign the annual report and the final accounts and that this should be confirmed by the end of the day in accordance with issues regarding interim accountable officer MB informed group members of the issue the CCG have had regarding the hosting arrangement with the Isle of Man and subsequent accounting treatment.

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The accounting treatment has a knock on effect with the agreement of balances exercise and has been raised with NHS England. MB informed the committee that he had agreed to make the changes which were in line with Manual for accounts and had been reflected in the accounts. JK queried whether this arrangement was appropriate for the CCG and whether this is something that we should be doing in the future? MB clarified to the Audit Committee that the issue is purely a transactional ledger issue that the CSU deal with directly and that the CCG does not directly get involved in the day to day processes but clearly the year end position has caused an additional amount of time / effort to resolve the relevant issues SW expressed concerns that this information will be in our accounts and that the public may raise queries regarding this. MB clarified that with the appropriate adjustments these will no longer appear BH explained that someone has to do the job of hosting for Isle of Man, providing it doesn’t cause any trouble for the CCG then his thoughts are to carry on supporting. SC asked if this generated any money to the CCG which MB confirmed that it does not generate any income for the CCG. JD explained that this is no financial risk to the CCG by delivering this and explained that the CCG should consider charging the CSU for the support that they are providing. MB advised he is minded to potentially pursue with the CSU and ask them to pursue alternative arrangements and was making contact with regards to reviewing these options. MB then presented the four primary statements of the 2013-14 Annual Accounts to the Audit Committee. MB explained the purpose of the statements and why some of the values within the statements had been left as blank (for information / learning purposes) and that potentially in future years they be removed if no relevant transactions The CCG have made further changes to the supporting notes over the past few days following agreement with external auditors and this will be reflected in the final version that will go to Governing Body on 3rd June. JK queried whether the related expenditure statement for GB members includes figures for GMS and PMS expenditure in GP members' practices. MB explained that they are not included in the budget as they are not the responsibility of CCG. JK queried what should qualify for inclusion under related party transactions and asked whether the secondary care doctor should not also be included as his wife is a GP?

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MB explained the rationale behind the related party transactions note in that transactions are included with third parties of a material nature and predominantly where the CCG party has significant influence and control within the organisation. MB further responded that although AS' (secondary care doctor) wife is a GP Partner in Wirral practice, there is an element of how far the scope of related party transactions can be extended, given it could extend to all 58 GP practices and that a line needs to be drawn at some point. Although AS is a voting member of governing body, the related party transaction would be directly with Aintree Hospitals (his employer) but there is no direct influence over contract expenditure and that the view has been formed that the transactions with his wife’s practices were beyond the scope of the note. JK queried what values were included in the figures as these financial values didn’t seem to link back to his knowledge of CCG expenditures. MB explained that transactions included within the note are predominantly made of local enhanced services, prescribing schemes and consortia developments. MB further explained that the related party transactions are further managed via the Approvals Committee within our organisational structure. JK asked MB to check figures in previous Approvals Committee notes to check for alignment. SW explained that the public will possibly like to see assurance with regards to this section and to what these values relate. JK asked if a note could be added to explain that the amounts don’t include GMS, PMS plus an explanation of figures and further explanation of the relevant governance systems (via Approvals Committee) behind these areas of expenditure. MB advised this would be updated to include this. JK queried regarding what was included in other income that had been received by the CCG. ES explained that the CCG have now received the reimbursement for the IT expenditure incurred initially by the CSU. MB explained with regards to note 5 of the annual accounts that the CCG have had discussions with Grant Thornton and although the CCG has an internal audit, the relevant figures are included under the heading Supplies and services – general not necessarily internal audit as this specifically relates to internal audit services provided by the external auditor. It was advised that a short note be made to state that ‘supplies and services’ includes payments made to Mersey Internal Audit Agency. ES to amend this accordingly. JK queried the figure quoted for the purchase of 'Non-NHS' healthcare. This

MB MB ES

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2.2

seems to total 15% rather than the 3% often quoted in our GB reporting. MB explained that alongside Non-NHS Contracts that this also includes expenditure on Continuing Healthcare which figure alone is £32 million. JK asked if the explanatory note could be expanded that explains this, given potential public concerns. BH raised issue with regards to the format of Note 1 re accounting policies and asked if this could be done as a separate document and not in the middle of the financial statements MB advised that notes followed the reporting guidance and format for collating this and that if we change this format it may cause difficulties with audit and consistency. LTM agreed and stated that the accounting policies are fundamental principles behind the numbers included in the statements is appropriate to be included on the 1st page, the document could possibly be narrowed down further as most notes are just general but this was discussed earlier in MB introduction. MB explained that finance had tried to ensure the accounts flow and are easy to read however that we were penalised for doing this by NHS England, as this was not in line with the National Guidance. JK asked for feedback to be provided to NHS England as appropriate re the format of this section. TF raised the issues of the page numbers through the document. ES explained that this issue is due to technical problems with the PDF writer and that this will be amended for the final version. MB explained that there remained a few areas to be amended: Note with regards to CHC Provision Note 4.2 regarding department of health and sickness figure Note 42- update of year end numbers With the changes and amendments as noted above, the Audit Committee agreed that the Annual Accounts should be presented to the Governing Body for their approval on 3rd June. JK, on behalf of the Audit Committee, thanked the teams at the CCG and Grant Thornton for all of their hard work, help and support in the preparation of these accounts. Review the CCG’s Annual report MB presented the Annual report to members. MB explained to committee members that this document is still work in progress and explained that the team have attempted to make the document flow to make the report more readable for its audience.

