Governing Body Meeting (in public) Agenda - AVCCG · PDF fileGoverning Body Meeting (in...

Governing Body Meeting (in public) Agenda

Thursday 9th April 2015 – 10:30 to 12:30 The Jubilee Room, The Gateway, Gatehouse Road, Aylesbury, Bucks

Clinical Chair: Dr Graham Jackson

No Agenda Item Desired Outcome(s) Contributor Papers 1 Welcome & Apologies Dr Graham Jackson, Clinical Chair

2 Declarations of Interest Dr Graham Jackson, Clinical Chair

3 Minutes of the meeting held on 12 March 2015 & action points update

Page: 3

4 Questions from the public Dr Graham Jackson, Clinical Chair

Corporate and Governance 5 Chief Officer’s Report: To inform the

Governing Body of local and national developments in the context of NHS Aylesbury Vale CCG

For information Louise Patten, Chief Officer Verbal Update

Clinical Commissioning 6 Clinical Leads Update: Elective Care For Information Dr Christine Campling Tabled Presentation

Quality & Performance 7 Quality Report: To update the

Governing Body on quality issues of commissioning service across the local health economy.

For information Alison Foster, Director of Quality Page: 16

8 Performance Report & Dashboard: Update on progress against National Operating and Outcome framework

For information Colin Thompson, Director of Operations and Performance

Page: 28

9 QIPP: Update on progress against Quality Innovation Productivity and

For information Colin Thompson, Director of Operations and Performance

Page: 43

Prevention (QIPP) plans

Finance

10 Chief Finance Officer’s Report: To update the Governing Body on the financial status of the CCG

For Information Robert Majilton, Deputy Chief Finance Officer

Page: 71

For Information 11 Executive Team – Minutes of the

meeting held on 26th Feb 2015 For information Page: 92

12 Audit Committee – Minutes of meeting held on 28th Jan 2015

For Information Page: 104

Meeting agendas will be published on the www.aylesburyvaleccg.nhs.uk

Anyone may ask questions relating to the agenda in advance either by post, telephone or email, or on the day in the question time slot at the start of the meeting. Questions about topics not included in the agenda are welcome by post, telephone or email and they will be answered, depending on the number, either in or outside of the meeting. All questions and answers will be published on the website.

By post: Aylesbury Vale Clinical Commissioning Group, First Floor, The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF

Tel: 01296 585900

Email: [email protected]

Website: www.aylesburyvaleccg.nhs.uk

If you would like to attend a meeting and need extra help to do so, for example because of a disability, please contact us as early as possible so that we can try to put in place the right support.

For further information about these meetings please contact: Administration team on 01296 585900 or email [email protected].

http://www.aylesburyvaleccg.nhs.uk/

mailto:[email protected]

http://www.aylesburyvaleccg.nhs.uk/

Chief Officer: Louise Patten

Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk

Quality Report Governing Body

April 2015Alison Foster

Aylesbury Vale CCG9 April 2015

1



Summary

2

Purpose of the paper Actions requested from the Executive

To provide assurance to the Governing Body that the quality of

healthcare services is adequately monitored and appropriate action

is taken where quality falls below expected standards. (Patient

safety, patient experience, clinical effectiveness).

Input and Approval of CQUIN paper

Executive summary Strategic objectives supported by this Paper (please tick)

This paper highlights the quality issues identified from commissioned

services, a summary of these have been provided. The paper is

structured by provider and lists current issues and related actions and

assurance.

Due to the Commissioning for Quality Meeting moving to bi-monthly,

CSCSU were only able to provider basic level of data with no analysis

of provider action follow up.

Key Areas highlighted in this report for Executive attention

• Provider Highlights

• MK Stroke Pathway update

• Safeguarding

• Multiagency review process

1. Improve people's health and reduce inequalities x

2. Enhance quality, safety and experience of patient

services

x

3. Ensure local people have greater influence and

management of own care

x

4. Deliver financial sustainability with headroom to

invest

5. Perform well as a CCG x

Equality Analysis completed y n n/a

x



BHT Highlights

Missing patient

BHT had an elderly lady with Dementia leave a ward 23 March 2015 and

then was missing for 24 hours. Her body way found a quarter of a mile

from the hospital. A debrief was conducted the day after with hospital,

police, BCC and the CCG. Staff were alerted to her leaving the ward

soon after she left and conducted a search and reported to the police as

soon as she could not be found. Police searches in the afternoon,

evening and morning did not find anything . There will be an ongoing

investigation and BCC, BHT and police will co-ordinate a response.

2014-2015 CQUIN Performance

Electronic Discharge, Safety thermometer and 7 day working were

discussed as lacking robust evidence for CQUIN. Following

negotiations at year end we agreed only to pay 85%.

7 day working is subject to a service development plan in line with

preparing for mandatory requirements in 2017.

Electronic Discharge will also be subject to a service improvement

plan until October and from October will be part of the Quality

Schedule.

CQUINS

Excellent commissioner and provider involvement and engagement.

Current status is agreeing the detail of the milestones. Review of all

measurements and reporting and provision of evidence to be finalised by

26/3/15. Each CQUIN has a lead to co-ordinate comments and queries

whilst Alison Wakeford is on leave.

Urgent Care CQUIN

Cross Thames Valley, this could delay the progress of development and

ultimately quarter 1 actions.

Quality Schedule

BHT have responded to the suggested schedule sent 17/3/15. In

general they are in agreement with the reporting requirements but have

suggested that there is further discussion and clarity around the

community schedule in particular. BHT leads have been identified for

specific areas of the schedule. It has been suggested that it is agreed in

principle but with some work to further develop it throughout the year,

and that it discussed at the CQRM. The next CQRM is due on 31/3/15.

Alongside and in support of this is the new Associate Director for

Healthcare Governance at BHT David Williams who wants to look at the

current reporting to the quality committees including CQRM. This will

include using the range of data captured and triangulation of data and

reporting against patient pathways.

CQC • CQC are conducting and inspection of community services this week.



Buckinghamshire Healthcare Trust

Quality Indicator

Harm Free Care

• 92.02% in January 2015 – Slight decrease on 92.85%

reported for December 2015. This is still below target

national 95% target & 98% BHT target.

(Source: BHT Board Report March 2015).

CDIFF

• 2 cases identified for January 15. This is a reduction

on the 6 cases reported in December 2014.

• CDIF cases stand at 33 for YTD. This breaches the

threshold of <30

(Source: Quality Scorecard March 15)

Pressure Ulcers

• There were zero hospital acquired pressure ulcer

SIRIs in February 2015. The number has been

reducing since December 2014. Reduction may be as

a result of SSKIN bundle (pressure ulcer action plan).

(Source: Quality scorecard March 2015)

Mortality

• Total Crude Mortality has returned within

expected control limits following unusual winter

activity which was reflected nationally. All December

deaths have been reviewed

(Source BHT March 2015 Board report)

Serious Incidents Requiring Investigation (SIRI)

There were 7 reported SIRIs in the February 2015 and 8

in January 2015. Some increase in deterioration patient.

(Source: STEIS March 2015)

Backlog clearance has been completed

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15

3 5 3 3 6 3 2 1 3 2 0

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15

2 1 3 4 5 2 5 3 6 2


90.77% 93.57% 93.36% 93.35% 91.46% 91.95% 92.65% 91.76% 92.85% 92.02% 91.97%


10 12 11 10 17 8 10 9 16 8 7



CQUIN Summary Update

BHT CQUIN and Quality Schedule SNAP SHOT

Operational Lead for CQUIN Sue Naidoo Deputy

Chief Nurse

Commissioning

Leads

Provider Leads Status

1. Local CQUIN

Frail Elderly

Ian Cave & Urgent

Care JET

Hasan Syed

Jo Birrel

3rd draft 18/3/15

Copied to BHT/CCG

With final revisions

To be agreed by next week.

2. Local CQUIN

Diabetes

Dr Kathy Hoffman

(GP) & LTC JET

Henrietta Brain

(Consultant)

Isobel Day

3rd draft 18/3/15

Copied to BHT/CCG


To be agreed by next week.

3. Local CQUIN

Reducing Pre -term Birth

Sue Burke & Joint

Commissioning JET

Dr Balakrishnan Public

Health

Audrey Warren

Geraldine Tasker

3rd draft 17/3/15

Copied to BHT/CCG


To be agreed by next week. Improving pathway for growth restricted babies

4. Local CQUIN

End of Life

Dr Bajwa/Dr Logan &

LTC JET

Tim Curry

Dr Helen Pegrum

Jane Naismith

3rd draft 17/3/15

Copied to BHT/CCG


To be agreed by next week

5. National CQUIN 0.5%

Urgent Care

Ian Cave & Urgent

Care JET

Isobel Day

Clinical lead to be

identified by BHT.

Discussed Urgent Care JET – suggested Thames

Valley wide CQUIN . SCAS CQUIN lead Ann

Dorothy and Kath Havisham CSU

6. National CQUIN 0.75%

Dementia 0.25%

Sepsis 0.25%

Acute Kidney Injury 0.25%

AVCCG

Joint Commissioning

JET

Sue Naidoo Deputy

Chief Nurse

Technical guidance released

17/3/15

Agree reporting mechanism

AW – 26/3/15

Quality Schedule Ali Foster Carol Watkinson

David Williams -

BHT responded. Agreed with measures and

suggested to work on reporting through the year.



Buckinghamshire Healthcare SIRI Analysis

Incidences of pressure ulcers have reduced by 25% following the

introduction of the SSKIN bundle in October 2014.

The reduction in harm from pressure ulcers is reflected in the most recent

safety thermometer data from Jan 15, which shows BHT reporting an

average level of pressure ulcer incidence compared to other integrated

trusts in the country.

BHT is an outlier for falls, reporting above average incidences of harm per

1000. This will be closely monitored.



Buckinghamshire Healthcare Patient Experience

Source BHT Board Report March 2015 – Patient Experience Tracker

Complaints

• In 2014/15 there was an increase in the number of complaints received

compared to last year. In 2013/14 the average monthly number of

category 4&5 complaints received was 51 with this year being 62.

• The Trust has experienced challenges in meeting the 85% target of

responding to complaints within 25 days during 2014/15. BHT average

response rate across the period is 79%. The complaints team have

implemented some small tests of change to improve performance

aiming for a target of 90% by April 2015. Along with this they are

achieving our additional targets to reduce re-opened complaints by

50% by April 2015 and those referred to the ombudsman by 25%.

(Source: BHT Board Report March 2015)

The top 6 reasons for

complaints received remains

reasonably constant, these being

1. Treatment and procedure,

2. Medical care,

3. Delays/cancellations,

4. Behaviour and attitude of

staff,

5. Diagnosis and

6. Nursing care.

Key areas to note

•There are 7 complaints

currently pending or undergoing

investigation with the

ombudsman.

•2013/14 - 7 cases were upheld,

•2014 to date - 2 cases have

been upheld.

FFT: Scores relate to how many patients would recommend

Source: BHT Board Report March 2015

There continues to be a marked improvement in A&E Performance in the

4th quarter. The hard work of A&E staff along with volunteers has

produced the best response rate and approval rating in February 2015

since the program began, it should be noted that the FFT score since June

2014 has been on an upward trajectory. (Source: BHT Board Report

March 2015)



Frimley Health

Quality Indicator

Serious Incidents Requiring Investigation

(SIRI) (Wexham Park Data)

3 SIRIs reported for February 2015. No

change from January 2015, but a reduction

on the 7 SIRIs reported for December

2014.(Source: STEIS)

Pressure Ulcers

1 pressure ulcer SIRI reported in February.

There were zero reported pressure ulcers in

January and 2 reported in December 2014.

(Source: STEIS)

Falls

Zero reported fall SIRIs in January and

February 2015. There was a spike of 4

reported fall SIRIs in December 2014.

(Source: STEIS)

Cancer

62 day wait for first treatment is under the

85% target, with 80.6% reported for January

15. This is a decrease on 82.6% reported for

December 2014.

The Trust has submitted an overarching

Cancer action plan and specific actions plans

for Breast and Urology. These were

approved at the Quality Committee.

• Percentage of cancer patients waiting < 62 days for first treatment


5 9 2 1 4 1 4 2 7 3 3


0 3 0 0 0 0 0 0 2 0 1


0 1 0 0 1 0 2 1 4 0 0


84.91% 75.61% 73.77% 84.62% 83.00% 78.23% 81.30% 80.00% 82.60% 80.60%



Oxford University Hospital

Quality Indicator

FFT A&E response rate –

• 8.2% for January 2015, an increase on 5.7% for

December, but below the 10.3% achieved for

November.

• Response rate target of 20% in Q4 likely to be missed.

(Source: NHS England FFT Data December 2014)

Cancer

• 62 day wait from referral to first definitive treatment is

71.8% for January 15, a decrease on 82.75% for Dec

14, below target of 85% .

(Source: Quality Scorecard (UNIFY)

Source: OUH Board Report March 2015


74.68% 80.00% 78.74% 79.76% 73.53% 74.20% 80.50% 79.50% 82.70% 71.80%


17.40% 12.40% 16.40% 16.80% 13.60% 12.60% 6.60% 10.30% 5.70% 8.20%



Milton Keynes

Quality Issue

Transfer to ASU within 4 hours of arrival

• There has been a slight increase to 36.8% compared

to 30.8% in November,.

• However this is still lower than 38.9% in October. This

remains significantly below the 95% target.

(Source: December 14 Quality Schedule)

FFT A&E response rate

• 5.4% in December 2014, an increase on 5.4% reported

in November 2014.

• This is below the MK improvement trajectory .

• (Source: Quality Scorecard (UNIFY))

A text back service is due to commence and will be

implemented at the beginning of Q4 (January - 2015).

(Source: operational MKFHT CQRM minutes Nov 14)

Cdiff

Cases on a downward trajectory, with 2 cases in January

2014, a reduction from 3 reported in December 2014 and 5

in November 2014

(Source: Quality Scorecard)

IPC steering group looking to have a system wide

improvement board on this area.

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

18.8% 47.1% 18.2% 33.3% 7.1% 35.3% 38.9% 30.8% 36.8%

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

4.6% 0.4% 2.3% 0.8% 4.3% 7.4% 6.2% 3.8% 5.4%


3 5 2 0 3 1 6 5 3 2



MK Stroke Update

Stroke Peer Review scheme was requested by the National Clinical

Director to see the stroke model for the trust in A&E. There was a

positive out of the review and they were happy with the position of the

trust.

MP gave the group an overview of improvements that they have been

making to the service at MK. Some of the progress was discussed as

follows:

• Advanced stroke practitioner has been appointed for stroke during

the latter end of last year to help improve the 4 hour target. Part of

her work is to promote stroke prevention awareness.

• MK unit currently is defined as an acute stroke unit however they

also take in medical patients when there is a need.

• There has been an agreement from the trust to keep 2 empty beds

(one each for male and female) for patients suffering stroke for the

second time in order to fast track stroke beds.

• They have implemented a second MDT team to help improve

quality.

• All stroke nurses attended a stroke course over the last year which

has resulted in a team of highly trained stroke nurses.

• Physiotherapy treatment has had uplift in the number of

physiotherapists thus improving quality of physio for patients.

• The OT numbers have been lower than the national average and a

paper was submitted to the Board for an uplift in numbers. Paper

has been acknowledge and is pending a reply from the Board.

• Developed close links with early support discharge team in the

community.

• MK CCG are in the process of commissioning four stroke beds at

Water Hall nursing home. Currently the CCG commission 2 beds

but the aim is to have 4 stroke beds for long term patients.

• MK CCG is looking at improving the current rehabilitation model for

stroke as they realize that there needs to be a more robust model in

place.

• A point of note that MK area has a small number of strokes in

comparison to the national SSNAP data. One of the reasons is that

MK has a lower age group demographic for their local population.

Source Stroke Care Pathway Coordination Steering Group minutes

Feb 2015

The CCG in discussion with the Health & Wellbeing Board chose to base

the local priority on improving stroke care. People who have had a stroke

who are admitted to an acute stroke unit within four hours of arrival at

Milton Keynes hospital was the selected metric. (MK CCG Board Report

March 15)



Safeguarding – key highlights

Children

• Health Assessments for looked after children remain below standard 28 days. Significant work and investment offered.

Some improvement from 1 out of 10 within the timeframe in January to 4 out of 10 in February. Joint Commissioners

looking at option

• Improvement Plan – Leaked Ofsted report received significant media coverage last week. More work to be done to

demonstrate better partnership working. March Safeguarding Board took place and there are planned workshops to

tackle priorities such as CSE across the agencies.

• We have a planned safeguarding steering group

• Annett is now attending the Leadership and Governance Workstream

• Ofsted will be back in May

Adult

• Care home

– Significant issues with one of our Care Homes (Four Seasons) – we have 8 patients here

– CHC have been in to this home and not signalled any issues, we have asked Chiltern to look into this

– CQC has carried out an inspection also, we are waiting final report after provider challenge

• BHT Missing patient

– The patient was not on a DoLs and our safeguarding lead will be part of the ongoing investigation and review into

the application of DoLs

– PREVENT Board had first meeting this month

GOVERNING BODY CORPORATE PERFORMACE REPORT

9 April 2015

Purpose of Paper

To inform the Governing Body of the performance of commissioned services against national and local performance measures and to request assurance of actions being taken where expected standards are not being achieved and to request actions.

Executive Summary

This report, the Organisational Performance Report for March 2015, provides assurance on the performance of the CCG and the providers of health care with which it commissions services against nationally and locally set quality and performance measures.