MB

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JK highlighted that in discussions with auditors that elements of remuneration information should be included in the report itself rather than as an appendix. MB agreed with this and had agreed to make this amendment. JK highlighted that there are some typo errors and grammatical errors. JK requested for any amendments to be made to this document to be sent to LW by the afternoon of 28th May in order to circulate to governing body. It was noted that given the CCG current situation, arrangements are still being confirmed in order to confirm the signature on the statements. JK drew to the committee’s attention to the tables on page 81-83 of the document. His attention had been particularly drawn to the figures included under the heading ‘Real increase in Cash Equivalent Transfer Value’ for a number of officers. JK queried the increased and relationship between salary and real increase. MB explained that the information had been provided by the Pensions Agency with some manual calculations being performed for the note locally. MB explained that the information presented is accurate and had been reviewed by external audit team but understood the reason for the query. MB explained his understanding that the increase will have come from changes to terms and conditions given roles with CCG between the respective financial years, but there was a need to understand the relevant explanations between each of the columns and that there is need to understand the technical definition behind the respective headings SC and JK again queried why the values looked the way that they did LTM explained that she has looked at other CCG figures for this and they are at similar amounts. MB explained that further information could be provided as per the manual for accounts, however there was a concern with regards to the time scale by which we have to have these documents completed and submitted. JK expressed his concern that given current situation of the CCG that the public may very reasonably have an extremely sharp eye on the figures the CCG release. The group noted the importance of ensuring that the correct figures are published and JK asked if a narrative could be added to address any further enquiries related to these figures. JK queried how members of staff who are not into the NHS pensions scheme are included within the information? MB confirmed that this correctly treated SW queried with regards to the figures in the taxable benefits column and MB clarified that this would be regarding any expenses claimed within the

MB ALL MB

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2.3 2.4

previous financial year. BH expressed that he found this report very useful however requested for a glossary to be included within the document to explain any acronyms for the public’s better understanding. LW agreed to include this list. An issue was also raised with regards to page 41 as there is no mention of the new audit lay members within in the section on audit committee. LW to include the new members. BH highlighted that the content of page 66 needs more of an explanation on the conclusion because as it stands it reads as more of a statement than a conclusion to the document. With the changes and amendments as noted above, the Audit Committee agreed that the Annual Report should be presented to the Governing Body for their approval on the 3rd June. JK, on behalf of the Audit Committee again thanked the teams at the CCG and Grant Thornton for all of their hard work, help and support in compiling and refining this report. Receive the CCG’s draft Annual Governance Statement The group reviewed the draft Annual Governance Statement and it was noted that Grant Thornton will review this further and provide feedback to MB with regards to the language and wording. Following discussion the Audit Committee agreed that the Annual Governance Statement should go forward to the Governing Body for their approval on the 3rd June. Receive the external Auditor Findings (ISA260) LTM presented the External Auditors progress report which highlights any issues/findings from the review. LTM explained that there will be a more detailed report of the review presented at the Governing Body on 3rd June. It was also noted that Grant Thornton are expected to give a specific opinion on the remuneration report. The executive summary of the report explains the purpose and any key audit and financial issues that Grant Thornton have found. LTM explained that Grant Thornton are currently awaiting the service audit opinion report from Deloitte regarding the CSU Grant Thornton are not expecting any major concerns however LTM highlighted that they are unable to sign this off until the CSU report had been received. LTM highlighted that the one issue that Grant Thornton has noted within the audit and financial reports is that of the Isle of Man which has been stated as a material error in the first draft of their report.

LW LW

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MB has agreed to change the presentation of these transactions as highlighted earlier in meeting (above). LTM expressed her thanks for how well the finance team and corporate team have worked together with Grant Thornton. It was noted than an update of this report will be presented at the Governing Body meeting to be held on 3rd June. ACTION - LTM to send CW updated report for the Governing Body It was highlighted that the adjusted misstatement section of the document will include MB’s comments and reasons for why this is not adjusted within the final document. The group noted that the Governing Body meeting to be held on Tuesday 3rd June is the final meeting that any accounts can go to for review and final approval. MB explained that MIAA’s Head of Internal Audit opinion was received at the last meeting held in April 2014 and therefore the document is for noting and review by members. LE agreed she is happy with this approach having discussed in detail at last meeting JK advised that to the above documents will be reviewed at the Governing Body to be held on 3rd June subject to the changes discussed with Audit Committee, Chief financial officer and Interim Accountable Officer.

LTM/CW

GA13-14/17

ITEMS FOR INFORMATION

3.1

No further items were received or noted.

GA13-14/18 ANY OTHER BUSINESS

4.1

There was no other business.

GA13-14/19 DATE AND TIME OF NEXT MEETING

The next meeting will be held on: 18th September 2014, 10am -12pm, Room 539, Old Market House. Please forward apologies / agenda papers to chelsea.worthington@nhs.net