The report provides a summary of Aylesbury Vale CCG performance against national and local indicators for the year to date up to Month 10 or 11 (January or February 2015) dependent on data availability.

The key quality highlights and assurance issues for this report are as follows:

• A&E 4 hour waiting time – The position has continued to be challenging in Februaryand the 4 hour waiting time standard was not met at any local Trusts (BuckinghamshireHealthcare Trust (BHT), Oxford University Hospital (OUH) and Milton Keynes General(MK)).

• Ambulance Targets – Neither, Category ‘A’ 8 Minute Response Time Red 1 nor Red 2and Category ‘A’ 19 minute response time targets were met in January at CCG level. At Thames Valley level only the Category ‘A’ 8 Minute Response Time Red 1 target was not met.

• C.Difficile – There were 7 C.Diff cases in February which is 3 above the CCG’smonthly limit. The Year To Date position is 2 cases above cumulative limit.

• Mental Health patients on Care Programme Approach - The target is for 100% of allpatients on Care Programme Approach to have a documented risk assessment. Whilethis is currently not being achieved, performance has increased from 91% to 93% over2014/15. A second target is for 95% of all patients on CPA to have a crisis contingencyplan. This has increased from 74% to 76% of all adults; and has increased from 30% inApril 2014 to 98% in older adults in January 2015

Actions requested / recommendation The Governing Body is asked to note the report.

1

Strategic Objectives supported by this Paper (Please Tick)

Improve people's health and reduce

Enhance quality, safety and experience of

Ensure local people have greater influence

Deliver financial sustainability with headroom

Perform well as a CCG Equality Analysis completed (please tick )

Yes No Not applicable

Author of paper Lead Director(s) responsible for this area of work

Paul Hutt AV CCG Katherine Woolley, CSU

Colin Thompson, Director of Operations & Performance

2

Organisational Performance Report

March 2015 Section One - Introduction and overall performance Introduction This report, the Organisational Performance Report, is designed to provide assurance to the Clinical Commissioning Group Executive team and Governing Body on the performance of the CCG and the providers of health care with which it commissions against nationally and locally set quality and performance measures. The report provides a summary of Aylesbury Vale CCG performance against national and local indicators for the year to date up to Month 10 or 11 (January 2014/February 2015), depending on data availability. The indicators are those that will be used by NHS England to assess the CCG’s performance against the CCG Assurance Framework, i.e.:

• Quality markers used in the Assurance Framework Assuring Quality of Care (Are local people getting good quality care?) (NB these measures are presented on a provider basis)

• Achieving Patient Standards (Are patients’ rights under the NHS Constitution being met?) • Improving Health Outcomes: CCG outcome measures grouped into their specific domains;

(Are health outcomes improving for local people?) From January onwards, the report includes additional indicators for mental health and community services and it is intended that these will continue to be refined and added to as we move forward. Most indicators have a RAG (Red, Amber and Green) assessment and these are shown in the dashboard in Section Two. Where an area is assessed as ‘Amber’ or ‘Red’ a short summary of issues generating these concerns is provided, with assurance of the actions being taken to improve delivery in Section Three. This section also contains a short summary of the overall performance within each category. The full set of indicators included in each area is provided separately. Headlines Locally the pressure on urgent care services reflects the situation which has been widely reported nationally with a number of targets not met in February:

• A&E 4 hour waiting time – The position has continued to be challenging in February and the 4 hour waiting time standard was not met at any local Trusts (Buckinghamshire Healthcare Trust (BHT), Oxford University Hospital (OUH) and Milton Keynes General (MK)).

• Ambulance Targets – Neither, Category ‘A’ 8 Minute Response Time Red 1 nor Red 2 and

Category ‘A’ 19 minute response time targets were met in January at CCG level. At Thames Valley level only the Category ‘A’ 8 Minute Response Time Red 1 target was not met.

• C.Difficile – There were 7 C.Diff cases in February which is 3 above the CCG’s monthly limit. The Year To Date position is 2 cases above cumulative limit.

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Section 2 - Performance Indicator Summary for all providers

Aylesbury Vale CCG 2014/15

INDICATOR OPERATIONAL STANDARD

LOWER THRESHOLD

REPORT MONTH

MONTH ACTUAL

YTDPerformance Movement

Admitted patients to start treatment within a maximum of 18 weeks from referral

90% 85% January 92.5% 90.2%

Non-admitted patients to start treatment within a maximum of 18 weeks from referral

95% 90% January 95.8% 96.1%

Patients on incomplete non emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral

92% 87% January 92.8% 92.2%

Number of patients waiting more than 52 weeks (admitted (unadjusted)) 0 January 0 5

Number of patients waiting more than 52 weeks (admitted (adjusted)) 0 January 0 3

Number of patients waiting more than 52 weeks (non-admitted) 0 January 0 3

Number of patients waiting more than 52 weeks (Incomplete) 0 10 January 0 7

RTT - Admitted Pathways Median Not Rated Not Rated January 7.0 6.7 RTT - Incomplete Pathways Median Not Rated Not Rated January 7.5 7.5 RTT - Admitted Pathways 95th %ile Not Rated Not Rated January 20.8 22.5 RTT - Incomplete Pathways 95th %ile Not Rated Not Rated January 20.4 20.4

Percentage of Patients waiting 6 weeks or more for a diagnostic test 1% 6% January 0.5% 0.7%

[BHT ]Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department

95% 90% February 91.5% 93.0%

[MKGH] Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department

95% 90% February 89.0% 92.5%

[OUH]Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department

95% 90% February 88.3% 90.2%

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP

93% 88% January 93.1% 94.1%

Maximum two week wait for first out patient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected)

93% 88% January 98.4% 94.6%

Maximum (31 day) wait from diagnosis to first definitive treatment for all cancers

96% 91% January 98.4% 98.9%

Maximum 31 day wait for subsequent treatment where that treatment is surgery 94% 89% January 100.0% 98.8%

Maximum 31 day wait for subsequent treatment where the treatment is an anti-cancer drug regime

98% 93% January 100.0% 100.0%

Maximum 31 day wait for subsequent treatment where the treatment is a course of radiotherapy

94% 89% January 97.4% 90.7%

Maximum (62 day) wait from urgent GP referral to first definitive treatment for cancer

85% 80% January 88.9% 87.3%

Maximum 62 day wait from referral from an NHS screening service to first definitive treatment for all cancers

90% 85% January 100.0% 95.1%

Maximum 62 day wait for first definitive treatment following a consultants decision to upgrade the priority of the patients (all cancers)

No operational standard

No operational standard

Category A ambulance callsCategory A calls resulting in an emergency response arriving within 8 minutes (Red 1)

75% 70% January 72.0% 73.4%

Category A calls resulting in an emergency response arriving within 8 minutes (Red 2)

75% 70% January 72.1% 70.9%

Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% 90% January 94.6% 92.9%

Breaches of Same Sex Accommodation 0 10 February 0 4

NHS CONSTITUTIONAL SECTION

Referral to Treatment waiting times for non urgent consultant led treatment

Diagnostic test waiting times

A&E waits

Cancer patients - 2 week wait

Cancer waits - 31 days

Cancer waits - 62 days

Mixed sex accommodation breaches

SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST

4


LOWER THREASHOLD

REPORT MONTH

MONTH ACTUAL

YTD Performance Movement

(BHT) All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding data within 28 days, or the patient's treatment to be funded at the time and hospital of the patient's choice

Not Rated Not Rated Q3 2014/15 0 1

(BHT) Number of urgent operations cancelled for a second time 0 0 January 0 0

(OUH) All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding data within 28 days, or the patient's treatment to be funded at the time and hospital of the patient's choice


(OUH) Number of urgent operations cancelled for a second time 0 0 January 0 0

(MKG) All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding data within 28 days, or the patient's treatment to be funded at the time and hospital of the patient's choice


(MKHFT) Number of urgent operations cancelled for a second time 0 0 January 0 0

Care Programme Approach (CPA): The proportion of people under adult mental illness specialities on CPA who were followed up within 7 days of discharge from psychiatric inpatient care during the period

95% 90%Qtr 3

2014/1597.2% 97.0%

Care Programme Approach (CPA): The proportion of people under adult mental illness specialities on CPA followed up within 7 days of discharge from psychiatric inpatient care during the period (Monthly) (Adult)

95% 90% January 91% 97%

Care Programme Approach (CPA): The proportion of people under adult mental illness specialities on CPA followed up within 7 days of discharge from psychiatric inpatient care during the period (Monthly) (Older Adult)

95% 90% January 100% 100%

All patients on CPA have a documented risk assessment (Adult) 94% 93% All patients on CPA have a documented risk assessment (Older Adult) 94% 93%

Patients on CPA have a crisis contingency plan (Adult) 80% 76% Patients on CPA have a crisis contingency plan (Older Adult) 98% 61% Delayed Transfers of Care (Number - Adult) 0 0

Delayed Transfers of Care (Days - Adult) 0 0

Delayed Transfers of Care (Number - Older Adult) 0 7

Delayed Transfers of Care (Days - Older Adult) 0 113

Mental Health measure IAPT - the proportion of people that enter treatment against the level of need in the general population (the level of prevalence addressed or ‘captured’ by referral routes)

15%Q3

2014/154.3% 12%

Mental Health measure IAPT - the proportion of people who complete treatment who are moving to recovery. 50%

Q3 2014/15

66.1%

Dementia Diagnosis rate 67% January 56.3% 56.3%

Transforming Care February 6

GP Health Checks

Improve the % of type 2 diabetics who on mono-therapy alone achieve a HbAic of 48m/mols or less

0.3500%

Local Indicator

not rated not rated January

Learning Disabilities

100%

95%

January

January

Januarynot rated not rated

Mental Health

Cancelled Operations

5


LOWER THREASHOLD

REPORT MONTH

MONTH ACTUAL

YTDPerformance Movement

Maternal smoking at delivery 1 >11% not rated Qtr 3 2014-15 9.2% 9.0%

Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

70Baseline

December 106 735

Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s9

BaselineDecember 13 84

People with long-term conditions feeling independent and in control of their condition

53% Jan 2015 Pub* 55.0%

Emergency admissions for acute conditions that should not usually require hospital admission

138Baseline

December 163 1590

Emergency admissions for children with lower respiratory tract infections11

BaselineDecember 79 189

Patient reported outcome measures for elective procedures: hip replacement Apr13 to Mar14 n/a 0.429

Patient reported outcome measures for elective procedures: knee replacement Apr13 to Mar14 n/a 0.254

Patient reported outcome measures for elective procedures: groin hernia Apr13 to Mar14 n/a 0.107

Patient reported outcome measures for elective procedures: varicose veins Apr13 to Mar14 n/a 0.046

Patient experience of GP out-of-hours services 70% Jan Pub* 68.0%

Risk Assessment of venous thromboembolism (VTE) (BHT) 95% December 95.2% 95.8%

Risk Assessment of venous thromboembolism (VTE) (OUH) 95% December 95.8% 94.0% Risk Assessment of venous thromboembolism (VTE) (MKHFT) 95% December 95.5% 96.3%

Incidence of healthcare associated infection (HCAI) i) MRSA - Includes Post Infection review

Yearly target 0 February 0 1*

Incidence of healthcare associated infection (HCAI) ii) C difficileCumulative

Target46 February 7 48

** Performance movement - equals improvement, equals decline, equals no movement

VTE - Proportion of all adult inpatients that have been assessed for risk of VTE on admission to hospital using the criteria set out in the National VTE Risk Assessment tool (achievement must be at least 95%)

5.Patient Safety - Treating and caring for people in a safe environment and protecting them from avoidable harm

6.Outcomes - Safety

OUTCOME MEASURES BY DOMAIN1. Preventing people from dying prematurely

2. Enhancing quality of life for people with long term conditions

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

4. Patient Experience - Ensuring that people have a positive experience of care

* MRSA - June MRSA case previously assigned to AV CCG has now been assigned to Provider (OUH) after PIR review.Number of women known to be Smokers At Time Of Delivery (SATOD) 1

* GP Out-Of-Hours - The latest data is from the January 2015 publication, collected during Jan-March 2014 and July-Sept 2014

6

Waiting times: 18 week, diagnostic & 52 week waits (January)

AdmittedNon-

AdmittedIncomplete Diagnostic >52 admit

>52 non-admit

>52 Incomplete

A&E 4 Hour wait (February) BHT OUH MKHFT

Cancer waiting times (December) All 2ww Breast 2ww31 Day 1st Treatment

31 Day (Surgery)

31 Day (Drugs)

31 Day (Radio)

62 Day Standard

62 Day (Screen)

62 Day (Upgrade)

Ambulance response times (Jan) Handover delays (Feb)

Red 1 - 8 Red 2 - 8 Cat A 19 SMH 30+ HWH 30+ OUH 30+ MKGH 30+ SMH 60+ HWH 60+ OUH 60+MKGH

60+

Cancelled Operations on or after day of admission not re-offered within 28 days - threshold to be set (quarterly) Q3 2014/15

BHT OUH MKGH

Urgent operations cancelled for a 2nd time (Jan)

BHT OUH MKGH

Mental Health CPA Q3 and Monthly (Jan) : Risk Assessment/ Contingency (Jan)/Dementia (Dec)

CPA (Q3)

CPA Adult

(Monthly)

CPA Older Adult (Monthly)

Risk Assessment

(Adult)

Risk Assessment

(Older Adult)

Contingency Plan (Adult)

Contingency Plan (Older

Adult)

Dementia Diagnosis

1 - Preventing people from dying prematurely (Jan 15) SATOD Q3 2014/15

HSMR 80 BHT

HSMR 80 OUH

Maternity (SATOD)

2- Enhancing the quality of life for people with long term conditions (Jan/six monthly) Unplanned Admits (Dec)

Unplanned Admits ACS

Unplanned Admits LTCs <19

People with LTCs Feeling

in control

3 - Helping people to recover from episodes of ill health following injury (Jan) Emergency Admits (Dec)

Stroke: 90% on SU

BHT

Stroke: to SU <4 hrs

BHT

Stroke: 90% on SU OUH

Stroke: to SU <4 hrs OUH

Stroke: 90% on SU

MKGFT

Stroke: to SU <4 hrs MKGFT

Emerg Admits children lower

resp

Emergency Admits not

normally needing it

PROMS measures

tbc

4- Patient Experience (Jan (GP OofH six monthly)) Complaints

Friends & Family tests

GP Out Of Hours survey

Complaints BHT

Complaints OUH

Complaints MKGH

5- Patient safety - CCG measures (Jan)

MRSA: CCG C Diff: CCG

5- Patient safety - Pressure Sores (Jan) VTE (Dec) Serious Falls (Jan)

Pressure Sores BHT

Pressure Sores OUH

Pressure Sores

MKGH

VTE BHT

VTE OUH

VTE MKGH

Serious Falls BHT

Serious falls OUH

Serious Falls

MKGH

Local Measure - Diabetes - percentage of people with diabetes on step 1 therapy who have an HbA1c less than or equal to 48 mmol/molIAPT - proportion entering treatment and proportion moving to recovery Q2

Roll Out Recovery

NHS Constitution & Supporting measures

CCG Outcome measures

Ambition Outcome measures

These charts reflect current position: i.e. Data to latest month available

Not MetAbove or close to

ThresholdMet

Target not set

Data not available

7

Section 3 – Exception reports

NHS Constitution Standards Exception reports are included for the following indicators which are amber/red for this month/quarter: • Ambulance response times; • Ambulance Handover Delays over 60 minutes. • A&E four hour waits. • Cancelled operations on or after day of admission (OUH). • Mental Health targets: Care Programme Approach; Dementia; Transforming care for People with

Learning Disabilities

Ambulance Response Times

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Se

p-1

3

Oct-

13

No

v-1

3

De

c-1

3

Jan

-14

Fe

b-1

4

Ma

r-1

4

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Se

p-1

4

Oct-

14

No

v-1

4

De

c-1

4

Jan

-15

Ambulance Clinical Quality Category A 8 Minute Response Time - Red 1

Actual Mean Lower Control Limit Upper Control Limit

60%

62%

64%

66%

68%

70%

72%

74%

76%

78%

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Se

p-1

3

Oct-

13

No

v-1

3

De

c-1

3

Jan

-14

Fe

b-1

4

Ma

r-1

4

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Se

p-1

4

Oct-

14

No

v-1

4

De

c-1

4

Jan

-15

Ambulance Clinical Quality Category A 8 Minute Response Time - Red 2

Actual Mean Lower Control Limit Upper Control Limit

84%

86%

88%

90%

92%

94%

96%

98%

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Se

p-1

3

Oct

-13

No

v-1

3

De

c-1

3

Jan

-14

Fe

b-1

4

Ma

r-1

4

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Se

p-1

4

Oct

-14

No

v-1

4

De

c-1

4

Jan

-15

Ambulance Clinical Quality- Category A 19 Minute Transportation Time

Actual Mean Lower Control Limit Upper Control Limit These indicators monitor the time it takes for an ambulance to respond to a 999 call. Category A calls are the most serious and are monitored as Category A8 and A19, which are calls that resulted in an emergency response arriving at the scene of the incident within 8 minutes and within 19 minutes. Category A8 is further split into two parts, Red 1 and Red 2. Red 1 calls are the most time critical and cover cardiac arrest patients who are not breathing and do not have a pulse, and other severe conditions such as airway obstruction. Red 2 calls are serious but less immediately time critical and cover conditions such as stroke and fits. Red 1 patients account for less than 5% of all ambulance calls. The service is contracted at Thames Valley level for performance rather than CCG level. Performance at a CCG level is reported by SCAS for information. SCAS is currently commissioned and the CCGs are monitored for performance at a Thames Valley contract level and not at CCG level. SCAS is required to deliver performance on an annual basis at Thames Valley contract level. It is noted that SCAS is short on performance for Red 1 and Red 2 year to date and these targets are likely to continue to be challenging through to the end of the contract year (31 March 2015). Performance against targets for January was:

Category A8 Minute Response Time: • At Aylesbury Vale level 72.0% of RED 1 incidents were responded to within 8 minutes which is

below the KPI target of 75%. YTD performance is below target at 73.4%.

• At Thames Valley level, monthly performance was below target at 73.2%. YTD performance is also below standard at 74.1%.

8

• At Aylesbury Vale level 72.1% of RED 2 incidents met the 8 minutes response target, against the KPI target of 75%.YTD performance is below target at 70.9%.

• At Thames Valley level, monthly performance was slightly above target at 75.1%. YTD performance is below standard at 73.1%.

Category A19 Minute Transportation Time: • At Aylesbury Vale level the 95% target has not been met in January with performance slightly

below standard at 94.6%. YTD performance is below target at 92.9%.

• At Thames Valley level, performance in January was above target at 95.5%. YTD performance is at standard at 95.0%

Monthly reporting on performance SCAS reported increased Red activity following the move to NHS Pathways which impacted their performance in Q3 2014/15, but this has reduced in January. SCAS has acknowledged that it is at risk of failing Red 2 at contract level, but will do everything to improve performance against all failing targets, and believes it can recover its position on Red 1 by the end of the contract year. The percentage of red calls decreased significantly in January; therefore there have been fewer incidents in which to recover performance. In January for Category A8 Red 1: 36 out of 50 patients had an emergency response arriving at the scene within 8 minutes. This equates to the target being missed by two. There were no long waiters of over 30 minutes and the longest wait was 18 minutes. For Category A8 Red 2: In 435 out of 603 cases emergency responders arrived at the scene within 8 minutes. This equates to the target being missed by 18. There were three waiters of over 30 minutes. The response times for each CCG area are reviewed at contract review meetings with Board members of SCAS and in further detail at quarterly Quality meetings. The later meetings review individual cases where a long wait was identified. Issues of harm being caused for AVCCG patients experiencing long waits will be fed back to the CCG through this performance report once they have been reviewed at the quarterly Quality meetings. In order to ensure timely response to significant events, Serious Untoward Incidents (SUIs) are reported as they arise. No SUIs were reported in January 2015. In terms of activity, there were 1965 incidents for Aylesbury Vale in January which is a decrease of 352 compared to December’s figures. There was a decrease in 999 calls made by the public and in see & treat and see, treat & convey. There continues to be a good increase in hear and treat activity now that NHS Pathways has been implemented. Ambulance Handover Delays (February)

High Wycombe 0 0 0 0 0 0 0 0 0 0 0Stoke Mandeville 6 4 9 14 2 11 2 4 74 50 9Heatherwood and Wexham Park 12 15 7 5 9 5 5 7 72 79 26Oxford University Hospitals 3 4 4 3 8 6 5 4 14 23 11Milton Keynes General Hospital 22 27 14 35 17 15 25 15 41 16 27

Ambulance handover delays over 60 minutes

April May June July Nov JanOctSeptAug Dec

2014/15

Feb

9

Buckinghamshire Healthcare Trust – The number of over 30 minutes handover delays continued to decrease in February compared to previous months (53 compared to January’s 124). The number of over 60 minute delays also decreased (9 compared to January’s 50). Milton Keynes General Hospital - The number of over 30 minute handover delays increased slightly in February (134 compared to January’s 122). The number of over 60 minute delays has also increased (27 compared to January’s 16). Oxford University Hospital - The number of over 30 minute handover delays decreased in February (74 compared to January’s 111). The number of over 60 minute delays has also decreased (11 compared to January’s 23). A&E – Four Hour Waits This indicator is a measure of the time that patients wait within an A&E department (or Minor Illness/Injuries Unit) before either being admitted, treated & discharged or transferred to another hospital and is measured by provider to ensure patients are seen within a nationally set time limit. The main hospitals Aylesbury Vale CCG residents attend are Buckinghamshire Healthcare Trust (BHT), Oxford University Hospitals (OUH) and Milton Keynes Hospital (MKFT). Consistent with the National picture, performance dropped significantly from October at all 3 local providers, (see charts below). However, it has improved over the last 2 months. Of the three providers Oxford University Hospital saw the poorest performance through January in terms of the A&E 4 hour waiting time standard.

In February:-

o BHT did not meet the A&E standard (95%) with performance below target at 91.5%. YTD

performance remains below the standard at 93.0%.

o MKGH did not meet the A&E standard (95%) with performance at 89.0%. YTD performance is below target at 92.5%.

o OUH did not meet the A&E standard (95%) with performance at 88.3%, YTD performance

remains below standard at 90.3%.

BHT performance has not recovered in February as well as anticipated, although better than the national average where A&E performance has been below 90%. This was due to a variety of factors:

10

• the high numbers of older people admitted in January with flu have required longer length of stay and more complex discharge packages than usual;

• acute trusts are balancing the use of bed capacity to meet 18WW targets and urgent care resilience as we approach the year end;

• many staff who have postponed annual leave earlier in the winter due to the pressures from flu admissions are trying to take it by the end of March;

• recruitment to key NHS and Social Care roles continues to be difficult, • and even with BHT opening a new ward with 24 beds at the end of January it is challenging to

find additional nursing staff to open additional escalation beds, so the actual bed capacity has remained fairly constant.

To tackle this, two additional CCG funded step down care home beds have been procured and BHT is procuring 12 other care home beds for “non-weight bearing” patents such as those recovering from orthopaedic surgery, to release acute bed capacity. As we approach Easter, BHT, Bucks CC and all other key partners are extending resilience projects to the end of April and repeating the “ideal week” exercise to focus all resources on maximising performance over the challenging four day holiday period. However, even with these actions BHT is extremely unlikely to achieve the 95% standard in Q4.

Cancer waiting time targets

• The 31 Day Wait Radiotherapy target (94%) was met in January with performance at 97.4%. However, although improving, year to date performance remains under target at 90.7%. AVCCG expects to maintain the improved level of performance following changes made in the service by OUH (See Chart).

Referral to Treatment (RTT) The number of patients with Referral to Treatment pathways greater than 52 weeks: Any patient waiting beyond 52 weeks for treatment is considered to be a breach and will trigger a red rating. In January there were no breaches for AVCCG patients on either completed or incomplete pathways at any provider. Admitted Pathways (90% Standard): In January the target was achieved with 92.5% of patients being admitted in less than 18 weeks. The YTD position is now above target. The specialties that missed the target were Ear Nose and Throat

11

(89.7%) Trauma and Orthopaedics (87.8%), Ophthalmology (88.5%), General Surgery (88.6%), Plastic Surgery 89.0%) and Dermatology (75%). There has been a steady decrease in the 95th percentile during 2014/15 from 24.6 weeks in April 2014 to 20.8 weeks in January 2015. However, during the same period there has been an increase in the median waiting times from 5.4 weeks to 7.0 weeks. Performance against 18 weeks targets is monitored on a weekly basis, with the Access & Performance Management meeting at BHT in place to discuss and manage 18 weeks pathways and balance clinics around the weekly pressures to support this. The CCG attends these meetings to obtain assurance over the robustness of review and actions taken in this area. Early indications through this meeting are that the February performance at BHT was above the target level for non-admitted pathways and incomplete pathways, but below the target level for admitted pathways. This is due to a further round of backlog clearance instigated by NHS England, the Trust Development Authority and Monitor to be undertaken in February and March. Cancelled operations on or after day of admission (BHT & OUH)

This indicator is measured quarterly by provider. It states: “All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient's treatment to be funded at the time and hospital of the patient's choice”. The target is set as 0 cases and anything above that is rated as amber or red. Although BHT did cancel a number of operations through Q3 for non-clinical reasons, all patients were offered another binding date within 28 days. Six patients at OUH were not offered a date within 28 days. Pressure is expected to continue on this target during Q4, as pressures from urgent care continue to cause operational issues for providers. However, we are assured that providers are taking steps to avoid cancellations in the first place; and where they are necessary, to offer a binding date within the requisite period.

Mental Health Indicators There are now 13 mental health indicators reported in the tables at the end of the report, the majority of which have national standards of expected performance. The paragraphs below provide exception reports for those indicators which are not meeting the expected standard. Care Programme Approach – Monthly Reporting Patients on Care Programme Approach to have a documented risk assessment: The target is for 100% of all patients on Care Programme Approach to have a documented risk assessment. While this is currently not being achieved, performance has increased from 91% to 93% over 2014/15 for adults (monthly performance 94%) and has increased slightly from 93% in April 2014 to 94% for older adults in January 2015.

2014/14 Q1 2014/14 Q2 2014/14 Q3BHT 1 0 0OUH 7 7 6

12

Patients on CPA to have a crisis contingency plan The target is for 95% of all patients on CPA to have a crisis contingency plan. This has increased from 74% to 76% of all adults; and has increased from 30% in April 2014 to 98% in older adults in January 2015. Measured on a Quarterly basis CPA is meeting the national targets. Dementia Diagnosis Rate Aylesbury Vale CCG is performing above the national average, but is still under the national target of 67%. Latest national data for the end of February shows AVCCG has recorded 57.71% of dementia diagnoses against the expected prevalence in the population. Local data extracted from EMIS on 17 March indicates further improvement to in excess of 58%. In addition, a revision in the prevalence calculator due to be brought in for April 2015 is expected to lead to a 4%-5% increase in performance for AVCCG, as the expected prevalence under the revised calculator is slightly less. As reported in the February performance report, in Buckinghamshire a local Dementia Diagnosis Plan has been initiated to increase diagnostic rates across the county, using the NHS England South of England Protocol for dementia data harmonisation. As well as the initiatives reported previously, practices are being asked to produce their NHS dementia registers prior to patient visits. These vary from QoF figures and also return a different cohort than the data harmonisation tool - however, these patients all definitely have a dementia diagnosis and so can quickly be recoded appropriately. Transforming care for People with Learning Disabilities The “Transforming care for People with Learning Disabilities (LD)” register is used to monitor inpatient placements of people with learning disabilities i.e. specialist hospital places for people with learning disabilities who may present challenging behaviour or have mental health issues; and whose needs can only be met within specialist LD services. As of 28 February 2015 AVCCG had six inpatients; (two are in specialist hospitals out of the area; four are in the local unit).

There have been no re-admissions and no discharges since the last report. In addition to the above Buckinghamshire has 5 individuals who have been placed by Specialist Commissioning services, which work across the both the region and nationally. The people in this group are forensic cases funded by NHS England specialist commissioning and will be placed in low, medium and high secure units outside of the area. Decisions regarding discharge will be made by the Ministry of Justice.

Note: Standard deviation in all charts is 2.

13

Outcome Measures

Exception reports are included for the following indicators which are red for this month: • Emergency and unplanned admissions for specific conditions • Patient experience of GP out-of-hours services (GP patient survey results) • C-Difficile Emergency and unplanned admissions for specific conditions (CCG measure)

This suite of indicators incorporates emergency admissions to hospital of persons with acute conditions (ear/nose/throat infections, kidney/urinary tract infections, heart failure, among others) that usually could have been avoided through better management in primary care. They measure the level of emergency admissions for long term conditions and for conditions which are not normally considered to require admission ie they are a proxy measure for avoidable admissions. The fact they are above target is consistent with the increase seen in emergency admissions as a whole but may be partially as a result a change in counting as CDU and SAU attendances were not counted as admissions in 2013/14 but are in 2014/15. Admissions data for children with lower respiratory tract infections show a large increase in both November and December. This may be related to Respiratory Syncytial Virus (RSV) which surveillance has shown increased at this time and is responsible for many lower respiratory tract infections and admissions, especially in the under 5’s. There are however a number of respiratory viruses circulating at this time of year and therefore it is not possible to identify a definitive cause of this increase. January data is not currently available due to a national decision to move the maintenance of SUS from BT to the Health and Social Care Information Centre (HSCIC). The data is expected to be available from mid- March. Patient experience of GP out-of-hours services and People with long-term conditions feeling independent and in control of their condition This indicator is taken from the GP patient survey which has taken place twice a year since July 2011. Questionnaires are sent to a selection of around 2.7 million adults who are registered with a GP in England over the course of the year. The latest GP survey data published relates to the period January-Sept 2014 and was published in January 2015. For the indicator on overall experience of GP Out-of Hours the score has increased from 61.0%.to 68.0%, which is just below the 70% target.

Measure (Rate of emergency admissions)

Monthly Baseline (2013/14) April May June July August Sept Oct Nov Dec YTD

Chronic ambulatory care sensitive conditions (adult) 70 103 84 71 75 72 61 76 87 106 735

asthma, diabetes and epilepsy in under 19's 9 11 6 7 7 11 4 14 11 13 84

For acute conditions that should not usually require hospital admission 138 187 196 182 173 163 160 182 184 163 1590

Emergency admissions for children with lower respiratory tract infections 11 7 9 5 3 5 5 23 53 79 189

14

Mixed Sex Accommodation There were no same sex accommodation breaches for Aylesbury Vale CCG in February. YTD total breaches are 4. MRSA There have been no MRSA bacteraemia cases assigned in February to Aylesbury Vale CCG. C.Diff Aylesbury Vale was 3 cases above trajectory in February. This takes them to 48, which is two cases below their annual target. Therefore AV CCG trajectory will only be met if there are no more than 2 cases in March. The C.Difficile objective for 2015-16 has now been released with Aylesbury Vale CCG set at 49 cases. A paper with full details will be submitted to the February Commissioning for Quality Committee. Other outcome measures In addition to the exception reports on the previous page, indicators on pages 3 to 6 show issues with performance levels against:

• Stroke indicators, specifically admissions to a stroke unit in under four hours at BHT and MKFT;

• Patient complaints at BHT; and • Pressure sores at BHT and VTE at OUH.

These items will be featured in the Quality Report.

15

OPERATING PLAN & QIPP MONITORING REPORT – GOVERNING BODY

9 April 2015

Purpose of Paper

This report presents to the Governing Body a view of delivery against the Operating Plan key QIPP programmes and outcomes. This assessment has been taken from milestone reporting from programme leads.

Executive Summary

This report provides an overview of progress against milestones and planned quality or activity improvement targets and associated planned productivity savings.

• The year to date position at month 11 is £2,264k QIPP savings achieved againstidentified planned savings of £3,656k (62% achievement).

• However, there remains £562k of unidentified savings which makes the total QIPPtarget £4,218k, giving a 54% achievement.

• £1,558k mitigation has been allocated to QIPP overall giving a final position of 91%achievement through the use of headroom.

• The Elective care, urgent care and early years programmes are assessed as onlypartially delivering on QIPP savings at 63%, 44% and 0% achievement to date.

• The forecast position is for year-end delivery of 88% of plan following mitigation.

Actions requested / recommendation

The Governing Body is asked to note the report.

Strategic Objectives supported by this Paper (Please Tick)

Improve people's health and reduce inequalities

Enhance quality, safety and experience of patient services

Ensure local people have greater influence and management of own care

Deliver financial sustainability with headroom to invest Perform well as a CCG

Equality Analysis completed (please tick )

Yes No Not applicable

Author of paper Lead Director(s) responsible for this area of work

Paul Hutt, AV CCG Katherine Woolley, CSU

Colin Thompson, Director of Operations & Performance

QIPP (Quality Innovation Productivity & Prevention)

Monitoring report, March 2015

(Reporting month 11, February 2015)

1.0 Introduction

QIPP (Quality, Innovation, Productivity and Prevention) as a concept has been part of the NHS for a number of years. Driven by a fundamental financial shortfall between available funds for the NHS and projected costs in a ‘no-change’ scenario, commissioning organisations have been challenged to undertake actions to improve quality, innovation, productivity and prevention in their local health economies. QIPP in its true sense involves removing costs from a health economy – either by avoiding activity in the first place, through prevention, improved quality or refined pathways; or by undertaking necessary activity in a more efficient way – using innovative techniques and becoming more productive. Simply moving a cost pressure from one NHS organisation to another will help to balance the books of the beneficiary, but does not help to establish a sustainable system.

To tackle the disease burden and for planning purposes Aylesbury Vale CCG (AVCCG) has adopted a life course approach – from pre-conception through pregnancy, infancy, early years, childhood, adolescence and teenage years, and through to adulthood and preparing for older age. There are specific opportunities and challenges at each stage of the life course and action is needed at all ages to avert the short- and long-term consequences of the main disease groups described above.

1.1 Link to strategic plan The Buckinghamshire Commissioners five year strategic plan from April 2014 recognises that investment is required in areas of the health and social care system to deliver a system of integrated care, where available money is spent in the most efficient and effective way, as shown below:

There are many facets to CCG strategic planning, and ultimately the QIPP plan is just one element, but in order to be successful it needs to connect with and support other areas of planning. Within the context of the CCG’s wider strategy, specific programmes and projects are in place to deliver the change required to move the system in the desired direction of travel, and deliver QIPP savings.

The ambition to transform and integrate services is aligned with the national aspiration to transfer 15% of acute activity into community based services, by implementing an integrated model of care which has the capability to respond to a wide range of levels of need and support individuals to remain at home. It is anticipated that the rebalancing of care will be most evident in sub-acute care of older people, i.e. those over 75.

1.2 Link to outcomes

The main drive of the Operating Plan is to improve key quality outcomes, in order to improve the lives of our population (value based commissioning). The priorities for improvement have been identified at both locality level through detailed public health profiles and then aggregated to give CCG wide prevalence rates. The objective is to give a clear understanding of disease burden across the CCG. This allows the team to target through an evidence based model, the most visible opportunities to improve outcomes.

The individual programme sections of this report provide a summary of the outcomes identified which require improvement, and how progress against them is being monitored. The report also tracks activity reduction aligned to delivery of the QIPP projects (activity and finance) and the assessment of delivery from the highlight reports (milestones).

2

1.3 Link to finance

The QIPP challenge for Aylesbury Vale CCG (AVCCG) for 2014/15 is £4,763k. Table 1 in section 2 shows this challenge, split between the main programmes within which multiple projects are under way. In the year to date, £2,264k of a required £4,218k has been delivered (54%). Use of financial headroom provides some mitigation (£1, 558k) to achieve 91% of the year to date QIPP requirement.

Within the framework of system transformation, and focusing on value based commissioning, the QIPP programmes should all lead to an improvement in quality, effectiveness, efficiency or a combination of all. While there is an over-arching QIPP challenge for the CCG to meet, not all QIPP schemes will necessarily have a positive financial impact within the current year. As such, while programmes have financial values associated with them, it is not always possible to do the same at a project level. This does not mean that delivery of all projects is not important in order to ensure sustainability of the system now and into the future.

1.4 Forecast

The finance tables within this report indicate that 62% of identified savings in the year to date have been delivered. This is expected to decrease to 60% delivery of identified savings by year end. Use of headroom of £1,700k is planned to bridge much of the remaining gap to a forecast 88%. A key risk within the forecast is that the planned delivery of identified schemes is loaded towards the end of the year. £3,656k was planned to be delivered by month 11. This is 88% of the full year plan for identified schemes, so a higher proportion needs to be delivered in the final month of the year just to maintain the percentage of plan delivered.

This report highlights the key issues and risks in Month 11, although much of the supporting data analysis relates to month 9 and 10. As this report outlines, the majority of programmes are experiencing under-delivery in the year to date. Mitigating actions have been undertaken in the second half of the year in order to maximise the value of QIPP delivery in the year. These are outlined in section 4.

1.5 2015/16 planning

As part of the planning processes for 2015/16, the QIPP programme for the year is in the process of being finalised. Current headline positions are that the minimum value required from QIPP schemes is £2.5m. Projects with a projected maximum value of £3.6m have been identified; however risk assessment of likely delivery of savings from these projects brings a likely value of £2.3m. Further schemes and projects continue to be identified and worked on, and will form part of a continuous review of QIPP savings through the year.

3

2.0 Headlines - QIPP Performance (Finance)

Table 1 below provides a summary of monthly QIPP achievement by programme and a forecast position for year end in financial terms.

• The year to date position at month 11 is £2,264k QIPP savings achieved

against identified planned savings of £3,656k (62% achievement). • However, there remains £562k of unidentified savings which makes the total

QIPP target £4,218k, giving a 54% achievement • £1,558k mitigation has been allocated to QIPP overall giving a final position of

91% achievement through the use of headroom. • The Elective care, urgent care and early years programmes are assessed as

only partially delivering on QIPP savings at 63%, 44% and 0% achievement to date.

• The forecast position is for year-end delivery of 88% of plan following mitigation.

The shortfall in meeting the QIPP savings target this month is assessed as being due to:

• Schemes delivering no savings to date which are mostly related to acute activity - reducing variation in out-patient procedures; A&E remodelling; and early years projects related to acute activity savings.

• These are partially offset by additional savings in running costs and the reducing variation in radiology scheme, as well as medicine’s management.

For each of these schemes there are a number of projects which contribute to delivering the savings. These are cross referenced within the programme milestone reports set out in the next section.

Achievement by project is shown in the Table 2 over the page.

4

Table 1 – QIPP Achievement by Programme

Table 2 - QIPP Achievement by Programme

5

3.0 Programmes Delivery

The programmes are reported under the following headings which are all programmes overseen by Joint Executive teams (JETs). It should be noted that the adult joint care programme does not have QIPP savings associated with it at this stage. Investment in schemes in this programme is designed to release savings in acute care. It is proposed to include a further section which we have called “localities” which will include reports from the locality structure within the CCGs. However, this needs to be discussed further.

1. Children & Young People

2. Adult Joint Care

3. Right Care (elective care)

4. InPACT (urgent care)

5. Medicines management, LTCs & End of Life care

Programme Activity Finance Milestones Children & Young People

Adult Joint Care

Right Care

Urgent Care

Medicines management, Long Term Conditions (LTC) & End of Life care (EoL)

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3.1 Children & Young People’ Board

Children & Young People Clinical lead Dr Juliet Sutton February 2014 RAG Ratings: (see

below) 2014/15 Savings:

YTD 2014/15 full year

Key messages Activity Planned (92) (100)

The maternity needs assessment is now complete and we are starting the process of looking at high priority areas where we could potentially make an impact. The terms of reference for an advisory group to work on the findings are being agreed. The report went to the CYP JET in January 2015, and the Maternity Needs Assessment Action Plan is on the agenda for the March Executive Committee.

Finance Actual / Forecast - - Milestones Over / (under) (92) (100)

Outcome measures

Admissions of children to hospital: When paediatric services across all sectors of the NHS and social care are working effectively, it could be expected that the rate of admissions of children into acute care would be at its lowest. Appendix 1b show graphs for non-elective admissions of children aged 0-19; fever admissions of children aged 0-4; and bronchitis admissions of children aged 0-4. There is currently no discernable reduction visible, but otherwise expected growth has been contained. There was, however, a spike in admissions of children in October to a level notably higher than any month since April 2012.

Low birth weight of term babies: Over the period since 2001, Buckinghamshire County has been consistently below national average for the percentage of low birth weight babies. However, from 2010 to 2012 (the latest available data) there was a notable increase in the rate in Buckinghamshire, seeing the gap to the national average eroded. See appendix 1b for graphs. Improvements in this area will reduce the number of low weight births back to the rates previously experienced in the County, which will lead to improved outcomes for this cohort of children and fewer demands on neonatal and paediatric services.

Infant mortality: Since 2001, Buckinghamshire County typically experienced infant mortality rates lower than the national average. From 2004 – 2007 the rates increased to be above national average (although the national average was also falling at the same time). See appendix 1b for graphs. By improving maternity services infant mortality could be brought back below the national average, improving outcomes for those affected in a number of significant areas.

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3.2 Adult Joint Care

Adult Joint Care Clinical lead Dr Karen West February 2014 RAG Ratings: (see



Key messages Activity Planned - -

The costs for the increasing demand for dementia care pose a significant risk across health and social care. There is also significant national attention on dementia diagnosis rates.

February dementia diagnosis rates for AVCCG are 57.71%, which is the third highest in Thames Valley and above the regional average. Data from EMIS in mid-March indicates a further improvement to approximately 58.2%, and a revision in the prevalence calculator has been assessed as likely to increase the diagnosis rate in AVCCG by a further 4%-5%.

Finance Actual / Forecast - - Milestones Over / (under) - -

Outcome measures

Dementia diagnosis rates: The CCG target is to achieve 67% dementia diagnosis rate based on the national prevalence calculator by 31 March 2015. Appendix 2b contains the latest data held in respect of this, showing progress made towards this target.

Other outcome measures relevant to this programme are in the process of being identified for future reporting.

8

3.3 Elective Care (Right Care Steering Group)

Elective Care Clinical lead Dr Christine Campling February 2014 RAG Ratings: (see



Key messages Activity Planned (1400) (1,600)

Work is ongoing with the MSK pathway, dermatology and gynaecology. An independent firm of clinical auditors has conducted an audit of procedures of low clinical value at BHT, looking at data from the first six months of 2014/15. A commissioner workshop was held in January to review audit findings, and a further session was held with representatives from BHT. This was a constructive session with some clear actions being undertaken to improve processes and procedures for 2015/16.

AVCCG is also liaising with the audit firm and BMI with a view to conducting the same process to activity carried out with that provider. We will be looking to ensure the same rigour is applied across all material providers to the CCG.

Finance Actual / Forecast (881) (961) Milestones Over / (under) (519) (639)

Outcome measures

The outcome indicators are measured at county level. The measures and Buckinghamshire’s position compared to the national average are:

• Excess weight in adults – Buckinghamshire at the national average

• Excess weight in children: measured at reception year and year 6 ie children aged 4-5 and 10-11 classified as overweight or obese – Buckinghamshire better than the national average and in the top quartile for both age groups.

• Percentage of physically active and inactive adults – Buckinghamshire better than the national average and towards the top quartile for active adults.

Information can be found in appendix 3b.

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3.4 Urgent Care (Unscheduled Care)

Urgent Care Clinical lead Dr Kevin Suddes February 2014 RAG Ratings: (see



Key messages Activity Planned (458) (500)

Contract activity data from the main acute providers show over-performance in non-elective admissions even after taking account of the inclusion of CDU/SAU activity in the non-elective admission data.

As noted in the Performance Reports in recent months, all local A&E providers have experienced a very challenging period through December, January, February and now into March in terms of delivering the A&E 4 hour target. BHT missed its agreed recovery trajectory for Q3 and Q4 looks highly unlikely to be achieved. Resilience schemes have been reviewed and extended through April where appropriate, and a further ‘Perfect Week’ exercise is planned in April.


Outcome measures

Graphs referred to below have not yet able to be updated from prior month.

AVCCG emergency admissions to BHT: See appendix 4b. Generally above prior year levels and above mean levels. Supported by BHT contract activity reporting.

AVCCG emergency admissions to BHT for over 75s: See appendix 4b. The early part of the year saw a step increase in admissions, most likely driven by the CDU/SAU counting as emergency admissions for PBR purposes this year. Significant reductions took place in December, however, to be near prior year levels.

Emergency admissions to BHT from AVCCG GP Practices: See appendix 4b. Activity has been around plan throughout most of the year, with the largest variance arising in October.

Emergency Admissions from Care Homes for AVCCG Practices: See appendix 4b. April and June and September were a clear step above prior year. All other months except for December also saw an increase, however not to the same extent. Patterns within this data need to be analysed and understood in order to derive conclusions.

ACHT contacts per 1,000 population: See appendix 4b. Largely consistent through 2014/15 to date, with CCG wide performance at around 100 contacts per 1,000 population.

ACHT Caseload per 1,000 population: See appendix 4b. Largely consistent through 2014/15 to date, with CCG wide performance at around 30 individual patients per 1,000 population.

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3.5 Medicines management, Long term conditions and End of Life Medicines management, Long term conditions and End of Life Clinical lead Dr Stuart Logan February 2014 RAG Ratings: (see



Key messages Activity Planned (1,312) (1,520)

Diabetes represents 10% of the total cost of the NHS. In AVCCG it is actually closer to 12% and could rise if not managed to 16% by 2020. The disease affects approximately 6% of people. This has been the focus of reporting of data to practices through the year, and a wider project is underway to take this further. A project Clinical lead has been appointed. Work will be done to identify the full cost of the disease in the CCG area, and attempt to track the impact of actions and patient outcomes against that cost.

The anti-coagulation service has been re-commissioned. Indicators are being worked up with baselines for QIPP reporting in 2015/16.

Work will be completed to link actions being undertaken in the area of long term conditions to outcome measures which can be tracked and monitored.


Outcome measures

Diabetes prevalence: The prevalence of diabetes in Aylesbury Vale, as measured by practices has shown a steady increase since March 2010.

Reduction in EQ5D scores at aggregate level: This is directly standardised average health status (EQ-5DTM) score for individuals aged 18 and over reporting that they have a long-term condition, weighted for design and non-response This data is collected twice a year from the GP patient survey: Baseline data is given in the table below compared to the national average.

Percentage of patients dying in their preferred place of death: This data is not yet available due to Information Governance issues to do with access to data. These are being worked through with partners.

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4.0 Mitigating actions

Below is a summary of the latest position of key schemes within different under-performing programmes, and what mitigating actions are under way.

4.1 Elective / Right care schemes update

• Follow ups – the QIPP report shows a challenge of £800k, which has been revised downward in the full year forecast to £536k. The month 11 SLAM report from BHT indicates £825k over-performance against plan on follow up outpatients. However, review of those specialties with QIPP targets indicates some are delivering savings, and across a number there has been an improvement in new to follow up ratio at BHT – over-performance is being driven by an increase in first attendances. Some of this is likely to be linked to 18 week backlog clearance work. Mitigation –a dedicated project manager has been assigned to the project from mid-September until the end of March, who has been working within BHT to drive actions and projects aimed at unlocking decreases in face to face follow ups. Review of data has been conducted to enable prioritisation of the remainder of her time on the areas with most potential, which currently appears to be T&O and rheumatology. General Managers within BHT were asked to work with their clinicians to scope out stretching but realistic targets and plans going into 2015/16, which will feature in QIPP plans for the year.

• Radiology – the CCG has worked with member practices to decommission radiology procedures of limited clinical value. However in month five the main provider BHT put forward a new cost of £250k direct access costs. No patient level data has been received. Mitigation – Challenged successfully through the contract executive assurance meetings.

• Procedures of Limited Clinical Value (PLCV) – The CCG has commissioned an independent firm to perform a clinical audit of PLCVs at BHT. Mitigation – The audit was completed in December. Approximately £1m of recurrent activity should be able to stop being done at BHT, generating capacity to undertake more commissioned activity, making 18 week pathways sustainable with less outsourcing of activity to other providers.

• Outpatient procedures – Over-performance at BHT is £968k to Month 11 for outpatient procedures. The CCG has raised this both with BHT in terms of obvious un-notified counting changes and also with the CSU in terms of the tariff and how are they engaging with monitor over this. Mitigation – Quarter one close dispute on payment of certain codes, which will be repeated through the year.

Summary – The level of ‘will’ from providers to reduce follow up costs and lose income has not being demonstrated through the year, however there are signs that this position is shifting. The system needs to understand this and further discuss options to achieve this change through a system wide approach on risk. The project on PLCV is a win/win to the commission and provider in terms of maximising surgical capacity in the system and for patients guaranteeing appropriate surgical procedures are being completed at the best waiting time. The CCG needs to work further through localities to engage member practices in regard to referral levels to both outpatients and to radiology and diagnostic services. To help this further work on practice level information is required as part of mitigation.

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4.2 Early years

• The annual QIPP target is £100K which is currently forecast not to be met. The current resilience programme has not prioritised any additional support for children’s emergency care over the winter. From the system wide profit and loss work attendance’s of children aged four and under is an outlier in Buckinghamshire. Mitigation – includes the completion of implementation of the five children’s urgent care pathways and the need to identify frequent attenders to general practice.

4.3 Urgent care/LTC

• Introduction - £1m saving has been badged against long term conditions in the original QIPP however this on review is not appropriate. The real challenge is overall containment / reduction of emergency admissions set against the significant level of investment in schemes to reduce emergency pressures. Unless the considerable system wide investments in BCF, resilience funding and social care show delivery it will be challenging to show the financial gain from the quality improvements we are clearly seeing in the’ live well’ programme, the COPD nursing service and improvements in Diabetes control. While it is too early to conclude on a pattern, data through Q3 is showing some reduction in admissions of over 75s, but this has been more than replaced with other admissions.

• System resilience plan – The Bucks system has seen an investment of £2.7m over the six months to 31 March 2015 to support the system in maintaining performance over the winter period. The challenge to the QIPP will be the establishment of an additional in-patient ward at BHT ahead of the improvement and development of an Ambulatory care unit. The system is also seeing investment of approximately £2m from ‘social care money for outcomes’ which should be launching a same day response service and the start to seven day working.

• Mitigation – AVCCG has worked in partnership with member practices to

commission additional support for the over 75’s population for this winter. AVCCG has an over 75’s population of 14,577 and has set a target to reduce admissions by 3.5% or 510 episodes of care. Potential for savings of £350k based on a notional tariff of £1,800. CSU analysis indicates over 75 emergency admissions cost AVCCG on average £2,390, making the opportunity closer to £1,200k.

• Mitigation – discharge co-ordinator at MKFT was an investment of £60K from the over 75’s fund, aim to reduce costs on access bed days of £200K.

• Mitigation – BCCR (Bucks co-ordinated care record), produced from a

directed enhanced service payment which was already within the primary care quantum. Through sharing of the information with out of hours services, end of life services and carers bucks aim to reduce emergency admissions by estimated 50 episodes, producing QIPP saving 100K. (Still to be validated).

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Appendix 1a – Project milestones – Children & Young People Project Milestone Due date Commentary/ exception

report

CAMHS Retender

Market testing Stakeholder engagement programme has been agreed with BCC

April Complete

Commissioning model and approach confirmed/ Building Specification

June

Procurement Process / Tender Commences

July

Agreed 6mth extension to contract

August Contract Extension signed for 6 months. Practices to be involved in procurement intentions through on line survey

Stakeholder and bidder workshops to inform service model

Sept Final Business Case to CCG Exec and Stakeholder Event completed in October

Finalise service specification & launch procurement process

November

Tender evaluation and decision on procurement outcome

February 2015

Tender moderation & provider presentations completed

Finalise evaluation; report to CYP JET & both Execs

March 2015

Start date for new contract October 15

Maternity Needs Assessment

PID sign-off April Complete

Advisory Group set up, Royal Colleges involvement agreed, stakeholder consultations drawn up

May Complete

Needs Assessment analysis and options paper drawn up Engagement plan starting Tariff work started First meeting of working group for national data set

September Update to C&YP programme board of needs assessment and stakeholder engagement Engagement events held and GP survey planned for October

Maternity Needs Assessment to CYP JET January complete Maternity Needs Assessment to CCG Execs

February Completed in January

Ensure recommendations are picked up in March Work on-going with BHT in

specifications and quality schedules for BHT & HWP 2015/16 contracts

DQIP to ensure continuous progress towards routine provision of data

Maternity Needs Assessment & Action Plan to CYP JET.

Paediatric Urgent Care

First draft of project communications plan. First draft of Asthma leaflet pathway completed and jaundice leaflet sign off.

April Complete. Plan to relaunch bronchiolitis pathways with asthma/wheeze pathway in September ahead of Autumn bronchiolitis peak. PLT planned with TV strategic care network to promote asthma care for children in primary care (November 2014)

Self harm information on public health website. Pilot school training and delivery plan. GP films rolled out.

May Self harm booklets for schools launched with training day and pilot started. Further conversations taken place with A&E to ensure implementation of self harm pathway in practice July self harm evaluation was sent out to schools

New paediatric urgent care framework rolled out.

June Children’s website re launched with media coverage-agreement reached to redesign so compatible with smartphones/app.

Review programme to date.

July Work with CSU to further map impact of revised paediatric pathways on urgent care has commenced in October.

Initiate work to develop self-harm awareness in special schools & in primary schools

January complete

Review implementation of new self-harm pathways.

February Complete

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Physiotherapy Review

Paediatric physio produce first draft for consultation. Specific liaison with project leads for early years and disability (physio).

May Slight delay-first draft to be presented at Children’s programme board in July

Workshop with physiotherapy team to include OH and SALT.

June

New Physiotherapy pathway testing with parents.

September Options for Physiotherapy from consultation process drawn up in August.

share physio review with provider November Shared with BHT in January

Paediatric Community Services

Data capture of acute and community paediatric activity

May Complete

Map total provision including services that report to Paediatricians

June Mapping of services complete

Stakeholder engagement

July Meeting with clinical commissioners and paediatricians to confirm service capacity and structure

Options appraisal to JET October Now scheduled for November JET

Participate in the recruitment of 2 new paediatric consultants

January

Work with provider to ensure Designated Doctor cover is provided & recruitment gaps resolved

February complete

SEN Reforms

Children and families bill to receive Royal Assent. Working with parents and young people to develop local offer. Agreed with BCC how to take this forward. Training and support offered to service providers affected by the reforms.

April

Draft SEN code of practice approved. Working with parents and young people to develop local offer. Training and support offered to service providers affected by the reforms.

May

Working with parents and young people to develop local offer. Training and support offered to service providers affected by the reforms.

June

Personal budgets available from Sept 2014 September Update localities re progress of

SEN Reforms (continued)

for Children’s Continuing Healthcare. (phased intro)

Children's SEN Health Plans. Ensuring that health have agreed their element of the local offer.

Implementation of new EHC plans September Agree process for Personal Health Bs; Follow up core group and Bucks system group to review initial progress.

Children with Complex needs and disabilities

Business Case July

Business case in July was agreed for looking at a model for providing an integrated provision of care for these families with a single point of access. Funding for a project manager to head up this project has been agreed between health and the local authority intended by September. Engagement and feedback from families and providers was gained earlier in the year.

Autism strategy and action plan in place. Autism commissioning manager in place December

Autism Commissioning Manager appointed

January

Autism Commissioning Manager in post; Health and Social Care self- assessment data collection & submission signed off by 27/02

February

15

Appendix 1b – Outcome measures – Children & Young People Infant mortality The outcome indicators are measured at county level: • Buckinghamshire is just better than the national average in terms of the

proportion of low birth weight babies and for infant mortality • However, the difference in mortality rates between areas of highest

deprivation (DQ5) compared to the lowest (DQ1) is significant and mortality rates in the highest areas of deprivation are above the England average. See chart below.

Trends in Infant mortality in Buckinghamshire by deprivation, 2001/03 – 2010/12

Urgent care The urgent care element of the CYP programme has focused on developing pathways for specific diseases and the emergency admissions for these pathways are being monitored to review the impact of the schemes. Key points to note - There is no discernable reduction in admissions of young children to BHT with bronchitis and fever but otherwise expected growth has been contained. Admissions for these conditions show marked seasonal variation and showed a sharp increase in November as winter infections hit.

NB due to a change in the national SUS provider, January data is not yet available.

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Appendix 2a – Project milestones – Adult Joint Care Project Milestone Due date Commentary/

exception report Integration: Integrated Falls Service

This is now a service and no longer a project

Integrated Community Teams

Roll out of Project Centaur. Alignment of current services ahead of more radical re-commissioning as part of BCF implementation.

April Managed under the integration pathway and project is a sub set of the s256 funding ; start date to be announced soon and will be communicated to the localities

Single access point through ACHTs operational in all localities

June Centaur project - Single access point through ACHTs operational in all localities.

Ensure alignment with other urgent response services (older people's mental health, BUC)

September s 256/BCF agenda - transfer of care pathway project group launched and first meeting in September ; Wexham Park system pulled together into a Bucks wide single pathway to ensure standardised pathway for all bucks patients.

Second draft tier 3 service design to Urgent Care forums; cross links to primary care strategy

February complete

PQQ for single service March

PIRLS

Staff recruitment completed and team fully established – delayed to May April

Full complement of staff in post from June. Confirmation of office base required, team at present based in John Hampden.

Final agreement on monitoring progress of service. Resource to be working in A&E, EAU wards including HW and SM monthly monitoring

June

Berkshire liaison model agreed.

through main contract.

Audit of service

September Revised model implemented – providing PIRLS to all adult wards in SMH

Audit of service from patients, BHT staff, GPs.

December Feedback sought from service users and stakeholders about draft MH strategy

End of year report on service delivery and options

March

Dementia

Recruit Memory Friendly Communities Co-ordinator. Review Diagnostic Rates for 2013/14 and action improvement plan. Complete Memory Clinic Set up in 4 GP practices (MACH).

April

On Track

Initiate Workforce Training group to assess current provision and need across whole system. Review progress across care home projects and identify need for future planning.

May

On Track

Run Whole System Partnership Workshop to identify gaps in pathway and evaluate national good practice examples.

June

Met to discuss new diagnostic target process and agreement to look at overlap between dementia support workers and other services

Hospital Befriending Scheme at Stoke Mandeville Hospital commences

Memory Friendly Communities Strategy Group set up

Evaluate Age UK Memory Advice Service and Alzheimer's Primary Care Worker.

September Business case/options appraisal for Dementia services across Bucks considered by Dementia Board

Set up Memory Friendly Communities Strategy Group.

Community matron in post December Provide practices with advice and guidance on Dementia review and stats

January 2015

Review national CQuIn - agree continuation with BHT/HWWP

February 2015 Final stages of negotiation

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Dementia (continued)

Assess capacity in memory clinics for 15/16; metrics at practice level; Flagging mechanism for GPs identification of dementia carers agreed.

March 2015

Neuro Rehab Review

Work with Strategic clinical networks to agree baseline April Complete

Develop terms of reference for LTNC network group May Complete

Review against revised spec for fit as part of monthly reporting June complete

Contract review of service profile inc backdated data.

December Quarterly data being reviewed

Ensure 2015/16 contract with BHT reflects agreed data requirements

March Discussions underway with BHT

Community Equipment

Preferred contract provider announced for community equipment April Complete

Contract awarded to new community equipment provider May

Complete, new community equipment provider identified. Determine KPI for urgent response times at 98%Contract awarded to new provider. Section 75 sign off

Start date of new service for CEls October Step-up preparation for

phase 2 for 01/04/15 go-live

Continence Service and Wheelchair service

Notice given by CSU to BHT for phase 2 transfer of continence & wheelchair products 30/09

November need confirmation of funding to be extracted - potential financial risk. Escalated to contract negotiation issue

Ensure current commissioning gaps in CYP understood & addressed for 2015/16

January 2015

Specification update for Wheelchair service

February 2015

Ensure 2015/16 contract with BHT reflects agreed change in service

March 2015 On track

New service commences April 2015

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Appendix 2b – Outcome measures – Adult Joint Care Dementia Diagnosis: The chart below shows the number of dementia diagnoses across each locality within the CCG. Data has been extracted from the Emis Enterprise system. It is dependent on dementia diagnosis being recorded under certain ‘read codes’. Data for two practices not using Emis is provided periodically by those practices. Data validation has been underway from October. The 67% target is what the CCG is being assessed on through its assurance reviews with the Area Team. National monitoring of performance is also being undertaken, and the local CCG data reconciles back to the national view. Currently AVCCG is at approximately 58.2% of expected diagnoses based on mid-March 2015 EMIS data (57.7% based on end of February national data). To get to 67% requires an extra 218 diagnoses. Various initiatives are underway to ensure that patients with dementia diagnoses are appropriately coded; and where appropriate, timely dementia assessments are being conducted to provide diagnoses.

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Appendix 3a – Project milestones – Elective Care Project Milestone Due date Commentary/

exception report

Outpatient follow-ups

(completion of 13/14 project)

Define actions to be taken forward during Q1 and Q1 project plan

April Engagement with BHT clinician at RCSG Monthly reporting at the RCSG and escalation via contract for over performance

End project report

June CSU has identified a member of staff to work with BHT to develop a clear action plan ( follow on from the inter mountain project) and this team working closely with plan for greater clinical change across chosen specialities;

Project refreshed December Action-plan is now in

place for refreshed project

Digitalisation of outpatient consultations

Investigate and map current AT system use and processes: Initial investigation of available AT options in the market place and other Health Service providers

June

Presented Q1 findings of AT outpatient appointment project. Steer from RCSG is that project should focus on telephone clinics now and agree with recommendation to suspend CSU project mgt and replace with AT Project Officer

Working with Service Delivery Units, commence planning the implementation of any “quick win” initiatives including business process mapping where required

September

End project report Proposed reductions for 2015/16 in signed contracts

March 2015 On track – subject to contract negotiations

Dermatology Outline business case May Previous business case

Project Milestone Due date Commentary/ exception report is under review. CSU is sending information on replies to the PIN together with initial service specifications and original business case. CCG will decide next steps.

Gateway decision June

Full business case July

Gateway decision

August CCG agreed that business case to be updated and considered at November executive team meetings.

Project implementation September As above

Service spec

October Delay – business case to be considered at November CCG executive meeting

November Timetable reset-

Specification completed and shared with GPs

January 2015

Exec agreement of specification and procurement plan

February 2015 Procurement process started

Develop tendering suite March 2015

Radiology

Publish plan- demand and spend analysis. Establish metrics.

May MRI by practice information received.

Radiology governance group to meet to validate BHT and other provider data to assure future planning assumptions

June Governance group established and actions agreed and Contract challenge to BHT for coding errors requested via the CSU.

Care UK contract monitoring compliance with clinical guidelines and

June Data received split by provider in September;

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Project Milestone Due date Commentary/ exception report

any corrective action monitoring of MRI referrals will continue against this baseline for BHT to deliver predicted savings through governance at the RCSG; current trajectory showing a marginal improvement on demand but not savings that requires further evaluation.

Receive regular MRI reports January

Choose & book advice & guidance

Project documentation produced

May Awaiting a paper from CSU which will go to Executives and start date for project agreed.

PID approved June Business case complete

Procurement decision to execs

Preparation

July Creation of Guidelines 6- 10. Embed pathway/guideline referral letters. Establish Clinical Reference point for guideline approval

Commence pilot of advice and guidance in 4 Specialties (Urology, General Surgery (inc Breast) ENT Respiratory)

August All current clinical guidelines pulled together for review and current clinical contents sent to BHT clinicians for clinical reviews/sense check in September. Clinical lead reports milestones are ambitious and likely to be delayed.

Project Milestone Due date Commentary/ exception report

Pilot finishes: End project report January 2015 Pilot now underway but

start was delayed Consultant to Consultant Referrals

Agree Audit process with BHT May Scope and process agreed by BHT awaiting date.

BHT to complete C2C Audit June

Agree pathway changes July

End project report August Audit now completed and results being reviewed

No further action agreed January

Review and Re-commission Local Improvement Schemes

Initial milestone plan to be revisited by CSU who will progress this.

Wound Care services – review and re-commission LCS

Governing Bodies approve new LES for Wound Care April Right care approved in

April

New LES implemented May Signed off by Executive.

Agree process for specialist treatment June

MSK Service review

Workshop completed and project initiated to assess re-commissioning options

November

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Appendix 3b – Outcome measures – Elective care

The outcome indicators are measured at county level. The measures and Buckinghamshire’s position compared to the national average are:

• Excess weight in adults – Buckinghamshire at the national average

• Excess weight in children: measured at reception year and year 6 ie children aged 4-5 and 10-11 classified as overweight or obese – Buckinghamshire better than the national average and in the top quartile for both age groups.

• Percentage of physically active and inactive adults – Buckinghamshire better than the national average and towards the top quartile for active adults.

Key Indicators for QIPP Savings (Finance)

Outpatient Activity – Aylesbury Vale CCG : The two charts show the trend in first and follow-up outpatient attendances at BHT compared to plan. The blue line on the chart shows GP referral rates.

Key Points to note:

• First outpatient attendances have been above plan since April 2014, except for in August when there was a reduction due to with the holiday period. The increase was mostly in specialties associated with the waiting list backlog clearance and can be largely attributed to this. There is funding available to mitigate the financial impact of this.

• Follow-up appointments show a similar pattern: increasing March to July, a dip in August, then back to an increasing trend in September and October. Work continues to bring the project to reduce follow-ups back on track.

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Appendix 4a – Project milestones – Urgent Care Project Milestone Due date Commentary/ exception

report Care Homes

Practices sign up to care homes LES April Complete Review of Care Homes Initiatives commences

June On target

Care Homes Initiatives Review Report completed with recommendations to exec

October Outcome of workshop on strategic way forward being considered.

Go/no go for Care Home LES; Medicines standards to BCC; Pilot pharmacy risk management tool live

January On target

Stock-take of Care Homes/ patients and support

January complete

ACHT Reform Benchmarking performance across localities and nationally

April Crystal Oldman has now made contact with Jackie Allain to support this process

Implementation of iPads by locality (mobile working solution)

May The countywide roll out is scheduled to begin late July in the South CCCG locality and then moves northwards. The anticipated roll out for AVCCG is late September.

Audit and evaluation of demand and productivity of 2 OOH Teams model pilot completes

May Awaiting the audit report or summary from BHT

HR processes begin to implement new team structure

July New team structure – no further update at present.

ACHT Review

To be confirmed

tbc First meeting scheduled 11 September ACHT will be led by Lesley Perkins on behalf of the system with support from Karen West

Out of Hours service re-commissioning

Re-procurement process on track. tbc OOH Programme Board established and procurement timeline. Extension of current provision being finalised. Moving to engagement phase.

Out of Hours service (cont)

Outline specification completed; January complete

23

Appendix 4b – Outcome measures – Urgent care

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

2013/14 inc. CDU/SAU 1055 1244 1238 1450 1101 1036 1217 1175 1311 1022 1144 1305

2014/15 976 1048 873 952 1050 956 1174 1035 1097 1020

Aylesbury Vale BHT 2014/15 Plan 926 957 926 957 927 957 957 926 957 957

0200400600800

1000120014001600

No o

f Adm

issio

ns

Emergency Admissions to BHT from SLAM for Aylesbury Vale CCG Practices

NB due to a change in the national SUS provider, January SUS data is not yet available so some charts cannot be updated in time for this report

ACHT contacts per 1,000 population by locality

Caseload per 1,000 population by locality (Number of different patients seen per month)

24

Key points to note: The trends in activity from the SLAM report – Chart 3 in column one above, show that emergency admissions continue to be above plan but not as much as last year after CDU & SAU figures are added in. • From April 2014 at BHT all CDU & SAU activity is counted as emergency

admissions. The all admissions data for 2013/14 has been adjusted to take account of the change by adding CDU/SAU into actual activity. This shows that there was an increase in admissions from March to May but it is within the boundaries of normal variation. The QIPP schemes are planned to deliver a 17.5% reduction in short stay admissions for people over 75. However, year to date activity shows a similar pattern and volume as last year bearing in mind that in this case no adjustment has been made to 2013/14 figures because an age breakdown of CDU activity is not available.

• Admissions from care homes have been above last year for most months but were below last year for the month of December.

• ACHT contacts per 1,000 are stable across the CCG through the year to date,

and amount to approximately 100 per 1,000 per month. Aylesbury North is notably higher than Aylesbury South and Central.

• ACHT caseload per 1,000 population is similarly stable at around 30 for the

CCG as a whole. It is notable that though Aylesbury North is again a step above the other localities, it is by a smaller margin that the number of contacts per 1,000 population. This may indicate that proportionally Aylesbury North community patients receive more visits than other localities on average.

25

Appendix 5a – Project milestones – Medicines management, long term conditions, end of life LTC- Live well 1) 1st 100 patients

evaluation 2) Addition of physical trainer to pilot

April/ May

Addition of nutritional support to pilot June

Delayed until August; nutrition support to Live Well now to be provided from dietetic service rather than via existing physical trainer role.

Year 1 evaluation of pilot project commences July

Decision to commission roll out of Live well to all localities

September Decision delayed. Evaluation process and funding agreed.

LTC: Integrated Community Diabetes Service

AV CCG diabetes quality map April

Complete

1) AVCCG PLT diabetes event to engage members 2) Bucks wide diabetes stakeholder event

May

Complete

Bucks diabetes redesign project plan June

Development of plan on hold while resource allocation from CSU to support service redesign is agreed. Project scoping to commence in parallel with clinical lead appointment from July

Implementation of service redesign proposals commences

September

Agreement at June JET to appoint clinical lead for diabetes redesign, shared resources across Buckinghamshire; service implementation now expected from April 2015.

Launch event to agree workstreams, leads, vision, principles; define best patient experience.

January

completed

LTC: Extending Access to Advanced Care Plans

Local Guidance to support Unplanned Admissions DES to be published/ BCCR updated to reflect requirements of DES

May

Complete

Practices sign up to Unplanned Admissions DES June

ISAs signed by all urgent care network providers (hospices/OUH/MKG)

July

Business case for BCCR for DES agreed in principle pending operational framework replacing previous investment line for ACP.

BCCR viewable by all partners to Urgent Care Network

September

Exec approved BCCR payment. Communication via newsletter out to members. BCCR visible to E Berks OOH and A&E planned for October.

top 2% of most vulnerable patients to have personalised care plans PROJECT COMPLETE NOW BAU

September

BCCR report now up and running on a monthly basis (December) - data quality issues to be fed back to practices to ensure improvement

Re-commissioning Anti Coagulation Services

Finance checks on modelling April Complete

Service spec finalised May Complete

PID approved May Complete

Patient and public involvement planning May Planning underway but not

completed Patient and public involvement commences June Delay to July

Notice served on existing providers (6 Months) July complete

Prescribing forums July

AQP process published (invitation to apply) July Provider information day

confirmed for 17th July 26

MM JET approves AQP process followed and makes recommendation to Exec

November On track

Award contracts/ Agree mobilisation with providers December

Mobilisation commences February 2015 Mobilisation discussions continue – solutions to issues with reporting being negotiated.

Contracts let and service commences

March/April 2015

Medicines Management: Wound Care services

New ONPOS contract in place

July New provider identified – target date of September to have contract in place

Medicines Management Nutrition

Re-audit initial high prescribing practices initiate joint formulary review of supplements

April

Complete

Review meeting timetable to be identified. April Complete

Take audit recommendations to Forums.

May Complete

Meeting with procurement to agree retendering programme (SIP feed contract)

May

Meeting reconvened to late June

Training to Care home on MUST June

complete

Develop COPD and nutrition PIL Review BHT policy re monitoring gastrostomies and tube feeding guidelines

September

complete

Service specification agreed across multiple organisation; business case for care nutrition dietician to Exec

January 2015

complete

New gluten-free policy communicated to GPs; design taper down policy for 16/17

January 2015

GF policy decision made, comms materials to be complete March 2015

Cowsmilk protein allergy guidance approved complete

27

Appendix 5b – Outcome measures – Medicines management, long term conditions, end of life

The prevalence of diabetes in Aylesbury Vale, as measured by practices has shown a steady increase since March 2010.

Key Indicators for QIPP Savings (Finance)

The headline KPIs to be reported are to be agreed but include:

Reduction in EQ5D scores at aggregate level: This is directly standardised average health status (EQ-5DTM) score for individuals aged 18 and over reporting that they have a long-term condition, weighted for design and non-response. This data is collected twice a year from the GP patient survey: Baseline data is given in the table below compared to the national average.

Period Region Indicator

value

Average health status

for all respondents

Denominator Numerator

July 2012 to March 2013 National 0.74 0.82 458774 335769 July 2012 to March 2013

10Y: Vale of Aylesbury CCG 0.78 0.85 1581 1227

July 2011 to March 2012 National 0.74 0.83 471670 344338 July 2011 to March 2012

10Y: Vale of Aylesbury CCG 0.80 0.87 1510 1181

Percentage of patients dying in their preferred place of death: This data is not yet available due to Information Governance issues to do with access to data. These are being worked through with partners

28

1 | P a g e Aylesbury Vale CCG: Finance Report – APRIL

Agenda Item: X

GOVERNING BODY MEETING

APRIL 2015

FINANCE REPORT

Purpose of Paper

The attached report provides an update from the Chief Finance Officer on the financial position to the end of February 2015.

Executive Summary

To the end of February the CCG is reporting an in-year surplus of £93k against a budgeted spend of £193,722k (0.05%). This is in line with plan. The CCG is forecasting a surplus of £2,577k, as reported in previous months, represented by the historic surplus of £1,992k, in year surplus of £101k and the return of £484k due to the underspend on the CHC Legacy Risk Pool.

The report highlights: • The year-to-date (11 months) surplus is £93k with an in year forecast of £101k.

• Actual spend within Planned and Unscheduled Care is based on the availablemonth 10 Contract Reports and estimated for month 11. The adverse variance of£3,043k is mainly on OUH and BHT as a result of movements in reported spendfrom Trusts and include a release of £3,100k from Reserves.

• The favourable variance of £96k includes the CHC Risk share refund of £484kwhich when removed shows an adverse variance of £388k (£247k the previous month) in Joint and Continuing Care which mainly reflects current monthly activity within continuing care, which is now showing an increase in spend as anticipated.

• £96k has been released from the commissioning reserves in month to cover acuteoverspend on programme.

• Other services show a favourable variance of £1,500k due to slippages in projectsand the release of legacy accruals.

• Running costs favorable variance of £727k is a result of staff vacancies, slippageon non-pay and the CCG Quality Premium allocation, for which the spend isincluded in the programme spend.

At this stage the forecast position is on plan.

Main risks are highlighted in the report.

2 | P a g e Aylesbury Vale CCG: Finance Report – APRIL

Actions Required Note the financial position and small planned surplus for 2014/15

Review risks to the financial position

Objectives supported by this Paper (Please Tick) Improve people's health and reduce inequalities

Enhance quality, safety and experience of patient services Ensure local people have greater influence and management of own care Deliver financial sustainability with headroom to invest X Perform well as a CCG X

ROBERT MAJILTON – CHIEF FINANCE OFFICER

Appendices

A Finance Report,

Aylesbury Vale Clinical Commissioning Group

Financial Performance to February 2015 (Month 11 2014/ 15) Page 1 of 19

FINANCIAL PERFORMANCE TO February 2015

MONTH 11 2014/ 15

Section A1 - Finance Dashboard:

Indicator Target Actual Actual % Rating this

month % DFT Explanation of target measure

Financial Position in month Planned monthly surplus 175 √ 0.00% Achievement of Plan target

Financial Position year to date Planned YTD Surplus 2,403 √ 0.00% Achievement of Plan target

Financial position forecast outturn Planned Annual Surplus 2,577 √ 0.00% Achievement of Plan target

Running Costs forecast outturn Breakeven 793 √ 15.40% Significant movement due to Quality Premium funding

QIPP year to date (395) X (9.40%) Achievement of Plan target

QIPP forecast outturn (582) X (12.20%) Achievement of Plan target

Creditors - Better Payment Practice Code Target of 95% 88.00% ! (7.00%) Target number of Non NHS invoices paid in 30 days

Monthly Cash Drawings 1.75% bank balance 15.00% X (13.25%) Balance in bank at end of month compared to cash draw down

Key Note:

On Plan √ +ive £ = positive performance (underspend against budget),

Take Note ! -(ive) £ = negative performance (overspend against budget)

Action Required X (this convention applies to all but the specific QIPP tables)

Aylesbury Vale

Clinical Commissioning Group


Section A2 – Key Issues and Actions in Financial Position:

Actions for: Issue: Key Drivers: Financial Impact YTD:

Action: Owner: Timeline: Further Detail:

CSU

CCG/CSU Joint Actions

Increase in forecast overspend on Independent Sector Providers

Acute FOT TBC Review current levels of spend to establish how much relates to RTT initiatives

CSU Finance and HIIA

Ongoing

Resolution of outstanding issues on the BHT in year performance, to enable agreement of the likely forecast position for the year

Acute FOT N/A Assumption shared with the Trust and list of areas to be resolved

CSU and CCG Finance

Apr-15

CCG QIPPs Delivery and monitoring

CCG to work with QIPP lead CCG Ongoing

Aylesbury Vale



Section B – Contents

Performance Against Plan

This Month Last Month Page Number

Year to date £93k surplus Vs plan spend £191.8m £84k surplus Vs plan spend £173.7m 4

In month £8k surplus Vs plan spend £18.1m £6k surplus Vs plan spend £17m 4

Historic surplus £1.826m surplus Vs plan of £1.826m £1.660m surplus Vs plan of £1.660m 4

Forecast 14/15 £2.577m surplus includes c/fwd surplus of £1.992m from 13/14 £2.577m surplus includes c/fwd surplus of £1.992m from 13/14 7

Risks to forecast

QIPP

In month £357k achieved with the use of headroom reserves Vs plan £548k £470k achieved with the use of headroom reserves Vs plan £547k 5 - 6

Year to date £3.8m achieved with the use of headroom reserves Vs plan £4.2m £3.3m achieved with the use of headroom reserves Vs plan £3.7m 5 - 6

Forecast £4.2m (88%) achievement Vs plan £4.76m £4.2m (89%) achievement Vs plan £4.76m 5 - 6

Plan £4.76m £4.76m 5 - 6

Commissioning

Planned and unscheduled care £2.8m adverse variance Vs plan spend £99.3m £2.1m adverse variance Vs plan spend £90.8m 8

Ambulance £356k adverse variance Vs plan spend £6.2m £255k adverse variance Vs plan spend £5.1m 8

Prescribing £154k favourable variance Vs plan spend £22.8m £253k favourable variance Vs plan spend £20.7m 9

Joint & continuing care £96k favourable variance Vs plan spend £34.6m £237k favourable variance Vs plan spend £31.6m 10

Reserves £1m released year to date £1.2m released year to date

Running Costs

Running costs £727k favourable variance Vs plan spend £4.5m £352k favourable variance Vs plan spend £3.7m 12

Commissioning

Locality budgets

Changes to plan Transfer of Quality Premium Funding to Running costs Recurrent allocation of £65k Specialist Services funding 13

Contracting monitoring 14 - 17

Treasury management 18

Glossary Table of abbreviations Table of abbreviations 22

Aylesbury Vale



Section C – Financial Performance:

Key Points

The year-to-date (11 months) surplus for the year is £93k, plus c/fwd. surplus of £1,826k. The year to date surplus was increased last month by £484k reflecting the underspend on the CHC risk pool, resulting in a total surplus of £2,403k.

The YTD adverse variance on planned and unscheduled care of £3m is mainly related to BHT, OUH and Independent Providers based on reported activity.

QIPP –The reported YTD under-delivery is mainly arising from overspends reported against Contract Plans and expected slippage on delivery, which has been partly mitigated through use of the CCG headroom reserve.

The positive variance of £96k in Joint and Continuing Care includes the return of £484k legacy CHC Risk Share, which if adjusted back would result in an adverse variance of £388k.

The favourable variance for Other Services of £1.5m relates to slippage on projects and the release of legacy accruals not being utilised in 2014/15.

Running costs favourable variance of £727k is a result of staff vacancies and slippage on non-pay and the inclusion of the Quality premium funding of £245k within the Running Costs plan. However the associated spend is included within program costs.

Aylesbury Vale



Section D – QIPP Overview and Forecast Performance

Key Points

All QIPP will be reported through the QIPP & Performance report.

The table above shows the QIPP plan and delivery to February 2015.

In month: Actual reported was £357k against a plan of £547k (65% achievement).

YTD: Actual reported was £3,822k against a plan of £4,218k (91% achievement).

CCG reserves have been played in to mitigate YTD underachievement.

Aylesbury Vale



Aylesbury Vale



Section E – Forecasts, Risks and Mitigation

Key Points:

The first table shows the potential range of risks for the 12 months to March 2015. The current range, before c/fwd., is from a £936k surplus (the “best case”) to a £2.4m deficit (the “worst case”).

The most likely forecast surplus was increased in previous months to £2,577k, an additional £484k in excess of the planned surplus of £2,093k. The £484k relates to the return of the unspent element of the CHC Risk Share Pool.

Whilst we have reflected this there is a significant risk that the forecast does not fully take into account of the financial pressure as a result of the recent system escalation level and on-going pressures to maintain system flow for the remaining of the year.

Planned and Unscheduled Care forecast is net of £3.1m acute reserves. It also includes an assumption around reinvestment of RTT penalties where nationally these have been suspended during the RTT catch up programmes.

Major issues include:

o Additional pressures from increasing activity in the acute sector

o Increasing activity in Adult CHC

Aylesbury Vale



Section F - Commissioning

F1/ F2 –Planned and Unplanned Care Summary

Key Points

There is a £3m adverse variance on Planned and Unscheduled care against plan at the end of the 11 months to February 2015.

Planned and Unscheduled care – YTD adverse variance mainly relates to overspends at BHT, £2.5m, in the areas of Outpatient activity and Emergency admissions. OUH, £598k adverse variance, mainly due to PbR Devices, Maternity, Critical Care and Outpatients activity. Independent providers’ £1.4m adverse variance due to 18 weeks activity which is netted off in the YTD position by monies received from NHSE for RTT.

Non-contract Activity includes activity passed to Independent Providers as part of the RTT initiative.

Ambulance services, adverse variance of £356k, relating to Delayed Transfers at hospitals and increased activity in emergency call outs.

NHS 111 is over performing by £98k against plan resulting from additional activity.

Patient transport service is over performing by £33k as a result of increase in patient journeys over the last quarter.

Out of hours adverse variance is resulting from higher SLA charges.

Aylesbury Vale



F3 –Prescribing

Key Points

The 2 month delay in the provision of the Prescribing figures nationally means the CCG has only received M9 data.

The PPA has adjusted the phasing of expenditure in its forecast outturn to reflect the impact of Category M drugs.

This means that the PPA forecast is more meaningful, therefore the CCG has utilised this estimate within its forecast outturn figures.

The increased spend in October reflects this adjustment, alongside influenza claims and increased spend on dressings.

The current forecast from the PPA suggests a forecast outturn position of a favourable variance of £173K. A reduction on the prior month forecast.

Aylesbury Vale



F4 – Mental Health, Joint & Continuing Care

Key Points

Overall the Mental Health, Joint & Continuing Care budgets are £96K underspent.

Adult fully funded continuing care budget reflects the 2014/15 CHC Legacy Provisions underspend of £484K, so the underlying position for this budget is that CHC continues to overspend.

After adjusting for the £484k mentioned above the budgets are overspent by £388k.

Mental Health Contracts position now reflects the increased local costs of the Complex Needs service. This service was centrally funded previously.

The current overspend on fully funded CHC cases is offset somewhat by reduced expenditure on the historic joint funded cases and Children’s CHC, as the number of these individuals has reduced and by a reduced call on Funded Nursing Care.

The Continuing Care Team is showing an adverse variance due to increased usage of agency staff and the budget being lower than the funded establishment. Work is on-going to identify costs incurred by the CHC Team of Legacy cases, as these costs can be reclaimed from the Provision with NHS England.

Aylesbury Vale



Section G – Running Costs

Key Points

There is an overall £727k favourable variance against the running cost allocation due to staff vacancies and non-pay slippage.

The variance has increased this month due to the inclusion of Quality Premium funding of £245k, which is required by NHSE to be shown under the running costs section. However spend against this funding has been included under program costs.

The running cost allowance is set nationally at £25 per head of population. Against this allowance the CCG is running at £20.93 per head for the year to date.

Based on current levels of spend, the forecast underspend for the year remains at £548k plus the Quality premium funding, as above, of £245k resulting in a revised forecast of £793k.

Aylesbury Vale



Section H – Changes to Plan:

Key Points

The changes in the budget this month:

Non-Recurrent £245k Quality premium scheme funding has been moved to the Running Cost budgets in line with national guidance.

Aylesbury Vale



Section I –Contract Update, Month 11

Buckinghamshire Healthcare NHS Trust;

Key Points:

The position reported by the Trust to month 10 is an over spend against Plan of £2,559k, 3% over plan (which is line with last month). This position will be amended for outstanding challenges still to be resolved and the confirmation of estimated values e.g. Best Practice Tariff, CQUIN achievement.

There is continuing significant overspend against Outpatient Procedures £864k which is 44% over plan in line with pressures shown in previous months. The other areas of over performance fall within Follow up Outpatient attendances at 18% over plan, A&E at 6% and Non-Elective spells at 7%. Critical Care is still showing some significant month on month fluctuation and has increased to 18% over plan, up from 11% last month.

Unbundled Radiology has a pressure of £388k, which is currently risk shared with the Trust under the application of national rules. Risk sharing of this area was not mandated nationally in the 2015/16 draft rules. It is therefore unlikely that this risk-sharing arrangement will continue into 2015/16.

Aylesbury Vale



Oxfordshire University Healthcare;

Key Points:

The position reported by the Trust to month 10 is an over spend against Plan of £598k which equates to 7%. This represents a further small improvement over the last 2 month, due to a reduction in elective work in December and January.

The main areas of over-performance continue to fall within Maternity of 41%, ITU beds 12%, A&E attendances 20%, Outpatient procedures at 21% and Excluded Drugs and Devices at 16%.

Aylesbury Vale



Milton Keynes Healthcare Foundation Trust;

Key Points:

The position reported by the Trust to month 10 shows an over spend against Plan of £302k.

The over performance mainly relates to Maternity Pathway 70%, Outpatient procedures 58% and Elective Spells 26%.

The significant underspend is within Non-Elective Spells 4%, and ITU bed-days of 38%.

Aylesbury Vale



Section J – Treasury Management

Aylesbury CCG 11 Statement of Financial Position

Key Points:

The SOFP shows little movement overall from previous month.

Current trade receivables and other assets have reduced by £0.8m in February to £1.6m. This is due mainly to deduction in NHS receivables £0.3m and reduction in Non NHS receivables and accrued income of £0.5m.

Cash balance at 28th February stands at £1m, a reduction of £1.3m on previous month.

Total current liabilities have reduced by £2.2m to £15.8m. This is mainly due to adjustment to NHS accruals and deferred income of £2.4m relating to invoices accrued relating to the next accounting period.

Statement of Financial Position as at:As at

31 Mar 14

As at

31 Jan 15Movement

As at

28 Feb 15

28 February 2015 £'000 £'000 £'000 £'000

Non Current Assets - - - -

Total Non Current Assets - - - -

NHS Receivables - Revenue 2,426 1,069 (315) 754

NHS Prepayments and Accrued Income 499 495 - 495

Non-NHS Receivables - Revenue 23 68 - 68

Non-NHS Prepayments and Accrued Income - 784 (522) 262

Other Receivables 7 2 6 8

Total Trade and Other 2,955 2,418 (831) 1,587

Cash 165 2,291 (1,270) 1,021

Total Current Assets 3,120 4,709 (2,101) 2,608

NHS Payables - Revenue (3,084) (5,457) 243 (5,214)

NHS Accruals and Deferred Income (1,706) 2,350 2,359 4,709

Non-NHS payables - Revenue (126) (974) 140 (834)

Non-NHS Accruals and Deferred Income (8,017) (13,729) (489) (14,218)

Other Payables (407) (162) (16) (178)

Provisions (16) (53) - (53)

Total Current Liabilities (13,356) (18,025) 2,237 (15,788)

Total non Current Liabilities (184) (184) - (184)

Total Assets Employed (10,420) (13,500) 136 (13,364)

General Fund (10,420) (13,500) 136 (13,364)

Total Taxpayers Equity (10,420) (13,500) 136 (13,364)

Aylesbury Vale



12 Receivables

Key Points:

Debtors at 28th February stand at £0.7m an increase of £0.2m on previous month.

There is a £0.7m of debt over 90 days, £0.4m of which relates to NHS England which was originally paid in error.

Of the remaining debt over 90 days, £3k relates to Non NHS.

13 Cash

Key Points:

The CCG processed a cash draw down of £16m in February, £170.9m in total for the year including CHC risk pool contribution of £0.3m.

The cash balance at 28th February is £1m which represents 6% of cash drawn in month plus opening balance at start of month.

This compares to 15% previous month and 5% target which is considered good practice.

The balance left for drawdown in March is £18.9m which is above the average drawdown in the year of £15.5m.

14 Payables

Note Creditors’ balances have been adjusted for invoices relating to future months.

Key Points:

Creditors (unpaid invoices on the system) stand at £13.6m at 28th February, £10.7m of which are not yet due for payment.

Value

(£000) No

Value

(£000) No

Value

(£000) No

Less than 31 days (not due) 61 3 - - 61 3

Between 0 - 30 days - - 66 1 66 1

Between 31 - 60 days - - - - - -

Between 61 - 90 days (44) 1 - - (44) 1

Greater than 90 days 655 11 3 3 658 14

Total 672 15 69 4 741 19

Total

Aged Debtors

NHS Debtors Non NHS Debtors

£'000 £'000 £'000 £'000 £'000

170,946 17,429 188,375 207,324 91%

Prescribing

Cash Charge

To Date

Total Cash

Drawings

To Date

Current

Allocation

Drawings to

Date as a %

of

Allocation

Main Cash

Drawdown To Date

Not Due Overdue Overdue Overdue Overdue Total

1-30 days 31-60 61-90 90+ days£'000 £'000 £'000 £'000 £'000 £'000

At 31 Dec 10,964 644 285 591 1,222 13,706

At 31 Jan 10,811 1,104 769 86 1,813 14,583

At 28 Feb 10,706 1,148 205 113 1,441 13,613

Aged Creditors - volume Nos Nos Nos Nos Nos

At 31 Dec 171 106 59 34 127 497

At 31 Jan 183 121 66 44 149 563

At 28 Feb 246 75 73 49 154 597

Aged Creditors - value

Aylesbury Vale



The total number of invoices outstanding has increased slightly from 563 in January to 597 in February, 246 of which are not yet due for payment.

BPPC

* 95% or more Green - 75% to 95% Amber - Less than 75% Red The above table gives the percentage of invoices paid within a 30 day period for year to date month 11. The Better Payment Practice Code requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is the later. Key Points:

NHS invoices paid continue to maintain at a level of 100% in value and 92% in terms of number of invoices.

Non NHS invoices have remained at similar level to previous month at 93% and Non NHS numbers at 89%.

Overall the BPPC performance on invoices for the year is 100% in value terms, and 90% in terms of number of invoices.

The graph below shows BPPC performance over the last twelve months:

Overall the payment performance has remained at a fairly consistent level on or above 85% over the last twelve months with the exception of a dip in Non NHS invoice numbers in October 14.

Value of

invoice

(YTD)

£'000

Number

(YTD)

Value of

invoices

(YTD)

£'000

Number

(YTD)

Value of

invoice

(YTD)

£'000

Number

(YTD)

Total invoices paid 141,392 2034 14,377 1595 155,769 3629

Total invoices paid within 30 days 141,849 1863 13,428 1407 155,277 3270

% Paid within 30 days 100% 92% 93% 88% 100% 90%

TotalNHS Invoices Non NHS Invoices

Better Payment Practice Code - payment

within 30 days (cumulative YTD)

65

75

85

95

105

115

125

% BPPC Performance 12 months to 28 February 2015

NHS Invoices - Value NHS Invoices - Number Non NHS Invoices - Value

Non NHS Invoices - number Target

Aylesbury Vale



Abbreviations and acronyms used:

2014/15 Financial Year from 1 April 2014 – 31 March 2015 NHSE NHS England

A&E Accident and Emergency PBR Payment By Results – payment system (based on Healthcare Resource Groups) used mainly in acute contracts

AT Area Team POD Point of Delivery – area of acute care activity of similar type (e.g. Inpatient or Outpatient)

BPPC Better Payment Practice Code- target (currently 95% of invoices to be paid within 30 days of receipt of invoice or goods/service.

QIPP Quality, Innovation, Prevention and Productivity – plans and associated savings / changes in financial costs

Break-even Position where actual costs are same as planned i.e. not in deficit or surplus

Reserves Monies set aside for a specific purpose eg Contingency reserves for unforeseen spend in year.

Budget A sum of money allocated for a specific purpose RTT Referral to Treatment is the definition by which patients waiting to be treated are measured

CCG Clinical Commissioning Group Revenue Resource Limit (RRL) Total funding allocated for the year set by the Department of Health

CHC Continuing Health Care RBH Royal Berkshire Hospital

CQUIN Commissioning Quality & Innovation SCAS South Central Ambulance Service

Deficit Financial variance where overall net costs are more than planned

SLAM Service Level Agreement Monitoring – i.e. contract monitoring information

Excess Bed Days

Term used in acute contracts to describe days chargeable under PBR in excess of the standard tariff (for example a tariff might set 5 days as standard stay and days above this are charged to the CCG)

Surplus Financial variance where overall net costs are less than planned

FPH Frimley Park Hospitals NHS Foundation Trust. Variance (Adverse) Difference against plan (overspend)

FOT Forecast Outturn Variance (Favourable) Difference against plan (underspend)

HWPH Heatherwood & Wexham Park Hospitals NHS Foundation Trust

YTD Year-to-date (from 1 April to the end of the reported month)

k Thousand

m Million

Executive Team Meeting Minutes Thursday 26th February 2015 - 1.00pm- 5.00pm

AVCCG Boardroom, The Gateway, Gatehouse Road, Aylesbury, Bucks

Executive Team Present: Dr. Rodger Dickson, North Locality Lead (RD) – Chair Dr. Christine Campling, Elective Care (CC) Dr. Stuart Logan, Long Term Conditions (SL) Dr Juliet Sutton, Early Years (JS) Colin Thompson, Director of Operations and Performance (CTh) Lesley Munroe-Faure, Practice Manager (LMF) Dr.Malcolm Jones, South Locality Lead (MJ) Alison Foster- Director of Quality (AF) Alan Cadman, Deputy Chief Financial Officer (AC) Dr. Karen West, Joint Commissioning and Partnership (KW) Robert Majilton, Chief Finance Officer (RM) Dr. Kevin Suddes, Unplanned Care Lead (KS) Dr. Graham Jackson, Clinical Leader (GJ) Louise Patten, Chief Officer (LP) arrived at 3.30pm

Other Attendees: Vicki Parker- minute taker (VP) Chiltern Exec Team (from 3.10pm) Lesley Perkins (LPk)(from 3.10pm)

Apologies: Trevor Boyd (TB) Dr.Charles Todd, Central Locality Lead (CT)

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Item No.

Agenda Item Lead

1 Welcome & Apologies RD

The Chair welcomed members of the Executive Committee Apologies were noted from: Dr Charles Todd, Trevor Boyd and a late attendance from Lou Patten (arriving at 3.30pm)

2 Declarations of Interest RD

No additional declarations were declared

3 Minutes of the meeting held 29th January 2015 and Action Points RD

For approval: LMF would like clarification on the Locality Clinical Lead contract end dates as she believes these are different to the previously advised dates. Agenda Item 11, second paragraph, should state the risk share is for the CHC not CSU. GJ - Exec Team member’s outlook calendars are still not showing the split between CCG time and practice time. Please can these be updated to show your schedules. Please see VP for assistance with this. Minutes of January 2015 approved. Action points update: 271114-3.1 LMF raised the issue of the cancer 2 week wait at the last PM Forum (around handing out the leaflet and explaining the importance of attending the appointment).Most of the GPs round the table have a verbal conversation with the patient instead of/or as well as handing out the leaflet. 290115.3 LP to bring a paper on succession planning to the February Exec Meeting – This will come as part of our OD session in April

Action Point

LP to confirm the exact contract

end dates for the locality leads

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290115.4 LP to write a proposal on clarify the contractual positions for GP Clinical leads on fixed term contracts This is being undertaken and will go to the GB for sign off as there is a conflict of interest 290115.15 SL to take the paediatric EOL care proposal to the LTC JET and confirm Chiltern CCG’s funding proposal. This is going to the JET on Tuesday 3rd March 2015

4 Quality Paper AF AF apologised for the delay in sending out the paper. This was due to the deadlines for the C4Q.

AF highlighted the following points: Bucks Healthcare Trust: The CEO and HR Director will be leaving in April 2015. There are concerns over the stability of leadership and discussions are being held with Caroline Morris to address this. BHT Clinical Strategy: AF has fed back our comments to David Williams. Our comments agreed with those from the Chiltern CCG Exec. Draft CQUINS: These have been circulated to some team members but more work is needed before they can be signed off. The national CQUINS have not been received. CQRM meetings (commissioning for quality contract meeting): It has been a struggle to get the meeting dates in the diary but will be realigned from April 2015 on a monthly basis. Exec members will be asked to volunteer for trust visits in the next 2 – 3 weeks. The team has created a central issues log to keep track of quality issues combined with the feedback from the MAD button. This log will be reviewed on a weekly basis with the Deputy Director of Nursing. Southern Health-have had their CQC report published. There are areas of improvement which are being worked on but in general 70% was “good”. This report did appear in a negative light in the media.

2015 02 18 Southern Health CQC

FEB C4Q FINAL papers.pdf

C4Q report is moving bi-monthly and may eventually be produced on a quarterly basis.

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5 Corporate Performance Report and Dashboard CTH

CTh highlighted the following points: The RTT position is holding to NHS contribution requirements and we are currently in a strong position to have our actual spend on supporting the waiting list position fully assured by NHS England. The mobile scanner at SMH has cleared over 300 patients. This has been well received and the Trust would like to keep on for another 6 weeks but the question is, who will pay? We need to look at why the backlog got to this level. The over 75 schemes are coming together and it was noted that these schemes have the potential to make a huge difference. CTh will be organising a sharing session to bring all the schemes together and a report will go to the Exec. Carers Text- Whitehill Surgery How the service works is that the GP surgery would send a text message to all of the patients, over the age or 18, they had mobile phone numbers for, asking them if they supported anyone with a physical or mental illness or that was elderly and frail. If they did and they would like to access free support services, the recipient would respond “yes” to the message and the surgery would then pass their name and contact details on to Carers Bucks. Once Carers Bucks had received the carer information contact was made and a concise assessment of their situation and needs was made. They were then registered with Carers Bucks and information on support and services was sent to the carer along with any additional information required due to a highlighted need. Carers Bucks also, if needed, made referrals to other agencies or sign posted the Carer to agencies that could provide an appropriate service for their needs. The level of support required varied from registration and information on services, to intense and continued support. There are some amazing success stories coming to light thanks to this project. CTh to check the Carers Bucks capacity in terms of rolling out to other practices. MJOG- discussions took place over the funding of the MJOG system. LMF advised the free texts via NHS mail is being pulled from September and there is no alternatives in place. GJ asked if the CCG has looked at the funding stream for MJOG? The practices do gain financial benefits from this system and we need to manage this so we do not loose membership engagement. CTh will update and recirculate the paper on the MJOG service Dementia rates- there will be an adjustment in the % rates as they were originally set over 10 – 15 years ago. Once adjusted our diagnosis rates will be 61% and discussions are needed to understand that appropriate coding and collection of data is happening. AVCCG is currently sitting at 56.9%

Action Point

CTh to check the Carers Bucks

capacity in terms of rolling out to other

practices.

Action Point CTh to circulate the

MJOG paper

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6 QIPP CTH

CTh highlighted the following points: We are heading towards £2m of achievement against target of £3.5m. The challenge is the crossover into next year. The main contract moved by nearly £2.1m on tariff and the gap changes on a daily basis. The draft QIPP paper will go to the March Governing Body and Executive Team Meeting. CTh reflected on the current year. Some of the large Right Care projects have started to come through. It was a challenging winter for urgent care while medicine management continues to perform well. CTh and RM are trying to maintain a PBR approval to the main contract. Follow ups currently stand at £12.5m across Buckinghamshire. The diagnostic rates vary between practices including the usage of the diagnostic tool kit. GJ wonders if practices really understand about the diagnostic rates? Should we share practice diagnostic data? It was agreed this would be useful at practice level, not by individual clinician. BHT Contract: Next year there are still approx 5 ongoing issues. The tariff changes have slowed negotiations down. There is a gap of around £6m across both CCG’s which is closable. There will be a need for some difficult decisions.

7 Chief Finance Officers Report RM

RM went through the Financial plan 15/16 The plan is still proceeding under NHS England guidance and we continue to plan on this basis. RM requested support on the following:

1. Continue to plan on basis of committing headroom for CHC legacy risk 2. Continue with currently planned QIPP recognising it is lower than expected by NHS England.

Agreed by the Executive Team QIPP QIPP schemes have been identified through the planning process and the summary below is broadly based on the summary e-mailed round to Clinical Executive leads and the operational team on the 11 February. The

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process this year has included assessment of Best case, most likely and worst case. QIPP remains a triangulation of identified schemes with the need to balance financial risks and growth. At the January executive the QIPP target was agreed at £2.5m with a stretch target of £3.5m to cover risk. The best case of the current version of QIPP is £3.4m and contract envelopes have been based on the delivery of the best case scenario, with identified mitigation in the financial plan to cover the difference between £2.5m and £3.5m In Risks & Contracts Some risks have been highlighted in the report and further work on mitigation will continue through contract negotiation as some of the unspecified areas are firmed up however current significant risks to the plan include:

• QIPP - £0.4m of identified risk rising to £1.2m based on worst case • Contracts – potentially between £1.5m - £2.5m • SCAS- there is a significant gap in the contract of £700k which is a significant risk which is not covered in

the plan. • BHT- Mitigated risks last year were £6m. There is only £2m next year plus the contingency.

The Executive team thanked RM for providing a clear and well written paper. A financial breakdown of portfolios is detailed in the embedded documents found throughout the paper.

8 Live Well Business Case SL

SL spoke about the LW business case. At the November executive meeting a paper detailing the findings of the Live Well pilot in the south locality was presented. That paper outlined the significant clinical benefits of the service to patients in managing their long term conditions (LTCs) but the data on its ability to create savings within the system was inconclusive. The Executive concluded that where patients received good clinical care savings often followed and would discuss the further adoption of the service subject to a robust business case. It is proposed to expand the service into the Central Locality from 1st April 2015 with adjustments to the core model (social services being more involved and better engagement with BME populations) The North Locality will be committed to the MCP work but it was suggested to seek the views of the locality membership, especially on the physiological support. Feedback from the Exec members:

• CC feels this is the right way to go for the patient, The results for reducing depression are impressive.

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LTC is the future and we need to support people with these conditions.

• This will link in with care planning, co-commissioning and MCP. An excellent opportunity to see them work together.

• GJ feels the paper does not demonstrate savings and lacks substantial evidence, is it right to commit this amount of funding when funding may be needed in other areas

• KW feels uncomfortable with this amount of money in parity of esteem. Agreed by AF. CTh feels there are arguments on both sides in relation to the parity of esteem investment.

Conclusions of the discussions If the project is rolled out it will have to be funded through the Mental Health spend (parity of esteem uplift). KW wants to review the services we need to provide for within the budget before committing a third of the funds on Live Well. The Executive Team understand the strategic aim and support the concept of Live Well. It is recognised the outcome data is not substantial, however the commitments on other projects are increasing with a decreasing budget. The Executive team have raised concerns about the full commitment of the business case and agree to carry on as a model pilot in the South Locality and will prioritise the roll out in the Central Locality in the overall parity esteem plans. Updated paper attached

Live Well Business Case Jan 15 FINAL 2.

9 MCP CTH

Removed from the agenda due to time constraints

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10 Medicine Management Investment Opportunities SL/JB

At the meeting of 29/1/15 the Exec was requested to approve recurrent funding for a Care Home Pharmacist, Care Home Technician and an assistant for the Dietitian to work in Care Homes. The request was not approved but an action for further discussion and identification of funding source was identified.

The budget for the Care Home LES is currently under spending by £50k and this could be transferred to fund the requested posts on a non-recurrent basis from the underspend (This would be a stop gap measure for the forthcoming financial year). The posts will deliver savings in year and become self-funding though not totally from the prescribing budget. Savings will also be generated in urgent care and GP practice patient contact.

Following discussion of whether Care Homes should sit under the LTC JET, it should be noted that there is a joint Care Home Support Strategy developed by the UCJET with a proposal for all work to link to a Care Home Steering Group. The Medicines Management Team already have a presence on the Steering Group and the current Care Home Pharmacist works closely with the Quality in Care Home team ensuring integrated working.

A discussion started on care home payments and Dr Graham Jackson and Dr Karen West (Governing Body Members) left the room as there was a conflict of interests. The following practices have received care home payments in this financial year: Haddenham, Mandeville, Poplar Grove, Cross Keys, Westongrove, Norden house and Whitehill. MJ is concerned practices are claiming payments and not fulfilling their commitment. RM has heard the concern and will take action. Agreement was given for CTh to look at the expenditure of the LES to confirm if the commitment is available for both positions from the underspend and CTh will confirm back to Jane Butterworth on Friday 27th February 2015.

Action Point CTh to look at the expenditure of the LES and confirm if funds can be

transferred

11 AOB

Date of next meeting: Thursday 26th March 2015 1pm – 4pm. Aylesbury Vale CCG Boardroom

12 Review of collaborative working AG/LP

The chair welcomed Chiltern CCG to the meeting and introductions were given. AG (Dr Annet Gamell) advised it has been a year since the last joint Executive and it is great to get everyone together to talk about joint working. Discussions have started on planning and transformation and there is a need to look at a Bucks wide model to be more efficient and avoid duplications.

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The CSU provides a service to the CCG’s on projects and programmes, managed through the JETS. We need to look at what we want if we pull this support and look for dedicated project management, possibly from alternative providers. How will the Localities fit into this? What is the matrix that binds the localities to the portfolios of the JETS? Localities will need to work together and swap ideas (a forum?). We need to aim for standardise project management so projects work and report in similar ways. This will be a massive support for clinical leads and would be extremely helpful in releasing more time to deliver projects. The reporting approach will be consistent and over laps will be easily identified. The system will need realigning in terms of bringing localities together to challenge ideas. A project manager would be putting the same pressures on the CSU but one person would be holding the “lead” and coordinating to avoid wastage and duplications of the resources. The programme office would be jointly owned and project management could be bought in. If we agree to these principles we need to bring in project management to organise and align the resources we have. Summary of discussions More thinking is needed in terms of the locality structure support (not as a JET) and we should now proceed to give notice for planning and transformation. We have the experience to specify the project support we now need and the JETS will be involved in the planning. We are on “middle ground” in terms of Quality. Chiltern CCG is at the give notice stage but Aylesbury Vale CCG isn’t. We need to come to a conclusion. What is the model for Bucks? One proposal is to look for a hosting arrangement for Quality. Chiltern CCG are proposing to host Quality on AVCCG’s behalf. LP wants this piece of work to be scoped and costed appropriately. Time is of the essence as staff recruited will be underway and may have to go through the TUPE process. AV will have to give 6 months-notice and need to protect our assurance on quality. GJ asked for clarity on this timeframe for Quality. The Execs need to report back to the Governing Body. It was agreed to bring this to the March 2015 Execs.

AF to action

13 Better Care fund S75 Update LPK Lesley Perkins provided an update on the S75 proposals.

The BCF plans were approved in Nov 2014 and a commissioning strategy has been developed which builds on the business case and describes the next steps.

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Implementation. The two key elements are the rapid response and the integrated teams and priority has been given on the rapid response. Work is being done to have a single point of referral up and running from April 2015. The work on the integrated team involves partnership joined up working and cannot be done in isolation. LPK asked both CCG Executive Teams to give agreement on the principles outlined in S75. Once signed off by the CCG’s the paper will be signed off by a BCC cabinet member and taken to the HWWB for review. The paper will then go the Governing Body for sign-off. LP needs to feel confident the Execs are aware of the risks. How will we manage the overspend risk? Over spends will be highlighted as they appear and discussed jointly in the partnership boards so joint solutions can be found. RM feels this does not manage risks in the same way as AVCCG would manage. Agreement was given to the principles outlined in S75 by both Execs

14 MSK Papers CC Jacci Shaw- AVCCG Locality Business Manager, Allison Jones- Principal - Planning and Transformation

NHS Central Southern Commissioning Support Unit, and Richard Dodds from STO Healthcare were welcomed to the meeting. The Papers presented to Exec members outlined the options and a recommended approach for the decision relating to the preferred route for the commissioning of an integrated MSK service across the Aylesbury Vale CCG and Chiltern CCG. The papers follow on from the discussions by the two Executive Boards in November and December 2014 Recommendation - The Hybrid solution Recognising that there are benefits to either solution as well as challenges to both CCGs, the MSK project team has identified that a combination of the structured collaboration approach coupled with the commissioning competition is likely to address the major concerns and misgivings one a single approach. This approach is set out in the recommendation below. To deliver the Hybrid solution (structured collaboration with the possibility of a commissioning competition) it is recommended that a facilitated workshop programme is initiated to provide the necessary assurance to both CCGs that the collaborative provider organisations group were positively progressing along the journey towards a fully collaborative integrated MSK model. This CCG assurance is envisaged in the form of a ‘go/no-go decision gateway. This structured collaboration process is intended to be a time banded period of negotiation, which if it fails or the CCGs were not assured at the ‘decision gateways’ that sufficient progress was being made, then a formal advertised competition would be implemented with the structured collaboration being set down. Support for the above recommendation was agreed by the joint Execs however this is NOT a commitment to the costs in the MSK paper Meeting closed 1645 with thanks to all the attendees

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Action Log – Executive Team Open action Points from previous meetings:

URN Date of meeting

Agenda Item No.

Action: Assigned to

Date opened

271114-4.1

27/11/14 4 AF to provide an update on the MK stroke pathway in March 2015

AF Open 27/11/14 CLOSED 26/03/2015

290115.3

29/01/15

3

LP to bring a paper on succession planning to the February Exec Meeting Update- this will come as part of our OD session in April

LP

OPEN 29/01/15 UPDATED 26/2/15

290115.4

29/01/15

4

LP to write a proposal on clarify the contractual positions for GP Clinical leads on fixed term contracts Update- this is being undertaken and will go to the GB for sign off as there is a conflict of interest

LP

OPEN 29/01/15 UPDATED 26/2/15

290115.13 29/01/15 13 LP will take the concerns raised over the OOH’s contract extension back to the UCJET and ensure a regular progress report from the JET comes to the Executive

LP OPEN 29/01/15

290115.15 29/01/15 15 SL to take the paediatric EOL care proposal to the LTC JET and confirm Chiltern CCG’s funding proposal Update- This is going to the JET on Tuesday 4th March 2015

SL OPEN 29/01/15 UPDATED 26/2/15 CLOSED 26/03/2015

Meeting Date: 26th February 2015 New action points

URN Date of meeting

Agenda Item No.

Action: Assigned to

Date opened

260215.5 26/02/15 5 CTh to circulate an updated MJOG paper to the Exec Team Members

CTh OPEN 26/02/15 CLOSED 26/03/2015

260215.5.1

26/02/15 5 CTh to check the Carers Bucks capacity in terms of rolling out the text alerts to other practices.

CTh OPEN 26/02/15

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CLOSED

26/03/2015 260215.10 26/02/15 10 CTh to look at the expenditure of the LES and confirm if funds can be transferred

Into the Medicine Management care home dietician/nutritionist posts on a one off from the underspend

CTH OPEN 26/02/15 CLOSED 26/03/2015

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Audit Committee Meeting Minutes Wednesday 28 January, 14:00-16:00

Copse Meeting Room, The Gateway, Gatehouse Road, Aylesbury, Bucks

1 Welcome & Apologies

The Chair welcomed members of the Audit Committee.

Apologies from Robert Majilton.

2 Declaration of Interest

Tony Dixon (TD), lay member for audit, Chiltern CCG (this is a standing declaration at every audit meeting and will be recorded as such).

Committee Members Abbrev Designation Present Apologies David Lunn DL Lay Member (Chair) Tony Dixon TD Lay Member, Audit Anita West AWe Practice Manager Representative Others Alan Witty AW Ernst & Young, External Auditor Kayli Shaw KS Personal Assistance (Minute taker) AVCCG Katie Laverick KL Ernst & Young, Associate Alan Cadman AC Deputy Chief Finance Officer, AVCCG Gareth Robins GR Tiaa, Counter Fraud Manager Tim Merritt TM Baker Tilly, Internal Auditor Jeanette Oakley JO Financial Reporting Accountant, CSCSU Robert Majilton RM Chief Finance Officer, AVCCG

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3

Minutes of the meeting held on 26 November 2014 The committee approved the minutes with no amendments.

4

Review Governing Body Assurance Framework & Risk Registers AC spoke through the document explaining that the risks have remained the same or gone down slightly. AC informed the Audit Committee that risks 2, 9 and 13 have reduced. They are based around the information flows including the locality budgets. There has been progress of over 75s fund which is now being used to offset acute pressures. Risk 14 has improved on performance and is slowly coming down, reducing the risk. The Red risk around Qipp and cost pressures remains high. The review of the risk is suggesting that the Qipp isn’t delivering. Qipps need to be looked at to ensure they are as realistic as they can be at the beginning of the year. The Audit Committee stated the importance of ensuring the risks are scored at a corporate level and not in a silo.

5 Receive other sources of assurance Alan spoke through the document and explained that there were 5 areas that have been mentioned; Constitutional changes, Quarter 2 assurance, Central Southern Commissioning Support Unit (CSCSU), Financial Plan and Outlook & Commissioning for Quality Committee Constitutional changes – There have been changes within the CCG’s Constitution in regards to co-commissioning. AVCCG have now revised their legislative powers so that AVCCG & CCCG can form a joint committee Q2 Assurance – AVCCG now fully assured across all domains. (Only assured CCG in the Thames Valley area.) CSCSU – South Central & South West have merged to cover the whole of South England. The CSCSU have now confirmed that they are part of the leader provider framework. Jeanette advised that the exec team has just received the Service Line Auditors report and they will be communicating the findings in due course. Financial Plan and Outlook– AC gave a verbal update. In December 2014 further allocations were given to CCGs, but we are still receiving the lowest allocations. Alan explained that whilst we do get additional funding the outlook it still not good. Commissioning for Quality Committee – to note the areas on the agenda.

6 Agree final accounts timetable and plans

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JO spoke through the timetable and noted that there are 3 papers they produce; key deadlines, Auditors Accounts & Final Accounts. It was explained that the notes to the Accounting Policies are genetic but they will be tailored to AVCCG once they know what our capital notes are and any key judgements that are made. It was noted that there will be named leads for each note. JO mentioned that she will be meeting with the CCG to go through where they are on the final accounts and get things cleared up before we hit march. TD wanted to ensure that we are assured due to the changes in the CSCSU. JO assured the Audit Committee that there are named individuals for each CCG and Jeanette will be working to fire flight in any CCG. Deadlines: 23rd April noon – Auditors Accounts 21st may – Final Accounts

7 Review of losses and special payments NONE

8 Finance Report AC spoke through the financial report, pulling out the key information. The CCG has increased its forecast, now forecasting a surplus of 2577K, from the 2093K. The increase of 484K relates to a return of the legacy risk share. Which NHS England have declared as not being utilised and that money we cannot touch in year, and have to carry forward to next year and then have to have a Business Case to release the funds. The CCG is still on course to return the original planned surplus of 2093K. Month 9 report – surplus of 79k, on plan and as expected. DL wanted to know where BHT is currently. Lou responded informing the Audit Committee that we entered this year with a fully PBR compliant contract. The CCG tried to get a block contract but couldn’t so we have to pay for the activity that is being done. We have challenged them on what they are doing, correct coding etc. We need to be clear on what they are doing and what they are supposed to be doing. Lou mentioned that there are bigger opportunities this year and that Simon Stevens has money to invest in providers getting together and thinking differently about reducing hospital activity.

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9 Financial Plan Update

AC spoke through the Financial Plan, updating the Audit Committe. The CCG put a plan together back in November which showed a 12M gap between expectations and what funding resources were available. In December we had an announcement of the addition monies coming through and the effect of that was the CCG obtained another 4.7M, with another 1M which has imbedded into our baseline to do with winter pressures as well. We have generated a 5% uplift in growth terms. AC ran though the planning, explaining there are certain business rules that have to be adopted. It was noted that there is a QIPP gap of 2.5M to get to a balanced position and that the running costs have been reduced by 10%, losing approx. 480K on the running costs budget. AC explained that there has now been a business case put into NHS England for the CHC drawdown, which the CCG hopes will release some funds.

10 Update of internal action log AC explained to the Audit Committee that the log was to show what risks we have had and what has been done. Used as an auditable trail. TM commented that the log was showing positive messages and when issues are arising the CCG is progressing from them.

11 Service Line Report – CSCSU Update from CSCSU SLA report has just been reviewed.

12 Review internal audit progress reports Progress is good/strong. There is one area where there is an issue with the governance effectiveness report, but that is still on going. TM informed the Audit Committee that they are seeing a lot of CCG’s base their information governance (IG) solely on the delivery of the IG Tool Kit. As a CCG we need to ensure we are clear on what the actual risk is to us and how we are managing our risks around IG.

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TM drew the AC’s attention to page 3 where he has given a very early heads up to the opinion. DoH give 4 options of opinion but Audit change that to just positive or negative. Currently positive, with 2 amber/red reports having been issued. TM explained that issues have to be raised but if they have been dealt with using the recommendations given, then they can be balanced off.

13 Internal Audit Reports There were 3 reports presented to the Audit Committee by TM. 2 with Green opinion – Contract Management and Key Financial Controls. 1 with Amber/Red – Adult Continuing Healthcare. 2 issues were raised; one was around making sure we are up to date with our assessments and the other was around the checks that have been done around the care homes that are being utilised. This was based on their financial sustainability and also the quality of care (evidence was not available for a number of cases). As a CCG we need to be able to show that there are controls in place.

14 CCG Sector Update from External Audit AW informed the Audit Committee of the key messages. Page 3 was based around the Kings Fund and what they are saying about the financial position and the over spend in 2014/15. AW confirmed that we are not in that position but it is good to be aware of what is happening elsewhere.

15 Review External Audit progress reports AW spoke through the progress report, touching on key points. AW picked up on ensuring there are people available throughout the audit process. It was noted that the Business Continuity Plan has been put in place, along with the adverse weather plan.

16 Review and approve annual counter fraud plans GR bought the draft work plan for 15/16 to the Audit Committee to be noted. GR explained to the Audit Committee that NHS protect set the landscape for what Counter Fraud should look like within the NHS, although they have yet to review their standards for commissioners. GR informed the Audit Committee that the resource is there for CCGs, should they need it/require it. LP said that she is very happy with the plan but would like to gain some knowledge on employment of GPs. As it has been picked up on, through experience of colleagues in other CCGs, as a higher risk area due to the lack of experience. LP explained that it would be helpful to view some case studies on employment of GPs (be careful of…). GR responded to inform the Audit Committee that information will be shared as it comes though.

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ACTION: Tim to talk to/share information with LP regarding some fraud issues that he is aware of. Plans Approved.

17 Review the effectiveness of the Local Counter Fraud Specialist

18 AOB In recognition of AW leaving the Audit Committee, DL gave vote of thanks.

Meeting closed at 15.29 Date of next meeting: Wednesday 25 March 2015

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Action Log – Audit Committee Meeting Date Date Action Owner Complete

23.07.2014 NT to create a table to send through to Robert for his approval. Nicola Trevalion

Complete

23.07.2014 Send to Governing Body before end of July 31st. – Ask Elaine. Kayli Shaw Complete

23.07.2014 TM to circulate questions from the handbook. Tim Merritt Complete 23.07.2014 KS to book some time in with DL Kayli Shaw Complete 23.07.2014 TD to send questions around the Audit Committee Tony Dixon Complete 23.07.2014 KS to add the review of the Audit Committee effectiveness to September’s

agenda. Kayli Shaw Complete

23.07.2014 Nick Carter-Meadows (now Alison Foster) to come in and give the Audit Committee a talk on the processes around quality.

Alison Foster Incomplete

26.11.2014 KS to re-send revised minutes. Kayli Shaw Complete

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